“It’s like looking in a mirror,” he said to Kelly.
—
WYATT HAD BEEN SEEING his therapist, Dr. Holmes, for a little more than a year when he reported to her that he was feeling like sticking his fingers down his throat. Not to throw up, he said. He didn’t really know why, and he said he didn’t know if this idea of his was physical or just in his head. He admitted to Holmes that he’d gotten really angry at his parents about something the week before and that he’d slammed his bedroom door so hard his parents took it off its hinges so he couldn’t do it again.
“I need to get my anger out,” he told Holmes.
“It doesn’t always work to slam things, though,” she said gently.
Wyatt didn’t seem to agree. Later in the session Holmes engaged him in play therapy. Wyatt identified several dolls as girlfriends of his at school, but they said mostly mean, backbiting things about him. One by one he walked each girl doll up to the grandmother-type doll, played by Holmes, to ask for advice about working things out instead of fighting with Wyatt. At the end of the session, Wyatt said, “Well, I didn’t expect them to say those nice things!”
Wyatt and Jonas were becoming much more independent of each other, but it was Wyatt who was more vulnerable to feeling misunderstood. After one particular fight with his brother, interrupted by their mother, Wyatt felt so aggrieved he wrote her a letter:
My anger doesn’t help. And I know that. It’s just that I feel like you favor Jonas over me and I’m not saying that just so you should favor me over him, but when something bad happens you kind of assume that I did something. And you always treat me like I’m a bad guy. I’m not! And whenever your mad at me Jonas boosts his good boy act up a notch and makes himself look better and nicer than me. And I feel like you think that he’s the perfect child and I’m just the “other” one. And when you do this stuff (all of the above) it makes me feel crappy. And when I sprayed Jonas you thought that I did it out of anger. I didn’t. He was just spraying me a lot and I just wanted to spray him back! And that’s the kind of stuff I’m talking about when I say you treat me like a bad guy. Mom, keep in mind that there are always two sides to every story. So don’t jump to any conclusions. And before you punish me for future incidents, let me speak, your always cutting me off and punishing me before I’m done talking.
—
IN ORDER FOR WYATT’S doctors to truly plumb Wyatt’s identification as female, he underwent his first full psychological evaluation in May 2007. The clinical psychologist at Eastern Maine Counseling and Testing Services, Tim Rogers, interviewed Kelly first, then Wyatt. Later, he observed Wyatt in the classroom. Rogers noticed he became especially nervous around people when he wore a new, feminine outfit. He loved his clothes, but he was increasingly conscious of what others thought of him and for this reason was suddenly finding it difficult to cultivate friends. When Rogers asked him about this, Wyatt told him, “Because I’m a boy who wants to be a girl and sometimes people don’t understand.” Rogers also noted Wyatt’s fondness for shotguns, bazookas, and explosions.
“I like violent things,” he told the psychologist. “I want to be a girl but I also like violent things. It’s fun to think about people I don’t like and destroying them.”
His greatest fear: “Going to high school looking like a guy.”
There were no real surprises in the results of the psych tests. The family already knew the depth of Wyatt’s identification with the female gender and certainly his fears and frustrations about possibly growing up male were likely fodder for some of his more violent fantasies. Kelly worried that the closer he got to puberty, the more anxious and upset he was going to get. Wyatt, she knew, really was transgender, and if he was beginning to make himself sick over the fear of facial hair and other masculine features, then it was time to find a doctor to take him the rest of the way.
II
The Sexual Brain
There is no nature, only the effects of nature.
—JACQUES DERRIDA
CHAPTER 14
The Xs and Ys of Sex
Humans have long thought they could control the sex of a newborn or, at the very least, influence whether a baby would be born male or female. Ancient Romans believed if a pregnant woman carried the egg of a chicken close to her breast, she would give birth to a boy. Aristotle contended that conception on the day of a strong north wind would result in a male child, on the day of a strong south wind, a female. In the first century, Pliny the Elder listed a host of recipes to increase the odds of a woman bearing a male child: Either the man or the woman should drink three cups of water containing lakeweed seeds before the evening meal for forty consecutive nights prior to conception, or drink the juice from the male part of the parthenon plant mixed with raisin wine. Last, but certainly not least, the one sure method of giving birth to a boy: eating a rooster’s testicles.
Not to be outdone, Greek physician Galen, in the second century, offered up the following suggestions: A woman could ensure the birth of a male child if, before sexual intercourse, she bound her right foot with a child’s white ribbon. A man could ensure the same if he engaged in intercourse while lying on his right side. Even a prank could influence the sex of a child if, unbeknownst to the pregnant woman, someone placed parsley on her head. Her baby’s sex would then be determined by the sex of whomever she next addressed.
Hippocrates’s solution, perhaps, was simplest, if also the most painful: binding of the right testicle for the birth of a girl; binding of the left testicle for a boy.
There is no shortage of only slightly more sophisticated theories today. For example, because X-chromosome-carrying sperm, which will produce a girl, swim slower and live longer than Y-carrying sperm, the odds of having a daughter are thought to increase if intercourse takes place several days before ovulation, giving male sperm more time to die off.
What we know for sure is that we all begin life essentially genderless, at least in terms of sexual anatomy. The last of our twenty-three pairs of chromosomes makes us either genetic males (XY) or genetic females (XX), but there are at least fifty genes that play a part in sexual identity development and are expressed at different levels early on.
Sexual anatomy, however, is determined in large part by hormones. All of us begin, in utero, with an opening next to the anus and a kind of genital “bud.” The addition of testosterone drives the fetus in the male direction, with the “bud” developing into a penis and the tissue around the hole fusing and forming the scrotum. (This accounts for the “seam” over the scrotum and up the penis.) An inhibiting hormone prevents males from developing internal female reproductive organs.
Without testosterone, the embryo develops in the female direction: The opening becomes the vagina and the labia, the bud the clitoris.
Sexual differentiation of the genitals happens at about six weeks, but the sexual differentiation of the brain, including gender identity and the setting of our gender behavior, is, at least partly, a distinct process. Again, hormones play the crucial role, with surges of testosterone indirectly “masculinizing” the brains of some fetuses, causing subtle but distinct differences in brain structure and functional activity. For instance, the straight gyrus, a narrow strip that runs along the midline on the undersurface of the frontal lobe, is about 10 percent larger in women than men. The straight gyrus, scientists have found, is highly correlated with social cognition—that is, interpersonal awareness. These same scientists, however, caution that differences in biological sex are not necessarily hardwired or absolute. In adults, they found that regardless of biological sex, the larger the straight gyrus the more “feminine” the behavior. For most males, the action of male hormones on the brain is crucial to the development of male gender identity. A mutation of an androgen receptor on the X chromosome can cause androgen insensitivity syndrome, in which virilization of the brain fails, and when it does, a baby will be born chromosomally male (XY) and have testes rather than ovaries, but also a short vagina, and the child’s
outward appearance will be female. Its gender identity is nearly always female as well.
In other words, our genitals and our gender identity are not the same. Sexual anatomy and gender identity are the products of two different processes, occurring at distinctly different times and along different neural pathways before we are even born. Both are functions of genes as well as hormones, and while sexual anatomy and gender identity usually match, there are dozens of biological events that can affect the outcome of the latter and cause an incongruence between the two.
In some ways, the brain and the body are two very different aspects of what it means to be human, especially when it comes to sex and gender. Who we are, male or female, is a brain process, but what we look like at birth, what we develop into at puberty, who we are attracted to and how we act—male, female, or something in between—are all embedded in different groups of brain cells with different patterns of growth and activity. Ultimately gender identity is the result of biological processes and is a function of the interplay between sex hormones and the developing brain, and because it is a process that takes place over time, in utero, it can be influenced by any number of environmental effects.
Studying gender identity in the laboratory with animal models is virtually impossible. There is no way to know whether a male monkey feels like a male monkey. There is no experimental model of the transgender person; there is no lab protocol; no double-blind, placebo-controlled, randomized trials. There are just human beings, each of us understanding, often without thinking about it, who we are, male, female, or something in between.
The permutations are myriad. Some individuals have the chromosomes of one gender but the sex organs of the opposite gender. Others are born with male genitals and testes, but internally have a womb and fallopian tubes. Still others have male genitals, small testes, and ovaries. Then there are cases like the pregnant woman in Australia who in 2010 discovered that though she was about to give birth to her third child, a large number of cells in her body identified her as chromosomally male. How could that be? The woman was herself likely the result of twin embryos—a boy and a girl—that merged in her mother’s womb. She was female according to her sex organs, but genetically she was female and male, a condition called chimerism. Some people have atypical chromosomal configurations, such as XXX or XXY or XYY, and still others may have different chromosomal arrangements in different tissues, a condition called mosaicism.
Beyond chromosomes, any kind of mutation, or change, in the balance of hormones will tip the sexual development of the fetus toward one side or the other independently of what the chromosomes “say.” Scientists have identified more than twenty-five genes that are involved in creating differences in sexual development. With the advancements in DNA sequencing, they are uncovering an enormous range of variation in these genes as well. For more than forty years, researchers were aware of widespread microchimerism, in which stem cells from a male fetus cross the placenta into the mother’s body and maternal stem cells cross over into the male fetus. But only recently have scientists discovered that those crossover cells can last a lifetime.
No one thing determines sex; rather, it’s a system, and as with any system, small changes or interruptions can lead to nonbinary results, neither wholly male nor wholly female. As many as one in one hundred infants are born with sexual anatomy that differs in some way from standard male and female anatomy, according to Brown University gender researcher Anne Fausto-Sterling. In the past, those born with this condition were called hermaphrodites. Today, scientists estimate that about one in every two thousand infants is born with genitalia so noticeably atypical that an expert in sex differentiation is consulted.
Historically, how doctors decided at birth which sex to assign to intersex infants was based less on biology than on cultural expectations and stereotypes. The most common instances of ambiguous genitalia are an enlarged clitoris for female babies and a microphallus for male babies. At some hospitals in the 1970s, the medical standard for assigning male gender was based chiefly on the length of the penis. A baby born with a penis smaller than 2.5 centimeters, the size generally required for a male to urinate standing up, was assigned female. Medical professionals, in these cases, felt uncomfortable about leaving an infant with ambiguous genitalia. Most therefore urged parents to decide on a sex for these babies immediately after birth, then hand the infants over to the surgeons to “correct” the confusion.
That was the situation one Catholic mother in New Jersey faced on August 14, 1956, when she gave birth to a baby who had either a very small penis or an enlarged clitoris. At the time, no one could say for sure which it was, and the situation so confounded the doctors they kept the mother under sedation for three days while they tried to figure it out. Finally, they suggested the parents assign the infant a male identity, so the parents took baby Brian home. Eighteen months later, however, doctors performed exploratory surgery on Brian and discovered a uterus and ovotestes—that is, gonads containing both ovarian and testicular tissue. Because of the presence of the uterus, the physicians told the parents they had been wrong. Brian was really a girl, and so her microphallus (or enlarged clitoris) was removed and the baby was renamed Bonnie. The doctors also suggested to the parents that for the sake of the whole family they should move out of state and throw away any photographs of the infant dressed as a little boy. The parents, believing the doctors knew best, obliged.
When Bonnie turned eight she underwent yet another surgical procedure, this time to remove the testicular part of her gonads. Her parents told her the operation would help her stomachaches go away. Finally, when Bonnie was ten, her parents told her the truth. Although deeply disturbed, the child kept the secret, focused on her schoolwork, and eschewed intimate relationships. Eventually she graduated from the Massachusetts Institute of Technology with a math degree and founded a tech company. In her late thirties she corresponded with gender experts and wrote an open letter published by the journal Sciences, asking people with similar intersex conditions to join the Intersex Society of North America, though the society didn’t actually exist at the time. She signed the letter with an alias: Cheryl Chase. Because of the wealth of responses, the organization soon came into being, and Cheryl Chase became a spokesperson for the intersex movement, advocating that doctors not do surgery on intersex babies but let them make that decision themselves when they reach an appropriate age.
The plea to hold off on surgery is based on the belief that sex assignment is a cultural pressure, not a biological one. Being intersex, Chase said, shouldn’t be likened to being malformed or abnormal or freakish, and so surgical remedy shouldn’t be the first thing doctors recommend.
Chase and the Intersex Society were standing in opposition to behaviorism, an approach that had a stranglehold on psychology, psychiatry, and sexual politics in the 1960s and ’70s. One of behaviorism’s most ardent proponents was Dr. John Money of Johns Hopkins University, who believed that gender identity was a social construct. In cases of ambiguous genitalia or abnormalities, he said, parents should simply choose the gender in which they wanted to raise their child, and, given appropriate clothing and encouragement to act in a certain way, the child would naturally adopt that gender.
Money’s “showpiece” was a child born in August 1965: a healthy baby boy—an identical twin, in fact—named Bruce. A cauterization to correct an obstruction accidentally burned off Bruce’s penis at the age of eight months. Money convinced the parents that it would be best to raise Bruce as “Brenda,” and so his testicles were eventually removed, and he was given a girl’s name, dressed and treated as a girl, and, unbeknownst to the child, administered female hormones during puberty, at which time he developed breasts. Brenda’s childhood was marked by incessant bullying and teasing, because despite feminine dresses and female hormones she neither felt nor acted female. As a suicidally depressed teenager, she was finally told the truth by her parents, and at the age of fourteen began the transition to being male. By his thirties,
Brenda, who now called himself David Reimer, had gone through a mastectomy, testosterone injections, and two phalloplasty surgeries to rebuild a penis. Eventually he married and adopted children, but he remained tortured by what Dr. Money and his parents had allowed to happen. His twin brother, who was mentally ill for much of his life, died from an overdose of antidepressants in 2002. Two years later, at the age of thirty-eight, David committed suicide as well.
While his patient was alive, however, Money continued to update the public about his “test” case of sex reassignment. In 1972 and again in 1977, he published articles extolling the success of the experiment. Not until the 1990s, when Dr. Milton Diamond tracked down the psychiatrist who treated David when he was a teenage Brenda, did the truth spill out. Money’s overwhelming success story was, in fact, an unmitigated disaster. Brenda had grown up tearing her dresses off, stomping on dolls, and being relentlessly harassed, referred to as a “gorilla” and called a “cavewoman.” The true story of David Reimer’s tortured life was revealed in an academic paper in 1997 and in a book in 2000 and did much to turn the focus on the nature versus nurture debate, at least as regards gender, back to the brain.
The more acceptable view became that gender was innate and determined before birth, but Reimer’s case did nothing to explain how there could be a disconnect between sexual anatomy and gender identity. In fact, Reimer’s situation might have made it harder to understand. In 1953, when former GI George Jorgensen returned from Europe—and the first widely known sex reassignment surgery of an American—as Christine Jorgensen, the idea that someone born a male would want to be female was considered not a medical problem, but a psychiatric one. Such people were referred to in sensational-sounding language as “sexual inverts,” “pseudo-hermaphrodites,” and “sex changelings.” By the 1970s, British author Jan Morris and tennis player Renee Richards made mainstream headlines and bestseller lists with their male-to-female sex changes, but transsexuals, as they were now called, were still outliers, aberrations of nature and scientifically inexplicable.
Becoming Nicole Page 9