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He wanted to "[tell] epic events in the third person and psychosexual events in the first person".

The siblings are orphans; their parents are victims of the ongoing Greco-Turkish War.According to scholars, the novel's main themes are nature versus nurture, rebirth, and the differing experiences of what society constructs as polar opposites—such as those found between men and women.It discusses the pursuit of the American Dream and explores gender identity.Eugenides sets Middlesex in the 20th century and interjects historical elements, such as the Balkan Wars, the Nation of Islam, the 1967 Detroit riot, and the Watergate scandal in the story.The accounts of Cal's family history start in 1922.Its characters and events are loosely based on aspects of Eugenides' life and observations of his Greek heritage.

It is not an autobiography; unlike the protagonist, Eugenides is not intersex.

His grandfather, Eleutherios "Lefty" Stephanides, lives in Bithynios, a village in Asia Minor.

Eugenides places the village high on the slope of Mount Olympos, above the city of Bursa, and describes incestuous marriages between cousins as a quietly accepted custom among the villagers.

The author decided to write Middlesex after he read the 1980 memoir Herculine Barbin and was dissatisfied with its discussion of intersex anatomy and emotions.

Primarily a coming-of-age story (Bildungsroman) and family saga, the novel chronicles the effect of a mutated gene on three generations of a Greek family, causing momentous changes in the protagonist's life.

After discovering in his library research 5-alpha-reductase deficiency, an autosomal recessive condition manifested primarily in inbred, isolated population groups, his perception of the novel significantly changed.