The Riddle of Gender

and that psychosexual well-being was dependent on developing a core sense of oneself as either a man or a woman. He declared that an individual’s sense of being either male or female was heavily influenced by the way that one was perceived and treated by parents and other close family members in the first two years of life, and that the behavior of parents was in turn heavily influenced by the external genitalia of their newborn. Any ambiguity in the appearance of the child’s genitals creates doubt in the minds of the parents about their child’s sex, Money said, which is then transmitted to the child like a virus, poisoning his or her life with uncertainty. He avowed that gender role “becomes not only established but also indelibly imprinted” by around eighteen months, and that by the age of two and a half years, gender role is “well-established and inviolable.”

Using a metaphor that was to appear regularly in articles and books published throughout his career, in the 1955 paper Money compared the establishment of gender role “through encounters and transactions” with other people to the acquisition of one’s native language. “Once imprinted, a person’s native language may fall into disuse and be supplanted by another, but is never entirely eradicated. So also a gender role may be changed, or resembling native bilingualism, may be ambiguous, but it may also become so indelibly engraved that not even flagrant contradictions of body functioning and morphology may displace it.”

By the time that Money and the Hampsons published their next paper, “Imprinting and the Establishment of Gender Role,” in the prestigious Archives of Neurology and Psychiatry, they not only had established the crucial importance of the sex of assignment and rearing but also had begun to promote the recommendations that were to have such a profound impact on the lives of intersexual persons. A decision as to the sex of assignment and rearing of an intersexual infant must be made as soon as possible after birth, with “uncompromising adherence to the decision” throughout the child’s life, they said. Moreover, the deciding factor in that crucial decision made in the first weeks of the child’s life should be “the morphology of the external genitals and the ease with which these organs can be surgically reconstructed to be consistent with the assigned sex.” No matter the gonadal or chromosomal sex of the child, the appearance of the child’s genitals and their amenability to surgical manipulation become the key issue in determining sex. Finally, “the earlier the surgical reconstruction of the genitals is done, the better.”

Surgery thus became the solution to the riddle of gender.

As the theories of John Money and his colleagues became increasingly influential, their views on the need for surgical intervention for intersexual children became standard practice. Those views are neatly summarized by Money himself in the second edition of his text Sex Errors of the Body and Related Syndromes: “Before contemporary medical interventions, many children born with a birth defect of the sex organs were condemned to grow up as they were born, stigmatized and traumatized. It simply does not make sense to talk of a third sex, or of a fourth or fifth, when the phylogenetic scheme of things is two sexes. Those who are genitally neither male nor female but incomplete are not a third sex. They are a mixed sex or an in-between sex. To advocate medical nonintervention is irresponsible. It runs counter to everything this book stands for, which is to enhance health and well-being to the greatest extent possible.”

“Enhancing the health and well-being” of intersexual infants and children required a wide range of surgical and hormonal manipulations, all focused on transforming anomalous genitals into the standard model. Clitorises larger than the norm and penises smaller than one inch were amputated, so that the genitals could be shaped to look more like average male and female genitals. Testicles and ovaries were removed so that they would not secrete at puberty masculinizing or feminizing hormones at odds with the assigned sex. Adolescents were dispensed synthetic hormones (usually estrogen) to promote the development of a secondary sexual morphology to match their assigned sex. The bodies of intersexual children became a map, says historian Susan Stryker, on which was inscribed the cold war view of sex—you are on one side or the other. “I think that many other binaries were structured by that binary,” says Stryker. “Material conditions do affect ideology, not in a strictly Marxian way, but they’re not unrelated, however complexly related they are.”

John Money’s views on the need for surgical reconstruction for intersexual infants were to remain virtually unchallenged for decades. Though the goal of such surgery was ostensibly to maximize health and well-being, when intersexual people themselves began to speak out about the effects of these surgeries on their physical and emotional well-being, their testimony directly contradicted that of the psychologists and surgeons who had instituted the neonatal intersex protocol. In contrast with the “health and well-being” predicted by Money, intersexual patients suffered physical pain and scarring from repeated genital surgeries, and emotional torment as the secret of their births was withheld from them by parents trying desperately to adhere to the facade of normalcy. Very few genital anomalies were “fixed” by a single surgery in the weeks after birth; instead, intersexual children often endured repeated surgeries and doctor visits focused on their genitals throughout childhood—often without any explanation by their parents or the physician about the nature of their problem. The secrecy created a deeply rooted feeling of shame and isolation, akin to that suffered by victims of childhood sexual abuse. Like sexual abuse victims, intersexual children suffered from an excess of adult interest in their genitals, and their privacy and bodily integrity were violated systematically by various health care providers over the years of “treatment.”

In 1993, Cheryl Chase founded the Intersex Society of North America (ISNA), a support and advocacy group, which began to break down the walls of “shame and secrecy” that had imprisoned intersexual people, ending their isolation. At the first weekend retreat of ISNA, participants spoke eloquently of their rage and pain, and their videotaped conversation was distributed by ISNA under the title Hermaphrodites Speak! On the tape, participants lash out at both physicians and parents who, attempting to follow the advice that they “uncompromisingly adhere” to the sex of assignment, had concealed from the patients their medical diagnoses and histories—even when surgeries and follow-up surgeries were performed in childhood, not infancy.

“I remember them removing my penis when I was five—oh, I’m sorry,” one participant says mockingly, “reducing it to the size of a normal clitoris.” The participant was diagnosed at birth as a “pseudo-hermaphrodite whose testes hadn’t developed properly, giving me ambiguous genitalia,” and the child’s parents were told instead that their baby was a girl whose ovaries hadn’t developed properly. “Basically, they [the doctors] lied to my parents, coercing them into letting the doctors perform plastic surgery, and giving me female hormones at puberty.” Unlike many intersexual persons, this patient received counseling, which was, she says “more like brainwashing sessions in which they tried to convince me that I was a normal little girl.”

Another participant says, “I was always led to believe that I was male. No one ever spoke to me at all about my state or condition,” even though it was clear that his penis was not at all like those of other boys. “I did have genital surgery” in childhood, he says, “though it was not called that.” Another participant recalled that his own surgery, for hypospadias (incompletely differentiated penis), was presented to him as a hernia operation. “For such a long time, I knew there wasn’t something quite right, but it took me quite a while to figure out what it was,” he says. Born with “a too small penis with a hole somewhere near the end and a femininized scrotal sac,” he says, “I wish people would have just stopped ‘helping’ me. Why do they insist on ‘fixing’ things?”

“Hopkins is where all this comes from,” says one participant bitterly.

In 2002, I sought out Dr. Paul McHugh, chair of the department of psychiatry at Johns Hopkins from 1975 to 2001—after John Money had repeatedly refused to speak with me, pleading old age and illness. McHugh frankly admitted that mistakes had been made. “We’re now seeing plenty of people who are saying, ‘Gee, why didn’t you just let me alone,’ “ he says, adding that in his opinion, “the best thing to do at that time would have been to let these kids grow up and see, to decide themselves”—precisely the point made by intersex activists. He is nonetheless quick to point out that “Dr. Money didn’t do this out of evil. He was trying to think about what would be the best [for the patients]. But we didn’t know enough—even though by that time the organizing force of prenatal hormones on the brain and on sexual behavior was well known in the animal literature, well established. Therefore, in my opinion, we should have held back.”

Dr. Ben Barres, the Stanford neurologist, proposed a different interpretation in our talk, one that acknowledges both the pioneering nature of Money’s intersex research and its limitations. “Money had an idea, a real hypothesis. He studied these issues and asked questions about them, and that’s the way that science gets done. You ask a good question, then you propose a good hypothesis, and then you test the hypothesis. Money did that. And that was pioneering on his part, and I think that he deserves an enormous amount of credit. Unfortunately, the problems begin in the way that he collected his data and designed his studies, and it ended up being an anecdotal report. I think the big moral of the story, as Simon LeVay has said, is that one should be careful about anecdotal evidence.”

The distinction that Barres draws between anecdotal evidence and hard data is an important one in science and medicine. It’s the difference between story and statistics, between my telling you that an herb has alleviated