Season 2:
Episode 1: Medical Students Stumble on to Something in the Jungle
Students from Maria New's school were allowed, during their last year in school, to travel anywhere in the world they wished, in pursuit of medical experiences they might not find in New York City. A few students wound up in the Dominican Republic, where they heard, in the rural clinic where they worked, of a group of villages in the mountains where the children were given gender neutral names.
Hiking up to these villages, they confirmed that little girls born in these villages were given the Spanish equivalent of names like "Chris" or "Pat" or "Leslie" or "Robin" or "Terry." When they asked why the girls were named this way, and not the baby boys, the villagers said the boys were born boys, and stayed boys, but some of the babies who looked like girls at birth would grow a "penis at twelve" and were called "Pene a los doce."
Asking to see some of these girls who changed into boys at age 12, they were, after some negotiations and reassurances, allowed to examine these boys.
These photos appeared in the early papers about this phenomenon:
These boys, remember, were raised "gender neutral" until they "declared themselves."
The medical students rushed home to tell Dr. New about what they had seen and she assigned a fellow in the department of pediatric endocrinology, Dr. Julianne Imperato, to investigate. Imperato obtained blood samples from the Pene a los Doce patients and she did an exhaustive family tree on all the affected patients. This was in the early 1970's long before the Human Genome project or any genomic technologies beyond karyotyping (which is astonishingly low tech--requiring nothing much more than a microscope fitted with a polaroid camera.)
What Dr. Imperato discovered was there was a high level of consanguinity (intermarriage) among the families in these villages and when you have consanguinity, autosomal recessive traits can flourish and emerge.
What she found from the blood, again run through Ralph Peterson's lab, was that these boys had an enzyme defect at the last stage of the testosterone hormone pathway: they made plenty of testosterone, but they could not convert that testosterone into dihydrotestosterone (DHT) and it's the DHT which actually masculinizes the external genitalia. At puberty, when you have a huge surge in testosterone, the traffic simply floods past the obstruction and enough DHT gets made to make the penis grow.
This disorder, called "5 alpha hydroxylase deficiency" is the basis for the book "Middlesex."
Of course, changes in sexual status is not unique to the species Homo Sapiens:
Red frogs can change sex.
Some fish can change sex. (Clown fish, Hawkfish, Sea bass, seahorses)
Some snakes can.
The Bicyclus anynana butterfly does it.
And now, we need to step back and understand more about sexual differentiation.
The best, most concise explanation of the steps which differentiate little boy babies from little girl babies is in this wonderful youtube presentation by Armando Hasudungan:
Episode 2: When the Blood Hormone Levels are normal, but the Patient is Not
So now you see the way things normally go. But, in nature, things do not always go that way, so you sometimes get ambiguous genitalia, male pseudohermaphrodism, because of biochemical enzyme deficiencies. In both cases presented, the reason the external genitalia, the male phenotype, did not develop normally was attribute to a lack of either testosterone or it's derivative, dihydrotestosterone.
But then, there is the case of people who make testosterone perfectly normally, but still have a problem.
On the Metabolic Research Center, a ward at The New York Hospital, run by Dr. Maria New and Dr. Imperato (who became Imperato-McGuinley) about a dozen patients were admitted during my student days who came to the hospital because they had not had menstrual periods. Not ever. They had "primary amenorrhea."
On physical exam, they had blindly ending vaginas and no uterus. They looked to be completely normal females, otherwise, apart from sparse pubic and axillary hair.
But when their pelvises were surgically explored instead of ovaries, what was found were testes, and their karyotypes were 46 XY.
And the students were again asked: What do we tell the patients? Are they men or women?
In this case, the students readily agreed these patients were women, XY chromosomes or not. They sure looked like women and they all functioned sexually as women. They had no doubts about their own gender and laying the "chromosomal sex" thing on them seemed absurd.
But how did they get to be so phenotypically women with the "wrong" chromosomes?
Their testosterone levels were, in fact, in the normal male range, in fact often in the highest ends of that range.
For this you need another concept: How does a hormone work?
In a very simplistic analogy, most hormones are like keys and they search for a lock into which they fit, and once they fit into that lock, they can turn on the ignition with a flip of that lock. What happens "downstream" from the key in the lock, is usually protein production and the cell, if it's a hair cell on your chin, hair will grow. If it's a muscle cell, it will grow big and strong. If it's a bone cell, it will grow and become hard.
These women have a malfunction in that hormone/receptor interaction: They have "complete androgen insensitivity" which is to say, they cannot respond to male hormone (testosterone or DHT) at all. They have "receptor dysfunction." The key goes in the lock, but no ignition occurs.
As a student, I thought, "Well, these are the most female people on the planet, because even if you try to masculinize them, you can't do it."
But what if the patient does not have complete insensitivity to male hormone, what if some cells have receptors which can respond at least a little or maybe half way? That would be "incomplete androgen insensitivity."
EPISODE 3: PUBLIC POLICY, RIGHT WING STRIDOR, TWITTER STORMS
There are two famous cases of individuals who have become the poster people for Tucker Carlson and the rest of his mob.
One is Caster Semenya, who is a person who likely has incomplete androgen insensitivity.
I cannot know, never having seen her and having no access to her medical records, but she looks quite completely female with respect to her visible external genitalia although she has powerful, well defined and bulky muscles. But many female athletes at the most elite levels have big, powerful muscles. And yet every time (or nearly every time) Semenya runs in a track event, she defeats even the most powerfully muscled women running against her and she breaks all the women's world records for that event.
Now, the thing about female world records is this: Apparently, if you look at any given world record in track, say the 800 meter or the 400 meter or the 100 meter races, there are, at any given time, about 1500 male athletes in high school or college or beyond, who run faster times. Ditto for swimming races.
High level male athletes simply obliterate female world records.
Which is not to say these female world record holders would not obliterate most males trying to run or swim in those events, but at the upper levels, two standard deviations from the mean, among elite athletes, there is a divide.
These are data which are "hard data" and can be measured in seconds.
Even subjectively, Serena Williams, said the best male players, like Roger Federer, are simply beyond her. And, in a very unscientific way, just observing casually, when you walk into a bar and see a basketball game on the flat TV across the room, you know immediately if it's men or women playing. Testosterone delivers a strength and quickness and power unavailable to those without the same level of it.
Which is why, presumably, we have women's tennis, women's golf, basketball and swimming.
What's the fun in running a race where the best women will in the world still predictably come in only fifth out of 10?
So we segregate sports into men's and women's sports.
This is a choice we make, for practical and social reasons.
It should be noted: Both women and men make testosterone. Men just make a lot more of it by a factor of nearly 10 and they make it from age 13 so by the time they are in high school, men's muscles and nerves and brains and joints have all been bathed in a very different bath from what most women have experienced.
One might argue this segregation of sports is unfair. We do not separate male athletes who play basketball into different classes based on their heights. We do not say, well, it's not fair for short men to be made to compete with tall men, when the tall men have that inborn advantage. We do not have professional 150 pound football and heavy weight football.
We do, of course, have weight classes for boxing and for wrestling, however. We make distinctions for those sports. In general, when the winner can win by superior skill, as in basketball--a small man like Step Curry can pop in a basket from 40 feet away--then the need to segregate for inborn advantages seems less important. But in boxing and wrestling, where the contest between two equally skilled athletes is determined by strength and power alone, segregation may be seen as appropriate and fair.
Before puberty, well trained, skillful girls can and do defeat boys in wrestling matches. But as soon as puberty kicks in, even the best girls are pinned by boys with half their skills.
The difference between lamb and mutton is puberty.
But, if we separate women from men in sports, for the sake of competition among more or less equals, then what do we do with Caster Semenya?
Is she a woman? Should she be allowed to compete with women? In what category do we place her?
If her muscles have been conditioned during puberty and after as a male's muscles, is she not at a competitive advantage?
Or, consider the transgender swimmer, Lia Thomas, who grew up a male but then underwent transgender therapy.
And what transgender therapy did she undergo?
That is not so easy to tease out on the internet.
But, for the sake of discussion, let us suppose she underwent orchiectomy (removal of her testes) and then got estrogen, so if you saw her undressed, she may not look male.
But her muscles have developed for years with the advantage of testosterone.
And she is breaking long held women's records and she is nearly indomitable in women's swimming. And her muscles may well have benefited from years of testosterone.
So, when the Tucker Carlson crowd howl and the Gregg Abbott Texans growl, do we reject their arguments simply because we know they are, overall, knuckle draggers?
They may, it must be admitted, have a point.
And much as I am loathe to find myself in any position other than complete opposition to that mob, I'm not sure, looking at the record books, and being a fan of women's sports--let me tell you about women's softball someday--I'm rather at a loss.
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