Dr. John Money was a psychologist at Johns Hopkins University whose research on transgender people and individuals with ambiguous genitalia led him to develop the theory of psychosexual neutrality. He became prominently involved in the case of the Reimer twins after one of the boys, Bruce, suffered a severe injury to his penis. Dr. Money persuaded Bruce's parents to proceed with a gender reassignment, which involved surgically removing his testicles and raising him as a girl named Brenda.

Dr. John Money

The David Reimer case serves as a significant cautionary tale, highlighting the complexities of gender identity and challenging the belief that socialization can override biological factors. The revelation of the case's true outcome prompted the scientific and medical communities to adopt more careful and considered approaches when managing cases involving intersex children and others with gender identity issues, aiming to prevent unnecessary harm.

Reimer Case's Influence on Pediatric Gender Identity Practices

The case of a Canadian twin boy who, after a surgical accident in infancy, was raised as a girl provides a critical lesson in human development. Despite being socialized as a female from a very young age, the individual consistently rejected this identity, experiencing severe psychological distress, and later chose to live as a man. Based on this outcome, what is the most significant conclusion that can be drawn from this case?

The case of David Reimer began in August of 1965 with the birth of twin boys, Bruce and Brian Reimer, in Winnipeg, Canada. When the boys were a few months old, they experienced urinary problems, and doctors recommended circumcision as a treatment. During the procedure, a malfunction of the medical equipment irreparably damaged Bruce's penis. Distraught, his parents, Janet and Ronald, sought expert advice and eventually discovered Dr. John Money at Johns Hopkins University and his theory of psychosexual neutrality.

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Gender identity is an individual's internal, personal sense of being a man, woman, both, or neither. It is a distinct concept from sexual orientation, which relates to attraction, although the two are often mistakenly conflated. While a person's gender identity often corresponds to their sex assigned at birth (based on chromosomes and phenotype), this is not always the case. Gender identity should also not be confused with gender expression, which is the outward presentation of one's gender. It is crucial for clinicians to understand these distinctions and be knowledgeable about gender-affirming care.

Gender Identity

The term Sex Assigned at Birth arose in the 1950s around the medical care of intersex infants. In particular, the term arose because physicians thought of intersex variants as harmful to the child and that assigning a child a sex and making sure that parents were not confused about the child's sex would be beneficial to the child. This belief lead to medically unnecessary medical procedures on some infants to bring their genitals or gonads more into alignment with the preceived norm of either male or female genitalia. These surgical procedures have lifelong consequences including sterilization. These surgeries are especially harmful for individuals whose gender identity is inconsistent with the sex they were assigned at birth. Sex Assignment at Birth and surgeries to coercievely assign the sex of intersex infants are still broadly practiced.

History/Presents of Sex Assigned at Birth in Intersex Infants

Spielman, R. M., Jenkins, W. J., & Lovett, M. D. (2020, April 22). Psychology (2nd ed.). OpenStax. https://openstax.org/books/psychology-2e/pages/1-introduction

OpenStax Psychology (2nd ed.) Textbook

Individuals who experience Gender Dysphoria and feel that their gender identity is incongruent with their sex assigned at birth experience psychological distress due deviation from the societal norm, and Compassion-based Art Therapy combined with mindfulness can help build self-compassion and greater resilience

Mindfulness-Based Art Therapy for Gender- Variant Individuals

Gender dysphoria is a condition listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that is characterized by an individual feeling distress due to their gender identity being different than their sex assigned at birth.

Gender Dysphoria

Intersex is a general term describing individuals whose sex traits, reproductive anatomy, chromosomes, or hormones differ from the typical binary ways human bodies develop. While some intersex traits are visible at birth, others may not become apparent until puberty or later. The terms 'intersex' and 'transgender' are not interchangeable; many transgender individuals do not have intersex traits, and many intersex people do not identify as transgender.

Intersex

The term cisgender refers to individuals who identify with the sex they were assigned at birth. The word utilizes the Latin prefix cis, meaning on the same side (in contrast to trans, meaning across). Similar to the term transgender, being cisgender does not indicate a person's sexual orientation, gender expression, or gender itself. Furthermore, many cisgender individuals do not actively use this term to self-identify.

Cisgender

Though progress is being made, many people still faces hardship, backlash, discrimination, and violence when they vary their gender identity or expression from the traditional gender norms. 

Challenges in Gender Identity Expression

The Case of David Reimer

Sexual orientation and gender identity are frequently confused, but they represent different facets of a person's identity. Gender identity is one's internal sense of their own gender, whereas sexual orientation is a separate, though related, concept concerning one's attractions to others. Recognizing them as two distinct concepts is crucial to avoid common misconceptions.

Distinction Between Sexual Orientation and Gender Identity

The term 'transgender' describes individuals whose personal gender identity does not align with the sex they were assigned at birth. People who are transgender may use a variety of terms to describe themselves, including the abbreviation 'trans' or identifying as 'non-binary'.

Transgender

For some transgender individuals, transitioning is a process of aligning their life with their gender identity, moving away from living in a manner associated with the sex they were assigned at birth. This process is highly individual and can encompass social, legal, or medical changes. However, it is not a required step, and not all transgender people will pursue any or all of these transition types.

Transitioning for Transgender Individuals

Contemporary understanding of gender identity is in a state of continuous evolution, providing more freedom for exploration and expression than in the past. This shift is particularly evident among younger generations like millennials and Gen Z. For instance, research shows a majority of millennials view gender as a spectrum rather than a binary, with 12% identifying as transgender or gender non-conforming. This evolving perspective is reflected in societal changes, such as the increased use of gender-neutral pronouns like 'they/them' and shifts in commercial practices, where retailers are moving away from gender-segregated marketing for items like toys and clothing.

Evolving Understanding and Expression of Gender Identity

While some cultures, such as the United States, have historically been cisnormative and based on a two-gender system classifying individuals as male or female based on their sex at birth, this is not a universal model. Many other cultures recognize more than two gender categories, with some of these identities being integral parts of their societies for centuries. These non-binary identities often predate modern Western definitions of gender and hold deep cultural significance.

Cultural Variations in Gender Systems

An individual named Kai was designated male on their original birth certificate. Kai enjoys wearing tailored suits, is romantically attracted to women, and has a deeply held, internal conviction that they are a woman. Which of these elements best describes Kai's gender identity?

The term sex assigned at birth is used to describe the legal and medical designation of male or female that is ascribed by doctors to infants at birth based on the presentation of their external genitalia. Assigned Male at Birth (AMAB) and Assigned Female at Birth (AFAB) are used to demark the identification one was give while also being used rhetorically to note the difference between both the sex someone was assigned and what their biological sex is - for instance in the case of intersex individual, and to differentiate between sex and gender identity.

Sex Assigned At Birth

Issues related to sexual orientation and gender identity are deeply influenced by sociocultural factors, meaning that the ways in which sexual orientation and gender are defined vary significantly from one culture to the next. For example, while the United States is historically a heteronormative society that views heterosexuality as the norm, other societies have different attitudes towards LGBTQ people. In some cultures, such as in parts of New Guinea, periods of exclusively same-sex sexual behavior are socially prescribed as a normal and necessary part of development and maturation for young boys to become men.

Sociocultural Influences on Sexual Orientation and Gender Identity

Many people conflate sexual orientation with gender identity because of societal misconceptions and attitudes about sexuality. In reality, while they are related, sexual orientation and gender identity are two fundamentally different aspects of who an individual is.

Sexual Orientation vs. Gender Identity

In the 1960s the term sex reassignment began to be used to describe surgical procedures for transgender patients - with the term reassignment borrowed from descriptions of the intents of the surgeries done on intersex infants, since some physicians in the 1960s conceptualized of transgender individuals as having a type of intersex variation. The term was later taken up and continues to be used by transgender individuals to critique the idea of legal sex and note that the practice of assigning sex on birth certificates is arbitrary. This critique came into focus in the mid 1960s when there began to be discussions in New York State of whether individuals should be able to change the sex listed on their birth certificate.

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