Male/female – a biological basis

This is the edited transcript of a talk which I gave recently on the subject of biological sex, gender disorders, current cultural trends from a medical point of view, following on from an earlier talk on the theological underpinnings of a Biblical understanding of sexuality and gender.

I’ve been asked to give a  biological and medical perspective on some of the current issues on gender and sexual differentiation.  A little bit of background on myself – I’m a GP, I studied medicine at QUB; I’m married with kids. I’m a Christian, and I am interested in the interplay between faith and science, between ethics and religion, not just as an interested, and sometimes troubled, observer, but as a practitioner on the ground, as a parent, and as a citizen. 

So why is this needed? What is it about today’s culture that needs me to stand up here and talk about something which is patently obvious to any layperson – that 99.9% of the time human beings are either male or female?

Up until five years ago, maybe, this was a non-issue. This was the accepted position in society, and had been for hundreds, if not thousands of years. But something has changed. Society has become unhitched from the past, from objectivity, from truth and arguably from common sense. 

Some portions of the society in which we live want us to rethink what exactly constitutes gender or sex, and want to separate us from the traditional understanding of what a human is. We are seeing aggressive campaigning by powerful liberal lobby groups, aided by an omnipresent media oligarchy drip-feeding us the new norm – you can be whatever you want! No-one can contradict you, or curtail you or categorise you. You are not a slave to authority or elders, your own body can’t even hold you back – you can change anything about who you are – this is freedom! And if you disagree, then you’re a hater, a dangerous oppressor, you might even be a straight white male! Your voice may be suppressed, you may be deplatformed, your employer may be informed, your position and reputation in society is at stake! It might sound fanciful, but these are genuine threats to people across Western world who disagree with this new idea of humanity. 

State of affairs in science

What has science got to say to this? There are conflicting voices within the scientific and medical world when it comes to issues such as gender and sexuality. On the one hand, our understanding of the human body, of how it works, how it breaks, how to fix it, our understanding is built upon the work done by scientists over the last couple of hundred years, and that shows no signs of changing. No-one is coming along to say that, actually, hearts pump backwards, smoking is good for your health, brains are just for keeping your body cool. By its empirical nature, science is a discipline of building on what is already established, rightly or wrongly. 

But science is open to be manipulated in insidious ways.  All scientists need funding. Every research project, certainly involving humans, requires ethical approval. Many researchers are employed by companies and universities. What we are increasingly seeing is the stifling of research which would potentially go against the current popular causes. It is nearly impossible in the current academic climate to run a study on people who regret having gender reassignment surgery. Professionally, it is suicide to talk about therapy aimed at helping people deal with unwanted same sex attraction. Not being completely affirming of someone with gender dysphoria is tantamount to physical violence, and risks provoking complaints and punishment. Even the hard sciences are not immune from this craziness.

So what can we do? Well, God has helpfully revealed Himself through His Word, but He has also revealed Himself through the book of nature, through general revelation. And what I’d like to go through briefly is a very short primer on the biological basis for sex. No-one questions these facts, and they are astonishing in themselves, but also, I hope, very reassuring to people casting about in today’s society for solidity and objectivity. I’m going to move from the lesser to the greater, looking first at genes and chromosomes, then moving up to cells, then organs, then bodies, then beyond. I’m going to talk about what’s normal. Then, we’ll briefly look at what can go wrong.
Chromosomes and genes. People think that James Watson and Francis Crick were the first people to discover DNA in the 50s, but it was actually first detected in 1860 by Swiss chemist Frederick Miescher. But it wasn’t until the early part of the 20th century that scientists started to realise what its function was. DNA is the name for a carefully arranged selection of protein building blocks found inside every cell in the human body – through many complex mechanisms, the coding on the DNA decides very many aspects of that cell’s function, and on a broader scale, the function of many parts of the body, from your hair colour to your risk of developing diabetes. Scientists recognise some of these codes are in certain areas, and do certain specific things, and we call these genes – some contain a little bit of coding, some are very complex indeed. The strands of DNA containing these genes form structures called chromosomes, and nearly every cell in our bodies has 22 pairs of different chromosomes, plus a pair of special chromosomes. And it’s these special chromosomes which are of interest to us at present, because these are the little clumps of protein which decide whether you start off life in a pink or a blue babygro. 

So these are the X and y chromosomes. If you have 2 copies of the X chromosome, then you are female. If you have an  X and a y chromosome, biology dictates that you are male. And every single cell in your body will have exactly the same configuration of X or y chromosomes (apart from sperm and egg cells, which only have one copy of the sex chromosomes). So the cells in my skin – if I analyse them, every one will have an X and a y chromosome, because I am genetically male. If I look at some white blood cells from my wife’s body, they will have two X chromosomes, because she is genetically female. So, say I don’t like being male, and want to change my y chromosome to another X chromosome – can I do that? I mean, I’ve heard about gene editing technology, gene therapy, whereby faulty genes might be able to be fixed using special viruses? No! It’s not possible! An X chromosome is so radically different in shape to a y chromosome – that one’s shorter, has different genes, folds differently, looks different. You can’t just chop one out and splice another one in like a bit of old cine film. I am happy to say without a shadow of a doubt, that there is no way to change your genetic sex from male to female, or vice versa. It just can’t be done! These things are set on a chromosomal level, a genetic level, a foundational building block level, and science has to admit defeat on this fundamental point. When Genesis 1 states “male and female He created them”, this is not just a broad theological statement, it is unalterable biological fact! Isn’t that reassuring?

But little bits of DNA seem very far removed from our lived experience, don’t they? How do they decide the broader aspects of who I am as a human being? The study of embryology is something which has fascinated me for years. It’s the study of the developing organism – how a sperm and an egg cell fuse together, how they combine their two separate half copies of a genetic code in an entirely new way to make a new and unique creature, and then how that newly formed organism grows and changes to become an independent and fully functioning life all of its own, capable of then reproducing and keeping the cycle going. It’s an amazing process, and we could spend hours over it, but what we’re interested is how that genetic code causes sex differences between male and female human beings. The weird thing is that, until 7 weeks of age, the human baby in the womb is not visibly male or female. He or she possesses a set of neutral structures in their body which have the potential to change into either male or female sex organs, depending on what their genes dictate. So for a female child, some structures automatically develop, and others automatically degrade and disappear, allowing the formation of ovaries and the uterus. For a male child, a set of genes kick in to cause the release of a particular hormone which stops this process, and gives the opposite effect – testes form instead of ovaries, and the structures which would have formed a uterus degrade and disappear. So even at this early stage of development, whenever the mother may not even realise that she is pregnant, her child’s genes are causing them to be not just genetically male or female, but anatomically male or female. And assuming all goes to plan, then the presence or absence of that little genetic signal starts a lifelong characterisation of that human being as either clearly male, or clearly female, microscopically and macroscopically. There’s no argument about this amongst scientists – these things have been shown and demonstrated for the best part of a hundred years. When David sings in Psalm 139 “you formed my inward parts; you knitted me together in my mother’s womb. I praise you, for I am fearfully and wonderfully made” he is amazingly prescient about these intricate processes that go into making us who we are. 

By 12 weeks, the human child in the womb is recognisably male or female, and there is no further physical development in terms of sex differences until puberty, whenever secondary sexual characteristics like body hair patterns and breast development occur. The real changes that are happening during those first few years of life are to do with brain development and socialisation, how a child learns from their parents and their peers their role as a boy or a girl in society, how to act, what to wear, what activities they will gravitate to. The age old debate over whether it is nature or nurture that causes a boy to gravitate to footballs and a girl to gravitate to dolls is as yet unresolved, despite many claims to the contrary, but I’m not sufficiently qualified to talk about that. But there are objective sex differences which do show themselves later on in childhood – girls will usually hit puberty earlier than boys; they will usually stop growing at an earlier age, and they will usually be shorter than their male equivalents. And in terms of other biological differences, the eggs which they have carried in their ovaries since they were 18 weeks old start to mature and be released on a monthly basis, ready to be fertilised, all through her adult life, to around her early 50s, when this process stops. Each girl has millions of egg cells from when she is herself in the womb – she doesn’t form any new ones after she’s born. She doesn’t start producing eggs during puberty in response to hormones – it’s the existing ones maturing. It’s different for boys, though – sperm cells aren’t formed in the womb, they start to appear during puberty and continue to be made anew all through adult life. Once again, you can see that we have profound biological sexual differences, no sane person is going to argue against these facts. I could go on to talk about gender roles in different societies, we could discuss evolutionary theories, we could look at animal models of sexual differentiation, but we would all come out at the same place – normal human biological development produces clear male and female individuals, with no interchange possible or necessary.

But that’s normal. What about when things don’t go according to plan? Because that’s where the confusion starts. It’s safe to say that abnormal chromosomes, abnormal gene expression, abnormal anatomical developments are all very rare. The vast majority of people in this world have a very clear normal physical expression of their chromosomal and genetic sex. But we need to consider this small minority, because it’s the fringe cases, the uncommon abnormal cases that are used to drive the liberal agenda, the exceptions to the rules which allow the rules to be dispensed with. So I’m going to work from the microscopic level to the macroscopic level again, we’re going to look at chromosomal abnormalities, then developmental problems, then psychological disorders.

Chromosomal abnormalities – broadly speaking, when you talk about these, you’re either looking at something which has been added on, or taken away; so Downs syndrome, for example, is whenever someone has a third copy of chromosome 21, and most of us are familiar with some of the profound problems that can cause. There are a number of sex chromosome abnormalities, but they are generally fairly mild and unexciting – the most common ones are found in males – something called Klinefelter syndrome – there’s still a y chromosome, but the patient will have extra X chromosomes – so they might be XXy, or XXXy. It can cause problems with intellectual development, and can affect fertility. But the patient is still recognisably male. It occurs in about 1:1000 live male births. Another reasonably common sex chromosome variant is Turner’s syndrome, which is where there is only a single X chromosome, and no extra X or y chromosome – the individual is recognisably female, but they generally don’t develop normally at puberty, and they are generally infertile – this occurs in about 1:5000 live female births. An even rarer variant is something called 45X/46Xy mosaicism – 1:15,000 live births – the individual actually has some cells which have Xy chromosomes, being male, and some cells with just an X chromosome, a bit like Turner syndrome. They are generally male in appearance, and can go through puberty normally, but they have other physical developmental problems, and quite often have problems with their external genitalia. I think it’s safe to say, that in the majority of these chromosomal problems, distressing as they may be for the individual and their parents, there is no confusion about which gender these kids are; they may need surgery, they may need artificial hormones to allow them to develop fully as adults, and it may be difficult or impossible for them to be parents, but they are generally clearly male or female.

Developmental abnormalities – this is where the confusion sets in! Basically, this is where there is some disorder of the expression of the genetic and chromosomal sex that leads to abnormal physical development of sex organs. This can be something very slight – a minor abnormality of male or female sexual organs which is only noticeable on close examination – it can be more significant, where there is some partial development of elements of both male and female sex organs – or it can be total transposition, whereby the chromosomal sex and the physical sex are opposite. We’ll look at the last two variants. 

So the presence of some sexual characteristics of male and female is sometimes called intersex, previously called hermaphroditism. It’s hard to say how frequent this is, but it is pretty rare. It’s often picked up at birth or in early life, and the ethical debate over the last few years is whether surgery is offered at a young age, or whether the child is allowed to reach an age when they themselves decide whether they want surgery, and which sex they want to be. 

The one that’s been getting all the press lately is a condition called androgen insensitivity syndrome (AIS), and similar disorders. I was talking about the structures in the 7 week old child earlier – the growth of one, and the wasting of the other depend on the presence or absence of a particular chemical – if that chemical isn’t produced, the individual develops female organs. That’s ok if they are a chromosomal female, but if they are actually chromosomally male and have problem with the expression of that key chemical, and go on to develop as a female, then that’s where the confusion comes in; and our most famous example of this condition is Caster Semenya, the South African middle distance runner – she is documented as having Xy chromosomes, so is genetically male, but was raised as a girl, and competes in women’s sports. The confidential details of her exact physical makeup obviously aren’t public knowledge, and it’s not wise or kind to speculate about them, but we can spend a little time thinking about this group of people – albeit a small group – it’s thought to occur in less than 1:20,000 live births. For a lot of people, they don’t find out until puberty, or even later, whenever they can’t conceive, or can’t father a child. Can you imagine how that must feel for someone? Discovering, perhaps in your early teens, or mid twenties, that you are actually not genetically the sex that you have been raised? We need to think compassionately about people with these developmental conditions. Most people, especially those with complete swapping of sex characteristics, will want to stay in the gender that they’ve lived in all of their lives, and that is generally manageable and reasonable with a greater or lesser degree of medical assistance. 

So I’ve dealt at some length with genes, proteins, development and organs. I haven’t yet touched on the big area of growth in the last few years – I’m referring to people who have no physical abnormalities, whose genetic sex matches the physical manifestations of their sex; but people who have the strongly held belief that their sexual identity is different from their biological sex. One term for this is transgender. I would say at the outset that I am not an expert in this, and I strongly suspect that no-one is an expert in this, because the field has exploded over the last five years, and continues to change and morph on a weekly basis into something constantly changing. What we as doctors and scientists accepted as being clear up until about 5 years ago is now murky and fraught with confusion. You might be confused about transgenderism – so are we! What we can do is trace the development of a disorder, how something which was initially rare and pathological came to be accepted on a wider societal scale, normalised, and actively promoted as a valid life choice. You can compare the path that transgenderism has taken to that of homosexuality – how something shameful, even criminalised, regarded as pathological, but because of vocal lobbyists and liberal pressure in a sympathetic media, came to be gradually accepted as normal and valid, rightly or wrongly, even aspirational.

Let’s consider what transgenderism looks like from a medical point of view. The patients whom I’ve known with this disorder have complained of a longstanding feeling that, deep down, they are not their biological sex. They may be male, but have a deep seated belief that they are really female; or vice versa. Sometimes this has been from a very early age, as long as they can remember, sometimes it comes with adolescence, rarely later in life. And this generally isn’t related to some sexual perversion – they identify with the opposite sex, and pursue activities usually identified with the opposite sex. They may be disgusted by their own body, by their own sexual characteristics. To meet the criteria for gender identity disorder, or the new term gender dysphoria, this must have gone on for at least 6 months.  It had until very recently been accepted that this was a psychiatric diagnosis, a psychological problem. And that was fine. There are a number of psychiatric disorders whereby someone has difficulty with the nature of reality, or the nature of their own existence, or even the nature of their body – we can compare this to anorexia nervosa – an anorexic weighing 4 stone can look at themselves in a mirror and see someone grossly obese, and want to starve themselves further. Their view of their own body is radically at odds with reality. Given the chance, they will starve themselves into an early grave, and it is a tragic thing, and no-one argues that they need intensive psychiatric and medical and psychological support for months and years; even then, there is a significant death rate. Consider people who have Obsessive-compulsive disorder, OCD – they may have very strong beliefs that something terrible will happen if they don’t check the front door lock exactly seventeen times, or that someone close to them will die if they don’t spend three hours cleaning the kitchen floor. To an outside observer, these beliefs make no sense, and we don’t hesitate to enlist specialist help for people with these beliefs. If we consider people with schizophrenia or bipolar disorder, often they exhibit the most florid delusions about things – they might have a fixed belief that they are, in fact, the second coming of Christ, or the Queen, or that they have the power to cure cancer – we don’t hesitate to try and restore these people to a version of reality that matches everyone else’s. And it used to be the way that, for someone who experienced gender identity disorder, they underwent counselling and therapy to allow them to be accepting and comfortable in their own body. However, that went out the window a long time ago, once scientists realised that, with surgical techniques to change the appearance of external genitalia, hormone blockers to block the body’s own hormones, and replace them with artificial hormones, you could make a fairly good attempt at changing someone from being male, to the appearance of being female. For many people with some form of gender confusion, this is what they look to as being their panacea, the end of their search. 

So what are the problems with all that I’ve said so far? Why can’t we just accept the current trends, as Christians, and accept these poor people as they want to be identified?

1.This is the only psychological disorder that I’m aware of in which a patient’s false beliefs are held to be true, and in fact reinforced and supported. This is like me saying to the anorexic that he looks a bit chubby today.

2. This is the only psychological disorder in which surgery is offered, not to remove a cancerous organ, or to remove diseased tissue, but to remove normal, healthy tissue because of a patient’s faulty beliefs.

3. This is a significant point, because this is a mainstay of the transgender lobby’s argument. Psychiatric disorders have a mortality rate, just like heart disease and cancers. A significant number of people with gender identity disorders self harm, and commit suicide, just the same way that people with depression or schizophrenia are at risk. The argument goes that, if we don’t affirm these people in their new identity, then we are putting them at risk of suicide. In fact, if they go on to kill themselves, that is our fault – we are responsible. That is quite an accusation. But we need to be careful when we listen to this rhetoric. The problem with statistics is that is very difficult to get accurate ones and to interpret them appropriately. One well performed study in Sweden found that identifying as transgender meant that you were 19 times more likely to commit suicide than the general population. But it also found that, even with hormonal treatment and surgery, the suicide and attempted suicide rate stayed the same. It did not decrease. In fact, there’s good evidence to suggest that the suicide rate increased. Surgery and hormone treatment does not cure this disorder.

4. At least half of people with gender identity disorder also have other mental health disorders, such as anxiety and depression, substance dependence or personality disorders. It is immensely difficult to treat multiple psychiatric disorders at the same time, and it is especially unwise to validate one while denying another. People with gender identity issues tend to be unhappy people, we need to tread carefully.

5. There’s also the issue of social contagion. It’s my opinion that, for some people, they need a way to express their deep unhappiness in some outward way that will elicit empathy from people around them; they need a shocking but socially acceptable way to do that – for some people that might be through self harming behaviour; for others, in our culture right now – it may be through questioning their gender identity. This deep seated dissatisfaction and turmoil within their hearts, whatever the cause of it may be – family stress, previous trauma, parental abandonment – is expressed consciously and outwardly as a turning away from their biological sex. Right now, this is fashionable, this is trendy – this is, in fact, what social contagion looks like. There is no other way of explaining why, all of a sudden, you get 5 kids in the same class who say they are all transgender. How do you explain that? What we see is the blurring of the boundaries between genuine psychiatric disorder and forms of cultural expression

6. Something like 85% of kids with gender dysphoria resolve spontaneously within a few years, without intervention. If we immediately refer all these kids for hormone blockers and surgery, and affirm them in their new found gender identities, we are actually preventing the resolution of an illness. Is it good medical sense to give medication that keeps someone from getting better? Not usually.

7. Hormonal treatments have profound effects on many aspects of their body. If you give a child at the age of 9 or 10 hormone blockers to delay puberty, or if you adminster artificial hormones, then you can cause untold damage. Bone density changes. Restricted growth. Infertility. Clots. Cancer. The studies haven’t been done to show what long term damage these meds can do when used in this way. Surgery causes complications, people get sick and occasionally die because of these interventions. The treatments are potentially harmful, and people will likely die as a result.

So, after all that, what can our response be as Christians?

  1. Compassion. We love these people as image bearers of God, even though we may disagree fundamentally with what they are saying. In fact, we have to work harder to love people who are more needy, so they should have more of our compassion than those around us who are easier to love! We should have a heart for the outcast and the oppressed. 
  2. Understanding. It’s ok to listen to their story, and try and see things from their perspective, but I would caution you all to be aware of the power of story. A good story, powerfully told, is able to catch you off guard, and before you know it, you can be emotionally involved with the teller, without engaging your critical faculties. Think! “Come, let us reason together”.
  3. Identify. None of us are who we want to be. None of us, on the inside, are what we show on the outside. At a fundamental level, we are all hypocrites. If our nearest and dearest knew what went on inside our hearts, they would shun us. We all have a disconnect at some level because of our sinful natures, and God knows this and recognises this, and acted to save us from ourselves. Not to stay in our sin, but to remake us in the pattern of Jesus. That is the narrative that we need to keep in mind. This is a powerful counter-narrative to the secular humanistic ideas that society is afloat with. It is not our bodies that need to change, it is our hearts that need radical life-giving surgery and then years of sanctifying therapy administered by the Holy Spirit and mediated through the Word. We should be able to identify with people who have gender identity issues, because we have identity issues too – like Paul says in Romans 7 “For I delight in the law of God in my inner being, but I see in my members another law waging war against the law of my mind and making me captive to the law of sin that dwells in my members. Wretched man that I am! Who will deliver me from this body of death?”
  4. Do we affirm? This is where we are going to be challenged. If things continue the way that they are going, many of us will be faced with people in our work, our schools, perhaps even our homes, who want to be recognised as being a different gender than their biological sex. Maybe they will want to be recognised as being one of these fancy new genders which are made up every day. Maybe they will want you to call them by a pronoun which they have decided upon, or give them a title which is gender neutral. What will we do? God calls us to wisdom. He calls us to be wise as a serpent, and to be gentle as doves. He also commands us not to lie. In these interactions, we will walk the fine line between not offending someone by being actively antagonistic, but also not being compromised or browbeaten into affirming something which is untruthful. Ultimately, if you are backed into a corner and being forced into calling black white, or white black, then you stand firm. The emperor has no clothes on – there, I’ve said it. What happens next is up to God. Do we seek out persecution, do we make ourselves obnoxious to court controversy – I don’t think that is the biblical way. But do we expect to be shunned, or laughed at, or singled out for having a biblical view of sexuality? yes, of course, increasingly so day by day. Might this affect our professional standing, our employability, our social acceptability? Of course it may! But here’s my advice – spend the time now to think about these things, to think through how you might deal with these situations. Have your position carefully thought through, and be “ready to make a defence  to anyone who asks you for a reason for the hope that is in you”. So for example, if a patient were to come to me requesting referral for gender dysphoria, then after listening and questioning them in the usual fashion, then I would have to politely decline their request, stating my reasons why I would not be happy to make that referral. I could advise them of some other resources, but ultimately my conscience would not permit me to be part of the process of that person being referred for forms of therapy which would be in contradiction to my firmly held beliefs. In the same way, if I get handed a script to sign for hormone tablets or injections for someone who is already in receipt of therapy, then I don’t sign it. But because I’ve thought through these scenarios and have a clear idea in my head, and have explained to my colleagues why there are certain things which I can’t in good conscience do, then when those situations arise, I can act with a clear head. I would advise all of you to consider your own circumstances and how you might react.

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