BECOMING MALE/BECOMING FEMALE

The underlying assumptions of the surgical approach to inter sex babies have not gone uncontested. Not everyone believes that sexual identity is funda­mentally malleable. By far the most dramatic of these debates has been an almost thirty-year battle between John Money and another psychologist, Mil­ton Diamond. In the 1950s Money, together with his collaborators, the Hampsons, argued that the sex assignment and sex of rearing predicted a her­maphrodite’s adult gender role and sexual orientation more accurately than did any aspect of h/her biological sex: ‘‘Theoretically, our findings indicate [that] neither a purely hereditary nor a purely environmental doctrine of the origins of gender role… is adequate. On the one hand it is evident that gender role and orientation is not determined in some automatic, innate, in­stinctive fashion by physical agents like chromosomes. On the other hand it is also evident that the sex of assignment and rearing does not automatically and mechanistically determine gender role and orientation.’’83

But were Money’s claims applicable to the majority of sexually unambigu­ous children? Had he and his colleagues—via the study of inter sex children— arrived at a general, possibly even universal, theory of psychosexual develop­ment? Money believed he had, and to prove it he pointed to the case of an unambiguously male child named John, who lost his penis at about seven months of age after a circumcision accident. Reasoning from his studies on intersexuals, Money counseled that the child be raised as a girl and surgically altered to fit her new status in life. A particularly compelling component of this case was the fact that there was a control: Joan (as she was renamed) had an identical twin brother. This case, Money hoped, would clinch his argument about the importance of sex of rearing. If Joan developed a female gender identity, while her genetically identical brother continued down the road to adult masculinity, then environmental forces clearly trumped genetic makeup.

The family ultimately agreed to the sex change, and by the time the child reached her second year she had had feminizing surgery and her testicles had been removed. With great delight, Money quoted Joan’s mother to the effect that Joan had grown to love wearing dresses, that she hated being dirty, and that ‘‘she just loves to have her hair set.’’84 Money concluded that his case demonstrated that ‘‘gender dimorphic patterns of rearing have an extraordi­nary influence on shaping a child’s psychosexual differentiation and the ulti­mate outcome of a female or male gender identity.’’ In a particularly enthusias­tic moment, he wrote: ‘‘To use the Pygmalion allegory, one may begin with the same clay and fashion a god or a goddess.’’85

Money’s account of psychosexual development rapidly gained favor as the most progressive, most liberal, most up-to-date point of view around.86 But not everyone thought it made sense. In 1965 Milton Diamond, at the time a young Ph. D., decided to take on Money and the Hampsons. He did so at the suggestion and with the help of mentors who came from a rather different tradition in the field of psychology.87 Diamond’s advisers proposed a new para­digm for understanding the development of sexual behaviors: hormones, not environment, they argued, were the decisive factor.88 Early in development, these chemical messengers acted directly to organize the brain; hormones produced at puberty could activate the hormonally organized brain to pro­duce sex-specific behaviors such as mating and mothering.89 Although these theories were based on studies of rodents, Diamond drew heavily on them to attack Money’s work.90

Diamond argued that Money and his colleagues, were essentially suggest­ing that humans are sexually neutral at birth. He challenged their interpreta­tions of their data, arguing ‘‘that the very same data may not be inconsistent with more classical notions of inherent sexuality at birth.’’ Diamond agreed that Money and his colleagues had shown that ‘‘hermaphroditic individuals. . . find it possible to assume sexual roles opposite to their genetic sex, mor­phological sex, etc.’’ But he disagreed with their broader conclusions, ar­guing, ‘‘to assume that a sex role is exclusively or even mainly a very elaborate, culturally fostered deception. . . and that it is not also reinforced by taboos and potent defense mechanisms superimposed on a biological prepotency or pre­natal organization and potentiation seems unjustified and from the present data

unsubstantiated.’’91 In other words, Diamond argued that even if Money and his colleagues might be correctly interpreting intersexual development, their work shed no light on what he called ‘‘normals.’’92

Diamond also pointed out that the John/Joan case was the sole example of ‘‘normal’’ prenatal hormone exposure being overcome by rearing. In opposi­tion to the Money and Hampson theory of gender neutrality molded by envi­ronment into gender identity,93 Diamond posed his own model of ‘‘psy­chosexual predisposition.’’ He suggested that male and female embryos each begin with partially overlapping but relatively broad potential for psychosex­ual development. As both pre — and postnatal development proceeds, however, there appear ‘‘limits and restrictions in the form of culturally and biologically acceptable sexual outlets within the total capability’’94 (figure 3.8).

Only one other scholar dared to challenge Money.95 In 1970 Dr. Bernard Zuger, a practicing psychiatrist, found several clinical case studies in which adolescent or adult intersexuals rejected their sex of rearing and insisted on changing sex. These individuals seemed to be listening to some inner voice that said that everyone in authority surrounding h/her was wrong. Doctors and parents might have insisted that they were female, removed their testes, injected them with estrogen, and surgically provided them with a vagina, but still, they knew they were really males. Zuger concluded: ‘‘The data from her­maphrodites purporting to show that sex of rearing overrides contradictions of chromosomes, gonads, hormones, internal and external genitalia in gender role determination are found unsupportable on methodological and clinical grounds. Conclusions drawn from the data as to the adoption of such assigned gender role and the psychological hazard of changing it after very early child­hood are shown not to be in agreement with other similar data found in the lit­erature.’’96

Money was furious. When Zuger’s paper appeared, he published a rebuttal in the journal Psychosomatic Medicine, fuming, ‘‘What really worries me, even terrifies me, about Dr. Zuger’s paper, however, is more than a matter of theory alone. . . it will be used by inexperienced and/or dogmatic physicians and surgeons as a justification to impose an erroneous sex reassignment on a child. . . omitting a psychological evaluation as irrelevant—to the ultimate ruina­tion of the patient’s life.’’97 In his 1972 book with Anke Ehrhardt, Money lashed out again: ‘‘it thus appears that the prejudices of physicians skew today’s hermaphroditic sex reassignment statistics in favor of change from girl to boy, and in male rather than female hermaphrodites. It would not be necessary to belabor this point except that some writers still do not understand it.’’98

But Diamond pursued Money with a determination worthy of Inspector Javert in Les Miserables. Throughout the 1960s and 70s he published at least five more papers contesting Money’s views. In a 1982 publication, he recounted how psychology and women’s studies texts had taken up John/Joan ‘‘to sup­port the contention that sex roles and sexual identity are basically learned.’’ Even Time magazine was propagating Money’s social constructionist doctrine. But Diamond reiterated his view that ‘‘nature sets limits to sexual identity and partner preference and that it is within these limits that social forces interact and gender roles are formulated, a biosocial-interaction theory.’’99 (Note that by 1982 the terms of the debate had shifted. Diamond now spoke of sexual rather than gender identity, and a new term, partner preference, slipped in. I will return to partner preference—the origins of homosexuality—later.)

Diamond did not write this article just to gripe. He had big news. In 1980 the BBC produced a TV documentary on the John/Joan case. At first the producers planned to feature Money and his views while using Diamond for an oppositional backdrop. But the BBC reporters had found that by 1976 Joan, then thirteen years old, was not well adjusted. She walked like a boy, felt that boys had better lives, wanted to be a mechanic, and peed standing up. The psychiatrists then caring for the child thought she was ‘‘having considerable difficulty in adjusting as a female’’ and suspected she would not succeed in remaining one. When the journalists told Money of these findings, he refused to talk further with them, and they broadcast the psychiatrists’ findings of John’s discontent without additional input from Money. Diamond learned of all this from the BBC production team, but the film did not air in the United States. In an attempt to bring the facts to light in North America, Diamond, in 1982, published a secondhand account of the documentary in the hopes of discrediting Money’s sex/gender theory once and for all.100

The paper did not make the splash Diamond had wanted. But he did not give up. He started advertising in the American Psychiatric Association Journal, asking the psychiatrists who had taken over John/Joan’s case to contact him so that they could get the truth out in the open. But John’s psychiatrist, Keith Sigmundson, who said he ‘‘was shit-scared of John Money… I didn’t know what he would do to my career,’’101 let years go by before he finally responded and told Diamond what no other professionals had known: in 1980 Joan had had her breasts removed, later had a penis reconstructed, and was married and living with a woman and serving as her children’s father. Finally, Diamond and Sigmundsen made front-page news when they published the update on John/Joan, whom they now referred to as Joan/John.102

Diamond and Sigmundson used the failure of John’s sex reassignment to dispute two basic ideas: that individuals are psychosexually neutral at birth, and that healthy psychosexual development is intimately related to the appear­ance of the genitals. Using the compelling details of the updated story, in which John/Joan/John’s mother now recounted his/her consistent rejection of and rebellion against attempts to socialize him as a girl, Diamond argued that far from being sexually neutral, the brain was in fact prenatally gendered. ‘‘The evidence seems overwhelming,’’ he wrote, ‘‘that normal humans are not psychosexually neutral at birth but are, in keeping with their mammalian her­itage, predisposed and biased to interact with environmental, familial and social forces in either a male or a female mode.’’103

Since the Diamond/Sigmundson expose, similar reports of rejection of sex reassignments and of the successful rearing as males of children born with malformed penises have received wide attention.104 Diamond and a few others have gained a foothold (although some still harbor doubts)105 in calling for new treatment paradigms— above all, postponing immediate and irreversible surgery and providing counseling instead. ‘‘With this management,’’ Dia­mond reasons, ‘‘a male’s predisposition to act as a boy and his actual behavior will be reinforced in daily interactions and on all sexual levels and his fertility will be preserved.’’106

The debate, however, is not over. In 1998 a group of Canadian psychiatrists and psychologists published a follow-up of another case of sex reassignment following ablatio penis (as accidental loss of the penis is so delicately called in the medical literature). This child was reassigned at seven months (much ear­lier than John/Joan, who was almost two years old when reassigned). In 1998 the unnamed patient was twenty-six years old and living as a woman. She had had love affairs with men, but had left her most recent boyfriend and now lives as a lesbian. She works in a blue-collar job ‘‘practiced almost exclusively by men.’’ The authors note ‘‘a strong history of behavioral masculinity during childhood and a predominance of sexual attraction to females in fantasy.’’ Yet they do not argue that the sex assignment was entirely unsuccessful. Rather, they insist that gender identity in this case was successfully changed by rearing, even if gender role and sexual orientation were not. ‘‘Perhaps,’’ they conclude, ‘‘gender role and sexual orientation are more strongly influenced by biologic factors than is gender identity formation.’’107

Their theories have sparked intense debate. Some sexologists, for exam­ple, argue strongly that this paper by Susan Bradley and her colleagues actually provides evidence for rather than against Diamond’s position. And the conver­sations have become even more nuanced as adult intersexuals have begun to contribute their viewpoints. Not incidentally, they also suggest more complex interpretations of the case studies than offered by academics or practicing physicians.108 Even John Money, who has refused to discuss the case, has adopted a more intricate position. In a comment on another case of ablatio penis, in which a dog attacked a child, he concedes that with both early and late sex reassignment, ‘‘the long term outcome is less than perfect.’’ He ac­knowledges that boys reassigned as girls often become lesbian, something he views as a negative because of the associated social stigma. Without ever citing Diamond or alluding to the debate, he concedes: ‘‘There is, as yet, no unani­mously endorsed set of guidelines for the treatment of genital trauma and mutilation in infancy, and no provision for a statistical depository of out­come data.’’109