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No more sex identification on birth certificates, New England Journal of Medicine article declares
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No more sex identification on birth certificates, New England Journal of Medicine article declares

Authors say sex designations can have 'particularly harmful effects ... on intersex and transgender people'

A New England Journal of Medicine article published last week states that birth certificates no longer should include sex identification "given the particularly harmful effects of such designations on intersex and transgender people."

What are the details?

The article said birth certificates in 1949 underwent a revision that "created a line of demarcation. The legally identifying fields above the line appear on certified copies of birth certificates, whereas information in the fields below the line, which is used for statistical purposes, is deidentified and reported in the aggregate. Race and parents' marital status, for example, were moved below the line of demarcation to permit self-identification and to avoid stigma, respectively."

Simply put, the authors said it's time to move sex designation below the line.

More from the article:

Designating sex as male or female on birth certificates suggests that sex is simple and binary when, biologically, it is not. Sex is a function of multiple biologic processes with many resultant combinations. About 1 in 5000 people have intersex variations. As many as 1 in 100 people exhibit chimerism, mosaicism, or micromosaicism, conditions in which a person's cells may contain varying sex chromosomes, often unbeknownst to them.2 The biologic processes responsible for sex are incompletely defined, and there is no universally accepted test for determining sex.

Assigning sex at birth also doesn't capture the diversity of people's experiences. About 6 in 1000 people identify as transgender, meaning that their gender identity doesn't match the sex they were assigned at birth. Others are nonbinary, meaning they don't exclusively identify as a man or a woman, or gender nonconforming, meaning their behavior or appearance doesn't align with social expectations for their assigned sex.

Sex designations on birth certificates offer no clinical utility; they serve only legal — not medical — goals. Certainly, knowing a patient's sex is useful in many contexts, when it is appropriately interpreted. Sex modifies the clinical suspicion of a heart attack in the absence of classic symptoms and is a proxy for many undefined social, environmental, and biologic factors in research, for example. But, in each of these applications, sex is merely a stand-in for other variables and is not generally ascertained from a birth certificate.

'Keeping sex designations above the line causes harm'

The piece emphasizes that "keeping sex designations above the line causes harm."

More from the article:

For people with intersex variations, the birth certificate's public sex designation invites scrutiny, shame, and pressure to undergo unnecessary and unwanted surgical and medical interventions.1Sex assignments at birth may be used to exclude transgender people from serving in appropriate military units, serving sentences in appropriate prisons, enrolling in health insurance, and, in states with strict identification laws, voting. Less visibly, assigning sex at birth perpetuates a view that sex as defined by a binary variable is natural, essential, and immutable. Participation by the medical profession and the government in assigning sex is often used as evidence supporting this view. Imposing such a categorization system risks stifling self-expression and self-identification.

People with intersex variations may undergo surgeries before they are old enough to consent, often losing reproductive capacity and sexual sensation as a result. Transgender people receive worse health care and have worse outcomes than cisgender people.3 Health care professionals have a particular duty to support vulnerable populations who have historically been harmed by clinicians and by the medical system in general.

The bathroom thing

The authors of the article go further and address safety concerns related to transgender individuals using locker rooms and restrooms of their choice. "But fears about privacy and safety violations in public accommodations aren't supported by evidence. A study examining the effects of a Massachusetts law protecting transgender people in public accommodations revealed no increase in violations. Meanwhile, many intersex and transgender people avoid public spaces, including restrooms, for fear of mistreatment."

Passports and other documents

The authors also say that if sex designations are removed from birth certificates, it would allow applicants for passports and other government-issued documents "to identify their gender without medical verification."


A number of article commenters questioned the authors' conclusions:

  • "I consider myself a left of center thinking person but this goes a little too far down a rabbit hole I don't want to step into," one reader noted.
  • "If a person who is male wants to pretend they are female, does that mean I legally have to pretend with them?" another reader asked.
  • "Tinkering with birth certificates will not alter the fact that humans are either men OR women, as little as the Flat Earth Society can make the earth flat," another reader commented. "There are tiny flat patches on earth and a tiny number of humans have ambiguous sex but this does not change the fundamental principles."
  • "This kind of thinking is just another example of how far we are wandering from truth," another reader said.

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