Prologue

Milton (Mickey) Diamond, PhD is a Professor in the Department of Anatomy and Reproductive Biology at the John A Burns School of Medicine at the University of Hawai‘i in Manoa, and is Director of the Pacific Center for Sex and Society.

Professor Diamond’s lengthy career has involved teaching, clinical activities and research—particularly in the fields of sexual behaviour, reproduction and the understanding of sexual development. Invitations to present his findings have been received from Australia, Asia, Britain and Europe, as well as throughout the United States.

Dr Diamond was invited to be a keynote speaker at the Fifth International Congress on Sex and Gender during 2002 in Perth, Western Australia. Before fulfilling that engagement, Dr Diamond and his partner, Dr Constance Brinton-Diamond, travelled through several Australian states giving lectures to enthusiastic audiences at various universities and organisations—including the rather stunned inhabitants of outback Queensland.

Currently, Dr Diamond teaches, conducts research and mentors medical and graduate students. He has produced several acclaimed television and radio series, eight books and well over one hundred articles and chapters. He is also a regular consultant for various agencies, institutions and individuals and has received awards too numerous to mention here.

The scope of Professor Diamond’s research work was largely unknown to the general public until the ‘John/Joan’ case (as it is known in the medical literature) created a storm of controversy. As a result of this case the whole area of intersex management came under scrutiny.

Eventually, encouraged by Mickey Diamond and author John Colapinto, David Reimer—the subject of that appalling experiment—came forward to tell his harrowing story and won widespread respect and admiration for his courage and indomitable spirit.

Apart from his life in research and teaching, Mickey enjoys folk music, photography, reading, travelling and good conversation.

First—Do No Harm

My PhD is actually a combined degree in anatomy and psychology. I received my doctorate in 1962 at the University of Kansas and my first job was teaching at the University of Louisville School of Medicine. After five years, we left Kentucky and came to live in Hawaii where I had been invited to take up a position at the new medical school that was developing here.

In the academic world of the United States one works his way up in the ranks from instructor to assistant professor, associate professor and then professor. Currently, I’m a Professor of Anatomy and Reproductive Biology. While that is my official title, I consider myself primarily a sexologist. At the medical school I teach medical sexology and neuroanatomy and basically those are my two main areas of research and teaching interest.

On a personal level, I was born in the city of New York in 1934 to European Jewish parents who emigrated from the Ukraine right after the First World War. They met in New York, married, and I am the youngest of three children. My father and mother owned a small corner grocery store where we all worked.

I got the name of Mickey when I was about ten or twelve. I was living in a neighbourhood where the kids found it easier to call me Mickey than Milton. The name stuck. Unfortunately, the neighbourhood was not one where my peers were academically inclined. A gang culture was more the norm and some of my earliest recollections of middle school were of becoming mixed up in rumbles and other street adventures not of my making.

During this period I started to feel an aversion to the fights and other negative influences at school. I began to find alternatives and often played hooky. Most of the time I wandered around the streets, went to museums, or read in the park. My parents’ insistence that I should get a good education as a means of achieving anything I wanted to do in America just didn’t make a great deal of sense at the time.

Some friends told me that they were taking a test to enter a special high school and since it provided a legitimate excuse to avoid school for a day I decided to take the test as well. That test turned out to be a major turning point in my life. I was admitted to the Bronx High School of Science and, although it meant travelling from Manhattan to the Bronx every day, it proved to be well worth while.

Camaraderie among my peers now replaced combativeness. It was fun to compete with each other to see who knew the most trivia while at the same time keeping up with the adult world, sports and extracurricular activities. My experience at the Bronx High School of Science convinced me my future would be in science teaching and research.

I entered college in January 1951 when the possibility of being drafted for the Korean War was a reality that all male college students faced. My choice of college was uncomplicated. Coming from a poor family meant that the only possibility was the subsidised City College of New York (CCNY)—now the City University of New York.

I enrolled as a physics major but, as with most universities, one was required to take courses outside a major area. The electives I chose were biology and philosophy courses.

I also joined the Reserve Officers Training Corps (ROTC). This offered a way to stay in school and also obtain the small stipend the Corps provided to help pay for my tuition. It also promised the GI Bill in the future—a promise of funds to help finance graduate studies.

I found my physics major courses engrossing but as I passed beyond the basic biology courses into more electives such as genetics and comparative anatomy I found the area particularly fascinating and stimulating. I then realised I wanted to somehow integrate biology into my physics interest and switched my major to biophysics. As far as I am aware, I was the first student to graduate from CCNY with that subject as an undergraduate major.

Although I had completed all the required courses and was eligible for graduation in January 1955, I was not yet twenty-one—which was the A’ minimum age at which I could be commissioned. Since the ROTC would pay for further schooling, I decided to remain in school for an additional semester so that I would be of age when I graduated and could receive my second lieutenant’s bars.

During this extra semester I took endocrinology and animal behaviour as additional biology electives and was fortunate that my teacher for both courses was William Etkin, whose knowledge of endocrinology and behaviour was extensive (some of his publications are as valuable today as they were then). He was an inspiring teacher and our discussions both in and after class led to our becoming good friends.

I loved the courses and the subject matter and realised that I wanted to understand behaviour and its underlying mechanisms. Before I had the opportunity to pursue this ambition further, however, I had a debt to repay to Uncle Sam. I chose to do that in the Corps of Engineers and was assigned to Tokyo, Japan, as a topographic engineering officer involved in the analysis and production of maps.

I married just before going to Japan and my wife and I lived in a traditional Japanese environment off the military base. We considered our time in Japan as our honeymoon. We enjoyed our Japanese experiences so much that I renewed my two-year military contract for a further year and seriously considered making the topographic service my career. My first professional publications were on cartography and mapping.

As it came time for me to leave military service I asked Professor Etkin to recommend the best schools at which to pursue the interface of behaviour and endocrinology. In his old-school manner he recommended not schools but individuals with whom to study.

One of those individuals was William C. Young at the University of Kansas, who accepted my application—and so it was that we left the urban environs of Tokyo for the rural environment of Lawrence, Kansas.

At the time, I would have preferred to major in psychology or zoology but Young was an anatomist. Anatomy was thus the discipline I was to follow. Once under Young’s tutelage I came to realise that the only behaviours in which he was interested were those associated with reproduction and that he was researching different endocrinological aspects of sexual behaviour. This aspect of my training came about without any real choice on my part.

The graduate school requirements of the University of Kansas also required a minor area of study and I chose experimental psychology where I came under the wing of Professor Ed Wike, who also became my friend and mentor. I found the combination of anatomy, endocrinology and psychology very enjoyable and beneficial, and this period set the stage for the rest of my academic career and my work in understanding sexual development.

The David Reimer (John/Joan) Case

Highly significant and relevant to my interest in development was the situation presented by the David Reimer (John/Joan) case. It had been widely reported in the 1970s that David (a male twin), following a circumcision accident, had been successfully transformed from the boy he was declared at birth into a happy girl with aspirations of entering womanhood. This case was presented to the world to demonstrate the so-called power of nurture to overcome nature and to bolster the associated management of intersexed children.

It was this challenge, contrary to all the other evidence I knew to be available, which drove me to find out the truth for myself. With the eventual cooperation of H. Keith Sigmundson—the psychiatrist who had originally been in charge of David’s local care—in 1995 I was able to meet this now famous twin and convince him to share his story.

With this culmination of nearly fifteen years of searching I felt a huge sense of accomplishment—not only for myself but also for all those researchers who had worked on the topic and found pieces of the puzzle of sexual development.

As it turned out, David is a male individual who was raised and treated (as far as can be determined) as a girl. He had been castrated and given female hormones to induce breast growth and a female-looking body. Where his penis had been, his genital region was reconstructed to have a female-appearing vulva.

Despite all these surgical, endocrine, and social efforts to convert David to a girl and woman, he came instead to feel that he was a boy—a male ‘as nature made him’—and not a female/girl as he was raised.

I believe that some biological predisposition to male-being told him he was a not a female; that he was different to all those girls he knew and more like the boys he knew. It is the same sort of predisposition that tells the majority of us we are male or female while telling transsexuals and intersexuals who and what they are—or ought to be.

It occurred to me that David’s story was similar to those of intersexed or transsexed persons who came to feel they were reared in the wrong gender and subsequently switched genders. It also led me to consider what the true outcome to his treatment might mean for countless thousands of intersexed children whose management would no longer be based on erroneous information.

Imagine for a moment that you are a paediatrician and you are presented with a newborn baby in whom the genitals are ambiguous—no vagina or penis, or some combination of both. How would you advise the parents? Do you think the child, if it is male, would have the greatest chance of happiness being brought up as a boy—or as a girl?

Would growing up without a typically functioning penis be so difficult that it would be better to bring up this child as a girl and then give him appropriate surgical and hormone treatment? Or would you consider his life as a male the most crucial factor—in which case it might be better to help him adjust to the loss of his penis, with an attempt to construct a new one later? What about bringing up a female with a phallus? Such cases are not exactly common but they force us to carefully consider what are the major influences on sexual development.

On The Development of Sexuality and Gender Identity

Our society traditionally supports a two-sex model. This is one in which men are expected to be males with an X and Y-chromosome, testes, a penis and internal systems for expelling urine and semen from the body. Women are conjectured to be females and have two X-chromosomes, ovaries and internal structures to transport urine and ova, as well as a system to support pregnancy and foetal development.

In addition to this basic model there are also a number of recognisable secondary sexual characteristics that cultures use to define men and women as being either ‘masculine’ or ‘feminine’ in appearance. While these expectations are generally met, there is more variation in how these sex and gender characteristics combine than is often recognised.

Chromosomal sex, internal accessory reproductive structures, hormonal sex, secondary sexual characteristics, gonadal sex and external genital morphology, all can vary. So do people’s notions of ‘masculinity’, ‘femininity’, ‘gender identity’, ‘sexual identity’, and ‘sexual preference’ or ‘sexual orientation’.

In any discussion of sexuality, therefore, it is extremely important to realise that definitions of ‘masculine’ and ‘man’ or ‘feminine’ and ‘woman’ (even for the description of traits) are often affected by retrospective judgements involved in establishing the original categories. And these definitions vary with different cultures.

The conclusion, for instance, that roundness or softness are feminine traits whereas angularity and hardness are masculine traits is a judgement based on the findings that most mature males have physical features that can be categorised as hard and angular and related to muscular activity. By contrast, most mature females have characteristics classifiable as soft and round, which can be related to child-bearing and nurturing.

One can certainly choose characteristics that will reflect sex differences but those choices, while they may be reality-oriented, are often idiosyncratic and can be subject to contrary opinion. Is mounting behaviour and aggressive sexuality considered masculine in a particular society? Is being mounted or being sexually submissive considered feminine?

We also have to consider observer bias in the definition of male versus female behaviour characteristics. To some observers, the masculinity or femininity of an individual is reflected in the choice of an out-of-the-home career, or preference for a domestic role. Choice of an adventurous and dangerous career is seen to be an indication of masculinity. Alternatively, the desire to have or spend time with children is considered an index of femininity.

For individuals in open societies, the ‘smorgasbord’ of choice is wide since so many different patterns, sex roles and gender roles are possible, and indeed are seen cross-culturally. Many families or situations, however, do not allow free choice and this stifles attempts at individual expression. Therefore, the presence of overly rigid forces such as parents or religion often thwarts the emergence of natural tendencies.

Social forces outside the family such as education and occupational requirements or legal strictures can also be powerful modifiers of preferred behaviours. The developing child observes the surrounding world and notes whether or not he or she is like other children in the category to which their families and other members of their community have assigned them—boy or girl. As long as they feel that they are part of the appropriate group there is no reason for them to question their gender. And indeed, only a minority of children challenges their gender assignment.

Problems arise when a child feels unlike others of the group, or feels a greater urge to belong to the opposite gender group. This can occur regardless of whether the child is appropriately masculine or feminine.

The strength of those feelings determines how the child will react. If a young boy feels strongly enough that he is a girl rather than a boy, he begins to envision himself becoming a girl and maturing into a woman. Similarly, if a girl strongly identifies herself as being a boy, she sees herself becoming a real boy and then a man.

In the same way that a child believes in the tooth fairy or Santa Claus, he or she may come to expect that it will only be a matter of time until they grow up to be the man or woman they want to be. When it becomes obvious that this is not going to happen automatically the child seeks ways and means of bringing about the desired change.

To change one’s gender, even in thought, is a big conceptual leap for a child and while the idea may come as an epiphany there is often a period of confusion. When a boy, for instance, experiences alienation from the gender allotted to him, and the only other category of child he knows is ‘girl’, it is only slowly that it will occur to him that he might be one of those—or should be.

Usually there is a period of doubt during which the child wonders how to reconcile these awkward feelings, particularly if he or she learns that any revelation regarding the preferred gender may set them at odds with their family, schoolmates and the community in which they live. Consequently, children will not necessarily tell their parents (or anyone else) about these thoughts. They may, however, express their feelings with appropriate or inappropriate behaviours.

Transsexuality

The way most people see their bodies (their sexual identity) and the way they recognise that society sees them—or the way they want society to see them (their gender identity)—are sufficiently in concert to satisfy ego needs and overcome any doubt as to their own sex and appropriate role in society. For some individuals this is not the case. For such persons, intense feelings of conflict and discomfort develop from this dichotomy.

Fluidity of language means that there is a difference in the way that scientists and laypersons use terms. In the sexology field several of us have tried to standardise the use of terms but many people prefer their own usage. Before proceeding, I think it advantageous to clarify at least four definitions I observe.

In academic discourse I prefer to use GENDER to refer to social and societal contexts and SEX to refer to medical and biological contexts. For instance, male and female are biological (sex) terms, while boy and girl, or man and woman are social (gender) terms. This facilitates understanding that males can act like girls and grow to be women and females can act like boys and grow to live as men.

Following on from that, the distinctions I make between SEXUAL IDENTITY and GENDER IDENTITY, as concepts, are crucial to understanding my discussion of transsexuality and intersexuality.

For the typical individual, sexual identity and gender identity coincide. He or she, as a male or female (in sexual identity) is viewed in society as a boy or girl, man or woman. That is their gender identity. To the typical person there is no conflict between sexual and gender identity—although the terms involved refer to different things.

Now consider how a transsexual perceives identity—for instance, the female who knows she has a female body but who thinks she should live as a man. This person recognises her sex (identity) is female but also recognises she is a male in her mind. She sees being a man as her suitable gender. That is her gender identity. For her, gender identity and sexual identity are in conflict (how she is and how she wants to be are in conflict). To reconcile those differences this individual says ‘I want to/must live as a man. To best permit me to do so, change my body not my mind’.

She knows that society interacts with her as a woman because that is the way she looks and her anatomy confirms it, but she would prefer that society interact with her as a man. As she gets older, if finances and her social situation allow, she chooses to have medical assistance (usually surgery and hormone therapy) to have her body conform to her mind.

A male body type will comfort her by giving her the sense of being the male she desires to be and assist the world in treating her as a man—the gender identity she prefers.

In the 1970s Virginia Prince promoted the term ‘transgender’ to describe people like herself, who accept themselves as males (or females) but who prefer to live as the opposite gender without undergoing surgery. Typically, the only things the ‘transgenderist’ wants to change are features of their gender rather than their sex. These changes are usually in behaviour patterns or in social manifestations of gender such as choice of clothing. They might choose to augment these changes with hormonal body modification.

To Prince, the term transgender could be applied to anyone who deviates from the norm in gender patterns without requiring or desiring surgery. The term, for Prince, thus excluded transsexuals. Since the 1970s, however, the term has become more and more inclusive. These days it is often used as an umbrella term to describe transsexuals, transvestites, drag queens, so-called gender benders and others.

At this point, it might be useful to introduce the term SEXUAL ORIENTATION. This refers to the type of person with whom one wants to have erotic and love relations. Usually, males are oriented towards females and vice versa, but many people are attracted to members of their own sex.1

Sexual orientation is a separate issue to gender identity and transsexuals have the same range of preferences in a partner as do the rest of the population. For these partner preferences—to get away from the confusion and social taboos when terms such as heterosexual and homosexual are used—I often prefer to use the terms ANDROPHILIC (male loving), GYNECOPHILIC (female loving), and AMBIPHILIC (both loving) for bisexual.

These different terms are of particular value in discussing transsexual and intersexed individuals. For instance, what would be homosexual or heterosexual for an intersexed person who has both male and female biology? And whose view would prevail—the transsexual’s or the onlooker’s—when considering the individual’s partner before and after sex reassignment surgery?

In dealing with nomenclature, another issue is how gender identity disorder (small letters) is viewed as a general expression in popular language, and how Gender Identity Disorder (capital letters) is seen as a medical condition. GID (also known as gender dysphoria) is a constellation of thoughts and behaviours that is still used by the scientific and medical communities to describe adult transsexuals only.

One of the major components which separates the GID transsexual from the members of all other groups subsumed under the term ‘transgender’ is that only the transsexual feels he or she is, or should rightly be, a member of the opposite sex. It is only the transsexual that persistently wants surgery and hormones to effect a ‘sex change’. Some people feel that the word ‘disorder’ has socially negative connotations but in the medical definition the term reflects the psychological distress that the transsexual usually shows.2

While drag queens, transvestites and others show aspects of gender blending, they don’t fit the medical definition of GID and, although these people often dispute society’s criticism of their freedom of expression, their condition doesn’t reach the level of intensity seen among transsexuals. They also don’t need the medical community’s assistance in effecting any change in their life roles and behaviours.

These concerns are well understood and are a repeated topic of discussion among therapists who try to adhere to the Standards of Care (SOC) proposed by the Harry Benjamin International Gender Dysphoria Association (HBIGDA). This is a professional society whose primary focus is on aspects of transsexualism and related phenomena. Named for the physician best associated with transsexuality, the HBIGDA recommends a standard of care for transsexuals that requires that prior to surgery the individual live for one to two years in his or her chosen gender as a ‘real life experience’. This is often seen as a real life test (RLT). If the candidate for surgery successfully negotiates this period, he or she has demonstrated sufficient understanding of what is involved in living the new gender to warrant access to sex reassignment surgery.

The problem being addressed is how to protect the individual and the professional in the interaction and decision-making process. The RLT meets this need. The full recommendations of the society are not written in stone and therapists interpret them differently, with the result that some are more liberal in implementing those guidelines than others.

‘Passing’ for the transsexual—being accepted as a member of the chosen gender—is often difficult. To facilitate social acceptance before surgery, hormones to help modify the body in the chosen direction are often desired. It has been suggested that it is cruel to expect him or her to live as the opposite sex for one year prior to going onto hormones, particularly if the person can’t easily be accepted in their chosen gender when cross-dressed.

A therapist may consider the administration of hormones at an earlier stage for someone who can’t pass easily in their chosen gender than they would for someone who is able to pass easily. Hormones can provide bodily changes that facilitate identification with the chosen life. Androgenic hormones, for instance, can induce beard growth in a want-to-be man and oestrogenic hormones can foster breast development in a want-to-be woman.

Hormone actions are not completely reversible but they are easier to change than surgery should the body modifications induced not be found compatible with anticipations. There is a big difference between a male wishing to live as a woman, or a female wishing to live as a man, and actually living the life.

The RLT allows the individual to try the role out before too many irreversible biological and social changes occur. Since the administration of hormones can induce changes that are difficult to reverse, they are usually given after the individual has at least some real life experience in, and feels comfortable with, living in their chosen gender.

Personally, I do think that caution is warranted and feel comfortable with the safeguards and flexibility offered by the Standards of Care. Doing away with the present SOC would certainly make it easier to transition but that is not always a good thing.

I’ve probably seen hundreds of transsexuals who have satisfactorily made the change and who now seem a lot happier and more satisfied with their lives than they were before the sex reassignment. I have, however, also seen two persons who had sufficient money to bypass the system and have their operations done in other countries that were less fastidious in their requirements for surgery. While the physical changes brought about by the surgeons were satisfactory and appropriate, the two were very unhappy with the social results. These two found out too late that their lives hadn’t changed as they had hoped and they couldn’t easily go back to living as they had been. I admit that the number of people who are disillusioned with the outcome is comparatively small but I think it does offer a warning not to bypass the test and evaluation procedure.

People make all sorts of decisions about their surgery. For example, there are individuals who undergo female-to-male (F2M) changes who have only an ovario-hysterectomy and their breasts removed and don’t have penile construction. Others want a penis and scrotum constructed. Some persons undergoing male-to-female (M2F) change have their penis and testicles removed and have extensive depilatory treatments, while others go on to have their Adam’s apple shaved and jaw reconstructed. Each person makes a decision for him or herself as to how much surgery he or she wants and can afford.

There is no evidence I know of that individuals change their sex for social reasons. But I guess that anything is possible if the stakes are extremely high. Frankly, I can’t even begin to imagine how high that might have to be. Certainly, a delusional male might think, if he was homosexually oriented, that it could be easier to attract a male if he were attired or built like a woman. However, the typical male homosexual or lesbian appreciates his or her genitals and doesn’t want to give them up.

Individuals change their gender to have it conform to their ‘brain sex’, and the brain is sexed during prenatal life. Making the choice to live the life of a transsexual is not a flippant decision and while the inclination may arise before a child goes to school it usually takes years to evolve and solidify.

A last comment is appropriate with regard to transsexuality. I believe there is sufficient evidence to consider it a subtype of intersexuality. While the genitals of transsexuals are not unusual and there is nothing noteworthy about their hormone balance or chromosomes, it has been found—at least for the brains of those transsexuals studied—that areas of their brains are significantly different from that of non-transsexuals.

Further, it has recently been reported that there are significant differences in genes (the aromatase gene, the androgen receptor gene, and the oestrogen beta-receptor gene) crucial for the hormonal actions needed for typical sexual differentiation of the brain.

There are those who are intersexed who are unhappy with surgery that has been imposed on them, while transsexuals seek surgery.

My association of transsexuality and intersexuality is currently not widely accepted but I think it is only a matter of time before more evidence of commonality becomes available.

Intersexuality

An intersexed person is one in whom different sexually dimorphic characters are mixed so that he or she carries both male and female biologic features not usually occurring in the same individual. Intersexed conditions might result in males with XY chromosomes yet impose genitals that look like a female’s. In conformity with their genital appearance, such individuals are typically raised as girls and go on to live as women.

Or an intersexed condition might manifest in a female with XX chromosomes but confer male genitalia.3 These persons are most often identified at (or soon after) birth, and are usually raised as girls since they will be fertile as females. They might also, however, be raised as boys.

The boys and girls just described have only testes or ovaries and medically are called pseudohermaphrodites. Some intersexed persons have both male and female gonads—a testis and an ovary or combined ova-testis. Such individuals are medically called true hermaphrodites. Such individuals can have genitals which are also a mix of those typically male and female or unambiguous.

Because male and female genitals develop from the same common precursor, intermediate morphology is not unusual, but the popular notion of two complete sets of male and female genitals in the one person is not possible. In addition to having both male and female features in their body, an intersexed person may also manifest these traits in their behavioural patterns and preferences.

A variety of recognized conditions fall under the ‘intersex’ banner. These include congenital adrenal hyperplasia (CAH); Turner’s syndrome; Klinefelter’s syndrome (KS) and its variants; mixed gonadal dysgenesis (MGD); androgen insensitivity syndrome (AIS)—with complete (cAIS) or partial (pAIS) forms; micropenis; hypospadias; progestin and androgen induced virilisation or diethylstilboestrol (DES) prompted feminisation. Almost all are due to different genetic and endocrine factors.

The incidence of intersexuality may well be higher than one in a hundred people. Since twins occur once in every eighty or so births the frequency of intersex is only slightly less than that of twinning. The majority of intersexed individuals, however, are not noticeable. An individual can be intersexed but parents or even physicians could be unaware of it without specific testing or evaluation.

For about one in two thousand people the condition is apparent due to genitals which are not clearly a penis and scrotum or a clitoris and vagina. That is to say, it is difficult to tell from our usual ‘anatomical signals’ of the genitals whether the person is male or female. Therefore, one in one hundred people may have an intersexed condition but only approximately one in two thousand will be readily identifiable at the time of birth.

For some newborn intersexed infants medical care is required right away. Most intersexed children, however, have conditions for which such attention is not needed. Surgery, when it is imposed, is typically done for cosmetic or social rather than health concerns. For instance, an intersexed female who will be brought up as a girl might have her clitoris reduced in size if it is much larger than usual. An intersexed male might have an opening in his penis closed.

In the past, when physicians thought a child would be better off in a gender other than its sex would typically dictate—such as when a male had a micropenis or a body that could not respond to androgens (as in AIS)—the child was often declared a girl and the parents encouraged to raise the infant accordingly. The child’s testes were then usually removed. While such management was quite common, it has often proved to be a poor solution. The treatment was primarily based on anecdotal evidence as to its value and adequate clinical evidence that such treatment was correct has yet to be demonstrated.

Gonadectomy, for instance, is rarely warranted since it removes essential hormones from the individual. In the case of intersexed conditions such as androgen insensitivity syndrome the castration can lead to later skeletal problems with osteoporosis. It certainly removes any chance for fertility, however slight, in those males raised as females or those remaining to live as males.

In a significant percentage of cases—for instance in those with pAIS or a related but non-intersex condition called cloacal exstrophy syndrome, individuals raised in one gender have been found to switch to the other later in life, and too often additional surgeries are needed to repair initial surgeries.

Parents are frequently counselled to act quickly because they are told it is a medical emergency. It is more often true that it is of social concern. What should parents tell others? Actually, people need to take the time required to fully understand all of the factors involved, and I believe irreversible decisions should be left for the child to make later in life.

Even the most well-meaning parent or physician cannot always predict how an intersexed child will prefer to live. The best choice of gender for the infant should be assigned based on available evidence for the particular intersex condition rather than on anecdote and painting all with the same brush. Cosmetic surgery without the individual’s permission should be avoided.

Some intersexed conditions are understood better than others. Probably the condition for which we have the best medical information is congenital adrenal hyperplasia (CAH). Individuals with this condition are generally brought up as females and this is probably usually correct. Such females are often born with an enlarged clitoris that surgeons usually want to cosmetically reduce in size.

My feeling is, so she has a large clitoris—so what? Who says that’s going to be a big problem? Is it different from the typical clitoris? Sure! Will she be embarrassed by it? She might be. On the other hand, she could find that she likes it the way it is, and her sexual partners might like it as well. There’s no way of predicting. No study that I know of has ever experimentally or systematically looked at anything like this. In addition, recent research has found that women who have had such surgery have less genital responsiveness and fewer orgasms than women who don’t have the surgery.

So-called ‘normalising’ treatments should be done only when the individual thinks that it is appropriate and has been fully informed of the pros and cons. Even if it isn’t thought that the treatment is harmful, the primary dictum in medicine is ‘first do no harm’. I therefore hold that nothing should be done unless it is clearly known that it will substantially help. I am conservative in this regard. Surgery is not always a benign process.

How do parents decide to which gender an intersexed newborn should be assigned? That depends upon the condition and each type of intersexuality has its own probability of favouring a boy-man or girl-woman prospective. Each condition has its own set of circumstances and one can’t always predict which way an individual, when mature, will want to go. With increasing clinical evidence we should be able to make better predictions.

The conditions of cloacal exstrophy and partial androgen sensitivity bring out the previous point most markedly. Persons with cloacal exstrophy are born essentially without any genitals: with a common area for the elimination of both urinary and bowel waste. Their medical treatment, and that of many persons with the pAIS condition, typically involves repair of the area, so these individuals—male or female—are given the genital features of a girl and the parents instructed to raise them as females.

The decision to raise such persons as girls is predicated on two factors. The first is the outmoded idea that children are sexually neutral at birth and can be simply socialised into boys or girls by their rearing. The second factor is the mechanical one that recognises that it is easier to fabricate female rather than male-appearing genitalia. There is also an erroneous presumption that a vagina is an insensitive aperture that only needs to be suited for insertion.

William Reiner of the University of Oklahoma Medical School has been studying individuals with cloacal exstrophy and has reported that a large number of those raised as girls come to identify themselves to be male and seek gender reassignment to live as boys to grow into men. Obviously there is much more to learn of this condition and its management—but the fact that rearing is not always deterministic is clear.

Persons with partial androgen insensitivity (who I am presently studying) provide similarly crucial findings. Persons with pAIS are XY individuals that are typically born with genitalia that are ambiguous. They have a genetic condition that decreases their body and nervous system’s ability to respond to the usual masculinising influence of androgens. Some are raised as boys and some as girls.

So far, of the men and women with pAIS who I am investigating, several raised as boys have switched to live as women and of those raised as girls, a few have switched to live as men. Obviously, for these individuals, any early surgery and castration done to coincide with the original gender of rearing could not easily be undone. It deserves repetition—I believe that only the intersexed person should decide how he or she wants to live and what surgery might be desired.

Frequently, in dealing with intersexed individuals, clinicians and others use terms such as ‘normal’ and ‘abnormal’ and speak of ‘defects’ and ‘errors of development’ or ‘mistakes of nature’. I advocate that those clinicians and others speak instead of matters that are ‘typical’ or ‘rare’, ‘common’ or ‘uncommon’.

All of the intersexed conditions are biologically understandable while statistically uncommon. Persons with these conditions are not freaks but varieties of men and women. We don’t all have the same height or weight, or the same arm span, or nose shape and size, and we all have a variety of eye and hair colour. Why should we all have the same genitals—any more or less?

For the most part, I believe these conditions are all to-be-expected birth variations. Some of these modifications are more inconvenient than others and some are undoubtedly potentially lethal. However, I believe that nature’s way is to provoke a great deal of variety. With it comes nature’s way to provide for evolution. One major difficulty is that, while nature generally favours variety, society usually doesn’t.

Personally, I would consider an intersexed condition a birth defect only if it seriously hampered the life of the individual—but most intersexed conditions, although they may leave the individual infertile, don’t necessarily adversely affect the individual’s physical life. They can, however, be traumatic and difficult psychologically. Much depends upon the society in which the individual develops.

Some societies care a lot about behaviour stereotypes and what genitals are supposed to look like and how they function, and others are less concerned. Certainly, in our society, intersexed people have often been regarded in the past as ‘defective’. And in some populations they still are. This leads to secrecy and concealment about aspects of surgery and management. This practice can take the form of a well-meaning but deceptive conspiracy between parents and physicians against the intersexed child. Patients often discover their condition from an inadvertent family slip, community gossip or personal investigation into puzzling aspects of their lives.

One must expect that the truth will emerge and when it does the patient will learn what she or he was never supposed to have found out anyway. If the patient is going to find out in any case, surely it is better for the physician or parent to initiate disclosure.

Even more disturbing than discovering the secret, the former patient also discovers that his or her intersexuality is unspeakably shameful in the minds of parents and physicians. Why wasn’t the intersexuality discussed? They wonder why they were not accepted and loved as they were. This wrongly imposed shame can make manifest a fear of romantic/erotic relations and reduce the pursuit of intimate contacts.

Lastly, the former patient learns that she or he has, since childhood, been systematically deceived by the very people who should have been the most trustworthy—parents and physicians. All this is damaging. Most of it is needless. I recommend complete honesty between physician, parents and the person primarily concerned—the intersexed individual. This will reduce shame and better enable the individual to act rationally on his or her own behalf.

Another problem with secrecy is that it hampers appropriate counselling and support from family, the medical community or others with similar conditions—and parents too can benefit from counseling, information and support.

A brief explanation might be in order as to how I’ve come to my convictions regarding understanding gender and sex as they pertain to an individual’s behaviours and feelings. A strong moulding influence was my own early experimental research, which showed how relatively simple it is to modify an animal’s genitals and adult sexual behaviours.

With a single injection of the male hormone testosterone to a pregnant rat, for instance, one can organise the genitalia and behaviour of the female embryos she is carrying. At birth, the pup’s genitalia can come out looking like that of a male and her reproductive behaviour upon maturity can mimic that of a typical male. Guinea pigs or monkeys, with a much longer gestation period, require a series of male hormone injections to achieve similar ends. But it can easily be done.

Among rat embryos, females that are nestled like peas in a pod between male embryos and therefore exposed to higher than normal androgen levels, behave more like males than females when they reach adulthood. Females surrounded in the womb by other females show more female-like traits and fewer male-like traits when mature.

The counterpart experiments were also conducted where, early in gestation, males were castrated to deprive them of testosterone. This produced males with atypical-looking genitals that could easily be induced to behave like females when adult.

These types of experiments, conducted on different species of animals, eventually confirmed the powerful role of testosterone in sexual differentiation. They led to a significant understanding of prenatal influences—particularly those from genes and hormones.

Two stages came to be recognised. The first is that resulting from organising influences (organisation). These are factors with influence from early on in life, usually during gestation, that mould morphology or behaviour for future development. The influences are made manifest after the second stage of activation.

Activation is some force—usually seen dramatically after puberty—which elicits what had been previously organised. The exact mechanism of such actions, and the evidence for such, need not bother us here. Any good physiology or endocrine text will have the details. Suffice it to say that these actions typically occur in all known mammals, although the exact extent and genetic-endocrine interactions involved might vary from one species to another.

While making the conceptual leap from experimental animals to humans is not always appropriate, in this instance the jump is not that far if one considers clinical evidence as experiments of nature. There are clinical conditions in which, during gestation, testosterone levels are unusually high in girls. When they are born, as in the CAH condition mentioned earlier, such females can have a male-looking phallus. Its presence is a marker that testosterone was present in the womb. As adults, such women, more often than their typical peers, exhibit traits and behaviours usually associated with masculinity.

In a mirror image sort of clinical condition, there are occasions when the testes of male foetuses do not produce typical amounts of testosterone, or do not do so at the appropriate time, or do so in individuals unable to respond to the endocrine. In these cases the males are born with less masculine genitalia or have genitalia resembling that of girls.

How does this help our understanding of transsexuals? Here are persons who act and choose to live as the opposite sex despite having genitalia that look typical, and who exhibit no readily apparent sign that there was anything unusual during gestation. Considering that there is rarely any indication that their rearing was atypical I ask, ‘Where do such feelings come from?’ To my mind I answer, ‘From some influences during pregnancy akin to those seen in intersexed persons’.

It might be that the testosterone was emitted at an atypical time, in an atypical dosage—too much or too little—or these individuals have genetic differences as mentioned earlier (or one as yet undefined). We do know that their brains and genes do show differences. We also know from animal experiments that the nervous system, the brain, is far more sensitive to testosterone than are the genitals. Thus, sexual behaviours can be effected at hormone dosages insufficient to modify the genitals.

Each individual, as he or she grows up, responds to a myriad of interacting biological, cultural and social factors. This interaction leads to immense variety in attitudes and behaviour. However, the individual will almost always be biased towards a particular sex because of the genetic and hormonal influences that operate before birth and continue operating until death. His or her sexuality will also be biased by the sexual mores of the environment in which he or she grows.

In Western society, for example, a boy who shows traits generally regarded as feminine is likely to be the target of more criticism and ridicule than a girl who acts like a boy. Yet in some societies, among certain American Indian tribes such as the Koniag, the Sioux (of Dances with Wolves fame), the Zuni of New Mexico and among the Siberian Chukchee, effeminacy in a man was traditionally taken to be a sign of extraordinary powers. Such men, usually referred to as berdache or winkitei, were often looked upon as medicine men (women too could be berdache or winkitei, if they displayed what the tribe considered significant masculine traits).

Growing up sexually involves more than physical development. In the fullest sense, it means evolving as a socially functioning man or woman. The fact that identical twins have much in common physically and mentally, even when brought up separately, is often cited as evidence that maturation proceeds largely in accordance with biology. Others believe that sexual development proceeds largely in accordance with social forces, with children naturally assimilating the characteristics and attitudes of their elders and peers.

Both points of view are correct up to a point, but it is not really a question of nature or nurture. To look most meaningfully at physical, socio-sexual, and erotic development, and at the development of sexual identity, we must recognise that innate factors and learned or experienced factors operate simultaneously and interdependently. I call these interaction effects the dual influences of society and experience interacting with biological predisposition.

Epilogue

I leave this essay with a final thought. As a scientist, I care deeply about understanding the factors that shape sexual development. The complex interplay of genes, endocrines, environment and nervous system offer a fascination sufficient to entertain my mind for a lifetime.

As a social being, however, I believe it makes little difference whether persons want to live as men or women, somewhere in between—or in a gender configuration of their own choosing. And I care not if this is because he or she is destined by biology, or by rearing, or by some interaction to do so.

It seems to me only ethical that the sole person qualified to decide how to live is the person him or herself. Our Western cultures will not break (nor even greatly bend) if we, as societies, allow that privilege, and assist those people tormented by gender demons the rest of us can only imagine.

 

END NOTES

1There is debate, and no clear resolution, as to whether one is attracted to a sex, or a gender, or to genitals. I believe that most individuals are quite aware and specific about the genitalia with which they want to interact. But this is not always clear. Drag queen prostitutes cater to other males offering a combination of womanly gender and male genitalia that obviously appeals to some. Basically, the variety in what appeals to one’s erotic sensitivities is only matched by the variety of sex/gender displays on offer. The rarity of some combinations, however, often makes it difficult for the seeker and offerer to get together.

2 Recently, many transsexuals have called for the condition to be known as Gender Euphoria since they are happiest when in their preferred gender. And they would prefer that it not be considered a medical condition. They also suggest that ‘sex reassignment surgery’ be known as ‘sex confirming surgery’ or ‘gender confirming surgery’. Other transsexuals, however, prefer that their condition be seen as medical. In that way, first, it confirms that it is not a matter of choice and, second, it might allow for treatment and surgery under a medical insurance claim.

3 Some individuals are born with chromosomal configurations different from the usual XY or XX combination. These might be something like XXY, XO, XXXYY and so on. And other persons have parts of their body carrying one set of chromosomes while another part carries another—this is called a mosaic condition. Intersexed individuals with any of these variations might or might not have readily obvious, visible distinctions, and are usually raised in accordance with the appearance of their genitals.


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