On page 49, Roen describes the ‘John/Joan case’. There are many serious ethical issues surrounding this case, including falsification and misrepresentation of scientific data, which I find particularly disturbing given the fact that this case lead to thousands of similar sex reassignments. I think it is important to understand this case to fully appreciate the damage such surgeries can lead to
David Reimer (aka Joan) was a famous patient of Jon Money, a psychologist at Johns Hopkins Hospital and a pioneer in the field of gender identity. David was born a male but his penis was accidentally destroyed during a routine circumcision when he was seven months old, and he underwent a sex reassignment procedure at Johns Hopkins (surgical castration and cosmetic labia construction) at the age of 22 months. David was raised as a girl after the surgery and was not told about his medical history until he was a teenager. Despite the fact that this famous case, known as Jon/Joan case, was presented to the scientific community as a success, David had struggled with accepting a female identity as a child and when he was around sixteen he made a decision to undergo several surgeries to reverse his sex reassignment and live as a man.
John Money believed that children are born gender neutral and that gender identity is learned early in life, so he saw David’s case as a perfect experiment with a build-in control, his twin brother. Although it is possible that in treating David Jon Money had good intentions and perhaps made a sensible decision based on the scientific knowledge that existed at the time, there are several factors that could have contributed to this experiment’s unexpected results, some of them are biological and some social.
First, David was born a biological male, this means that prenatally and very early postnatally his brain was organized in a typical male pattern. His sex reassignment surgery happened at 22 months of age, and recent MRI studies in human and animal models show that several nuclei of the amygdala, cerebellum and the preoptic area of the hypothalamus have higher neuronal connectivity and/or density in brains exposed to testosterone very early in development. Also, studies in animal models show that not every organized effect has to be activated in order to be expressed, so Davis’s early brain organization could have been sufficient for expression of typical male behavior.
Second, even after his surgical castration, David’s adrenal glands produced testosterone, and there is evidence suggesting that sometimes adrenal glands take over in the absence of testes and produce larger amounts of androgens. For example, there is overexpression of genes responsible for the production of adrenal androgens in prostate and testicular cancer patients that underwent clinical castration. Even if David’s adrenals produced a small amount of testosterone, it may have been sufficient to support his brain masculinization during childhood. Several areas of the brain exhibit elevated levels of aromatase in males, facilitating the conversion of all available testosterone to estrogen and further masculinizing the brain.
Third, David was administered estrogen at puberty to support the development of secondary sex characteristics. Being born as a male, David did not have circulating alpha-fetoprotein, which prevents brain masculinization in females. Therefore, taking estrogen may have further masculinized his brain while feminizing the body.
Finally, there are social factors that may have contributed to the development of David’s gender identity. David was raised as a boy during the first two years of life, this could have established his behavioral patterns before the sex reassignment. For example, as a child David preferred typical “boy toys”, and it has been observed that toy preference emerges between 12 and 24 months. Although he hadn’t retained explicit memories of his early life, David may have known subconsciously that he was a male.
Here is the original article published in The Rolling Stone, December 11, 1997
And another great article called “Ambiguous Sex”–or Ambivalent Medicine? by Alice Domurat Dreger
There is a documentary about David’s life and eventual suicide
There are several other aspects of Roen’s essay that require further explanation. She writes ” Despite the promising claims about girls not needing vaginas, the 2001 survey of European and Mediterranean centres treating children with CAH (congenital adrenal hyperplasia) showed that most centres were still carrying out surgical vaginal construction in early childhood (Riepe et al., 2002: 199). Data from 125 centres showed
vaginoplasty being carried out between the ages of 0.1 and 18 years, with a median
age of 2.5 years. ”
So, what is CAH and why does it require vaginoplasty?
CAH is the most common cause of anomalous sexual differentiation in human females (1 in ~13,000 birth). CAH is caused by several gene mutations and it results in prenatal exposure to androgens (testosterone). In Congenital Adrenal Hyperplasia, the adrenal glands produce high concentrations of androgens instead of cortisol which results in moderate to severe masculinization of genitalia in females. Performing vaginoplasty on these patients in infancy is risky and does not resolve any of the serious health problems these patients actually have. Also, vaginoplasty, despite its name, does not create a functional vagina. Female vagina is a complex organ, it is self-cleaning and self-lubricating, it maintains proper pH and secrets chemicals responsible for our immune defenses. What vaginoplasty provides is a surgical opening that can accomodate a penis.
On page 57 Roen discusses Hypospadias ‘Repair’
What is Hypospadias?
Hypospadias is the most common disorder of sex development in males (1 in ~770 birth)
The urethral meatus is located on the underside of the penis, rather than at the tip.
It does not affect fertility (but a risky surgery to correct it definitely can!) and it is not life threatening.
Total number of people receiving surgery to “normalize” genital appearance – 1 or 2 in approximately 1,000 birth ( source Randy J. Nelson an Introduction to Behavioral Endocrinology; 4th Edition)