Sex vs. Gender

Sex is about biology, gender is about identity

Hand holding two wooden blocks, one with male and female symbols, the other a question mark
Hand holding two wooden blocks, one with male and female symbols, the other a question mark. Gerardo Carnero / Getty Images

Sex and gender are two different things. Sex is about a person's biology. It describes their chromosomal make up, their hormones, and/or their anatomy. Gender, in contrast, describes a person's understanding of themselves as male, female, or another gender entirely.

There is a misconception that there are only two sexes—male and female. The truth is more complicated. While most people's biology fits into those categories, other people's bodies exist on a spectrum between them.

Individuals whose bodies can not be definitively categorized as male or female may be described as being intersex, having intersex traits, or having differences or disorders of sexual differentiation.

In addition to sexual diversity, there is a growing awareness of gender diversity among humans. This reflects the increasing visibility of transgender individuals—those whose gender identity is not what would be expected for their assigned sex at birth.

Transgender individuals may have both binary and non-binary genders, and gender, like sex, exists on a spectrum. Intersex people may also identify as transgender or gender diverse.

Understanding Sex

The biology of sex starts with a discussion of chromosomes. There are two types of sex chromosomes—X and Y. Most people have two sex chromosomes, and those with two X chromosomes are usually female and those with an X and a Y are usually male.

However, some people have one sex chromosome or three sex chromosomes. They may be categorized as intersex or as endosex (binary male or female). In addition, some people have two chromosomes but some of the genes on one of the chromosomes may not function correctly. That can lead to someone being, for example, an XY woman.

The next major aspect of biology that determines a person's sex is their hormones and hormone receptors. Exposure to androgens, such as testosterone, leads to the development of structures associated with male sex.

Lack of exposure to androgens, or ineffective exposure to androgens, leads to the development of structures associated with female sex. Ineffective exposure to androgens occurs when there is a problem with the proteins (androgen receptors) that respond to stimulation by those hormones. Lack of exposure to androgens occurs when the body does not make testosterone or DHT.

Finally, it's important to note that the sex recorded on a person's birth certificate isn't about their chromosomes or their hormones, it's about their anatomy. While most of the time individual's anatomy is a reflection of their chromosomal make-up, that's not always true. Sex is more complicated than just X and Y.

Understanding Gender

Gender describes a person's understanding of themselves as male, female, or another gender. Most people's genders are what would be expected for their recorded sex at birth, and people for who this is true are described as cisgender. Individuals whose gender is not what would be expected for their recorded sex at birth can be described as transgender or gender diverse.

As with sex, gender has a number of components. Most of the time when talking about someone's gender, we are talking about their gender identity, which is described above. However, in addition to gender identity, people also have gender expression.

Gender expression describes the gendered ways people present themselves to the word. This may or may not be a reflection of their gender identity. For example, a cisgender woman with short hair who likes to wear tailored suits is still a woman. A transgender man with long hair is still a man.

Gender expression is highly culturally constructed. What is understood to be a male or female presentation depends a great deal on the place and time. There was a time when pink was thought to be too strong and masculine a color for women to wear.

Sex vs. Gender

To sum up, sex is about biology, but gender is about identity. Where sex and gender match, there is generally no need to intervene. Where there is a mismatch between sex and gender, individuals may choose to seek out care.

Healthcare When Sex Differs from Gender

Some individuals whose sex and gender do not match choose to seek out gender affirming medical treatment or surgical procedures in order to affirm their gender. The goal of gender affirming care is to relieve gender dysphoria, discomfort with a mismatch between a person's body and their identity.

However, some people conceptualize gender affirming care as being a way to achieve gender euphoria—a sense of happiness and fulfillment in their gendered body.

Intersex Care: Consent and Controversy

Historically, doctors and parents have performed early surgeries on infants and young children with intersex traits in order to "normalize" the appearance of their genitalia.

This was often not discussed with children, even as they aged, and many intersex individuals were treated without being given any knowledge of their condition or allowed to make informed decisions about consent.

It was thought that making the child's genitals appear to be clearly male or female would make it easier for them to live as healthy, happy young men or women. However, the foundational work that established this pattern of care later turned out to have been deeply problematic

The John/Joan Case

In the 1960s, a psychologist at Johns Hopkins University, John Money, encouraged the parents of a young boy to raise him as a girl after the child experienced devastating damage to his penis during a failed circumcision.

Surgery was performed to give the child female appearing genitalia, and he was given female hormones during puberty. The child never was told that he had been born male.

The early results from his case were used to justify hundreds or thousands of unnecessary surgeries on other children with intersex conditions or other genital differences. John Money said his case demonstrated hat it was only the way of rearing that affected a person's gender identity, and medical practice changed accordingly.

Unfortunately, John Money was wrong. In his teen years, the child rejected the female identity he had been assigned. He eventually learned that he had been born male and started undergoing medical and surgical care to help his body reflect his gender identity and the sex he had been born in.

Sadly, he suffered from depression for much of his life and committed suicide in his 30s. Even more sadly, it took years longer before the medical establishment began to consider that genital surgeries on children might not be in their best interests.

There is a growing recognition that performing genital surgeries on intersex children is a violation of their human rights that can have devastating effects on their medical, physical, and sexual health throughout their lives..

In the United States, prestigious children's hospitals such as Bostons Children's Hospital and Lurie Children's Hospital that have historically performed these surgeries have begun to stop offering some or all non-medically necessary procedures until patients can participate in their own care.

This represents an enormous step forward in respecting the right of children to have full, happy lives that include the possibility of healthy sexual function as adults.

However, some researchers, physicians, and parents still argue that having genitals that appear to be binary is more important to children's lives and well-being than giving them the opportunity to make decisions about their course of care.

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2 Sources
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  1. Garland J, Slokenberga S. Protecting the rights of children with intersex conditions from nonconsensual gender-conforming medical interventions: The view from Europe. Med Law Rev. 2019;27(3):482-508. doi:10.1093/medlaw/fwy039

  2. Wisniewski AB, Tishelman AC. Psychological perspectives to early surgery in the management of disorders/differences of sex development. Curr Opin Pediatr. 2019;31(4):570-574. doi:10.1097/MOP.0000000000000784

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