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Being Brenda
They were meant to show that gender was determined by nurture, not nature—one identical twin raised as a boy and the other brought up as a girl after a botched circumcision. But two years ago Brian Reimer killed himself, and last month David—formerly Brenda—took his life too. The Guardian's Oliver Burkeman and Gary Younge unravel the tragic story of Dr Money's sex experiment.

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A Journal of Religion, Culture and Public Life. Fr. Richard John Neuhaus is Editor-in-Chief.

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SURGICAL SEX

When I became psychiatrist-in-chief at Johns Hopkins, I realized that by doing sex-change operations the hospital was fundamentally cooperating with a mental illness. We would do better for these patients, I thought, by concentrating on trying to fix their minds and not their genitalia.

Photo: Getty ImagesWhen the practice of sex-change surgery first emerged back in the early 1970s, I would often remind its advocating psychiatrists that with other patients, alcoholics in particular, they would quote the Serenity Prayer, "God, give me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." Where did they get the idea that our sexual identity ("gender" was the term they preferred) as men or women was in the category of things that could be changed?

Their regular response was to show me their patients. Men (and until recently they were all men) with whom I spoke before their surgery would tell me that their bodies and sexual identities were at variance. Those I met after surgery would tell me that the surgery and hormone treatments that had made them "women" had also made them happy and contented. None of these encounters were persuasive, however. The post-surgical subjects struck me as caricatures of women. They wore high heels, copious makeup, and flamboyant clothing; they spoke about how they found themselves able to give vent to their natural inclinations for peace, domesticity, and gentleness—but their large hands, prominent Adam's apples, and thick facial features were incongruous (and would become more so as they aged). Women psychiatrists whom I sent to talk with them would intuitively see through the disguise and the exaggerated postures. "Gals know gals," one said to me, "and that's a guy."

Where did they get the idea that our sexual identity as men or women was in the category of things that could be changed?
The subjects before the surgery struck me as even more strange, as they struggled to convince anyone who might influence the decision for their surgery. First, they spent an unusual amount of time thinking and talking about sex and their sexual experiences; their sexual hungers and adventures seemed to preoccupy them. Second, discussion of babies or children provoked little interest from them; indeed, they seemed indifferent to children. But third, and most remarkable, many of these men-who-claimed-to-be-women reported that they found women sexually attractive and that they saw themselves as "lesbians." When I noted to their champions that their psychological leanings seemed more like those of men than of women, I would get various replies, mostly to the effect that in making such judgments I was drawing on sexual stereotypes.

Until 1975, when I became psychiatrist-in-chief at Johns Hopkins Hospital, I could usually keep my own counsel on these matters. But once I was given authority over all the practices in the psychiatry department I realized that if I were passive I would be tacitly co-opted in encouraging sex-change surgery in the very department that had originally proposed and still defended it. I decided to challenge what I considered to be a misdirection of psychiatry and to demand more information both before and after their operations.

Two issues presented themselves as targets for study. First, I wanted to test the claim that men who had undergone sex-change surgery found resolution for their many general psychological problems. Second (and this was more ambitious), I wanted to see whether male infants with ambiguous genitalia who were being surgically transformed into females and raised as girls did, as the theory (again from Hopkins) claimed, settle easily into the sexual identity that was chosen for them. These claims had generated the opinion in psychiatric circles that one's "sex" and one's "gender" were distinct matters, sex being genetically and hormonally determined from conception, while gender was culturally shaped by the actions of family and others during childhood.

The first issue was easier and required only that I encourage the ongoing research of a member of the faculty who was an accomplished student of human sexual behavior. The psychiatrist and psychoanalyst Jon Meyer was already developing a means of following up with adults who received sex-change operations at Hopkins in order to see how much the surgery had helped them. He found that most of the patients he tracked down some years after their surgery were contented with what they had done and that only a few regretted it. But in every other respect, they were little changed in their psychological condition. They had much the same problems with relationships, work, and emotions as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled.

We saw the results as demonstrating that just as these men enjoyed cross-dressing as women before the operation so they enjoyed cross-living after it. But they were no better in their psychological integration or any easier to live with. With these facts in hand I concluded that Hopkins was fundamentally cooperating with a mental illness. We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia.

Women psychiatrists would intuitively see through the disguise and the exaggerated postures. ‘Gals know gals,’ one said to me, ‘and that’s a guy.’
Thanks to this research, Dr. Meyer was able to make some sense of the mental disorders that were driving this request for unusual and radical treatment. Most of the cases fell into one of two quite different groups. One group consisted of conflicted and guilt-ridden homosexual men who saw a sex-change as a way to resolve their conflicts over homosexuality by allowing them to behave sexually as females with men. The other group, mostly older men, consisted of heterosexual (and some bisexual) males who found intense sexual arousal in cross-dressing as females. As they had grown older, they had become eager to add more verisimilitude to their costumes and either sought or had suggested to them a surgical transformation that would include breast implants, penile amputation, and pelvic reconstruction to resemble a woman.

Further study of similar subjects in the psychiatric services of the Clark Institute in Toronto identified these men by the auto-arousal they experienced in imitating sexually seductive females. Many of them imagined that their displays might be sexually arousing to onlookers, especially to females. This idea, a form of "sex in the head" (D. H. Lawrence), was what provoked their first adventure in dressing up in women's undergarments and had eventually led them toward the surgical option. Because most of them found women to be the objects of their interest they identified themselves to the psychiatrists as lesbians. The name eventually coined in Toronto to describe this form of sexual misdirection was "autogynephilia." Once again I concluded that to provide a surgical alteration to the body of these unfortunate people was to collaborate with a mental disorder rather than to treat it.

This information and the improved understanding of what we had been doing led us to stop prescribing sex-change operations for adults at Hopkins—much, I'm glad to say, to the relief of several of our plastic surgeons who had previously been commandeered to carry out the procedures. And with this solution to the first issue I could turn to the secondnamely, the practice of surgically assigning femaleness to male newborns who at birth had malformed, sexually ambiguous genitalia and severe phallic defects. This practice, more the province of the pediatric department than of my own, was nonetheless of concern to psychiatrists because the opinions generated around these cases helped to form the view that sexual identity was a matter of cultural conditioning rather than something fundamental to the human constitution.

Several conditions, fortunately rare, can lead to the misconstruction of the genito-urinary tract during embryonic life. When such a condition occurs in a male, the easiest form of plastic surgery by far, with a view to correcting the abnormality and gaining a cosmetically satisfactory appearance, is to remove all the male parts, including the testes, and to construct from the tissues available a labial and vaginal configuration. This action provides these malformed babies with female-looking genital anatomy regardless of their genetic sex. Given the claim that the sexual identity of the child would easily follow the genital appearance if backed up by familial and cultural support, the pediatric surgeons took to constructing female-like genitalia for both females with an XX chromosome constitution and males with an XY so as to make them all look like little girls, and they were to be raised as girls by their parents.

All this was done of course with consent of the parents who, distressed by these grievous malformations in their newborns, were persuaded by the pediatric endocrinologists and consulting psychologists to accept transformational surgery for their sons. They were told that their child's sexual identity (again his "gender") would simply conform to environmental conditioning. If the parents consistently responded to the child as a girl now that his genital structure resembled a girl's, he would accept that role without much travail.

There is a deep prejudice in favor of the idea that nature is totally malleable.
This proposal presented the parents with a critical decision. The doctors increased the pressure behind the proposal by noting to the parents that a decision had to be made promptly because a child's sexual identity settles in by about age two or three. The process of inducing the child into the female role should start immediately, with name, birth certificate, baby paraphernalia, etc. With the surgeons ready and the physicians confident, the parents were faced with an offer difficult to refuse (although, interestingly, a few parents did refuse this advice and decided to let nature take its course).

I thought these professional opinions and the choices being pressed on the parents rested upon anecdotal evidence that was hard to verify and even harder to replicate. Despite the confidence of their advocates, they lacked substantial empirical support. I encouraged one of our resident psychiatrists, William G. Reiner (already interested in the subject because prior to his psychiatric training he had been a pediatric urologist and had witnessed the problem from the other side), to set about doing a systematic follow-up of these children—particularly the males transformed into females in infancyso as to determine just how sexually integrated they became as adults.

The results here were even more startling than in Meyer's work. Reiner picked out for intensive study cloacal exstrophy, because it would best test the idea that cultural influence plays the foremost role in producing sexual identity. Cloacal exstrophy is an embryonic misdirection that produces a gross abnormality of pelvic anatomy such that the bladder and the genitalia are badly deformed at birth. The male penis fails to form and the bladder and urinary tract are not separated distinctly from the gastrointestinal tract. But crucial to Reiner's study is the fact that the embryonic development of these unfortunate males is not hormonally different from that of normal males. They develop within a male-typical prenatal hormonal milieu provided by their Y chromosome and by their normal testicular function. This exposes these growing embryos/fetuses to the male hormone testosterone—just like all males in their mother's womb.

Although animal research had long since shown that male sexual behavior was directly derived from this exposure to testosterone during embryonic life, this fact did not deter the pediatric practice of surgically treating male infants with this grievous anomaly by castration (amputating their testes and any vestigial male genital structures) and vaginal construction, so that they could be raised as girls. This practice had become almost universal by the mid-1970s. Such cases offered Reiner the best test of the two aspects of the doctrine underlying such treatment: (1) that humans at birth are neutral as to their sexual identity, and (2) that for humans it is the postnatal, cultural, nonhormonal influences, especially those of early childhood, that most influence their ultimate sexual identity. Males with cloacal exstrophy were regularly altered surgically to resemble females, and their parents were instructed to raise them as girls. But would the fact that they had had the full testosterone exposure in utero defeat the attempt to raise them as girls? Answers might become evident with the careful follow-up that Reiner was launching.

Before describing his results, I should note that the doctors proposing this treatment for the males with cloacal exstrophy understood and acknowledged that they were introducing a number of new and severe physical problems for these males. These infants, of course, had no ovaries, and their testes were surgically amputated, which meant that they had to receive exogenous hormones for life. They would also be denied by the same surgery any opportunity for fertility later on. One could not ask the little patient about his willingness to pay this price. These were considered by the physicians advising the parents to be acceptable burdens to bear in order to avoid distress in childhood about malformed genital structures, and it was hoped that they could follow a conflict-free direction in their maturation as girls and women.

Reiner, however, discovered that such re-engineered males were almost never comfortable as females once they became aware of themselves and the world. From the start of their active play life, they behaved spontaneously like boys and were obviously different from their sisters and other girls, enjoying rough-and-tumble games but not dolls and "playing house." Later on, most of those individuals who learned that they were actually genetic males wished to reconstitute their lives as males (some even asked for surgical reconstruction and male hormone replacement)-and all this despite the earnest efforts by their parents to treat them as girls.

Human sexual identity is mostly built into our constitution by the genes we inherit and the embryogenesis we undergo.
Reiner's results, reported in the January 22, 2004, issue of the New England Journal of Medicine, are worth recounting. He followed up sixteen genetic males with cloacal exstrophy seen at Hopkins, of whom fourteen underwent neonatal assignment to femaleness socially, legally, and surgically. The other two parents refused the advice of the pediatricians and raised their sons as boys. Eight of the fourteen subjects assigned to be females had since declared themselves to be male. Five were living as females, and one lived with unclear sexual identity. The two raised as males had remained male. All sixteen of these people had interests that were typical of males, such as hunting, ice hockey, karate, and bobsledding. Reiner concluded from this work that the sexual identity followed the genetic constitution. Male-type tendencies (vigorous play, sexual arousal by females, and physical aggressiveness) followed the testosterone-rich intrauterine fetal development of the people he studied, regardless of efforts to socialize them as females after birth.

Having looked at the Reiner and Meyer studies, we in the Johns Hopkins Psychiatry Department eventually concluded that human sexual identity is mostly built into our constitution by the genes we inherit and the embryogenesis we undergo. Male hormones sexualize the brain and the mind. Sexual dysphoriaa sense of disquiet in one's sexual rolenaturally occurs amongst those rare males who are raised as females in an effort to correct an infantile genital structural problem. A seemingly similar disquiet can be socially induced in apparently constitutionally normal males, in association with (and presumably prompted by) serious behavioral aberrations, amongst which are conflicted homosexual orientations and the remarkable male deviation now called autogynephilia.

Quite clearly, then, we psychiatrists should work to discourage those adults who seek surgical sex reassignment. When Hopkins announced that it would stop doing these procedures in adults with sexual dysphoria, many other hospitals followed suit, but some medical centers still carry out this surgery. Thailand has several centers that do the surgery "no questions asked" for anyone with the money to pay for it and the means to travel to Thailand. I am disappointed but not surprised by this, given that some surgeons and medical centers can be persuaded to carry out almost any kind of surgery when pressed by patients with sexual deviations, especially if those patients find a psychiatrist to vouch for them. The most astonishing example is the surgeon in England who is prepared to amputate the legs of patients who claim to find sexual excitement in gazing at and exhibiting stumps of amputated legs. At any rate, we at Hopkins hold that official psychiatry has good evidence to argue against this kind of treatment and should begin to close down the practice everywhere.

For children with birth defects the most rational approach at this moment is to correct promptly any of the major urological defects they face, but to postpone any decision about sexual identity until much later, while raising the child according to its genetic sex. Medical caretakers and parents can strive to make the child aware that aspects of sexual identity will emerge as he or she grows. Settling on what to do about it should await maturation and the child's appreciation of his or her own identity.

Proper care, including good parenting, means helping the child through the medical and social difficulties presented by the genital anatomy but in the process protecting what tissues can be retained, in particular the gonads. This effort must continue to the point where the child can see the problem of a life role more clearly as a sexually differentiated individual emerges from within. Then as the young person gains a sense of responsibility for the result, he or she can be helped through any surgical constructions that are desired. Genuine informed consent derives only from the person who is going to live with the outcome and cannot rest upon the decisions of others who believe they "know best."

We psychiatrists should work to discourage those adults who seek surgical sex reassignment.
How are these ideas now being received? I think tolerably well. The "transgender" activists (now often allied with gay liberation movements) still argue that their members are entitled to whatever surgery they want, and they still claim that their sexual dysphoria represents a true conception of their sexual identity. They have made some protests against the diagnosis of autogynephilia as a mechanism to generate demands for sex-change operations, but they have offered little evidence to refute the diagnosis. Psychiatrists are taking better sexual histories from those requesting sex-change and are discovering more examples of this strange male exhibitionist proclivity.

Much of the enthusiasm for the quick-fix approach to birth defects expired when the anecdotal evidence about the much-publicized case of a male twin raised as a girl proved to be bogus. The psychologist in charge hid, by actually misreporting, the news that the boy, despite the efforts of his parents to treat him and raise him as a girl, had constantly challenged their treatment of him, ultimately found out about the deception, and restored himself as a male. Sadly, he carried an additional diagnosis of major depression and ultimately committed suicide.

I think the issue of sex-change for males is no longer one in which much can be said for the other side. But I have learned from the experience that the toughest challenge is trying to gain agreement to seek empirical evidence for opinions about sex and sexual behavior, even when the opinions seem on their face unreasonable. One might expect that those who claim that sexual identity has no biological or physical basis would bring forth more evidence to persuade others. But as I've learned, there is a deep prejudice in favor of the idea that nature is totally malleable.

Without any fixed position on what is given in human nature, any manipulation of it can be defended as legitimate. A practice that appears to give people what they want—and what some of them are prepared to clamor forturns out to be difficult to combat with ordinary professional experience and wisdom. Even controlled trials or careful follow-up studies to ensure that the practice itself is not damaging are often resisted and the results rejected.

I have witnessed a great deal of damage from sex-reassignment. The children transformed from their male constitution into female roles suffered prolonged distress and misery as they sensed their natural attitudes. Their parents usually lived with guilt over their decisions-second-guessing themselves and somewhat ashamed of the fabrication, both surgical and social, they had imposed on their sons. As for the adults who came to us claiming to have discovered their "true" sexual identity and to have heard about sex-change operations, we psychiatrists have been distracted from studying the causes and natures of their mental misdirections by preparing them for surgery and for a life in the other sex. We have wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it.

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January 26, 2005

PAUL McHUGH is University Distinguished Service Professor of Psychiatry at Johns Hopkins University.

This article was reprinted with permission from “First Things” (www.firstthings.com). Copyright (c) 2004 “First Things” 147 (November 2004): 34-38. All rights reserved.

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READER COMMENTS
09.13.06   Peter_Abelard says:
Hi,thanks for your fascinating article.Please could you elaborate on a few points.1.) You say "The most astonishing example is the surgeon in England who is prepared to amputate the legs of patients who claim to find sexual excitement in gazing at and exhibiting stumps of amputated legs."I would be interested in having some justification of this comment, because whilst I know of one (now retired) psychiatrist in the UK who did believe such an approach to be viable, I know of no surgeon who ever put that into practice.2.) I fully commend your views on the management of intersex infants, and delaying decisions about genital surgery etc. until they are of an age to make their own decisions. However, you are not clear what the approach should be where such adolescents seek an assignment other than that given at birth. Are you saying that later surgery should only be confirming of the assignment decision made on their behalf as infants?3.) As you no doubt are aware, Benjamin promoted sex reassignment because he found that the treatment then available (that would encourage people to remain in their birth-sex) was not successful. Here in the UK, evidence-based medicine is very important. I would be interested to know of the evidence base you have to support that your method of treating transsexuals is more effective than the previous one of sex-reassignment. Given that the time between Benjamin's work and yours, and from when you were in a position to start your experiment and now are roughly the same, I would have expected that to be quite substantial by now.PA

01.25.06   lvngembrs says:
These are all familiar points for anyone studying psychology at a college or university. What believers in the field of psychology need is not a re-hash of data that genetics and hormone elicited changes in the body and the sexual development of children, but a bit of guidance on how to allow our faith into the practice of our field.If I might take my cursory knowledge of genetics and the interaction of the nvironment to show other readers that the field of psychology, biology, and other fields dealing with evolution are quite over the whole nature/nuture dichotomy.First of all, "innate" is not a good term, as it's Latin base says that traits are first beginning at birth, how ever empirical observations have been conducted with Mallard duck eggs showing that they do not learn to prefer the Mallard maternal call at birth, but rather in the egg, as the embryos can hear in the eggshell. So, when we talk about how traits are acquired, nothing in effect in inherited, but acquired through the individual's interaction with the environment.Secondly, anything and everything can be an environment, even the human womb is an environment, where the experience of hormones, nutrients, and chemicals elicit changes to a child until it is born. Additionally, your internal mechanisms contribute to your environment, so that facial hair for males appears to be inherited by mere fact of being male; but it is acquired through the experience (although unobservable) of released hormones.So, yes the experience and the process in which one's gender is determined is a gradual, graded process that is dependent upon one's environment.But biology is not the only thing that affects gender selection, especially once outside the womb. It's true htat we cannot change one's gender (yet -- either inside or outside the womb), but the psychological and sociological environment one is exposed to plays a great role. It is sociologically that we are geared towards blue or pink, bany dolls or toy trucks. But psychology plays a role, and it is this that first attracted me to this article, as there are numerous ways in which the determined gender comes into question and is challenged by the individual. I suppose that information is for another article, as I am not about to reiterate my psychology textbooks for you on sexual/gender disorders.As for anyone interested in the Interactionist theory I wrote of: Moore, D.S. (2001) The Dependent Gene: The Fallacy of "Nature vs Nuture". Henry Holt: New York.

05.09.05   dreamlife76 says:
What if there is a transexual person in your church and you don'tknow. How would that make you feel?

04.22.05   gliberty says:
This was a very interesting article. However, I think that only two options were considered where there may be more than two present. The article seemed to require one of two beleifs. Either you have to beleive that gender is not biologically driven (as some psychologists clearly had believed, but which medical science has not supported in many years); or you must beleive that since it is driven biologically, thee can be no sound reason for a person to surgically change it, and that the desire for surgery must be a psychological problem. This is a maistake. Scientists have learned, particularly with the advent of genetic science, that biological sexuality is not at all simple, nor does it happen all at once. As the article described, in utero testosterone has a large impact on male sexuality and identity - yet that is a separate (although related) process from the underlying chromosomal factors. About 1 in 1000 babies are born with XY chromosomes and because of a missing SRY gene, develop ovaries and are born partially female. XX males would be females but for a translocated SRY gene. 15% of those with this problem have undescended testes. XX males lack spermatogenesis. There is also X;Y translocation, mutation of downstream factors and other genetic disorders that may result in partially sex-reversed births. Severe congenital adrenal hyperplasia may mean the identification of a male at bith, who is genetically female. In many of these diseases, it is possible that the sexual identity and the sexual organs are determined by different genetic factors, resulting in genitals that are just as incorrect as those created by a surgeon after the birth. So, just as those baby boys, turned into girls by a well-meaning surgeon, have true sexual dysphoria and want to recreate their original physical identity - the same phenomenon might occur in these genetically disordered babies. Many of these disorders are not diagnosed until the person goes to a fertility clinic. It is known that some trans-sexuals may have one of these disorders, and that this may be why they have sexual dysphoria. To assume that something is purely psychological is to blame the victim of a genetic disorder and rather than treat the disease, to treat his discomfort with the disease. We would not treat the surgically changed child this way, with palliative psychological counseling, if we have surgical techniques to reverse the mistake - should we not treat someone the same if a genetic disorder did the surgery for them? To treat them any differently is like with-holding kidney surgey from someone with a disease, and only giving it to someone who was stabbed in the kidney.

04.08.05   laurelin says:
Dr. McHugh's research proves what I have often suspected about transsexuality. My question is, now that so many operations have been performed, how are we, as Christians, to deal with the people who are now living in a body that is not reflective of their real identity, and even in some cases, in a marriage, which may not really be valid, if one does not believe the Church condones same sex marriages? I don't think we can recommend another operation, should one even be possible, and we must still minister to these confused believers. Thank you.

02.24.05   dreamlife76 says:
I found your article to be articulate and well written. I especially agreed with the potion about Innersexed children being left as there were biologically born.I do have a few questions: Your study states subjects who are MTF-- Male to Female transexuals. Did you study the effects of adulthood sex reassignment on FTM-- Female to Males? I am curious because I know that the effects of testosterone can masculinize a female much more than estrogen can feminize a man. With this being the case, would their psycological mind be more clear after the proceedure because they are able to blend into society much more than their counter-parts? Thanks in Advance

02.03.05   TonyC says:
This article reaffirms for me the moral and cultural emptiness that has followed from the postmodern deconstruction of society and culture. And while I would agree that postmodernism has freed us from unhealthy constraints to speak out on behalf of truth, it has also given rise to an emperor-has-no-clothes syndrome in which Western society confused by relativism says nothing as its time-tested cultural foundations are eroded. This article also reaffirms the Christian understanding that there is no contradiction between science and faith (or here, perhaps better stated, theological anthropology), and that pursuit of truth in the sciences will lead to the same truths affirmed by the sensuus fidei. Great choice of article! TonyC

01.27.05   Godspy says:
When I became psychiatrist-in-chief at Johns Hopkins, I realized that by doing sex-change operations the hospital was fundamentally cooperating with a mental illness. We would do better for these patients, I thought, by concentrating on trying to fix their minds and not their genitalia.

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