The Academic Assault on Sex in Medicine
Some academics are attempting to eliminate sex as a variable in medicine. Scientific research and medical case studies reveal the reasons why this is dangerous.
Illustration by Cynthia (@PTElephant).
“Sex is a pseudo-medical construct…,” a sobering statement that begins the descent into the rabbit hole of ideological capture.
The Union County Pride Intersectional Dynamic Pride 2023 Seminar starts with a woman clumsily explaining how to join online (Union County Pride). She gives instructions about accessing the conference call and talks about color-coded name tags that signal your willingness to be approached in the conference room. The screen goes black, and a bored-looking woman is on screen, waiting for the video conference to begin. The screen cuts back to the first woman who explains that this seminar is featuring guest speaker Bethany Corrigan, a “Gender, Equity, Diversity, and Inclusion Specialist with over 14 years of experience in social justice and human rights in over 50 countries worldwide.”
Bethany is a slender, high-energy woman who goes by they/them pronouns. She directed a program that was cited in the World Health Organization (WHO) HIV/AIDS Guidelines on specific risk to “transgender youth.” Along with her transition of labels from “woman” to “nonbinary,” Bethany also transitioned from a voting board member to executive director of Transcend Charlotte – a North Carolina based organization that provides “free and/or low-cost mental health, social support, and education services to trans and gender-expansive folks” over the age of 18 (or so they say, but we will get back to this point later) – so long as you can click past the constant pop-up asking for donations every time you load a page on their site.
She begins by explaining that instead of doing her planned presentation on Gender Affirming Social Services, she is switching to a presentation that focuses on divorcing the “concept of the social construct of gender from what people will term as biological facts” and is intended to help the listener prepare for “fights” they may end up in with politicians and doctors.
Already, we can see that Bethany sees facts and people who do not align with her beliefs as adversarial. She says that medical support is a human right and so is “cultural and individual affirmation of our identities” but that legislative decisions are conflating the two. She also says that despite being prepared with your “arsenal” of her pseudoscientific jargon, the listeners may find that “you can’t logic with people who are unwilling to be logic-ed with.” Again, Bethany uses language that prepares the listener for a battle and gives a convenient out: if their tactics fail, it’s simply because the listener has encountered someone who was illogical and refused to listen. Herein lies a major issue: Bethany and activists like her believe that unless one fully capitulates, they have not listened. They don’t believe that disagreement is possible if someone hears their arguments. For someone who goes out of her way to mention the seminar is taking place on “indigenous lands” and encourages the listeners to go to a site for indigenous people to honor and give to the “rightful people that came before us,” it seems odd that she expects everyone to share her worldview.
After a bit of awkward banter, Bethany finally starts to get to the point of the presentation. She asks the listeners, “True or false: sex and gender are the same?” The answer is a resounding, “false.” Thankfully, she responds with, “That’s correct!”
However, any hope this may have given you that the presentation will have a shred of reality in it is quickly dashed by her next claim:
“Sex is a pseudo medical construct wherein a physician or a midwife or whomever is going to document either F or M on a vital record.”
She argues this is because the person recording the sex of babies are merely looking at genitals and nothing else.
External Indicators for Internal Issues
Activists who make this argument overlook an important fact: genitals are not just a meaningless, random appendage. They are part of the reproductive system, just as the heart is part of the cardiovascular system. They are the overwhelming external indicator of the system within, along with the body that developed around it. It is a foundational part of the human body structure that informs health and development throughout our lives. However, because activists have so completely disassembled the human body into a random assortment of parts that just so happen to work together, they fail to understand that the systemic interactions are integral to our existence.
But let’s digress for a moment to address the other part of Bethany’s issue. How do doctors “assign” sex at birth?
When babies are born, there is a standard evaluation that takes place. This assesses whether there are any abnormalities that would signal a health issue that may need to be addressed (Gantan & Wiedrich 2023). The evaluation is essentially from head to toe, looking for everything from sacral hair tufts on the baby’s back to palpation of various parts of the body, like the clavicle to check for asymmetry and swelling. Among this full body exam is an evaluation of the genitals, with its own standards that include palpation of the testes to ensure proper descent, and even expectations of vaginal secretions that may be observed.
The assessment takes into account “ambiguous” genitalia, such as hypospadias (the urethra not opening at the head of the penis), fused labia, clitoromegaly (abnormal enlargement of the clitoris), etc., and notes protocols that prompt consultations with various specialists in urology, endocrinology, and genetics for further evaluation and potential treatment, depending on the severity.
So, to address Bethany’s claim in short, doctors do not “assign” a sex at birth; they observe and record it, just as they do with every other part of the body they evaluate at birth. It’s not a judgment, it’s not arbitrary, nor is it something that happens at a glance. It is an assessment backed up by evidence of organs that indicate health and function of someone’s body, just as it is for the spine, limbs, head, stomach, etc.
Again, just as any abnormalities that may arise during other parts of the evaluation may indicate a health issue that requires treatment in other parts or systems of the body, abnormalities in the genitalia may indicate the same thing. These abnormalities are often incorrectly referred to as “intersex,” but they each are related to specific genetic conditions that each result in males or females. These disorders require medical treatment and continued observation because of the health issues that may come with them. This is why being able to further evaluate these individuals with disorders of sex development (DSDs) relies on knowing what male and female are. Without that understanding, we would be unable to give them the adequate medical care that some of them literally need to survive.
The Intersex Myth
Bethany later argues that these “intersex” cases are not disorders because she feels that “intersex” is an identity and that the word really means that someone’s body might fall “outside the typical limits of what certain medical guidelines have deemed male or female.” She also argues that someone may be “intersex” and never know, that it’s merely an atypical chromosome combination with no other effects, and that “there are about as many people estimated to be intersex in our world as the population of Russia, as number of naturally occurring redheads on this earth.” That’s as bold a statement as it is incorrect.
The “common as redheads” myth originates from the claim that 1.7% of the population are neither male nor female, which Bethany illustrates with a PowerPoint slide. But 88% of the 1.7% number comprises a condition known as Late Onset CAH, which involves unambiguous males or females who are almost always fertile. This drops the number to 0.2%. But even within this percentage, almost all reproductive disorders do not cause any sex ambiguity. The fetus still develops a clear phenotype organized around sperm or ova. The cases that result in ambiguity are less than 0.02% of the population, and within these cases, sex can still be identified by analyzing gonadal tissue and internal genitalia to see what reproductive pathway the fetus was going down when the condition occurred (Sax 2002; Leon et al 2019).
Claiming that “intersex” is as common as redheads and that it does not have serious side effects muddies the reality of the individual conditions, furthers misinformation regarding the biological details necessary for accurate medical treatment, and "others" people out of their sex just because they have a disorder. Endocrine and reproductive problems affect the two sexes differently, and it is paramount we understand this to provide safe and effective medical and psychological care.
The Anatomical Inventory
During Bethany’s presentation, she suggests that instead of having a marker for sex on medical records, doctors should use an anatomical inventory. Her argument relies on the belief that a sex marker could be used to discriminate against specific individuals while an anatomical inventory would provide the necessary medical information without the potential threat of discrimination. However, what Bethany fails to realize is that a person's sex is vital to giving the appropriate medical treatments and interventions.
First, let’s think about Bethany’s claims of discrimination and the application of an anatomical checklist, which are, perhaps, the easiest to dispel.
If a marker on one’s chart can lead to discrimination or prejudice, why wouldn’t the same prejudice apply to a person because of their anatomy? Bethany makes the erroneous assumption that breaking a person’s body up into pieces on a list would somehow dissuade a bigoted doctor from discrimination. However, letters on a document do not cause discrimination. If someone hates females or is disgusted by someone with a disorder of sex development, they will inevitably find out about the person’s biological sex via the checklist, still group the individual with other people who have the same things on their checklist (like a vagina) and discriminate against them. The sex marker is merely a shorthand to understand which conditions a person might be more inclined to have. This would change nothing in terms of discrimination.
The practicality of instituting such a checklist would not only be pointless, but also time-consuming. Imagine having to fill out or run through the checklist every visit to a doctor or hospital where wait times can already be lengthy. Also consider how anatomically literate the average person is, how this would affect people who didn’t speak the language of the country in which this was implemented, or how a person with a lower IQ, impaired cognition, memory retention, or speech/hearing difficulties might be impacted. In her aim to be inclusive toward trans and “queer” identified individuals, Bethany has in fact suggested a system that would be more difficult for many other groups.
Sex Is More Than a Checklist
Our sex is more than just an anatomical inventory. A 2012 study found that sex differences appear at the cellular level in key cell functions, specifically a process called apoptosis (Straface et al. 2012). Apoptosis has been shown to impact multiple disease processes including cardiovascular disease, neurodegenerative diseases like dementia and Alzheimer's disease, autoimmune diseases, and cancer (Favaloro et al. 2012). This means that these differences on a cellular level can have a huge impact on how males and females experience these conditions.
In fact, the importance of sex as part of medical research has become increasingly apparent over the past 30 years. In 1993, the Food and Drug Administration (FDA) lifted restrictions preventing medical trials from including females of child bearing age (FDA 2018). Although these restrictions were meant to prevent unknown effects to the reproductive system of women, excluding women was causing worse medical issues. Excluding women, however, essentially made the entire female population at risk of unknown complications from medications. While their intention had seemingly been to prevent harm from befalling women in medical trials, they inadvertently turned all women into experiment participants without consent and misled the medical community into the efficacy of these medications on women.
Even after such protocols were in place, changes had to be made to medications because of the metabolic differences between males and females. These differences could not be accounted for by weight differences or by hormonal differences. A review of new drug applications reviewed between 1995 and 2000 showed that of the 300 total applications, only 163 had trials that included a female and a male trial group. Of those 163, the difference in action of the medication between the male and female groups was as large as 40% (Watson et al. 2019). This is worrisome on its own, but it gets worse. Worldwide and across all age ranges, females are admitted to the hospital more often than males and are prescribed more medications than males. As a result of the difference in action of medications and the exposure to more medications, females are more likely to experience adverse drug reactions (ADRs) and are more likely to be hospitalized from ADRs.
The medical differences between males and females do not stop at medications. The human body is constantly attempting to maintain a stable, internal balance so that the body can operate efficiently. This is referred to as homeostasis. An example is a person's internal body temperature. When a person's internal body temperature is too high, it attempts to cool down by producing sweat. When a person's temperature is too cold, it attempts to warm the body through shivering. The many regulatory processes involve multiple organ systems and tries to maintain the body's natural state of homeostasis (Libretti & Puckett 2023). We refer to the state of homeostasis in a person's body as their baseline.
In medicine, we can measure the changes in these states to diagnose diseases and disorders. Sex is an important factor because some lab values differ based on the individual's sex. In other words, males and females have different natural baselines. These differences are of such importance that it can literally be a matter of life and death.
In 2016, a transman by the name of Cameron Whitley became very sick. Although their symptoms started as just an earache, eventually this led to the discovery of chronic kidney disease (CKD). Whitley's kidneys were failing, requiring dialysis and a kidney transplant. But one thing interfered and delayed Whitley's treatment: she never told the doctors she was female. Everything from her legal documents to her medical records listed Whitley as male (Zaria 2020).
How could such a detail prevent adequate treatment? At one point during the diagnosis of Whitley's condition, she describes having an ultrasound where the tech got up and left without saying anything. Although Whitley claims this was an example of denial of care, what happened was confusion. The tech found themselves observing female anatomy in a person who was supposedly male. This is an abnormal finding and likely required notifying their supervisor. In addition, ultrasound techs are not allowed to give diagnoses, only doctors can give a diagnosis. The techs had no choice but to say nothing. While the doctors should have been finding the cause of her kidney failure, instead they were looking into DSDs that caused kidney failure.
Additionally, knowing that Whitley was female could have changed considerations for treatment. Females tend to have slower progression of CKD, make up fewer fatal cases, and often don't require kidney transplant or dialysis. Males, however, often require kidney transplants and dialysis. Although in some ways these differences can be the result of sex hormones, these differences are consistent even through periods of life without strong hormonal differences between males and females (Mayne et al. 2023). Even more concerning is that females who undergo dialysis tend to die more often than females who do not undergo dialysis. For whatever reason, dialysis tends to eliminate the advantage females have for survival over their male counterparts (Carrero et al. 2010).
Because of these differences, a doctor may attempt to manage CKD in females differently than in males. Doctor Patrick G. Dean at Mayo Clinic in Minnesota suggests that, if possible, doctors should refer patients to kidney transplants prior to dialysis as it causes increased risks of heart and vascular disease associated with the procedure (Mayo Clinic 2023). With the slower progression of CKD in females, avoiding dialysis is more likely.
But Whitley didn't reveal she was female. Instead, Whitley underwent dialysis that resulted in massive blood loss. This delayed the surgery to provide her with the much needed kidney transplant.
The next problem involved Whitley's blood work. In CKD, kidney function is the estimated glomerular filtration rate (eGFR). This is used to determine the stage of CKD. In adult males, eGFR is higher than in adult females, but as previously stated, male GFR also declines at a faster rate than female levels (Wetzels et al. 2007). When determining CKD stage, it is represented by a percent of function. Using the male values to determine the function percent meant that while Whitley's kidneys were failing, the test results said that her kidneys weren't failing. According to the National Kidney Foundation, kidney failure is determined by < 15% kidney function. By using the male parameters, Whitley's kidney function was more than 15%. By the time the doctors had used the female reference range, Whitley had a kidney function of 8%.
If we go back to Bethany’s checklist idea, the doctors still may have assumed Whitley had a DSD. If sex is detached from anatomy, as sex spectrum proponents claim, they would not have attached Whitley’s sex and the corresponding kidney function values to Whitley’s anatomy, thereby failing to adequately give her the proper treatment. The medical mismanagement in Whitley's case would have resulted in her death. As it is, Whitley nearly died by ignoring the importance of her sex.
One might argue this is simply just Bethany’s opinion and that they won’t get far, but that would be wrong. There are a multitude of articles that argue for a sex spectrum approach to humans, including a recent piece published in the November 2023 edition of the medical journal Hormones and Behavior (Massa et al. 2023). The authors of the article, like Bethany, believe that we should do away with biological sexes altogether in medical research. And, just like Bethany, the authors fail to see the futility and immaturity of their argument.
Almost immediately they make a bold and false claim: that using biological sex as a category makes researchers overlook variations within those sexes. To illustrate this, the authors point to a study done on female mice and humans and the estrous cycle (Rocks et al. 2022). The authors of the Massa et al. paper try to argue that this study was only possible because we were looking strictly at “ovarian hormones” and not biological sex.
What they’re failing to acknowledge and realize is that ovaries developed because of biological sex being dimorphic and antagonistic. This resulted in only one of the phenotypes able to have fully developed and healthy ovaries that could be used in study: the female sex. And like Bethany, they also make it clear their paper is a “call to arms,” using the same language meant to turn any opposition into the enemy. This is not how unbiased, objective research is done. This is an ideological agenda hiding behind academia. Science and objectivity have no reason to paint anyone as an enemy. It exists with or without the approval of others. Doing away with the category of biological sex does nothing to change that, and testing each mouse or person regardless of their sex to see if they had fully developed ovaries would’ve been both absurd and needlessly time consuming, just like Bethany’s anatomical checklist. It also would do little for validating the gender identities of the mice involved.
The simpler and realistically more inclusive way of treating patients is to use the shorthand of biological sex and leave the burdens of screening the body to the physicians instead of the patients. Bethany and her cohorts’ methods have an elitist view that leads them to coddle those who are easily offended or who are so deeply afflicted by mental illness that the mere mention of their sex sends them into a panic.
It is unclear why Bethany and others would want to encourage these individuals to think such an instance is worthy of panic, as opposed to helping them be comfortable in their bodies and accept things they cannot change. What is certain is that ignoring the importance of sex leads to serious and sometimes deadly consequences. There is no kindness or healing in that.
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