Sex and Gender are totally different concepts. Sex is typically determined at birth by examining the external genitals. Males usually have a penis and scrotum. Females have a vagina and vulva. This is the classification normally given in the birth certificate and in the hospital and municipal records.

Gender refers to the social and cultural roles, behaviors, expressions, and identities of men, women, or gender-diverse people. It is a complex interplay of psychology, society, and culture rather than just biological sex.

Sex – Male or Female

From a biological point, sex is categorized as either male or female based on reproductive anatomy, chromosomes and hormone levels.
Those with XX chromosomes are categorized as female and XY as male. However, variants like XXY or XO exist. Genetic testing alone does not always align with physical sex characteristics or gender identity. Some individuals with XY chromosomes have female external anatomy due to conditions like androgen insensitivity syndrome.
Sex determination can be quite complex in some cases of intersex conditions.

Medical Tests for determining Biological Sex

There are no definitive medical tests that can conclusively prove whether a person is male, female or transgender.  Some of the medical tests and assessments commonly used are:

• Karyotyping: Analyzing chromosomes can show whether someone has XX (typically female) or XY (typically male) pairs. It can identify variations like XXY in Klinefelter syndrome.
• Hormone levels: Measuring testosterone, estrogen, LH, FSH levels provides clues about gonadal sex. Testosterone dominance suggests male sex, while estrogen dominance suggests female sex.
• Imaging studies: Ultrasounds, CT scans or MRIs of reproductive organs help identify the presence of ovaries, uterus, vagina (female sex) or testes, penis, prostate (male sex). However, as intersex conditions demonstrate, there is natural variation in genital development. Some individuals have ambiguous genitalia not clearly definable as male or female.
  Genetic testing: Testing for SRY gene or other sex-related genes provides information about genetic sex.
  
  
  

Gender Identity

Gender identity refers to a person’s internal sense of being male, female, both or neither. It may or may not correspond with the sex assigned at birth. Medical tests are not very useful for determining gender identity

Tests for determining Gender Identity:

• Clinical evaluation: A mental health professional can diagnose gender dysphoria based on psychiatric criteria like discomfort with anatomical sex, desire for opposite gender roles etc.
• Hormone levels: Measuring hormones may offer clues but can’t give definitive proof about gender identity. Hormone testing can measure levels of androgens like testosterone versus estrogens. But hormone levels vary greatly across individuals and populations, so there are no clear cut-off levels that would definitively categorize someone as male or female. For example, some women have higher testosterone while some men have lower levels.
• Brain scans: Studies show transgender individuals may have certain structural and functional brain patterns similar to their gender identity, but these are not conclusive.

Transgenders

The age old binary male-female sex classification fails to capture the intricate variation in human sexual development. Gender further complicates the picture, as a person’s identity may differ from biological attributes. Transgender individuals may have a gender identity different from the sex assigned at birth. Non-binary people identify outside of male-female categories.

Transgender has been legally recognized as the third Gender. Defining and differentiating between male, female and transgender individuals involves complex biological, social, and legal considerations. Medical testing alone cannot capture the full complexity of human sex and gender.

For transgender and gender diverse people, medical interventions like hormone therapy and surgeries help better align physical sex characteristics with gender identity. However, procedures are not universally accessible or desired. Individuals ultimately have to define their own gender based on a deeply felt, internal sense of self.

While the above tests may provide supporting evidence, they cannot offer 100% conclusive proof of whether someone is male, female or transgender. Comprehensive psychological, medical and social evaluation is needed for determining gender identity. Mental health professionals can help by making a diagnosis of gender dysphoria based on clinical assessment criteria.

Gender Change – Sex Reassignment Surgery (SES)

A few persons are not happy with their gender. They may have:

• A strong conviction of being or wish to become the opposite gender.
• A persistent dislike or discomfort with their sexual anatomy.
• A strong desire to obtain the physical features of the opposite gender.
• A strong preference for the clothing, activities and roles associated with the opposite gender.

Section 15 of the Transgender Persons (Protection of Rights) Act, 2019, reproduced hereunder, has recognized this and permits  such persons to under go  sex reassignment surgery (SES) and hormonal therapy:

 “15. Healthcare facilities.—The appropriate Government shall take the following measures in relation to transgender persons, namely:—
(a) to set up separate human immunodeficiency virus Sero-surveillance Centres to conduct sero- surveillance for such persons in accordance with the guidelines issued by the National AIDS Control Organization in this behalf;
(b) to provide for medical care facility including sex reassignment surgery and hormonal therapy;
(c) before and after sex reassignment surgery and hormonal therapy counselling; (d) bring out a Health Manual related to sex reassignment surgery in accordance with the World Profession Association for Transgender Health guidelines;
(e) review of medical curriculum and research for doctors to address their specific health issues;
(f) to facilitate access to transgender persons in hospitals and other healthcare institutions and centres;
(g) provision for coverage of medical expenses by a comprehensive insurance scheme for Sex Reassignment Surgery, hormonal therapy, laser therapy or any other health issues of transgender persons.

If a person undergoes sex reassignment surgery to align their anatomy with their gender identity, they are legally and clinically classified according to their post-surgical sex. However, gender diverse people who transition, but do not opt for surgery, can also change their identity. Self-identification is paramount.

Sex change – Sex Reassignment Surgery (SRS) – decisions on

Chinder Pal Singh a female gender wanted to undergo SRS to get her gender identity changed from female to male for certain gender identity disorder. In this case, the Rajasthan High Court granted her permission for the purpose of sex reassignment surgery taking into consideration the provisions contained in the Central Act.
                             Chinder Pal Singh v. The Chief Secretary, Government of Rajasthan and others (S.B. Civil Writ Petition No. 14044 of 2021 decided on 25.5.2023) Rajasthan High Court.

Myra Grace Bandikalla (formerly known as Mr. Swaroop Rajarao Bandikalla), a transgenders’ application for the purpose of facilitating her visit to Bangkok for getting SRS done was granted by the Bombay High Court. In this case, the petitioner was suffering from gender dysphoria and was accordingly desirous of SRS.
                        Mr. Swaroop Rajarao Bandikalla) v. Airport Authority of India and Others (Writ Petition (L) No. 1976 of 2018) order dated 4th July, 2018 of Bombay High Court.

Neha Singh, a woman constable in U.P. Police, an unmarried women found in herself all the traits of a male personality.  She claimed she was suffering from Gender Dysphoria and wanted to undergo Sex Reassignment Surgery (SRS) to get herself identified and personalized as a male with true male physical character. She applied for necessary permission which was delayed. On 18.8.2023, the Allahabad High Court directed the Director General of Police to dispose off her application by 21.9. 2023.
                                      Neha Singh Petitioner vs State Of U.P. And 2 Others WRIT – A No. – 7796 of 2023 – Allahabad High Court  (matter pending)

I have written a book on the Law of Transgender Rights in India. It is available on Amazon and other sites.