“It is not right to define bodily integrity from the outside, especially in a gender-related evaluation.”

Reporter: Belgin Günay

Assoc. Prof. Koray Başar from Hacettepe University Faculty of Medicine, Department of Mental Health and Diseases answered my questions about the rights of intersex people, the problems they face in the medical field and the developments in this field.

I would like to mention a small thing to explain how valuable Assoc. Prof. Dr. Koray Başar’s contribution was for me. From the age of 14, I was initiated into a process of doctor visits, laboratory visits, hormone injections and medications without my consent, and I was operated on at the age of 17 on the grounds of a non-existent health problem. In the surgery, in fact – a few months before my coming of age, without asking me and by lying to me – another intervention was carried out that would affect my entire identity, my body and my health, which was not necessary. Before the operation, I think as part of the official procedure, the doctor also referred me to a psychiatrist to authorize the operation. This psychiatrist did not warn me or inform me about the lie told to me, and only asked me a few questions such as “how are you? what do you do in your free time? do you like movies?” in five minutes and concluded that I was “very good, very happy” and sent me away. I won’t go on and on about the psychological problems I have been experiencing and continue to experience for years afterwards, but in the following years, I voluntarily received psychological counseling twice for various periods of time from places of my own choosing. In other words, after the medical abuse and indifference I have experienced, seeing the support of experts like Koray Başar gives me hope for at least the next generation. I will now leave you with his comprehensive and valuable answers.

What is gender, how would you define it?

It is not easy to define gender as we do not accept it as a concept with a single meaning, a structure with a single dimension. Since the way of thinking that considers sexuality only related to reproduction is still widespread, a person is assigned a gender based on the reproductive organs they have when they are born. In this way, there is a gender that we assign based on body characteristics; this is defined within the dichotomy of male/female. Legally, this gender is recorded in documents and the parents are told that this is the gender of their child. The child is treated as being of that gender. I prefer not to call this biological sex, because I don’t think it is purely biological to evaluate them in groups and gender them according to their relationship to reproduction, rather than according to the biological differences we find between them.

Moreover, we know that bodily characteristics related to reproduction, moreover any bodily characteristic, is not an absolute determinant for other bodily characteristics. I’m mixing it up; the fact that a person has a penis does not necessarily determine the level of a hormone in their blood during puberty, nor does it necessarily determine how hairy their body will be in response to that hormone. Or that a person has a vagina does not tell us which chromosomes they have or whether they have ovaries. For those who get uneasy in their seats when I say this because I am denying such a fundamental dualism of male and female, I am not denying differences between groups. So when you group people according to a characteristic and compare large groups to each other, you can find significant differences. But this does not mean that all individuals who fall into the groups you have separated exhibit similar characteristics and are different from the other group. On the contrary, we exhibit a wide diversity of bodily characteristics associated with sex. But apart from the sex assigned at birth, there are categories of gender that are closely related to these sexes, but whose content is shaped within society; the aspect of a person that includes the way they dress, look, behave, and relate to others. The characteristics expected of you depending on which group you belong to in relation to this aspect of ourselves called gender, the gender role, are not directly related to bodily characteristics or bodily differences; they are a set of characteristics established within society. Moreover, the set of characteristics related to any gender category is not the same in everyone’s mind. You may live in the same society, be a member of the same family, have the same profession or religion, but it is not possible for the social characteristics you understand and expect when you think of a man to coincide perfectly. Just as the dominant expectations in society change over time, the characteristics that the same person associates with gender do not remain constant throughout their lives. Therefore, we also exhibit a wide diversity in the social aspects of gender. In this respect, I can say that gender is not limited to two options.

What is intersex, how would you define it?

Intersex is the definition that people choose for themselves when the physical characteristics associated with the sex they were born with do not fully conform to one of the male/female binary that is accepted as the rule by medicine. This is sometimes the reason for the difficulty in determining gender at birth, or later in life when it becomes clear that the physical characteristics do not correspond to one gender or the other.

In the past, the term ‘hermaphrodite’, which has been used in medicine since ancient times, was used for people with this condition. Referring to the combination of characteristics of both sexes. But the truth of the matter is that each individual’s body already has a combination of characteristics that are more associated with some men and some more associated with women. In other words, according to the intergroup comparisons I mentioned above, there are bodily characteristics that are called male and female characteristics. In this respect, the rule is to have traits of both sexes, the exception is to exhibit a pure gender trait. In other words, the prominence of your Adam’s apple and the thickness of your voice can be considered in favor of masculinity, but the lack of facial and body hair, short stature, and small hands and feet can be considered in favor of femininity. At the turn of the millennium, the term hermaphrodite was replaced by the diagnosis of “disorder of sex development”, which we do not prefer to use because it equates the condition with a disease. This is still the diagnosis used in records and research. Unfortunately, this category has also been retained in the World Health Organization’s diagnostic classification system (ICD 11) that will be implemented in the coming days. However, it is now recognized that the developmental course of sex-related bodily characteristics exhibits a wide range of variation. It is not correct to label any deviation from bodily characteristics in line with the binary gender, which we know is no longer valid at birth or later on, as a “disease” or “disorder”. Although we know more about the development of the physical characteristics associated with gender than we used to, not every step and every factor has been determined. We know that differences in some steps in this process have important health consequences beyond gender determination and sometimes require intervention. The term “disorder” is defended on this basis.

However, I believe that such a label does more harm than good. Alternatives are also being considered. For today, I and many other health professionals working in this field prefer the term “intersex”, which is commonly used by people. Recognizing intersex as a disorder implies that it is a fundamental gender-related disorder. The person is not ‘normal’. This is a presupposition that not only the body, but also the personal and social aspects of gender, sexuality, and the mental structure, individual and social functions of the person related to these are or will be disordered. However, this is not the case, nor does it have to be so. All these characteristics related to gender are not catastrophic when they do not fit into one of the two categories, and they are not as interconnected as they are assumed to be. Where you fall on the spectrum of any bodily aspect of gender does not mean that your body is broken; it does not determine your mental makeup; it does not break you spiritually and socially.

What does a person’s body and bodily integrity mean for their mental health and sense of self?

I hope it is clear from what I have said before, but I must emphasize: it is not right to define bodily integrity from the outside, especially in a gender-related assessment. Whether it is society that makes this definition or medicine that thinks it is immune from social judgments, it is based on the expectation of a single type of person that does not correspond to the diversity that people exhibit. When imposed on individuals, this bodily integrity creates unrealistic ideals that cause not only intersex people, not only trans people, but all people to compare themselves, to feel more or less. A person’s mental health or well-being is related to how well their body fulfills their expectations about their physical characteristics, how satisfied or dissatisfied they are with their current characteristics, how these characteristics are perceived by others, and how much importance they attach to them. If there is a unity about these, it is a unity related to one’s own perception, not someone else’s evaluation. There is no universal set of traits that applies to everyone. Moreover, these are not traits that should remain constant throughout one’s life. A person needs to discover what it is that allows them to experience physical, mental and social well-being, as independent as possible from the expectations of society – and perhaps of medicine – and to access the support that is available to help them achieve what they feel comfortable with. Again, this is not specific to intersex or trans people. Whatever I can do when I believe I should be muscular, when I feel comfortable being hairy or hairless, intersex and trans people should have the right to do the same. This should be guided by the will of the person, not the physician, not the judge. Of course, there are limitations regarding medical practices and as a doctor, I would have suggestions. Of course, there are some legal regulations, and there should be in the current situation. But neither medical nor legal regulations should condemn people to characteristics they do not want, or force them to practices they do not prefer.

What do you think about the medical and/or mental health approach to intersex people?

The medical approach has changed significantly over the years; it is not possible to talk about a single approach. However, the approach that we still see traces of is that medicine, which has adopted a binary gender approach, accepts all physical characteristics as a problem, often in the absence of the person, and tries to fit them into the binary. At a time when it could not see the diversity of human beings in this respect, and even more so when it considered any non-conformity to the binary as a disorder, medicine recognized that this would be a problem for both the individual and society. With the development of methods that could be applied to fit in, it assumed that it was in the best interest of the person to apply this intervention at the earliest possible stage. The early implementation of these interventions was influenced by the assumptions of psychiatry and psychology at the time about the development of sexual identity: the illusion that bodily characteristics and family upbringing are the main determinants of a person’s gender identity, expression and sexual orientation. The aim is thus to construct the person physically and psychologically in the dichotomy that society expects of them.

It has only become apparent over the years that this “corrective” approach does not serve the expected purpose and that the difficulties experienced by individuals are not eliminated by assigning a specific gender and raising them accordingly, whether through surgery or hormone treatments. Intersex people are the ones who make this visible and continue their struggle. Moreover, these interventions, which often take place early in life, are carried out without adequate knowledge of the person, in most cases even the family, and almost always without asking for the person’s consent. Regardless of whether the person prefers these procedures or not, they have serious traumatizing effects. Even if the procedures are not wrong, it is very understandable that someone who is insisted that they have a disorder and that they should keep themselves a “secret” will have psychological, if not physical, scars. Research shows that intersex people are subjected to very serious stigmatization and discrimination, in some studies at the highest rate among LGBTI groups. The message that they need to be corrected, the insistence that they should keep their condition a secret, and the assurance of family and physicians that their experiences will not be accepted if they are found out do not build resilience against all this stigmatization and discrimination.

On the contrary, it can lead to internalization and often entitlement. Fortunately, in recent years, a more intersex-centered medical approach has become more common. In other words, rather than trying to alleviate the anxiety of the family and meet the expectations of society, medicine should act on the side of the person and defend their rights. In doing so, it should not assume the omnipotence to make decisions for the person as it did before. This is why in many countries, in the absence of vital necessity, irreversible medical procedures are postponed to an age when people can participate in decision-making processes. Unfortunately, this approach is not widespread and standardized enough. Some centers in Turkey are adopting this current approach and trying to adopt it. Of course it is not enough, it should be on the agenda more. Even though I can say that there is a positive development in the approach, I can say that the approach of medicine, which is limited to diagnosis and medical interventions, is and will remain incomplete. We know that there must be many people who have been subjected to medical monitoring and interventions. When research is conducted, it is revealed that they have physical, mental, sexual and social problems. But they are not visible. I am not talking about visibility in the public, they are not in the health system. I don’t think they can access the health services they need. Studies conducted in other countries show that it is common to be discriminated against in the field of health when they apply for other reasons. For this reason, people may be hesitant.

How do you find the care and counseling services offered to intersex people?

I don’t think they are offered. I know that they are not offered in a systematic way. Both the individual and the family need very serious psychosocial support and the continuity of this support. We expect the health institutions they interact with from the beginning to provide this. However, unfortunately, there is no comprehensive care plan beyond diagnosis, investigations into the cause, hormone and surgical interventions. Such a plan should be carried out in a way that both the family and the person are informed from the beginning and are included in decision-making processes. We know that families need serious psychosocial support for this, and that they experience intense anxiety and uncertainty, especially in the first period. For this reason, families sometimes insist on medical interventions. However, there are studies showing that this anxiety and distress does not subside even with medical procedures. Therefore, although this is difficult, healthcare professionals should be able to provide psychosocial support that will allow the family to manage their initial reaction.

It is important that the child is informed and included in the process in accordance with his/her developmental stage. These are not unrealistic, utopian expectations that cannot be implemented. Yes, it is difficult, but this is how health care should be planned, with the intersex at the center and the intersex, not the family or the community, as the subject of care. In these cases, these procedures are often carried out in advanced health care institutions where multiple medical specialties are involved. However, I believe that psychiatrists and psychologists are given a much lower role than they should be. Mental health specialists are often consulted in cases where gender assignment is required or in the decision-making process regarding surgical procedures. However, long-term support extending into adulthood is needed. The dimension of this support that empowers the individual and the family against stigmatization, guides communication and increases mental resilience is neglected. It is a great loss that the individual and family are left alone with social prejudices about gender diversity at the decision-making stages of medical interventions. Everyone pays the price for this, intersex people most of all. Maybe I need to elaborate on gender assignment. There are serious problems with the family’s decision on which gender to raise the child in case of gender ambiguity, and which gender to tell the environment that the child is. It is not absolutely possible to predict gender identity with an assessment early in life. In different cases, and there are dozens of medical conditions associated with being intersex, the rates and probabilities of the development of gender identity are known. However, in a situation where neither medical signs nor early psychological evaluation can provide absolute results, it is unrealistic to try to alleviate the uncertainty by jumping to conclusions. The family needs to be able to be open to diversity regarding the physical and psychological development of gender, to act with the child rather than in front of it, and to stand by it in a way that protects it. Without ensuring this, it is not feasible to expect that the gender to be raised will not be determined and to suggest that the child be raised genderless.

Ignoring the expectations of the family and society is not a realistic expectation today. We know the importance of peer support for people and families experiencing difficulties related to sexual orientation and gender identity, and its contribution to their mental well-being. However, intersex people and their families have to cope with the feeling that the situation has only happened to them. The health system needs to develop mechanisms that will allow and encourage contact with people and families who have similar experiences.

Is intersex mentioned in the education in your field, and if so, in what way?

It is not mentioned, it is very clear. It is not included in adult psychiatry training, maybe it has a place in child and adolescent psychiatry specialty training, I am not sure. But I am sure it is not enough. I am sorry to say that in medical school, when we are trained as physicians, intersex is taught in a limited and as mechanistic way as possible. I can say that the time devoted to diagrams about which enzyme deficiency and which hormone excess can result in what kind of situations related to gender development is not devoted to the difficulties that individuals and families have experienced and will experience, and to suggestions on how to deal with them, and to possible mistakes in medical practice.

Child and adolescent psychiatry specialists who are involved in the process during infancy, childhood and adolescence need to be trained on the diversity of gender development, the dimensions of sexual identity, their understanding outside the binary system and their interrelatedness. It is not easy for these specialists to move away from binary gender attitudes and practices that are ingrained in the bones of medicine; it is not possible with theoretical training alone. The development of medical practices on this issue was actually made possible by the interventions of intersex people. We need to find ways to include intersex people and their families in the daily clinical practice of health professionals.

What is/will be your approach to intersex people in your professional life?

I practice sexual therapy and my general field of work is sexual identity. I have come into contact with intersex people at birth or when people whose gender identity does not coincide with their medically assigned sex apply for gender reassignment.

In adulthood, I can say that I became aware of the gaps and deficiencies in this regard by listening to their retrospective stories, family relationships and current difficulties. The process of gender adaptation is about adopting the physical and social characteristics of the gender that the person adopts for himself/herself. Therefore, we try to build a process that progresses with the choices of the person, similar to those of people who are dissatisfied with their current characteristics who apply to the psychiatric clinic for this purpose. In doing so, our main function is to understand the diversity of gender, gender identity, expression and sexual orientation and to support the person to make decisions about themselves by going beyond the binary thinking imposed by society. We carry out a process similar to that of transgender people with intersex people, but with more significant shortcomings in medical and legal aspects. Moreover, for applicants over the age of sixteen who apply for psychiatric evaluation related to medical procedures, we try to continue the interview and follow-up with the person and their family as much as possible in the way I have just described. However, I don’t think we receive enough applications except for the gender reassignment process. It is difficult for us to encounter a group where the medical support that can be provided in adulthood is not sufficiently publicized, especially in a group where negative experiences about medicine in the past are so loaded that they prevent the application. Therefore, at this stage, I can say that I am focusing more on increasing the awareness and knowledge of the psychiatric community and healthcare professionals in general.

The Sexual Education, Treatment and Research Association (CETAD), which I was a member of the board of directors and one of the trainers for a while, plays an important role in mental health related to the diversity of sexual identities. I can say that I have made attempts to include this issue in the trainings and meetings of this association. At the last CETAD national congress held in Istanbul, we organized a panel on this issue with the participation of an intersex activist. I believe that this panel raised important questions in the minds of professionals working on sexual health. We also participated in the national congress of specialists who perform surgical interventions in childhood with the same person. In this way, I think that intersex activists and health professionals who are sensitive to the issue have caused a spark. I am happy to say that in the last few years, medical students have organized many events on this issue, they are curious about this issue and have put it on their agenda. Changes in medical practices are not easy, but I am hopeful.

I believe that it is important for both LGBTI+ organizations and LGBTI+ family groups to make efforts for intersex visibility and for health professional organizations to become more sensitive and active on this issue. In 2020, the updated version of the Turkish Medical Association’s Ethical Declarations was published. In the declaration on gender, it is clearly stated that for medical procedures related to gender that are not vital and irreversible, the person should be expected to reach the maturity to be involved in decision-making processes. I can say that these are important achievements. But there is still a long way to go.

Do you think that intersex people are exposed to medical malpractices and that this causes trauma for them?

I think that many intersex people are subjected to medical malpractices and deprived of proper healthcare and support. I can repeat this sentence for their families as well. There is significant physical and psychological damage that can be caused by this situation, some of which can last a lifetime. I cannot say that everyone has the same experience and is traumatized in the same way.

It’s not about the malicious intentions or different interests of the people who engage in these malpractices. At least not all of them. But I would argue that medicine owes a debt to intersex people and their families. Even if these practices are considered scientifically correct and have positive outcomes for the individual, support for their long-term effects should be provided systematically and without delay, and changes should be made quickly to prevent similar practices from continuing in the future. Medicine makes changes in its practices based on up-to-date scientific knowledge; this is necessary for healthcare professionals to protect their professional identities. In the past, wrong practices regarding sexual orientation, gender identity and diversity that did not coincide with the society’s understanding of gender and sexuality, including homosexuals and transgender people, were reversed. This was achieved through the struggle of the LGBT movement and the scientific findings obtained through studies in this field. The same change is possible for intersex people, who are always mentioned in the LGBTI+ acronym but not explicitly addressed. For this to happen, intersex people and their families need to continue their struggle for their rights and health professionals need to review their practices and make efforts to change the system.