At the end of June 2020, the Albanian Ministry of Health approved a protocol that stops parents and medical professionals from enforcing surgical intervention on intersex babies.
Prior to this protocol, it was left to parents to decide on whether an intervention should take place, and what sex the in fact would be assigned. Now, this can no longer happen and surgical intervention can only take place if it is deemed necessary for health reasons.
If parents do not follow the protocol and guidance of a doctor, the Child Protection Unit will be informed. If doctors deliberately do not follow the protocol, they can risk losing their license and facing criminal charges.
While this is good news for Albanian intersex children, it raises a number of questions about implementation, penalties, and the attitudes that prevail in a society that enforces strict gender roles and stereotypes.
I spoke with Anisa Metalla from the Tirana Legal Aid Society, and the Ambassador of the Kingdom of the Netherlands Guusje Korthals Altes, both of which have been integral in Albania taking this historic, and important step.
What is intersex?
“Intersex‘ is a term used to describe bodies that fall outside of the conventional male/female binary. Generally, it refers to an individual who is born with reproductive anatomy that cannot be considered solely “female” or “male”.
Being intersex is a naturally occurring variation in humans and it is not a deformity, defect, or medical condition. In cases where there are no other health issues, the child does not need medical interventions or hormone therapy to “correct” the situation.
Being intersex is more common than many realise. There are no official statistics available for Albania, mainly because Albanian doctors do not categorise intersex. Anisa said that they go by the global rate which is around 1.7% of all live births. This makes being intersex about as common as having naturally red hair.
Children in Albania that are born as intersex are usually categorised as being born with congenital defects or abnormalities. There is not much awareness on intersex and no official categorisation of children that are born this way. Those that are born as intersex are either operated on immediately as an infant, or await surgery when they are a bit older, but still a child.
The issue arises when other medical issues present themselves. Some intersex children are born with other medical issues. Sometimes it is assumed that these issues are related to being intersex and surgeries are performed.
Because of this assumption that it is linked to other medical issues, this has led to a situation where even those that do not present other medical issues are operated on needlessly. Performing the surgery without any basis can mean pain and discomfort, psychological issues, and a lifetime of being on hormone therapy.
“There are three kinds of situations we see; those that are intersex with no issues, intersex that don’t need surgery but that need medication, and intersex that need surgery,” Anisa said.
Due to confusion about intersex and other conditions that can present themselves, doctors often think that surgery is the way to solve it. But this is not always the case.
An intersex child with no other medical issues can live a normal and healthy life. They may choose to remain as intersex, they may decide to undergo surgery to assign a gender later in life, or they may decide to align with gender without undergoing any medical procedures or treatments.
Under Albanian law, a child can only be registered as male or female, there is no third option, nor is there a process whereby the gender can be changed later in life. In some cases, this can make registering a birth impossible unless the child undergoes surgery as an infant, and is assigned a gender.
It was cases like this that Made Tirana Legal Aid Society, and Anisa aware of the situation.
“We were being referred to these cases and it was a surprise as it was the first time we were aware of this issue. We investigated, found more cases, and understood how the situation was being approached. We understood that this wasn’t just a civil registry issue, but rather it was indicative of a bigger problem. The fundamental rights of these people were being infringed by the inexistence of dedicated legislation that addressed their situation.”
From that moment on, they began to work with contacts in the medical field, Child Protection, and social workers and started creating a system of identifying cases
“It is not easy to identify these cases,” she said. “There is a lot of stigmas. We usually find out from doctors because of other medical issues the child might have.”
Anisa tells me that the TLAS has recently won a court case, allowing an intersex individual to change their assigned gender marker on their birth certificate. Another case is in the courts and she is helpful that this will set a precedent for changes in legislation.
“We are working to change the civil law as well. We believe the time has come to allow the changing of gender and to offer a third option on official documents.”
I asked Anisa whether she has concerns about the protocol being ignored and forced surgeries going underground. She told me that while the protocol is just a guide, not a law, it is binding to medical professionals. If there is any indication that a doctor is not following the law, they are subject to charges of medical malpractice which are provided for in the criminal law. There are also administrative sanctions that can be applied in these situations.
She is quick to note that this doesn’t mean every doctor who doesn’t follow the protocol will be arrested and lose their license. Implementing something like this requires time, training, and dialogue. Therefore, any violations will be assessed on a case-by-case basis- at least at first.
Consent and Body Autonomy
One of the main issues that arise as a result of intersex children and the protocol is that of consent and body autonomy. Anisa explains that they have tried to push and educate on the matter of informed consent.
In cases where surgery is deemed necessary, the protocol will oblige the doctor to notify the Child Protection Unit as there are cases where parents are forcing a particular gender on a child. In these cases, it is deemed they are not acting in the interests of the child and are violating their autonomy and human rights. In fact, the UN Human Rights Commissioner has condemned forced gender surgical interventions as torture and inhuman treatment.
If parents demand surgery that is not medically necessary, the authorities will be informed and steps can be taken to protect the child.
Unfortunately, there are many struggles when it comes to getting families to accept a third gender option.
“We face a lot of problems with some families as they just don’t want to consider a third option. They cannot accept it- not because they are bad people, but because they were raised to believe in only two genders,” Anisa said.
This has also been an obstacle with some medical professionals. When a doctor has spent their professional life studying male and female sex and gender, to consider that intersex is a thing and not an abnormality, often contradicts what they have learned.
She goes on to explain how this mentality is inherited and cannot be changed overnight. Anisa is firm however on the fact that the need for changes to the law should not wait for society to evolve. The law should acknowledge the problems of society and address them, then society should change.
The Embassy of the Kingdom of the Netherlands to Albania has been instrumental in providing support for this matter. Ambassador Guusje Korthals Altes told me that the embassy, in fact, signed the project with TLAS on the same day that the Netherlands issued their first gender-neutral passport.
She noted that the Albanian authorities were receptive to the initiative and offered the cooperation of all relevant structures. Two years later, the medical protocol for doctors was adopted, marking impressive progress on the matter.
With the paperwork now done and dusted, the challenge is to raise awareness in society.
Ambassador Korthals Altes said; “Raising awareness is an integral component. TLAS have done an excellent job but we also have to commend the work done by the Ministry and judicial institutions. We are optimistic that the project will conclude with even more results.”
In an effort to increase awareness, a documentary called “Born Intersex” was produced. In Albanian but with English subtitles, it provides information and understanding about children that are born intersex, and on the dilemmas, their parents and families go through. Confronting prejudice and discrimination is big focus of the video, as these are some of the toughest challenges intersex individuals will have to overcome.
TLAS have also embarked on a social media and media campaign. Through the documentary, interviews and written articles, they are hoping to create awareness of this issue in Albanian society. Anisa tells me that generally there is a complete lack of information on the topic and that some media is only interested in sensationalising it, without going to the root of the matter.
“It’s a complex and delicate situation. You cannot address these topics with sensationalism as you are dealing with people’s lives. We should be careful to deliver messages in the right way,” she said.
Acceptance and Progression
The acceptance of intersex in Albanian society will take some time. In a country where infants are assigned their gender and this gender goes on to then define their path in life, behaviour, and even future, a third gender poses an issue.
Imposing gender roles and stereotypes on a child is harmful enough for a non-intersex child. Dressing a child in pink/blue, only allowing them to play with “girls” or “boys” toys, and the implication that women are weak, subservient and need protection, while men are strong, macho, and protectors are commonly applied to children both in Albania and other countries. Studies have shown that this can lead to depression, exposure to and tolerance of domestic violence, and leaving school early.
But imagine the damage that can be inflicted on an intersex child when they are forced to align with sex, gender and stereotypes that they cannot identify with.
“This is a human rights issue,” Anisa says. “The right to life, the right to have a name, the right to be registered immediately after birth, the right to health and bodily autonomy.”