A closer look at gender ambiguity

Dear Dr G,

I WAS interested in your article last week about the ambiguous genitalia caused by excessive male hormones in girls.

Who would have thought that the adrenal glands also get involved in the development of gender differentiation.

I would like to put Dr G on the spot as the topic of gender ambiguity heats up even in the Olympic arena.

I have been glued to the TV set since the beginning of the Paris Olympics and one major news piece that caught my attention was the Algerian boxer causing a storm inside and outside the boxing ring.

Although I have no concerns about my own gender identity, I still would like to put Dr G on the spot for personal interest.

As my biological knowledge from school is a bit rusty, can you remind me how and when sexual differentiation occurs?

Apart from genes, what else plays a role in determining gender?

On that basis, what can go wrong, and give rise to gender ambiguity?

Then more to the topic of the Algerian female boxer; who exactly is Imane Khelif, and is this individual male or female?

I understand there are some issues of transgender, if so, is Imane Khelif genetically male or female?

Finally, what are the ways to determine her true gender?

I am completely fascinated by this topic of intersex, and am looking forward to some clarifications from Dr G.

Regards

Fascinated Fiona

Human sexual determination is controlled by the XY sex-determination system. Humans have 46 chromosomes, including two sex chromosomes. The Y chromosome carries the essential genetic materials for testicular formation and the XY chromosome will determine a male and XX chromosome a female.

Environmental sex differentiation refers to a differentiation of sex via non-genetic cues such as social factors. Therefore, sex differentiation does not always follow a typical path.

A human foetus is initially anatomically indistinguishable as male or female and lacks production of any particular sex hormone. Specific genes will induce gonadal differentiation, in turn producing hormonal production and subsequent anatomic differences.

This will eventually lead to psychological and behavioural differences in male and female. Sexual differentiation in humans includes development of different genitalia and the internal genital tracts, breasts, body hair, and plays a role in gender identification.

There is no clear consensus definition of intersex and no clear delineation of which specific conditions qualify an individual as intersex. Such individuals have reproductive or sexual anatomy that doesn’t fit into an exclusively male or female (binary) sex classification.

Intersex traits might be apparent when a person is born, but they might not appear until later, especially during puberty or even adulthood.

Intersex traits may not be observed externally or emerge after a surgery or imaging test. An estimated 1 in 100 Americans is intersex. Around 2% of people worldwide have intersex traits.

Being intersex can present in about 40 different ways. One of the most common intersex traits include combination of chromosomes.

Individuals who are intersex may have a mix of chromosomes, such as XXY. A person who is intersex may also have mixed genitals and gonads, for instance having both ovarian and testicular tissue (ovotestes). Otherwise, genitals that are associated with being assigned male at birth, like a penis, or internal reproductive anatomy or hormone levels more closely associated with being assigned female at birth.

Klinefelter syndrome is one of the most common intersex, where a genetic condition that results when a boy is born with an extra copy of the X chromosome. Klinefelter syndrome may adversely affect testicular growth, resulting in smaller than normal testicles, which can lead to lower production of testosterone.

The syndrome may also cause reduced muscle mass, reduced body and facial hair, and enlarged breast tissue. Most men with Klinefelter syndrome produce little or no sperm, but assisted reproductive procedures may make it possible for some men with Klinefelter syndrome to father children.

The debate over transgender athletes has reared its head once again at the 2024 Olympics, centred around 25-year-old Algerian woman boxer, Imane Khelif, after defeating an Italian rival in 46s.

For born women, intersex can include unusually high levels of testosterone which can aid aggression and weight gain for training as well as speed and power, as well as XY chromosomes being present in their genetic code.

The storm comes over the gender ambiguity of Khelif following the International Boxing Association (IBA) decision to ban her on the eve of the 2023 World Championships. The body had subjected her to a test during which the IBA refused to publish results on private medical grounds. Khelif does not publicly identify as transgender, especially as being a member of the LGBTQ community is punishable with a three-year jail sentence in the North African nation of Algeria.

The German-American socialist and Lutheran theologian, Paul Tillich, who was one of the most influential philosophers of the twentieth century once said: “The awareness of the ambiguity of one’s highest achievements (as well as one’s deepest failures) is a definite symptom of maturity”.

Although Khelif is thought to be intersex which can cause women to have excessive characteristics typical of the opposing sex, when Dr G is put on the spot for his view on her true gender and fairness against other athletes, his view is: “The recognition of ambiguity is truly one’s highest achievement to have the dialogue about intersex!”