Book Review

As Nature Made Him: The boy who was raised as a girl

N Engl J Med 2000; 342:1457-1458May 11, 2000

Article

As Nature Made Him: The boy who was raised as a girl
By John Colapinto. 270 pp. New York, HarperCollins, 2000. $26. ISBN: 0-06-019211-9

A variety of conditions may cause an infant to have ambiguous genitalia. The treatment of choice is a topic of hot debate among professionals and, more recently, among support groups of adults born with such intersexual conditions. One issue concerns the factors that determine a “good outcome” and thereby the policy of sex assignment. Sexual identity, the experience of oneself as male or female, is a core component of this outcome. Unfortunately, the empirical knowledge needed to make decisions about sex assignment is scanty.

Such knowledge was virtually nonexistent in 1967, after a male twin had lost his penis in a circumcision accident at the age of eight months. At Johns Hopkins Hospital, John Money, an authority in the field of sexology, advised the parents to reassign the sex of the child. At the time, Money was one of the very few scientists who questioned the existing policy of assignment according to the sex of the gonads. His view was based on his studies of intersexual patients. In the great majority of such cases, sexual identity appeared to be shaped by rearing instead of by chromosomes, gonads, or sex hormones. In Money's view, even a healthy boy could, after genital traumatization, develop a female identity, provided that the reassignment was timely and the child was raised unambiguously as a girl.

For many years, this case was considered to be the ultimate evidence of psychosexual neutrality at birth. It had a considerable effect on decisions concerning sex assignment of intersexual children throughout the world. Early reports showed that, in contrast to the twin brother, the reassigned child seemed to develop as a “real girl,” although she had many tomboyish traits. However, it later became apparent that the child had serious problems with sexual identity. When, at the age of 14, she was informed of her sex at birth, she immediately decided to live as a boy again. Asked for his reaction to this outcome by the press and professionals, Money was reluctant to respond. Diamond and Sigmundson published a follow-up of the case three years ago, when the patient was in his early 30s. Unlike Money, they considered the development of male identity to be determined to a considerable extent prenatally, through the brain's exposure to androgens. In their opinion, the case invalidated the theory of psychosexual neutrality at birth.

Colapinto's book contains two stories. One is the sad account of a family with a child who had to live with an unwanted sex role. The other provides the medical and psychological contexts of this tragedy. The personal story vividly describes how horrible life can be for a child with an incongruence between sexual identity and sex of rearing. For such children, stigmatization, bullying, and alienation from peers and family are daily problems. When confronted with so much suffering, it is hard not to look for someone to blame. Whereas in many cases of childhood problems of sexual identity there is no clear culprit, in this particular case the obvious candidate is John Money.

It is proper that medical mistakes or wrongful approaches to patients be exposed, but it is regrettable that this book devotes so much attention to the psychological makeup of just one clinician. Colapinto uses much of his well-researched material to reveal each and every one of Money's flaws. Unfortunately, in doing so, Colapinto himself makes mistakes (e.g., he incorrectly describes the work of a scientist who defended Money's theoretical position by presenting another case of ablatio penis in which there were no identity problems) and depicts the medical and psychological treatment of transsexuals as one of Money's idiosyncratic hobbies. Transsexualism is a young field of study, full of prejudice and taboos. Colapinto doubtless wrote his book intending to protect the interests of intersexual patients, but ironically, he will probably make life harder for a group of equally vulnerable patients — transsexuals. Colapinto overshoots the mark. Instead of launching a personal crusade, he could have focused on the challenges faced by clinicians in the field of sexual identity or tried to understand what the life of the reassigned twin would have been like if he had been raised as a boy without a penis. Such discussions would have given the book a broader and more balanced view of the complex issues at hand.

Despite these criticisms, the book is interesting and will be accessible to a large audience. It shows how much more we need to know to prevent personal tragedies such as that suffered by the boy who was raised as a girl.

Peggy T. Cohen-Kettenis, Ph.D.
University Medical Center Utrecht, 3508 GA Utrecht, the Netherlands

Citing Articles (1)

Citing Articles

1. 1

   Hervé Sitbon. (2001) Carte des intimités dans la famille et différenciation sexuelle de l'enfant. Cahiers critiques de thérapie familiale et de pratiques de réseaux 27:2, 59
   CrossRef