Rhetorics of the Culture Wars: Is Biological Sex a Spectrum?

There's a moment during V for Vendetta when the voiceover tells us ominously that at a certain point in the recent history of the authoritarian dystopia which the film depicts, "America's War" reached England. The film was released during the days of the War of Terror and is saturated with the rhetoric and imagery of that era. Fifteen years on and it is the American Culture Wars that are threatening to make a wholesale jump over the Atlantic, and nowhere is this felt more strongly than in the politics of sex and gender. 

One skirmish linked tangentially but significantly to current struggles over transgender-rights is whether biological sex is binary or exists as a "spectrum". A relatively recent article in Scientific American by their associate graphics editor Amanda Montañez, has even gone so far as to create a visualisation purporting to show the spectrum of biological sex and how each position within the spectrum relate to each other during development from birth, through puberty to adulthood.

The Anglophone world has seen huge changes over the past half century in the way in which sexuality and gender are conceived. We're by now familiar with thinking of both in a variety of different ways, and thankfully long gone are the days when homosexuals like Alan Turing would be prosecuted and subjected to electric shock treatment. More recently has been a rise in the prominence of trans-politics and rights claims being made in order to depathologize and demedicalize the status of transgendered people and the process of changing a person's legal gender. In the UK this has risen to public consciousness owing to proposed changes to the Gender Recognition Act (2004) that would allow a person to change their legal gender without the need for approval by doctors or psychiatrists. 

The proposals and subsequent public consultation have elicited a backlash from some women's groups; one of their claims being that so called "self-ID" would undermine women's spaces by making it too easy for biological men to change their gender and access them. There are also questions about the impact of potentially removing the sex based exemptions from the UK Equality Act which has allowed spaces like women's refuges to deny access to trans-women and to exclude them from women's sports.

In most discussions around these issues the biological basis of sex is still thought of as binary. That being said there is also evidence of a great deal of slippage and imprecision between notions of biological sex, a person's gender "identity", and their legal gender. It is occasionally difficult to establish precisely what is being disputed or the depth and breadth of some of the claims being made. Beneath the radar however it is clear that the binary basis of sex has begun to be challenged and several controversial articles in scientific publications have appeared in recent years. At the core of the argument is the expanding field of research into so called differences or disorders of sex development (DSDs) and the status and significance of Intersex people. 

To give some indication of the ground being covered and what "biological sex" here refers to, here is a concise summary from a review article in Nature from 2014: "Mammalian sex determination is the unique process whereby a single organ, the bipotential gonad, undergoes a developmental switch that promotes its differentiation into either a testis or an ovary. Disruptions of this complex genetic process during human development can manifest as disorders of sex development (DSDs)".

One of the first articles I've seen (also from the Nature website) which cites the notion of a spectrum of sex is Claire Ainsworth's informative summary of our broadening understanding of the developmental processes involved in biological sex from genetics, through endocrinology and anatomy. Although the data on these expanding bodies of knowledge is compelling she does not so much argue the claim that sex is a spectrum as assume it based on the very fact of the variety of intersex conditions. This is clearly question begging. The same can be said for a more recent article by Liza Brusman which presents some of the same data from the Ainsworth's article but with a far stronger emphasis on the spectrum interpretation and its possible political ramifications. 

For instance she suggests expanding the language of US civil rights law such as Title IX to include "all" sexes and genders. Though clearly to do that we would need to first settle on precisely what and how many new sexes we are talking about, and which Intersex conditions to append them to. Brusman though is adamant that society has to catch up: "The science is clear—sex is a spectrum".

Is this really the case? Does the diversity of DSDs and our broadening understanding of them at multiple levels of the human organism force us to conclude that sex is a spectrum?

It's worth noting that the category DSD is not some old-world received medical term designed to erase the hitherto unacknowledged existence of a spectrum of the sexes. It was in fact brought in with the Consensus Statement on Management of Intersex Disorders in 2006, which was the outcome of an international conference involving experts from a diversity of fields and patient advocates under the auspices of the Pediatric Endocrine Society and the European Society for Paediatric Endocrinology. 

It replaced otherwise unscientific and stigmatising terms such as pseudohermaphroditism, hermaphroditism and sex reversal from the accepted medical terminology. Despite this, some Intersex advocacy groups reject the term on the basis that 'disorder' remains stigmatising. DSDs are defined in the literature as “congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical”. Nowhere in this medical literature is an argument made for DSDs constituting 'new' sexes.

As the most up-to-date of the writing on this subject concedes, the total proportion of live births with conditions falling under the general category of DSDs may amount to no more than 1-1.7%. Of these cases the vast majority consist of late onset (non-classical) Congenital Adrenal Hyperplasia, a condition caused by a deficiency in one of a number of enzymes involved in hormone production, and which only presents symptoms at puberty. The remaining proportion of DSDs include a wide range of genetic conditions, each impacting on an individual's appearance, fertility and development in different ways and to different degrees. Amanda Montañez' graphic demonstrates this quite neatly and has considerable didactic merit in this regard.   

To better answer the question (which by now the reader should recognise as very much a meta question) of whether DSDs constitute evidence of a spectrum of the sexes, we might start with asking what exactly IS a spectrum, and what is it the claim that sex is a spectrum is actually meant to do to our traditional understanding of sex as binary. To enquire in this way is not to question the science; the science is clear, there are lots of different DSDs and people with intersex characteristics as a consequence. This is a question about how a large body of scientific and medical research enters public consciousness and intersects with the demands and hopes of political activists and commentators. It is necessarily a question of interpretation.

Spectral Rhetoric in LGBT+ Discourse

Dictionaries are rarely reliable places to discover the meaning of terms as they are used in the heat of contemporary political disputes. It's a particularly pedantic trapping of Anglophone culture to demand strict consistency with dictionary definitions when engaged in argumentation. Anglo-Saxons are still resistant to the notion that the ultimate meaning of words come through their use, and similarly that the endless possibilities inherent in human practices consequently means that a word's definition can never be final. 

Nevertheless the Oxford English dictionary offers two definitions for spectrum: 1. a band of colours, as seen in a rainbow, produced by separation of the components of light by their different wavelengths. 2. Used to classify something in terms of its position on a scale between two extreme points.

The second of these definitions would seem to have obvious significance for describing biological sex as a spectrum, especially as it is visualised by Amanda Montañez in her graphic. The extreme points would be the typical biological male and typical biological female. And indeed it is at the extreme edges of her graphic that we find those positions. The first definition highlights that spectrum was first used in a scientific sense to classify the range of colours in the rainbow and later by extension the whole continuum of wavelengths of electro-magnetic radiation. The paradigmatic spectrum then is the rainbow, which is also the iconic flag of the LGBT+ movement. This is not without significance, nor is the fact that Montañez has used the rainbow as an indicative part of her graphic. The semiotics of the rainbow and by extension the way in which the term spectrum is used within LGBT+ discourse draws in a wide variety of inferences and associations which makes the claim about biological sex more complex than it seems.

The "spectrum model" of gender and sexuality is a much more familiar notion than a spectrum of the sexes. It's become a more common description as the range of sexual practices and gender identifications continues to diversify in Western societies. Dating apps are good place to get up to speed on the cutting edge ways in which many people identify themselves and their sexuality. In addition to hetero, homo and bisexuality it's not uncommon to see people identify as Queer, pansexual, sapiosexual, and even asexual. 

There are also intermediate and modal variations which signify that an individual may identify with two or more forms of sexuality. Or in the case of so-called homo and hetero-"flexibles" a person may have a general tendency but admit exceptions and not wish to identify as bisexual. Diversity is implicit in the iconography of the rainbow and is matched by the avowed openness of the LGBT+ movement to both non-conformity and change.  

The situation is at least if not more diverse in the case of gender, as the concept draws in a broader range of influences than just those involved with sexuality. The website Genderspectrum.org describes gender as involving a complex interrelationship between our experience of our body, our identity and society. It's arguable that each of these categories imply each other and indeed it would seem impossible to think of a personal identity that could exist without a social component. If there are no private languages then by extension that would seem to rule out private identities. Another way of thinking these three domains might be as the embodied, the personal, and the interpersonal. Gender identity - as the website states - is "our internal experience and naming of our gender. It can correspond to or differ from the sex we were assigned at birth".

We would expect the naming of our gender identity to also involve these three domains of experience. Names never exist in isolation and the signification of a gender identity is a matter of social contestation, appropriation and development. Think of how the notion of masculinity has been challenged, reasserted and reappraised during just the latter half of the 20th century. Think of how "traditional" ideas of womanhood have changed during the same period, often in response to developments in reproductive technologies or the wholesale entry of women into the workforces of Western economies. Indeed it is commonly held that "detraditionalisation", as it is known in the sociological literature, has been one of the principal drivers of diversification in the fields of gender and sexuality.

Like those traditional categories of man and woman, contemporary gender identities like non-binary, transgender, genderfluid and genderqueer are similarly rooted in social practices and so are never stable or fixed; further diversification and change is inevitable. The variety of sexual and gender identities are social facts, continuously emerging from the complex interplay of forces within modern societies. Analogous to the openness of language itself, conceiving gender and sexuality as spectra is a necessary correlate to the fact of human freedom and the capacity for change and diversification brought about though human practices. Another way of putting it is that their existence depends on the nature of the human as a free, acting and self-fashioning being.

Can we say the same for biological sex?

One of the many graphics illustrating the spectra of gender identity and sexuality. This one also includes biological sex.

One thing the LGBT+ movement has been extremely good at is contesting the hegemony of the so-called typical case. In sexuality this has traditionally been targeted at the assumption that heterosexuality is the norm (so-called heteronormativity). And in gender there have been significant advances in challenging social stereotypes associates with being a man or a woman, as well as the opening up of a myriad of gender non-conforming identities. Insofar as the rainbow is synonymous with the spectrum model, it signifies clearly that there is no typical case, no hegemonic norm. All positions within the spectrum are equally valid, and equality - especially in Law but also in terms of cultural legitimacy - are two of the principle political aims of LGBT+ activism and advocacy. 

This is the context and set of inferences brought to bear when it is argued that biological sex is also a spectrum. We could say then that to describe it as such is to claim biological sex territorially for the semiotics of LGBT+ discourse. It is to say that the things which are ordered within the observable range of biological sex are ordered in a way significantly similar to those things within the spectra of sexuality or gender. It is also to contest the hegemony of the norm, which in this case is the status of the "typical" biological male and female.

Unpicking the meaning of the attribute "spectrum" when used in this context helps us to understand the incongruities when it is applied to something like DSDs and biological sex more generally. The most important difference is this: DSDs like PMDS, 5-alpha reductase deficiency, and conditions caused by missing or additional sex chromosomes are not the product of human freedom and practice. They are not social facts. Before these conditions were discovered and their genetic basis understood they still existed. The biological basis of DSDs is not sustained by discourse and contestation; they are not brought into being by creative self fashioning. They are very different types of things to gender or sexual identities. 

There are also only so many DSDs (currently about 40 are known). Unlike the open ended nature of human practices they do not admit to the infinite realm of possibilities that we associate with the continuum of sexual and gender identities captured by the spectrum model. This is not to say that new DSDs won't be discovered or appear owing to natural genetic variation, but here we are clearly talking of discovery rather than creation.

The scientific significance of DSDs is undoubted. But scientific significance does not automatically equate to political significance, or at least the kind of political significance that neatly maps onto established strategies and forms of argumentation within the LGBT+ movement. As mentioned above, one of the signal functions of LGBT+ activism is to contest the validity of hegemonic norms and assert the equality of all members within the spectrum of identities. This is problematic in the case of biological sex for at least two reasons. 

Firstly, even Montañez's graphic marks biological male and female as the typical cases to which all the DSDs are related. Indeed it's questionable whether any of the "gradations" she visualises can be thought of independently of their relation to one or both of those typical cases. This is especially so as each of the DSDs included are caused by genetic defects of what would otherwise have been a typical case.

To better illustrate this point lets go back to the spectrum of sexual identities. Let's consider Sapiosexual, which is someone who identifies with being particularly attracted to intelligence. In order to understand this do we need to make reference to other identities within the spectrum? Seemingly not. Aside from a general understanding of what a sexual identity is Sapiosexual is perfectly intelligible without reference to other points on the spectrum. Indeed even if there were no other sexual identities Sapiosexual would still be intelligible in every significant way. It is a discrete member of the set of sexual identities. This however is not the case with DSDs. Each condition by its nature is a specific variation from the typical observed case and this is reflected in the names given to many DSDs such as "deficiencies", "dysgenesis", "disorders" etc.

Secondly, there is I think a strong claim that Montañez's graphic and much of the popular writing which uses DSDs to claim that sex is a spectrum misrepresents the data. It is always worth remembering that the way complex scientific data is presented goes a long way when making arguments that revolve around interpretation. It is undeniable that the way the graphic is presented - especially with the inclusion of the rainbow strip on which are listed the names of various DSDs - calls out "spectrum". But this is only one way of showing the data and perhaps it is missing a very important component, weighting. 

Outline of the 21-Hydroxylase deficient variant of CAH

As already mentioned the total range of DSDs may account for only 1-1.7% of live births and that perhaps only 0.2% are made up of conditions other than Late Onset Congenital Adrenal Hyperplasia (CAH). That means that the genetically and physiologically typical cases make up at worst over 98%. When you take into consideration people with Late Onset CAH are karyotypically normal and experience no physical symptoms until puberty, you are left with a figure of around 1 in 500 live births potentially showing some signs of DSDs. Also worth noting is that the cases of ambiguous genitalia - the DSD that gets most coverage in popular media - affects an estimated 1 in 4500 births.

If this weighting were taken into account the graphic would look very different indeed. The typical biological male and female, which in Montañez's version form the extreme ends of her spectrum would, when weighted correctly, look like brick sized slices of bread between which an ultra wafer-thin slice of cheese would be located representing the totality of DSDs. Would a non-specialist looking at such a graphic be likely to conclude that biological sex exists as a spectrum? I suggest this is unlikely and what such a weighted visualisation would instead do would be to emphasise that biological sex is only intelligible as a binary, but that there also exist a small minority of exceptions to the typical cases, which are of wide ranging types. 

However, those exceptions are only explainable as exceptions by relation to the typical binary cases. Androgen insensitivity is only observable owing to the fact of the typical level of "sensitivity" being understood; just as mutations in CYP21A2 or SRD5A2 genes are only understood owing to the sequence for the functioning enzymes they code for being known from the typical cases. None of the conditions falling under the category of DSDs are defensible as discrete sexes in their own right. They are quite simply different kinds of things to gender and sexual identities and to treat them as if they were not is nonsensical.

I said above that the 2nd definition of spectrum - to classify something in terms of its position on a scale between two extreme points - might superficially have greater applicability to biological sex. At least this notion of spectrum acknowledges the validity of the extreme points; something the continuum version of spectrum - the one used when we talk about sexuality and gender - does not. It does however make little sense to claim that DSDs represent "gradations" between the typical biological male and female that can be used to plot a scale from one to the other. 

Each condition has its own specific aetiology and characteristics at the genetic, hormonal and physiological level. Classifying them as more or less male or female is a forced abstraction that is rooted neither in the science or the way in which these conditions are approach from a practical medical standpoint. And even if one could in some remote way describe the distribution visualised by Montanez as having genuine "spectrum-like" qualities it is still less than obvious what the political significance and benefits of this might be for those individuals who could be described as belonging to one or more new non-binary sexes.

What are the Political Implications?

So what are some of the political implications at stake here? What would be the virtue of arguing for a spectrum of the sexes and how might such an interpretation impact current advocacy issues around Intersex people?

Homosexuality used to be considered a illness with potential criminal tendencies; it was treated "medically" with drugs and torturous treatments like electric shocks. Despite homosexuality being legalised in the UK in 1967 it wasn't until 1987 that it was fully removed as a "mental disturbance" from the DSM (The American directory of mental disorders). Depathologizing homosexuality was a big step towards reducing social stigma and paving the way for gay rights in areas such as anti-discrimination law and most recently marriage. 

DSDs, however, are by definition disorders, their cause is traceable to anomalies in the building blocks of life, our DNA, and can result in extreme cases (as with the salt-wasting variant of Congenital Adrenal Hyperplasia) in life threatening illness. As genuine medical conditions many of them demand some kind of appropriate, compassionate medical response, and it is not at all clear how depathologising them under the rubric of a new spectrum of the sexes would benefit people born with DSDs.

A great deal of Intersex advocacy does focus on healthcare responses. One area where there is a considerable amount of work being done is in the area of laws protecting the bodily integrity of intersex people, especially where it concerns non-consensual genital surgeries, sometimes called "assigned sex". This is to do with those rare cases of babies born with so-called ambiguous genitalia and the medical responses that ensue. In many cases there is little in the way of ambiguity and the child's sex is not in dispute. Surgery might take place - for example in boys - because the genitals are not considered "male" enough. This has resulted in cases where new born boys have had their penises removed and been raised as girls, sometimes only finding out the truth much later in life.

The Phall-O-Meter, developed in the 1990s by the Intersex Society of North America (ISNA), was a satirical activism tool to highlight how doctors made subjective judgements about atypical genitalia then based their surgical advice on that analysis. From Human Rights Watch Website

There is also evidence that in cases of serious ambiguity the tendency in the past has been to surgically create genitals that appear male, thus effacing many women at birth.  Intersex advocacy tends to focus on delaying non-consensual and irreversible surgeries until an intersex person reaches the age of informed consent. From a consent perspective there seems to be little that is added by way of arguing for a spectrum of the sexes.

There is also little evidence that the interpretation of sex as a spectrum is being driven by Intersex people themselves. The decision in Germany in 2013 to allow some Intersex infants to be classified as a third sex was roundly criticised by rights groups and Intersex advocates. There is a concern that allowing a newborn child to be registered as a third sex would encourage more surgeries on intersex infants as parents are unlikely to feel comfortable with the uncertainty. Many countries also have sex based rights legislation or link access to certain welfare provisions to sex . Subsequently, Intersex people classified other than male or female may well fall between the cracks while legislators attempt to catch up with the new non-binary system.

Thinking of DSDs as constituting sexes in their own right would also appear to reverse the famous anti-reductionist mantra that "genes are not destiny". Now it appears to some extent they are. You are your persistent Mullerian duct syndrome, your defective androgen receptors, your ambiguous genitalia. Your hidden fallopian tubes are the secret of your true nature rather than just a rare and slightly Lovecraftian result of a point mutation in a single gene.

Is there any reason to believe that people with Turner or Klinefelter syndrome need to be classified as a unique sex in order to access specific legal rights and protections that are currently unavailable to them, or that this would lead to a better quality of life? Many of the conditions categorised as DSDs do not result in symptoms that put the sex of the person into question. MRKH affects genetic females and causes incomplete development of the uterus, cervix and/or vagina. Though they do have normal ovaries, people with MRKH are sterile. Being told that such a condition means you are not a biological female doesn't sound like a very progressive move. 

The same could be said of Klinefelter syndrome which involves a genetic male having an additional X chromosome. Symptoms are often subtle and hard to detect even after the onset of puberty. Would such a person benefit from being classed as other than male at birth? And finally, would social justice in general be served by treating biological sex as a spectrum rather than binary? These are the sorts of questions which are as yet unanswered by advocates of the spectrum interpretation.

There is an assumption among many radical social constructivists and theorists of detraditionalization that any increase in indeterminacy or breakdown of hegemonic norms is by definition emancipatory. There seems to be little reason to take this for granted. It is perhaps worth bearing in mind the fact/value distinction; the distinction between "is" and "ought" which captures the difference between scientific claims and value or ethical claims. 

The value claims made (or assumed) from interpreting biological sex as a spectrum do not necessarily follow from the facts, and need to be argued for on their own merits rather than asserted on the basis of their applicability for gender identity and sexuality. Traditional LGBT+ activism may well have an important role to play as an ally in advocating against unnecessary surgery, especially where such surgery has tended to favour "masculinisation" of ambiguous genitalia; or in resisting the impact of gender stereotypes on Intersex people whose conditions mean they don't necessarily fit the mould. 

There is however a potential conflict as currently one major aspect of trans-rights is arguing for access to precisely the kind of medical interventions (hormone treatment and surgery) that many Intersex advocates are trying to minimise. We live at a time where public self-assertion and group-think often run ahead of a cool examination of the facts and the implications of drawing communities with markedly different concerns into already matured forms of political activism and ideology. How the current articulation of medical interventionism and identity politics would impact Intersex people if the spectrum interpretation prevails is unclear. In any case we might well question whether dragging individuals with a complex range of conditions into the current culture war is at all desirable.