"The near-perfect quasi-experiment"

 

One of the most intriguing findings to come out of sex research is that female sexual responses are usually gender-nonspecific, while males sexual responses are gender-specific. The strongest evidence that this sex difference is not due to sociocultural influence comes from "the near-perfect quasi-experiment": XY males without Disorders of Sexual Development (DSD) who were raised as females.

During the second half of the 20th Century, a medical scandal took place, where XY males with "inadequate" penises were surgically reassigned female. This includes boys who lost their penises in an accident (penile ablation), and those born with penile agenesis (aphallia), cloacal exstrophy, or classical exstrophy. The most famous of these cases is the patient of John Money, David Reimer. Initially reported as a "successful" reassignment to female, it later came out that he rejected being reassigned female, had reclaimed a male identity, and eventually committed suicide at age 38. 

These cases are "the near-perfect quasi-experiment" because "neither cloacal exstrophy nor surgical accidents are associated with abnormalities of prenatal androgens. Thus, the brains of these individuals were male-organized at birth, or at least as male-organized as those of typical boys are at birth, on average." (Bailey et al., 2016)

Gynephilia and Male Identity in non-DSD XY Males Raised Female

There were at least 77 different cases of non-DSD XY Males raised Female, as reported by Meyer-Bahlburg (2005). Unfortunately, the vast majority of these cases failed to report sexual orientation outcomes, "presumably because of the sensitivity of asking the question" (Bailey et al., 2016)(Meyer-Bahlburg, 2005). 

Bailey et al. (2016) managed to retrieve 7 cases where sexual orientation was reported. The first case is David Reimer, who suffered penile ablation, was reassigned female at 17 months, reclaimed a Male identity by age 32, and was gynephilic. The second case is "Experiment of Nurture", who suffered penile ablation, was reassigned female at 7 months, reported a Female identity by age 26, and was "predominantly" gynephilic (Kinsey scale sexual fantasy = 5, Kinsey scale sexual behavior = 3, self-reported sexual identity = "bisexual"). The remaining cases are 5 of William G. Reiner's cloacal exstrophy patients, all of whom reclaimed a Male identity, and were all gynephilic. In other words, 7 out of 7 cases were predominantly or exclusively gynephilic. Each of these cases describes self-reported sexual attraction instead of physiological sexual arousal, but there is little reason to doubt patients who self-report gynephilic attraction. Although Bailey et al. (2016) fail to mention any of the other cases that were reported as androphilic or bisexual, they did not do so without good reason. 

William G. Reiner followed more than 5 cases of XY cloacal exstrophy males raised female, and his experience caused him to question the protocols put forward by John Money. In one report, Reiner & Gearhart (2004) described how 6 of the 14 cases reclaimed a male identity, 2 were "unclear", and 1 "would not discuss". All 5 who retained a female identity were under age 20 at the time of assessment. Of the 6 who reclaimed male identity, 3 reported attraction to females (gynephilia). None of the patients reported attraction to males (androphilia). Of the 5 patients who retained female gender identity, none dated and none disclosed sexual behavior or attractions. These findings led Reiner & Gearhart (2004) to conclude: "Routine neonatal assignment of genetic males to female sex because of severe phallic inadequacy can result in unpredictable sexual identification. Clinical interventions in such children should be reexamined in the light of these findings."

In the second report, Reiner & Kropp (2004) reported on 9 cases of XY cloacal exstrophy males raised female. 4 reclaimed Male identity, and 2 of these reported attraction to females (gynephilia). None of the 9 patients reported attraction to males (androphilia). Instead, the remaining 7 were either too young, or refused to disclose ("Will not say"). These findings led Reiner & Kropp (2004) to conclude "our data, in concert with a number of historical studies, do not support hypotheses underlying clinical decisions to sex assign neonates with a Y chromosome and active prenatal androgens to female."

Androphilia and Female Identity in non-DSD XY Males Raised Female?

Meyer-Bahlburg (2005) reviewed the gender identity outcomes of 77 non-DSD XY males raised female, including those with penile agenesis (aphallia), cloacal exstrophy, classical exstrophy, and penile ablation (traumatic accident). He reported that most of the underage patients did not reclaim a Male identity, while around half of the adult patients did so, concluding that: "The findings clearly indicate an increased risk of later patient-initiated gender re-assignment to male after female assignment in infancy or early childhood, but are nevertheless incompatible with the notion of a full determination of core gender identity by prenatal androgens."

This is similar to the Editorial Comment left on Reiner & Kropp's (2004) article, which was written by Moneer K. Hanna of the Cornell Medical Center of New York. Hanna describes 14 46,XY males raised female, including 4 cases of aphallia, 4 cases of micropenis with dysgenetic testicles, 3 cases of cloacal exstrophy, 1 case of classical exstrophy, and 2 cases of androgen insensitivity. It is unspecified whether the 2 cases were partial androgen insensitivity or complete androgen insensitivity. Hanna describes how approximately 50% of these patients "converted back to male". In contrast with Bailey et al. (2016), 4 of these patients were described as "sexually active as females" and 1 was "bisexual". Hanna reaches a different conclusion from Reiner & Kropp (2004), stating "Our experience is in direct contrast to that of the authors. It is possible that preemptive total body feminization and lack of psychosexual analysis could be the reason that our patients appear to be content with their gender."

However, there is reason to question Meyer-Bahlburg's report. In Table V, Meyer-Bahlburg (2005) describes 7 patients with penile ablation. Two of these patients are listed as "Male": David Reimer, and Bernardo Ochoa's "Case 2" (the one case Ochoa oversaw who was reassigned female; he reclaimed Male identity 14 years later). The remaining patients are listed as "Female", where one is indicated to be dubious. This includes two cases of formerly conjoined twins (Diamond, 1999)(Zucker, 1999) where only one twin could receive male genitals, and three patients described by Gearhart & Rock (1989). Gearhart & Rock's (1989) cases include a 3 year-old and 2 adult patients. Although very little follow-up was done with these patients, the adult patients are described like so: "Psychosexually, both of the older children have developed a feminine gender identity and are active sexually on followup evaluation by medical sexologists." Meyer-Bahlburg (2005) describes the first of these 2 cases as "Well-adjusted" and "sexually active", implied to mean "sexually active as female". The second case is "Experiment of Nurture", who is described as "Tomboy in childhood; required psych counseling before vaginoplasty in adolescence". 

Meyer-Bahlburg (2005) summarizes these findings like so:

• Male: 2
• Female: 4+1?

Here, Meyer-Bahlburg (2005) has artificially inflated the number of patients who retained a Female identity. 

In addition to David Reimer and Bernardo Ochoa's "Case 2", both of the conjoined twin cases should be tallied as "Male". The first conjoined twin case was described by Milton Diamond (1999) as wanting Gender Reassignment "to make the transition to the boy that she believes she should be". The second conjoined twin case was described by Kenneth Zucker (1999), who advised against drawing conclusions about Gender Identity: 

Several years ago, I evaluated another set of conjoined male twins who also shared one set of genitalia, one of whom was sex-reassigned at the time of surgical separation (5.5 years) (see Filler, 1988). Because of the twins' living conditions prior to surgery, they were both somewhat developmentally delayed at the time of surgery, but appeared to catch up subsequently. At age 12, the sex-reassigned twin shared many "boyish" interests with her brother, but, based on interview data with the youngster and her father, appeared to have differentiated a female gender identity. Given the apparent course of events in the O'Neill et al. (1988) case [Described by Diamond (1999)], it would be premature to draw any firm conclusions about the ultimate gender identity of this patient. 

This was wise on Zucker's part. It was later revealed that this patient had reclaimed a Male identity, as noted by Meyer-Bahlburg (2005) himself: "According to the Globe and Mail of June 25, 2005, an article by Jan Wong, entitled Twin Peaks, reports that the second patient (Filler, 1988; Zucker, 1999) listed on Table V of this article is now 23 years old and lives as a man."

"Experiment of Nurture" is the one case who could be arguably listed as "Female". In the remaining cases, it is more accurate to describe them as "not indicated" or "Unknown" instead of "Female". This is especially true for the 3-year old patient.

A more accurate tally would read:

• Male: 4
• Female: 1
• Unknown: 2

Bailey et al. (2016) explain why they didn't include the other cases reported as androphilic or bisexual: "Several of the other cloacal exstrophy cases were still living as female. Notably, none of them would discuss their sexual attractions, in contrast to two adolescents with cloacal exstrophy who were born female, and who discussed their attractions to males. We suspect that the former cases—natal males reassigned as female and still living in the female role— are highly likely to be gynephilic. Certainly, however, it is scientifically important to obtain data from such cases. It would also be desirable to support any self-reported claims of androphilia (i.e., attraction to males) with objective measures. This is because those individuals still in the female role may feel social pressure to claim attraction to males even if none exists." 

For these reasons, female identity and especially androphilia are probably less common in these patients than Meyer-Bahlburg (2005) reported. Bailey et al. (2016) have good reason to suspect that all of them are gynephilic.

"Experiment of Nurture"

There is also reason to doubt the self-reported bisexuality and Female Identity of "Experiment of Nurture". John Colapinto (2000) claims that this was another one of John Money's patients: 

In a shocking parallel to David’s case, this child (also, coincidentally, a Canadian) had lost his penis to a bungled circumcision by electrocautery and had subsequently been castrated and reassigned as a girl at seven months of age in 1971. Now twenty-six years old, the patient was described by Zucker as still living in the female sex. “She denied any uncertainty about being a female from as far back as she could remember,” Zucker wrote, “and did not report any dysphoric feelings about being a woman.” At the same time, Zucker admitted that the case could not be deemed an unalloyed example of the efficacy of sex reassignment, for he was obliged to acknowledge that the patient, in childhood, had always enjoyed “stereotypically masculine toys and games”; that as an adult she works in a “‘blue collar’ job practiced almost exclusively by men”; and that she is currently living with a woman, in her third significant sexual relationship with a member of the female sex.

Nevertheless, Zucker concluded, “In this case…the experiment of nurture was successful regarding female gender identity differentiation,” and he cited the case as convincing proof that her rearing as a girl “overrode any putative influences of a normal prenatal masculine sexual biology.”

Struck by the seeming incongruity of these conclusions, I spoke with Zucker about the case at his office in Toronto in the summer of 1998. Our conversation only served to raise further doubts about the paper’s conclusions, for Zucker was unable to answer any of my specific questions about whether the patient might not have been telling the researchers what they wanted to hear when she stated that she had never harbored any doubts about her gender. By now I understood that this is a phenomenon endemic to all areas of sex research that rely on patient testimony, but particularly so in the fraught and sensitive world of sex reassignment, where as one ISNA member told me, “You feel so embarrassed and ashamed to be talking to someone that you’ll basically tell them anything so you can get the hell out of there.” Zucker agreed that such scenarios are not unfamiliar, but he couldn’t say whether such a dynamic was at work in the case in question. And for a simple reason. He had never met the patient and had based his reporting solely on information supplied to him by the people listed as coauthors of the paper. These included a gynecologist with no training in the assessment of gender identity, and a psychiatrist who had conducted only two interviews with the woman—the first when she was sixteen, the second when she was twenty-six.

There was, as well, further reason to feel uneasy about the paper’s conclusions, and this had to do with its murky provenance. It was only in the closing moments of my interview with Zucker, after I had turned off my tape recorder, that he let fall that the paper had another silent collaborator— an investigator who, when notified of the researchers’ efforts, had hastened to supply records he had gathered on the patient in her early childhood. The investigator was John Money, who had authorized and overseen the patient’s sex reassignment in infancy and who had, true to practice, conducted a number of annual follow-ups with the child until she (for reasons unspecified in Zucker’s paper) stopped returning to Johns Hopkins.

The other adult patient of Gearhart & Rock (1989) was likely similar to "Experiment of Nurture" in terms of sexual attractions and gender identity. I do not know if this was another one of John Money's patients. 

Given these details, it is possible that these patients are repeats of David Reimer, where they were misreported as "successful" cases of surgical reassignment. For these reasons, the tally should arguably read: 

• Male: 4
• Unknown: 3

"Baby Doe"

In As Nature Made Him (2000) Colapinto describes another case of a newborn infant who suffered penile ablation from a bungled electrocautery circumcision on Aug. 22, 1985. Dubbed "Baby Doe", Colapinto (2000) claims that this was another one of John Money's patients who was reassigned female. The description is very similar to Gearhart & Rock's (1989) 3 year-old patient, who is described as undergoing "elective newborn circumcision with a Gomco clamp and electrocautery at 2 days after birth". 

It may be noteworthy that Gearhart & Rock (1989) actually listed two near-identical patients, who both suffered bungled electrocautery circumcision. This is similar to how "Baby Doe" had a twin brother, who suffered a very similar injury but was not reassigned female:

"In pursuit of further data, doctors and researchers will almost certainly pay particularly close attention to events that began at Atlanta’s Northside Hospital in 1985, when on a single day two developmentally normal newborn boys suffered severe penile burns from bungled electrocautery circumcisions. One boy lost his penis entirely, the other a significant portion. The parents of the child in the former case agreed to sex reassignment of their child as a female; the other parents opted to have their child receive plastic surgery to create an artificial penis" (Colapinto, 2000)

This is different from Gearhart & Rock's (1989) description, where it is stated that both newborn patients were reassigned female.

It is unknown to me if "Baby Doe" is the same as Gearhart & Rock's (1989) 3 year-old patient. If so, Gearhart & Rock's (1989) erred in describing the other twin as having been reassigned female. I was unable to find more information about "Baby Doe".

Is As Nature Made Him a Reliable Source?

Colapinto (2000) meticulously exposes the David Reimer scandal in As Nature Made Him. However, there is reason to question whether his work contains inaccuracies. Below is his description of Kiira Triea:

There was Kiira Triea, assigned as a boy at age two, who did not learn of her intersexuality until puberty, when she began to menstruate through her phallus. At that stage she was referred as a patient to Dr. Money at the Psychohormonal Research Unit, where she was treated from age fourteen to seventeen, in the mid-1970s, concurrent with Brenda Reimer. 

Kiira and David have never met or spoken, but Kiira’s story bears striking parallels to his. She describes how Dr. Money, evidently attempting to ascertain whether she possessed a male or a female gender identity, questioned her about her sex life—in the frank language for which he is well known. “Have you ever fucked somebody?” she remembers Money asking. “Wouldn’t you like to fuck somebody?” She also describes how Money showed her a pornographic movie on a projector he kept in his office. “He wanted to know who I identified with in this movie,” she says. 

Contrary to Money’s claim that an intersexual baby reared as a boy will develop an unequivocal male gender identity, Triea’s sexuality and sense of self proved to be far more complicated than that. At fourteen she agreed to undergo feminizing surgery at Johns Hopkins to simulate female genitals, but when she became sexually active for the first time at age thirty-two, her erotic orientation was toward women.

Kiira Triea (named after a Star Trek character) was an Autogynephilic charlatan, who falsely claimed to be intersex and "HSTS". This casts doubt on the reliability of some of Colapinto's claims.

The Role of Exogenous Testosterone

While William G. Reiner worked with cloacal exstrophy patients, the protocol was to administer exogenous hormones "beginning at age 12 or 13 years" (Reiner & Kropp, 2004). Likewise, one study suggests that FTMs male-shifted patterns of sexual arousal, possibly due to testosterone treatment (Raines et al., 2021). Is it possible that gynephilia resulted from testosterone therapy?

Reiner & Gearhart's (2004) 14 XY cloacal exstrophy patients who were reassigned Female can be summarized like so:

• Subjects 1-5: Retained Female identity
• Subject 6: "Would not discuss"
• Subjects 7-8: "Unclear"
• Subjects 9-14: Reclaimed Male identity

The 2 patients with "Unclear" identity had declared a Male identity at 9 years old, but were forced to live as Females by their parents. Their parents forced them to take exogenous estrogen, which they were only "intermittently" compliant with, as they wanted to take testosterone instead. The 1 patient who "Would not discuss" identity was Subject 6, who "angrily refused her sexual identity with anyone after learning, at the age of 12, that her birth status was male. After 2 1⁄2 years of suggestions from her physician, she recently began taking estrogen but continues to refuse to discuss sex." 

Subjects 1-5 would not discuss sexual activity or sexual attractions. Likewise, no information is provided about the sexual attractions of Subjects 6-8. Subjects 9, 10, and 14 reported gynephilic attractions. Although they are stated to have "discussed sexual interests and activity", no information is provided about the sexual attractions of Subjects 11, 12, or 13, who were 10 years old, 8 years old, and 10 years old respectively. 

Notably, Subjects 9, 10, and 14 were administered testosterone treatment. Reiner & Gearhart (2004) do not specify the ages at which these patients reported gynephilic attraction, which makes it unclear whether these attractions were induced by exogenous testosterone. The one exception is Subject 9, whose gynephilia manifested prior to testosterone: "The three adolescents initially assigned to female sex take testosterone and are compliant with treatment. Because of a severely dysfunctional family, Subject 9 received no testosterone until he was incarcerated in a maximum security prison for armed robbery at the age of 17 years, yet he dated and was sexually active with girls from the age of 15 years." 

Reiner & Kropp (2004) reported on 4 XY cloacal exstrophy patients who were reassigned Female, but reclaimed a Male identity. These patients were 7, 8, 9, and 10 years old respectively. When Bailey et al. (2016) asked Reiner for additional information, he described two of those patients as gynephilic. If these patients reported these attractions while under age 12, it is doubtful that this was induced by testosterone. Unfortunately, Bailey et al. (2016) did not specify the ages of the patients, leaving some ambiguity about the role of exogenous testosterone.

As for the penile ablation cases, David Reimer only reported sexual attractions after he had begun receiving exogenous testosterone (Diamond & Sigmundson, 1997): "John's first sexual partner was a girl. He was 18 years old. While living as a girl and afterward as a boy, John was approached sexually by males. He claims never to have been attracted to any and his responses to such questions were matter-of-fact and not homophobic. John thinks his first recognizable sexual interest occurred about the age of 17 or 18 years although he does recall wanting to go see the sexy Rockettes in New York on one of his trips to see the consultants." However, "Experiment of Nurture" was never administered testosterone and still reported "predominantly" gynephilic attraction.

Taken together, there is some ambiguity about the effects of exogenous testosterone. "Experiment of Nurture" and Subject 9 suggest that testosterone treatment does not induce gynephilia, but in the other cases it is unclear.

References

Bailey, J. M., Vasey, P. L., Diamond, L. M., Breedlove, S. M., Vilain, E., & Epprecht, M. (2016). Sexual Orientation, Controversy, and Science. Psychological Science in the Public Interest, 17(2), 45-101. https://doi.org/10.1177/1529100616637616 (Original work published 2016)

Bradley, S. J., Oliver, G. D., Chernick, A. B., & Zucker, K. J. (1998). Experiment of nurture: ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood. Pediatrics, 102(1), e9-e9. https://doi.org/10.1542/peds.102.1.e9

Colapinto, J. (2000). As nature made him: The boy who was raised as a girl. HarperCollins Publishers.

Diamond, M. (1999). Pediatric management of ambiguous and traumatized genitalia. Journal of Urology, 162, 1021–1028.

Diamond, M., & Sigmundson, H. K. (1997). Sex reassignment at birth: Long-term review and clinical implications. Archives of pediatrics & adolescent medicine, 151(3), 298-304. https://www.cirp.org/library/psych/diamond1/

Filler, R. M. (1988). [Discussion]. Annals of Surgery, 208, 311–312.

Gearhart, J. P., & Rock, J. A. (1989). Total ablation of the penis after circumcision with electrocautery: A method of management and long-term followup. Journal of Urology, 142, 799–801.

Meyer-Bahlburg, H. F. (2005). Gender identity outcome in female-raised 46, XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation. Archives of Sexual Behavior, 34, 423–438.

Ochoa, B. (1998). Trauma of the external genitalia in children: amputation of the penis and emasculation. The Journal of urology, 160(3 Part 2), 1116-1119. https://doi.org/10.1016/S0022-5347(01)62712-5

Raines, J., Holmes, L., Watts-Overall, T. M., Slettevold, E., Gruia, D. C., Orbell, S., & Rieger, G. (2021). Patterns of genital sexual arousal in transgender men. Psychological Science, 32(4), 485-495. https://doi.org/10.1177/0956797620971654 

Reiner, W. G., & Gearhart, J. P. (2004). Discordant sexual identity in some genetic males with cloacal exstrophy assigned to female sex at birth. New England Journal of Medicine, 350, 333–341. 

Reiner, W. G., & Kropp, B. P. (2004). A 7-year experience of genetic males with severe phallic inadequacy assigned female. Journal of Urology, 172, 2395–2398.

Zucker, K. J. (1999). Intersexuality and gender identity differentiation. Annual Review of Sex Research, 10, 1–69.