As Nature Made Him (28 page)

Paula seems to be a young woman determined not to look back. She says that she has no criticism of those intersex activists who are lobbying the medical profession for change, but she takes the position, for herself, that it is better just to get on with life and not stir up the past. When her mother left the house, Paula admitted quietly, “Maybe they
should
wait and give kids the choice about surgery.” That, however, is an opinion she is unlikely to pass on to the medical profession. She has turned down a recent request from Johns Hopkins to participate in a follow-up study on sex reassigned patients. She simply does not want to relive her childhood—which she nevertheless insists was a perfectly happy one. But that some degree of unresolved emotion around her childhood might linger is perhaps suggested by the fact that Paula chose obstetrics and gynecology as her nursing specialty. Today she helps to deliver babies in the same small hospital where she was born twenty-seven years ago, as Michael Edward.

The medical establishment’s refusal to listen to those intersexes who
have
elected to speak about their experiences is no surprise to Cheryl Chase. “Our position implies that they have—unwittingly at best, and through willful denial at worst—spent their careers inflicting a profound harm from which their patients will never fully recover,” Chase once wrote. She says that she does not expect the medical establishment to change its practices unless forced. Chase plans to force them. “I think a context will open up for surgeons who keep doing this to be vulnerable to lawsuits,” she told me. “But it’s going to take a while to create that context. Right now we can’t sue because it’s standard practice, and parents give permission. The first thing we want to have happen is that when they make their recommendation to parents, they tell them it’s experimental and there’s no evidence that it works and that there’s plenty of people who’ve had it done to them who are mad as hell.”

There are other needs as well. Anne Fausto-Sterling, an embryologist at Brown University, says that the medical establishment will have to provide education and emotional support to help parents with the difficult task of raising an infant whose genitals are atypical. “At the moment there is no ongoing counseling done by people skilled in psychosexual development,” Fausto-Sterling says. “If there was really a wholesale change in this, the medical profession would have to do something like what they’ve done with genetic counseling—which is to develop a specialty of people who would work with these families long term and help them resolve both emotional and practical questions. The practical questions are very real: What do I do when it comes to undressing in gym? How do I intervene with the school system? There’s a different infrastructure that needs to be built and put into place. I think it’s the responsibility of the medical profession to do it.”

Perhaps the biggest change that will have to take place is in the medical profession’s current view of what it means to be reared with ambiguous genitals, since the Money and Hopkins guidelines are predicated on the belief that such a childhood would be psychologically and psychosexually devastating. Studies that would prove the truth of this intuitive observation are hard to come by; case histories of children reared with ambiguous genitals are rare because so few intersexual newborns have avoided surgical intervention. In 1989 a study did appear in the
Journal of Urology
on the lives of twenty males with micropenis who were reared in their biologic sex. Drs. Justine Reilly and C. R. J. Woodhouse of St. Peter’s Hospital and The Hospital for Sick Children in London described how these patients, who ranged in age from ten to forty-three years, had all formed healthy male gender identities and “participated in normal male activities in childhood and adolescence.” They also reported that nine (75 percent) of the older patients were sexually active and that “vaginal penetration usually is possible but adjustment of position or technique may be necessary.” The researchers drew two main conclusions: “A small penis does not preclude normal male role and a micropenis or microphallus alone should not dictate a female gender assignment in infancy.”

Reilly and Woodhouse’s study, however, looked at the lives of only twenty patients, all of whom had the same syndrome. A much more exhaustive study exists on the lives of untreated intersexes who display a much wider range of conditions than micropenis alone. Written before the advent of the 1955 protocols, it is a unique and fascinating monograph that reviews over two hundred and fifty cases of intersexes who received no surgical intervention as babies. Furthermore, the study directly addresses the question of how children fare when they grow up with genitals of the sex opposite to that in which they are reared. “Do [these people], with such manifest sexual problems to contend with, break down under the strain, as psychiatric theory may lead one to believe,” asked the study’s author, “or do they make an adequate adjustment to the demands of life?”

Far from manifesting psychological traumas and mental illnesses, the study showed, the majority of patients rose above their genital handicap and not only made an “adequate adjustment” to life, but lived in a way virtually indistinguishable from people without genital difference—a result that clearly amazed the study’s author.

“One would not have been surprised had the paradox of hermaphroditism been a fertile source of psychosis and neurosis,” the investigator noted. “The evidence, however, shows that the incidence of the so-called functional psychoses in the most ambisexual of the hermaphrodites—those who could not help but be aware that they were sexually equivocal—was extraordinarily low. The incidence of neurotic psychopathology of the classic types, sufficiently severe and incapacitating to be unmistakable, was also conspicuously low.” The study pointed out that genital ambiguity led to a “disheartenment” of mood in some patients and a social “reticence” in others but went on to say of these individuals, “there was no evidence that their disheartenment or reticence ordinarily accumulated to the proportions of psychopathology, seriously impairing their ability to cope with the essential business of life”—such as completing their education, going to the office each day, and earning a living each week.

Of particular interest are the study’s in-depth interviews with ten intersexes who received no surgery or hormone treatments until they were old enough to make their own decision. Their lives only strengthened the investigator’s impression that the condition of the genitalia plays a strikingly insignificant part in the way a person develops a stable and healthy gender identity, not to mention a secure and confident self-image. One patient with an enlarged clitoris at birth did not have the organ surgically reduced until the age of twelve, yet her childhood with masculinized genitalia left no wound on her psyche and did not impair her sense of herself as a girl. “[O]ne appreciates her remarkable stamina and the self-reliant way in which she had consolidated it,” the author noted. A second girl with a similar medical history demonstrated a marked “social deftness and complete poise” and, despite her mother’s depressions, “had emerged more stable than her adult sister or brother.” About another girl whose masculinized genitals were not surgically altered until she consented to it at age twelve, “one would not be justified in saying that she is different from scores of other adolescents.” A boy with an untreated micropenis had married at age twenty-four and, the study reported, “is meeting life most successfully without any suspicion of psychopathology. . . . His life is an eloquent and incisive testimony to the stamina of human personality.” A “true hermaphrodite” with a micropenis, split scrotum, and breasts at puberty lived as a male with no surgery to correct these anomalies. “The youth is another living testimony . . . to the stamina of human personality in the face of sexual ambiguity of no mean proportions.” A seventeen-year-old boy whose micropenis went untreated through childhood and adolescence “is making a stalwart and almost heroic adjustment to life.” Likewise, a twenty-year-old born with a small, hypospadic penis that required him to sit to urinate and that went uncorrected until age nineteen; this patient “was almost a model of what the average citizen believes a healthy, well-adjusted American youth should be,” the author noted: “confident, self-reliant, and optimistic.”

Unfortunately, no experts in the debate on intersex treatment—including Milton Diamond, Bill Reiner, Anne Fausto-Sterling, or Cheryl Chase—has ever made reference to this valuable report. That such a rare and unique study has been overlooked is perhaps not surprising. Never commercially published or distributed, it can be obtained only through written application to the Widener Library at Harvard University, where it was submitted as a senior dissertation to the college’s Ph.D. program in 1951. The author was a thirty-year-old doctoral candidate named John Money.

15

J
OHN
M
ONEY HAS NEVER
explained the shift that occurred in his thinking between the time he finished his Harvard thesis and the time he wrote his first papers on inter-sexes four years later, and he has never publicly commented on any aspect of his work since the revelations in Diamond and Sigmundson’s paper.

Now seventy-eight years old and in semiretirement, he has nevertheless remained a prolific and opinionated writer on the subject of sex and sexuality. His latest book,
Unspeakable Monsters
, was published in the spring of 1999. Through the last two decades, his books and articles have continued to appear with regularity, and in the late 1980s he enjoyed an intense courting by the media over the publication of his book
Lovemaps
—Money’s term for an individual’s particular constellation of erotic tastes and impulses. Profiles and interviews with Money appeared in
Playboy
,
Cosmopolitan
,
Psychology Today
,
Omni
, and the
Atlantic Monthly
. In
Rolling Stone
’s 1990 “Hot Issue,” Money was celebrated as the “Hot Love Doctor,” and he appeared on various TV programs.

Meanwhile Money was negotiating a subtle shift from his earlier extreme position on the primacy of rearing over biology in the making of boys and girls. In a May 1988 magazine profile, he seemed at some pains to characterize himself as a longtime champion of the role of biology in psychological sex differentiation, saying that when he was publishing papers on the behavioral influence of prenatal sex hormones in the 1950s, “many people in various branches of the social sciences were just enraged at the idea that hormones in the bloodstream before you were born could have a sex differentiating influence on you.” In the same article, however, Money reiterated his claim that infant boys can, with surgery and hormone treatments, be turned into heterosexual women.

If the last two decades have seen the consolidation of Money’s international reputation as one of the single most influential sexologists of the twentieth century, his career at Johns Hopkins has not been without its setbacks. The seeds for Money’s problems were sown as early as 1975, when Dr. Joel Elkes, chairman of the Psychiatry Department and Money’s longtime protector within the institution, was replaced by Dr. Paul McHugh.

By almost any measure, McHugh, a practicing Catholic and a sworn enemy of all fashions and fads in psychiatry, was John Money’s diametrical opposite—save for the forcefulness of his opinions and his determination to put them into action. Today McHugh is famed as psychiatry’s most outspoken scourge. In referring to McHugh’s “ceaseless campaign to restore sanity to his own profession,” a 1997 Baltimore Sun profile dubbed him “Dr. Iconoclast” and listed his “annihilating opinions on everything from doctor-assisted suicide (utterly wrong) to multiple personality disorder (it doesn’t exist).” The profile also highlighted his excoriating disdain for “dubious practices—and practitioners—in the medical profession,” including Dr. Jack Kevorkian, whom McHugh was quoted as calling “insane,” and Dr. Bruno Bettelheim, the famous expert on children, whom McHugh called “a habitual liar, thankless friend, vicious bully, and brazen plagiarist.”

McHugh has always reserved special scorn for the practice of sex-change surgery on adult transexuals. Classifying transexualism as merely one symptom in a larger complex of personality disorders, McHugh had long believed that psychiatrists should treat such patients with the talking cure, not radical, irreversible surgeries. In a 1992 article in the
American Scholar
, McHugh lambasted transexual surgery as “the most radical therapy ever encouraged by twentieth century psychiatrists” and likened its popularity to the once widespread practice of frontal lobotomy. “Johns Hopkins was one of the places in the United States where [transexual surgery] was given its start,” McHugh pointed out in this article. “It was part of my intention, when I arrived in Baltimore in 1975, to help end it.”

Two years after McHugh arrived at Johns Hopkins, Dr. Jon Meyer, a Hopkins psychiatrist and former director of the Gender Identity Clinic, produced a long-term follow-up of fifty postoperative and preoperative adult transexuals treated at Johns Hopkins since the clinic was founded in 1966. Meyer reported that none showed any measurable improvement in their lives and concluded that “sex reassignment surgery confers no objective advantage in terms of social rehabilitation.” Presented at the American Psychiatric Association’s Annual Convention in May 1977, the paper was published two years later in the
Archives of General Psychiatry
. The transgendered community reacted with outrage to the paper’s alleged nonscientific methods and aims. To no avail. Its publication was heralded by an October 1979 press conference at Johns Hopkins, where it was announced to the assembled reporters that the Gender Identity Clinic was now closed. John Money was not notified about the press conference and was not consulted about the clinic’s closing—an ignominious position for the man who had—virtually singlehanded—spearheaded the movement to open it.