Part 2: How I Realized I Had No Idea What Sex Was and Neither Do You
It was my final year at Johns Hopkins University and, like many other seniors, I had no idea what I was going to do with my life post-graduation. I was, however, pretty confident about certain truths. For example, I knew that while Harvard curved to a B, JHU curved to a C (which meant we were smarter and it was thus fine that we didn’t get into Harvard). I also knew that you could interoffice loan articles so that instead of walking (gasp) all the way to the library, you could get someone else to scan them and e-mail them to you. And I knew that biological sex, i.e. male and female, was an innate binary reality, because, of course, why would it not be?. However, all that changed when I began working with my professor, mentor, friend and fellow zooborns aficionado, Dr. Amy Wisniewski.
At that point in my training, I had already realized that research on neurological sex and sexuality differences was fraught with sampling bias and threats to both construct and content validity. After running straight and gay men and women through a maze for a research class I discovered that my straightest-brained straight man had been making out with another man at a party. I started to question the results, not only of my trial, but of other studies on so-called “gay” brains. How could one be certain that the brains we were researching accurately captured the brains of our population or of the behavior of interest? Were the brains of women and men, let alone heterosexuals and LGBTQ people, even all that different in the first place? None-the-less, I was still pretty certain that, even if gendered brains weren’t all that real, sex was pretty clear.
Enter Amy. Amy had been conducting research alongside Claude Migeon, an endocrinologist with a thick French accent who had been practicing literally since the endocrine system was discovered and who was best known for his work on congenital adrenal hyperplasia (CAH). We briefly discussed this health condition in the Human Sexuality class Amy taught and I was eager to learn more. It was from this space of curiosity, that I entered her cramped office in the Park Building above the old Children’s Center. Two years later I left it entirely changed.
CAH occurs when the body is missing an enzyme (there can be several types missing but it is typically one called 21-hydroxylase (21-OH). 21-OH is necessary for the production of cortisol. Often called the “stress hormone,” our body produces cortisol not only to deal with physical and emotional stress but also to help regulate aspects of metabolism. When our body isn’t getting enough cortisol (including when we are developing in the womb), it turns on the adrenal glands and tells them to produce more of the building blocks or pre-cursors to cortisol. These then get assembled or synthesized into the finished product. However, if one of these building blocks is missing or can not be produced, as is the case with individuals with CAH, the body keeps producing the other pre-cursors since it doesn’t know when to stop (i.e. the feedback loop is broken since no end product is ever developed). As this process continues, the other precursors and the hormones that are made alongside those precursors build up to elevated levels. For individuals with CAH, this includes androgens.
Exposure to hormones (like androgens) play a role in shaping our internal and external reproductive structures while we are still developing in the womb. Our organs start out looking the same and then change shape and grow in various directions in response to the hormonal milieu around us. Most people are familiar with terms like penis, clitoris, vagina, scrotum and see these as very different organs… but, really, they start out the same. Like pasta, a basic dough can be used to make a wide range of shapes. Also like pasta, there is a wide degree of variation across brands, errr… body parts.
This became increasingly clear to me as I learned more about CAH, intersexuality and about sex in general. It turned out that I actually couldn’t prove my own sex with certainty. I had never had my chromosomes tested so how could I know what category they fit into without seeing them? I wasn’t even sure we had enough categories; if 46,XX chromosomes were labeled female and 46,XY were labeled male, where did we put 47,XXY or 45,XO? Clearly, genes alone weren’t enough to categorize sex. But maybe genitals would be better?
As I would come to find out, genitals also weren’t always reliable for categorizing bodies. For people with CAH who have 46,XX chromosomes, that additional prenatal androgen exposure changes the way their genitals develop. And it doesn’t just make “girl” bodies into “boy” bodies; that would be way too binary. Genital shapes really are more of a spectrum (even for people who DO neatly fit under a specific socially-agreed upon sex category). For people born with a difference of sex development (DSD) or who might identify as intersex this might just be more apparent.
But, for arguments sake, let’s say that you could ignore the fact that a person doesn’t know their chromosomes. And let’s assume that you think that your body looks pretty binary from the outside. How could someone still possibly question their sex? Well, most of us have never seen our internal organs and certainly few of us have had them biopsied to be sure that the tissue inside a thing that looks like a testicle actually is testicular tissue, for example. Working with Amy and Claude, I learned that even internal organs can vary and that the ways these organs function is also contingent on both internal hormonal levels as well as external factors like stress, overall health, exposure to toxins, etc. The argument that sex was binary and that someone could even presume to know someone else’s sex just by looking at them was crumbling before my eyes.
So, if “sex” as we know it isn’t a discrete category and, in reality, the average person does not know what anyone else’s chromosomes, genitals or internal organs look like… what does that M or F mean on our driver’s license? The answer? It’s actually your gender.
Though most people are raised as a certain gender based on their sex assignment at birth and we thus assume that gender is rooted in sex, the reality is that, in day-to-day practical application, we know VERY little about the sex of the people we interact with. Sure, there are a few hints to go off of… like secondary sex characteristics (i.e. facial hair, voice pitch, body-fat distribution) but there is a wide variation in how people look and groom themselves, so that’s not always reliable. For the most part, we rely on someone’s gender presentation to make inferences about their biology, not the other way around as bathroom bills would have it.
For example, when I show up to the MVA to get my license, I bring a tattered and faded piece of paper that is nearly four decades old and from a different state, and that was filled out by someone who I (let alone the clerk sitting at the MVA window) never met. In fact, there is nothing to have stopped me from having printed that out myself. However, the clerk never questions me. Why? Because the way I dress and style my hair matches that M. That is, of course, my privilege as a cisgender person, but it also highlights the reality that our judgments about someone else’s sex are largely dependent upon the evidence those people put before us rather than some innate truth about bodies. Furthermore that evidence is dependent upon the norms that any given society or societal subset determines to be masculine or feminine, all of which is subject to change.
When it comes to bathroom bills and other gender policing efforts, unless we are all willing to have our mouths swabbed to test our chromosomes and submit to a physical exam and ultrasound, and then wait several days for the results, we will never be able to know the sex of anyone else in the stall next to us. Instead, we will have to trust that people know what bathroom they belong in and continue to prosecute bathroom-related crimes the same way we do now, regardless of the gender expression of the person involved.
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