Fall 2000

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Book Review

AS NATURE MADE HIM: The Boy Who Was Raised As A Girl. By John Colapinto Published by Harper-Collins, 2000.

Reviewed Annette H. Lansford, M.D. Urbana-Champaign, IL

The July 2000 issue of Pediatrics has a case report and discussion on Gender Self Reassignment, written by Phornphutkul, Frusto-Sterling and Gruppauso. This report is followed in the same journal by an AAP statement on the evaluation of the newborn with development anomalies of the external genitalia. The Phornphutkel et al report mentions the famous John/Joan case, the long-term outcome of which was reported by Diamond and Sigmundson in 1997 in the Archives of Pediatric and Adolescent Medicine.

The John/Joan case was that of a normal infant boy whose penis was ablated during circumcision at age seven months; he who was subsequently raised as a female, on the recommendation of John Money, Ph.D., psychologist and internationally known sex researcher at John Hopkins. Dr. Money's theory was that gender identify at birth is highly malleable. He believed that children are born wholly undifferentiated in terms of their psychological sex and they form a conception of themselves as masculine or feminine solely through rearing.

The reported success of the John/Joan case stood as the precedent upon which a great number of sex reassignments in infants were done. However, this child (John/Joan) ultimately reassigned his own gender during mid-adolescence. Study and the follow-up of this case lead Diamond and Sigmundson to propose alternative principles for the management of intersexual children and of boys suffering from penile trauma.

As a result of the outcome of this case and a number of others which have been studied and reported, including the case reported by Phornphutkul et al, the American Academy of Pediatrics' recent statement (2000) has altered its recommendation. Although the AAP statement continues to recommend that the newborn and infant with abnormal genital development be quickly diagnosed to allow for a comprehensive and appropriate treatment plan, it acknowledges that the decision as to appropriate sex of rearing for a baby born with ambiguous genitalia should be based on a number of considerations that have an impact on the infant's future.

It is noted in the AAP statement that historically, it has been assumed that the psychosexual development of infants with an intersex disorder is largely the result of rearing rather that intrinsic. However, the statement observes in the past decade, it has become apparent that testosterone imprinting of fetal brain may play a role in determining male sexual orientation. The statement goes on to state that until further data become available, caution should be exercised when a recommendation is made that the sex of rearing should differ from the chromosomal sex.

John/Joan would certainly agree with this last statement. The book by John Colapinto, AS NATURE MADE HIM, is the fascinating and tragic story of Brenda/David Reimer. John Colapinto originally wrote about David as John/Joan in the magazine Rolling Stone in December 1997. David Reimer wanted his story told in greater detail by this journalist and agreed to have his identity revealed in Mr. Colapinto's book.

Making David's story even more fascinating is the fact that he is one of identical twin boys, making his brother a "matched control". From the time of David's sex reassignment, which occurred at age seven months, initiated by a series of surgeries, until he was 14 years old, he struggled and attempted to reconcile his emotions of not feeling that he was truly a girl. He was finally informed of his medical history at age 14, after many trips to see Dr. Money at Johns Hopkins. Social rejection and ridicule by peers due to his masculine behavior, and feelings of isolation, depression and suicide, resulting in years of psychotherapy, David made the decision to live as a male. The toll that this journey took, not only on David, but his parents and twin brother, was tremendous. David is now married and living with his wife and two stepdaughters in Canada, attempting to live a normal life as a male adult, husband, and father.

The historical and medical context of this case is intriguing to the reader, as it looks at the age-old nature vs. nurture debate and how it has influenced researches' biases, perceptions and interpretations of this complicated issue. Nature was destined to win out in this case. By virtue of this young man's long-term trauma, his case has resulted in a major change in current thinking regarding how intersex cases should be handled. This book offers engrossing and enlightening reading for pediatricians, psychiatrists, psychologists and others who treat children.

References:

American Academy of Pediatrics. Evaluation of the Newborn With Developmental Anomalies of the External Genitalia. Pediatrics. 2000 106(1):138-142

Phornphutkul C, Fausto-Sterling A, and Gruppuso PA. Gender Self-Reassignment in an XY Adolescent Female Born With Ambiguous Genitalia. Pediatrics 2000 106: 135-137.

Diamond M, Sigmundson HK. Sex reassignment at birth. Long-term review and clinical implications. Arch Pediatr Adolesc Med 1997 Mar;151(3):298-304

Dr. Lansford is a member of the Section’s Executive Committee

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