Darien, Illinois, United States
|Venus is considered to be the epitome of feminine beauty in the western world. Does it matter that she has no arms?
Venus de Milo. Louvre Museum. Photo by Tupungato on Dreamstime.
“The more you know the more you realize you don’t know.”
— Aristotle (384 BCE-322 BCE)
On March 22, 2022, a US senator asked the nominee for Associate Justice of the United States Supreme Court: “Can you define the word woman?” The nominee replied, “I can’t.” The senator followed up with, “You can’t?” “Not in this context. I am not a biologist,” said the judge. The senator then proceeded to express surprise by asking, “The meaning of the word woman is so unclear and controversial that you can’t give me a definition?”1 That was the cue for one side of the political spectrum to express faux indignation. The judge had adroitly sidestepped a controversial matter while the other side was pleased that the nominee parried a “gotcha” question with a “nonanswer.” Even a non-partisan physician called it a “prudent nonanswer” in his opinion piece in the Chicago Tribune on April 11, 2022.2
But was it a nonanswer?
Whether we consider genetics, development of gonads, hormonal actions or lack thereof, general physiognomy, genital anatomy, or psychological and organic changes in the brain, one must be careful in defining a woman or a man.
The simplest genetic concept is that a woman has two X chromosomes (46XX) and a man has one X and one Y chromosome (46XY). Unfortunately, biology is messy. If we accept, on a chromosomal basis, that only a person with two X chromosomes is a female and only someone who is 46 XY is a male, then what about a woman with Turner syndrome who is 45XO or a man with Klinefelter syndrome who has 47 XXY chromosomes?
If left untreated, females with Turner syndrome do not develop secondary sex characteristics, are amenorrheic, and are generally infertile because they lack ovarian function. Their development and menstrual function can be normalized by administering female hormones. They can carry a baby to term with a donated oocyte for in vitro fertilization (IVF). Conversely, a female with Swyer syndrome or pure gonadal dysgenesis is 46 XY but has normal female external and internal genitalia except for her gonads. Her uterine function can be restored by hormonal supplementation and she too can carry a baby to term by donor egg IVF. Also of importance, since the testes in the person with Swyer syndrome never developed or produced testosterone, there is no androgen imprint on the fetal brain of these women.3
Despite their two X chromosomes, individuals with Klinefelter syndrome are normal males at birth, are raised as such, and continue to function as males. They are usually diagnosed only after puberty when they demonstrate hypogonadism and gynecomastia.
People with complete androgen insensitivity syndrome (CAIS) do not have ovaries, a uterus, or fallopian tubes, but externally they appear as normal females. Hence, they are raised as females and are often diagnosed only when they fail to menstruate at puberty. With the intraabdominal testes in situ, they develop into tall, willowy, well-developed females with a minimum of body hair, normal female external genitalia, and a functional though foreshortened vagina. The above description could be an advertisement for the ideal female fashion model.
Individuals with mixed gonadal dysgenesis, also known as asymmetrical gonadal dysgenesis, have a chromosomal mosaic of 45XO/46XY. They have a streak gonad on one side and a dysgenetic testis on the other, along with a potentially functional uterus and a fallopian tube on the side of the streak gonad. People with ovotesticular dysgenesis, previously known as true hermaphroditism, have varied external and internal anatomies ranging from a nearly normal male development to that of an apparently normal female. About 80% of them are 46 XX. Forty-six percent have an ovary or a testis on one side with an abnormal gonad – the ovotestis – on the other side, while approximately a third of them have an ovary on one side and a testis on the other. The remaining 20% have ovotestes on both sides. These situations clearly demonstrate that individuals with mixed gonadal dysgenesis and ovotesticular dysgenesis are not easily classified as males or females.
In the past, childrearing and anatomical reconstructive procedures were based upon the appearance of external genitalia, the success of certain surgical reconstructive techniques as compared to others, incorrect concepts regarding the ability to change the sex of rearing in infancy, and a lack of knowledge about the androgen imprint on the developing fetal brain.3 Mistakes were made and patients were hurt.
Although gender fluidity has been known for ages, the term gender dysphoria was first employed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 2013 (DSM-5).4 It states that gender variance by itself is not the pathology. Gender dysphoria occurs because of discordance between the body and the mind and it is also the result of how society treats these people. Transgender patients are distraught and often mutilate themselves or submit to procedures by untrained individuals when they do not have access to proper medical and psychiatric care. They have even been known to become so disheartened as to commit suicide.5 The fact that they are willing to make drastic changes in their lives, take supplemental hormones and subject themselves to major surgical procedures, knowing full well that complications could occur and that society will ridicule and humiliate them, indicates the seriousness of their commitment. There must be inherent changes in the brain that lead to this phenomenon, although we have not yet identified them definitively.6
Transgender athletes routinely have invective spewed on them. It seems extremely unlikely that they would transition just to win an athletic event or even to extend an athletic career that inevitably will be close to its end, if not definitely over, by the time the athlete is in their mid-thirties. It is true that a person that transitions from male to female after puberty has some testosterone-induced benefits for a while. However, the benefits are not uniform across the board. While a high testosterone level may be associated with better performance in some activities, it does not seem to offer any advantage in other sporting activities. For example, androgen-induced run time advantage over a mile and a half may persist for more than two and a half years after transitioning. On the other hand, male power lifters and about one in four elite male track and field athletes have low testosterone levels.7 Apart from not defining when and where the testosterone is beneficial, science has not yet determined how long it takes for androgen-induced advantage to be neutralized in individual activities. In addition, minimal attention has been paid to the other side of the equation. Once androgens are no longer functioning in them, female transgender athletes must propel the same larger body even after hemoglobin levels drop to female parameters within three to four months and power is generated by a reduced muscle mass.8
There are at least a million transgender individuals in the United States alone.9 Add to that the incidence of disorders of sex development (DSD), which is believed to be 1 per 1,500–2,000 births. Approximately 3.6 million babies were born in the US in 2020. Accepting the lesser incidence of 1 in 2,000 as the frequency of DSD and even with the reduced birth rate during the pandemic, we still added 1,800 individuals with DSD to the group in one year and will continue to do so every year. These two groups do not seem to represent a large portion of the overall population, but they are individuals with needs that have to be taken into consideration and are a part of society.
Athletic organizations are procrastinating in making regulations because of a lack of objective information. As they drag their feet, transgender advocates are forcing political decisions on them, which in turn is triggering a backlash. Both transgender and so called cis-gender women are suffering.
This whole issue of androgen-induced advantages could be avoided if individuals transitioned before puberty, but it is highly unlikely that would ever be accepted, regardless of what the data indicates. Because of the political, social, and religious sensibilities of the populace, there is much misinformation and disinformation on the subject. Data demonstrates that concern about these children wishing to detransition later seems to be grossly overstated. An overwhelming majority of these individuals experience gender dysphoria commencing early in life. In one study of 155 transgender women (TW) and 55 transgender men (TM), 73% (112) of TW and 78% (41) of TM first experienced gender dysphoria by seven years of age and their earliest memory was at 4.5 years for TW and 4.7 years for TM. Therefore, making them wait into adulthood seems unnecessary, and for parents to help make that decision for their son or daughter is not child abuse.10 The actual incidence of detransitioning is extremely low, there being only thirty-eight cases (0.17%) in a series of 22,725 individuals treated by a cohort of surgeons. Patients requested detransitioning for a variety of reasons such as rejection or alienation from family, loss of social support, difficulty in romantic relationships, and unhappiness arising from complications of surgery, along with twenty-two (0.09%) who cited a change in gender identity.11
Either intentionally or inadvertently, the judge gave a scientifically accurate answer. Furthermore, the senator was wrong in her conclusions. The Justice’s stand and statement informs girls that their voices matter, that they are not second-class citizens, and though it may take time, the matter will be resolved scientifically and not by the legal profession, political pressure, or posturing.1
- Ward M (2022): Blackburn to Jackson: Can you define ‘the word woman’? Politico 3-22-2022. https://www.politico.com/news/2022/03/22/blackburn-jackson-define-the-word-woman-00019543.
- Franklin C (2022): Have we become too reliant on deferring to experts. Chicago Tribune April 11, 2022.
- Radhakrishnan J, Alam S (2004): Androgen Insensitivity Syndrome In Bajpai M (ed) Progress in Paediatric Urology, Penwel Publishers PLC, New Delhi, India 7:93-114.
- American Psychiatric Association (2013): Diagnostic and statistical manual of mental disorders 5th. ed (DSM-5). Arlington, VA American Psychiatric publishing.
- Radhakrishnan J, Jayaram B (2022): Orion H Stuteville: A surgeon’s surgeon. Hektoen International Sections/Doctors, Patients & Diseases/Spring 2022. https://hekint.org/2022/03/28/orion-h-stuteville-a-surgeons-surgeon/.
- Altinay M, Anand A (2020): Neuroimaging gender dysphoria: A novel psychobiological model. Brain Imaging Behav. 14(4):1281-1297 doi: 10.1007/s11682-019-00121-8.
- Radhakrishnan J (2021): Sports and the uneven playing field. Hektoen International Sections/Science/Summer 2021. https://hekint.org/2021/08/23/sports-and-the-uneven-playing-field/.
- Harper J, O’Donnell E, Khorashad BS, et al (2021): How does hormone transition in transgender women change body composition, muscle strength and hemoglobin? Systematic review with a focus on the implications for sports participation. Brit J Sports Med 55:865-872. doi:10.1136/bjsports-2020-103106.
- Meerwijk EL, Sevelius JM (2017): Transgender population size in the United States: a meta-regression of population-based probability samples. Amer J Public Health 107(2)e1-e8. https://doi.org/10.2105/AJPH.2016.303578.
- Zaliznyak M, Bresee C, Garcia M (2020): Age at first experience of gender dysphoria among transgender adults seeking gender-affirming surgery. JAMA Netw Open 3(3):e201236. doi: 10.1001/jamanetworkopen.2020.1236.
- Danker S, Narayan SK, Bluebond-Langner R, et al (2018): Abstract: A survey study of surgeons’ experience with regret and/or reversal of gender-confirmation surgeries. Plast Reconstr Surg Global Open 6(9)suppl:189. doi: 10.1097/01.GOX.0000547077.23299.00.
JAYANT RADHAKRISHNAN, MB, BS, MS (Surg), FACS, FAAP, completed a Pediatric Urology Fellowship at the Massachusetts General Hospital, Boston, following a Surgery Residency and Fellowship in Pediatric Surgery at the Cook County Hospital. He returned to the County Hospital and worked as an attending pediatric surgeon and served as the Chief of Pediatric Urology. Later he worked at the University of Illinois, Chicago, from where he retired as Professor of Surgery & Urology, and the Chief of Pediatric Surgery & Pediatric Urology. He has been an Emeritus Professor of Surgery and Urology at the University of Illinois since 2000.