“Biological sex”, empirical backfire: How transphobes gambled on COVID-19 – and lost

Zinnia JonesAs the pandemic coronavirus has spread around the globe, the growing numbers of infections have revealed a surprising pattern: from China to Italy to the United States, men are more likely than women to contract the virus. And among those infected, men show a consistently greater likelihood of suffering from a more severe course of the disease, and men make up a clear majority of COVID-19 deaths.

These trends in infections and disease severity offer an opportunity for fruitful research, as scientists and medical professionals investigate the factors that could provide greater protection from serious or fatal COVID-19 disease and whether this may point the way toward beneficial treatments. On the other hand, if you’ve made a career out of transphobia, then mass death and worldwide economic devastation offer something far more important: a chance to remind everyone that trans people don’t matter.

Behold the enlightened commentary of The Times’ Janice Turner:

And in a pandemic that double X is a true blessing: one X chromosome in a cell can spot the invading virus, while the other X works on killing cells that are infected already. With just a single X and a weedier Y, men lack that double-barrelled protection. Moreover, higher levels of testosterone in men, says Dr Moalem, repress the immune system, while oestrogen stimulates it.

How extraordinary that it took Covid-19 to expose the absurdity of an utterly unscientific argument gaining mainstream traction, and posed as recently as the Labour leadership election, that biological sex is not real but an artificial construct, randomly “assigned” to babies at birth. In fact, sex is coded in our very cells and, as this epidemic reveals, can affect our odds for life or death.

Turner’s sentiments were quickly seconded by Maya Forstater, who holds the rare honor of a court ruling against her in which it was found that her tweets misgendering trans people were so noxious and inappropriate, it is definitely okay for an employer to fire her:

Also chiming in to remind us of their priorities during a global crisis with no end in sight were Christiana Holcomb of the Alliance Defending Freedom, who reduced these observations of COVID-19 sex differences to mere bookends for a lengthy complaint that trans girl athletes have worked hard and excelled in track and field, and Andrea Jones of the Heritage Foundation, who made explicit the stronger claim that “subjective gender identity” is less relevant to this specific disease than “biological reality”:

Science has consistently recognized sex as an objective physical trait determined by an organism’s overall organization with respect to reproduction. Humans, like other mammals, are a sexually dimorphic species, with recognizable characteristics distinguishing males and females. Every cell in the body carries chromosomes that indicate a person’s sex and direct physical development.

This reality has well-recognized implications for medical care. Men and women have notably different rates of illness, heart disease, and diabetes, and they differ in their responses to medication, which is critical knowledge when treating a patient.

Subjective gender identity or social presentation is no substitute for biological reality when it comes to medicine. As the NHS’s questionnaire indicates, sex distinctions do matter when treating COVID-19.

Countless lay transphobes have made similar assertions, claiming of trans women that “Their chromosomes are XY. Women are XX. . . . Biology will always matter more than any gender identity”, among other assorted mouth farts.

None of this is even slightly surprising, aside from their complete inability to focus on anything else even during near-apocalyptic times, or their failure to realize that even if every trans woman dropped dead of COVID-19 we would inevitably have spread it to many others whose lives transphobes presumably still value. Invocations of “biological sex” have long been treated as some kind of trump card by those seeking to invalidate trans people’s genders, positioning some set of biological features as somehow being more substantial, more real, and ultimately more important than a person’s gender identity. The reduction of complexity to a catchphrase by those who would shout “biology!” has, predictably, led to sloppiness about what exactly is meant here by biology. Is it about genitals, which can be changed? Is it about sex chromosomes, which can’t? One anti-trans organization, having invested in an entire bus devoted to transphobia, was seemingly unable to make up their mind. Is it about testosterone, and certain levels of it? Such definitions have been used in practice to exclude even cis women from membership in the category of women athletes.

Janice Turner may inveigh against the notion “that biological sex is not real but an artificial construct”, yet transphobes have been constructing different concepts of biological sex in their own particular ways all along – the only unifying feature seems to be that “biological sex” means whatever can be wielded against trans people. This approach does not lend itself to rigor. Turner’s own peculiar storytelling on biology and sex chromosomes, in which one X chromosome apparently restrains the coronavirus while the other X chromosome gives it a taste of Jack Johnson and Tom O’Leary, does not at all reflect the actual statements of the doctor she cites: that a doubled availability of X chromosomes increases the likelihood that a person will have genes for both the effective recognition of the coronavirus as well as an effective response to it. This is probabilistic, not categorical – someone with XX chromosomes could still be unlucky enough to have genes for both poor recognition and poor response to this virus, and nothing precludes the possibility that an individual with XY chromosomes could still have the genes for doubly effective antiviral fisticuffs (Dr. Moalem: “I can only hope that my one X has the genes that can recognize the virus — and can kill it, too”). Turner then proceeds to point out a lack of sex-disaggregated data, in which separate data is provided on COVID-19 specifically in men and in women, but terms this “a paucity of sex aggregated data”, which is the opposite of that.

Of course, a tenuous grasp of the life sciences has never stopped any transphobes from lecturing us on the importance of biology, and Turner’s confidence in her philosophy is similarly out of proportion to her competence. Indeed, kudos to her on taking a brave stand against the menace of those who roam the halls of maternity wards and allocate sex assignments and birth certificate gender markers solely on the basis of some kind of random number generator, a problem I had somehow remained completely unaware of until I was subjected to her trenchant insights. The only point she’s made here is that it is exceptionally easy to attack an argument when you misrepresent it as something plainly ridiculous. Nothing about the recognition of assigned sex as something distinct from identified gender implies such an absurd practice. And the recognition of a misalignment between assigned sex and identified gender as experienced by trans people does not at all imply any kind of denial of the physical, anatomical, or biological basis upon which sex is typically assigned.

What purpose does Turner’s objection to the notion of assigned sex really serve? If we cannot even speak of assigned sex as something that can be distinguished from, and does not necessarily line up with, identified gender, then all that is left is whatever construction of “biological sex” transphobes happen to be advancing at the given moment – that is all we can have and all that matters. It is a way of dictating the terms of the debate from the outset such that trans people, characterized by the disconnect between their assigned sex and identified gender, cannot by definition even exist in the first place.

What does it mean to insist that concepts of “biological sex” are not an “artificial construct”? It means attempting to pull the rhetorical sleight-of-hand of claiming that her chosen definition is not actually a deliberate choice made by her at all, but simply a set of facts about reality, and those who agree with her have properly recognized those facts, while those who disagree with her have failed to acknowledge reality. Transphobes may love their 8th grade biology, but this is philosophy 101: the map is not the territory. National and regional borders are not the same thing as physical earth features – and if, in a border dispute, you were to accuse your opponent of denying the existence of mountains and lakes, it would become immediately obvious that you’re as disingenuous as Janice Turner. This isn’t a disagreement taking place at the level of whether certain things are true or untrue in reality. This is about the choices that are made – chromosomes? genitals? hormones? – in deciding what gets left in and left out of the concept of biological sex, which is a way of organizing those facts and making sense of what we see in the world around us.

Turner, Jones, and others who appeal to the all-important sex “coded in our very cells” seem to have given little thought to what exactly that genetic code actually does beyond merely existing as a template upon which to project transphobic interpretations. The expression of those genes, producing the physical development of certain sexually dimorphic characteristics, can be regulated by sex hormones – including the cross-sex hormone therapy taken by many trans people. Trans women and transfeminine people who lower their testosterone and raise their estrogen levels experience the growth of breast tissue that is anatomically and histologically identical to that of cis women (Phillips et al., 2014; Maycock & Kennedy, 2014). Trans men and transmasculine people taking testosterone can experience the growth of prostate tissue within the vagina (William et al., 2020). Trans women tend to exhibit brain structures distinct from the sexually dimorphic brain structures of both cis men and cis women (Flint et al., 2020). Neuroscience texts have included gender identity itself as a component of the neurobiology of sex (Purves et al., 2001), and professional associations of endocrinologists have stated that there is a biological component to gender identity. All of these things involve human biology and biological sex characteristics, and the biology of sex does not begin and end at an inert karyotype – sex chromosomes are just one part of an expansive and complex system, a system which just might conceivably have some relevance to how we think about “biological sex”.

When you get down to it, just what kind of argument is Turner actually making? Susceptibility to coronavirus infection and severity of COVID-19 disease appear, in aggregate, to differ by assigned sex. Does it therefore follow that biological sex is solely and completely determined by sex assignment at birth, and that biological sex cannot be defined or conceptualized otherwise? COVID-19 susceptibility and severity is influenced by sex chromosomes. Does it therefore follow that biological sex must be determined solely and completely by sex chromosomes, and is entirely unchangeable?

What happens if that turns out not to be the case? What if this situation turns out to be something completely different?

Let me now try my hand at Janice Logic:

COVID-19 susceptibility and severity is influenced by sex hormone levels. Therefore, biological sex must be determined by sex hormone levels, and is completely changeable.

Of course, that isn’t actually any better of an argument. But if Turner insists on hitching her biological sex wagon to the COVID-19 horse, that appears to be the direction in which it is now heading.

On April 27, the New York Times reported that doctors in Long Island and Los Angeles are conducting trials of estrogen or progesterone treatment of COVID-19 in cis men and postmenopausal cis women:

The Stony Brook estrogen trial is recruiting 110 patients who come to the hospital’s emergency room with symptoms like fever, cough, shortness of breath or pneumonia, and who have either tested positive for Covid-19 or are presumed to have the illness, as long as they do not require intubation.

The trial is open to adult men as well as to women aged 55 and older, since they have low levels of estrogen. Half of the participants will be given an estradiol patch for one week, while the other half will serve as a control group, and researchers will follow them to see whether estrogen reduces the severity of their disease.

Crucially, the idea to use estrogen or progesterone treatment in cis men was inspired by the observation that women with COVID-19 have less severe disease and higher survival rates:

“There’s a striking difference between the number of men and women in the intensive care unit, and men are clearly doing worse,” said Dr. Sara Ghandehari, a pulmonologist and intensive care physician at Cedars-Sinai in Los Angeles who is the principal investigator for the progesterone study. She said 75 percent of the hospital’s intensive care patients and those on ventilators are men.

And pregnant women, who are usually immunocompromised but have high levels of estrogen and progesterone, tend to have mild courses of the disease. “So something about being a woman is protective, and something about pregnancy is protective, and that makes us think about hormones,” Dr. Ghandehari said.

Other scientists pointed out that this difference in outcomes may be genetic and not just due to hormones:

“We see this bias across the life course,” Dr. Klein said. “Older men are still disproportionately affected, and that suggests to me it’s got to be something genetic, or something else, that’s not just hormonal.”

“Estrogen has immune modulatory properties — don’t get me wrong,” she continued. “You could get a beneficial effect in both men and women. But if women are better at recovery at 93 years old, I doubt it’s hormones.”

This broad approach reflects the current understanding of the role of biological sex factors in the immune system. Lotter & Altfeld (2019) point out that the study of sex differences in immune response must take into account genetic differences as well as sex hormones:

While it is now well established that sex represents an important variable in these diseases, significant gaps remain in our understanding of the precise mechanisms mediating sex-biased immune responses and how this affects the outcome of human diseases. Future research is required (i) to define the pathways that are mediating these sex-specific differences, (ii) to dissect the effect of sex hormones on different compartments of the immune system, (iii) to determine the role of sex chromosome-encoded genes, and (iv) to assess the contribution of sex-differences in the microbiome. Clinical studies should not only take the sex, but also the age, reproductive status, and use of exogenous hormones into account when interpreting outcomes. Studies both in animals and humans have to be designed accordingly.

Schurz et al. (2019), Taneja (2018), and Rubtsov et al. (2010) have likewise pointed out that both sex chromosomes and sex hormones play a part in the differing immune responses seen in men and women. Other doctors and researchers have recommended this same line of investigation based on the apparent role of estrogen in lessening the severity of coronavirus infection. In a non-peer-reviewed preprint of a March 30 study from Wuhan, higher estradiol levels were found to be associated with less severe disease (Ding et al., 2020). Notably, women who were postmenopausal experienced worse outcomes than women who were not, weighing against the assertion that this is solely determined by the presence or absence of XX chromosomes. La Vignera et al. (2020) also suggested that estradiol may have a protective effect in COVID-19 and that men undergoing testosterone replacement therapy might be advised to reduce their dosage. An April 28 preprint by Wang et al. (2020) raised the possibility that the enzyme TMPRSS2, used for entry both by SARS-CoV-1 (the 2002-2003 SARS coronavirus) and SARS-CoV-2 (COVID-19), could be inhibited by estrogen or antiandrogens to treat the infection; other preprints contest this and claim that modulating androgens would have little effect on TMPRSS2 (Baratchian et al., 2020). A previous study of SARS coronavirus in mouse models found that treating female mice with an estrogen antagonist or removing their ovaries significantly increased their likelihood of death from SARS (Channappanavar et al., 2017).

Certainly none of this is conclusive. Indeed, unlike Janice Turner and Maya Forstater, actual doctors and scientists have conspicuously not concluded anything along the lines of “sorry, no XX chromosomes, you’re screwed”. Instead, recognizing the real complexity of biological sex, they’ve seen this for the opportunity that it is: a chance to use those elements of biological sex to investigate treatments that may reduce human suffering and save lives. Maya Forstater, following the ruling that her incessant trans-hostile behavior makes her extremely fireable, stated: “My belief … is that sex is a biological fact, and is immutable.” Meanwhile, healthcare workers on the front lines of COVID-19 wards are in the process of muting it right now. Janice Turner may like to pretend that her transphobia is accomplishing anything of value. But it wouldn’t have accomplished this.

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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