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Programmed gender identity is irreversible

The irreversibility of programmed gender identity is clearly illustrated by the sad story of the John-Joan- John case (i.e. the case of David Reimer). In the 1960s and 1970s, in the context of the concept of behaviorism, it was postulated that a child is born as a tabula rasa and is subsequently forced in the male or female direction by society's conventions. Although it is true that, in humans, self-face recognition appears to emerge at around 18 months of age (26) and that by the age of 2-3 years children are able to correctly label themselves and others according to gender (27), there is no evidence that external or social events might modify these processes. However, J. Money argued that: "Gender identity is sufficiently incompletely differentiated at birth as to permit successful assignment of a genetic male as a girl. Gender identity then differentiates in keeping with the experiences of rearing" (28). This view had devastating results in the John-Joan-John case (29). Money maintained that gender imprinting does not start until the age of 1 year, and that its development is well advanced by the age of 3-4 years (30). This was, indeed, the basis for the decision to make a girl out of an 8-month-old boy who lost his penis due to a mistake during minor surgery (i.e. an operation to correct phimosis). The testicles of this child were removed before he reached the age of 17 months in order to facilitate feminization. The child was dressed in girls' clothes, received psychological counseling and was given estrogens in puberty. According to Money, this child developed as a normal female. However, Milton Diamond later made it clear that this had not been the case at all. In adulthood, this child changed back to male, married, and adopted several children (31). Unfortunately, he had a troubled life and committed suicide in May 2004.This story illustrates the enormous programming influence of the intrauterine period on gender. Other cases have been described in the literature (32), due to enzymatic disorders (33-35) or to cloacal exstrophy (36), that support the existence of early permanent programming of brain sex by biological factors and androgen exposure, rather than by social environment and learning(17,37).

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BACKGROUND Cloacal exstrophy is a rare, complex defect of the entire pelvis and its contents that occurs during embryogenesis and is associated with severe phallic inadequacy or phallic absence in genetic males. For about 25 years, neonatal assignment to female sex has been advocated for affected males to overcome the issue of phallic inadequacy, but data on outcome remain sparse.

METHODS We assessed all 16 genetic males in our cloacal-exstrophy clinic at the ages of 5 to 16 years. Fourteen underwent neonatal assignment to female sex socially, legally, and surgically;

RESULTS Eight of the 14 subjects assigned to female sex declared themselves male during the course of this study, whereas the 2 raised as males remained male. Subjects could be grouped according to their stated sexual identity. Five subjects were living as females; three were living with unclear sexual identity, although two of the three had declared themselves male; and eight were living as males, six of whom had reassigned themselves to male sex. All 16 subjects had moderate-to-marked interests and attitudes that were considered typical of males. Follow-up ranged from 34 to 98 months.

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Of 84 total patients, 69 were reared female, but only 32 lived as female, while 29 lived as male; four patients refused to discuss sex-of-living; parents of four patients rejected their declarations of male identity. All 15 patients reared male lived as male including two genetic females.

Conclusion: Active prenatal androgen effects appeared to dramatically increase the likelihood of recognition of male sexual identity independent of sex-of-rearing. Genetic males with maletypical prenatal androgen effects should be reared male.

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