Gender and Sex: A Simplified Explanation of a Complex Topic

By Joshua Haiar

Published March 14, 2021 at 3:48 PM CDT

ART CREDIT: SDPB's Joshua Haiar

Written by Anne Dilenschneider, PhD, LPC-MH, WPATH Certified Gender Specialist

Sex and gender may seem to be simple; we are told there are men and there are women. However, according to scientists, medical and mental health professionals, and others who specialize in human development, the reality is much more complicated.

Dr. William Kobler of the American Medical Association said in 2016: “Sex and gender are more complex than previously assumed. It is essential to acknowledge that an individual’s gender identity may not align with the sex assigned to them at birth.”

Definitions – Terms and concepts regarding sex and gender?

Assigned Sex (aka “Sex Assigned at Birth”)

The sex a baby is determined to be, and legally classified as, is based on a visual observation of their genitals at birth.

According to the American Medical Association (2017, 2018), sex is assigned at birth, but sex is not binary which means there are more possibilities than male or female. Sex is a spectrum because there are many variations in genitals, gonads, and chromosomes – some are visible; some are not. Approximately 5.5 million Americans ( about 15,000 South Dakotans) are intersex (Harvard, 2016). That refers to times when a babies’ sex cannot be determined at birth.. Historically, when there was ambiguity, a decision was made about a baby’s “sex” at birth. Often, mistakes were made. This is no longer best practice.

Assumed Gender and Gender Identity

A person’s gender is assumed based on their sex as it is assigned at birth. This is only a presumption; we cannot know a person’s gender without asking them. An individual is the only one who can tell us how they experience their gender, and what they know it to be. This is their gender identity.

What determines sex and gender?

It is important to understand that the key DNA decisions related to sex and gender take place at different developmental points during pregnancy (Sanbonmatsu, 2018).

Sex: Genitals transform into (usually) either female or male during the first trimester of pregnancy.

Gender: Brain structures, on the other hand, transform into (usually) female or male during the second trimester of pregnancy.

How this happens, and how well it happens, is based on a number of factors. These include the mother’s uterine environment, the baby’s hormone receptivity, and the signaling of the DNA within at least 12 of the baby’s genes.

As a result, sex and gender don’t always “match” --- this is called Gender Incongruence. Gender incongruence may cause a person distress or dysphoria.

A transgender woman (or girl) is someone whose sex appears to be male (they were “assigned male at birth”), but whose experienced gender identity is female.

A transgender man (or boy) is someone whose sex appears to be female (they were “assigned female at birth”), but whose experienced gender identity is male.

Some people are Gender Diverse or Gender Expansive (older terms are “Gender Non-Binary” and “Gender Non-Conforming”). As the American Medical Association notes – gender is a spectrum and not everyone fits into binary definitions of “male” and “female.”

A cisgender person (“cis” = “same”) is someone whose assigned sex and experienced gender identity “match.”

Sexual orientation is who we are attracted to emotionally, romantically, spiritually, and/or physically (these may or may not be the same). This is not determined by sex or by gender. Sexual orientation is distinct from gender identity – every person has both. A person may be straight, gay, bisexual, pansexual, asexual, etc. Some persons initially think they are gay or lesbian because they have no words for being transgender.

What do I say?

Using any person’s preferred name and pronouns is a fundamental way we respect their identity as a human being and help them feel safe. This is not a matter of “political correctness.”

The mis-use of names and pronouns is the greatest trigger for suicide among transgender people.

The best way to help another person feel safe is to introduce yourself first – using your name and your preferred pronouns. For example, “My name is Anne and my pronouns are she/her/hers.” Then ask the person how they would like to be addressed.

The only way you will know you are using a person’s preferred name and pronouns is to ask.

This is a medical condition

In 2019, the World Health Organization (including the United States) and its 195 member countries determined that Gender Incongruence (when the assigned sex of a person’s body does not match their experienced gender identity) is a biological, medical condition. It is not a mental disorder. That determination is based on more than 50 years of peer-reviewed, international, replicated scientific research.

Beginning in 2022, all medical providers, health systems, and insurance companies in the world — including the United States — will move to using the new revision of the International Classification of Diseases (ICD), a global standard for coding health data from the WHO. The ICD-11 recognizes , Gender Incongruence as a medical condition.

Transitioning

Medical Transition – this is what most people think about

Medical transition involves hormone and/or surgical interventions to more closely align a person’s body with one's experienced gender identity. A transgender person may choose to medically transition fully, somewhat, or not at all. Healthcare professionals follow the Standards of Care.

Legal – this is about safety

Legal transition involves changing identity documents to have a name and gender/sex marker that reflects one's gender identity. This is possible for all U.S. federal identification documentation (Passport, Social Security, Selective Service, Medicare, etc.). In each state, legal ID changes depend on that state’s laws.

When a person’s name and gender identity differ from what is on their driver’s license and other forms of identification (ID), they are in danger of discrimination, harassment, assault, and refusal of service or employment.

Social – this is the biggest challenge

Social transition is “coming out” and creating a personal environment in which a person's gender identity is known and, ideally, respected by others, including family, friends, and coworkers. This can challenge our culturally expected gender norms and roles.

Respect is shown by using the transgender person’s preferred name and pronouns – this, literally, saves lives. A transgender person may choose to socially transition fully, somewhat, or not at all. Social transition is usually the biggest challenge, and navigating it requires the most support from family, friends, and coworkers.

Medical Treatment

If a person has Gender Incongruence (formerly Gender Dysphoria), there are ways to treat the condition to relieve the person’s distress and bring the person’s body (sex) more closely into alignment with their gender identity. Since the 1970s, treatment has been based on a set of international Standards of Care; these are followed by licensed medical and mental health professionals, as well as by insurance companies.

Treatment is a collaboration between the person, their parents (if they are a minor), the mental healthcare provider(s), and the medical providers (primary care, endocrinologist, surgeons). There are specific guidelines for treatment, and for the timing of treatment. Insurance companies will not cover treatment if these requirements are not met.

At puberty, a young person, their parents, and their medical and mental health team members may decide that reversible puberty suppression will reduce the youth’s distress. Research (Pediatrics, 2020) has shown that puberty suppression lowers the likelihood of the youth attempting suicide (the suicide attempt rate for transgender youth is about 60%). Both estrogen and testosterone production are suppressed during this time. Parental consent is required.

At the age of 16, and only with parental consent, hormone replacement therapy (HRT) can be initiated. There are a number of prerequisite conditions that must be met and documented before this begins. HRT is administered in micro-doses so that the form of puberty appropriate for the teen will follow its natural, slow, developmental course. A transgender girl would begin taking estrogen and a testosterone-blocker at this point. A transgender boy would begin taking testosterone.

Chest masculinization is sometimes done at age 16, with parental permission and the agreement of the youth’s medical and mental health teams, however many insurers will not cover that procedure until at least adulthood (age 18 in the U.S.). Again, there are a number of prerequisite conditions that must be met and documented beforehand.

Genital surgeries and facial surgeries are usually done after a person has reached adulthood (age 18 in the U.S.). These decisions are reached by the person and their medical and mental health teams. These surgeries have to be pre-approved by the person’s insurance company. Again, there are a number of prerequisite conditions that must be met and documented before these steps are taken. Not all transgender persons undergo genital and/or facial surgeries.

Although gender-affirming medical and surgical interventions are necessary to support the health of transgender people, some insurance policies exclude these services. For example, South Dakota Medicaid does not cover any mental health or medical treatment for transgender persons.

Note: 58% of transgender persons who have had a professional try to stop them from being transgender and living as their experienced gender identity have attempted suicide. So-called “conversion therapy” has been condemned by the American Medical Association and the other major medical and mental health professional associations in the United States. It is banned in 20 states and Washington, DC.

Discrimination

In 2020, the Supreme Court of the United States ruled it is illegal to discriminate against a person because they are transgender.

Transgender people face discrimination in all sectors of society including education, health care, housing, and employment. This makes them disproportionately vulnerable to depression, suicide, Post Traumatic Stress Disorder, substance use disorders, physical and sexual victimization, and HIV infection.

Transgender students report not being allowed to dress as themselves, being verbally harassed, physically attacked, or expelled. Poor treatment in school is associated with increased risk of suicide, homelessness, and working in the underground economy.

Respect is essential – It is, literally, a matter of life and death

60% of transgender children, teens, and young adults with unsupportive families have attempted suicide.

34% reported a first suicide attempt at younger than 13 years old.

39% reported a first attempt between 14 and 17.

20% reported a first attempt between 18 and 24.

ONLY 4% of transgender children and teens with supportive families have attempted suicide.

Family support saves lives.

Approximately 82% of transgender people have seriously thought about killing themselves at some point because of the ways they are treated by others.

48% of transgender persons have seriously thought about killing themselves in the past year (vs. 4% of the U.S. population)

44% of transgender persons have been denied service at businesses and agencies.

50% of transgender persons have been sexually assaulted.

About 50% of transgender persons report being fired, not hired, or denied a promotion because they are transgender.

58% of transgender persons who have had a professional try to stop them from being transgender and living as their experienced gender identity have attempted suicide.

This is the single most important thing needed for everyone:

Being able to live, love, play, study, and work in an environment where anyone can be fully open about their gender identity and expression without fear of discrimination.

Resources to learn more about gender and sex

Video Resources

SDPB’s “On Call with a Prairie Doc” with Sanford reproductive endocrinologist Keith Hansen, MD and Anne Dilenschneider, PhD, LPC-MH

A 12-minute TED talk on: “The biology of gender, from DNA to the brain” with Dr. Sanbonmatsu, a principal investigator of DNA and gender at Los Alamos National Laboratory; her work is funded by the National Institutes of Health and the National Science Foundation.

A 90-minute presentation on: “An Introduction to Transgender/Gender Diverse Health for Counselors” by Anne Dilenschneider `for South Dakota counselors in June 2020. (Password: 9d=GF64f)

Online Resources