VSC/DSD and sexual identity

Persons with Variations of Sex Characteristics (VSCs)/Differences of Sex Development (DSDs) may feel the need to explore their sexual identity during their lives, just like everybody else.

Sexual identity is a construct developing over time in a process that combines biological, psychological and social factors. Its components are: sex assigned at birth, gender identity, sexual orientation and gender role.

The sex assigned at birth refers to a person's status as female or male according to the appearance of the external genitalia: a child born with a penis and testicles is assigned male at birth, while one born with a vagina is assigned female. However, the sex assigned at birth is independent of the person's gender identity, which is the deep, intimate sense of belonging to a gender, whether female, male, or other.

This is of utmost importance in the case of a VSC/DSD. Indeed, individuals who present congenital characteristics at birth that vary from the stereotypical definitions of female or male, who are assigned a gender on the basis of the appearance of their external genitalia, may in some cases have a gender identity that differs from their assigned sex. For this reason, the child's gender identity must be thoroughly investigated. The recommended approach involves counselling and psychoeducational and monitoring interventions with the family and the minor regarding the stages of development of gender identity, as well as multidisciplinary work on the network aimed at creating a serene and safe family, school and social environment in which children can freely express their gender identity. This is to promote the best psychological balance. As development progresses and from the moment in which the person will be able to express informed consent, if a gender identity different from the sex assigned at birth persists and if requested by the person, it will be possible to evaluate the possibility of a hormonal and/or surgical procedure based on specific requests and needs.

Another dimension of sexual identity is sexual orientation, i.e., physical and/or romantic attraction to other people. Sexual orientation can include attraction to people of a gender different from one's own (heterosexual orientation), of the same gender (homosexual orientation), of both of the same gender and of a different one (bisexual orientation), or  be gender- independent  (pansexual orientation), etc. It is worthy of note that sexual orientation is defined not by the sex assigned at birth, but on the basis of a person's gender identity. This dimension, therefore, is wholly independent of genital appearance or the presence/absence of a VSC/DSD.

Finally, with the gender role we refer to the set of behaviours and attitudes that are socially and culturally recognized as acceptable, appropriate, or desirable for a person based on that person's assigned sex at birth. Gender expression, which is a component of gender role, indicates how a person expresses their gender through names and pronouns, make-up, clothing, and body language. Gender expression, as well as gender role can vary in relation to the historical period and from culture to culture (for example, the colour pink today is associated with the female gender, while in the first half of the 19th century it was associated with the male gender). The components of sexual identity are found to combine freely and uniquely in every person.

Bibliography
Alderson J, Hamblin RP, Crowne EC. Psychological Care of Children and Families with Variations or Differences in Sex Development. Hormone Research in Paediatrics. 2023;96(2):222-227
Coleman E et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022 Sep 6;23(Suppl 1):S1-S259 
Cools M et al. Caring for individuals with a difference of sex development (DSD): a Consensus Statement. Nature Reviews. Endocrinology. 2018 Jul;14(7):415-429
Hegarty P. The psychology of people with variable sex characteristics/intersex. Current Opinion in Psychology. 2023 Feb;49:101539