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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.The novel contains many allusions to Greek mythology, including creatures such as the Minotaur, half-man and half-bull, and the Chimera, a monster composed of various animal parts.Narrator and protagonist Cal Stephanides (initially called "Callie") is an intersex man of Greek descent with 5-alpha-reductase deficiency, which causes him to have certain feminine traits.Middlesex is a Pulitzer Prize-winning novel by Jeffrey Eugenides published in 2002.The book is a bestseller, with more than four million copies sold since its publication.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.

Instead of trying to create a separate person, I tried to pretend that I had this [physical feature] and that I had lived through this as much as I could".

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.

The latter half of the novel, set in the late 20th century, focuses on Cal's experiences in his hometown of Detroit and his escape to San Francisco, where he comes to terms with his modified gender identity.

Entertainment Weekly, the Los Angeles Times, and The New York Times Book Review considered Middlesex one of the best books of 2002, and some scholars believed the novel should be considered for the title of Great American Novel.

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He intended Middlesex to be "the story [he] wasn't getting from the memoir".