The sex of a newborn child is of keen interest to the parents, but some children are born with ambiguous genitalia, having both testicular and ovarian tissue, or genetic syndromes that confound a simple designation as male or female. The term gender assignment refers to practices that are used to discern and impose a gender identity on a newborn child.
Suzanne J. Kessler has described how cultural ideals of sex influence the practice of gender assignment. She showed that some physicians have made decisions about gender assignment in accordance with the size and expected function of a child's genitalia rather than in accordance with more complex hormonal and genetic assessments (Kessler, 1990; 1998). If a male child was likely to have a very small penis, for example, some physicians and parents used surgery to assign a female identity to that child. Advocates of this kind of intervention argue that a secure gender identity depends on having appropriate sexual genitalia.
The gender assignment of John/Joan has received a great deal of attention (Colapinto, 1997). In 1966 a physician burned the penis of boy beyond repair during a circumcision that involved an electrocautery needle. Fearful of what the boy's life would be like, his parents took him Johns Hopkins University for evaluation. The psychologist John Money proposed gender reassignment from male to female on the assumption that the loss of the penis was so damaging that it would be better for the child to be raised as female; he also believed that gender identity can be shaped after birth. With the consent of the parents, in 1967 physicians removed the boy's testicles at the age of 22 months, repositioned the urethra, and induced a preliminary vaginal cleft. The parents selected a girl's name and began to treat and raise the child as female (Colapinto, 2000).
From 1972 on Money reported the child's gender assignment as successful. He said that the case showed that gender identity is plastic and can be shaped during early childhood. One's sense of self as male or female is not, he held, determined by anatomy, genetics, or prenatal history. Health practitioners translated that evidence into practice guidelines and encouraged gender interventions. One advocate said that the possibility of female sex assignment with genetic males "must be considered whenever the severity of the genital abnormality is such that it is likely to be extremely difficult or impossible to correct for normal adult functioning" (Baker, p. 266).
In fact, the gender reassignment of this child failed. The child consistently rejected female identification and exhibited male-typical interests and behaviors. Eventually the child refused further interventions, and at that point the family told the child the truth. The fourteen-year-old immediately reclaimed a male identity, adopted a male name, started male hormone treatments, underwent breast removal, and eventually was treated with phalloplasty, the construction of a penis. None of those events were reported in the professional literature until 1997. Thirty years passed between the beginning of this experiment and its publicly described failure (Diamond and Sigmundson).
Some commentators believe that that failure provides evidence that gender assignments do not work, but that conclusion is not fully supported by the evidence. Gender assignment in children has not been well studied, but even if this case failed spectacularly, other interventions might succeed. It also should be noted that the intervention made sense at the time of an unsettled debate about the extent to which gender identity can be influenced after birth. The unfortunate outcome has rightly forced broad reconsideration of gender assignment practices. Various commentators have noted that gender assignment can reinforce dubious notions such as the view that a person cannot be male unless he has a large and intact penis and that it is better for a child to grow up as a sterile female than as a male with a very small or damaged penis.
Some commentators have argued that gender assignment violates children's autonomy (Dreger, 1999). That argument is not convincing because newborns and very young children lack the cognitive powers that justify respect for people's choices. More convincing are worries that early gender interventions are not effective or work to the advantage of anxious parents, not to the benefit of the children. Concerns of this kind suggest that gender assignment in the case of ambiguous genitalia or intersex conditions at the very least should not be treated as inherently shameful or as a social emergency.
Physicians should propose gender interventions to parents only after a rigorous evaluation of the risks and benefits. Among other things, practitioners should advise parents that some individuals live happily with atypical genitalia or intersex conditions and that gender assignment can be carried out later on if that is desired by the child (Dreger, 1998). Parents need support as they think through decisions about gender interventions with their children, and this support should include nonpathologized images of intersex people. In the 1990s the Intersex Society of North America began its education and advocacy efforts to improve options for intersex people and their healthcare providers, and this group explicitly rejects a pathological view of intersexuality.
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