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When 32-year-old Alterina Hofan was jailed early this month, the curious case of a girl supposedly growing up to become a man attracted nationwide interest.

Alterina, who is married to a woman, is currently on trial at South Jakarta District Court for allegedly falsifying his identity.

Prosecutors say Alterina is in fact a female who swapped gender status from female to male in 2006, while the defense claims he has always been a man but that his genitalia developed late because of Klinefelter syndrome.

Rare as the story sounds, Alterina is far from the only example. In the Banyumas district of Central Java, census takers were recently confounded when 15-year-old Maemunah, identified as a girl in the birth certificate, told them he was now a boy with the requisite sexual organs to prove it.

Tests have been recommended for Maemunah, to determine whether he has the same condition Alterina claims to have.

Klinefelter syndrome, according to Indra G Mansur, an andrologist from University of Indonesia, is a chromosomal disorder affecting males that causes them to look like females.

“Someone who suffers from Klinefelter syndrome is still a man. He is born a man, but a problem with his chromosomes caused his manhood to develop improperly,” Indra said.

A man should have an XY chromosomal makeup, but those with the syndrome have an extra X chromosome, which results in a low testosterone level and resulting gender confusion.

“The low testosterone causes problems that can include a micro penis, decreased gonad function or small testicles,” Indra said, adding that people living with Klinefelter also tend to be shorter and have smoother skin. Many of them don’t have facial hair and even grow breasts.

Indra says about one in 500 boys is born with the disorder. Other sources say one in 500 have an extra X chromosome, but that the syndrome manifests in only of 1,000 male births.

Indra said the biggest medical problems for Klinefelter syndrome sufferers were a low sexual drive and malfunctioning reproduction system. Most men living with this condition are unable to have children.

“There are only very few men who can have children when they have this condition; the chance is very slim,” he said.

He added while the low sex drive could be fixed with regular hormone therapy, the infertility often remained incurable. The inability to reproduce, Indra said, often triggered mental pressure.

There are additional psychological impacts. The syndrome is not usually detected until the sufferer reaches puberty, at which time changes in the body occur. Some parents, therefore, believing their child is female, raise them as such, which “often causes great frustration because they feel like a man but are forced to live as a woman,” he said.

Indra said it was very important for the parents to recognize the symptoms of Klinefelter before the children grew up in confusion.

“Monitoring the growth of your children and paying attention to their genital development is very important, when your child is 9 or 10, find out whether their genitals are developing properly,” he said.

“Don’t be selfish; if the child’s sexuality is not what the parents thought it was and they want to live differently, the parents should let them,” he said.

Surabaya-based psychiatrist Yuniar Soenarko said sexual ambiguity could lead to mental health issues ranging from depression to suicidal tendencies.

“If somebody has to live under a certain sexual assignment, they might comply out of respect to their parents, but it’s going to be a lifetime stressor,” she said.

Yuniar said psychological therapy would be needed in order for the entire family to embrace the change, if the child later decided to live as a man instead of a woman.