Theoretical understanding of psychosexual development, particularly in regard to sexual identity, has undergone several historical changes. Most notable has been the transition away from a learning paradigm, which held that individuals are psychosexually neutral at birth and that they develop their sexual identity due to rearing. This has shifted to contemporary acceptance that an interaction of both nature and nurture is responsible for psychosexual development. That there probably exists an inherent predisposition or bias toward a male or female identity, which is inferred by prenatal influences, is also current theory. However, while this shift has occurred in the theoretical understanding of the phenomenon, a comparable shift has not occurred in the clinical management of individuals where sex assignment or reassignment is a real issue. The theoretical change and real case management should be concordant.
In 1992, Gooren,1 reviewing the work of John Money, stated, “Those who know Money’s work will recall his loathing of the anachronistic dichotomies of heredity and environment, biological and social, or innate and acquired, in favor of the flexibility of the nature/critical-period/nurture paradigm.” And most recently Money,2 in a historic review, recounts in this journal his own work in the area of psychosexual development and states that, at least for transsexuals, “gender role ... develops under the influence of multiple factors, sequentially over time, from prenatal life onwards. Nature alone is not responsible nor is nurture alone.”
For historic accuracy it should be noted that while this is Money’s present stated belief for those with gender dysphoria, the combined influence of nature and nurture in sexual identity and orientation was recognized but not accepted by that investigator until about 1975. This, even though consideration of the interaction of innate and social forces in human psychosexual development with critical-period involvement had been introduced by this writer 10 years earlier.3 And it had been established years earlier for nonhuman mammalian species.4
From 1955 to 1975, Money, while occasionally mentioning biological influences on psychosexual development, essentially argued that rearing and social vectors were either alone or the dominant forces in developing an individual’s psychosexuality. Social psychologists such as Reiss5 still adhere to this thesis, and this paradigm was an underlying premise of a major study by Laumann and colleagues.6 Neonatologists and pediatric surgeons still often advise rearing as female, a male born with a small or nonfunctioning penis,7-11 in effect ignoring any possible prenatal psychosocial influences. Kessler12 documents in some detail how clinicians still attend to Money’s original thesis of psychosexual neutrality at birth. Such occasions prompt this clarification.
Money’s classical work of the 1950s and 1960s was primarily directed to demonstrating that an individual comes to the world neutral and without any sexual “nature.” He believed that one’s sexuality developed essentially due to rearing and the forces of the social environment. Consider these statements:
In place of a theory of instinctive masculinity or femininity which is innate, the evidence of hermaphroditism lends support to a conception that psychologically, sexuality is undifferentiated at birth and that it becomes differentiated as masculine or feminine in the course of the various experiences of growing up.13
The sex hormones, it appears, have no direct effect on the direction or content of erotic inclination in the human species. These are assumed to be experientially determined.14 (p.1396)
Now it becomes necessary to allow that erotic outlook and orientation is an autonomous psychological phenomenon independent of genes and hormones, and moreover, a permanent and ineradicable one as well.14 (p.1397)
It is more reasonable to suppose simply that, like hermaphrodites, all the human race follow the same pattern, namely, of psychological undifferentiation at birth.
Establishment of core gender identity is obviously a process of learning, insofar as it takes place in social interaction)15
To be accurate, it must be said that Money did occasionally refer to the importance of considering biological and prenatal factors and their influence in structuring a person’s gender role and orientation,16 but the role for these factors was always seen as of lesser importance than the subsequent social forces. The psychiatrist Nathaniel McConaghy,17 in reviewing this area, says that in the Money et al. work m the 1950s, “the area of human sexuality established as entirely learned … [includes] sexual identity, sex-linked behaviors identified as masculine or feminine, the sex to which one wished to belong, and the sex of persons to whom one was attracted” (p.163). Hyde 18 also reviews this area and states, “Thus, Money argues that the human is ‘psychologically neutral’ at birth and that gender identity is produced by the environment and learning (p. 81). Docter19 writes, “The social assignment of socialization as a boy or girl during that [first 2 to 3 years of life] period seems to be a particularly significant gender learning experience. Such social learning has been shown by Money and Ehrhardt (1972) to be sufficiently powerful to override whatever biological determinants of gender identity may he formed in utero” (pp. 84-85) . Many others have interpreted Money's early opus similarly.20,21
A germinal test of Money’s belief in the psychosexual differentiating power of upbringing came with his participation in the treatment of a male child whose penis was traumatically burned sufficient for the boy to be essentially penectomized. The child was reassigned as a female at the age of 17 months. Surgical reconstruction to a female, including orchiectomy, started soon after. Although the child had had a normal pregnancy and male nervous system, the parents “were given confidence that their child can be expected to differentiate a female gender identity in agreement with the sex of rearing” 22 (p.119) . As the child matured, Money continued as the prime therapist involved in the child's psychosexual development. In 1975, Money and Tucker23 stated “Although this girl is not yet a woman, her record to date offers convincing evidence that the gender identity gate is open at birth ... and that it stays open at least for something over a year after birth” (p. 98). They also wrote, when the child was 9-10,23 “The girl’s subsequent history proves how well all three of them [parents and child] succeeded in adjusting to that decision” (p. 95).
The effects of this and comparable reports were widespread for and practice. Sociology, psychology, and women's study texts were rewritten to argue that, as Time magazine reported on January 8, 1973, “This dramatic case … provides strong support ... that conventional patterns of masculine and feminine behavior can be altered. It also casts doubts on the theory that major sex differences, psychological as well as anatomical, are immutably set by the genes at conception.”
Belief in this malleability also became the dictum for clinicians faced with newborns with ambiguous genitalia or infants with traumatized genitals. The following quotes from pediatric texts are typical: “ In determining the sex of rearing, adequacy of the phallus is usually the major consideration.”24 “The sex of rearing of a chromosomal male is contingent on phallic size and the probability that the phallus will function normally. A neonate with a penis shorter than 2.0 cm will probably never function normally as a male [and should thus be raised as a girl].”7
We now know, however, that for the child and his parents reported on originally, rearing as a female was not progressing as reported.25 Subsequent interviews with the individual reveal he has switched his sex, sought and received phalloplasty, and is now husband to a wife with three adopted children.26,28
The thesis of psychosexual neutrality at birth was challenged by this writer more than 30 years ago.3 At that time, I proposed that individuals start life with certain predispositions or innate biases with which they will interact with the world in the development of their sexuality. In the process of growing up, I indicated that “critical periods” are important in this development, and I mentioned two such periods. The first and most salient critical period occurs during the first few years after birth. The second occurs at puberty. I also indicated, in text and diagram, that these critical periods were particularly notable regarding sexual/reproductive phenomena. At these times, certain behaviors are learned not only better than at other times but often most easily. At other than critical periods, some things may be learned but with difficulty or never. This is in distinction to the theory of imprinting given by Money to answer how gender and other aspects of psychosexuality indelibly accrued to the individual. Consider:
It may well be that homosexuality, and other behavioral disorders of sex, are fundamentally disorders of cognitional eroticism ... [that] should be regarded as imprinting phenomena. ... imprints that are actually misprints ... [that] can be established only at a specified critical period in the life history.14 (p. 1397)
To date, no data have been presented to substantiate any imprinting process for humans. But even if there were some to bolster the argument, it would have to be allowed that there may possibly be something unique in that particular individual to make him or her receptive to the imprint while not effecting others. I have frequently called for an acceptance of the interaction of both innate and environmental forces in shaping psychosexual development.3,25-27,29,31 It should be clear that, rather than being seen as a “disorder” or a “misprint,” heterosexuality. homosexuality, and bisexuality as well should be viewed as variations on a normal ontogenetic theme. In this vein the most humane developmental pattern is one in which individuals are invited to “express who and what they are”31 (p. 55).
Thus, at least since 1965. the interaction of nature and nurture, rather than separating them one from the other, was an available theme: “Sexual predisposition is only a potential setting limits to a pattern that is greatly modifiable by ontogenetic experiences. Life experiences most likely act to differentiate and direct a flexible sexual disposition and to mold the prenatal organization until an environmentally (socially and culturally) acceptable gender role is formulated and established”3 (p. 167). In 1979, I suggested a mode for this interaction: “An individual is born with a certain biased predisposition to interact with the world in certain ways. Part of this bias leads to a cognitive frame (cognitiveschemata and internal symbolism) which provides a preprogrammed standard against which possible behavior choices will be considered”3 (p. 54). Such are the templates against which transsexuals and others match themselves as they interact with environmental forces and features.35,36
Since the 1960s, many arguments and data have accrued to support this complex interaction of constitutional and environmental forces. It is sale to say that a version of the biased interaction theory is now a popular, if not the dominant, thesis used in explaining psychosexual development, with much exciting work investigating some of the mechanisms leading to the “bias.” Such recent works include the genetic, neurological and theoretical papers of Bailey and Pillard,37,38 Diamond,26,27,30,31,36,39 Hamer, LaVey, and colleagues,40-43 Whitam, Diamond and Martin,44 and Swaab, Hofman, and Gooren.45,46
The prolonged adherence to a theory of psychosexual neutrality at birth, a persistent belief in the overriding force of postnatal influences over prenatal ones, and confidence in the indelibility of the first two years of life have had significant clinical repercussions. Individuals who might have been given a sex assignment that recognized any prenatal bias and influence of nature were not given options in the matter. Certainly these issues appear at birth, when the individual primarily involved is not capable of entering into the discussion. However, the majority were reared as if the most important component of development fell to environmental and rearing forces, and any consideration of nature’s prenatal bias was ignored. XY individuals born with a micropenis, and children who lost a penis due to trauma prior to age two, for example, were most often raised as girls. The mantra was: “It is easier to make a cosmetically good vagina than a cosmetically good penis. and since the sexual identity of the child will basically reflect upbringing, and the absence of an adequate penis would be psychosexually devastating, fashion the genitalia into a normal looking vulva and raise the individual as a girl.” We now know this has not always been successful.25,27,47
Females with masculinized genitalia, in a comparable manner, often were raised as boys if the hypertrophy was great, or they had clitoral reductions to cosmetically fashion the vulva to a more normal female appearance and were then raised as girls. Aside from reducing potential adult genital sensitivity, such procedures neglected the significance of any behavioral or psychological predisposition toward the individual’s own preferred sexual identity or gender roles, which the genital appearance might reflect as a bio-assay. Certainly, these treatments were done with the best interests of the child in mind and to satisfy parental anxieties that their child appear as normal as possible. This approach has been challenged in the clinical literature before,48 and it is now again time to rethink it.
Adding impetus to this renewed call for change in practice is the recent assertion by intersexed individuals of different stripes, true hermaphrodites, or pseudohermaphrodites (those with congenital adrenal hyperplasia, micropenis, or other intersexed conditions) of their own voices as “consumers.” They argue that they themselves should have been given a say in the type and extent of surgery to which they were subjected, and that they should not have been automatically assigned to a sex based on the adequacy of a potentially functional phallus. They call for physicians to make the most astute judgment possible as to future sex preference of the child and advise rearing accordingly, but to do nothing surgically that might need be undone. And they call for clinicians to offer counseling and appropriate education about intersexed conditions, first to the parents and then to the intersexed person as he or she develops.
This education and counseling should prepare the individuals themselves to identify their proper place in the adult spectrum of human sexualities and allow them to choose the social gender role that best matches their internal biological sexual identity, however it manifests itself. It is not known how many, by themselves, and against the wishes of their physicians, switched sex in the past or might wish to do so in the future, but the number is probably not insignificant.
Cheryl Chase, the leader of an intersex group, wrote: “Because the cosmetic result may be good, parents and physicians complacently ignore the child’s emotional pain in being forced auto a socially acceptable gender. ... Some former intersexuals become transsexual, rejecting their imposed sex.”49 It is known that many who challenge their physicians or therapists about their condition, feelings, and future treatment are met with hostility, disbelief, or avoidance. This is due to the misguided but well-intentioned belief of the clinician that any acquiescence to doubt expressed by the patient would decrease the likelihood of an eventual successful outcome.2 Yet now, with the benefit of hindsight, at least several intersexed individuals are calling for acceptance of their intersexed state from the beginning, not as a deviance, defect, or sex error:
I was born whole and beautiful, but different. The error was not in my body, nor in my sex organs, but in the determination of the culture, carried out by physicians with my parents’ permission, to erase my intersexuality. “Sex error” [the term used by Money] is no less stigmatizing than defect or deficiency. Our path to healing lies in embracing our intersexual selves, not in labeling our bodies as having committed some “error.”50
It is also known, particularly from transsexuals, that casting doubt as to sexual identity may force the individuals involved to be more introspective, analytic, and secure as to their preferred life’s direction even though this is counter to their upbringing and parents’ wishes and may result in less than adequate genitalia.35,36 Indeed, in the interview of any purported transsexual, the astute clinician expresses full doubt as to the client’s assertions and asks for proof of the claim. Then, if convinced, the therapist/clinician assists the client in fulfilling the transition. It appears to me, from a theoretical and a clinical perspective, that practice should follow theory in dealing with children whose genitals have been traumatized or with intersexed individuals as well. While parents will still want their children to be and look normal, physicians will have to provide the best advice and care they can, consistent with knowledge. This might mean referring the parents and child to appropriate long-term counseling rather than immediate surgery.
As I first asserted in 1965,3 we must consider the interaction of nature and nurture in structuring an individual’s psychosexual development. In the light of available evidence, clinicians must recognize that any prenatal biased predisposition must be given more than lip service in considering the future for persons born with traumatized or ambiguous genitalia. For individuals with postnatal traumatization of the genitalia, I suggest rearing in their biological sex, the sex of their original assignment, and predict that despite the appearance or not of normal genitalia, they will be happier in that condition.25,28,47 Genital reconstruction for such individuals can begin as soon as surgeons think appropriate. For those with ambiguous genitalia, however, I recommend that genital reconstruction be delayed until the individual is competent to decide for him or herself how this should best be fashioned. In such cases, medical intervention should consist primarily of education of the parents, the individual, and others as to the best way to deal with the situation. Long-term follow-up studies are also called for to see how these recommended treatments compare with the present ones.
Certainly Money has done many things for the field of sexology, and he should he honored for them. But being an early supporter of a biological underpinning to sexual development or being consistent in this belief are not such features. He has changed his initial views, and that is to his credit. It remains for the ardent environmentalists, surgeons, and others to similarly catch up. Nature must be given its due, or it will extract it.