Androgenous, Hermaphrodites, Tumtum, and Conjoined Twins

The subject of discussion is true hermaphrodism, male pseudo hermaphrodism, female pseudo hermaphrodism, androgenous, and tumtum. Generally speaking, hermaphrodites have an appearance of external genitalia that make us suspect if they are male and female, only male, or only female.

Female pseudo hermaphroditism is described in Williams Textbook of Endocrinology (ninth edition) as a female having a uterus with normal ovaries and Mullerian ducts, with the anatomic abnormality limited to the external genitalia. Some are born with a womb without ovaries but they have Mullerian ducts. Some are born with a uterus but the opening to the vagina is sealed.

A gonadal streak is a form of aplasia (defective development at birth) of the ovary that is a functionless tissue. Scanning devices cannot tell if it is a functioning ovary or not. A pathological diagnosis of the tissue is done to test for absence of normal tissue, appearance of just a stroma, or for a support structure without any normal follicles.

Male pseudo hermaphroditism is described on page 1377 as a heterogeneous condition in which the gonads are exclusively testes but the genital ducts and / or external genitalia are incompletely masculinized. Their karyotype is XY and they have internal testes and Wolffian ducts without a womb or ovaries. The clinical spectrum varies from individuals with female external genitalia to those with mild impairment of masculinization of the external genitalia, as represented by hypospadias, cryptorchidism, and minimal ambiguity of the external genitalia. Hypospadiac males have an incomplete fusion of the penile urethra. Cryptorchid males have undescended, not palpable testes. In many cases it is caused by a defective testes, or due to fetal pituitary gonadotropin deficiency.

Consequently, with a pseudo hermaphrodite hypospadiac and cryptorchid child we suspect his external genital organ to be either an underdeveloped phallus or an overgrown clitoris even if there is no apparent vagina, because there are cases of an underdeveloped sealed vaginal opening, although there is a uterus, cervix and vagina. The phallus and scrotum of a non pseudo hermaphrodite hypospadiac and cryptorchid child appear normal.

The term "female external ducts" means that there is an outward appearance of a vagina and an underdeveloped penis that is suspect of being a clitoris.

With pseudo hermaphrodites and true hermaphrodites, the term "ambiguous external ducts (genitalia)" means that they look suspicious either because of their own appearance or because there is an external appearance of a vagina and a phallus. If the vaginal opening appears normal, then the contradiction causes us to suspect that the opening may be a vagina that does not open into a womb because there is no uterus, or that the penis is an overgrown clitoris, or that they are the vagina and penis-scrotum of a true hermaphrodite having both testicles and ovaries. If there is a small opening then we may suspect it of being a urethra. If there appears to be a small penis then we suspect it to be a somewhat enlarged clitoris.

True hermaphroditism is described on page 1356, as the presence of both ovarian and testicular tissue in either the same or opposite gonads. The ovary must have oocytes to designate the rudimentary gonad as an ovary.

An expert cannot tell by looking, if the opening opens into the uterus, or if it ends blindly (does not lead into a uterus). There some openings that are suspect of being a urethra because they are small. If there is a womb, then the vagina will lead into the womb. If the opening to the vagina is sealed, plastic surgery can remedy the situation.

With a true hermaphrodite, the term "ambiguous external ducts" means an outward appearance of a vagina and a phallus that upon testing could be male or female.

There are basically two external tests to determine if a phallus is a male organ or an enlarged clitoris. A) If the urethra is at the tip of the phallus and he urinates from it. B) Feeling for the presence of testicles in the descended or non- descended scrotum. In the case of a male pseudo hermaphrodite the testicles are small and not easily felt. This method is 80 percent accurate. The exception to this is a rare case of herniated ovaries that fell into the oversized clitoris and feel like testicles, or they remained in the inguinal canal and are palpable.

The invasive method is A) to surgically open the body to look for them, and B) the chemical HCG test that will stimulate the testicles to produce testosterone; if it is not produced then we assume that there are no testicles present. The exception to this is a rare case of twisted testicles that caused them to die due to lack of nourishment and are there but they do not react to testosterone. There are also biochemical hormonal tests for testicular tissue. They can be seen through various scanning devices such as through a sonogram and cat scan, MRI, and also through a genitogram, and a laparoscope.

The male phallus-scrotum and the enlarged clitoris are both biologically and genetically similar. Therefore, in the case where there are no testes and the child is a female pseudo hermaphrodite but she urinates from the enlarged clitoris, many in the medical profession would label it a phallus.

We do not call a vagina that ends blindly a pseudo vagina because it is a female vagina with the same structure, glands, tissue, and secretions of a female vagina, and likewise with a uterus of a true hermaphrodite.

The primary factors that cause an embryo to develop as a male and not as a female are A) the testes produce considerably more androgen than the ovaries, B) the adrenal glands produce androgen, and C) the male tissue responds to the androgen. In the case of defective testes, testosterone can be taken to grow a child as a male.

The book "Pediatric Urology" page 2606 states that there are reports of both fertility and spermatogenesis in true hermaphrodites, but the chart number 56-2 page 2601 states that there is no fertility with either true hermaphrodites or male pseudo hermaphrodites. Williams Textbook of Endocrinology ninth edition, page 1357 states that spermatogenesis is rare with true hermaphrodites, ovulation is not uncommon, and pregnancy and childbirth can occur with patients with a 46,XX karyotype, whereas only one 46,XX true hermaphrodite has been reported to have fathered a child. With male pseudo hermaphrodites they report some cases of spermatogenesis with 5à- reductase-2 deficiency (page 1392).

Let us now look at the situation from the halacha.

1. A male is determined if he has a testis regardless if they are descended or not descended, even if they are small, as long as they can be identified by having testicular tissue. Any and all reliable tests for the presence of testes are accepted. If, after doing all the tests available, it is definite that testicles are present, then he is a male. Today's testing for testes as described before are almost always reliable. If the testes are not that obvious, then a second expert should be consulted and a competent "posek". The general rule is that the tests for testes must be as reliable as menstruation cycles are reliable that there is a womb. In general this means that you must also observe the presence of something that can be testes although they may be small and ambiguous in appearance. There may be cases when there are testes but they cannot be observed for certain reasons. Each case is to be examined individually.

2. A female is determined if she has a womb even if she is born without ovaries. Any reliable internal test is accepted to verify if there is a womb or not; if not, it is not a female. Today's tests are almost always reliable especially when using a laparoscope to find a small uterus. In talmudic days they relied upon menstruation cycles to indicate the presence of a womb.

3. The sex is not determined by the karyotype XY with Wolffian ducts, or XX with the ovary and Mullerian ducts. If we can view the gonads and ducts we can see if there is a womb or testes. The external ducts are usually the initial check if a problem exists.

4. Therefore, a person having a uterus and testes is an "androgenous," he is both male and female. However, it is a halachik impossibility for one person to be both a halachik male and a halachik female; this results in, that according to halacha an androgenous has a questionable status of being either a halachik male or a halachik female. An androgenous may blow Shofer for another androgenous because if the gender is male, then they are all male, and a male is permitted to blow Shofer for another male. If the gender is female, then they are all female. This type of questionable status can be compared to the halacha of Bain-Hashamoshos (evening twilight) which is a combination of both day and night at one period of time. However, it is a halachik impossibility to be both day and night at the same time. This results in, that according to halacha Bain-Hashamoshos has a questionable status, it is either day or night.

If a sperm and egg are taken from a single androgenous and an IVF is performed leading to the birth of a child, which results in a child being produced from one body (the same way the cloning method can produce a sheep from the same body), the halachik status of the child produced from the androgenous may be the same as a child created through cloning (as discussed in my article on IVF and cloning, and there would be also Rabbinical ordinances pertaining to this "golem"). If the child has testes he is a boy, if the child has a womb she is a girl. As far as parental relationship is concerned, we apply the previous rule that it is a halachik impossibility for one person to be both the halachik father and the halachik mother of the child, therefore, we are left with a questionable status, that the androgenous is either the halachik father or the halachik mother of the child.

If an androgenous married a woman and his wife gave birth through her egg being impregnated by her husbands sperm, the father is the husband and the mother is the wife, because only fatherhood can be transmitted through a sperm and not motherhood. If the reverse occurred with an IVF surrogate pregnancy, where the androgenous contributed the egg and someone else the sperm, then the androgenous is the mother and the contributor of the sperm is the father, because only motherhood can be transmitted through the egg and not fatherhood.

The halachik issues regarding an androgenous are of primary importance at the time of puberty when the child becomes Bar Mitzvah or Bat Mitzvah and is required to follow the halacha. In the old days if a child was born with a vagina and palpable testicles he could either be an androgenous or a male without a womb where the vagina ends blindly. At puberty there should be menstruation if the child is an androgenous, if not, this raises doubt about the status of the child. The time when a female is supposed to menstruate varies, and the medical professionals of the society where the question arises are to be consulted as to at what age is it safe to decide that the child will not menstruate. If the decision is that the child will not menstruate, then the we assume that the child is a male with a vagina ending blindly. This was not an issue that could be resolved in those days by an operation; they were unable to perform such an operation, as opposed to a simple operation on the scrotum to check for testes that was available in those days. Therefore, the teenager would be classified as a male according to halacha. The halacha as it applies to our times is, that even if the child is born with a sealed vaginal opening that leads into a uterus, and the child's appearance is not suspect of having female genitalia; nevertheless, since the halacha accepts an operation to determine if there are testes then other invasive methods are accepted to determine if there is a uterus.

5. The sex of a child is determined by what he was at birth. If a woman undergoes a hysterectomy, according to halacha she remains a female. If a man undergoes a castration, according to halacha he remains a male. There is a significant amount of males with somewhat enlarged breasts and a feminine voice, and a significant amount of females with breasts that appear as male and a masculine voice. No where is it mentioned in halacha that such cases cause us to question their sex status. Therefore, plastic surgery and drug treatment does not alter the person's sex according to halacha, and an androgenous at birth remains so the rest of his life. Furthermore, just as an androgenous is required to be circumcised because of his questionable male status, so is it forbidden to castrate him, even if they cannot grow the phallus. According to the Chasam Sofer it is a definite Biblical prohibition to castrate an androgenous since his male organ or genital is not in question; it is definitely halachikly a male organ. The same halacha applies according to Tosofos and the Rosh who are of the opinion that an androgenous is a male. If there is a reasonable chance that he will develop testicular malignant tumors (as will be explained), they usually would only need to remove the testes; but they could grow the phallus-scrotum first and then remove the testes. However, with true hermaphrodites, gonadal malignancy is rare.

In certain circumstances it may be permitted to perform a hysterectomy since it is a questionable Rabbinical prohibition. If they need to stop negative hormonal production that will make him appear as a female, it is sufficient to render the ovaries dormant by taking drugs, injecting into them chemicals, or severing them from the uterus using minimum invasive procedures. However, it is medically preferable to remove the dormant ovaries from the body because dead organs that remain in the body may become malignant.

Pertaining to pseudo hermaphrodites, the known percentage of risk of gonadal malignancy is rare for Herni uteri inguinalis (cryptorchid male pseudo hermaphrodite), and is small for, A) testicular feminization syndrome, B) dysgenetic testes, C) mixed gonadal dysgenesis, D) pure gonadal dysgenesis XY type. The actual percent of risk depends on many factors which become more important to consider when we are dealing with transgressing a Biblical commandment. We must consider the type of pseudo hermaphrodism, if any size tumor is noticed, and if the child is monitored by frequent checkups and then when it is caught in time they remove the testes, is there still a percentage of danger to his life, plus other factors must be considered in the percentage of risk. The situation must be studied by several experts and a competent Posek must decide. If the risk factor is one percent they may be required to remove the gonads, if the risk factor is a half percent they may not be permitted.

6. The tumtum discussed in the halacha was a person who had an opening that appeared as a vagina and a phallus without palpable testes. As a child it could be male or female or an androgenous. When the child matures and does not menstruate, the odds are that it is a male with undescended testes because the vast majority of women with a uterus menstruate, and the chance of being an androgenous is extremely rare. If it does menstruate, then the odds are that it is a female and not an androgenous, as explained.

In the first case of a tumtum where the person does not menstruate, the halacha regards it as a question that can be clarified through an operation to see if there are testes, and therefore we do not go according to the majority cases that he is a male. In this case we must differentiate between the unknown status of a tumtum and other halachik rulings pertaining to doubtful cases. When there is only a question regarding a mitzvah we do not regard the ability to operate on someone as a question that can be clarified, and we do not require such clarification; and we invoke the rule of "ruling according the majority." With the case of a tumtum, it is a question of a lifetime of performing mitzvahs, which mitzvah must he do and which he may not do. If accidentally the scrotum is torn and they do not find testes and he is then regarded as a female, then what would be of his marriage to a female? Furthermore, since the person was born with physical abnormalities of the genitalia, they suspect the presence of other abnormalities, such as a womb that does not menstruate, or an enlarged clitoris where she urinates through it, or an androgenous. Therefore, the Sages ruled that the status of a tumtum that does not menstruate, or that urinates through what appears as a phallus, can be clarified, and if he wishes to live a normal life he should have the operation performed. We do not suspect him of being an androgenous because being an androgenous is so rare that we do not pose this question in our mind unless there is positive evidence of female genitals and strong evidence of the presence of male genitals as will be explained. The appearance of blood from the vagina that may not be due to menstruation is not considered strong evidence of the presence of a womb.

Regarding the second case, when she menstruates, she would no longer be considered a tumtum since there would not be a doubt in our minds that she is female because the chance of being an androgenous is extremely rare. If the person also urinates through the phallus, then we suspect that the person has testicles and is an androgenous. Therefore, the person is either female or an androgenous which results in that the person's male or female status is in question and that he is a tumtum.

7. According to halacha a tumtum is required to perform mitzvahs but the tumtum cannot blow Shofer for another tumtum because perhaps the one blowing the Shofer is a female and the one hearing it is a male. With our advanced medical techniques we can see if there are male or female genitalia, therefore today there is no status of a tumtum. We cannot define a tumtum to be a person who definitely does not have either male or female organs, because then it would be neither male nor female but a new breed appearing outwardly human but it would not be required to perform mitzvahs. I have not found such a case reported in medical books.

8. As far as marriage is concerned today, relating to a tumtum, there is no halachik tumtum today, because today we can clarify the doubt if the child is male or female. Furthermore, even if a tumtum or an androgenous is impotent and a "seris chamah" (most of the time due to defective testes), he is permitted to mary because the cause was due to natural causes and not due to an accident. Nevertheless, when pursuing a partner the potential partner must be made aware of the situation beforehand. This requires a medical checkup that includes the feasibility of producing children either naturally or through the IVF method using the husbands sperm and the wife's egg.

There is a halachik controversy if an androgenous can marry a woman according to those who hold that his status is questionable, because if the androgenous is female she cannot marry another female, and lesbianism is prohibited. The Rambam (Maimonides) is of the opinion that the androgenous may mary because if he is male then it is a marriage, and since they are living as man and wife there is no lesbian relationship. There is another opinion (Tosofos and the Rosh) that is brought down in the "Shulchan Aruch" that holds that an androgenous is a male because a female is the absence of a male, but when the person has the male organ he is a male and the female organ is superfluous. The Nodah B'Yehudah permits the marriage without reciting the marriage ceremony blessings. Therefore, there is a basis for a major "posek" to permit the marriage of an androgenous to a female, depending on the circumstances. Relying on the opinion of the Tosofos and the Rosh is a basis to permit an androgenous to be brought up as a male although the Rambam and Shulchan Aruch are of the opinion that due to the persons questionable status, the person must dress neutrally, not specifically as a man and not specifically as a woman, and likewise with the persons hair style. This is also a basis to permit the couple to recite the marriage ceremony blessings if they would be embarrassed to perform the wedding ceremony without reciting them.

There are male pseudo-hermaphrodites that outwardly appear as female, especially the "testicular feminization syndrome", and they are often at birth erroneously entered as a female. Therefore, to avoid a tragedy, if a girl does not menstruate she should also be tested for pseudo-hermaphroditism. The medical books state that these types of male pseudo-hermaphrodites should be raised as girls. This is contrary to the halacha, and they must be raised as a male and undergo plastic surgery if it can help. According to the halacha they are permitted to marry a jewish women who is willing to marry him under these circumstances, and a urologist can fit him with an artificial male limb.

If an infant was born a conjoined twin who is single in upper body and double in lower body and one lower body part has male genitalia and the other has female genitalia leading into a uterus, if the person is considered one individual and not two, then is the person an androgenous?

We must first draw guidelines when a conjoined twin is one person and when is it considered two persons. It is considered two persons if each one has a full complement of vital body parts so that if they were separated each one could continue living on his own. This rule includes the cases even when there lacks the surgical skills or technology to separate them. It would be prohibited to separate them if they must sacrifice one of the twins life to save the other. If there is only one full complement of vital body parts then the conjoined twin is one person and any unwanted body parts may be removed for reasons of either health or in order that he may appear as a normal human being, so long as he does not endanger his life with the procedure.

Conjoined twins are formed by a monozygotic (single fertilized) ovum, therefore, they would be of the same sex and have an identical genetic constitution. There are three general forms of conjoined twins. (1) Twins that are single in the lower body and are double in the upper body. (2) Twins that are single in the upper body and are double in the lower body. (3) Twins that are united at the midpoint of the body. Hermaphrodism is found among infants formed through monozygotic ovum, therefore, it is conceivable that a, terata- anadidyma conjoined twin, can also be born a true hermaphrodite where one lower body part has male genitalia and the other has female genitalia leading into a uterus, and being that he is one person he is an androgenous. In this situation there is no value to, and is consequently not permitted to, grow him as a male unless the excess body parts can be removed without endangering his life, in order to grow him as a normal male.

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