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Re: Ablatio Penis: More on the John v Joan Case

Dear Editor,

In their timely review regarding gender assignment in newborns with physical intersex conditions, Ahmed et al [1] made a cursory reference to the ‘John v Joan case,’ noting that it ‘famously challenged’ John Money’s hypothesis about the importance of the rearing environment vis-á-vis gender identity differentiation and formation. Ahmed et al comment that ‘this single, rather atypical case of gender identity change from female to male gender may have over-exaggerated the role of prenatal hormones in the development of gender identity in all cases of complex genital anomalies...’ (p 848).

Ahmed et al do not really provide the reader with any specific information about the nature of the John v Joan case. The patient, whose real name was David Reimer, was, at birth, a normal biological male. He happened to have an identical twin. At the age of 7 mos, Reimer’s penis was literally burned off during electrocautery for circumcision, which was required due to phimosis. A decision was made to raise Reimer as a girl around the age of 17 mos, and castration and initial genital reconstruction were instituted around the age of 21 mos. [2].

Because Reimer was born a normal biological male, some theorists touted this case as one of the most stringent tests of an ‘experiment of nurture’ with regard to gender identity differentiation. When it was subsequently reported that Reimer appeared to be developing a female gender identity during childhood, it was argued that this was evidence in support of the rearing environment in determining gender identity formation [3]. Unless Reimer was ‘predisposed’ to be a male-to-female transsexual, how else could one account for a normal biological male apparently developing a female gender identity?

Subsequent follow-up reports of Reimer in adolescence and adulthood indicated that the ‘experiment of nurture’ did not work. By early adolescence, Reimer had rejected his identity as a female, ‘reverted’ to the male social role, began to receive testosterone injections, and efforts were made at phallic reconstruction. Reimer’s sexual orientation appeared to be exclusively sexually attracted to women. At age 25, he married a woman and adopted her children. As a result, the long-term outcome of the Reimer case has been used by other theorists to challenge the importance of the rearing environment in determining gender identity formation [4]. Moreover, many critics have used the case to challenge the general principle that the rearing environment is an important factor in gender identity formation and, as a result, clinicians are now more uncertain about making recommendations for gender assignment with regard to the various physical intersex conditions that were reviewed by Ahmed et al. (As an aside, two other tragic developments about the Reimer case are worth noting. In 2002, Reimer’s twin brother committed suicide and, in 2004, at the age of 38, Reimer also committed suicide[5].)

In their review, Ahmed et al failed to mention another case of ablatio penis that our group described [6]. Our patient’s penis was also burned off during electrocautery, at the age of 2 mos. A decision to raise our patient as a girl was made at 7 mos, at which time castration was performed. At the age of 26 years, our patient was interviewed for a psychosexual follow-up. Our patient reported a female gender identity. Her recalled gender role behaviour in childhood was ‘tomboyish’. As an adult, she worked in an occupation typically populated by men. Her sexual orientation in both phantasy and behaviour was bisexual.

The gender identity outcome of our patient was, therefore, strikingly different than in the Reimer case. Both Reimer and our patient were, however, ‘tomboyish’ during childhood. Whereas Reimer appeared to be exclusively attracted sexually to women, our patient was sexually attracted to both women and men. Thus, there were both similarities and differences in psychosexual differentiation in these two cases of ablatio penis.

We agree with Ahmed et al that the outcome in the Reimer case should be interpreted cautiously with regard to clinical management principles for patients born with physical intersex conditions. The outcome of our own case makes the matter even more complicated.

References

(1). Ahmed SF, Morrison I, Hughes IA. Intersex and gender assignment; the third way? Arch Dis Child 2004;89:847-50

(2). Zucker KJ. Intersexuality and gender identity differentiation. Annu Rev Sex Res 1999;10:1-69

(3). Money J. Ablatio penis: normal male infant sex-reassigned as a girl. Arch Sex Behav 1975;4:65-71

(4). Colapinto J. As nature made him: the boy who was raised as a girl. Toronto: HarperCollins, 2000

(5). Chalmers A. Boy raised as girl commits suicide. The National Post, May 10, 2004