Sex Testing or Gender Verification: Is There a Difference and Does it Matter?

We were delighted to see the three commentaries published in the December 2010 issue of JOGC addressing issues surrounding the ethics of sex testing in high-level sports (Caplan 2010; Hercher 2010; Wonkam et al. 2010). We concur that the situation surrounding Caster Semenya highlights a number of significant ethical concerns that need to be addressed and challenged. However, we noted that all three commentaries use the terms “sex” and “gender” interchangeably, as synonyms. The usage of these terms in this way reflects how they are used by sport governing bodies, the media, and indeed an increasing number of academic publications (Haig 2004; King 2010). Despite this, the intention of the two terms was to convey different meanings. The distinction between the meanings of the terms sex and gender has been well established in the social science and medical fields and is clearly defined by, for example, the World Health Organization (WHO 2010), American Psychological Association (APA 2001) and the Institute of Medicine (IOM 2001). Sex is defined within a context of biology and physiology. Parameters of sex can include chromosomal sex, gonadal sex, hormonal sex, internal reproductive structures, external genitalia and “brain” sex (Migeon & Wisniewski 1998). In contrast, the concept of gender is constructed based on the socially defined patterns of society and culture and can be thought of as a combination of gender identity and gender role (Money & Ehrhardt 1972). Gender identity refers to an individual's fundamental sense of belonging to a sex. Gender role on the other hand is defined as behaviors, attitudes and personality traits within a given cultural and historical context. Gender role most often falls between masculine and feminine and is typically, but not always, correlated with a specific sex (male or female). We were pleased that the commentaries pointed out that physical sex is in fact multidimensional in nature; one parameter does not necessarily trump the others. This is well illustrated by disorders of sex development, where some indicators of sex- such as chromosomes - do not necessarily dictate other biological indicators of sex such as body morphology or hormone levels. Similarly, one is not always either 100% masculine or 100% feminine - gender is quite fluid and dependent on circumstance. Thus, neither sex nor gender is unequivocally definable in binary terms. Further, although gender – similar to many other traits - may be influenced (not necessarily determined) by genetics, non-biological influences confound any attempt to measure expression of gender by looking at biological characteristics. Essentially, gender can only be measured psychometrically (Thompson et al. 1992), and any attempt to measure the construct through biological investigation is based on a fallacy. By assessing factors such as anatomy, genetics, and endocrinology, the International Association of Athletics Federations (IAAF) and International Olympic Committee (IOC) are not “verifying gender,” at best they are gathering information about sex (IAAF 2006). We appreciate that often the motivation for using the term “gender” when the issue under consideration is actually “sex” is the commendable desire to use language that is less reactionary and provocative. We argue, however, that this strategy is misguided as it disregards the fundamental differences between the two concepts outlined above. Most specifically, ensuring that these two terms retain different meanings allows us, as genetic counselors, to communicate more accurate and nuanced information with all patients and families, but particularly those affected by disorders of sex development (DSDs) and gender identity. Some DSDs, for example, have clinically established sex and gender identity outcomes, such as the typical female body morphology and feminine identity of individuals with complete androgen insensitivity syndrome (Hines et al. 2003; Schoenbucher et al. 2010; Wisniewski & Migeon 2002). Affected families and individuals face significant challenges in conceptually understanding and finding the language to describe DSDs. As health care professionals if we are clear ourselves about the conceptual differences between sex and gender, we may be better able to help our patients and their families understand and articulate issues they face, and more generally, we will be better placed to effectively counsel our patients (Gough et al. 2008). We commend the authors of these commentaries for tackling practices of the athletic community related to “gender verification” for athletic competition and advocating for confidentiality, sensitivity and justification when it comes to this testing process. In addition, we feel it is important for the genetic counseling community to challenge tendencies in the broader community to conflate the concepts of sex and gender. What we lose by buying into the synonymic use of these words are sensitivity and cultural competence in our care of patients. The distinction between the social and the biological is lost. We may be alienating ourselves from those who, consciously or unconsciously, express gender differently than that culturally assigned to their sex. By perpetuating stereotypes we may be treading on the beliefs, attitudes, values and expectations of our patients as well as missing out on important information about those under our care. We hope that future discussions may reflect the distinction between sex and gender in hopes of improving our practice and our awareness of this fundamental issue.

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