To Be or not to Be, Man or Woman.

There is and always has been much confusion in the public mind about sex, gender, and the Olympics. I am not surprised by this because it is challenging to explain sex and gender problems to most lay people and even young physicians in training. It would appear that the Olympic Committee might have the same issues as other non-professional athletic committees dealing with complex problems.

This issue arose with the recent boxing matches between women and the heated controversy over two female boxers, Imane Khelif of Algeria and Lin Yuting of Taiwan. As a disclaimer, I am not their doctor, and all I say is a deduction based on stories from the press. However, I believe that this issue can be made clear when we understand a bit about the biology of sex and gender.

My involvement with sex and gender is as an endocrinologist, immunologist, rheumatologist, and, more recently, geneticist. I am keenly interested in why women and men acquire certain diseases relative to their sexes. That topic is even more complex than two women's status in the IOC’s boxing matches.

Let me first say that sex and gender are two different things.  Sex cannot be chosen; gender can. The biological sex is called the genotype, and the gender is called the phenotype or how you present yourself to others. Both of these ladies were listed as female on their birth certificates.  Nevertheless, International Boxing Association president Umar Kremlev told the Russian State News agency TASS that both women had X and Y chromosomes, which would make them biologically male (XY).

So, what is going on? One thing must be clear: these ladies are not transgender people whose gender “identity” differs from their birth sex. Transgender people have a sense of being male or female that does not align with their biological or physical characteristics.  Such people transition in many different ways, usually through hormones or surgery. These Olympic boxers are not confused or contest their gender identity.  As far as their families and physicians are concerned, they are female from birth.

The two Olympians in question are biological males but metabolically females.  In all likelihood, they have what we call DSD or differences in sex development. These are rare conditions in which the individual is born with sexual characteristics that distort their genitalia.  As an example, a young man might not have an average penis and no testicles, looking like a female.  So, at birth, the child is pronounced a girl when, in fact, she is an XY male. The genitalia are irreversibly different. As a biological male, she would be infertile and unable to menstruate.  The differences in the genes or how the patient responds to sex hormones determine the phenotype (male or female appearance) versus the genotype (XX or XY). Often, genitalia are the result of epigenetic differences or the effect of environment on gene expression.  They have sexual chromosomes, but the environment or hormones alter the expression of the DNA. During development, hormones can make the individual look like a female. The two times to determine DSD are at birth or puberty.  It is, therefore, no surprise that the local doctor pronounced both boys as girls at birth. Perhaps the most common cause of DSD in boys is androgen insensitivity syndrome, where the male body does not respond to male hormones.  Many well-known female celebrities with this condition mature as beautiful women after being treated with estrogen during development when, in fact, they are men.

Many such conditions are genetically—not epigenetically—inherited, meaning that chromosomes are unevenly inherited from a parent.  Our Olympians do not suffer from these conditions because they would be disqualified immediately.  These conditions are Turner Syndrome (XO, or girls with only one X), Klinefelter Syndrome (XXY, boys with an extra X), or a condition called congenital adrenal hyperplasia (CAH, where certain hormones are not made due to an inherited lack of an enzyme). Like DSD syndromes, you must be a professional to recognize these changes in a young person, but here it is more commonly found at puberty.

The fundamental question is whether the young ladies with DSD have the build and strength of a man from youth and are more robust and better able to fight in a boxing match than an average XX woman. I have read that testosterone levels were measured in these females and were negligible. DSD females are usually raised as girls, and in most cases, male hormone blockers are given, as well as estrogen, to ensure secondary female characteristics.  I am unsure about the complexities of Olympic selection from various countries and the procedures to ensure equitable and fair selection of the proper genders. Still, it would be best to understand that these two young boxers are biologically male but phenotypically women.  Finally, I wonder why they chose boxing rather than some other sport.