I have recently been thinking about doctors, sexuality, and the field of psychology. One doctor, or rather, psychologist, who I know the most about who has been involved with sexuality is the famed John Money. John Money is the first doctor (PhD) to have created a medical protocol that was adopted across the world to treat intersex infants, starting in the 1950s. Below, I give a background of his work on intersexuality, which is an excerpt from my undergraduate thesis. The works that I cite are Katrina Karkazis’ book Fixing Sex: Intersex, Medical Authority, and Lived Experience published in 2008 (if you haven’t read it, its a great addition to the field), Alice Dreger Intersex in the Age of Ethics, and Anne Fausto-Sterling’s Sexing the Body: Gender Politics and the Construction of Sexuality published in 2001.
John Money is an important figure because, not only did he develop a protocol to medically manage intersex infants, but many psychological theories about gender identity development are based on his medical publications. Money is one of the most influential people in both the medical world and as a dominant paradigm in the United States. Money’s theories about the way one is properly supposed to develop has seeped both into the influences of people who write about child-rearing and into dominant consciousness. He is not simply a man that influences the lives of people who are intersexed, but every single individual.
John Money: The Man and the Doctor
John Money was the first scientist to create a universal treatment paradigm for surgery on intersex infants. John Money immigrated to the United States from New Zealand in 1947 to obtain a PhD in psychology from Harvard. While at Harvard, Money discovered his interest in hermaphroditism when he came upon a case of a child who was raised as a boy despite having a sexual organ akin to a clitoris. As his interest evolved, Money came to publish his doctoral dissertation on hermaphroditism. His dissertation called “Hermaphroditism: An Inquiry into the Nature of a Human Paradox” observed past surgical interventions as faulty because of the focus on gonadal tissue (Karkazis 2008: 48). He challenged this management because of its lack of focus on psychological dispositions of the person and physical developments at puberty, both of which could change. In order to prove his point “… Money did a comparative analysis of 248 published and unpublished case histories (from 1895 to 1951) and patient files, as well as an in-depth assessment of ten living individuals classed as hermaphrodites” (Karkazis 2008: 49) . Although Money found this to be true, his development of a protocol did not reflect his insight.
In his research, Money found few cases of homosexuality and stated most fared well psychologically, which he argued meant having a girlfriend or being married to a person of the opposite sex (Karkazis 2008: 50). Although Money was concerned for the most part with making gonadal tissue correlate with that of assigned gender, he also imposed his ideas of healthy sexuality. Money found it natural that those who were assigned the gender of a girl would be attracted to men and vice versa. If this attraction failed, the gender assignment and thus gender identity was contradictory. This also meant that Money judged a person’s sexuality based on the “sex of rearing” and when a person was homosexual, the psychological technique of rearing had failed. Money found that those who had the most gender identity contradictions fared the worst, which led him to later conclude that those who raise the child need to be convinced of the infant’s gender/sexual identity. Money in his analysis did not question external value structures, but focused on pervading systems and the individual.
Where before hormones played a large part in determining the sex of the child, Money claimed environment played a large part. “These findings supported his emergent theory, expressed more fully in 1955, that the sex of rearing was a primary determinant of an individual’s gender role and psychosexual orientation” (Karkazis 2008: 50). Also, more interesting is that his study was based not on how it would change medical treatment but what implications hermaphroditic management would have for contemporary psychological theories concerning sexual behavior/desire and psychosexual roles.
After his dissertation, John Money came to Johns Hopkins in 1951 when he was offered a position as a professor. While there, he joined Lawson Wilkins, the only other medical practitioner who treated intersexuals. Lawson Wilkins started a pediatric endocrine clinic in 1935 called the Harriet Lane Home in Baltimore and organized a team of researchers to treat hermaphroditic conditions. “Wilkins, seeing the merit of an interdisciplinary approach to intersexuality, assembled the first cross-specialty team to deal with infants with intersex conditions (Redick 2004)” (Karkazis 2008: 51). This team included Howard Jones, William Scott, Joan and John Hampson, and later in 1951, John Money. When John Money joined the team in 1951 he was the first pediatric psychoendocrinologist and “founded the Psychohormonal Research Unit to study ‘all the different types of hermaphroditism in order to discover all the principles of psychosexual differentiation and development that they would illuminate’ (Money 1986:10)” (Karkazis 2008: 51). Until the 1960s Wilkins was the director of the program and made treatment decisions that were carried out by Scott and James. Money and the Hampsons provided their psychological expertise and conducted outcome studies (Karkazis 2008: 51). Through this opportunity Money and the Hampsons started to develop their own theories and protocols for the medical management of intersexuality.
“Money and the Hampsons first introduced principles and protocols for the medical management of intersexuality in a series of articles published in the 1950s (Hampson 1955; Hampson, Hampson, and Money 1955; Money, Hampson, Hampson 1955a, 1955b, 1956, 1957, Money 1956)” (Karkazis 2008: 52). In these articles, Money used gender role/identity as a governing principle in influencing the way in which he recommended surgery be done. “Based on a study of sixty-five ‘ambiguously sexed people,’ the authors declared it inappropriate, even unwise, to rely solely on gonadal, hormonal, or chromosomal criteria for gender assignment” (Karkazis 2008: 52). Money and the Hampsons did further studies among 105 intersex individuals in which most of them (all except 5) had gender identities congruous with their gender assignment and rearing (Karkazis 2008: 53). From these studies, the researchers made a revolutionary proposition: “…they considered gender-role development a multistage process that relied on multiple attributes of biological sex and social variables but that could not be said to derive from these exclusively” (Karkazis 2008: 53). Through this reasoning, parents could rear a child towards a specific gender. Money and the Hampson’s proposal was to fill a gap, the gap that Money found in his dissertation.
Money’s budding theory of gender development, which suggested that sex of rearing was critically important for gender acquisition and development, filled this gap and, when coupled with surgical and hormonal treatment, could ensure that the child avoided physical developments incongruous with the assigned gender (Karkazis 2008: 54).
Critiqued by some for being culturally and environmentally deterministic, Money’s approach was applauded and applied by others. “Contrary to recent characterizations of Money’s theory as exclusively social, he actually suggested a complex system of psychological and physiological interaction and development” (Karkazis 2008: 54).
Given their belief in some flexibility and malleability in gender development and formation, Money and his colleagues proposed moving away from identifying an indvidual’s supposedly true sex and toward a new model of gender assignment that would take into account multiple biological variables of sex and its future development at puberty to select the optimal gender for the individual (Karkazis 2008: 55).
Now instead of sex, intersexuality became predominantly about gender, psychological health, and belonging.
This publication led to Money and the Hampsons establishing a treatment protocol for treating the intersexed. Instead of treating adults, they decided to manage infants in order to shape gender identity because according to Money gender identity developed around eighteen months of age. Therefore, the first suggestion they had addressed was when to assign gender to the infant. “They suggested a small window of flexibility and opportunity- until roughly eighteen months of age- during which gender assignment could be most successfully accomplished” (Karkazis 2008: 55) . In relation to this, they said that sex assignment should be made within the first few weeks of life. These recommendations were based on a “belief that successful gender assignment required complete certainty on the part of the child’s parents as to whether the child was male or female” (Karkazis 2008: 55). After age two, changing gender could cause psychological disturbance so assigning gender as early as possible was increasingly important. Also, “According to Money’s theory, once sex assignment was made, surgery should be done as soon as possible so that the genitals could be made to match the assigned sex (Money, Hampson, and Hampson 1955b: 291; Money 1974: 216)” (Karkazis 2008: 57). In determining the need to do this they would weigh the functioning of the gonads and if treating an older child or adults, they would make sure genitals conform to gender of rearing (Karkazis 2008: 56). Money firmly believed in surgery because in making a person aesthetically look like a female or male, they became part of what was assumed to be the natural gender binary. “Money and his colleagues believed that current techniques enabled surgeons to ‘make’ females, but not males; even though the surgical removal of the penis (or clitoris) left no clitoral equivalent, they argued that erotic feeling and sexual climax were still possible (see e.g. Money, Hampson, and Hampson 1955b: 288, 295)” (Karkazis 2008: 57). In providing reason for favoring surgery, Money said it would help with gender identification and rearing. “The reason for this was twofold: first, Money felt that the child was more likely to develop a proper gender role with genitals matching those of the assigned sex; second, parents troubled by gender ambiguity might waver in their commitment to raising the child in the assigned gender” (Karkazis 2008: 57-58). Of utmost importance to Money, was to highlight psychological health, one which was based on fitting social norms.
According to Money’s theory, all children are born essentially psychosexually neutral at birth, and thus surgeons can make any child any gender as long as the sexual anatomy can be made reasonably believable. For this reason, it did not matter how the genitalia looked originally, according to Money, because you could always teach gender or sex roles. “…if children are to develop stable gender identities (and by consequence be happy and mentally healthy), they must have “correct” looking genitalia” (Dreger 1999: 11). Intersex surgery was more cosmetic because of the desired result to have a normal-appearing body. This normal appearing body would insure proper psychosexual development to what Money considered the proper gender and, in turn, assume the appropriate (hetero)sexuality. In choosing a gender, the child could be integrated into society if everything is done “to assure that the child and h/her parents believed in the sex assignment” (Fausto-Sterling 2001: 46).
Money also advocated being frank and truthful with the parents to minimize psychological disturbance. Yet in practice, Money said that parents should be told immediately if the child was a girl or boy because of the stigmatization of the intersex being labeled as “half-boy”, “half-girl”. He insisted that the parents be told genitals would be finished through surgery (Karkazis 2008: 59). Thus, the parents were not always told the full truth about the child’s condition and surgery was usually performed if discovered at birth.
Surgeries were performed if their were noticeable differences according to definitions of typical genitalia. Surgeries were done if boys were born with a phallus that was less than 2.5 centimeters; doctors would reduce it and proclaim the baby a girl. If a girl was born without a Y chromosome and had a clitoris longer than 1 cm the doctors would seek to reduce it because they thought that “it will bother the child’s parents and interfere with bonding and gender identity formation” (Dreger 1999: 12). Hormone treatments were used later if needed, under the conditions that the individual had different ratios of testosterone or estrogen then was determined as normal by the medical field. Out of a commitment to do no harm doctors did not usually tell the parents or the children all that they knew because it will “confuse or complicate the family’s understanding of gender. All of the professional energy is aimed at producing a physically ‘right’ girl or boy who, presumably, the parents will then be able to raise in an unambiguous way” (Dreger 1999: 12). Surgery was intended to produce a heterosexual happy person who could have relationships with their family, without ever knowing they were born intersexed until later.
Before puberty, Money advocated giving the child information about their condition (Karkazis 2008: 59). “Somewhat confusingly, then, Money and his colleagues advocated both honesty and concealment- a fact that may have led many clinicians to assume that given the option, concealment might prevent more harm and engender less confusion” (Karkazis 2008: 60). His form of concealment led parents to hide countless surgeries from children. Although his protocol was not full-proof, Money’s methods became the dominant model for over forty years.
Money is revolutionary because his methodology for treating the intersex took hold and persisted for an extended period of time. Money was the first person to suggest a multistage model to treat intersex infants and the first to provide a complicated view of intersexuality that recognized phenotypes of diagnoses and prepared for later physical developments (Karkazis 2008: 60). Also, his work and implementation of the protocol was met with widespread approval and integration. “Following publication, the treatment protocols were quickly incorporated into medical practice and texts, and they achieved a remarkable dominance for the following forty years” (Karkazis 2008: 60).
This section epitomizes most of my thesis, especially the last sentence. My intention in my thesis or my argument, which is the last thirty pages or so, analyzes the current change in medical protocol. What I found most interesting in my readings is that medicine does not usually follow umbrella protocols, but addresses individual cases, unlike say, political public policy. I found this interesting and a rare occurrence in medicine which allowed for unethical decisions to be made such as concealment which as referred to by Money, was a vague concept.
I recognize in Money that what he did was revolutionary. In the end I still ask myself, as an aspiring medical practitioner, what I would do? If I was a parent, what I would do? As an intersex adolescent, what might I do? How would I feel? I have no idea. What is the right thing to do? And I still puzzle over that and always will.