“Biological sex is not a spectrum: there are only two sexes in humans” with Claire Graham

This article is part of a series of interviews featuring international perspectives on the ramifications of the concept of ‘gender identity’ within public policy. We are grateful to all the women who have agreed to be interviewed. Their perspectives will sometimes disagree, which enriches the series. Most importantly, thank you to Dominican newspaper El Caribe for its commitment to support women’s right to discuss public policy openly and without censorship.

The sudden introduction of the concept of ‘gender identity’ into public policy across the globe has generated quite a turmoil, riddled with worldwide confusion and clashes of mismatched theories relating to the meaning of sex, gender and personal identity.

Those of us who followed closely the intense ‘summer of gender’ which recently took place in the Dominican Republic, in which some sectors of society where arguing for or against gender policies being taught in public schools (an effort spearheaded by the Ministry of Education) will remember a video recorded by a charismatic media personality in which she tried to explain the differences between sex and gender.

The didactical video, which went viral, shows the curly-haired publicist stating: “We are currently in the midst of a fight to the death between sectors of society which support gender policies and those who are opposed to it, because they understand that behind them lies an effort to impose a gender ideology. Before we define the difference between gender policies and gender ideology, we need to clarify two concepts which are often confused: sex and gender. Sex refers to the biological differences which defines us as masculine, feminine or intersex, depending on which genitals we were born with.”

What this media personality denominates “a fight to the death”, is something which I would refer to as an urgently needed democratic debate, but these are trivialities. It is worth pointing out that among the twenty one references which are cited in the video as alleged scientific evidence which support her arguments, almost all of them are about trans politics and twelve of those argue that ‘gender identity’ (an internal feeling of being feminine or masculine) resides within our brains. Quick question: I thought Departmental Order 33-2019, the cataclysm of this summer’s gender debate, was simply about ending violence against women and teaching children about equality?

Well, no matter! In this article we will speak with English lawyer Claire Graham. She currently works as a school teacher for special needs children, but she became renowned within UK feminism as an advocate for the rights of intersex people (previously referred to as ‘hermaphrodites’), like her.

Raquel Rosario Sánchez: Dear Claire, thank you so much for granting us this interview. My first question is, how did you become involved in the sex and gender debate?

Claire Graham: I am currently a teacher for special needs children but I am also an intersex advocate. I have a blog where I write about intersex conditions, or differences of sex development (DSD). This stems from a Twitter account where I wrote about MRKH, which is the DSD I was diagnosed with at the age of 18. From this, I meet other people with DSDs and started learning about them too. As I learned, I shared the information. I’ve been fortunate to meet people who’ve been very generous with their time and knowledge.

Right. Let’s just get down to it: what is sex?

CG: Sex is the language we use to describe reproduction. So, if we’re talking about humans, there are people who belong to the group with the potential to produce sperm, or people who belong to the group with the potential to produce ova. The names for these are male or female.

At the moment, there is a human rights case being heard in the United States which could have drastic repercussions to their laws and policies regarding sex and gender. One of the Supreme Court Judges assessing the case, Justice Elena Kagan, has used the language of “sex being assigned at birth” by doctors. How does this work? Is biological sex assigned or determined at birth?

CG: For most of us, our sex is observed. When we’re born, the midwife looks at our genitals. Usually this is a good indicator of our sex. If we have a vagina, we’re recorded as female. If we have a penis, we’re recorded as male.

That’s not to say this is a perfect system, there are very rare people who may be born with a vagina, but who have XY chromosomes and internal testes. This means they are genetic males but with a female phenotype (the outside of their body looks like any other woman or girl). We call these 46 XY DSDs. The most well-known example is probably CAIS. Although understanding they’re male is important for healthcare, they are raised as and socially accepted as female. This makes sense, 46XY DSD women have similar issues to genetic females, such as gynecological needs and female socialization. This isn’t the same as assigned sex.

Assigned sex is really a term for IGM, intersex genital mutilation. In the past, and sadly still in many places today, if a child was born with genitalia that didn’t look typically male or female (what we call ambiguous genitalia), doctors would perform surgery to make the genitals appear “normal”. Due to the limitations of surgery, doctors developed a theory: “It’s easier to build a pole than dig a hole”. This meant children with ambiguous genitalia would have a surgically created penis and be assigned male, even if they were female. In these cases, we use the term “assigned sex”. It’s important that we have unique language to describe that experience.

But if Differences in Sexual Development (DSD) trouble the idea of binary sex, wouldn’t that mean that sex should be understood as more of a spectrum? If so, how many sexes are there? Some cultures are said to acknowledge five or seven sexes…

CG: It is not a spectrum, although I know that’s a popular theory. There are only two sexes in humans. As I say, sex is the language we use to describe reproduction. People have potential to be either large gamete producers, or small gamete producers. No one produces both; no one produces something else.

Some people are infertile, but that doesn’t make them sexless. Doctors can tell what sex infertile people are, hence, we have different treatment options for males and females to help with fertility problems. To be slightly explicit, doctors do not look at the testicles of an infertile male and wonder if they should be producing sperm or ova.

During the national conversation about sex and gender, which took place this summer in the Dominican Republic, we heard several reputable non-profit organisations and State agencies make the claim that the category of ‘intersex’ constitutes a 3^rd sex. Would you agree? If not, why not?

CG: I don’t agree, mainly for the same reasons that I don’t agree that sex is a spectrum. It seems odd to me that anyone would look at a man with Klinefelter’s (a condition where males have an extra X chromosome) and a woman, like me, with MRKH, and try to argue we are the same sex as each other.

This isn’t a policy that has come from intersex organisations. They have always been against being classed as a third sex. Germany changed their law a few years ago to say any child born with ambiguous genitalia had to be recorded as a third sex. Intersex organisations all over the world condemned this. It’s arguable third sex markers encourage more surgeries on intersex infants as parents are unlikely to feel comfortable with the uncertainty. It’s also unnecessary. We can work out the sex of children with ambiguous genitalia. This is a key factor in diagnosing their specific DSD, which is information every intersex person is entitled to.

Do you consider sex to be a political issue? If so, is there a difference between how feminism and how trans activism politically theorise about sex?

CG: Sex is very much a political issue. On a basic level, it’s important for healthcare so, especially in countries with socialized healthcare, governments need to understand our sex to ensure resources are distributed accordingly and public health campaigns reach the right audience. It also has huge implications for women. Sex based discrimination happens all around the world. There are specific issues, such as female genital mutilation, sex selective abortion, female infanticide, etc. Countries that are successful in addressing and eliminating these practices do so through legislation. They are issues politicians and governments have to engage with to fix.

Even where laws are successful with addressing this, women have additional needs, such as access to maternity care or menstruation products. Time out from work to have children also means women’s earning potential and pensions can be affected. In some countries, women have been denied the right to vote, drive, be in employment, own property or have credit in their own name. Women can also have difficulty accessing public life for other reasons, such as a lack of single sex spaces. UNESCO released a report last year that stated lack of access to single sex toilets is one of the biggest barriers to education for girls around the world. One of the jobs of politics is to address structural inequalities like these and ensure women and girls are protected from discrimination or being disadvantaged because of their sex.

I think this probably illustrates the tension that exists between trans activists and feminists. Feminism historically is about the advocacy for women’s rights based on the equality of the sexes. In other words, all those issues I’ve just mentioned are the focus of feminism. Trans activists, on the other hand, argue sex is a social construct, which denies the material reality of women as a sex class and makes talking about the specific inequalities and discrimination they face difficult. If we can’t identify the group, we can’t name the problem and address it.

Forgive me if this is intrusive, but there is a very common myth that intersex conditions equal significant numbers of people with what you refer to, in your work, as “ambiguous genitalia.” Could you give us some basic statistics as to how common intersex conditions are? And does it really come down to what genitals you have as a baby when you’re born?

CG: To be honest, there are no questions that I find too intrusive when I’m talking about DSDs. I’ve had to lose any embarrassment over talking about genitals to be able to do what I do. I want to encourage open and honest conversations.

The statistic you’ll often see is 1.7%. If we use that, we are not actually talking about people with ambiguous genitalia in all cases. In fact, 1.5% are people with late onset CAH. This is a condition that doesn’t manifest until later in life, so people with it are not different at birth in any way.

This leaves us with 0.2% of the population who are born with a difference, what we call congenital conditions. Most of these are not ambiguous at birth either. Take MRKH, my phenotype is typically female, so I looked no different to any other girl at birth. Internally, I don’t have a cervix and my uterus never developed properly. I also have a slightly short vagina, although I do have ovaries and an XX karyotype so am genetically female. None of this was noticed when I was born, as people don’t go looking for your internal organs. Most congenital intersex conditions are similar in that regard and each one is quite rare. The most common is Klinefelter’s, which affects 0.1% of the population, then the others increase in rarity. MRKH, for example, affects around 1 in 5000 women.

Cases of ambiguous genitalia are extremely rare. Due to the surgeries in the past and secrecy surrounding intersex conditions, exact numbers are hard to find. To give a picture though, of the 40 or so conditions encompassed by the term DSD, only a handful result in a child being born with ambiguous genitalia. These include PAIS, 5-ARD deficiency, CAH and gonadal dysgenesis. That’s not to say everyone born with these conditions will be ambiguous at birth either. So, it’s a tiny fraction of a tiny fraction, probably less than 0.001% of all births.

I should point out, ambiguous genitalia is a slightly misleading term. Most people think it means genitals that cannot be classified as male or female at all. This isn’t accurate. What we’re talking about is genitalia that may not appear clearly male or female upon initial observation. This could include a female who is virilized. Virilization means masculinized, so the girl’s clitoris is larger and may look more like a penis and her labia may be fused so it looks like a scrotal sack. For males, it can include a hypospadias, where the urethra opens on the underside of the penis, or a small penis that looks more like a clitoris, or it can mean their testicles haven’t descended so the scrotum looks like a labia.

Something a lot of people don’t realize is ambiguous genitalia is treated as a medical emergency. While the genitalia itself does not pose an immediate risk to health, it can be a symptom that other things aren’t right. In the case of CAH, which only involves ambiguous genitalia in genetic females, there are two different types, one of which is salt wasting CAH. If this is not diagnosed and managed it can be fatal. So, when someone is born with ambiguous genitalia, a whole raft of experts gets involved. It’s important doctors understand the child’s sex and anatomy for accurate diagnosis.

I guess, therefore, to answer your question, it kind of does all boil down to which genitals you are born with, even more so for people with ambiguous genitalia.

We’ve seen in the news the case of Olympic gold medalist Caster Semenya, who is an intersex person. Why is the intersex condition such a complex matter for sporting bodies? In your opinion, in which category should people like Caster Semenya compete?

CG: Cases like Caster Semenya are complicated, and I find the sports debate quite difficult from an intersex point of view. Semenya has a 46XY DSD, so she is genetically male. I haven’t seen her medical records, but I’ve read the judgment and the rules and they’re quite specific. Although this is also a slight oversimplification. Some women with 46XY DSDs are not included within the rule, such as those with CAIS or Swyer Syndrome. This is because either they are unable to respond to testosterone or they do not have internal testes, so are not considered to have a significant advantage compared to genetic females.

The issue boils down to whether women with 46XY DSDs, internal testes and an ability to produce and respond to testosterone at a higher rate than genetic females, have an advantage in sport. Arguably they do, when Semenya was made to reduce her testosterone, we know her performance dipped. The next question is whether that advantage is unfair and if so, should she not be allowed to compete or maybe take medication to reduce her advantage.

From an intersex advocacy standpoint, the second option is not appealing. Intersex activism has always argued against enforced or unnecessary medicalization. Some medical organizations, in fact, released statements, telling their members not to agree to agree to provide the treatment as it could be unethical. It’s not an intervention for health benefits. That poses difficult questions for athletes who agree to comply with the rules.

It’s difficult for me to argue that women like Semenya should be made to race with the men, and I know this is contentious. While some 46XY DSD women may have an advantage over genetic females, they would not stand a chance in the male competition. This would mean we would lose athletes like Semenya from elite sports. Seeing an intersex woman, not ashamed of being different, and succeeding is important for young girls with DSDs.

Fairness is in the eye of the beholder here. I can’t pretend I have an answer as to what should happen, and intersex is just a tiny portion of the sports debate. Although Semenya is obviously high profile, so her case gets a lot of attention. I think it’s a shame that her case came around while trans inclusion in sport is under scrutiny. It’s unfair to compare DSD athletes to trans athletes. They do not share the same advantages and are asking to be able to compete as the sex they were recorded as at birth.

You argue that you are a reluctant advocate for intersex rights and that your advocacy started as a response to trans activists appropriating intersex conditions. Would you say that there is a conflict between the aims of intersex advocacy and the goals of trans advocacy?

CG: I would say trans activism has many aims that are at odds with the intersex community, although not all intersex people agree with me. Intersex activists would rather minimize medical interventions, as I explained with the Caster Semenya case, whereas trans activists often campaign for free access to many of the same interventions. They include children in this, which is really the antithesis of intersex aims.

I don’t think the sex spectrum is great for intersex people either. When surgical interventions happen to babies often this includes the child never being told the truth about their sex and their medical history. This is sometimes achieved by using vague or inaccurate terms. Hermaphrodite is probably one most people are familiar with. In the past, this would be the “diagnosis” recorded for a child with ambiguous genitalia, then a sex would be assigned, or other unnecessary surgeries performed. I see the sex spectrum as being like that. It just leaves a question mark. There’s no need to do that when our understanding of sex and DSDs is so much more advanced.

Could you tell you a bit about how you were banned from social media, please? It is bizarre that your voice has been censored on social media when this debate benefits so much from understanding the complexities of sex and gender from the perspectives of intersex advocates.

CG: It’s an odd story. My account wasn’t popular with trans activists, so they often reported me for hate speech. I would get notifications from Twitter, telling me about unsuccessful reports. Then, a few months ago, Twitter banned me, alleging that I was “managing multiple accounts for abuse purposes”. I only had two accounts, MRKHvoice, and a tiny personal account which I didn’t use anymore. They haven’t deleted that account, so I’m unsure what they mean. I’ve tried appealing but speaking to a human being at Twitter is almost impossible.

My account was never abusive. Some people may not like what I say, but my campaign is about protecting women’s rights by acknowledging their recognition as a sex class and ensuring people with DSDs have fair representation in a debate that is often about us, but usually without us speaking.

What would be something that you would like our Dominican audience to understand about intersex conditions?

CG: I think the thing to remember is most intersex people aren’t interested in being used as a political tool. Most of us understand ourselves as male or female but with a medical condition that caused a difference in how we developed. A lot of the arguments you hear about intersex in the mainstream media either don’t come from intersex people or don’t represent how many of us see ourselves.

It’s great to raise awareness about our conditions because they are rare, but it’s important, if you’re doing so, to make sure what you’re saying is accurate and helpful. When you talk to intersex people, that’s usually what they want; access to clear information and a better understanding of their body and development. Using us as props in someone else’s argument only makes finding that information harder as it just gives us more to sift through.

Also, don’t expect people with DSDs to necessarily want to share that information about themselves, or have it shared about them. There’s no reason to be ashamed of being intersex, but it is a medical condition. Like everyone else, we’re entitled to privacy surrounding that. You may know people with DSDs, but you wouldn’t be able to tell. I have a mixture of people in my life who know and who don’t. It’s obviously not a secret, but it’s not like I greet people with it or use it as small talk.

This is quite an instructive interview. I have to ask, though, what would you say to people who argue that by speaking about chromosomes and karyotypes you are “reducing women to their biology”? The year is 2019 and yet here we are, having conversations about who can claim menstruation and what constitutes sperm. Shouldn’t society be past this stage and just strive for “equality”?

CG: Women face discrimination and inequality because of their biology. This isn’t something made up by feminists, it’s material reality. Equality isn’t achieved by denying or ignoring this, but by seeing it and openly talking about its causes and remedies. This doesn’t have to conflict with other people’s rights or identities. I think everyone should have the right to dress, act, think, believe and do whatever they like, as long as they’re not hurting anyone.

I also think it’s important we build our laws and understanding of the world on objective, observable facts though. How else will we know if we’re achieving equality?

A thousand thank you’s to English teacher and lawyer Claire Graham for her time and most importantly, for her advocacy for intersex people’s human rights. Our next interview will focus on how the new generation of activists and thinkers are navigating the suffocating sex and gender debate within the feminist movement.

Raquel Rosario Sánchez is a writer, campaigner and researcher from the Dominican Republic. She specialises in ending male violence against girls and women and is currently pursuing a PhD with the Centre for Gender and Violence Research at the University of Bristol.

The original, shorter version of this interview was published by Dominican newspaper El Caribe on October 21^st, 2019. You can read it in Spanish here.

Read all the interviews in the El Caribe series on sex and gender identity here