Declaring With Clarity, When Gender Is Ambiguous
Dr. William G. Reiner, a faculty member at the University of Oklahoma and Johns Hopkins, says he is just a "dull guy leading a dull life."
That seems unlikely. A 57-year-old psychiatrist and urologist, Dr. Reiner is a leading specialist in the treatment of children with the intersexual condition, boys and girls born with ambiguous genitaliA.
"I like working with these children," he said on a break in a meeting in Washington, where he had made a presentation before the American Association for the Advancement of Science. "They've had atypical life experiences, and they tend to be extraordinarily sensitive and vulnerable. They see an aspect of what it means to be alive in a different way from the rest of us."
Q. How did you begin with your unusual specialty?
A. In the early 1980's, I was a urologist in central California, and this remarkable 14-year-old "girl" came to my office. "I'm a boy, not a girl," this child declared.
The child had an intersex condition. At birth, he didn't have a penis, but rather something that appeared more like an enlarged clitoris. He had a partial testicle on one side. Internally, he was half female, and he looked more female than male. Indeed, since infancy, his parents had raised him female.
Since puberty, however, that one testicle had begun producing enough male hormones to masculinize him. To all he now insisted, "You've got it wrong: I'm a boy!"
And this child wanted me to help convince his parents he was male. Moreover, he wanted me to help him get surgery so that his phallic structure looked more like a penis. I was able to do both.
That was the beginning for me. Over years, I saw dozens of children with anomalies of their genitaliA. Eventually, I retrained in psychiatry so that I could help them with the nonsurgical aspects of what they encountered. These children moved me. When you hear someone declare with such clarity that they know themselves far better than the experts, it is life changing.
Q. Aren't these intersex conditions rather rare?
A. There are probably around 1,000 intersex babies born every year in the United States. The numbers can add up. The term actually refers to six different conditions where children are born with ambiguous sexual structures.
The majority are the result of something going wrong early in a pregnancy, where the fetus is exposed to an inappropriate amount of hormones in the uterus.
You can get genetic girls who look from the outside like males because they were exposed to male hormones at a critical stage of fetal development. Conversely, you can get genetic males looking like females because they didn't get enough male hormones in utero.
There are a whole group of more mixed external manifestations of gender that also occur.
Until the 1950's, when an intersex child was born, they were let be. But starting in the 1950's, the general approach was to make the child into one sex or another. If it was a partially masculinized female, there was a surgical attempt to turn her into a "normal" female. Structures were created so that she could have intercourse later.
If the child was a genetic male, the question was, Will the adult penis be large enough for sexual intercourse? The vast majority of the children with severe inadequacy of the penis were converted to "female" surgically and then raised as girls.
Q. So the prescription for the intersex boys was castrate them and put them into a dress?
A. The problem was, In a large number of children, as with my first intersex patient, it never took. Gender has far more to do with other important structures than external genitals.
Q. How do you know what constitutes gender identity?
A. As part of a research study, I've personally seen and assessed 400 children with major anomalies of the genitals. Of those, approximately 100 might be called "intersex." Our findings have been many and complex. The most important is that about 60 percent of the genetic male children raised as female have retransitioned into males.
We also found that of this group there were some genetically male children, who despite genital anomalies were raised as males, and they continued to declare themselves as male.
Q. What conclusions can you draw about the eventual sexual identity of an intersex child?
A. That you can castrate a male at birth, create a female genital structure, raise the child as a girl, and in a majority of the cases, they'll still recognize themselves as male. Now many of the children I've seen are still young. I don't know what will happen as they get older.
The larger point is that it's been a monstrous failure, this idea that you can convert a child's sex by making over the child's genitals in the sex you've chosen. This began in the 1950's, when surgeons who felt helpless when they encountered intersex children thought they were helping them with sexual reassignment. The psychologists were saying, "You can make a boy or a girl or anything you want." It wasn't true. The children often knew it.
Q. The idea of sexual reassignment surgery started at Johns Hopkins, where you are a part-time faculty member. Has there been a change in attitude among the staff members there?
A. It's my understanding that the originators of that standard of care may still support that idea and are still on staff. But I've also spoken with the Johns Hopkins Institutions' pediatric urologists, and my sense is they'd be very leery of sex assigning a genetic male to female.
Q. Can children grow up mentally healthy if they have ambiguous genitalia?
A. I think that these sexual assignments often create more problems than they solve. The children grow up with unhealthy secrets. What the kids tell me is that while they didn't know they were males, they always knew something was wrong because they were "too different" from all the other girls.
In my psychiatric practice, I've had families where the parents asked me to be with them when they told their children, "You were actually born a boy." That turned out to be a critical moment because every child converted to being a boy within hours, except for two. With those two, they refused to ever discuss their sexual identity again. Still, none of them stayed female.
Q. Because of all this new research, is the accepted standard of care of intersex children changing?
A. There's no one standard now. Five years ago, a genetic male child born without a penis or a severely inadequate one almost universally would have been assigned female at birth. Today, about two-thirds of the pediatric urologists say they wouldn't go that route, which means that one-third still might. That says that we're not sure of the right way, yet.
It's an irony to me that surgeons have gotten the worst criticism from intersex adults for these practices. Certainly psychologists and endocrinologists were also involved.
From what I've seen, it's the surgeons that have made the biggest changes the fastest. I think part of the reason for that is that surgeons do things to their patients physically and are, therefore, very sensitive to doing the right thing.
Q. What conclusions do you draw from your study?
A. That sexual identity is individual, unique and intuitive and that the only person who really knows what it is is the person themselves. If we as physicians or scientists want to know about a person's sexual identity, we have to ask them.
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