It was considered a medical triumph 33 years ago when John became Joan.
John was 8 months old when his penis was accidentally destroyed during minor surgery to correct a problem with the foreskin. Doctors advised his horrified parents to raise the child as a girl, and surgery to create female anatomy followed shortly thereafter.
The 1964 operation made headlines around the world. It also became the standard of practice in cases involving freak accidents like John's or when children are born with severely deformed genitals, a rare defect occurring in about 1 out of every 100,000 births.
Now, however, two doctors involved with John's case from the start have tracked the results, and they say the decision to raise John as a girl was all wrong.
John, who reverted to being a male as a teenager, had always felt he was a boy, even though he was called Joan, wore dresses and had female genitals, say the authors of the report, published today in the Archives of Pediatric & Adolescent Medicine.
In addition to calling into question the practice of sex reassignment, as the treatment is called, the case yields valuable insight about what it means to be male or female. It also provides stark evidence that a person's brain predetermines sexual identity--not one's anatomy or social environment, experts say.
"The question this case doesn't answer but lends data to is: What is the origin of gender identity? How do we know we are a girl? How do we know we are a boy? And when do we know it?" says Dr. William Reiner, a child psychiatrist at the Johns Hopkins Hospital in Baltimore, where John was treated. "John, in spite of being raised as a girl and being treated with hormones and estrogen, said, 'Forget it. I'm a boy.' "
Children who undergo sex reassignment provide a unique opportunity to explore the complexities of sexuality, says Reiner. While only one case, John's story is particularly strong testimony that the roots of sexual identity lie deep inside the brain, as more recent scientific studies have attested.
Even as a child, Joan, who had not been told what had happened, said she "felt like a trapped animal."
That was not what doctors would have predicted three decades ago, when notions of sexuality were much different. In proposing the sex-change surgery, doctors told John's parents that infants were sexually neutral at birth and that children learned their gender as they grew up and as hormonal influences kicked in at puberty.
"The teaching has been to convert these children because you can surgically construct a sexually functioning female but you can't surgically reconstruct a child to function as a male," says Reiner, who wrote an editorial accompanying the report.
Moreover, many experts believed that a male child could not grow up psychologically healthy without a penis--an assumption not supported by data, Reiner says. Doctors have also assumed, until the past decade or so, that a child will reflect its upbringing.
"Doctors haven't been doing this willy-nilly. They have tried to do what they think is the right thing," says Milton Diamond, co-author of the report and an expert in anatomy and psychology at the Pacific Center for Sex and Society, University of Hawaii-Manoa. Diamond served as a consultant to the British Broadcasting Co. in its coverage of the case in the 1960s and 1970s.
Indeed, the surgery on John was followed by a host of reports on the case touting it as a success. A 1973 Time magazine article noted: "This dramatic case . . . provides strong support . . . that conventional patterns of masculine and feminine behavior can be altered. It also casts doubt on the theory that major sex differences, psychological as well as anatomical, are immutably set by the genes at conception."
The case was quickly written into textbooks on pediatrics, psychiatry and sexuality--where it remains today--as an example that gender should be based on an infant's anatomy, not on chromosomes or the individual's feelings about his or her sexuality.
"The case led to a lot of excitement that this could even be done," Reiner says. "It was a very difficult clinical situation that could now be handled. It created a lot of enthusiasm and, probably, relief in the medical world."
The case received little more attention, however, until the retrospection published today, which is heartbreaking in its portrayal of John's and his family's suffering.
The article is based on interviews in 1994 and 1995 with John, his wife and his mother. According to Diamond, John wanted his story told, although he requested the use of the pseudonyms John and Joan.
The article suggests that the sex reassignment was wrong from the outset.