Medical events continue to recall to question the preferred practice for dealing with neonatal or pediatric cases of ambiguous, traumatized, or ablated genitalia. One recent case involved a deranged father who, as punishment, cut off his young son’s penis (Los Angeles Times, 1980), and in another case, where I was one of several consulted, a male child was born with a microphallus. The first case was resolved with successful surgery to reattach the penis. In the second, the child was originally assigned as a female and then, within a few days, reassigned as a male.
Despite a host of literature, a clear resolution has not developed as to the preferred treatment in cases of males born disfigured or so traumatized. Some advocate rearing some types of XY individuals as males despite the absence of a normal penis (Grumbach, 1979), while others recommend rearing as a female (Blizzard, 19792). During the last several decades, one preponderant recommendation has been to rear such individuals as females, based on the hypothesis that social forces are predominant in organizing sexual identity and that the absence of a penis would irrevocably prevent normal development of a boy to a man.
Of particular significance in the development of such a recommended treatment is a report of monozygotic twin boys, one of whom had his penis accidentally ablated during circumcision by cautery at 7 months of age (Money and Ehrhardt, 1972; Money, 1973). After a great deal of consideration and anguish, the decision was made to rear this boy as a girl. To this end, the child at 17 months was reassigned as a girl, was orchidectomized, had preliminary surgery to fashion a vagina and was later put on a program of female steroids to facilitate and mimic female pubertal growth and feminization (Money and Ehrhardt, 1972). The outcome was reported as favorable (Money, 1973; Money and Tucker, 1975).
Of even greater significance than this single case as a clinical report, however, are the ramifying effects of its theoretical impact. Numerous elementary psychology and sociology texts (e.g. Robertson, 1977; Van der Zanden, 1977) and women’s study publications (e.g., Sargent, 1977; Tavris and Offir, 1977; Weitz, 1977; Frieze et al., 1978; Unger, 1979) that discuss sexual development use this single case and the subsequent reports of the twin’s success in adopting the female role to support the contention that sex roles and sexual identity are basically learned. Time magazine, in an extensive report of this case said, “This dramatic case … provides strong support for a major contention of women’s liberationists: that conventional patterns of masculine and feminine behavior can be altered. It also casts doubt on the theory that major sex differences, psychological as well as anatomical, are immutably set by the genes at conception” (Time, Jan. 8, 1973, p. 34). Masters and Johnson have referred to this case as “dramatic documentation of the importance of learning in the process of gender formation” (Kolodny, Masters, and Johnson, 1979, p. 65). The contention is that it is basically nurture, not nature, that determines sexual identity as male or female and the attendant gender roles. In 1975, when this child was 12, John Money, the investigator who originally reported the case, said, “The girl’s subsequent history proves how well all three of them [(the parents and child)] succeeded in adjusting to that decision” (Money and Tucker, 1975, p. 95).
My own research and clinical experience in dealing with homosexuals, transsexuals, and other individuals with various sexual and gender identities while on the Board of Directors of the Hawai‘i Sexual Identity Center and as a medical school faculty member have led me to suspect otherwise, and I have several times challenged the correctness of the theory and the validity of the recommended practice as well as the predicted success of the outcome of this case (Diamond, 1965, 1968, 1976, 1978, 1979). Others, too, have questioned the theory and practice (Zuger, 1970, 1975; Gadpaille, 1980).
Most recently, clinical reports have strongly supported the role of nature versus nurture in organizing an individual’s sexual identity and partner (object) choice (Imperato-McGinley et al.,1974, 1976, 1979). These reports provide data emphasizing how males, despite rearing and socialization as females, can at puberty assume a sexual identity as a male with erotic preference for females.
It is in regard to my work in this field of sexual development and my strong belief in the force of an inherent male or female nervous system bias for the development of sexual identity and partner choice (Diamond. 1965, 1968, 1973, 1976, 1978, 1979) that I was called to consult for a BBC television production on the “twin case.” The program’s producers, impressed with the widespread popular scientific writings referring to this case, sought to review the facts and examine the predominant power of rearing in permitting a genetically normal (nonhermaphroditic) male to develop successfully as a female. In this effort, the BBC reportedly contacted Dr. Money for his help and assistance. He was the logical choice since he was the senior researcher (along with his colleague Dr. Anke Ehrhardt) to have written of these twins in the “first person.” According to the BBC, Dr. Money expressed his approval of the project, offered his assistance, and was to be the prime spokesperson in the program (Williams and Smith, 1980). I was asked to give my opposing position as a foil against which the main thesis could be argued. My argument was that an individual’s biological heritage sets limits to the degree of sexual variation any person can comfortably display. My view, presented first in 1965, is that nature sets limits to sexual identity and partner preference and that it is within these limits that social forces interact and gender role are formulated, a biosocial-interaction theory (Diamond, 1965, 1968, 1973, 1976, 1978, 1979; Diamond and Karlen, 1980).
In the course of developing their program, it was reported (Williams and Smith, 1980) that, instead of a successful switch to life as a female, the twin in 1976, when 13 years of age and first seen by a new set of psychiatrists, was said to be beset with problems. Therapists familiar with the case report that the twin “refused to talk about any particular difficulties that she had had in the past and was reluctant to discuss sexual matters of any kind”; “Our assessment (at that time) was that here was a child that was having significant psychological problems” relative to her role as a female and revealed “fantasy material [and other evidence that] reflected some considerable ambivalence” regarding her past and present situation as a female1. Presently, psychiatrists familiar with the case (Williams and Smith, 1980) claim the following:
a. “At the present time the child refuses to draw a female figure and when asked to draw a female, refuses, saying it’s easier to draw a man.”
b. “The child …has a very masculine gait, er, looks quite masculine, and is - being teased by each group that she attempts to make overtures toward … they will call her cavewoman and they make reference to the fact that she is not particularly feminine.”
c. “At the present time, she feels that boys have a better life. That it’s easier to be a boy than it is to be a girl. She aspires to masculine occupations, wants to be a mechanic.”
d. Further, the general opinion of the staff is to continue to treat the child as a girl, not raise the question of the child’s being a male, and leave open the possibility that she will inquire about her original sexual assignment. It is not now clear if the twin knows of her true status or has memory that she was born a male. The psychiatrists would not, on their own, reveal this to the twin or raise the issue with her.
e. The twin is not thought to be a happy child. She has difficulty making friends and is ambivalent about her status. Predicting a favorable outcome for this individual at this time is not possible.
f. This teenager “is having considerable difficulty in adjusting as a female. … At the present time [1979] she does display certain features which make me suspicious that she will ever make the adjustment as a woman.”
The BBC journalists informed Dr. Money of their findings and sought to film the interview they had previously arranged with him. They report that he refused and withdrew his initial support. The BBC broadcast detailing the above with verbatim interviews by the psychiatrists was aired in Great Britain on March 19, 1980 (Williams and Smith, 1980).
In a previous publication (Diamond, 1965), I challenged the then prevalent theory of sexual neutrality at birth and presented a theory of inherent sexual identity and gender forces. It was allowed, since no experimental cases were on hand, that treatment in any individual case could be debated. The original course of treatment for this case, no doubt, was at the time seen as proper. It now appears, however, that despite the claims of success (Money and Ehrhardt, 1972; Money and Tucker, 1975) corroborating evidence is lacking. However, without more data on the individual’s early socialization and recent life experiences, it is difficult to say what scientific value this case does hold or ever held in terms of the relative influences of nature and socialization. It is clear, however, that the present evidence does not support a thesis of sexual identity primarily dependent on social learning.
The question remains of what to do in subsequent cases of penis amputation. It is my belief that such males retain a male-biased nervous system and thus should be unequivocably raised as males with suitable counseling and medical and surgical help. Admittedly, this course of action is not predicted to be easy for patient or counselors. With cases of microphallus, this may also be the best course, but reservations are dependent on how much the microphallus may, as a bioassay, reflect similarly poor sexual differentiation within the nervous system (Diamond, 1976). Perhaps tests for androgen receptors are appropriate.
As for the twin, it is scientifically regrettable that so much of a theoretical and philosophical superstructure has been built on the supposed results of a single, uncontrolled and unconfirmed case. It is further regrettable that we here in the United States had to depend for a clinical follow-up by a British investigative journalist team for a case originally and so prominently reported in the American literature. The issues raised by this case are too important to be settled by the media. For scientific and medical reasons, a full updated scientific report on both twins is called for and hopefully will be forthcoming from the team presently associated with this case. The report should assess both of the twins with the best objective and subjective measures available and provide full details of their earlier childhood socialization experiences. The task of this current team is a difficult one and can probably benefit from wide-ranging input. It is further hoped that this particular case will be resolved to the best interest of the particular twin and family involved. The twin should be allowed to truly express any desired sexual identity with familial, social, and medical support. This continues to be a goal for all those troubled by genital or sexual identity conflict (Diamond, 1965,1978, 1979). A full review of this and other such cases is needed for better understanding of the many factors involved in sexual identity formation.