For many Americans, birth certificates aren't just an important identity marker, they are an entry point into many parts of life. But for trans and nonbinary people, birth certificates can be a hurdle - a document that invalidates their identity - unless they amend it.
Now, the American Medical Association, the country's largest association of physicians, has taken a significant step in easing that burden. In a June report, the AMA's LGBTQ advisory committee advised the organization to push for removing sex labels from the public part of the birth certificate.
Assigning either a "male" or "female" sex at birth, the authors wrote, "fails to recognize the medical spectrum of gender identity."
"Participation by the medical profession and the government in assigning sex is often used as evidence supporting this binary view" of gender, the report continued. Not only does that stifle a person's ability to express and identify themselves, it can lead to "marginalization and minoritization."
For nearly two months, the recommendation went largely unrecognized by supporters and detractors alike, but it resurfaced recently after the popular medical website WebMD shared an article about the decision on its social media accounts.
The article went viral, thanks in part to right-wing publications and conservative personalities, who pushed back against the AMA's recommendation. Among them was former United Nations ambassador Nikki Haley, who tweeted that it was "the most ridiculous thing I have ever heard."
Rep. Mary Miller, R-Ill., also responded, tweeting, "Is this 'The Science' we are supposed to be trusting?"
For LGBTQ advocates, the AMA recommendation is a significant step in acknowledging people whose identities don't fit squarely into gender and sex binaries. But some cautioned against celebrating the news too soon.
"People are still really committed to a binary sex model," said V. Varun Chaudhry, an assistant professor of women's, gender and sexuality studies at Brandeis University, whose pronouns are he/they.
This includes conservative lawmakers across the country who have moved to ban trans and nonbinary children from receiving health care and participating in youth sports.
"The recommendation may say sex is not important for something like a birth certificate, but if people are still committed to a binary sex model, they find other ways to determine those things," said Chaudhry.
Birth certificates are not public documents, but they play an important role in affirming a person's identity and allowing them to work, travel or start a family. They are required to get passports or driver's licenses, and for registering for school, adoptions, employment or marriage.
This is a problem for nonbinary or trans people, whose gender identities don't match the sex assigned on their birth certificate. According to a study released in June by the Williams Institute at the UCLA School of Law, about 1.2 million nonbinary LGBTQ adults live in the United States.
Most states now allow for people to amend the sex designation on their birth certificate to reflect their gender identity, but the process can vary greatly from state to state. Fifteen states allow people to use a gender-neutral "X" when a baby is born.
Moving away from sex designations, as the AMA recommends, is "deeply exciting" said Chaudhry.
Even if amending a birth certificate isn't costly, it can be time-consuming, and often requires institutional knowledge - being familiar with the process or having someone who can guide you through it.
Removing assigned sex from the public portion of the birth certificate doesn't just acknowledge the "diversity of bodies" that exist on the gender and sex spectrum, said Chaudhry; it could also remove a major barrier gender-nonconforming people confront when trying to participate in society.
Chaudhry points specifically to children growing up now whose identities don't align with their birth certificate.
It would be "one less hurdle that those future children will have to deal with. And that's pretty exciting," they said.
But there are still lots of variables to consider in whether medical providers will adopt the recommendation, Chaudhry noted, predicting that there will be disparities in how the guidance will be applied. It also doesn't prevent officials from enforcing gender binaries in other ways.
Chaudhry pointed to recent state bills restricting how transgender youth participate in sports. Lawmakers in Florida, for example, proposed that children undergo a "routine sports physical examination," in which their genitals and testosterone levels would be inspected before they could compete. (This requirement was removed from the final version of the bill, which was signed into law in June.)
The AMA recommendation also falls well short of what intersex people have been lobbying for years, said Kimberly Zieselman, who leads the intersex youth advocacy group interACT.
Intersex individuals are born with sex characteristics associated with males and females (genitals, internal reproductive organs, hormones or chromosomes). When a child is born intersex, doctors might perform medically unnecessary surgeries so that they fit more squarely into a "male" or "female" sex category. Often, children are under the age of 2 when they receive these surgeries, and cannot consent to them, said Zieselman
The AMA recommendation is helpful in reinforcing the idea that sex and gender are not as "black-and-white or cut-and-dried as we once thought," said Zieselman. But she and others have been lobbying the AMA for years to publish guidelines barring the surgeries outright: "This isn't even close to the number one issue for the intersex community."
While striking sex assignment from a birth certificate might relieve parents of the pressure to pick a box when their child is born, the core issue of bodily autonomy still hasn't been addressed, said Zieselman.
"It's a step in the right direction, but it's long, long overdue for them to be taking other steps."
The AMA did not respond to a request for comment.
Still, Kimberly Inez McGuire, executive director of Urge, an advocacy group focused on reproductive and gender issues, says recommendations like the AMA's are "essential" for moving the needle forward.
"Young people are creating a world with such an expansive concept of gender," said Inez McGuire. "They're articulating gender identities that we don't even have the language for yet."
Inez McGuire doubts the recommendation will have much impact in socially conservative areas, where people may simply not pay attention. She's particularly concerned about young people of color who are queer, trans and nonbinary.
"A birth certificate without a [sex] marker means something, but it doesn't mean as much as creating a world in which they can be safe and live with dignity," she said. Still, she said, it's a validating move from an influential group.
"It's so important to recognize any win, of any size, because we know that any win for gender justice is incredibly hard-fought."