Tag Archives: Anne-Fausto Sterling

John Money

Introduction

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 In order to prove his point “… Money did a comparative analysis of 248 published and unpublished case histories (from 1895 to 1951) and patient files, as well as an in-depth assessment of ten living individuals classed as hermaphrodites” (Karkazis 2008: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).

Conclusion

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.

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Intersex Research

Hi all,

As I have noticed over the past few months, one of my most frequently visited pages is the one on Intersex Resources. To those who find the information interesting or identify as being intersex, I have news. I am going abroad next semester to study in Amsterdam, Netherlands and am doing research on the treatment of intersex individuals in the medical field.

Here is my proposal:

Question I want to answer

Upon reading Sexing the Body by Anne Fausto-Sterling I became interested in how society and political beliefs, among many other factors, influence the experimental findings and ideologies of science. One of the main groups of people Fausto-Sterling focuses on, are people who identify as intersexed, to prove a point about how sex identification is a prominent part of human culture. I have been prompted, by Fausto-Sterling, to investigate the treatment of intersexed people further and to propose ideas in which to categorize less and to self-identify more. In conclusion, I want to answer the question of how people who identify as intersexed, both as individuals and as a collective, are medically considered and socially regarded by endocrinologists, neonatalists, and medical students in the surrounding area of Amsterdam.

What method do you want to use?

To go about answering this question I want to interview medical students, neonatalists, endocrinologists, and those who identify as interceded. In addition, I would do historical research about the treatment administered to people who had “ambiguous genitalia” in the past few hundred years.

What I am asking for

I was wondering, if any of you who had any research backgrounds, knew of places I could grants? or…if there are any intersexed individuals out there, that they would be willing to share their stories?

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Being Intersexed: Resources

Introduction

Many people do not know what intersex means because it was commonly referred to in the past as being a hermaphrodite. Being intersexed is very in the closet because of the general belief in American society that gender fits into a binary. Being intersexed proves that gender is complicated, sex is complicated, and identity is complicated (as are many more things that influence being intersexed and anything in general).

I am not intersexed, I am not an expert, but I wish to distribute information. This is what I have found, encountered, believe, etc. I can not be expert advice, but I can be a start.

I highly recommend visited the ISNA website, whose acronym I explain below. It is an excellent resource and has been advocating for intersex rights ever since Cheryl Chase helped create it.

What is Intersex?

““Intersex” is a general term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. For example, a person might be born appearing to be female on the outside, but having mostly male-typical anatomy on the inside. Or a person may be born with genitals that seem to be in-between the usual male and female types—for example, a girl may be born with a noticeably large clitoris, or lacking a vaginal opening, or a boy may be born with a notably small penis, or with a scrotum that is divided so that it has formed more like labia. Or a person may be born with mosaic genetics, so that some of her cells have XX chromosomes and some of them have XY.

Though we speak of intersex as an inborn condition, intersex anatomy doesn’t always show up at birth. Sometimes a person isn’t found to have intersex anatomy until she or he reaches the age of puberty, or finds himself an infertile adult, or dies of old age and is autopsied. Some people live and die with intersex anatomy without anyone (including themselves) ever knowing.” (http://www.isna.org/faq/what_is_intersex)

To find out more about this, go to the ISNA’s website (which I will cover later in this post). They have a bunch of information, links, and recommendations.

What Intersex Condition do you have?

To find out what conditionmay fit to your genitalia, explore this website, but be sure to confirm with a clinician.

Intersex Conditions: http://www.isna.org/faq/conditions

How common is intersex?

“To answer this question in an uncontroversial way, you’d have to first get everyone to agree on what counts as intersex —and also to agree on what should count as strictly male or strictly female. That’s hard to do. How small does a penis have to be before it counts as intersex? Do you count “sex chromosome” anomalies as intersex if there’s no apparent external sexual ambiguity?1 (Alice Dreger explores this question in greater depth in her book Hermaphrodites and the Medical Invention of Sex.)

Here’s what we do know: If you ask experts at medical centers how often a child is born so noticeably atypical in terms of genitalia that a specialist in sex differentiation is called in, the number comes out to about 1 in 1500 to 1 in 2000 births. But a lot more people than that are born with subtler forms of sex anatomy variations, some of which won’t show up until later in life.

Below we provide a summary of statistics drawn from an article by Brown University researcher Anne Fausto-Sterling.2 The basis for that article was an extensive review of the medical literature from 1955 to 1998 aimed at producing numeric estimates for the frequency of sex variations. Note that the frequency of some of these conditions, such as congenital adrenal hyperplasia, differs for different populations. These statistics are approximations.

Not XX and not XY one in 1,666 births
Klinefelter (XXY) one in 1,000 births
Androgen insensitivity syndrome one in 13,000 births
Partial androgen insensitivity syndrome one in 130,000 births
Classical congenital adrenal hyperplasia one in 13,000 births
Late onset adrenal hyperplasia one in 66 individuals
Vaginal agenesis one in 6,000 births
Ovotestes one in 83,000 births
Idiopathic (no discernable medical cause) one in 110,000 births
Iatrogenic (caused by medical treatment, for instance progestin administered to pregnant mother) no estimate
5 alpha reductase deficiency no estimate
Mixed gonadal dysgenesis no estimate
Complete gonadal dysgenesis one in 150,000 births
Hypospadias (urethral opening in perineum or along penile shaft) one in 2,000 births
Hypospadias (urethral opening between corona and tip of glans penis) one in 770 births
Total number of people whose bodies differ from standard male or female one in 100 births
Total number of people receiving surgery to “normalize” genital appearance one or two in 1,000 births

1 Dreger, Alice Domurat. 1998. Ambiguous Sex—or Ambivalent Medicine? Ethical Issues in the Treatment of Intersexuality. Hastings Center Report, 28, 3: 24-35.

2 Blackless, Melanie, Anthony Charuvastra, Amanda Derryck, Anne Fausto-Sterling, Karl Lauzanne, and Ellen Lee. 2000. How sexually dimorphic are we? Review and synthesis. American Journal of Human Biology 12:151-166.

We were recently asked to update these frequency figures, and a lively discussion arose between two staff members.” (http://www.isna.org/faq/frequency)

The ISNA: Intersex Society of North America

The ISNA, as found on their website (by their mission statement) stand for:

“systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female.

We have learned from listening to individuals and families dealing with intersex that:

Click here to learn more about our agenda. With your help, we can make the world a safer place for families dealing with intersex conditions.” (http://www.isna.org/)

Doctors for the Intersexed

You can find this at this website: http://www.aissg.org/52_CLINICIANS.HTM

NOTE: This is only a start and from limited sources I found online and thus can be outdated. I would recommend getting in contact with someone from ISNA to talk about this or finding a support network in your area where you can feel safe in asking about a doctor who will provide you with safe service and make you feel comfortable.

What to do once you found out you are intersexed

Support groups:

http://www.isna.org/support

Find a doctor who can confirm hormonal/genetic difference: http://www.aissg.org/52_CLINICIANS.HTM

You may have a lot of questions, just discovered it yourself, and may feel overwhelmed. I do not recommend this website right away, but it is incredibly helpful and from what I have seen, considerate:

http://www.isna.org/faq

Excellent Resource: Sexing the Body by Anne-Fausto Sterling

Sexing the Body: Gender Politics and the Construction of Sexuality. By Anne Fausto-Sterling. New York: Basic Books, 2000, 473 pages.

Spanish Translation: Cuerpos sexuados. Editorial Melusina: Barcelona, Spain, 2006.

“Professor Fausto-Sterling’s most recent work, entitled Sexing the Body: Gender Politics and the Construction of Sexuality, was published by Basic Books in February 2000. It examines the social nature of biological knowledge about animal and human sexuality.

Sexing the Body received the Distinguished Publication Award in 2001 by the Association for Women in Psychology. In 2000 it was chosen as one of the Outstanding Academic Books of 2000 by CHOICE Magazine, Published by the American Library Association. It was also co-winner of the Robert K Merton Award of the American Sociological Association Section on Science, Knowledge and Technology.

From the back cover:

“Why do some people prefer heterosexual love while others fancy the same sex? Do women and men have different brains? Is sexual identity biologically determined or a product of social convention? In this brilliant and provocative book, the acclaimed author of Myths of Gender argues that the answers to these thorny questions lie as much in the realm of politics as they do in the world of science. Without pandering to the press or politics, Fausto-Sterling builds an entirely new framework for sexing the body-one that focuses solely on the individual.” (http://bms.brown.edu/faculty/f/afs/afs_publications_books.htm)

More books:

http://www.isna.org/books

Conclusion

I do not know much about the experience of being intersexed because I am not. I wish to increase the visibility of intersex while keeping people who identify as intersex safe. I hope that the gender binary begins to blur or that everyone can accept others differences. I hope this is a valuable resource and if you wish to hear more about this particular subject, feel free to contact me.

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