How Endocrinologists Attacked the Sex Binary

They provided air cover so shrinks, lawyers, and activists could rush in with “gender identity”

“Where there is sperm, there is maleness.”

–An endocrinologist who didn’t want to say “men produce sperm” (1966)

The sex binary is a construct, you’ve probably heard. It’s not real, and divvying people up into “male” and “female” is actually impossible. The theory of human sexual dimorphism has nothing to do with science. It’s about imposing cis white patriarchal schema on BIPOC.

Sex nihilism like this is often blamed on postmodernism or queer theory. But its lineage actually traces back through pharma scientists in the 1930s and Harry Benjamin, the mid-century huckster endocrinologist. These commercial actors wanted people to think of sex as a spectrum, not a binary, because they sold hormones intended to change consumers’ position on the (imaginary) spectrum. 

In recent times, endos have shifted their argument. They don’t plot sex on a single axis. Rather, they depict it as a multi-dimensional hodgepodge of characteristics like genes, “hormonal milieu,” and “social role,” which cannot be distilled into a single word like man or woman. Their message: sex is too messy and confusing to base laws on. Go with “gender identity” instead.

Endos insinuate that the sex binary is just about appearances because sex is “assigned at birth” based on how the baby’s genitals look. They’re projecting. In fact their view of sex is fixated on appearances (e.g., growing a beard enhances one’s maleness), so much so that it minimizes the role of reproduction. It’s form over function.

Endos aren’t the only gender professionals who obfuscate the sex binary. Shrinks have tried to elide it since John Money in the 1950s. But the endo attack matters more to today’s pro-trans legal arguments.

This post is about endocrinologists’ role in convincing the world that humans are not sexually dimorphic.

The Hormone Hunt

The idea that “internal secretions” influenced human appearance and behavior arose around the late 19th century. Soon companies started questing after sex hormones – the chemical “essences” of men and women, respectively. Among other uses, they hoped that medicinal hormones could cure homosexuality.

I’m drawing this from Bob Ostertag’s Sex Science Self.

Beginning in the 1920s, researchers discovered that animals of both sexes produced the same hormones, albeit in different amounts. Testosterone wasn’t unique to males, and estrogen wasn’t unique to females. This frustrated scientists who’d set out to isolate (and sell) “sex hormones.” They rationalized the discovery by positing “gender spectrum theory.” In Ostertag’s words:

“The rigid binary of male and female chemicals was rescued by sacrificing the rigid binary of people. People were no longer clearly male or female, but chemicals were.”

This idea jibed with the model of “bisexuality” that German sexologists like Magnus Hirschfeld had been developing over the previous few decades – everyone was partly male and partly female, in their view (the term didn’t refer to sexual orientation). As Helen Joyce writes in Trans:

“After Darwin, any definition of ‘male’ and ‘female’ other than as developmental pathways directed towards and shaped by reproductive roles should have been dead in the water. But for Hirschfeld and his colleagues at the Institute [of Sexual Research], it was as if Darwin had never existed.”

The idea of nonbinary sex served certain agendas: commercial actors’ drive to profit off hormones and sexologists’ intellectual curiosity about sex change.

Gays Think They’re on the Gender Spectrum (1930s - 40s)

Pharma started selling synthetic hormones in the US in the late 1930s. The hype around them seems to have sparked the idea in some gays that there was something wrong with their sexed bodies, which they could fix with estrogen or testosterone. 

In 1939, a young lesbian named Pauli Murray clipped articles touting the effects of testosterone pills on “effeminate” boys and men. She then identified physicians who studied the endocrine system and started asking them to “experiment” on her, as she suspected she was a “hermaphrodite” whose isolation could be cured with hormones. The doctors never obliged; she kept living as a lesbian and became an icon in the struggles for black civil rights and women’s equality.

Joanne Meyerowitz pinpoints the late 1930s as the moment when the American popular press frequently reported (sensationally) on European sex-change experiments and discoveries about hormones. She discusses a 1939 magazine feature about a woman who’d suddenly started masculinizing, with “alarming symptoms” (the magazine’s words) like finding “herself irresistibly attracted to members of her own sex.” It turned out she had a benign tumor near her ovaries. Once it was removed, she went “back with her husband … soon [to be] a mother.” The reader’s takeaway would have been: homosexuality comes from curable physical disorders.

Around the 1940s, a 12-year old California boy began sneaking his mother’s estrogen pills (prescribed after a hysterectomy). He later tricked UCLA doctors into believing he was a woman named Agnes with a disorder of sex development; they castrated him in 1959. Agnes’ motivations didn’t make it into the historical record, but he had a boyfriend whom the researchers perceived as gay. 

In 1948, a lonely young gay man named George Jorgensen read a pop science bestseller called The Male Hormone. It blew his mind; he decided he was a woman. In 1952 he underwent genital surgery in Denmark. He returned to the US as Christine. The press fawned over the army vet, whom it dubbed a “blonde bombshell.”

Notice that Murray, Agnes, and Jorgensen didn’t dose up with their own sex’s hormones. Rather, they leaned into their sex-atypical personalities and preferences. Some gay men tried to become straight by taking testosterone, but Ostertag reports that the drug just made them gayer (by supercharging their sex drive).

Harry Benjamin’s New Job (1952 - 1966)

When Jorgensen’s story hit the tabloids, Harry Benjamin was an endocrinologist with a checkered past. In Joyce’s words, he’d “started his career as an out-and-out quack”:

“[Benjamin] arrived in New York in 1913 [from Germany] as the assistant of a swindler selling the ‘turtle treatment,’ a fake tuberculosis vaccine. That fraud was exposed, and Benjamin moved on to touting testosterone supplements and vasectomy as anti-aging treatments.”

Benjamin became Jorgensen’s endo after meeting him at a dinner party in 1953. US surgeons weren’t offering cosmetic genital surgery, so Benjamin’s link to a post-op transsexual gave him a unique status. He threw himself into life as a trans activist.

According to Joyce:

“At a 1954 symposium sponsored by the American Journal of Psychotherapy, he argued that everyone was made up of a ‘mixture of male and female components,’ and that male ‘transsexualists’ had a ‘constitutional femininity, perhaps due to a chromosomal sex disturbance.’”

Benjamin soon connected with Reed Erickson, a wealthy lesbian who wanted to transition and bankroll a transsexual movement.

Erickson granted $50,000 (worth about $490,000 in 2024) to Benjamin around the same time she funded John Money to launch America’s first gender clinic at Johns Hopkins in 1966, according to Ostertag. The clique met monthly in Benjamin’s office. 

“The Transsexual Phenomenon” (1966)

In 1966, Benjamin published The Transsexual Phenomenon. From page 1, it seems to destabilize sex. Keep reading, and you realize he’s not challenging the biological view of sex as a binary. He just doesn’t care about biology.

The first paragraph:

“There is hardly a word in the English language comparable to the word ‘sex’ in its vagueness and in its emotional content. It seems definite (male or female) and yet is indefinite (as we will see). The more sex is studied in its nature and implications, the more it loses an exact scientific meaning. The anatomical structures, so sacred to many, come nearer and nearer to being dethroned. Only the social and legal significances of sex emerge and remain.”

Benjamin admits again and again that sex change is impossible, but also flirts with the opposite idea (without quite endorsing it). For example:

“What would be the situation after corrective surgery has been performed [on a man] and the sex anatomy now resembles that of a woman? If the ‘new woman’ still a homosexual man? ‘Yes,’ if pedantry and technicalities prevail. ‘No’ if reason and common sense are applied and if the respective patient is treated as an individual and not as a rubber stamp.

“Again the thought clearly emerges that what we call ‘sex’ is of a very dubious nature and has no accurate scientific meaning. Between ‘male’ and ‘female,’ ‘sex’ is a continuum with many ‘in betweens.’”

While this sounds like sex is one-dimensional, as in the old “gender spectrum,” elsewhere Benjamin states that we have multiple sexes – gonadal, psychological, etc.

Benjamin squishes the entire concept of reproduction into one of the two subvariants of gonadal sex:

“The germinal sex serves procreation only. The normal testis produces sperm and where there is sperm, there is maleness. The normal ovary produces eggs (ova) and where they are found, there is femaleness.”

The Maleness & Femaleness Law (Minneapolis, 1975)

Minnesota has been at the vanguard of gender since its flagship public university opened the nation’s second MTF genital surgery clinic in 1966.

In 1975, Minneapolis amended its anti-discrimination laws to protect people for “having or projecting a self-image not associated with one’s biological maleness or one’s biological femaleness.” I believe it’s the first time a statute in the US was enacted to protect trans-identified people against discrimination.

Note how the law isn’t worded: “ … a self-image not associated with one’s sex.” That would have been clearer. Someone with influence must have argued that sex was a problematic word.

Blocking Puberty (Amsterdam, 1987)

When the Dutch psychologist Peggy Cohen-Kettenis wanted to try blocking “transgender” kids’ puberty, she turned to the endocrinologist Henriette Delemarre-van de Waal.

The pair could have test-run their idea in a lab. As Michael Biggs has pointed out, de Waal was an academic scientist with rats at her disposal for experiments just like this. But she chose not to use them.

Like Benjamin, de Waal put adventurism ahead of inquiry. Other gendocrinologists kept up the tradition. It’s fallen to professionals in other fields to pick up the slack. Sallie Baxendale, for example, is a neuropsychologist. She recently reviewed all the pertinent research, which includes just a few studies on humans delaying normal-age puberty, and found no evidence that “you can pause a developmental stage and then restart it and everything will be okay.”

About DSDs…

Trans activists cite disorders of sex development (DSDs) as evidence that sex isn’t binary. This argument is a canard.

First, people with DSDs are all either male or female, meaning their bodies are patterned to produce sperm or ova; none of them produce some third type of gamete. Here’s a plain-English NHS guide to DSDs and how doctors detect them in infants.

Second, DSDs are disorders. Something’s gone wrong.

Q: How many wheels does a bike have?

A: Some have two wheels; others have one, for example if they’re in the shop waiting for the wheel to be replaced. It’s impossible to say generally how many wheels a bicycle has.

Bikes don’t become ineffable if somewhere in the world there’s a broken bike. And the word “man” doesn’t become impossible to define because Caster Semenya’s testicles are in the wrong place. 

Norman Spack’s Saliva (2007)

Around 2006 Norman Spack, an endocrinologist affiliated with Boston Children’s Hospital, started prescribing puberty blockers as gender medicine. In 2007 he launched the hospital’s Gender Management Service (GeMS), a trailblazing kiddie gender clinic. He’s repeatedly said that when he first learned about the Dutch puberty blocker experiment, he was “salivating.”

Spack traces his interest in trans youth to around 1985, when he was in his 40s and an FTM recent Harvard grad, M, sought his services. He treated her for free in exchange for the chance to hang out with her and her friends. While he reveled in the transsexual youth social scene, he pitied its denizens because they didn’t really pass. 

M married an MTF and killed herself in her 40s.

Spack also treated trans “street kids” in the 1970s in Boston. (I researched this cohort in other cities and suggested it was a subculture of underage transsexual prostitutes abetted by gender doctors, including Benjamin.)

Spack – who is still around today in an emeritus capacity – has a blunt manner. 

2008:

“If a girl starts to experience breast budding and feels like cutting herself, then she's probably transgender. If she feels immediate relief on the [puberty-blocking] drugs, that confirms the diagnosis.”

He treats trans kids’ bodies like bears he wants to wrestle into submission. "And so [the blockers protocol] buys you time ... without the tremendous fear of their body getting out of control." “They are no longer a hostage to their bodies.” He’s compared puberty for a trans kid to “Pinocchio turning into a donkey.”

In his 2013 Ted Talk, Spack boasted that one of his MTF patients, Jackie, had been a semifinalist in the Miss England competition. He mocked the girls who competed against him: “[Jackie] has more natural self than half the contestants. Some of them have been rearranged a little bit, but it’s all her DNA.” (Jackie is the son of the infamous Susie Green, former head of the UK’s Mermaids charity.)

Spack tries to mystify sex. In his Ted Talk he clumsily alluded to DSDs:

“[I]n cases in which there are mismatches in the externals or between the externals and the internals … we literally have to figure out what is the description of your sex. But there is nothing definable at the time of birth that would define you.”

By Spack’s lights, gender identity is rock solid:

“But, at the time that puberty begins … the child who says they are in the absolute wrong body is almost certain to be transgender and is extremely unlikely to change those feelings[.]”

(Michael Biggs sussed out the “slender evidence” for this claim.)

In 2009, Spack’s trade association, the Endocrine Society (ES), let him co-author a Clinical Practice Guideline that advised clinicians to administer puberty blockers to “transgender” kids at the first stage of puberty. For the ES, it was a stepping stone to publishing something more influential.

The Endocrine Society Guideline (2017)

Most ES Guidelines are supported by evidence that's “low quality” or worse, and 20% by “very low quality” evidence, according to a 2015 study.

In 2017 the ES released a guideline for treating “gender-dysphoric/gender-incongruent persons” that actually acknowledged “we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols.” It did not explain why clinicians shouldn’t wait for the rigorous evaluations.

According to the chair of the drafting committee, the guideline was “designed to provide a better understanding of the presentation of gender dysphoria so that treatment … will be carried out more smoothly.”

The committee was comprised of fewer than a dozen endos, almost all of whom were leaders in WPATH, according to Paul Hruz’s testimony in ongoing pediatric gender medicine litigation. The full ES membership never reviewed or approved the guideline.

The guideline defined sex in a way that made no reference to reproduction:

"Biological sex, biological male or female: These terms refer to physical aspects of maleness and femaleness. As these may not be in line with each other (e.g., a person with XY chromosomes may have female-appearing genitalia), the terms biological sex and biological male or female are imprecise and should be avoided."

Confusingly, after the vocab lesson, the Guideline then emphasizes that only mental health providers “recommend” patients for gender medicine. OK – but then why not defer to a psych authority, like the Diagnostic and Statistical Manual, for definitions of terms like sex and gender identity? 

Whatever the reason, this move was a boon for the ACLU. The ACLU relentlessly flogs the term “medical” to distract the judge from the fact that its claims are actually grounded (if anywhere) in mental health authority. After the 2017 ES Guideline dropped, the ACLU started citing it in its lawsuits.

For example, in its 2021 complaint challenging Arkansas’ pediatric gender medicine ban, the ACLU alleged:

“The terms ‘sex designated at birth’ or ‘sex assigned at birth’ are more precise than the term ‘biological sex’ because there are many biological sex characteristics and they may not align with each other in a single direction. … [T]he Endocrine Society, an international medical organization of over 18,000 endocrinology researchers and clinicians, warns practitioners that the terms ‘biological sex’ and ‘biological male or female’ are imprecise and should be avoided.”

Norman Spack, a gender doctor who possesses the characteristics of a human

What Is an Endocrinologist?

The modern American endo trades salary and glamour for work-life balance. Pediatric endos are especially low-paid relative to other specialists. 

As for training, after a three-year residency in internal medicine or pediatrics, endos complete a two-year fellowship.

Most endo patients suffer from diabetes, obesity, or thyroid issues. Treatment is motivational, as meds alone aren’t a panacea: patients have to diet and exercise, too.

Endos rely heavily on lab results to make diagnoses and treatment plans.

Trawling Reddit and other doctor-gossip sites, I couldn’t believe how foreign all this sounded to gender medicine. The modern endos I’ve encountered in gender-world, like Spack, Kathryn Ackerman, and Deanna Adkins, come off like grasping egomaniacs, not wholesome work-life balancers. I can’t picture Adkins dishing realtalk to her patients about diet and exercise; rather, she promises that synthetic hormones are a cure-all. And her north star definitely isn’t objective lab results – it’s subjective gender identity.

Endocrinology sounds like a great career that probably attracts very smart, engaged people. Indeed, several endos have spoken out brilliantly against gender medicine. But maybe the field doesn’t do a good job of screening out charlatans.

Expert Endos (2015 - today)

When the ACLU first entered the gender fray in 2005, it seemed to have trouble recruiting a medical doctor to testify congenially. But by 2015 that changed. It had a pediatric endocrinologist testify on behalf of Gavin Grimm, a high school girl who wanted to use the boys’ bathroom.

Since 2021, the ACLU has been suing red states that banned gender medicine for kids under 18. These suits typically feature a raft of plaintiffs, one of whom is a pediatric endo or pediatrician. That clinician may testify as a witness; a different pediatric endo steps up as an expert witness.

Only one of these cases has made it to trial so far – Brandt, in Arkansas. There, the endo Deanna Adkins gushed about her patients’ mental health and batted away questions about side effects. As I've noted, Adkins should not have been permitted to testify about mental health because it was outside her area of expertise, and the testimony she gave within her field of expertise was dishonest.

Before trial, the endos provide written reports to the court that back up the ACLU’s sex nihilism. For example, here’s an affidavit submitted by Daniel Shumer in Loe v. Texas in 2023:

“Sex is comprised of several components, including, among others, internal reproductive organs, external genitalia, chromosomes, hormones, gender identity, and secondary sex characteristics.”

“Gender identity does not refer to socially contingent behaviors, attitudes, or personality traits. It is an internal and largely biological phenomenon.”

(Gender identity is not biological.)

These definitions appeared under the heading “MEDICAL AND SCIENTIFIC BACKGROUND ON SEX AND GENDER IDENTITY.”

Whereas Benjamin was a thought leader, today's gender endos are props: MDs who class up the whole activist circus by flashing their credentials and testifying to whatever the ACLU wants.

The Sex Binary on Life Support

Healthcare

The American Medical Association had this to say about sex in 2021:

“Sex assigned at birth

“A concept used to describe a person’s sex assigned at birth, typically based on a subjective evaluation of external anatomic structure(s) and its comparison to various sex categories. This may or may not align with how they identify themselves.”

To put that in perspective, the AMA is in a death spiral. Less than a quarter of practicing doctors pay dues to it and Republicans have stopped taking it seriously. That’s hugely damaging because it’s a lobbying group.

Medicine’s larger shame is that it doesn’t have any major institutions countering the AMA’s sophistry and standing tall for the sex binary.

Law

While many courts have deployed preferred pronouns and “sex assigned at birth” terminology (at least in cases where a party is pushing it), I’m not aware of any that adopt the Endocrine Society’s view of sex. Rather, judges who rule for trans litigants tend to sidestep the question.

Where federal statutes use the word “sex,” the Obama and Biden administrations have interpreted it to mean “gender identity.” This aligns with the Spack/ES view that sex is hopelessly imprecise and should be replaced.

The Discourse

Gender doctors know they’re playing word games. They’ve all aced biology tests by saying humans have an innate quality, which is binary, that directs their bodies to produce small or large gametes. They just refuse to call that quality “sex” now that their grades are doled out by the Human Rights Commission.

But rank and file trans activists are not in on the joke. Lots of kids and foolish adults right now believe that human reproductive capacities exist somehow on a spectrum. Or that it’s wildly inappropriate to recognize bodies as having reproductive functions. Or … actually I think they do believe in the sex binary, they just don’t even realize it.

Why Not Change the Definition of Sex?

Meanings change over time. We could decide as a society to let sex, male, and female become terms that refer to visible attributes. Likewise, we could treat reproductive capacities as too frivolous to merit discussion, or too technical to raise in the context of important topics like identity. Let’s see how that would play out.

Using the Endocrine Society’s definitions of male and female, this is how a woman must explain her desire to transition:

“I want surgery so I can resemble a man, which is a person who looks male, which means a person who embodies maleness, which is the property of being a man, which is a person who looks male, which means a person who embodies maleness …”

Her task is impossible. But if sex is defined in terms of reproductive roles, the woman can say:

“I want surgery so I can look male, which means a person whose body is designed to produce small gametes.”

Defining sex by the body’s reproductive function works best even for the people who don’t want to do it.

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This post was lightly edited on Sept. 29, 2024.