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were hard to decipher. But even now, when most of the facts are apparent, it is still difficult to decide what the Bruce/Brenda/David story tells us
about how the sexes of humans begin and our perceptions of those sexes.
One thing seems clear: surgery, hormones, dresses, and dolls weren’t
enough to convince this boy that he was a girl. David’s story ended
tragically. His marriage to Jane was rocky from the beginning. He often
fell into prolonged dark moods that excluded nearly everyone. He felt
inadequate and unable to perform his true duties as a husband. And
during his depressive periods he often exploded in anger.
Then, in the spring of 2002, twelve years after David married Jane,
his twin brother, Brian, committed suicide using an overdose of antidepressants. David fell into a deep despair. Shortly before Brian’s death
David had lost his job and had been swindled out of about sixty-five
thousand dollars. Neither the loss of the money nor the job was critical
financially (David had made a sizeable sum of money from selling his
story), but the shame was considerable.
In May 2002 Jane suggested a trial separation. David left in a rage.
Two days later the police called to tell Jane that David was dead.
Shortly after David had stormed out of the house, he’d returned
to the garage, taken his shotgun, and neatly sawed off the barrel. Then
he’d driven to a nearby grocery store parking lot and ended his life.6
There the boy-made-girl-made-man emptied his head of shame, confusion, and pain.
What about the others, the people who have had sex-enhancing or
-defining surgeries under better circumstances? Surprisingly, it wasn’t Outcomes 131 until the early 2000s that the medical community got serious about
asking those most directly affected by our decisions and surgeries how
they felt about what we had done to them. Given the chance to speak,
these people had some very interesting things to say.
When Surgery Is Essential, Does Sex Matter?
Cloacal exstrophy is not truly an intersex condition, but it is one in
which sex reassignment through surgery is typically required, not
optional. Cloacal exstrophy is the term physicians use to describe a rare
type of abnormal fetal development in which the whole bottom portion
of the abdominal wall fails to form properly. In these people, where
their legs join, there is a hole. Through that hole, portions of the intestines and bladder often protrude outside of the body, and the genitalia,
and sometimes the anus as well, do not form at all. The survival of these
children depends on early and expert surgery. Because there is often a
complete absence of genitalia of any sort, as part of that first surgery the
doctors assign a sex.
The most commonly assigned sex for babies with cloacal exstrophy has been female, due most directly to the relative ease with which
doctors could fashion a semifunctional vagina compared to an even
barely functional penis. For genetic females, this approach seems generally satisfactory. But in genetic males with cloacal exstrophy, the testes form normally and produce normal amounts of male hormones
before and after birth. So these boys’ brains and bodies—like those of
Bruce/Brenda/David—are steeped in male hormones for several months
before a surgeon can remove their testes. Because of their peculiar situation, these people offer physicians an opportunity to assess the general
relevance of the Bruce/Brenda/David incident.
In one long-term study conducted at the Oklahoma Health Sciences Center in 2003, eight of fourteen boys who had originally been
assigned as females because of cloacal exstrophy declared themselves as
males during the course of the study. Four of the boys chose reassignment spontaneously. The other four chose reassignment after “learning
that they were born male.” The authors of this study concluded that 132 Between XX and XY prenatal androgens were “a major biologic factor in the development
of male sexual identity.”7 Some of these boys, like Bruce/Brenda/David,
found that their minds could not accept the bodies that they’d been
given. But that was true for only about half of the boys, making the
likelihood of success a near coin toss. That made many people suspect
that even the Bruce/Brenda/David incident was an anomaly, or just bad
In support of this, another study, performed in 2004 at Columbia
University in New York City, reached a similar conclusion. This study
reviewed published accounts of 46,XY persons with penile agenesis (an
extremely rare disorder in which the penis fails to develop at all), cloacal exstrophy, or penile ablation (similar to Bruce’s experience). On the
basis of their review of the literature, these authors concluded that the
majority of 46,XY babies assigned as females did not choose to change
their gender later in life, although there was a slight increase in gender
reassignment as these girls reached adulthood. In the end, about half
these people originally assigned as females chose to continue life as
females, and about half chose sexual reassignment as adults.8
Clearly, some genetic boys arrived at adulthood uncomfortable wit...
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This document was uploaded on 02/04/2014.
- Spring '14