Powerful as the paper was in presenting anecdotal evidence of the neurobiological basis of sexuality, it also served as a clear warning to physicians about the dangers of surgical sex reassignment for all newborns—not just those like David who are born with normal genitals and nervous system. Diamond argued that the procedure was equally misguided for intersexual newborns, since physicians have no way of predicting in which direction the infant’s gender identity has differentiated. To change such children surgically into one sex or the other, he argued, was to consign at least half of them to lives as tortured as David’s.
Accordingly, Diamond and Sigmundson offered a new set of guidelines for management of babies with ambiguous genitalia. Recognizing that a child must be raised as either a boy or a girl, they recommended that doctors continue to assign a firm sex to the baby—but only in terms of hair length, clothing, and name. Any irreversible surgical intervention, they said, must be delayed until the children were old enough to know, and be able to articulate, which gender they felt closest to. Or as Diamond put it to me, “To rear the child in a consistent gender—but keep away the knife.”
Diamond was aware that writing the paper would inevitably raise the specter of a personal vendetta against Money. To minimize this danger, he removed from David’s quoted utterances all reference to the famous psychologist. “In fact,” Diamond says, “Money’s name is only mentioned once. I didn’t want it to be an argument ad hominem. I wanted it to be a theoretical discussion.”
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Nevertheless it took Diamond and Sigmundson two years to find someone willing to publish their paper.
“We were turned down by all these journals that said it was too controversial,” says Sigmundson. “The New England Journal, The Journal of the American Medical Association.” The article was finally accepted by the American Medical Association’s Archives of Pediatrics and Adolescent Medicine in September 1996, with publication set for March 1997. In the intervening months, Diamond and Sigmundson felt considerable apprehension as they waited for their bombshell to go off. “We were basically telling all these physicians that they’d been doing the wrong thing for the past thirty years,” Sigmundson says. “We knew we were going to be pissing a lot of people off.”
Some critics, as expected, attempted to dismiss the paper on the grounds that Diamond was simply using David’s history to embarrass a scientific rival, but at least one physician who saw a prepublication copy of the paper was inclined to agree strongly with its conclusions. Dr. William Reiner had two years earlier launched the first comprehensive long-term follow-up study of patients who had been sex reassigned. Trained as a pediatric urologist, Reiner had actually spent the first eighteen years of his medical career in California performing “normalizing” genital surgeries on intersexual children. It was early in his career that Reiner had his first glimmer of doubt about the Johns Hopkins treatment model. “I got babies and two-year-olds and four-year-olds and eight-year-olds and sixteen-year-olds,” he says. “So I really saw a longitudinal view of all these urological conditions—all these birth defects—and I was therefore able to visualize in a relatively short period of time the kinds of effects that these conditions have on the lives of these kids and their families.” Then, in 1986, Reiner met a patient who changed his life.
She was a fourteen-year-old girl—a Hmong immigrant—who had announced that she was dropping out of high school because she was “not a girl.” To all outward appearances an anatomically normal female, she had nevertheless always rejected girls’ play and had insisted on wearing gender-neutral clothes. At puberty she had arrived at the unshakable conviction that she wanted to change sex and live as a male. Referred to Reiner to discuss the possibility of reconstructive surgery, she was threatening suicide unless her wishes were met.
“I had a complete medical workup on the child done,” says Reiner. Tests revealed that “she” was biologically a he—a 46XY male who suffered from a rare chromosomal condition that prevents masculine differentiation of the genitals. Reiner performed sex change surgery, after which the former girl effortlessly assumed the sex written in his DNA. The case convinced Reiner of what he had suspected for years: that the biological underpinnings for psychosexual identity are not so easily overridden by social and environmental rearing as he (and every other pediatric urologist, endocrinologist, psychiatrist, and psychologist) had been taught. This further forced Reiner to the uncomfortable conclusion that he had been doing the wrong thing in his surgical career in helping to steer intersexual children into one sex or the other at birth. In a 1996 edition of the Journal of the American Academy of Child and Adolescent Psychiatry, Reiner published a paper on the Hmong case, along with a warning to his fellow physicians about the long-accepted theory that rearing prevails over biology in shaping human sexuality.
Reiner also did something else. After eighteen years as a surgeon, he put down his scalpel. He began to retrain as a child psychiatrist specializing in psychosexual development and intersexual conditions. In 1995 he was hired by Johns Hopkins as an assistant professor in psychiatry. There he launched his study on the long-term psychosexual implications of sex reassignment. Reiner set out to follow sixteen patients, focusing particularly on six genetic males who were born without penises and as a result were castrated and raised as girls. Two years into his study, he noted that all six sex-changed boys were closer to males than to females in attitudes and behavior. Two had spontaneously reverted to being boys without being told of their male (XY) chromosome status.
“These are children who did not have penises,” Reiner told me, “who had been reared as girls and yet knew they were boys. They don’t say, ‘I wish I was a boy’ or ‘I’d really rather be a boy’ or ‘I think I’m a boy.’ They say, ‘I am a boy.’ ” Reiner stressed the parallels between the children he was studying and David Reimer, who also “knew,” despite his rearing as Brenda, that he was not a girl. Reiner wrote a supportive editorial in Archives of Pediatrics and Adolescent Medicine to accompany Diamond and Sigmundson’s John/Joan paper.
Today Reiner says that both David’s case and the trend in his own study support the findings that have emerged on the primacy of neurobiological influences on gender identity and sexual orientation. He cites the now-classic study done at Oxford University in 1971, which showed anatomic differences between the male and female brain in rats. Six years later, at UCLA, researchers narrowed these differences to a cluster of cells in the hypothalamus. A study done in the mid-1980s in Amsterdam located the corresponding area in the human hypothalamus, noting that it is twice as large in homosexual as in heterosexual men. Further studies have supported this finding. In 1993 and again in 1995, researcher Dean Hamer announced that in two separate studies of gay male brothers, he had found a certain distinctive pattern on their X chromosomes. The finding suggested that sexual orientation may have a genetic component.
Although Hamer’s studies have failed to be replicated by other scientists, few sex researchers today dispute the mounting evidence of an inborn propensity for acting as, and inwardly identifying with, a particular sex. “It’s quite clear that the vast majority of boys born with functioning testicles have masculine, brains,” Reiner says. He endorses Diamond and Sigmundson’s recommendation to delay surgery in cases of penile loss or intersexuality and to impose only a provisional assignment that can be changed should the child voice a strong desire to live as the other sex. Reiner suggests that this treatment model is diametrically opposed to the one pioneered at Johns Hopkins by Money and his colleagues, in which a sexual identity is imposed on a child through unshakable fiat of physicians, and any doubts or confusions the child may express about the assignment are denied by caregivers. Reiner says that on the basis of David’s case and the others he has studied, the decades-old Johns Hopkins treatment model needs to be reevaluated. “We have to learn to listen to the children themselves,” he says. “They’re the ones who are going to tell us what is the right thing to do.”
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Before Diamond and Sigmundson’s journal article appeared in the Archives of Pediatrics and Adolescent Medicine in March 1997, the American Medical Association’s public relations department alerted the media that something explosive was coming. On the day of the article’s publication, the New York Times ran a front-page story headlined SEXUAL IDENTITY NOT PLIABLE AFTER ALL, REPORT SAYS, in which writer Natalie Angier described David’s life as having “the force of allegory.” Twenty-four years after publishing news of the case’s success, Time magazine ran a full-page story declaring, “The experts had it all wrong.” Similar news accounts appeared around the world—and soon Diamond and Sigmundson were deluged with calls from reporters in several countries seeking an interview with the young man now known simply as John/Joan.
David agreed to appear on two television newsmagazine programs. He was shown in darkened silhouette on ABC-TV’s Primetime Live and with his face obscured in a Canadian Broadcasting Corporation documentary. It was during the latter taping, which took place in New York City in June 1997, that I was introduced to David by Diamond and Sigmundson. The researchers had passed along to David the names of the many reporters who had requested an interview with him, but David (a rock ’n’ roll fan) had chosen the reporter from Rolling Stone.
At that first meeting with me, David was nervous and guarded. He explained that his childhood had made it difficult for him to trust strangers, but later, over a beer at the Hard Rock Cafe, he grew more relaxed. He spoke about how his parents and brother had been crucial supports in a childhood that he described as “a pit of darkness.” I soon learned that a formidable sense of humor had also played a role in his survival. Describing the physical differences between himself and his heavier, slightly balding twin, he shouted over the pounding music, “I’m the young cool Elvis. He’s the fat old Elvis.”
But the strongest impression I was left with was of David’s unequivocal masculinity. His gestures, walk, attitudes, tastes, vocabulary—none of them betrayed the least hint that he had been raised as a girl. And indeed, when I asked whether he thought his extraordinary childhood had given him a special insight into women, he dismissed the question. David had apparently never been a girl—not in his mind, where it counts. He insisted that his conversion from Brenda at age fourteen marked nothing more than a superficial switch in name—as if the double mastectomy, two phalloplasties, and lifelong course of testosterone injections he needs to compensate for his castration were mere details. “I’ve changed over,” David said, “but mainly by name. The rest was all cosmetic. I just had repaired what was damaged. That’s all.”
Through the summer and fall of 1997, David’s story continued to receive media coverage. With this coverage, another set of voices in the debate over the heretofore unexamined practice of infant sex reassignment began to be heard. These were the voices of those intersexes born after the publication of Money’s 1955 protocols—people in their thirties and forties who as babies had undergone normalizing genital surgeries and sex assignments and who were now ready to speak on the record about their lives.
They had already begun to emerge as a public voice four years earlier, largely through the efforts of one person: a San Francisco–based activist named Cheryl Chase, who had been lobbying for changes in intersex treatment since the early 1990s. “I wasn’t getting very far,” admits Chase, a short-haired woman with a dry, rational manner that belies the passion driving her. “That changed overnight when the John/Joan case blew up.”
At her birth in suburban New Jersey in 1956, Chase presented a classic case of ambiguous genitalia. Instead of a penis and testicles, there was a somewhat vaginalike opening behind her urethra, and a phallic structure of a size and shape that could be described as either an enlarged clitoris (if she were assigned as a girl) or a micropenis (if a boy). After three days of deliberation, the doctors told Chase’s parents that their child should be reared as a boy. She was christened Charlie. But a year and a half later, her parents, still troubled by Charlie’s unusual appearance, consulted another team of experts. They reassigned her as a girl and told her parents that she would grow up to be a happy, healthy, normal woman. Her parents changed her name from Charlie to Cheryl, and the doctors removed her clitoris.
Like David Reimer, Chase was then raised without knowledge of her true birth status. Thus, like David, she experienced a childhood punctuated with mysterious, unexplained surgeries and regular genital and rectal exams. Also like David, she grew up confused about her sex. “I was more interested in guns and radios,” Chase says, “and if I tried to socialize with any kids, it was generally boys, and I would try to physically best my brother. I didn’t fit with boys or girls, I was stigmatized and ostracized by my peers, and picked out for teasing all the time.” At age ten, Cheryl’s parents brought her to a psychiatrist, who attempted to prepare Cheryl for her role as wife and mother. As a preadolescent, she recognized that she was erotically attracted to females.
By age nineteen, Chase had done some of her own medical sleuthing and understood that she had been subjected to a clitorectomy as a child, and she began to search for her medical history. She was thwarted by her doctors, who refused to reveal the circumstances of her birth. It took three years for her to find a physician willing to disclose her medical records. It was then that Chase read that doctors had labeled her a “true hermaphrodite”—a term that refers to people whose gonads possess both ovarian and testicular tissue. This was also when she first learned that she had spent the first eighteen months of her life as a boy named Charlie, and that her parents, doctors, aunts, uncles, grandparents, and family friends had conspired to keep this secret from her. She also learned that the operation she had undergone at age eight (to relieve “stomachaches”) had actually been to cut away the testicular part of her gonads.
Horrified and angered at the deceptions perpetrated upon her and aggrieved at the loss of her clitoris, which had rendered her incapable of orgasm, Chase began to seek out others like herself. Through letters to the editors of medical journals and magazines, news articles, listings with crisis hotlines, and ultimately on a website, she established a network of inter-sexes in cities across the country. In 1993, she dubbed the group the Intersex Society of North America, a peer support, activist, and advocacy group. By mid-1999, Chase had been contacted by nearly four hundred intersexes from around the world—many of whom told stories almost identical to her own.
To meet Chase and members of ISNA—as I did in the spring of 1997, when they held a peaceful demonstration outside Columbia Presbyterian Hospital in New York, where Chase’s clitoral amputation was performed—is to enter a world where it is impossible to think of sex with the binary boy-girl, man-woman distinction we’re accustomed to. There was Heidi Walcutt, genetically male with an XY chromosome constitution but born with a rudimentary uterus, fallopian tubes, internal sperm ducts, and a micropenis, who describes herself as a “true American patchwork quilt of gender.” There was Martha Coventry, born with an enlarged clitoris but a fully functioning female reproductive system, who is the mother of two girls. There was Kiira Triea, assigned as a boy at age two, who did not learn of her intersexuality until puberty, when she began to menstruate through her phallus. At that stage she was referred as a patient to Dr. Money at the Psychohormonal Research Unit, where she was treated from age fourteen to seventeen, in the mid-1970s, concurrent with Brenda Reimer.
Kiira and David have never met or spoken, but Kiira’s story bears striking parallels to his. She describes how Dr. Money, evidently attempting to ascertain whether she possessed a male or a female gender identity, questioned her about her sex life—in the frank language for which he is well known. “Have you ever fucked somebody?” she remembers Money asking. “Wouldn’t you like to fuck somebody?” She also describes how Money showed her a pornographic movie on a projector he kept in his office. “He wanted to know who I identified with in this movie,” she says.
Contrary to Money’s claim that an intersexual baby reared as
a boy will develop an unequivocal male gender identity, Triea’s sexuality and sense of self proved to be far more complicated than that. At fourteen she agreed to undergo feminizing surgery at Johns Hopkins to simulate female genitals, but when she became sexually active for the first time at age thirty-two, her erotic orientation was toward women.
The other intersexes in Chase’s group show a similarly complex sexuality. Max Beck was first assigned and reared as a girl named Judy. Despite strong masculine thoughts, inclinations, behaviors, and attitudes, Judy tried to stick with her assignment in order to placate worried parents and relatives, even going so far as to marry in her early twenties. But at age twenty-seven Judy left the marriage and divorced. At the age of thirty-two she stopped taking estrogen, changed her name to Max, and began taking testosterone by patch. Yet even today, Max resists the simple designation of male. “I have always felt—and continue to feel myself to be—intersexed,” he recently e-mailed me. “ ‘Masculine’ is simply a more comfortable compromise, testosterone a tastier hormonal cocktail than estrogen.” Not all the intersexes who joined Chase were sex-reassigned as babies. Dr. Howard Devore, the psychologist who studied under John Money in the 1980s, was born in 1958 with acute hypospadius (a penis open from base to tip) and with undescended, underdeveloped testicles, but was raised as a boy. Beginning at age three months he endured some sixteen “normalizing” surgeries through childhood, aimed at giving him a cosmetically convincing penis. The experience, Devore says, was emotionally devastating—and wholly unnecessary. His genitals still do not resemble those of a normal male and the sole result of his constant hospitalizations is a psychological scarring far worse than he would have experienced had he been raised with counseling to accept his atypical genitals. Devore refrained from making this argument to Money. “I learned very early that if you choose to do battle with John,” he says, “you have to deal with a very, very angry man who’s going to make you feel horrible for challenging him.” (Devore says that only in the wake of the “ John/Joan” revelations has he felt emboldened to make his intersexuality public—and to openly challenge his former professor.)
As Nature Made Him Page 20
