As Nature Made Him (25 page)

Through the BBC, Diamond found the name of a psychiatrist who had worked on the case—Dr. Doreen Moggey. That spring, he called her.

It had been fourteen years since Moggey terminated therapy with Brenda. She told Diamond that she did not know the final outcome of the experiment. She did, however, offer to give Diamond a phone number for the man who had overseen Brenda’s psychiatric treatment: Keith Sigmundson.

“I remember the first words Sigmundson said to me when I called,” Diamond recalls with a chuckle. “It was to the effect of ‘I was wondering how long it would take for you to get here.’ ”

By that time Sigmundson was living in Victoria, British Columbia, where he had become head of the province’s Division of Child Psychiatry. “Mickey said, ‘Keith, we gotta do this,’ ” Sigmundson remembers. At first Sigmundson tried to beg off, but Diamond, he says, “kept on badgering me a little bit.”

As someone who had seen firsthand the results of a reportedly successful sex reassignment, Sigmundson was inclined to agree with Diamond’s thesis that the procedure of turning baby boys into girls was wrongheaded. Still, Sigmundson had been warned by colleagues that Diamond was a “fanatic” with an ax to grind. Further conversations with Diamond and a reading of his journal articles convinced Sigmundson otherwise. “I came to see that Mickey is a serious researcher and a caring guy who really believed that Money’s theory had caused—and was continuing to cause—great harm to children.” Sigmundson agreed to contact David Reimer and ask if he would be willing to cooperate with a follow-up article on his life.

“I wasn’t sure what it was all about,” David says about the call he received that spring from Sigmundson. At that time David had been married for less than a year and wanted nothing more than to put his tortured past behind him. Sigmundson was persistent, however, and David finally agreed to meet Diamond and see what happened.

Diamond flew to Winnipeg to meet David. Over lunch at a local diner, David learned for the first time about his own fame in the medical literature and how the reported success of his case stood as the precedent upon which thousands of sex reassignments had since been performed—and continued to be performed. “ ‘There are people who are going through what you’re going through every day,’ ” David recalls Diamond telling him, “ ‘and we’re trying to stop that.’ ”

David was staggered. “I figured I was the only one,” he says. “And here Diamond tells me they’re doing all these surgeries based on
me
. That’s why I decided to cooperate with Mickey.” And there was another reason: David sensed in Diamond one of those people whose response to his sufferings was not purely detached and clinical. “When I told him a few things about my life,” David says, “I saw that Mickey had tears on his cheeks.”

Over the course of the following year, David and his wife and mother recounted to Diamond and Sigmundson the story of David’s harrowing journey from boy to girl and back again. Using these interviews plus the detailed clinical records that had accumulated at the Child Guidance Clinic, Diamond set out, as the paper’s lead author, to write up the results. He had promised the Reimers anonymity, agreeing to obscure their location, to omit the names of the local physicians, and to refer to David by pseudonym—or rather pseudonyms, since Diamond was faced with the narrative problem of retelling David’s double life as both he and she. He settled on the solution of calling David variously Joan (for when he was Brenda) and John (following his switch back to his genetic sex). Only in a conversation with me two years later did Diamond notice that he had bestowed on John/Joan the Christian names of Money’s two most important collaborators: Drs. John and Joan Hampson—an act that Diamond assured me was purely unconscious.

Written over the winter of 1994, the paper cast David’s life as living proof of precisely the opposite of what Money had said it proved. Citing the Kansas team’s classic work from the late 1950s, Diamond wrote that David’s case was evidence that gender identity and sexual orientation are largely inborn, a result of prenatal hormone exposure and other genetic influences on the brain and nervous system, which set limits to the degree of cross-gender flexibility that any person can comfortably display. Diamond argued that while nurture may play a role in helping to shape a person’s expressed degree of masculinity or femininity, nature is by far the stronger of the two forces in the formation of a person’s private inner sense of self as man or woman, boy or girl.

Powerful as the paper was in presenting anecdotal evidence of the neurobiological basis of sexuality, it also served as a clear warning to physicians about the dangers of surgical sex reassignment for all newborns—not just those like David who are born with normal genitals and nervous system. Diamond argued that the procedure was equally misguided for intersexual newborns, since physicians have no way of predicting in which direction the infant’s gender identity has differentiated. To change such children surgically into one sex or the other, he argued, was to consign at least half of them to lives as tortured as David’s.

Accordingly, Diamond and Sigmundson offered a new set of guidelines for management of babies with ambiguous genitalia. Recognizing that a child must be raised as either a boy or a girl, they recommended that doctors continue to assign a firm sex to the baby—but only in terms of hair length, clothing, and name. Any irreversible surgical intervention, they said, must be delayed until the children were old enough to know, and be able to articulate, which gender they felt closest to. Or as Diamond put it to me, “To rear the child in a consistent gender—but keep away the knife.”

Diamond was aware that writing the paper would inevitably raise the specter of a personal vendetta against Money. To minimize this danger, he removed from David’s quoted utterances all reference to the famous psychologist. “In fact,” Diamond says, “Money’s name is only mentioned once. I didn’t want it to be an argument ad hominem. I wanted it to be a theoretical discussion.”

Nevertheless it took Diamond and Sigmundson two years to find someone willing to publish their paper.

“We were turned down by all these journals that said it was too controversial,” says Sigmundson. “
The New England Journal
,
The Journal of the American Medical Association
.” The article was finally accepted by the American Medical Association’s
Archives of Pediatrics and Adolescent Medicine
in September 1996, with publication set for March 1997. In the intervening months, Diamond and Sigmundson felt considerable apprehension as they waited for their bombshell to go off. “We were basically telling all these physicians that they’d been doing the wrong thing for the past thirty years,” Sigmundson says. “We knew we were going to be pissing a lot of people off.”

Some critics, as expected, attempted to dismiss the paper on the grounds that Diamond was simply using David’s history to embarrass a scientific rival, but at least one physician who saw a prepublication copy of the paper was inclined to agree strongly with its conclusions. Dr. William Reiner had two years earlier launched the first comprehensive long-term follow-up study of patients who had been sex reassigned. Trained as a pediatric urologist, Reiner had actually spent the first eighteen years of his medical career in California performing “normalizing” genital surgeries on intersexual children. It was early in his career that Reiner had his first glimmer of doubt about the Johns Hopkins treatment model. “I got babies and two-year-olds and four-year-olds and eight-year-olds and sixteen-year-olds,” he says. “So I really saw a longitudinal view of all these urological conditions—all these birth defects—and I was therefore able to visualize in a relatively short period of time the kinds of effects that these conditions have on the lives of these kids and their families.” Then, in 1986, Reiner met a patient who changed his life.

She was a fourteen-year-old girl—a Hmong immigrant—who had announced that she was dropping out of high school because she was “not a girl.” To all outward appearances an anatomically normal female, she had nevertheless always rejected girls’ play and had insisted on wearing gender-neutral clothes. At puberty she had arrived at the unshakable conviction that she wanted to change sex and live as a male. Referred to Reiner to discuss the possibility of reconstructive surgery, she was threatening suicide unless her wishes were met.

“I had a complete medical workup on the child done,” says Reiner. Tests revealed that “she” was biologically a he—a 46XY male who suffered from a rare chromosomal condition that prevents masculine differentiation of the genitals. Reiner performed sex change surgery, after which the former girl effortlessly assumed the sex written in his DNA. The case convinced Reiner of what he had suspected for years: that the biological underpinnings for psychosexual identity are not so easily overridden by social and environmental rearing as he (and every other pediatric urologist, endocrinologist, psychiatrist, and psychologist) had been taught. This further forced Reiner to the uncomfortable conclusion that he had been doing the wrong thing in his surgical career in helping to steer intersexual children into one sex or the other at birth. In a 1996 edition of the
Journal of the American Academy of Child and Adolescent Psychiatry
, Reiner published a paper on the Hmong case, along with a warning to his fellow physicians about the long-accepted theory that rearing prevails over biology in shaping human sexuality.

Reiner also did something else. After eighteen years as a surgeon, he put down his scalpel. He began to retrain as a child psychiatrist specializing in psychosexual development and intersexual conditions. In 1995 he was hired by Johns Hopkins as an assistant professor in psychiatry. There he launched his study on the long-term psychosexual implications of sex reassignment. Reiner set out to follow sixteen patients, focusing particularly on six genetic males who were born without penises and as a result were castrated and raised as girls. Two years into his study, he noted that all six sex-changed boys were closer to males than to females in attitudes and behavior. Two had spontaneously reverted to being boys without being told of their male (XY) chromosome status.

“These are children who did not have penises,” Reiner told me, “who had been reared as girls and yet
knew
they were boys. They don’t say, ‘I wish I was a boy’ or ‘I’d really rather be a boy’ or ‘I think I’m a boy.’ They say, ‘I
am
a boy.’ ” Reiner stressed the parallels between the children he was studying and David Reimer, who also “knew,” despite his rearing as Brenda, that he was not a girl. Reiner wrote a supportive editorial in
Archives of Pediatrics and Adolescent Medicine
to accompany Diamond and Sigmundson’s John/Joan paper.

Today Reiner says that both David’s case and the trend in his own study support the findings that have emerged on the primacy of neurobiological influences on gender identity and sexual orientation. He cites the now-classic study done at Oxford University in 1971, which showed anatomic differences between the male and female brain in rats. Six years later, at UCLA, researchers narrowed these differences to a cluster of cells in the hypothalamus. A study done in the mid-1980s in Amsterdam located the corresponding area in the human hypothalamus, noting that it is twice as large in homosexual as in heterosexual men. Further studies have supported this finding. In 1993 and again in 1995, researcher Dean Hamer announced that in two separate studies of gay male brothers, he had found a certain distinctive pattern on their X chromosomes. The finding suggested that sexual orientation may have a genetic component.

Although Hamer’s studies have failed to be replicated by other scientists, few sex researchers today dispute the mounting evidence of an inborn propensity for acting as, and inwardly identifying with, a particular sex. “It’s quite clear that the vast majority of boys born with functioning testicles have masculine, brains,” Reiner says. He endorses Diamond and Sigmundson’s recommendation to delay surgery in cases of penile loss or intersexuality and to impose only a provisional assignment that can be changed should the child voice a strong desire to live as the other sex. Reiner suggests that this treatment model is diametrically opposed to the one pioneered at Johns Hopkins by Money and his colleagues, in which a sexual identity is imposed on a child through unshakable fiat of physicians, and any doubts or confusions the child may express about the assignment are denied by caregivers. Reiner says that on the basis of David’s case and the others he has studied, the decades-old Johns Hopkins treatment model needs to be reevaluated. “We have to learn to listen to the children themselves,” he says. “They’re the ones who are going to tell us what is the right thing to do.”

Before Diamond and Sigmundson’s journal article appeared in the
Archives of Pediatrics and Adolescent Medicine
in March 1997, the American Medical Association’s public relations department alerted the media that something explosive was coming. On the day of the article’s publication, the
New York Times
ran a front-page story headlined S
EXUAL
I
DENTITY
N
OT
P
LIABLE
A
FTER
A
LL,
R
EPORT
S
AYS
, in which writer Natalie Angier described David’s life as having “the force of allegory.” Twenty-four years after publishing news of the case’s success,
Time
magazine ran a full-page story declaring, “The experts had it all wrong.” Similar news accounts appeared around the world—and soon Diamond and Sigmundson were deluged with calls from reporters in several countries seeking an interview with the young man now known simply as John/Joan.

David agreed to appear on two television newsmagazine programs. He was shown in darkened silhouette on ABC-TV’s
Primetime Live
and with his face obscured in a Canadian Broadcasting Corporation documentary. It was during the latter taping, which took place in New York City in June 1997, that I was introduced to David by Diamond and Sigmundson. The researchers had passed along to David the names of the many reporters who had requested an interview with him, but David (a rock ’n’ roll fan) had chosen the reporter from
Rolling Stone
.