Gender: An XX-rated Review

If you are uncomfortable hearing about sex, do not read this article and do not listen to U.S. Senate hearings that question Supreme Court nominees. Your children should leave the room when the junior senator from Texas starts interrogating African-American women who have served with distinction on lower courts.  If they listen to this Senator, your children will plague you with at least one of his gender-based questions, that being, “How do you define the word ‘woman.” The candidate for a seat on the highest court in our land answered, “I cannot. I am not a biologist.” Well, candidate Madame Justice, I am a biologist, and I cannot define it either.  When I was 12 years old, it seemed simple enough, but over the decades since, defining and applying that word to the various forms that humans assume has been increasingly problematic.

In college, I learned that human cells have tens of thousands of genes, the instructions for our construction, arrayed on 46 strands of material called chromosomes. To create the first living cell that may develop into a viable person, a full complement of 46 chromosomes is usually necessary. Half of those chromosomes are contributed by the individual’s father in his sperm and the other half  (23) are contributed by the individual’s mother in her egg. [If you do not know how the egg and the sperm get together, do not worry.  It is not all that important.] Each chromosome from the father has a match from the mother, except when it comes to the chromosomes that determine the sex of the resulting fetus. The mother’s egg has a chromosome referred to as “X.” The father’s sperm has either an ”X” or a “Y.” If the fetus that develops from the fusion of the egg and the sperm ends up with two “X” chromosomes, the fetus will develop into a girl, and if the fusion of egg and sperm results in a fetus with one “X” and one “Y,” it will be a boy…usually.

It is with the ‘usually’ that the trouble starts.  In nature, what is usually true is not necessarily always true. Gregor Mendel, an Austrian monk who jump-started the field of genetics in the Nineteenth Century, worked out the most basic rules of inheritance by studying sweet peas. The flower colors of these plants obeyed strict patterns generation after generation. He described his radical insights to the greatest scientific minds of his era.  None of his contemporaries understood or showed any interest in his work. Consequently, he tried to interest a famous botanist known for his work on snapdragons by reproducing his genetic studies in those plants.  Mendel failed because snapdragons do not obey the rules he discovered and by which most flowering plants abide. Mendel quit his research and busied himself with administrative tasks at the monastery. 

When I got to medical school, I started hearing about the numerous exceptions to the simple boy/girl, man/woman definitions I had mastered by the time I was 12 years old.  A gynecologist told the class about a recently married couple who consulted a colleague of his. The husband and wife were frustrated in their efforts to have children, despite their having a very active and satisfying sex life. The husband had all the characteristics on examination of a healthy, young man. The wife exhibited all the characteristics typical of a healthy, young woman. The husband’s sperm was active and sufficient to impregnate a woman of child-bearing age. The wife, on the other hand, had no eggs. In fact, she had no ovaries, the organs that supply the eggs with which the sperm fuses.  Instead of ovaries, she had organs in her lower abdomen typical of testicles, the organs that make the sperm.  Further testing revealed that both the husband and wife had the gene complement [XY] typical of males.  The wife had breasts, a vagina, and female external genitalia, all unambiguously typical of a woman, but her genes were typical of a man.

This condition occurs in about one out of 20,000 live births.  It is called testicular feminization, and it is a life-shattering diagnosis for many of the people affected. The tissues of the developing fetus are insensitive to the male hormones that would lead to typical male features.  In the absence of a response to male hormones, the fetus and the resulting adult develop typical female features. That there is anything ‘male’ about the affected individual will not be evident until the woman is challenged to get pregnant.

In cases of testicular feminization, many physicians will explain to the affected individuals that they have a fertility problem that can only be solved by use of a donor egg, a surrogate mother, or adoption. The profoundly insensitive gynecologist involved in evaluating this couple simply told the husband, “You cannot have children with your wife because you married a man, not a woman.” The husband spent a few days trying to digest this revelation before he committed suicide.

There are numerous other genetic and hormonal variations that defy neat categorization of a person as either a ‘man’ or ‘woman.’  Added to that is the issue of gender identification, the sexual persona with which an individual is most comfortable, and gender re-assignment. In cases of gender re-assignment, our social systems have yet to catch up with medical realities.  If an individual is designated as ‘male’ on his health insurance application and undergoes procedures to be identified as ‘female,’ the supercomputers of our insurance corporations may find the change “does not compute.”

Mother Nature is constantly experimenting with our genes and our psyches and is indifferent to our desire for clarity, whether it comes to what is normal human behavior or what defines a man or a woman. The genetic tests from the Twentieth Century are as unhelpful in assigning gender as the archaic terms we use in daily conversation. Resorting to conventional terminology can have tragic consequences, as it did in the case of the infertile couple discussed here. 

What the junior senator from Texas and many of his colleagues fail to recognize is that they are asking questions that stopped being meaningful or informative nearly a century ago.  If U.S. Senate hearings are going to be vocabulary quizzes, we would be better served if the candidates being scrutinized were asked to define words like inclusiveness, diversity, equality, and community.  Save the quiz on terms like man, woman, birth, and death for the biologists you want to appoint to the Supreme court.

Dr. Lechtenberg is an Easton resident who graduated from Tufts University and Tufts Medical School in Massachusetts and subsequently trained at The Mount Sinai Hospital and Columbia-Presbyterian Medical Center in Manhattan.  He worked as a neurologist at several New York Hospitals, including Kings County and The Long Island College Hospital, while maintaining a private practice, teaching at SUNY Downstate Medical School, and publishing 15 books on a variety of medical topics. He worked in drug development in the USA, as well as in England, Germany, and France.

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