GIRES Research Award for 1999

Awarded to Professor Milton Diamond and Professor Kenneth Kipnis

The GIRES Research Prize for 1999 has been awarded to Professor Milton Diamond and Professor Kenneth Kipnis for their article: “Pediatric Ethics and the Surgical Assignment of Sex”, published in the Journal of Clinical Ethics. The Professors examined the existing medical practice of performing surgery on infants with ambiguous genitalia, loss of penis, or a large clitoris and then raising them in the assigned sex without ever informing them of this treatment.

Research conducted around 1970 had postulated that gender identity is initially malleable and only becomes fixed when an infant reaches the age of 18 to 24 months. One highly influential case involved nonhermaphroditic identical twins one of whom had suffered destruction of penis as a result of a botched circumcision. At the age of 17 months, that twin was surgically refashioned with approximately female genitalia and thereafter raised as a girl. The psychologist responsible for that gender reassignment, which included oestrogens from the age of 12, affirmed its continuing success.

Professor Diamond located that twin, now in his thirties, and found that he had never functioned successfully as a girl. The twin had, at the age of 14 requested reassignment as male which has since included hormone treatment and mastectomy. He now lives as a man and has married a woman who is the mother of three children. The article also describes a study of six comparable infants. The behaviour of all was more masculine than feminine and two changed to the male gender.

A further study referred to in the article describes the satisfactory life experiences of twelve males, raised as boys, whose micropenises were retained even though they were within the standard for surgical removal.

The article also questions the use of a standard for surgical correction of an over large clitoris in infant girls in the absence of research that demonstrates the benefits of this treatment.

The article recommends that: no such sex assignment surgery be performed without the informed consent of the patient; this ban stays in force until research has shown that it has a positive effect; and former patients be informed of the surgery.

The professors have provide GIRES with a synopsis of their thinking and a most helpful list of related reading. These are included in our annual report of which copies may be obtained via our telephone, fax or email addresses.

The American medical profession is beginning to give serious consideration to the professors’ recommendations. They were considered in April this year during a special symposium entitled “Pediatric Gender Reassignment: A Critical Appraisal” at the American Urological Association annual meeting. The meeting accepted the call for consideration of all three recommendations and specifically to have the Section of Urology of the American Academy of Pediatrics establish a registry for all intersexed children and to perform look-back evaluations of treatment and management.

GIRES considers that the article deserves to be considered by the medical profession within the UK where it seems likely that about 30,000 people have intersex conditions. The question of gender assignment in babies has worried and challenged British paediatric surgeons for many years. Discussions are now taking place with the leading authorities in this field who are responding in a very positive and open way to the issues that have been raised and will include GIRES in their debate of how best to deal with them.

The article has also provided highly valuable data on which GIRES has based its recommendations to the Home Office Interdepartmental Working Group which is examining the issues concerning birth certificates and related matters.

GIRES Award 1999

Professor Milton Diamond and Professor Kenneth Kipnis “Pediatric Gender Ethics and the Surgical Assignment of Sex – A Critical Reappraisal, Journal of Clinical Ethics.” [1998, 9:398-410]

Background

A famous surgical alteration of a small child involved a male whose penis was accidentally destroyed when he was eight months old. Dr John Money, who had extensive experience of treating children born with ambiguous genitalia recommended that the child’s genitals be constructed to have a female appearance and that he be raised as a girl even though all other sexual factors were congruent and were male. The doctors also recommended that his ‘history’ as a male be hidden from him.

This surgical alteration case made headlines in 1973. Dr Money reported that the child and the parents had successfully adapted to the sex/gender alteration. The case was, for many years, believed to support the assertion that, in cases of ambiguity of genitalia at birth, or accidental damage shortly thereafter, a child’s gender identity could be largely determined by ‘nurture’, so long as the external characteristics were made consistent with that nurture before the age of two.

For more than twenty years, the scientific literature continued to report that the surgical alteration was successful and the child’s gender identity was female. This case made headlines again in 1997 when Professor Milton Diamond and Professor Keith Sigmundson reported in the Archives of Pediatric & Adolescent Medicine that the boy who had been turned into a girl was now living as a man.

According to the Diamond and Sigmundson report, and the later article by Diamond and Kipnis in the Journal of Clinical Ethics, John (a pseudonym) had always thought of himself as different from other girls. As a child, he preferred ‘boy’ type toys and preferred to mimic his father’s rather than his mother’s behaviour. He also preferred to urinate in a standing position although he had no penis. Because of the cognitive dissonance, Joan (a pseudonym used by the authors to describe John while he lived a female life) often had thoughts of suicide.

At twelve, Joan was put on an estrogen regimen. She rebelled against this regimen and often refused to take the medication. At fourteen, Joan confessed to a doctor that she had suspected that she was a boy since second grade. At that point, the doctors agreed with Joan that she should be remasculinised and become John once more. At age fourteen. Joan/John returned to living as a male. He received male hormone medication and a mastectomy. He underwent surgery to reconstruct a phallus at ages fifteen and sixteen. John was eventually accepted as a boy by his peers. He is now married and helping to raise his wife’s three children.

The inference that may be drawn from the failure of the imposed gender reassignment trealrnent is that any similar attempts to impose gender identity, without taking account of the pre-existing sex differentiation of the brain, risk failure and may be intensely damaging to the individual.

The article by Diamond and Kipnis, in combination with other reports of maladaptation of intersexed individuals who have been surgically assigned at birth, has caused the medical and psychiatric communities to question their beliefs about sex and gender identity, and the implications for the treatment of individuals born with intersex conditions. Moreover, its findings challenge any assumption that gender dysphoria can be caused or cured by social conditioning.