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Sex, Gender, and Sexuality: It’s Complicated

When a baby is born, the obstetrician or midwife announces “It’s a boy” or “It’s a girl.” As toddlers, children learn to classify everyone as either boy or girl. When our firstborn was very young, we overheard her talking to herself as she grappled with the concept:

Let’s see… I’m a girl, and Kimberly [her baby sister] is a girl, and Mommy’s a girl… but Daddy’s not a girl… He’s a boy. [Pause followed by exasperated sigh] Cause he doesn’t know any better!

As with most things in science, the concept of boy versus girl is more complicated than it appears at first glance. It’s not a simple dichotomy. We humans like to classify everything into neat pigeonholes, but Nature’s inventiveness outsmarts us at every step.

Etymology and meaning of the word gender

Gender originally meant “kind.” The English word was derived from the Latin word “genus” via Old French. In common use, it came to denote masculinity and femininity. Its main application was in grammar, where words were classified as having masculine, feminine, or neuter gender. In 1926, Henry Fowler argued that it was a purely grammatical concept that should not be used in other spheres. In today’s dictionaries, one of the accepted definitions of gender is as a synonym for “sex.” The words are often used interchangeably, although the preferred usage is to use sex to refer to biological differences and gender to refer to social roles. (Which becomes problematic when you’re not sure if a given trait is determined by biology or culture.) The modern academic sense of gender was popularized by the feminist movement. As a result, scientists have sometimes chosen to extend the use of the word to biological differences in an attempt to show their sympathy with feminist goals. Some have even argued that “sex” is a just another social construct.

Many factors combine to determine sex and gender, and not one of them is simple black and white

Chromosomal sex. Males are XY, females are XX. But there are individuals who are XXY (Klinefelter syndrome), XYY, a mosaic of XX and XY cells, XXX, XO (Turner’s syndrome), and various other accidents of cell division gone awry. How are these anomalies to be categorized? How do they affect behavior and gender role?

Intrauterine hormonal effects. In congenital adrenal hyperplasia (CAH), a female fetus (XX) is exposed to high levels of adrenal hormone and is born looking like a boy. In androgen insensitivity syndrome (AIS), a male fetus is unresponsive to androgens and is born looking like a girl. In 5-alpha reductase deficiency (5-ARD), androgen levels are normal but an enzyme necessary for male genital development is missing; these individuals may appear to be female and may be raised as girls, but at puberty they develop masculine secondary sex characteristics.

Internal sexual organs. Are there testes or ovaries? Both? Is there an ovotestis?

External sexual characteristics. Is there a penis? A vagina? Both? Neither? An enlarged clitoris? Hypospadias? In concealed penis, a penis is normally developed but hidden from view under fat in varying locations. In 1 in 10 million male births, there is aphallia: a failure of the penis to develop in an otherwise normal XY fetus.

The sex of rearing. Was the individual raised as a boy or a girl? Even this isn’t so straightforward. In the case of 5-ARD, if it is known they will develop the appearance of males at puberty, rearing may be ambiguous. John Money’s famous patient, a boy whose penis was amputated in a circumcision accident at the age of 8 months, was raised as a boy for 17 months before he was re-assigned to a female gender and raised as a girl. (That didn’t work out too well!)

Sexual desire. Is the individual attracted to men, women, both, neither? To children, animals, or fetish objects like shoes or cars? Is suffering or humiliation a turn-on? Are non-consenting partners preferred? If you think you know about the wondrous variety of sexual interests, check out this list of paraphilias and you may discover a new one. I was intrigued to discover plushophilia, the sexual attraction to stuffed toy animals.

Sexual behavior. Does the individual act on those sexual desires or suppress them?

Social gender. Does the individual play the role expected of a male or female in society? All the time, or part of the time? Does he/she sometimes dress in clothes of the opposite sex, publicly or in secret? Do friends and associates perceive the individual as male or female?

  • The bathroom test: does the individual go through the door marked “men” or “women”? Do the other patrons object?
  • The language test. Does the person refer to himself/herself as a man or woman, Mr. or Ms.? Does he/she prefer others address him/her as “he” or “she”? (In the case of androgynous uncertainty, it’s OK to ask which they prefer.)

Legal gender. My former secretary Doris’ birth certificate mistakenly listed her as male; she only succeeded in getting the error corrected after she had become a grandmother. Gender can be legally changed after sex-change surgery. The laws may make different provisions for males and females (draft registration, maternity leave), and may prohibit same-sex marriage. Pension systems often have different retirement ages for men and women.

Gender dysphoria. Does the individual feel he/she was assigned the “wrong” sex? Is it a mild discomfort or an overwhelming conviction? Does it lead to changes in behavior?

Surgically altered external genitalia. What do we call someone who has undergone sex change surgery? What do we call someone who wants the surgery and is waiting for it? At what point in the long sex-change process can the sex be assumed to actually have changed?

Are there parallels in animals?

There are examples of intersex and sex chromosome abnormalities in animals. Homosexual behaviors have now been reported in 1500 species of animals. In animals, particularly fish, there are examples of organisms that are born as a male and change sex to become a female, and vice versa. There are also bidirectional sex changers that have both male and female gonads and change sex according to social status. Animals have frequently been observed attempting copulation with animals of other species.

Sex is a spectrum on several axes

Science has not been able to categorically distinguish a male from a female. There’s no one simple test to determine whether an individual is a woman or a man. It’s not an either/or dichotomy, but a multidimensional spectrum on several axes, from the biological to the social to the psychological. And science has not conclusively shown which characteristics are biologically determined.  Nature and nurture interact and influence each other; it’s difficult to tease out the contributions of each. Each axis has its own continuum, with degrees of strength.  A person can fall at the male end of the spectrum on some axes and at the female end of the spectrum on others.

So what are we to do? Reject the very ideas of sex and gender and stop trying to classify people? Reject the dichotomy? Of course not! The binary classification is sufficient for most practical purposes and is very useful. In medicine, the knowledge that a patient is male or female helps to guide diagnosis and treatment. We know that men and women have different responses to medications and different incidences of various diseases.

It is enough to remember that male/female categories are arbitrary and not absolute. Science is not simple. We try to categorize, but nature is infinitely inventive.

 

 

Posted in: Science and Medicine

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21 thoughts on “Sex, Gender, and Sexuality: It’s Complicated

  1. nybgrus says:

    Excellent post Dr. Hall. And I’ll refrain from dragging the discussion to certain sociopolitical ramifications of this (particularly in this country) and rather just add to your story with a brief anecdote.

    Last year on my pediatrics rotation we had a morning report every day. At one of them the attending came in and did the usual – posed a clinical question and asked the group to work through every nuance of it. In this case he started out by saying:

    “You are in the delivery room and the mother delivers a baby. APGARs are 9 and 10. Otherwise no complications. You are the obstetrician and the parenst ask, ‘How’s my baby?’ How would you respond?”

    Seemed confusingly straightforward. We asked all the standard questions and each time the attending said that the baby was supremely healthy from every medical standpoint. But he still kept pressing us. “What do you say to the parents?” Finally we agreed: “You have a very healthy baby! Congratulations!” The attending asked, “A healthy baby what?” Aha! We had all neglected to ask the sex of the baby. So now we asked.

    He then hands us a few full color photographs taken of a baby delivered at our hospital just the previous day and asked us to make the determination. I think everyone can guess where this is going.

    The genitalia were completely ambiguous. We all argued over whether it was likely a girl or a boy. We then discussed how to actually determine it and what the complications could be (including CAH). But the questioned remained – what do we say to the eagerly waiting parents who are expecting – and want – to hear that they have a healthy baby girl or boy.

    The key principle the attending was trying to relate to us was that we should not commit to a sex/gender statement at that time, because that could lock the parents into something. We would have to stress that the baby was indeed healthy but that we would need to do a few further tests.

    So yes, while a useful and generally quite robust tool dichotomizing gender/sex does in fact fail in many ways.

  2. windriven says:

    Is the point to parse language so finely that no outlier is left unmentioned or to build a social fabric with a valued place place for everyone? The notion that every aberration needs to be warmly nestled in language where it does not naturally fit is inane and ultimately unproductive.

  3. rork says:

    Thanks for this. Some people seem unaware that there are a zillion unusual situations. Check OMIM. NR5A1 foul-ups are my favorite cause they figure into some adrenal disorders.

    I do find it a bit disappointing that there need to be legal definitions, and particularly as relates to marriage exceptional people do show that any such definitions have problems.

    I’ll grant that specific knowledge is important when doctoring, but I think I’d want non-medical examples to show it’s important in other situations. I see some convenience for many of us when shopping for clothes, but it’s not that important: We dichotomize them, but they live on a continuum. I’m not scared of the buttons being on the other side of the shirt, or if those sandals are marketed mainly to women, maybe that’s part of why I’m wanting my culture to be less 0/1.

    I do admit to being curious about other people’s genes and genitals and desires, but I try to fight it, telling myself that it is usually not my place to pry. But that leaves me almost no mechanism to indicate to the other person that I’m open-minded, since I never mention it.

  4. WilliamLawrenceUtridge says:

    Nature’s inventiveness outsmarts us at every step.

    I would call it “indifference to our taxonomies” :)

  5. superdave says:

    Before the theory of relativity, astronomers using the best tools of the day could calculate many celestial events with extremely good accuracy, but some outliers persisted. We needed an entirely new theory to explain these outliers and show that they are actually not outliers at all, they just needed a more sophisticated understanding of physics to fully grasp. I feel like this is what has happened to modern theories of gender, and its a great thing that we are able to learn new things about all of human nature from a few less common but totally normal people.

  6. Lost Marble says:

    The only reason to find out what’s in someone’s pants is if you want to get in their pants (for medical or sexual purposes) We could all be a little less interested. I do wonder how the medical community feels about having an ‘other’ category when asking for gender/sex. I know some countries are starting to allow a third ambiguous gender on identifying papers. Really just having M/F option doesn’t always give all the needed information to healthcare.

  7. nybgrus says:

    I agree Lost Marble.

    In fact, it is often commented to me that my “Gaydar” is broken because I often don’t notice that people are gay (or even when men are hitting on me). I’ve even twice been to gay bars – with groups of people for a fun night out – and not realized I was in a gay bar till the next day when someone laughed at how oblivious I was. I don’t don’t think my gaydar is “broken” but I just care that little about whether you are gay or straight or whatever you may be. It simply has zero bearing on how I interact with a person (except in the two cases you mention and perhaps some other specialized circumstances that may come up, but the latter of the two is a moot point entirely since I am currently engaged to be married).

  8. cervantes says:

    I think this gets a little easier to process with some historical perspective. Obviously, most people are born with unambiguous biological sex, and in turn most people’s sexual orientation is toward the (usually unambiguously) opposite sex. These facts have been basic organizing principles for human societies throughout history. Most societies have been pretty rigid in their gender role definitions and norms, which as I say usually, but not always, track well with biological sex.

    There is obviously considerable variation in exactly what those social gender roles have been, and there are a few societies (before our very complex and fast changing modern era) that have had accepted gender roles in addition to the standard 2 (e.g., Native American “Twin Spirits,”) or have allowed for sexual relationships between men and boys (Sparta) or other variants. But it’s a recent phenomenon, in keeping with our post-Enlightenment scientific and liberal worldview, to at first discover or acknowledge (the existence of homosexuality has obviously always been known, but avoided), and then begin to normatively accept, the less common variations Dr. Hall discusses.

    It is not surprising that it takes language, etiquette, habits and practices a while to catch up with previously unrecognized realities, and changing mores. I hope that people will be tolerant and sympathetic to the struggles lots of folks will have during this process. It takes some getting used to, especially for people raised with fairly rigid morality, which is strongly tied to gender role norms, but really for everyone who hasn’t much contemplated it all before. I had a professor in college who changed gender, and it did kind of freak people out at first, but ultimately it was okay. This was in the ’70s. Could not have happened much before that, I think.

  9. DugganSC says:

    @Lost Marble:
    When I went through my security clearance paperwork, one of the government databases had 7 choices, 7! Due to the fact that this did relate to clearances, I was not allowed to peer more closely as they entered the data (knowledge of data structure is a key step to learning how to break a system), but I have for years now speculated on what the seven choices could be. Male and female are givens, and there’s probably either a hermaphroditic or neuter category. Two might be assigned to “male sex change” and “female sex change”. But that leaves two. Merms and Ferms (terms I’ve seen used to describe intersexed individuals who are mostly toward one side or the other)?

    The invocation of paraphilias in the area of gender and sex definition does come off a bit odd to me. Outside of homosexuality, and possibly pedophilia (last I heard, there are studies showing that pre-pubescent children of either age generally register as female to viewers when isolated parts of their body other than genitals are shown, which implies that male homosexual pedophilia would be a rare thing, contrary to the stereotype of homosexuals going after very young boys), how many of them are relevant to the topic of gender or sex? Or is it more of a general sexuality thing that gets intertwined with it?

  10. rmgw says:

    Bravo, bravisimo, William Lawrence Utridge

    “I would call it “indifference to our taxonomies” :)

    so would I.

  11. Alex07321 says:

    “Are there parallels in animals?”

    Could you provide some references to prove sex abnormalities and homosexual behavior in animals?

  12. WilliamLawrenceUtridge says:

    rmgw, my wife wants the compliments to stop because I’m becoming unbearable. And she’s right. I’m barely sufferable on a normal week, let alone when strangers on the internet say good things about me :)

  13. Quill says:

    “It’s complicated.” Yes! Which is why I appreciate this post, a good collection and discussion of some of the main complications. I think one can make all sorts of social and societal allowances and accommodations in how someone wants to be addressed or viewed, but the overall binary nature of humans is very important medically.

  14. Davdoodles says:

    “Could you provide some references to prove sex abnormalities and homosexual behavior in animals?”

    Your choice of the word “prove” portends mala fides, and your apparent inability to type “homosexuality” and “animals” into Google suggests you are at work. Nevertheless, here are some links to get you started:

    http://www.yalescientific.org/2012/03/do-animals-exhibit-homosexuality/
    http://www.cambridge.org/gb/knowledge/isbn/item5708830/?site_locale=en_GB
    http://news.nationalgeographic.com.au/news/2004/07/0722_040722_gayanimal.html
    http://pactiss.org/2011/11/17/1500-animal-species-practice-homosexuality/

    And, as if to provide “balance”, here are some links to, well, the religious… erm… rebuttal:

    http://creation.com/homosexual-animals
    http://www.probe.org/site/c.fdKEIMNsEoG/b.4223027/k.4C29/Is_Animal_Homosexuality_Proof_that_Its_Normal.htm

    “Probe Ministry” – faboulous!
    .

  15. nybgrus says:

    Davdoodles:

    Indeed. It was clear he has an agenda and needs to demonstrate that homosexuality is a choice in order to maintain his worldview and faith. Because after all, the simple argument that homosexuality is inborn demolishes the notion that god must hate the act since god created homosexuals that way in the first place.

    The best part though? I click on your probe ministry link (just ‘cuz) and quickly skimmed and came across this:

    It is true that many animals engage in homosexual behavior. It is also true that a very small percentage of human beings do as well. As Petter Bockman said, ‘Homosexuality has been observed in more than 1,500 species and the phenomenon has been well-described for 500 of them.’ In addition, the article states that a quarter of all swan families are parented by homosexual couples.

    Bam. End. Of. Story.

    Unless god created all these animals homosexual for some reason we are done, aren’t we?

    Of course not. Let the rationalizations begin.

    However, for most scientists, homosexual behavior has been viewed as biologically deviant, since at the heart of evolution is sexual reproduction.

    And so on. I won’t bother rehashing it, but you get the gist. It essentially involves around this incredulity that evolution would predict homosexual behavior. That’s the funniest part – they argue against the validity of inborn homosexuality by using a caricature of evolutionary theory; a theory they themselves thoroughly denounce.

    It still sometimes impresses me the mental gymnastics these folks will go through.

  16. Lost Marble says:

    @DugganSC- that’s interesting that there were 7, can’t think of what they all could be either. I have this image in my head that way off in the future when asked for gender there will be a graph, with male and female on the x-axis, neutral and androgyny on the y, and one can pick a point on the scatter plot.

    @cervantes – I do understand the historical perspective, and that mind sets change slowly, which is why we have to slowly prod people to shed some archaic beliefs. To say ‘oh well, it’s always been this way’ is a cop out and seems contrary to what this site is about. (I’m not trying to accuse you of this attitude)

  17. DugganSC says:

    @Lost Marble:
    I think also it sometimes becomes a matter of practicality. It’s possible that we may one day arrive at a point where we refer to ourselves as 73% male, 23% female, 4% otherkin, but at the end of the day, if there’s any significance behind the distinctions, we eventually wind up in a pigeonhole. Take skin color, or heredity in general. A person could describe themselves as “a light coffee brown, not unlike the surface of a cappuccino that has been dappled in mare’s milk” but for the most part, people get a single label. It makes it easier to collate data to, for example, indicate that due to one’s darker skin, there’s a higher risk of a Vitamin D deficiency. Similarly, if the maleness or femaleness of a given person matters, there comes a time when we have to pick categories. People won’t fit wholly into pigeon-holes — someone who’s “black” can be anywhere from a light brown to a purplish color and someone with “red hair” could range from a flaming red to strawberry blond to auburn (and does someone stay a redhead if they had red hair as a child, or their hair is red under certain lights or when bleached by sunlight?). On a complete side note, the divisions of colors within languages is a pretty fascinating one. Did you know that the Japanese don’t distinguish between green and blue the same way we do?

    Incidentally, is there any consensus on what’s meant by “trans man” or “trans woman”? It has always seemed to me that the term gets used interchangeably, at least in common parlance, for whether the “man” or “woman” refers to the prior or current sex/gender. Makes it confusing sometimes. In person, it’s generally a bit easier to know (although I’ve once or twice gotten bit by mistaking a transvestite for a transexual, although fortunately no one took offense in those cases).

  18. Lost Marble says:

    @DuganSC I do agree with the comment on practicality. In regards to trans-man/woman, I have only heard the man/woman part to refer to which the individual identifies as. So Trans-woman is a male-female-transsexual. I suspect that when it is used otherwise it is actually a misunderstanding of what the word is meant to mean.

  19. WilliamLawrenceUtridge says:

    Otherkin. There is a sexual identity that I have a hard time pretending to take seriously.

  20. WilliamLawrenceUtridge says:

    It is astonishing to me that this post, this post and this post got hundreds of comments, all together more than 500, yet the meatiest, most substantive, and most revealing of Dr. Hall’s actual thinking and grasp of the complexities on sex and gender, got less than 20. So I’m bumping it up. This was a good, evidence-based, science-based post on sex and gender. I referred to it multiple time on other threads in an effort to get people to recognize that Dr. Hall is not a trans-hating monster or cissexual. It’s been up for longer than 2 of the 3 other related posts. That’s plenty of time to try to understand Dr. Hall is actually coming from. But it didn’t happen. I suspect pure confirmation bias is the root cause, people want to believe Dr. Hall is a big, ignorant meanie. I see this post as proof that this is not the case.

    So bump.

  21. DugganSC says:

    Unfortunately, other than a brief mention on the right sidebar of the latest post, quickly drowned out by ten more posts to the insanity in the other threads, this doesn’t do much to bump things. Although, maybe it’s for the best. Otherwise, me might spend the next year seeing those three articles at the top. :)

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