Last Thursday, the New England Journal of Medicine (NEJM), widely considered to be the world’s most prestigious medical journal, published an article entitled Failed Assignments—Rethinking Sex Designations on Birth Certificates, arguing that (in the words of the abstract) “sex designations on birth certificates offer no clinical utility, and they can be harmful for intersex and transgender people.”
“I’m a pediatrician,” wrote one Oregon-based doctor. “The growth curves for male and female babies are notably different. Am I to just give up on tracking normal growth and development?”
In apparent anticipation of such responses, the NEJM authors write that “moving [sex] designations below the line of demarcation would not compromise the birth certificate’s public health function but could avoid harm.” The term “line of demarcation” refers to a separator on birth certificates.
In effect, the authors are urging that a person’s biological sex be downgraded to the same secondary, below-the-line information category that includes, for instance, a child’s race and the marital status of his or her parents.
Being male or female is an important basic human variable that affects health and illness throughout the life span. Differences in health and illness are influenced by individual genetic and physiological constitutions, as well as by an individual’s interaction with environmental and experiential factors. The incidence and severity of diseases vary between the sexes and may be related to differences in exposures, routes of entry and the processing of a foreign agent, and cellular responses. Although in many cases these sex differences can be traced to the direct or indirect effects of hormones associated with reproduction, differences cannot be solely attributed to hormones. Therefore, sex should be considered when designing and analyzing studies in all areas and at all levels of biomedical and health-related research.
The idea that there are no sex differences in human neuroanatomy—that we are all blank slates, so to speak, and so any observable variation must be the result of cultural conditioning or sexist bigotry—always plays well in the lay media, as it accords well with the expansive progressive understanding of sexism. Meanwhile, the actual facts, boring as they may be to most social media users—that “a variety of neurological and psychiatric conditions demonstrate robust differences between the sexes in their incidence, symptoms, progression and response to treatment”—barely received any notice whatsoever.
Such language disguises the plain fact that sex is defined functionally based on the type of gamete (sex cell) that forms the basis for an individual’s reproductive anatomy. Males comprise the sex that produces small, motile sex cells (sperm); while females comprise the sex that produces large, sessile sex cells (ova). It doesn’t matter whether any individual can actually, or eventually does, produce gametes. An individual human being’s sex is determined by their primary sex organs, and an individual’s sex is accurately recorded over 99.98 percent of the time using genitals as a proxy for underlying gonad type.
Intersex conditions, whereby a person may have ambiguous genitalia or a mismatch between sex chromosomes and external phenotype, are real but extremely rare. And they do not result in a third sex. Nor do they demonstrate the existence of some mythical sex “spectrum” (notwithstanding several science journalists’ efforts to pretend as much), given that there is no gamete that exists between sperm and ova for one’s anatomy to produce (or be structured to produce).
While I share the belief that surgeries on intersex infants should be withheld until patients can give proper consent, and that nobody should be pressured into unwanted surgery, birth certificates are not the culprit here. Rather, what needs to be reconsidered is the societal notion that there is only one narrow way for biological males and biological females to look.
A trans person is someone who is male or female, but who self-identifies as someone of the opposite sex—which, of course, they’re free to do, but which does nothing in and of itself to change their underlying biology.