In special cases, alter a peer-reviewed article is published, expansion and response are provoked with publication, and subsequent appropriate commentaries follow in a Letters or Forum section of the journal. This allows all ideas and those willing to speak on them to compete openly and fairly for space. The present concomitant critique by Ken Zucker was solicited, however, to clarify my original article1 and augment it. The Zucker commentary,2 despite its occasional tongue-in-cheek references to earring fetishes, the liberation of Saigon, falling apples, questioning an acknowledgment to persons who happen to be male, and other such banter, raises interesting points and questions.
The purpose of my article1 was intended to be straightforward and narrowly so. (Zucker’s response is some 40% longer than my paper and this re-response is similar in length.) The first part of my original paper was to clarify some historic influences in the field of sexual development. These were prompted by several comments that, to this reader, appeared to use Zucker’s term, “revisionist.” The second part used such clarification to emphasize that a reassessment in the management of certain pediatric conditions was called for. Indeed, it was felt that the contemporary literature on and clinical treatment of intersexuals or those with ambiguous genitalia should be reexamined The purpose of my brief paper was not to evaluate the work of John Money and Joan and John Hampson and their colleagues nor to review the field of psychosexual development. I offered a timely critique in the past,3 and both Money’s and my ideas have even been presented concurrently so the differences in our scientific interpretations could be most apparent.4-6
Zucker reviews Money’s analysis and his early work and recounts instances where contributions of biology to an individual’s gender orientation are mentioned. Zucker then concludes the gist of Money’s work was to correct “the tyranny of the gonads.” In this vein, Zucker would dismiss Money’s argument7 that homosexuality might be due to an environmental imprinting as, perhaps, something said in jest. I, however, find that idea an archetypal remark and that Money believed nurture is psychosexually all-powerful. In fair distinction, then, Zucker might have also said, “Diamond would like to correct the ‘tyranny of the environment’ and reiterate his 1965 call;3 clinicians must pay more than lip-service to the interaction of nature and nurture and treat humans accordingly.” Indeed, I believe the three of us, Money, Zucker, and I, as well as all others in this field, hold a common goal to somehow better humane treatment. The debate then is how to best serve this interest.
First, I will deal with some simple issues. Zucker questions if the date 1975 has any real significance in how Money was viewing the world and if I was interpreting Money’s work fairly. In my paper I recognized that Money’s early works did discuss the role of biology in development and said that he, nevertheless, continued to deemphasize its importance “until about 1975.” I was actually giving Money the benefit of the doubt as to the date. Certainly before that time, but still in 1975 and even after, he was claiming that an individual’s psychosexual development was, despite biological contribution, basically a social phenomenon. If Zucker would care to say this didn’t occur until later, I have no objection.
To illustrate that I was not alone in my interpretation of Money's work, I offered as evidence quotations or citations from the works of Docter, Doyle, Goldstein, Hyde, and McConaghy.8-12 Zucker ignored these references and the implications being made by the authors. To those I could add many more but will settle with the following few. All these authors find that Money did refer to some roles of biology in psychosexual development yet always ended tip downplaying them in deference to social forces:
In the last decade, Money and the Hampsons have expressed the view with which I agree: Gender identity is more or less fixed by primordial experiences, especially in the first eighteen months of life.13 (p. 232)
Money and the Hampsons broke down their seventy-six cases by the seven categories [chromosomes, external sex organs, etc.] and found that the only factors that almost always agree are gender identity and the sex of assignment and rearing. In other words, whatever people are labeled and raised to be, that is what they think they are and live as—no matter what the genes, gonads or even external genitals indicate to the contrary.14 (p. 349)
Based on a number of studies of this type [Money and colleagues] concluded that all people have the potential for either male or female behavior and identity at the moment of birth. It is not biological sex but life experiences that determine gender identity behavior.15 (pp. 126-127)
Several noted researchers, even after 1975, have compared my work with that of Money in attempts to make the distinctions between us clear. Masters, Johnson and Kolodny19 say:
Milton Diamond believes that prenatal hormones organize sex differences in the brain that are important determinants of later behavior.6 John Money and his colleagues agree that prenatal programming of sex differences occurs but emphasize that for most individuals, gender development is mainly influenced by social learning.16-18 (p. 178)
Frank Beach4 wrote:
Here, it seems to me, is clear evidence of Money’s conviction that although hormones and other biological determinants play a major role, particularly during early stages of differentiation, psychosocial forces usually have, so to speak, the last word. … In fact, [Money believes] psychosexual feminization is possible even if the androgen stimulation continues after birth and produces outright signs of virilism. In such cases, according to Money, “the variable that holds the balance of power would seem to be the consistency of the experiences of being reared as feminine, especially in the early years.” (pp.63—64)
[According to Diamond] male and female programs are laid down in both sexes; but masculine mechanisms are more strongly developed in genetic males and feminine mechanisms are more strongly developed in genetic females. Because of these inborn differences in reactive capacity, very young boys and girls are likely to show different responses to the same treatment. This prediction is in accord with some of the observations made by Jerome Kagen20 (page 23) … that identical treatment can produce different results in different sexes, and also relates to Davenport’s21 search for cultural universals.” (p. 88).
Thus, despite the assertion that Money from early on espoused interaction, the consensus on Money’s analysis was that “nurture rules.” If this assertion is not “proven beyond a reasonable doubt” it certainly seems to meet the “preponderance of evidence” test.
Money’s advice to raise a penectomized child as a female, despite his otherwise being a normal male, can be interpreted as saying, in effect: The environment calls the tune despite how the individual comes to it and since the child does not have an “environmentally crucial” penis, raise him (and others like him) as a girl.22,23 I, on the other hand, say: The tune called by nurture is limited by the biology the individual brings to the environment and since this individual (and others like him) still has a normal nervous system, gonads and scrotum, continue to raise him as a boy. My theory of biased interaction followed birth is in contrast to one of psychosexual neutrality at birth. Both Money and I attempt with our theories to explain how an individual meets the world. I think my theory offers a closer fit to reality and thus leads to better clinical results.
Nevertheless, it seemed apparent to me that, at least from Money’s latest writings, he now, more than in the past. acknowledges the importance of the prenatal environment in shaping how an individual must meet the world after birth.24 When exactly he came to that epiphany, I’ll not contest. References to feminist opposition to Money’s ideas are all after 1975—all but one after 1980.25-29
Now to the second, and actually more important, related point. Extrapolations from theory significantly affect the way humans are treated in clinical situations. As Zucker correctly indicates, this has been put to test most numerously in the virilization of infants with congenital adrenal hyperplasia (CAH). It is also seen in other cases of ambiguous genitalia and in those rare instances where a male’s penis is traumatized sufficiently to effect a penectomy. The theoretical implications apply to the treatment of hermaphrodites, intersexes of any stripe, and those whose genitals have somehow been mutilated. In such cases pediatric texts are almost unanimous in recommending, regardless of the basic etiology of the problem, that management be decided upon by the size and nature of the phallus and that the individual be reared in a manner coincident with how the organ is dealt with. This is usually taken to mean: remove a significantly small penis on a boy and reduce a significantly enlarged clitoris on a girl and rear them both as girls. For instance, in the latest edition of Oski’s pediatric text, Catlin and Crawford30 say, “In instances [of ambiguous genitalia] in which phallic tissue is inadequate for the construction of a functional penis, the parents should be apprised of the facts and advised to rear the neonate in the female gender role” (p. 424). For a female with an enlarged clitoris who will be raised as a girl, these physicians advise that “skillful reconstruction of the genitalia to harmonize with the gender role … is essential … it may be an emergency, at least in social terms, to do this even before the infant first goes home” (p. 427). These clinicians are not alone. The typical advice is to cosmetically reduce or remove the “excess” phallic tissue and continue the child as a female.31-33
Reference to these and other clinical papers attest that these dictums are associated with the implications of Money's thesis. From a theoretical postulate that one’s adult gender role is dependent on rearing and relatively independent of biology comes the clinical advice to choose the least difficult and most promising genital surgery and raise the child accordingly. A subpostulate is healthy psychosexual development is related to the appearance of the genitals, so cosmetically make the genitals as close to normal as possible (and if that means sex reassignment for an intersexed individual or for a boy with trauma to his genitals, so be it). I see danger in this.
To assign a child to one sex or the other based primarily on surgical considerations seems to short-change the nervous system. Such an assignment does not allow for any influence that might be present yet not manifest by general appearance. There are numerous experimental results, starting from the early classical work of Barraclough and Gorski34, Phoenix, Goy and Resko35, myself36 and others that the nervous system and behavior are much more labile to prenatal endocrine and other influences than are the genitals. By the time the genitals are modified, the nervous system has already probably been significantly effected. Further, to treat children predominantly on the shape and size of the genitalia doesn’t allow for individual variation where two individuals may have the same phenotype but quite different genotypes. Individuals can also receive comparable childhood surgeries and yet choose different sexual life paths as adults.37 And there are classic clinical repots in the literature that show sex assignment on the basis of predicted genital functioning has not always been successful.38-41 On the other hand, it is true that genital appearance, when quite different from the norm, may be seen as a bio-assay of what had happened in the nervous system and lead one to treat infants accordingly. Cases of micropenis can lead to a female assignment22 and extreme clitoral hypertrophy can lead to assignment as a male.41 And, as Zucker adequately references, the results can be either satisfactory or not.
Zucker calls attention to the situation of CAH girls; genetic females subjected to a prenatal (and occasionally postnatal) excess of androgens. The typical CAH female is reared as a girl with surgery performed to reduce or remove her enlarged clitoris. While I did not discuss CAH individuals as such, Zucker discusses them extensively. In any case, these persons are 44, XX individuals raised as females. Money, Zucker, and I would agree this is usually the correct management. But our reasoning for this management would probably be different. Money and Zucker would emphasize that the postnatal forces of rearing would determine their sexual identity as females. I would argue that the majority of these females have a prenatally organized bias to identify as girls and then women and rearing them as such would bolster that in competition with any virilization of the nervous system that might have also occurred prenatally. All three of us would agree that rearing these CAH infants as girls would also preserve their general physiognomy and fertility. Money and Zucker would probably advise clitoral surgery to have the genitals conform as closely as possible to the norm to support the girl’s adjustment and remove ambiguity in rearing. I would not.
My caveat in such cases is to postpone any cosmetic clitoral surgery until the individuals can themselves understand the situation well enough to participate in the decisions. Despite the social and cosmetic abnormality, any CAH individual might enjoy the pleasurable sensations derived from her phallus and not want to chance losing them. She might even prefer to live as a man in accordance with the virilization of her nervous system. Or she might have other reasons, as will be discussed below. There are reports a-plenty that CAH women are often quite masculine. Zucker, himself, admits that some of these individuals become transsexuals and more than a few demonstrate gynecophilic (homosexual) behavior. This, I offer, stems more from their nature than their nurture.
I accept that leaving such women without clitoral surgery is contrary to standard pediatric practice and is a minority view. (Concern here and in further discussion is only regarding cosmetic surgery. I have no hesitation about surgery for medically threatening reasons.) Zucker43 himself, in discussing CAH children, admits that “it is surprising how little work had been done to determine how CAH youngsters themselves understand their condition and what impact this has on their psychosexual development’’ (p. 146). Hampson44 herself has said, “Oddly, even in children old enough to have some opinion, in our experience it has been rare that they have been given any opportunity to express it. Historically a change of sex has been imposed more often than consented to” (p. 267). One of my recommendations is that, when possible, the children have a say in any cosmetic surgery and absolutely be involved in any sex reassignment.
Early on, Money and the Hampsons reported that clitorectomy did not adversely affect the female sexual response of the women they studied.44,45 The issue is, to say the least, debatable. Azziz and colleagues,31 in their review of 50 years of CAH cases at Johns Hopkins—from whence Money’s cases came—report that 10% underwent sex reassignment to male and only 37% of their patients older than 16 years of age had ever had any heterosexual relations. With these sorts of findings, we should he less presumptuous in claiming to predict what a neonate can respond to or would want when past puberty. Yes, a woman with an enlarged phallus may be subject to ridicule or shame, but this might be no worse a consequence than being unable to respond sexually in an erotic situation or being a female who subsequently chooses to live as a man yet is deprived of any phallus. Comparative and in-depth studies on such issues are needed.
It is true, as Zucker mentions, that clitoral excision techniques have been largely replaced by those of clitoral reduction, which are supposedly advantageous for the majority of females who remain as women. However, this technique has its critics and has not been accepted as a panacea. Barrett and Gonzales,32 for instance, find “disadvantages of recession [over clitorectomy] include the possibility of painful erections and progression of clitoral enlargement should the patient with congenital adrenal hyperplasia be poorly controlled.” Others too report similar problems with clitoral recession.46 Newman, Randolph, and Parson47 write: “Reports of long-term follow-up in patients having clitoral reconstruction have focused almost exclusively on the anatomic appearance with minimal data concerning sexual function. … A relatively small number of patients were willing to engage in the intense evaluation, the frank discussion with parents, and the necessary recollection of distressing memories.” The sexual functioning of women who have had these surgical procedures has been openly challenged by some of these women themselves.37 Newman, Randolph, and Parson47 conclude: “Although this has been deemed a drawback by a number of authors, it is our current belief that preservation of all clitoral tissue is highly desirable in achieving the most nearly normal sexual response … preservation of erectile tissue seems to he a major determinant of sexual expression.” Masters and Johnson,48 too, had recommended that preservation of the clitoral tissue is to be preferred.
A few remarks are appropriate to this discussion regarding males with hypospadias since they can be considered the male counterpart to CAH females. This is a common clinical condition that engenders a similar caliber of clinical distress. In this condition, males are born with a small phallus in which the meatus opens at some point along the penile shaft or underside of the glans penis. Most often these children are reared as males following surgery, but occasionally they are reassigned as females after extirpation of the penis. While more than 150 surgical techniques have evolved to repair the situation,49 studies of the psychosexual implications of the surgery or the condition itself are rare. And cosmetic surgical intervention has been called into question.50,51 Mureau and colleagues50 found there is little correlation with the individual’s satisfaction with his surgery and with the appearance of his penis: also, “although patients with hypospadias had a more negative genital perception … they did not experience retarded sexual adjustment or different sexual behavior as compared to normal males.” And it must be borne in mind that, typically. surgery in cases of CAH or hypospadias require multiple returns to the operating room over many years. Any or all of these procedures may themselves engender negative psychological sequelae that are worse than those accompanying maintenance of the original condition.
Suzanne Kessler52 has reported on a significant set of surveys she conducted. Among responding women, about one quarter indicated under no circumstances would they have wanted their parents to allow reduction of a large clitoris at birth; about half would have wanted the reduction only if their physical health would have been impaired, and the other quarter wanted reduction only if the reduction would not have impaired pleasurable sensitivity. Kessler asked men the more complicated, yet somewhat comparable question about having a micropenis at birth and the potential for sex reassignment. All but one “would not have wanted surgery under any circumstance. ” Kessler, in a personal communication, sums up her findings by saying: “Everyday people have very different conceptions of genital variability and surgery than physicians.”
Zucker next refers to genetic males with 5-alpha-reductase deficiency. This reference is to 44,XY individuals born without male genitalia and thus raised as females. These children typically are not reared as females as an experiment or with the knowledge they will masculinize at puberty. They are reared as normal females because that is what they appear to be to their doctors and parents. Thus, in only exceptional cases and only recently since the medical condition has become known, is ambiguity in their upbringing sometimes evidenced when there seems ambiguity at birth. At puberty the genitalia of these individuals virilize, and, in the main, these persons successfully switch to living as boys despite their having been reared as girls. The papers documenting the endocrinology and social success of such reversion deserve mention. They are the well-known works of Julianne Imperato-McGinley and her colleagues53-56 and others.57,58
These 5-alpha reductase, CAH, hermaphrodite, and other intersexed individuals probably have a flexibility unavailable to others to accept or adapt to a reassignment of sex. It is a function of their biological heritage concomitantly signaled by the intersex condition.3, 59-62
Zucker and I agree that the significance of the original “twin” reports has been overplayed. This is certainly true for the credit the twins’ story of female conversion received as supposed proof of the power of gender conditioning. The actual failure of this sex reassignment has not been as widely recognized—possibly since it was not a surprise, not as newsworthy, or not a politically correct finding—although it had been referred to several times.22, 63-69 A full and extensive report on this case is now under review.23
This case was widely used to substantiate the power of nurture over nature. Zucker correctly mentions that Money has not himself written a follow-up although he was the first to introduce this case to the literature. Despite Money’s assertion,70 quoted by Zucker,2 I had nothing to do with Money leaving this case. As reported originally,22 it was Money and the BBC that were allied to show the power of rearing and to document that individuals were psychosexually neutral at birth. According to the producers, Money was more than a willing accomplice. This cooperation, they say, ended when the BBC team discovered, in interviews with the child’s psychiatrists (BBC personnel themselves never met the twin), that the boy had not turned out as indicated. When the BBC wanted to question this discovery, Money then refused further interviews or cooperation. Only after the BBC’s new knowledge and their inability to continue as originally planned. and to salvage their program, was I called to consult as a foil against which the original theses could be judged and evaluated. My opinion that the “switch’’ would probably not work and didn’t make sense theoretically was based on my clinical and experimental experiences elsewhere. It was only years afterward that I came to meet and interview the twin, his family, and the therapists involved.
But the twin case does teach us. His story shows that, despite being reared as a girl from the age of seven mouths and being sexually reassigned at 17 months, an otherwise normal male is not so plastic as to accept an imposed life as a girl and woman. (The cautery accident occurred at seven months of age. At that time the local physicians, in telephone consultation with Money, were advised to begin rearing the child as a girl and schedule genital reconstruction as early as possible. That was done with the parents’ cooperation. Removal of the testes and the initial stages of vaginal reconstruction were completed at 17 months of age.) This case also shows that despite the absence of a normal penis, and being reared from early on as a female, a male can come to identify as a boy and aspire to live as a normal man and then do so. Even in Introductory Psychology we leant that an N of 1 is not able to prove a theory but it is sufficient to challenge one. We can then look for additional cases to enhance our confidence level in one theory or another.
Regarding the twin, Zucker makes a point in his commentary, which he has made before,43 about individuals who, for one reason or another, grow up contrary to expectation. He says we don’t have all the details of the individual’s life with which to judge all the pertinent influences. Money, similarly, when a sex reassignment doesn’t succeed, holds recourse to the probability that there were ambiguities in the child’s upbringing or other influences with which we may or may not be aware. Bu whose life is ever without conflicting forces? This is equally true for those whose lives go according to expectations. Boys and girls in everyday life are subject to ridicule, praise, shame, reward, guilt, exhortation, and so on without any record. As infants they can he dressed in clothes appropriate for the opposite gender or in quite neutral garb, they can be addressed in sex-appropriate ways or in abstract terms such as “Marshmallow” or “Creature.” The typical boy, gay or straight, is often labeled as “homosexual” for failure to somehow measure up to peer male standards, and girls are labeled tomboy or worse for not acting appropriately feminine. Girls and women who refuse heterosexual advances are often labeled “lesbian” by their rejected suitors. And certainly for enjoyment, curiosity, dare, or from disposition, normal boys and girls themselves occasionally knowingly indulge in cross-gender behaviors. Thinking that unusual events or behaviors only happen to the atypical child is without foundation. Transsexuals are most noted for choosing a life for which there seems no identifiable prior social influence; those who engage exclusively or occasionally in homosexual relationships also often seem in do so in defiance of their upbringing. 68, 71-73 A fundamental question we have to ask is why do certain environmental forces, when they do, seem to effect only some particular persons.
I’m confident Money, Zucker, and I agree that more research is needed on this matter. Actually reports on several additional cases are in press.37 Besides Money, Zucker, myself, and many other capable investigators are also actively continuing research in this area. And while Zucker “plans” an ideal experiment of 1,000 male infants in which half are reared normally with the other half having surgery and hormones as females and raised accordingly, I would like to enlist 1,000 CAH infant females, all without surgery or further treatment, and raise them similarly, half as boys and the other half as girls. And to make the experiment methodologically neat, an experimental group of 1,000 normal females should similarly be garnered for out hypothetical test. Half would be reared as normal girls and the other half given androgens sufficient to develop large clitorides. My prediction is that a significantly high percentage of normal males reared as girls (even with penectomy amid orchiectomy) would seek re-reassignment to live as men and very few reared as intact boys would choose to switch to live as women. Among the CAH females reared as males, a significant percentage, I predict. would accept their status and continue as men and among the group left to be reared as girls, many would desire to switch also. Among the group of originally typical females my prediction is that the virilized group would have more than a few choose to live as men past puberty while almost all of those raised as girls would choose to continue as women. All groups would be responding to biologic pressures that interact with the social overlay.
Lastly, the clinical implications of my original discourse are distilled by Zucker into four points. In his own way he restates my summary and asks: “What’s new about the clinical recommendations?” New evidence was presented that questioned traditional ways of thinking and ways of managing cases of those with ambiguous or traumatized genitalia. New attention was also called to a voice previously unheard in the debate. From the classical work of Joan Hampson 40 years ago reporting on the absence of such a consumer input,44 there are now finally groups attempting to speak for intersexuals: The Intersex Society of North America (ISNA) and its newsletter Hermaphrodites with Attitude (P.O. Box 31791, San Francisco, CA 94131) was mentioned. Other support and advocacy groups include: The Androgen insensitivity Syndrome (AIS) Support Group (4203 Genesee Avenue, #103-436, San Diego, CA 92117-4950, and 2 Shirburn Avenue, Mansfield, Nottinghamshire, NG18 2BY, UK). The K.S. and Associates Support Group exists for those with Klinefelter syndrome and related male sex chromosome variations (P.O. Box 119, Roseville, CA 95678-0119), and a Turner’s Syndrome Society (811 Twelve Oaks Center, 155500 Wayzata Blvd., Wayzata, MN 55391) is active.
ISNA is a peer-support, education, and activist group operated by and for intersexuals. Their call is for health care workers and others to accept them as a broad group, with individuals recognized and accepted for their diversity rather than seen as people whose genitals or lives need restructuring in ways not of their own desire. They call for a proud acceptable identity, not as male or female, but as intersex. They eschew having to be one or the other and thereby lose advantages that might be gained by retaining their bodily integrity and garnered by psychic stability and peer support. In a traditional gender-dichotomous society, which sees only female or male, girl or boy, woman or man. an intersex is an anomaly. In a world that recognizes that social forces have to contend with biological diversity, however, recognition and acceptance of intersex makes both medical and social sense. Attention to this concept had been called for, notably by Fausto-Sterling74 in her well-cited paper, by Kessler,29, 75] and by Devor and Bem.76,77 It is our hope that clinicians, parents, and families of intersexed persons, as well as the general population, will listen.
Yes, this is a complicated area of study, and the clinical ramifications are many, with much still to he learned. But the legacy of biology to psyche is ignored only at great peril, especially when we now have to contemplate genetically mediated olfactory input,78,79 histocompatibility interactions,80 and immune responses81 as factors impacting on human sexual behaviors. Zucker, Money, I, and others involved in this area agree more research is needed. Interchanges such as this also help clarify points and extrapolations from research. These communications help to insure that the best interpretations, theory, and clinical management evolve. I concur with Zucker’s2 call for more critics. More than philosophies, reputations, and theories are involved; people’s lives are at stake.