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This paper draws on a forthcoming book that examines contemporary debates over sex and gender. The book draws on over ninety interviews with activists from across the political spectrum, including LGBTQ+ activists, trans-inclusive feminists, conservative activists, and gender-critical feminists, to accurately and empathetically present different positions related to sex and gender. One major “gender collision” concerns disagreement over the extent to which sex, which I define as a designation made by medical professionals based on biological criteria about whether someone is male or female (West and Zimmerman 1987), remains a relevant, legitimate, or useful category. Increasingly, progressive activists insist that sex should be replaced by gender identity, or a person’s internal sense of whether they are male or female. Those who argue that sex is relevant in certain situation are accused of being biologically essentialist or, worse, transphobes. Yet, there are situations where sex matters. Denying this may do unintentional harm, including to transgender people. This paper focuses on two contexts where sex matters: medicine and women’s sports. It calls for acknowledging biological complexity and for the importance of having difficult conversations about competing social-justice priorities.