זכר - ולא טומטום ואנדרוגינוס
“A male” - and not a tumtum or androgyne.
In addition to male and female, the Talmud describes two other gender categories: tumtum and androgynous. The tumtum is a person whose genitalia are somehow hidden or covered, so that it is not known if they are male or female. In contrast, the genitalia of the androgyne (an ancient Greek word formed from ἀνδρός andros - “man” and γυνή gune, - “woman”) are in plain sight. It just isn’t clear whether they are male or female organs. The two are mentioned on at least twenty-three pages of the Babylonian Talmud, and in no fewer than nine halachot in the Jerusalem Talmud, so let’s figure out what, from a medical perspective, they are.
There is no ambiguity about the gender of a tumtum. We just need to get a glimpse of the genitals. (The eleventh century dictionary known as the Aruch connects the word tumtum with the word atum (אטום), meaning sealed.) The problem is that the genitals are covered by what is usually described as skin. Once this cover is surgically opened, the gender will be revealed. In fact according to Rav Ammi (Yevamot 64a), both Abraham and Sarah were each a tumtum. Yes, you read that correctly. Each had genitalia that were hidden. Rav Ammi suggests this as an explanation as to why the couple were infertile for so many years. Once the covering had been removed the couple could then procreate as normal, and along came Isaac.
אמר רבי אמי אברהם ושרה טומטמין היו שנאמר (ישעיהו נא, א) הביטו אל צור חוצבתם ואל מקבת בור נוקרתם וכתיב (ישעיהו נא, ב) הביטו אל אברהם אביכם ואל שרה תחוללכם
Rabbi Ami said: Abraham and Sarah were originally tumtumin, as it is stated: “Look to the rock from where you were hewn, and to the hole of the pit from where you were dug” (Isaiah 51:1), and it is written in the next verse: “Look to Abraham your father and to Sarah who bore you” (Isaiah 51:2),
חוצבתם - נעשה לו זכרות: “Hewn”: He was made into a male
נוקרתם - נעשה לה נקבות : “From where you were dug” which made here a female
Urologists have yet to identify this syndrome.
In 1797 the physician James Parsons, published a book which he dedicated to the Royal Society of London, of which he was a Fellow: “ A Mechanical and Critical Inquiry into the Nature of Hermaphrodites.” Parsons noted that the Romans “had laws made against their Androgyni [which were] remarkably severe; for whensoever a child was reputed one of these, his sentence was to be shut up in a chest alive, and thrown into the sea…
Parsons was not only well-read in Roman law; he cited the fourth chapter of the Mishnah in Bikkurim, which contains a list of the ways in which the androgne sometimes resembles a man, and sometimes a woman:
ביכורים פרק ד
כֵּיצַד שָׁוֶה לַאֲנָשִׁים: מְטַמֵּא בְּלֹבֶן כַּאֲנָשִׁים, וְזוֹקֵק לְיִבּוּם כַּאֲנָשִׁים, וּמִתְעַטֵּף וּמִסְתַּפֵּר כַּאֲנָשִׁים, וְנוֹשֵׂא אֲבָל לֹא נִשָּׂא כַּאֲנָשִׁים, וְחַיָּב בְּכָל מִצְוֹת הָאֲמוּרוֹת בַּתּוֹרָה כַּאֲנָשִׁים:
In what ways is the andogyne like men?…He dresses like men; He can take a wife but not be taken as a wife, like men. [When he is born] his mother counts the blood of purification, like men; He may not be secluded with women, like men. He is not maintained with the daughters, like men…And he must perform all the commandments of the Torah, like men.
כֵּיצַד שָׁוֶה לַנָּשִׁים: מְטַמֵּא בְּאֹדֶם כַּנָּשִׁים, וְאֵינוֹ מִתְיַחֵד עִם הָאֲנָשִׁים כַּנָּשִׁים, וְאֵינוֹ עוֹבֵר עַל "בַּל תַּקִּיף" וְלֹא עַל "בַּל תַּשְׁחִית" וְלֹא עַל "בַּל תְּטַמֵּא לַמֵּתִים" כַּנָּשִׁים, וּפָסוּל מִן הָעֵדוּת כַּנָּשִׁים, וְאֵינוֹ נִבְעַל בַּעֲבֵירָה כַּנָּשִׁים, וְנִפְסַל מִן הַכְּהֻנָּה כַּנָּשִׁים:
And in what ways is he like women?… he must not be secluded with men, like women; And he doesn’t make his brother’s wife liable for yibbum (levirate marriage); And he does not share [in the inheritance] with the sons, like women; And he cannot eat most holy sacrifices, like women…. he is disqualified from being a witness, like women…
The Androgyne & Congenital Adrenal Hyperplasia
One of the most common causes of androgyny is congenital adrenal hyperplasia (CAH), caused by a mutation in the CYP21 gene. The adrenal glands, which sits atop the kidneys, are where the action takes place. They produce androgens, which are then converted into the potent sex hormone testosterone. In most (95%) cases of CAH, there is a deficiency of the enzyme 21-hydroxylase. As a result, the adrenal glands produce excessive amounts of the virilizing hormone androgen. (It also causes severe salt wasting, which can be very dangerous, but we are not getting into that now. And there are different severities of the syndrome, but you’ve got a limited attention span, so we will keep it simple.) This excessive androgen production does very little in (XY) males; their genitalia look normal. But in genetic (XX) baby girls the androgens affect the external genitalia and they may become ambiguous: the clitoris becomes enlarged, sometimes to the degree that it resembles a penis. In very severe cases the baby girl has what appears to be an empty scrotum, and may be raised as a boy, all the while being an XX girl with CAH.
Today all newborns are screened for 21-hydroxylase. The deficiency can be treated with hormone replacement, and the genital ambiguity may be corrected, although this latter intervention has, over the last decades, become very controversial.
The androgyne and the hermaphrodite
The Soncino Talmud identifies the androgyne as a hermaphrodite, that is, a person with both male and female genitalia. So does Goldschmidt’s German translation (“der zwitter”). Cases of true hermaphroditism are extremely rare, and there are only a few scattered case reports in the medical literature. (You can read one reported from Sheba Hospital in Tel Aviv here.) Rather than there being two sets, in these cases the genitalia are ambiguous, and although they have both ovarian and testicular tissue the scrotum does not always contain testes.
Alice Dreger, formerly a Professor of Medical Humanities and Bioethics at Northwestern University, (it’s complicated) wrote a terrific (and controversial) book that tackles some of the issues facing intersex people - those who were once called hermaphrodites. In the past, when faced these difficult cases of intersex or ambiguous genders, clinicians focused on what she calls a “gonadal division.” (Since biopsies and genetic sequencing were not available to the rabbis of the Talmud, they, like clinicians, focused on this gonadal division, for what else could they do?) But, she notes,
a system that emphasizes gonadal anatomy above all else suffers from two major deficits. First, it is scientifically questionable, because it relies on the anatomy of the gonads (functioning or not) more than any other considerations. Second, it provides little clinical help, often confusing and harming the patient, and sometimes also the physician.
Instead, she advocates for a description based on etiology and the patient’s needs. “Such an approach would have the salutary effects of improving patient and physician understanding and reducing the biases that are inherent in the use of the current language of 'hermaphroditism'.”
The many Shades of Gender
We are used to think that when an egg carrying an X chromosome meets a sperm carrying an X or Y chromosome, one of two things will happen: a genetic female (46XX) or a genetic male (46XY) with genitalia to match. But in fact it is way more complicated than that. We know that there are at least 14 genes involved in the process of sexual differentiation, and many more will likely be discovered. A mutation or malfunction of any of these has a dramatic effect on the process of gender differentiation. For example if there is a defect in the enzymes involved in producing testosterone, there may be ambiguous external genitalia; deficiency of the enzyme 5α-reductase results in variable degrees of under-masculinized external genitalia and genital ambiguity; individuals with partial androgen insensitivity syndrome may also have ambiguous genitalia, and there is no consensus regarding an optimal sex of rearing them; and newborns with congenital adrenal hyperplasia, may have male appearing genitalia while all the time being 46XX.
We have previously noted the strange effects of yet gene discovered in the 1980s. This sex-determining gene on a tiny bit of the male Y chromosome is called the sry gene. That gene tells the body to develop into a male or female appearing body. Sometimes the sry gene sneaks off of the Y gene and makes its way into the DNA of an XX female. As a result, she will develop male anatomy while genetically remaining an XX female. (Please read that sentence again, just to be sure you have understood it.) And sometimes the sry gene on an XY genetic male can mutate and not work. In that case, the genetic male appears to have the organs of a female, which is what occurs in Swyer syndrome. (You can hear more about the amazing sex-changing effects of sry in this fascinating podcast.)
And then there is the small community in the Dominican Republic where there have been a number of cases in which little girls grow a penis and turn into little boys. These observations were first reported to the scientific community in 1974, and are caused by a deficiency of the steroid 5α-reductase. Here is how the BBC explained what is going on when they reported about it in 2015.
When you are conceived you normally have a pair of X chromosomes if you are to become a girl and a set of XY chromosomes if you are destined to be male. For the first weeks of life in womb you are neither…Then, around eight weeks after conception, the sex hormones kick in. If you're genetically male the Y chromosome instructs your gonads to become testicles and sends testosterone to a structure called the tubercle, where it is converted into a more potent hormone called dihydro-testosterone. This in turn transforms the tubercle into a penis. If you're female and you don't make dihydro-testosterone then your tubercle becomes a clitoris…the reason [some genetic males] don't have male genitalia when they are born is because they are deficient in an enzyme called 5-alpha-reductase, which normally converts testosterone into dihydro-testosterone.
So the boys, despite having an XY chromosome, appear female when they are born. At puberty, like other boys, they get a second surge of testosterone. This time the body does respond and they sprout muscles, testes and a penis.
So gender identity is very complicated. James Parsons, that physician who wrote the book on hermaphrodites in 1797 tackled some of the difficult questions that were addressed in Mishnah Bikkurim: can a hermaphrodite get married? (yes, but to which gender varies by case); can they be a witness? (only if the “predominating sex” is male); can they be ordained as a minister? (no); The rabbis were puzzled as to the “true” gender of the androgyne, and so classified them as sometimes male, and sometimes female. It was the best they could do at the time, and Parsons, writing 1,500 years later did the same. Thanks to modern medicine we have learned why these intersex cases occur, but as a society we have still a long way to go to help make their lives easier.