Doctors Push to Rethink Sex Designations on Birth Certificates

Doctors suggest moving sex designations below the line of demarcation on birth certification to reduce harms to gender-diverse individuals.


In an editorial for the leading medical journal, the New England Journal of Medicine, doctors, and researchers from Brown University Medical School and the Vanderbilt University Law School call on the government to rethink how sex designations are reported on birth certificates. The authors, Vadim Shteyler, Jessica Clarke, and Eli Y. Adashi, propose moving sex designations below the line of demarcation to protect gender-diverse, intersex, and transgender people from legal discrimination.

“Moving information on sex below the line of demarcation wouldn’t compromise the birth certificate’s public health function. But keeping sex designations above the line causes harm,” the authors write.  

Transgender and gender-diverse individuals face higher rates of psychiatric diagnoses, and their experiences of discrimination lead to increased stress. Previous research has shown that non-gender affirmative treatments are associated with severe psychological distress, while gender-affirming interventions can reduce mental health issues. For example, transgender youth reported reduced depression and suicide when their chosen name is respected.

The current designation of sex as male or female on birth certificates perpetuates the problematic narrative in viewing sex and gender identity as binary.  As the understanding of the experiences of intersex, transgender, and gender-diverse individuals have increased, it has become clear that sex designations on birth certificates have little to no clinical utility but serve primarily legal purposes.

“We believe that it is now time to update the practice of designating sex on birth certificates, given the particularly harmful effects on such designations on intersex and transgender people,” the authors write.

There are two sets of health information collected on the current birth certificates: the information above the demarcation line and the information below the demarcation. The information above the line of demarcation has legal purposes for identification, and the information below the line is used for statistical purposes. Certain information, such as race, was moved below the line of demarcation for more accurate self-identification and to avoid potential stigma.

 “The birth certificate has been evolving documents, with revisions reflecting social change, public interest, and privacy requirements; we believe it is time for another update: sex designations should move below the line of demarcation.”

In fact, the article mentioned that about 6 in 1000 people identify as transgender or nonbinary, and 1 in 5000 people have intersex variations. In addition, 1 in 100 people may contain varying sex chromosomes without knowing it. The current sex designations fail to reflect the diversity of people’s experiences, which could compromise transgender and gender-diverse individuals’ health by adding unnecessary stress due to inaccurate identification and limits to self-expression.

“For people with intersex variations, the birth certificates’ public sex designation invites scrutiny, shame, and pressure to undergo unnecessary and unwanted surgical and medical intervention,” the authors explain.

“Sex 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.” 

The authors also recognize that health care professionals should feel more responsible for advocating for sexual and gender minorities who the medical system has historically harmed. For example, many people with intersex variations underwent surgeries without their consent, which can lead to losing sexual sensation and the capacity to reproduce.

Lastly, the authors urge governments and more facilities to change the current practice of sex designations and to move sex designations below the line of demarcation on birth certificates so that people can identify their gender without medical verification. This change will reduce the likelihood that transgender and gender-diverse individuals will become the target of discrimination and allow them to self-identify their gender at an older age.

The authors conclude:

“Today, the medical community has a duty to ensure that policymakers don’t misinterpret the science regarding sex and that medical evaluations aren’t being misused in the legal context. To protect all people, birth-certificate sex designations should be moved below the line of demarcation.”



Shteyler, V. M., Clarke, J. A., & Adashi, E. Y. (2020). Failed Assignments-Rethinking Sex Designations on Birth Certificates. The New England journal of medicine383(25), 2399-2401. (Link)

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Chia Po Cheng
Chia Po Cheng is a doctoral student in Counseling Psychology at University of Massachusetts in Boston. Prior to his doctoral study, Po graduated from the dual master's counseling program at University of Pennsylvania and worked as a licensed professional counselor in Philadelphia. He is interested in examining the impact of policy on mental health as well as how Asian values influence individual psychology.


  1. To be honest I am weary of the global neurosis about genitals. The world is heating up from runaway climate change. The gulf stream is going to usher an Ice Age to Europe. Famine and dearth are going to be the birth certificates of a trillion newborns and all the thinkers want to do is ponder the imponderables of genitals, as if genitals are a kind of wound that needs mending, like people used to do with hearts, when they’d say their heart was broken. I appreciate that it is great to treat everyone equally and make no distinction between any person. That is my goal. All are one. However, I see the erasure of the distinction between things like male and female as being a bit like the erasure of the distinction between rich and poor or child and adult. If there is no record of whether someone is female or a child or poor how can their rights to special considerations be protected? If a child is no longer deemed a child but a mini adult they might be coerced to have sex by adults who tout that everyone should be welcome to go to kindergartens. We have distinctions for good reasons. Although regretably these distinctions can be be abused by cruel stigmatizers who oppress those so protected or distinguished or oppress those who are not part of that group. Specialness flips over to stigma and back again at the stroke of a bureaucratic pen.

    As a mad person I know all about stigma but I dont ask my friends to change and be similarly as mad as myself so as to help me feel less excluded. Madness is not a wound that I think the whole globe should kiss all better. Madness IS the mending of the wound. The beauty of the authentically real mad people I know is that they invariably want nothing from anybody. For that they stand free. And for being free they are punished by society who cannot control such original people who cannot be bought.

    I am not taking any one position here. As a mad person I have been everyone. I have been gay, straight, trans, gender fluid, non binary. I was writing about the glory of these specific ways of being over a decade ago, long before the word ‘woke’ was conjured up. I believe all are equal, in our wonderful differences. Difference is to be loved and celebrated and deemed special.

    As for the birth certificates piece in the article, why stop at ‘male’ and ‘female’ being obscured? Why not resist even saying its a human baby since maybe it will want to remain only designated the definition of zygote, or perhaps years later identify just as a mammal? Does a whole continent’s legislation have to change just because I am schizophrenic and believe I am not just me but a ‘group’ of divine beings? Was my midwife negligent for not documenting my birth as multiple? Hims and hers? The law can only cushion so many of our identity fantasies before the establishment of someone’s basic legal rights bumps up against the solemnity of someone elses basic legal rights. The law is an ass that can only do the basics. But the basics can be more workable than the attempt at utopia. The path to utopia is always littered with war crimes.

    I feel people can choose to be as they want to be good enough these days in the West. Other countries are a whole other debate. But what gender we all want to be will soon take second stage when climate change gatecrashes our decadent party.

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    • I hear you absolutely, and you courageously break down some crucial contradictions. But I don’t consider you a “mad person,” unless you “identified” that way before psychiatry labeled you something else. We shouldn’t “other” ourselves by internalizing the projections and othering of others. But that’s another conversation.

      All I can say is that you’re brave to even broach the questioning of various narratives you bring up here. I will abstain from the debate, as this is something that women and gay people will ultimately have to resolve amongst themselves, other than to note that the conflation of “sex” and “gender” leads to similar confusion as the conflation of “brain” and “mind.”

      Also I’m not clear how this piece is related to psychiatry. I’m not about to engage in a long contentious thread, my main concern here involves romanticizing the term “madness,” which can be positive in some circumstances but I believe overall perpetuates the same myths as psychiatry, but using “identity” terminology.

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  2. I’ve had a little nap and am just wanting to say to Chia Po Cheng that I omitted to say I like your article.

    A cinema offered to change some of its seats to welcome different tall people. They gave the seats more leg room, of course it meant other seats had to have crampy leg room. Then people who were paraplegic arrived at the cinema in beds, so people had to take some seats away to make room. Then very sporting people came and said they did not want cinema seats at all but an easily accessible track between seats where they could jog through any movie boring bits. They wanted the right to keep physically fit even mid trailer. Then people of the light came and said they felt excluded by having to sit in dark auditorium. So one half of the cinema was so brightly lit you could see people kissing in the back row, and these people asked for a privacy screen installed by an architect and for it to be drawn, but lonely people sitting in row twelve felt humiliated by the plush velvet privacy screen since it kind of made the snoggers seem more worthy of special regard. Then a hippie arrived and said he did not agree with seats on spiritiual grounds because they are bad for bodily chakras and really the cinema ought to welcome those who want to watch a car chase from a bean bag. Then a besuited executive breezed in and wanted all the seats restored to how they used to be back in the nineteen thirties. Then a breast feeding mom with ten children asked that some seats be adaptable as diaper changing tables.

    The cinema owner sat up all night by candle light trying to include everyone who ever felt they had a difference that needed cherishing by provision of specially made cinema seats. He was desperate to make everyone feel welcome but the physical properties of the communal space of the building made it difficult to meet everyone’s needs without demolishing the cinema. That would be sad because alot of people had enjoyed the cinema over the years. Nobody complained about seats before because seats were not regarded as harmful, just uncomfortable for an hour. But now people were of the belief that being uncomfortable for an hour could lead to suicide. The tall person could grow nihilistic from being forced to feel uncomfortable because of the wrong type of seat. The kisses could wind up in a double suicide without the comfort of their curtain. The mom feeling uncomfortable could start hitting her kids during adverts and the kids could grow up suicidal. The hippie, after even five minutes on a rigid square chair, could succumb to a depth of melancholy that could finish him. Everyone now equated inclusion with life and exclusion with death because of the rise of the serious importance of suicide. Suicide that everyone feels on an hourly basis, from millionaires to minors. Suicide that used to be so elusive it was only the discreet parlour game of toffs who were arrested for even thinking such thoughts. But now anything that reeks of discomfort could be deemed exclusion and therefore a potential source of decline into suicide, and everyone knows…cinema seats are insuffereable for anybodies body after popcorn and fizzy cola, you get clicky knees, and so cinema seats are unjust and unfair and need sweeping changes to stop everyone leaping off bridges clutching their tragic blockbuster ticket. Everyone fears they may suddenly go suicidal at a shopping mall if they sat in discomfort for an hour at cinema that did not love them enough. It is a mass hysteria about death, in this era that comes in the guise of frighteningly easy suicide. And it combines with a mass hysteria about a perceived societal lack of love. Everyone has been sold the notion they can only survive death by suicide with the bankable, kitch, phoney love pedalled by capitalism. That love has fairy dust and Valentines cards and unconditional families and unrealistic smaltz that only a paragon of perfection could utter. Everyone is chasing that paragon of perfection and expecting that of even a humble cinema owner, and if that unrealistic love proves disappointing and the uncomfortable is not made comfortable immediately then the cinema owner is guilty of causing everyone to suicide. It reminds me of the mass hysteria during the Spanish Inquisition where humble herbalists in there millions were set up on flickering stakes for not making people comfortable in their fear of death.

    We all want to feel included and loved and none of us want to feel suicidal or cause others to feel that way. All are equal in differences, so all are equal. But our many trillions of differences cannot bring about a perfect cinema, or perfect world, for us, without inconveniencing the perfect cinema or perfect world of someone else. That is if the perfect world is the human built civilization variety of world. The actual real world is the natural world and is enormous and accomodates many different kinds of creatures very easily and without qualms. A tall giraffe gets a comfortable tree. A hippie crocodile gets a comfortable woodstock mud pool. A maternal breast feeding minky whale gets a whole ocean.

    Birth certificates seem to be this month’s uncomfortable chair. As someone who did the trans things for a while I cannot see why having others find out you used to be another sex could not be a source of ecststic celebration, like revealling you used to be poor or unmusical or unartistic but now you are the glorious fruition of that beginning not a shamed appologist for that beginning. The shame needs ousted not the origins. As a schizophrenic I could inadvertantly buy into societal shame about my schizophrenic origins and cover my schizophrenia with proper convincing “sanity” and request that my certificates be changed to conceal it. But I prefer to dance with society’s need to shame…to fix society.

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  3. @Oldhead, thank you for your thoughts on my self description as a mad person. I very much like your gentle persuasion in a world where nobody can say what they are without it getting in trouble for it.

    I did the meyers brigs personality test in my teens. I did it in my twenties. I did it recently. Every time it gives the same result. I am an INFJ. Only two percent of the world’s population think like me. I am outgunned. I have had a life of being met with bewildered stares after I have spoken. It has given me the option of either agreeing that I am embarrassingly bewildering or that I am, as the meyers brigs test says “rare”. I prefer “rare” as it suits my penchant for vainglory, but another word I use for myself is “mad”. To me it is “Mad poet” “Mad as a hatter” “Madly in love with life” “Mad not to” “Mad as a March hare” “Mr Rochester’s Mad woman in the attic” “Macbeth’s three mad witches” on and on. I like calling myself mad because it sort of says to the world “I am not you”. Of course I could just say that but it gets exhausting because the repeated follow on question from others is “Why are you not me?” “Why don’t you agree with my opinions?” “Why do you not see the logic of my argumentation, politics, religion?”. I feel my life is too short to pander to peoples need to understand the minutiae of why I am as I am. Declaring myself Mad is a shutting down of other people’s bullying, a way of saying “Leave me alone to think and be and say and do as I freely choose and realise I do not have to pay lip service to whatever verbal trends are in vogue”. But also I see my own self definition of Madness as declaring that I am commited to not feeling a burden to always “make sense”. My madness is therefore a way of “being” that I like to celebrate for myself. I am not saying everyone else has to concur. I am aware other people loathe that word and have felt themselves excluded from society by it. I always relish being excluded from society because society is a prison.
    I am aware that people have felt hurt by psychiatry rubber stamping them as “Mad” but to me that word is arbitrary. It could be the word “Lemons” or “Pineapples” or “Gay” or “Jew”. Any regime can use any word to point an accusatorial finger and signal “difference” but ultimately it is only the “difference” that is being oppressed, and I feel proud to be different. I do not want to be the same as everyone else. I do understand that many survivors feel they have been tortured on the strength of such a mere word, a mere three letters, like “Jew” is three letters. In life people are so frightened of the “different” they are always going to dream up one word or another to disdain the “different”. The problem is not the word but the fear behind the use of such words, that drives outward bullying to seek to control the “different”.

    But there is a very complicated other reason for my using terms to describe myself that you might dearly wish I would not. It is this… one aspect of my schizophrenia is a dominating dictator being who likes to demand that all day every day I say I am schizophrenic. If I do not he tortures me. So between his ordering me to say the word schizophrenia and antipsychiatry telling me not to I fall into a chasm of extra suffering. I cannot please everyone. And in any case after all these years my using the word schizophrenia to describe myself is now water off a ducks back. Indeed I have grown to like the word for myself, like having been forced into a marriage where I have to accept the surname. After all these years I am okay with it. Whilst here I may as well also say that not all bodies are made in a factory. Everybody’s body and brain are unique to them. I know for myself that my schizophrenia feels like an illness at times to me. People can say it is or it isn’t, according to brain scans and test tubes and science, but until someone opens up my brain, MY BRAIN, that is unique to me and did not come out of a factory where all brains are identical it is possible my schizophrenia is a real illness that MY BRAIN, not anyone else’s brain, has given me. And after years of antipsychotics I can well believe that those chemicals alone may have given me an added boost of schizophrenia, of a brain damage sort.

    I did play with calling my schizophrenia something else and I did play with always couching that term in quotation marks but it began to feel to me like I was being bullied into “talking nicely”, which is what the institution of psychiatry are ever keen to impose.

    I understand that in activism there can be a tight control of a replacing ideology and this often grows a new emancipating language and if you refuse to echo it you are not “one of us”. But then to me that smacks of “othering” and flagging up “difference” and fearing “difference”. In a campaign to shout loudly that we are not all like factory produced eggs in an egg box I feel there should be a looser kind of tolerance. But that is just my opinion today. Being “Mad” I might change it all tomorrow and wave the banner against using the word schizophrenia for myself or describing myself as mad. But really it is my choice.

    I am often swayed in my choice by hearing other peoples gentle wisdom. But I cannot listen all day, every day, to eight billion people’s bits and pieces of wisdom or I would become even iller. Sometimes I prefer to stay refreshingly stupid.

    And as a blank staring stupid person I am away now to paint my hall floor a suitably blank shade of paint, whilst my gruelling manifesting symptoms of psychosis lurch around after me, demanding that I keep telling myself I am schizophrenic and if I refuse I will get persecuted to point of suicide.

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    • My only problem with others’ choice to accept an othered identity like ‘mad’ is that it does not just identify the individual who doesn’t mind being referred to that way, it effects all whom society has deemed different and to whom they are applied. But they also effect all those to whom they have not been applied as a sort of warning to what could be applied if they don’t follow the social dictates of the era.

      Of course, the social dictate of this era is the absurd notion that someone can identify their way into a group they clearly and objectively are not. And those objecting to the delusion then get more labels. Not very nice labels. Labels intended to socially ostracize them.

      So you see, labels can still actually do a lot a harm even when some don’t mind them or have gotten over minding them. Labels are great when you’re trying to find which jar the sugar is in.

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    • Well, I don’t consider you “schizophrenic” either. “Mad” and “schizophrenic” are two sides of the same coin, and are both forms of “othering.”

      I’m not trying to persuade you to change, just exploring the implications of the term”madness,” which are different for different people. I’m more of the “mad as a hatter” persuasion, or of seeing “madness” as a state of inspired creativity — not describing the characteristics of a “special” sub-class with a separate “culture.”

      While I know there are always exceptions, most “mad ” people don’t originally define themselves as “mad,” though many grew up feeling weird and ostracized. Almost always those who claim to be “reclaiming madness” have initially been labeled by psychiatry then, rather than rejecting labels altogether, adopt new “mad” labels and call “madness” their new “identity.” The “othering” remains constant; only the label changes.

      So what’s in a phrase? I also remember an old movement slogan “Women aren’t mad, they’re angry.”

      Anyway thanks for all the energy, I know this is hardly an adequate response.

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  4. I HAVE SCHIZOPHRENIA. It causes a being in my brain who every three or four minutes orders me to regard myself as schizophrenic and mad. If I do not comply I suffer greatly. Am I to suffer more to because Mad In America commenters want me to be no longer psychotic?

    Because of my psychosis I CANNOT HELP my choice of words I use to describe myself. Everyone is free to use their OWN choice of words to describe themselves or even no words. That FREEDOM is a beautiful thing.

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    • DW, you certainly seem to be suffering. And you make a good argument for the possibility that the labels were originally meant for the kind of suffering you experience. I have no tangible experience with that degree of psychosis. And I think that those of us who have had the labels erroneously applied also have a right to raise awareness about how the labels function in the greater scheme of things to control social behaviors at the population level.

      But I can’t help but notice that you say everyone has the freedom to describe themselves they way they choose and yet you say that you have no control over how you describe yourself. It seems like you regard others as having more control over their choice of words than you currently think you could have. I guess my inner voice may not be as loud or destructive as yours, but it still tells me to resist these labels and I have learned to listen when she guides me.

      I do very much enjoy your comments and I don’t want to be the cause of your continued upset, and so I can but wish you health and peace and leave you with that.

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  5. I am humbled by your kindness Kindred Spirit, and indeed Oldhead. My story is long and maybe would give people a clearer understanding of why I use the words I use. One day I hope to add it to the canon of marvellous literature of life experiences that other survivors have written. But at the moment I barely get any peace from my psychotic intrusions to write at all. Each comment I make is like a song a bullied kid might attempt to sing whilst being repeatedly hit. If I get a comment out all of a piece I feel uplifted all day. I don’t have alot of time to be precious about my word choices, and like I say, there are some choices that are foisted on me. My only recourse is to try to downplay those impinged choices. I realise this may tread on toes of those who maybe don’t want me to use those words. I guess its easier to think of me as like a Tourettes sufferer who offends everyone by swearing out the damning words loudly and louder and louder still. But in my estimation societal decency and societal bullying do not reside in actual words but in the spirit with which any word is sanctified or weaponized. Bullying is an underlying energy, like a gas. It fits into vessels that are neutral words that carry the energy or lob it at passers by, but yesterdays love words… gay….can be a neutral vessel for delightful energy….or a neutral vessel given bullying energy for tyrannizing homosexual persons…or then morphed into that same neutral vessel word for celebratory energy.

    I do see how any activists want to overhall the language that was used in oppressive years. But language is neutral. It is how it is uttered that is where the bullying resides, but the utterance is just so many sound waves hitting an eardrum, the utterance is the hiss of a snake, the uttereance is not the actual snake itself. I feel too much focus is put on seizing upon neutral words that yes may now have grown stained with the blood of bullying, but the words are false trails, like once lovely but now bloody garments. You seldom find the bully IN the garments. Seeing victims waste alot of activism hours chasing the neutral words themselves is what the bullies adore.

    But I only say these thoughts as “my thoughts”, which I know will be quite the wrong thoughts for others. I am glad we can have diverse thoughts here. So much of any activism that seeks to abolish a cult can itself become oppositionally linguistically cult-like in its genuine heartfelt wish to save everyone. Not that there is anything wrong with cults. I like cults. They are often keepers of huge wisdom.

    Look, I dont have all the answers. I am just this ill person trying to chip in with occasional responses. I like the word “schizophrenia”. Its punk. But I also am forced to use it by a invisible bastard who hits me unendingly if I do not.

    I hope you all do not hit for using it…or then being hit by everyone simultaneously, I really will grow Tourettes syndrome.

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