Research and discussions on reproductive and sexual health have shifted our eyes to look beyond the binary. Despite this progress, conservative and patriarchal ideals continue to shackle healthcare.
In the Philippines, where legal and cultural systems almost exclusively operate on the male-female binary, individuals are often pushed to conform to their sex assigned at birth—even when later developments complicate that designation.
Pieces of the puzzle
When discussing biological sex, chromosomes are often brought up as the ultimate deciding factor. A large amount of confidence is often placed in the X and Y chromosomes’ ability to determine the sex of a person, as they induce the development of either the male or female sex organs. However, as it turns out, sexual differentiation is much more complex than a single genetic switch.
“When you talk about biological sex, there are actually three components to it,” says Dr. Ryan Lintao, a research associate professor at the Institute of Reproductive Health. “There’s chromosomal sex, there’s what we call gonadal sex, [and] there’s also genital sex.”
Dr. Lintao further elaborates that whether gonads develop into testes or ovaries depends on what the SRY gene in the Y chromosome produces. Genital sex is subsequently determined by the hormones these gonads produce. He identifies several key players in the process: after the testis-determining factor (TDF) promotes testicular development, the organ produces anti-müllerian hormone and 5-dihydrotestosterone to suppress the development of the female genitalia and induce the formation of male external genitalia, respectively.
While the X and Y chromosomes are foundational in sex determination, they are far from being the only factors. There exist more determinants to biological sex than just the simple pairings of the sex chromosomes, offering more possibilities than the binary and “rock-solid” XX and XY categories often portrayed in modern discourse.
Nature is never just binary
Variations can occur at multiple stages of sexual development. Dr. Lintao classifies these as Differences of Sex Development (DSDs), or conditions that arise when chromosomal patterns, hormone levels, or tissue responses do not follow typical developmental pathways.
These variations are not biological “errors,” but natural diversities in development. Even individuals with typical XX or XY chromosomes may experience variations in sexual differentiation. For instance, a person with XX chromosomes, usually classified as female, may develop male-associated traits if exposed to higher levels of androgens, the primary male hormones. Conversely, someone with XY chromosomes, usually classified as male, may develop female-associated traits if their body is insensitive to testosterone.
The features of DSDs are not confined to external physical appearance and reproductive anatomy. “There are definitely different genes that are important in the normal functioning of the body that are expressed or present in those chromosomes,” Lintao elaborates. Certain syndromic DSDs are associated with higher risks for cardiovascular diseases, obesity, metabolic complications, infertility, as well as mental health challenges like anxiety and depression.
Taken together, these instances illustrate that chromosomal sex, gonadal development, hormone production, and physical traits do not always align in predictable ways. Biological sex is not determined by a single factor, but by a cascade of genetic and hormonal processes.
Living in the in-between
When the body is in conflict with one’s internal sense of self, the risk of developing gender dysphoria increases significantly. According to Dr. Lintao, this disruption often arises when sudden physiological changes clash with societal gender roles. This leaves individuals suddenly feeling they “don’t fit into certain expectations” for them in their gender roles.
For many people, living with DSDs means navigating medical complications alongside deeply embedded personal and social challenges. According to Dr. Lintao, some DSDs are “technically ambiguous, but will suddenly appear during puberty,” a vital stage of rapid physical and social development. “As a society, we’re not equipped to be able to handle [this] situation,” he explains, adding that doctors alone will have a hard time addressing the medical, mental, and social needs of people with DSDs. A society that still holds conservative values and ideals often derails care for people with DSDs who contradict what is labelled “normal.”
This bias is even in routine medical encounters. For example, an individual with a DSD, or even a woman with endometriosis, may have chronic pain that needs to be addressed, yet the first thing some doctors ask is if their concern is infertility. People with DSDs and women are pressured by patriarchal systems, cultural expectations, and certain gender roles that instead of seeking consultation when they first start feeling symptoms, “their reproductive health problems are checked only when they worsen,” Dr. Lintao clarifies.
These instances are only amplified by patriarchal structures that still burden and govern healthcare systems—especially fields that are geared toward women’s reproductive health, such as obstetrics and gynecology.
Activism from the women’s liberation and health movements has opened important conversations about the long-neglected health concerns of people outside the gender binary. But this alone does not constitute a transformation. Unless we uproot the systems that have long governed healthcare and scripted our understanding of gender, we have not achieved true reform. All we have done is simply lacquer injustice in purple, titled the veneer as “progress,” and applaud the performance as “reform.”
