The Riddle of Gender

Attempting to identify the masses, Barr discovered that they were present only in the cells of female animals. Later investigators would discover that these “Barr bodies” were in fact inactivated X chromosomes, switched off to prevent an overload of genetic information in the cell. Initially, Barr bodies were identified in biopsies of skin tissue, but in 1956, scientists realized that simply scraping some cells from the mucosa of the mouth would produce accurate results. Sex chromatin typing gave rise to a new science, cytogenetics, and a new method to determine sex.

Intersexual and gender-variant persons were among the first to undergo genetic testing, and certain anomalies were revealed to be genetically caused. Others were found to have no apparent genetic basis.

“It was as a graduate student in the Harvard psychological clinic that I first became directly acquainted with the phenomenon of human hermaphroditism,” Money writes in Gendermaps, published in 1995. He describes the case of a seventeen-year-old boy born with two un-descended testes and external genitalia that “resembled a vulva with a clitoridean organ instead of a penis.” The boy was suffering from a condition then called testicular feminizing syndrome, but today known as androgen insensitivity syndrome (AIS), in which cells throughout the body of an XY child fail to respond to androgens. The child thus develops a female body shape and genitals. Prior to the discovery of a test to determine chromosomal sex, such children were usually raised as girls, though as adults they were infertile. Money’s first intersexual patient “had been reared as a boy after a sex reannouncement from female to male early in infancy on the advice of a wrongly informed physician who had promised surgical and hormonal treatment in the teenage years so as to allow the boy to become a man.”

No such treatment was available, but when doctors informed the seventeen-year-old seeking the promised treatment that he could instead live as a woman, “it was an option too alien for him to contemplate,” says Money. This first experience with an intersexual person led Money to recognize the possibility that the sex of the mind could be at odds with the visible sex of the body. “It pointed clearly toward the principle of a discontinuity between the development of the body, from prenatal life through puberty, as feminized, and the development of the mental life as masculinized, despite the restrictions imposed on genital masculinity by anatomical and hormonal femininity.”

After completing his doctoral dissertation at Harvard, “Hermaphroditism: An Inquiry into the Nature of a Human Paradox,” Money joined the staff of the Pediatric Endocrinology Clinic at Johns Hopkins Hospital. A protege of Lawson Wilkins—often called the father of pediatric endocrinology—Money was recruited by Wilkins to work at Johns Hopkins as a psychoendocrinologist, a clinician/researcher whose primary goal was to develop an understanding of the mental and behavioral changes caused by treatment with hormones. At Johns Hopkins, Money’s caseload of intersexual patients expanded to sixty. His psychological evaluations of these sixty patients convinced him to “abandon the unitary definition of sex as male or female,” based on the commonly accepted criteria of either chromosomal or gonadal sex. Instead, he identified “five prenatally determined variables of sex that hermaphroditic data had shown could be independent of one another”—chromosomal sex, gonadal sex, internal and external morphologic sex, and hormonal sex—and “a sixth postnatal determinant, the sex of assignment and rearing.”

To these six variables, Money added a seventh, one that had previously been absent from scientific and medical discussions of sex: gender role. “The term ‘gender role’ is used to signify all those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively. It includes, but is not restricted to, sexuality in the sense of eroticism,” Money writes in his first published paper on the topic at Johns Hopkins. The term “gender role” was conceived “after several burnings of the midnight oil,” says Money, and was originally “conceptualized jointly as private in imagery and ideation, and public in manifestation and expression.” In Gendermaps, Money confesses that in defining gender role he “had in mind the example of an actor whose greatness derives from his becoming the character whose role he plays on stage.” In the same way, he says, gender role “belongs to the self, within, and concurrently manifests itself to others, without.”

A few months after the publication of that first paper in the Bulletin of the Johns Hopkins Hospital, Money published an expanded definition of gender role in “An Examination of Some Basic Sexual Concepts: The Evidence of Human Hermaphroditism,” cowritten with Joan and John Hampson. In this more fully articulated definition, gender role has expanded to include “general mannerisms, deportment and demeanor; play preferences and recreational interests; spontaneous topics of talk in unprompted conversation and casual comment; content of dreams, daydreams and fantasies; replies to oblique inquiries and projective tests; evidence of erotic practices, and finally, the person’s own reply to direct inquiry.” More significantly, in this paper Money and the Hampsons first attempt to establish which of the other six variables is most significant in establishing gender role in intersexual patients, and produce an answer that was not only to profoundly alter the medical treatment of intersexual children, but also to sever the link between biological sex (as manifested in chromosomes, gonads, and external anatomy) and the newly developed concept of gender role.

Money and the Hampsons based their findings on seventy-six inter-sexual patients treated at Johns Hopkins over a period of four years. They state early in the paper that the study’s primary purpose is to explore the hypothesis first presented by Freud at the turn of the century—that human beings are innately bisexual, “that instinctive masculinity and instinctive femininity are present in all members of the human species, but in different proportions.” Bisexuality in Freud’s theory is a biological concept, not a description of a person’s sexual orientation; it is an “innate and constitutional psychic bisexuality,” the presence of both male and female elements in each person, irrespective of reproductive anatomy. Money and the Hampsons chose to study intersexual people in order to “ascertain if new and additional information relevant to the psychologic theory of sexuality might be obtained.” From the very start they assumed that data obtained from intersexual people could be used to explain the process of gender differentiation in all people. A fatal assumption, some would later argue.

The 1955 paper describes patients with a variety of clinical conditions, from “true hermaphrodites” who possess both testicular and ovarian tissue to various forms of “simulant” males and females whose external genitalia are somehow at odds with either their chromosomal or their gonadal sex, or who have ambiguous genitals. In each case, the researchers compare the sex of rearing with the other six variables to determine the weight of each in determining the person’s gender role. In each case, they find that the influence of the sex of assignment and rearing trumped the competing variable.

Of the twenty patients whose gonadal sex (ovaries or testicles) conflicted with their sex of assignment and rearing, only three rejected the sex they had been assigned at birth. Of the twenty-seven people whose hormonal functioning and secondary sexual body morphology (breasts, body hair, body shape) were at odds with their sex of assignment and rearing, only four displayed ambivalence or anxiety about their assigned gender role. Twenty-three of the seventy-six patients had lived for more than two-thirds of their lives with an obvious difference between the appearance of their genitals and their assigned sex (girls with penises; boys with vaginas). In all but one instance, according to Money and the Hampsons, they had accepted the gender role assigned to them at birth.

The life experiences of this last group appeared to make a great impression on the researchers, one that produced a marked difference in the language used to describe them. Money, the primary author of the paper, uses subjective emotional language to describe the travails of the subjects with ambiguous genitalia. He writes, “there was considerable evidence that visible genital anomalies occasioned much anguish and distress. Distress was greatest in those patients whose external genital morphology flagrantly contradicted, without hope of surgical correction, their gender role and orientation as boy or girl, man or woman. Distress was also quite marked in patients who had been left in perplexed conclusion about the sex to which they belonged, in consequence either of personal or medical indecision, or of insinuations from age-mates that they were half-boy, half-girl. Uniformly, the patients were psychologically benefited by corrective plastic surgery, when it was possible, to rehabilitate them in the sex of assignment and rearing.”

Contained in this single paragraph are the seeds of the two most significant outcomes of Money’s research: first, the promotion of corrective surgery for intersexual persons, to normalize their genitalia and to save them from that “perplexed conclusion about the sex to which they belonged;” second, the support of sex-reassignment surgery for people whose “external genital morphology flagrantly contradicted … their gender role and orientation as boy or girl, man or woman.” Add to that the paper’s conclusion—that “the sex of assignment and rearing was better than any other variable as a prognostica-tor of the gender role and orientation established by the patients in this group”—and one sees a virtual blueprint for Money’s future career.

Throughout the next forty years, Money would continue to promote these themes in book after book, lecture after lecture. He insisted that “a person could not be an it”—neither male nor female, nor both male and female—