Excellent BMJ editorial on sex and gender

[2Rebecca]

twitter.com/bmj_latest/status/1372890963278958594
Makes a change from the Stonewall influenced stuff on gender that usually graces the BMJ. Not sure how to attach the pdf

@AnnieLobeseder

I used to work as a biomedical editor and now I'm a medical writer. I've been on a one-woman crusade to ensure that 'sex' and 'gender' are used correctly in every academic article I have edited and written over the years. The number of academics, and even medics, who really don't get it just baffles me. I'm very pleased to see the BMJ offering solid advice.

I almost never review an article without needing to mention SAGER and why I'd like to see disaggregation by sex in the reporting and data analysis - even if it's to explain that the investigators didn't do it or the data weren't available.

You might think that this

" For example, a lack of inquiry means we have no accurate data or high quality evidence on whether gender diverse people are more or less affected by covid-19, and thus whether public health and medical advice ought to be different for trans people taking cross-sex hormones."

would mean that people on such hormones would actively want to stand up and be counted accurately, so that their medical care might be improved.

In fact, I would have thought that making sure you were transgender would be something anyone transgender would want to be counted as being in the census, because the more of them there are the more they will get the treatments they need in the NHS -- but it seems many don't see it that way.

It's a great article. Thanks for sharing.

I really do despair at what's happening in Scotland. I think the phrase 'biological sex' is considered a hate crime by some.

It's absolutely insane. I'm going to send a copy of this to the office of the national statistician.

Crikey, that's almost revolutionary. Simple clear hitting the nail on the head.

Thanks for linking…

Science as it should be - thanks for linking! The amount of ‘wrong think’ is worrying

And yet they didn't use sex in their own resolutions https://blogs.bmj.com/bmj/2021/03/08/ten-steps-to-gender-equity-the-bmjs-resolutions/?utmcampaign=shareaholic&utmmmedium=twitter&utmsource=socialnetwork&fbclid=IwAR2lTfIeCt1lSqzfMK-OueGY9l4K1NyvtvPKpTsHiE5NCdwCppyGfybFSOE

I think there are plenty of people who have been waiting for some sort of official pronouncement which they could use to start pushing back. The definition of sex for the Census gives them the ammunition they have been waiting for. If the Census is the gold standard of data collection on what basis would you deviate from its definitions.

Super thank you.

@AnnieLobeseder loving your work! I've taken to contacting everyone who uses gender when (it seems) they mean sex & it's time consuming so I can Imagine the pushback you get for this in work! Keep 'er lit!

Bewley and McCartney are actual bad ass heroes.

And it provides a heavyweight, irrefutable citation, clearly stating the issue

Very good to see this. I always enjoy hearing Margaret McCartney on Inside Health on Radio 4 - she's a regular contributor and voice of reason. Not on this topic, necessarily, but generally.

There is a Rapid Response, criticising it and bemoaning a "chromosomal essentialist view of sex". Silly us, we should realise it's all about hairstyles and make up.
"It is disappointing that the BMJ has chosen this as an editorial. The authors are not Gender Identity Specialists, and this editorial is the latest in line of number of letters and articles co-authored by Professor Bewley and Dr McCartney over the past few years where they have taken a stance which is against the consensus of Gender Identity Specialists with little to no evidence to support their position.

The lack of expertise of the authors is glaringly clear in the editorial itself. They start by saying that sex relates to “the gametes, chromosomes, hormones, and reproductive organs”, and then go on to argue that natally assigned sex should be recorded on all NHS systems so “relevant information about biological sex” is available for research and service delivery. But someone who is a trans woman may or may not have had hormonal treatment; she may or may not have had gender affirmative surgery. It is extremely likely that she has XY chromosomes, but even that is not an absolute certainty. Which of those is the “relevant information about biological sex”? They provide three references for “avoidable harm” that can happen when sex specific laboratory reference ranges are used for people whose gender but not “biological sex” is recorded. However, the first reference does not mention the topic. [1] The second states “once individuals have commenced gender-affirming hormone therapy, the reference range of the affirmed gender be reported” (with the exception of PSA and cardiac troponin). [2] The third does flag up the potential for harm in inaccurately calculated eGFRs, but rather than an automatic reversion to calculation on natal gender assignment, an individualised approach based on muscle mass is suggested. [3] The important part of “biological sex” (both to patient and researcher) in these cases is more complex than natally assigned sex. As they mention, sex differences in drug metabolism certainly exist; however, a large number of these are hormonally mediated, meaning again that in those cases a trans person on hormones would be categorised correctly under their recorded gender. [4] Their example of not having data on the Covid-19 outcomes trans people on hormonal treatment would be utterly unchanged by having natally assigned sex recorded, as that gives no clue as to whether or not the person is on hormonal treatment.

They seem to be worried about trans people being on inappropriate screening registers – but trans women on hormonal treatment will develop natural breast tissue, and should attend breast screening in the same way as any other woman, so getting that automated invite is entirely appropriate for them. [5] The obvious answer to the issue is having flexibility in the system to respond to those who do not fit into their norms (which of course includes, for example, cis women who for whatever reason do not have a cervix).

There is still a great deal of research to be done into transgender health, and women’s health is still all too often seen as just a deviation from a male norm. However, neither of these are served by over-simplification. “Sex” is a combination of multiply interacting things which may not fit into neat boxes, whether naturally (intersex conditions) or through human intervention (hormonal treatment for trans people). To say that a trans person’s natally assigned gender is their sex is (for many people) to say that the chromosomal always trumps the hormonal, and it is definitely not clear that this is the case. Exactly what is needed to be recorded and extracted for the best research and service delivery is probably not yet certain.

However, I have to suspect given the previous publications of two of the authors that this is not a topic which is raised in good faith. Rather, raising the spectre of trans people contaminating research outcomes gives another avenue for fearmongering about trans people and advancing a particularly chromosomally essentialist view of sex.

Saying this, I have no intention to shut down discussion and debate around trans health. But the reality is that in the British medical press, there is little debate; rather a small number of clinicians and academics who are critical of mainstream gender services and critical of the main organisations representing transgender people are published again and again. I am sure that the authors of the article will respond that they only have the health and wellbeing of the trans community at heart. Looking at a group of (apparently) cisgender, non-experts who mobilise their professional credentials to gain a platform for views which many trans people would consider harmful, the trans community can be forgiven for doubting how sincere this is."
Margaret I White
Specialist Trainee in Intellectual Disability Psychiatry
Community Learning Disability Team, Astley Ainslie Hospital, Edinburgh

"It is extremely likely that she" (a trans woman) "has XY chromosomes, but even that is not an absolute certainty."

Surely it is a stone-cold certainty, because otherwise she wouldn't be trans, would she? I mean, she has to have transed (what is that short for?) from something, and it isn;t going to be from XX.

“Sex” is a combination of multiply interacting things which may not fit into neat boxes, whether naturally (intersex conditions) or through human intervention (hormonal treatment for trans people).

I wish people would leave intersex or DSD out of this discussion - even self-appointed interlocutors should know of the repeated calls for this.

To say that a trans person’s natally assigned gender is their sex is (for many people) to say that the chromosomal always trumps the hormonal, and it is definitely not clear that this is the case.

So that's another person saying 'gender' is the thing that's assigned at birth. (And that 'sex' is a complicated fuzzy unmeasurable thing).
Shizuku said it isn't, it's 'sex'.
Mermaids says it's 'gender identity'.

They're.... sort of exactly proving the point of the original editorial which said 'contemporary medical research and clinical practice often erroneously use sex and gender interchangeably'?

This response doesn't seem to refute the claims made about the definitions of sex and gender, but tries to mix them up a bit? They try to redefine 'sex' in a 'it's complex' way, but don't give a corrected definition of gender, so is that an implicit agreement that the definition given was correct? ie "Gender relates to societal roles, behaviours, and expectations that vary with time and place, historically and geographically."

Who on earth knows what this is even saying?! and
"They start by saying that sex relates to “the gametes, chromosomes, hormones, and reproductive organs”, and then go on to argue that natally assigned sex should be recorded on all NHS systems so “relevant information about biological sex” is available for research and service delivery. But someone who is a trans woman may or may not have had hormonal treatment; she may or may not have had gender affirmative surgery"

How is the 'but' sentence in any way related to the first? Are they saying that because some trans people don't have hormonal treatment (?) natally assigned sex shouldn''t be recorded on anyone's records? Or are they saying the presence or lack of this treatment means everyone should have 'gender' recorded instead? It just does not follow.

The authors are not Gender Identity Specialists
....the credentials given by the person who wrote that screed indicate they're not either (Specialist Trainee in Intellectual Disability Psychiatry)

This much is correct The obvious answer to the issue is having flexibility in the system to respond to those who do not fit into their norms

But the most robust norm against which to record the variations from it is surely sex. It is objectively definable, gender isn't.

No one gives a fuck about the rapid responses in the BMJ. Which is a pity, really, as the whole letter is a massive self-own

@MissLucyEyelesbarrow

No one gives a fuck about the rapid responses in the BMJ. Which is a pity, really, as the whole letter is a massive self-own

I remember when they used to be referred to as Rabid Responses in The People's Medical Journal (or PMJ).

Sometimes there are fascinating discussions but it feels rare - and the more contentious issues generate a mass of heat, light but very little understanding.

There's a second rapid response now, from a Maya Forstater...

Excellent reply by Maya. The RRs matter to a degree because people on the committees of the BMA and the diversity officer and diversity committee will be more likely to look at it. The BMJ and BMA don't want to be too out of step with their members and readers or they lose members and income.

Maya's response is gold! From the second half of the response:

More than ten years ago the NHS recognised the need for clear systems for recording biological sex and making sure it was not conflated with social gender. They carefully set up a system of data and definitions which could deal with both.[1]

The data standard for the CUI written in 2009 explained:

“The term ‘Gender’ is now considered too ambiguous to be desirable or safe… ”

The data standard set out definitions for patient “sex” and “current gender” and warned:

“Users may confuse the terms current gender and sex, or assume that they are synonymous. Therefore, it is essential that all NHS applications display and explain current gender and sex terminology and values in a clear and consistent manner.”

The data standard set out in detail how to keep these two characteristics separate and unconfused, and how to design computer interfaces to ensure that sex data was captured (with social gender as an optional extra). It also set out potential consequences of not adhering to these standards including:

• The patient is given the wrong treatment as a result of a failure to identify the patient correctly.
• The patient is given the wrong treatment as a result of a failure to match the patient correctly with their artefacts (samples, letters, specimens, X-rays, and so on).
• The patient is given the wrong treatment as a result of a failure in communication between staff, or staff not performing or checking procedures correctly.
• The patient is categorised with a value that cannot be utilised by any other systems.
• The patient is categorised incorrectly from a legal perspective.
• The patient is categorised incorrectly from their perspective.[2]

However despite establishing the basis for meeting these principles this system was not implemented. The current NHS data dictionary differentiates, "phenotypic sex" (as observed by a clinician) and "patient stated gender", but in practice “male” and “female” are recorded only against gender and the phenotypic sex field typically remains empty.

Policies to allow patients to change their registered "gender" are now embedded across the NHS.

The GMC tells doctors to change a patient’s sex/gender as recorded on medical records on request. This does not require any medical diagnosis, anatomical changes or a legal gender recognition certificate. [2]

Public Health England tells GP surgeries to change a patient’s’ recorded sex/gender on their medical record at any time, without requiring diagnosis or any form of gender reassignment treatment. They are given a new NHS number and previous medical information must be "gender neutralised" and transferred into a newly created medical record. They will be sent screening appointments (e.g. for cervical smear tests or prostate cancer screen) according to their new gender (i.e. invitations to attend the wrong screenings). [3]

Gender (self identified as male or female) is held by the Patient Demographic Service (PDS) for matching rather than clinical purposes. But it has recently been removed from the API because of sensitivity of people who identify as non binary and do not wish to be identified by their sex.[4]

This approach shows the way forward. Sex should not be confused with gender identity, or any other of the myriad definitions of gender. Accurate information on everybody's sex should be held in their NHS record but it should only be disclosed or displayed when it is needed and should not be used for matching purposes.

The authors state that "sex and gender should not be used interchangeably". In fact data quality risks mean that "gender" should not be used as an attribute at all, because it is undefined and invites confusion.

Aspects of social gender such as titles, name used, and preferred pronouns can be recorded in other fields to facilitate social interaction. Transgender identity may be recorded.

Given that the law allows people to change their legal sex, a field may be needed where people's legal sex is recorded, without changing the record of their biological sex (since this, in fact, has not changed and it destroys day integrity for everyone if the field can contain either biological or legal sex).

If someone has a diagnosis or medical treatment such as hormones or surgery to change the appearance of their sex, this of course should be in their medical record.

Greater clarity about definitions, privacy, confidentiality and data protection would allow people to keep their sex private in situations where it is no one else's business but maintain the integrity of medical records. In NHS systems this would need to include a general system of not displaying the last digit of NHS numbers on screen.

Data protection principles apply to everybody and currently the NHS (along with the Passport Office and DVLA) are failing in these principles by requiring information about individual's sex, but then processing it in such as way (mixing it in a category with self declared gender) that the data is corrupted.

As the ONS case over the census highlighted by the authors shows, there will be legal challenges. The Digital Identities Trust Framework being developed by DCMS is also an opportunity to fix the problem of data corruption of the sex attribute.
The NHS should establish a task force to understand the corruption of sex data across medical records and establish a plan to fix it.

Public Health England tells GP surgeries to change a patient’s’ recorded sex/gender on their medical record at any time, without requiring diagnosis or any form of gender reassignment treatment. They are given a new NHS number and previous medical information must be "gender neutralised" and transferred into a newly created medical record. They will be sent screening appointments (e.g. for cervical smear tests or prostate cancer screen) according to their new gender (i.e. invitations to attend the wrong screenings). [3]

I mentioned this on another thread. It is so important for a GP surgery to know a patient's birth sex that my family member's practice has had to create their own secret sex marker for these patients.

Thank goodness for people like Maya.

Secret sex marker - bloody hell.