Our university recently circulated an email message, the contents of which I found somewhat strange. Or rather, I might have found it strange had I spent the past decade or two in a coma. The message was a carefully worded reflection on how academic freedom can be reconciled with the university’s updated and strengthened policies of diversity, equity, and inclusion (DEI). Although it strategically avoided specifics, one might justifiably infer that academic freedom presents some kind of threat to DEI.
As I understand it, academic freedom means that what we publish and what we teach need only be judged for relevance and for support by the evidence base. In addition, it now appears that research must be compatible with institutional priorities. Less clear is where exactly these two guiding principles are expected to clash. In an attempt to understand this, I will reflect on a recent experience that may shed some light here.
I am a paediatric endocrinologist, with teaching duties in the Department of Paediatrics (cross-appointment in Human Genetics), at McGill University in Montréal. For a number of years, I had been giving the lecture on DSD, as part of the Reproduction and Sexuality series. This lecture is given to each class of medical students and it addresses a group of rare conditions involving individuals who are born with genital organs that are not clearly male or female. DSD used to stand for “disorders of sexual differentiation” but now the words “difference in sexual development” are increasingly being used to fit the same acronym—“disorders” is felt to be stigmatizing, and “differentiation” is too binary.
A few months before the lecture, I received an email from the Component Chair informing me that, “as you may have heard” (I hadn’t), there had been “some controversy” about the lecture. One example was given: the term “ambiguous” was disrespectful and the term “atypical” should be used instead. The Chair asked if I would meet with the two students who had presented the concerns. I was glad to accept—being advised of one’s error is priceless education. Call me naïve, but I did not allow myself to be distracted by the fact that my question about who exactly these two students represented, was ignored and remained unanswered.
The meeting was respectful, civilized, and constructive. The students agreed to put in writing their views on the matters we discussed, and I also summarized my responses in writing. I disagreed with many of the points the students brought up, but several others did make me improve the delivery of my lecture and even some of its substance. After the lecture, the two students thanked me for my openness to their concerns. So, I was surprised to receive an email from the administration, thanking me for my many years of teaching and informing me that I was being replaced—the result of “student feedback.” In their brief explanations, the course decision-makers drew a parallel between the negative student feedback my lecture had received and unrelated complaints about “obstetrical violence” in another professor’s lecture in the series. My offer to meet my replacement for a brief chat was ignored by the administration. I can only hope that the broader academic community and the public will show more interest in the possible reasons for the decision to silence me. My content was not questioned on grounds of relevance or support by the evidence; could it be that it was considered a threat to DEI?
Let me start with the only one of the students’ concerns that is of meaningful substance in caring for DSD individuals: surgery on young infants, to make their genitals conform to a specific sex, is indeed a legitimate issue in healthcare ethics. This procedure is typically performed on female infants with the most common single cause of DSD, congenital adrenal hyperplasia (CAH). Because of a genetic defect, these patients’ adrenal glands cannot produce adequate amounts of corticosteroid hormones, a life-threatening situation. Instead, they produce abnormal steroids which act as androgens (male hormones). The life-saving and non-controversial treatment is to prescribe the missing corticosteroids in pill form. This restores hormonal equilibrium and allows these newborns to grow into healthy adults. The controversy centres around a surgical procedure called reduction clitoroplasty.
In females with CAH, exposure to androgens before birth often makes their clitoris large enough to resemble a penis; their labia majora look like the two halves of an (empty) scrotum, giving the external genitals a male look. Inside, everything is normal female, with perfectly fertile ovaries, uterus, Fallopian tubes, and vaginal cavity. These individuals, in their majority, seem to grow up to be well-adjusted, fertile females.1 The surgery involves removing the shaft of the clitoris, while sparing the glans, where the sensation of sexual pleasure resides. Performing this surgery in infants had been, until recently, standard-of-care (definition: the kind of thing that a doctor could be sued over not doing for a patient). But the purpose is largely cosmetic, in order to put the parents’ mind at ease about the gender of the baby and, eventually, help her adjust into the gender identity that is by far the most congruent with her functional reproductive capacity.
In recent years, with broadening societal views on gender conformity and a more rigorous examination of patient autonomy and consent, the procedure has raised concerns. Is it ethical, even legal, to perform irreversible cosmetic surgery on an important body part of an infant, whose function will not be needed until consent age? California and some European countries introduced legislation banning it outright. The legislation didn’t pass; largely as a result, I suspect, of opposition by the CARES Foundation, the largest and most credible peer-support organisation representing girls and women who have had the procedure, and their families. CARES advocates a pro-choice view, defending the right of parents to choose.
In recent years, I have been counselling such families about the option to postpone any surgery until consent age. I even point out that a large clitoris may be an advantage for a woman. But, perhaps not surprisingly, I’ve had no takers so far. In my lecture I presented the matter as an ethical dilemma. Here I was offering an intellectual challenge, to engage my audience’s young minds in preparation for the many other kinds of ethical challenges they will face in their careers. But, I have to conclude, nothing short of outright condemnation would have been approved. This I could not do, out of respect for the majority opinion of the procedure’s survivors.
Having dealt with the only issue of substance, let us turn to euphemisms, misconceptions, and taboos, typical of current trends that are distorting public discourse.
I presented “Disorders of Sexual Differentiation” and “Differences in Sexual Development” as interchangeable, indicating my preference for the former. Does the latter really reflect the sensibilities of DSD persons themselves? Has a representative sample of them been polled? These conditions interfere with a fundamental human function—reproduction (not to mention heterosexual intercourse, another function highly valued by a clear majority). The individuals affected come to us as consenting adults asking for counselling and for their healthcare needs to be met (with hormones and, yes, surgery).
In their list of concerns, the students quoted a Nancy Ehrenreich text, stating that the stigma that results from calling DSD a “disorder” has the same effect as religion-based genital mutilation—a small example of how far outside a sensible, secular-humanist view of the world some activists are capable of placing themselves. Does calling asthma a “respiratory disorder” somehow stigmatize people with asthma and prevent society from embracing, including, and equitably treating them? Imagine going to your doctor in search of help, only to be informed that asthma is just a “difference in breathing.”
The students also asked me not to include any reference to gender in my discussion of DSD. Gender should be considered elsewhere, in a different lecture by a different lecturer—obviously to dissociate it from biology. It apparently does not matter that gender is the main preoccupation of the parent-newborn trio we have to deal with as paediatric care providers in DSD cases. My mention, for example, of raising a child as a boy or as a girl, represented “outdated and stereotyped conceptions of gender and childrearing.” Instead, what should be taught is “raising kids to be who they are and accepting them as such.” It’s disturbing that these two approaches are presented as incompatible and mutually exclusive: the only way to embrace, include, and equitably treat those who do not conform to typical gender identities, is to obliterate gender from the rest—the vast majority—of society.
In my lecture, I was careful to make the distinction between social gender (how one is viewed and treated by society, including one’s own parents) and gender identity (the gender, if any, that one feels oneself to be). I explained that we make parents aware of the option of not assigning gender at birth (again, no takers so far). More importantly, we advise them to keep an open mind and be sensitive to cues from their DSD child. But none of that was enough. Gender had to be expunged from the discourse on sex biology. That gender is an important part of most people’s personal identity was presented as a problem. To end gender-based social ills, we must abolish the very concept. Really? Try explaining that to a trans person, seeking surgery and hormone treatments so that their anatomy can live in peace with their internally felt gender identity, that this felt identity is too binary, that it is a social construct or, as Judith Butler proposes, merely performative.
My statement that DSD is a psychological emergency also drew fire. Was I really proposing that DSD is a life-and-death matter, requiring emergency surgery? Glad you asked. The beginning of their second year is a good time for medical students to learn what an emergency is. The term isn’t defined by life, death or, for that matter, surgery. It is a situation where immediate response is called for—reassurance, explanations, and counselling in the case of DSD. Imagine a paediatrician responding to the questions, anxieties, misconceptions, religious, cultural, or other biases and worst-case fears of the parents of a DSD newborn with: “What, that? It’s just a difference, not urgent, let us discuss it at the six-month checkup visit!”
Finally, I was expected to talk about the effect of hormones on any other part of the body except the brain. Masculinisation of the fetal brain by testosterone is an interesting (but widely misunderstood) phenomenon that requires discussion, the importance of which goes beyond caring for individuals with DSD. Do hormones have anything to do with cognitive and behavioural differences between genders?
On the question of cognitive abilities, multiple studies have shown that gender differences are small, buried within the general inter-individual variation, and go in either direction, as subcategories within each type of ability are dissected. Such differences don’t explain workplace and career disparities. On the other hand, substantial gender differences in self-declared interests and career preferences have been reproducibly found in study after study. These align with the underrepresentation of females in fields such as math and engineering, and the underrepresentation of males in the humanities, education, and health (including, increasingly in recent years, medical school admissions). In a minimalist summary, men statistically tend to be interested in things, women in people. Preschoolers choose to play with toy trucks vs. dolls, strongly along gender lines. Social conditioning and attitudes, lingering from millennia of social disparity in opportunity, may explain some part of this. But how can we be so sure that biology is irrelevant?
In my lecture, I presented the case of females with CAH as a fascinating experiment of nature that can help us answer questions of universal importance. Here is an opportunity to study nurture (almost all girls with CAH are raised as females) dissected from its coupling to nature (in utero exposure to androgens). Interestingly, 95 percent of these individuals are comfortable in the female gender,1 indicating that gender identity has flexibility that can escape fetal exposure of the brain to male sex hormones. On the other hand, this exposure does have a measurable effect on interests and preferences, as has unquestionably been demonstrated by a growing body of research on CAH girls.
The evidence was recently synthesised by one of its pioneers, Penn State’s Sheri Berenbaum in ‘Beyond Pink and Blue: The Complexity of Early Androgen Effects on Gender Development.’ Minimalist summary: CAH girls tend to prefer to play with toy trucks rather than dolls, bucking the play-preference gender polarisation observed in preschoolers. Evidence is also accumulating that this apparent effect of fetal hormones tracks into adolescence and adulthood. Fascinating science that, I was hoping, would stimulate some thinking on fundamental questions. But I was not permitted to talk about the biology of gender and, when I refused to abide, I was silenced. Could this affair be a test case of limiting academic freedom to protect DEI?
A difference in acronym interpretation might actually affect the prospects of a DSD person being admitted in a competitive studies program, or hired and promoted as faculty. In evaluating grades and track records, equity dictates a reasonable allowance for obstacles that had to be overcome. Substituting “difference” for “disorder” will, if anything, deny such consideration—whether the obstacles stem from the biological reality of DSD or from prejudice by a society still in need of much enlightenment. Does knowledge of brain masculinisation need to be suppressed to save DEI? By the time an individual applies to a university for studies or a faculty appointment, an already established track record exists, defining the applicant’s position along the broad and widely overlapping male and female bell-shaped curves of interest in the specific field. Gender adds nothing useful to the evaluation, so there is no need to suppress scientifically established knowledge that will make us a little wiser when we use equality of representation in a specific field as a proxy measure for equality of opportunity. Perhaps more importantly, this knowledge ought to motivate us, as a society, to place a more equitable value on endeavours favored by each gender.
Perhaps I am getting carried away. Maybe the censorship to which I was subjected had nothing to do DEI—it was just another case of a spineless university administration bowing to pressure from a small but loud minority. This is not a personal grievance. I remain a tenured full professor, and my main academic interest is in the genomics of childhood diabetes, not in DSD. I have more important things to do than teach undergrad courses. But it is sad to see established facts now suppressed along with undesirable beliefs and opinions. And to see our institutions of higher learning being led to this kind of neo-obscurantism in the name of enlightened social attitudes.
1 Dessens AB, Slijper FM, Drop SL. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. Arch Sex Behav. 2005 Aug;34(4):389-97. doi: 10.1007/s10508-005-4338-5. PMID: 16010462.
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