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hromosomes or Genitalia:
Which Provides Our Sexual Identity?

"Tarot Card: The World" by Julie Waters

John became Joan due to a medical accident in 1964. Eight months old, his penis was destroyed during minor surgery. Doctors advised the parents to raise him as a girl and performed surgery to create the necessary anatomy. Hailed as a triumph which became the standard for babies born with genital defects, this case has again made headlines because it is now regarded as a wrong decision.

"The case led to a lot of excitement that this could even be done. It was a very difficult clinical situation that could now be handled. It created a lot of enthusiasm and, probably, relief in the medical world...The question this case doesn't answer but lends data to is: What is the origin of gender identity? How do we know we are a girl? How do we know we are a boy? And when do we know it?" Dr. William Reiner is a child psychiatrist at the Johns Hopkins Hospital in Baltimore, Maryland, where John is treated. "John, in spite of being raised as a girl and being treated with hormones and estrogen, said, 'Forget it. I'm a boy.'"

New research by the doctors who performed this operation indicate that John, who reverted to being a boy as a teenager, always felt he was a boy and consistently rejected his female identity, even while he wore dresses and despite the fact he was never informed of the accident or subsequent surgery, according to a report published in the Archives of Pediatric & Adolescent Medicine. The roots of sexual identity lie deep inside the brain, as John's case and several major medical studies have shown. Even as a child, John "felt like a trapped animal." His case was written up as an example that gender should be determined by anatomy rather than chromosome or the individual's feelings about their own sexuality.

John's mother recalled, "As soon as he had the surgery, the doctor said I should now start treating him as a girl, doing girl things, and putting him in girl's clothes. But that was a disaster. I put this beautiful little dress on him...and he (immediately tried) to rip it off. I think he knew it was a dress and that is was for girls and he wasn't a girl.

"Joan" rejected almost everything feminine. When her twin brother refused to share his toys, Joan saved her allowance and bought herself a toy truck. She began to suspect she was a boy around the ages of 9 to 11. "There were little things from early on. I began to see how different I felt and was from what I was supposed to be. But I didn't know what it meant. I thought I was a freak or something...I looked at myself and said I don't like this type of clothing. I don't like the types of toys I was always being given. I liked hanging around with the guys and climbing trees and stuff like that, and girls don't like any of that stuff. I looked in the mirror and (saw) my shoulders (were) so wide. I mean, there (was) nothing feminine about me. I (was) skinny, but other than that, nothing. But that was how I figured it out, but I didn't' want to admit it. I figured I didn't want to wind up opening up a can of worms."

At fourteen, she told her endocrinologist about her suspicions. Alarmed at the threat of suicide, the doctors and her parents decided to offer a second gender conversion, which Joan gladly accepted. "All of a sudden everything clicked. For the first time, things made sense, and I understood who and what I was." John's peers rallied around him, after some initial shock.

Thirty years ago, doctors believed babies were sexually neutral at birth, learning their gender as they grew and hormonal influences kicked in. "The teaching has been to convert these children because you can surgically construct a sexually functioning female but you can't surgically reconstruct a child to function as a male."

Experts believed a male child could not grow up psychologically healthy without a penis. Reiner says the data does not support that assumption.

"This case is another brick in the edifice of understanding sexual identity and shows that we are born with most of these feelings. The largest sex organ is between the ears, the report says. In cases where the genitals are traumatized, I believe it's never appropriate to change sex, because you haven't changed the brain," stated Milton Diamond, co-author of the report and an expert in anatomy and psychology at the Pacific Center for Sex and Society, University of Hawaii-Manoa.

This report, also authored by Dr. H. Keith Sigmundson of the Ministry of Health in Victoria, Canada, is rekindling the discussion of what approach to take with infants born with genital abnormalities, as well as cases of sex chromosome abnormalities, gender identity disorders, and metabolic adrenal or testicular errors--all conditions in which sexual identity and orientation can be unclear. "We need to have a strong discussion on what are our data. Are we doing the right thing? John gives us reasons to pause and question what we're doing," Reiner concluded.

The report advocated postponing sex reassignment surgery in infants in favor of counseling to eventually determine the child's feelings about his or her gender. Dr. Francine Ratner Kaufman, an endocrinologist at Children's Hospital in Los Angeles disagrees. "I think we have come back to stressing the importance of the biological. So (the paper) is important data for us to have who deal in this field and have to assign gender....In newborns, the problem should be fixed as soon as possible. The families are devastated. And I think we understand enough, biologically, to come up with a good resolution."

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