Casting doubt on gender theory

Boys surgically altered, raised as girls identified as males, report shows

January 22, 2004|By Jonathan Bor | Jonathan Bor,SUN STAFF

In a new twist on the age-old question of nature vs. nurture, Johns Hopkins scientists following 14 boys who were surgically altered as infants and raised as girls found that the majority grew up identifying strongly as males.

Some of the patients spontaneously took on boys' names and began wearing male clothing before anyone told them the circumstances of their births - while others decided to live as boys once they found out.

Warning against sweeping conclusions about the foundations of gender identity, the researchers noted that the study was limited to boys who were "assigned" to the female gender because of a severe birth defect involving the abdominal organs and penis.

But the doctors said their finding casts further doubt on a theory, made popular in the 1960s by a Hopkins sex researcher, that gender is largely a function of how you look and how you're raised.

"You always have to challenge the accepted dogma," said Dr. John Gearhart, director of pediatric urology at the Johns Hopkins Children's Center. "Science will sometimes prove that the dogma is wrong."

A report of the findings, by Gearhart and Dr. William G. Reiner, appears in today's New England Journal of Medicine. Reiner, a former Hopkins child psychiatrist and urologist now at the University of Oklahoma, said doctors can't assume that they can surgically and medically alter the way a person sees himself.

"They will probably have a high chance of seeing themselves as boys regardless of efforts to change them," Reiner said of patients like those in the study. "This tells you that we don't know all the processes behind the identity of gender roles."

The boys were all born with a defect called cloacal exstrophy, which is rooted in embryonic development when the body doesn't properly fuse down the middle. The disorder is extremely rare, occurring once in every 400,000 live births.

The result is a bladder and intestines that spill outside the abdomen. In boys, the penis is small or nonexistent, despite the presence of testicles. Many patients also have open spines, a potentially crippling condition known as spina bifida.

Today, prenatal ultrasound tests can detect the problem early in fetal development. Because many parents decide to terminate the pregnancy, doctors are seeing the disorder less often than in the past.

Gearhart called the defect one of the most severe and disfiguring a doctor will see. Even without deciding the gender issue, "surgical reconstruction is massive," he said. The surgeon must join the pelvic bones and relocate the bladder, intestines and other tissues into the abdomen.

The disorder is three times more common among boys than girls, who face the same medical complications but not the same questions of gender.

Only recently have surgeons been able to fashion a cosmetic penis for boys with the disorder. So for years, doctors at Hopkins and other hospitals typically removed the male reproductive organs and surgically fashioned a cosmetic vagina. The babies were raised as girls and given the female hormone estrogen once they approached puberty.

Hopkins stopped the practice about 10 years ago as surgeons learned better ways to construct a penis. Elsewhere, the practice has faded more slowly, and it persists at some hospitals.

Gearhart and Reiner first raised questions about the surgery when four patients who were raised as girls came to the Hopkins clinic several years ago, reporting that they felt like males and wanted to live as boys. Hearing that, the doctors tracked down ten similar patients and asked detailed questions about their lives.

As a group, the patients ranged in age from 5 to 16.

Five of the patients were happily living as girls when questioned. Three were unclear about their sexual identity, though two had declared themselves as male. The remaining six had reassigned themselves, taking on boys' names and dressing in masculine clothes.

"Even though mom and dad had told them they were girls and they had girls' names, they still always felt they were male," Gearhart said. In two cases, the patients had begun to live as boys before their parents told them the truth.

One child who had grown up feeling like a boy fought the doctor who tried to inject him with estrogen, a treatment designed to spur development of breasts, soft hair and other feminine traits.

"They tried to hold her down but that wasn't possible," said Reiner. "The endocrinologist was exasperated and said, `Why are you making it so difficult to give you these estrogen shots?' "

"I'm not a girl. I'm a boy," was the patient's reply.

Gearhart and Reiner said they strongly recommend raising boys with the birth defect as males, and suggesting penile reconstruction at a later age.

Though not identical, the study reflects some of the same questions raised several years ago by scientists who looked into the case of a Canadian who was raised as a girl after doctors obliterated his penis during a botched circumcision.

The patient, David Reimer of Winnipeg, was castrated, dressed and groomed as a girl and given the name Brenda. His parents followed the advice of Dr. John Money, a famous Hopkins sexologist who assured them that he would identify as a girl if raised as one.

Though the truth was kept from him until he was 16, Reimer said he felt like a boy throughout childhood and fought all efforts to feminize him. Four years ago, he cooperated with author John Calapinto in a book about his life.

"Kids will tell you what they want you to know without saying a word," Reimer, now 37, said in an interview yesterday. "You know who they are when you watch them play with toys, when they pick out clothes and you watch the types of activities they play. It all starts before kindergarten."

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