Trans News > Articles > "As Nature Made Him" Returns > NY Times "Sexual Identity Not Pliable After All, Report Says" (1997/03/14)

The New York Times
March 14, 1997, Friday
National Desk

Sexual Identity Not Pliable After All, Report Says


By NATALIE ANGIER

A classic case of a gruesome surgical accident and its consequences that was long used as evidence of the pliability of sexual identity turns out, in follow-up, to suggest the opposite: that a sense of being male or female is innate, immune to the interventions of doctors, therapists and parents.

In 1973, researchers published an account of an infant boy whose penis had been accidentally cut off and who was subsequently reared as a girl. The child appeared to have accepted the new identity and to be happy with life as a female.

Reported by the sexologist Dr. John Money of Johns Hopkins University in Baltimore, the case became famous and entered the textbooks as proof that infants are more or less sexually neutral at birth, establishing sexual identification only with socialization and exposure to the binary world of boys and girls, blue and pink, guns and Barbies.

Now, Dr. Milton Diamond of the University of Hawaii-Manoa in Honolulu and Dr. H. Keith Sigmundson of the Ministry of Health in Victoria, British Columbia, have presented an in-depth follow-up that refutes the initial reports of a glowing success. They report that far from being satisfied with his reassignment to girlhood, the boy renounced his female identity at the age of 14 and chose to live as a man, even undergoing extensive surgery to attempt a reconstruction of his genitals.

The patient, whose identity is being kept secret, is now in his 30's, married, and is as well-adjusted as can be expected in one who has been through such an extraordinary ordeal, the two researchers report in the current issue of The Archives of Pediatric and Adolescent Medicine.

In recounting the case of a patient variously referred to as Joan or John, Dr. Diamond and Dr. Sigmundson say they seek not only to set the record straight, but also to argue that the case underscores the importance of prenatal events like hormone exposure in building a sexual self.

''Despite everyone telling him constantly that he was a girl,'' Dr. William Reiner of Johns Hopkins Hospital said in an interview, ''and despite his being treated with female hormones, his brain knew he was a male. It refused to take on what it was being told.'' Dr. Reiner wrote an editorial to go with the report.

Dr. Dean Hamer of the National Cancer Institute, who has studied genes that may influence male sexual orientation, said: ''It's a fascinating case in the history of gender theory. It offered one of the strongest arguments for the extreme view that adult gender identity was purely a product of upbringing, and now that's gone.''

At this point, Dr. Hamer said, ''most researchers, including John Money, generally agree that gender identity is partly innate and partly cultural.''

Dr. Money's secretary said yesterday that he could not discuss the case because he did not have the patient's consent.

Yet the debate remains as to how much of sexual identity is instilled by nature and how much by nurture, experts said, and the current paper does not settle that issue. Moreover, few agree on what it means to talk about ''maleness'' or ''femaleness'' to begin with.

''From a distance,'' said Dr. Barbara Mackoff, a psychologist who studies gender issues and is the author of the new book ''Growing a Girl,'' ''this looks like a paradigm to address the question that people seem so preoccupied with,'' that is, the origins of male and female differences. ''But I don't see this tragic story as a way of helping us to define gender identity,'' Dr. Mackoff said, ''or what it means to be a boy or a girl in our culture.''

Dr. Diamond and his colleague use the case study to call for changes in the treatment of babies born with ambiguous genitalia, a condition found in about 1 in every 1,000 births, which results from a variety of chromosomal and hormonal abnormalities. As it is now, the majority of such infants are designated female, largely because it is considered surgically easier to turn ambiguous genitals into a vagina than into a penis.

But the scientists propose that many of these constructed females may be unhappy with their enforced identity, particularly if they have a Y chromosome -- the most overt mark of a male -- and were likely to have been exposed to male hormones in the womb. In these infants, the scientists write, ''the psychosexual bias'' from prenatal events may bias them strongly in a masculine direction, and they would be better off being reared as boys.

Debate over the medical treatment of ambiguous genitalia in infants has grown fierce, as an increasingly vocal group of intersexuals protest that many of the surgical techniques used in an attempt to correct anomalous genitals can be mutilating and harmful in the long term.

''Diamond's recommendations aren't going to help this problem,'' said Cheryl Chase, founder of the San Francisco-based group, Intersex Society of North America. ''Instead, clinicians who treat intersex children will start assigning more of them as males, and doing a different sort of horrible intervention,'' for example, by trying to construct a phallus from a small amount of tissue. ''They can't conceive of leaving someone alone,'' Ms. Chase said.

Whatever its wider impact, the case of Joan/John has the force of allegory. The patient, born a normal male with a twin brother, had his penis accidentally cut off at 8 months by a surgeon trying to repair a fused foreskin. Convinced that it would be impossible for a boy to adjust to the loss, the doctors recommended that the parents rear him as a girl and keep his past a secret.

The infant's testicles were removed and a preliminary attempt to fashion a vagina was made. The parents did their best to regard their child as a daughter, choosing feminine clothes, toys and activities. In an attempt to encourage female identification, Joan was put in the care of female psychiatrists.

As the current report relates the case, through recollections of the parents and of the adult John, the new identity never took. Joan would tear off her dresses, reject dolls and seek out male friends. Her mother would try to get Joan to imitate her makeup ritual; instead, she mimicked her father shaving. She often tried to urinate standing up, despite the mechanical difficulties. But her rebellion was uneven, and sometimes, the mother said, Joan would be quite ''feminine,'' keeping herself ''neat and tidy.''

In Dr. Diamond's view, the intermittent attempts at girlish behavior were to be expected from a child who was desperate for parental approval. Her classmates teased her mercilessly, saying she looked like a boy, calling her ''cave man'' and ''gorilla,'' and they refused to play with her. She spent a lot of time having her genitals scrutinized by doctors and not understanding why.

At the age of 12, Joan began receiving estrogen treatments and grew breasts. But she disliked the hormone and its feminizing effects and stopped taking it. She was not attracted to boys. She had no friends and considered suicide. At age 14, still unaware of her past or her Y chromosome, she refused to continue living as a girl or to have any more vaginal surgery.

Finally confronted, her father broke down in tears and told her of the accident and its sequelae. Rather than being devastated, Joan was relieved. ''For the first time everything made sense,'' the article quotes her as saying, ''and I understood who and what I was.''

Joan became John, requested male hormone shots, had a mastectomy and began phalloplasty to try rebuilding his male genitals with skin grafts. After the various treatments, John was accepted by his peers as Joan had never been. ''He got himself a van, with a bar in it,'' Dr. Diamond said in an interview. ''He wanted to lasso some ladies.''

At 25, John married a woman and adopted her children. Surgical reconstruction was only partly successful; much of his penis is without sensation, and though John is capable of having intercourse and orgasm, he admits that his wife is more interested in coitus than he is. Of greater importance, John says, he is happy with life as a man.

''He's still bitter, of course, and who wouldn't be?'' Dr. Diamond said. ''But he's got a great sense of humor, and his head is on straight.'' And it is the head, Dr. Diamond added, that holds the primary sexual organ, the source of one's identity, and the organ that does not lie.




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