Humans have long held fanciful theories on how to control the outcome of a baby’s sex. In Ancient Rome, it was thought that a pregnant woman carrying a chicken egg would ensure a boy. Ancient Greek physician Galen believed that if a woman bound her right foot with a child’s white ribbon before sexual intercourse, she would conceive a male child.
Nutt opens her largely scientific chapter by establishing what people assumed about sex and gender historically, highlighting how little was (and is still) known about sex, gender, and what influences these characteristics. These examples, of course, are recognizably absurd because the modern reader now knows that carrying a chicken egg or a white ribbon would have no bearing on sex.
Today, those theories are only slightly more sophisticated: because sperm carrying X chromosomes swim slower and longer than those carrying Y chromosomes, the odds of having a daughter are thought to increase if intercourse takes place several days before ovulation, giving male sperm more time to die off. Nutt writes that humans all begin life essentially genderless. Our chromosomes make us either genetic males (XY) or females (XX), but at least 50 genes play a part in sexual identity.
At the same time, Nutt shows how little knowledge there still is concerning what causes sex and gender, and how those two developmental processes can be influenced. Nutt establishes quickly that these processes are far more complicated than which sperm can reach the egg.
Sexual anatomy, on the other hand, is determined largely by hormones. All humans begin in utero with an opening next to the anus and a genital “bud.” The addition of testosterone allows for a penis and scrotum to develop and an inhibiting hormone prevents the development of internal female reproductive organs. Without testosterone, the opening becomes the vagina and the bud becomes the clitoris.
Nutt first illustrates how sex and anatomy are connected, as the presence of testosterone (and one’s ability to receive that hormone) spurs the development of male sexual anatomy. Nutt will also demonstrate how testosterone is crucial to the development of sexual identity, but that there are key reasons why sex and sexual identity might be different.
The sexual differentiation of the genitals happens at about six weeks, but the sexual differentiation of the brain, including gender identity is at least partly a distinct process. Hormones again play a crucial role, causing subtle differences in brain structure. For example, the straight gyrus, which is highly correlated with interpersonal awareness, is 10 percent larger in women than men. But scientists caution that differences in biological sex are not absolute—regardless of biological sex, the larger the straight gyrus, the more “feminine” the behavior.
Nutt shows how sexual identity is a distinct process from the development of anatomy. Differences in brain structure can be correlated with differences in a person’s behavior and gender identity. This concept begins to set up the idea that gender identity is innate, runs along a spectrum, and is a part of many other personality traits coded into the brain.
In addition, for most males, male hormones are crucial to the development of male gender identity. A mutation of the receptors for these hormones can cause “androgen insensitivity syndrome, in which virilization of the brain fails.” In this case, a baby will be born chromosomally male and will have testes but will also have a short vagina and will outwardly appear female. Its gender identity is nearly always female. In other words, genitals and gender identity are not the same. There are “dozens of biological events that can affect the outcome of the latter and can cause an incongruence between the two.”
Here Nutt comes to her primary point: that chromosomes, genes, and hormones all play a different part in the development of sexual anatomy and gender identity, and while these things are related, they are not necessarily the same. This statement, supported by the rest of the chapter, seeks to remedy the misconception held by many people that sex and gender are the same.
Some individuals have chromosomes of one gender but the sex organs of the opposite. Others are born with male genitals and testes, but internally have a womb and fallopian tubes. Some people have atypical chromosomal configurations, like XXX or XXY. Still others have different chromosomal arrangements in different tissues. Regardless of chromosomes, any change in the balance of hormones will tip the sexual development of a fetus in one direction or another.
Nutt provides yet more examples of how these different biological factors interplay and can have different variations. But regardless of these variations, Nutt makes it evident that much of our sex and gender identities are innate and determined before birth.
“No one thing determines sex,” and small changes can lead to “nonbinary” results. As many as one in 100 infants are born with sexual anatomy that differs in some way from standard male and female anatomy. Historically, doctors decided gender at birth based on cultural expectations and stereotypes, chiefly the length of genitalia. A baby born with a penis smaller than 2.5 centimeters was assigned female. But in the case of ambiguity, infants were assigned a sex and then surgeons “corrected” the confusion.
After establishing how people can have a variety of anatomic combinations and gender identities, Nutt transitions to demonstrating how the lack of knowledge about this in prior decades led to poor choices. For example, “correcting” children’s anatomies without understanding what their gender identity might be was a common practice.
In August 1956, a baby was born who had either a very small penis or an enlarged clitoris. Doctors were extremely unsure of the baby’s sex, but finally they suggested the parents assign the infant a male identity. The parents did so and named the baby Brian. Eighteen months later, however, doctors discovered that Brian had a uterus and ovotestes (containing both ovarian and testicular tissue). Doctors told the parents that their initial advice was wrong and surgically removed the microphallus. They parents renamed the child Bonnie and were told raise the child as a girl, throw away photographs of Bonnie as a boy, and move out of the state.
Doctors here prove their ignorance surrounding intersex babies at the time. Additionally, it is notable that their decision to perform surgery on Brian stems largely from social pressures and stereotypes. Society would clearly be unaccepting of Brian as an intersex child (evidenced by the doctors’ advice to his parents to move out of the state) and thus Brian’s parents make uninformed choices that affect him for the rest of his life.
When Bonnie turned eight, she underwent surgery to (unbeknownst to her) remove the testicular part of her gonads. At 10 years old, she was told the truth and was deeply disturbed by what her parents had done. She grew up and graduated from MIT with a math degree. Later she formed the Intersex Society of North America under the name Cheryl Chase, and advocated that doctors not do surgery on intersex babies but let them make a decision themselves when they are of an appropriate age.
With so little knowledge surrounding intersex babies (like Brian/Bonnie), Chase advocates for doctors to acknowledge their ignorance in this area and allow for a child to have agency over their own body when they grow up. Additionally, it is notable that Chase’s pride in her identity allows her to form the Intersex Society and advocate for others like herself.
Chase stood in opposition to proponents of behaviorism like Dr. John Money, who believed that gender identity was a social construct. He believed that in cases like Chase’s, parents should simply choose the gender they wanted to raise they child and given that encouragement the child would adopt that gender.
Money stands in opposition not only to Chase, but also to Nutt’s own arguments. Nutt proves repeatedly how one’s gender identity is an innate part of a person, not something that they can change by social pressures (as Wyatt’s case also clearly indicates).
Money’s most well-known example was a child born in August 1965: a baby boy named Bruce. A cauterization to correct an obstruction accidentally burned off Bruce’s penis as an infant. Money convinced the parents to raise Bruce as “Brenda,” and so his testicles were removed, he was dressed and treated as a girl, and was unknowingly administered female hormones during puberty. Brenda neither felt nor acted female, however, and became depressed and suicidal as a teenager. His parents told him the truth, and he transitioned at 14 to being male.
Nutt provides another example in which the lack of knowledge surrounding gender identity proved detrimental for a patient. Money’s belief that gender was not a part of one’s “nature” but instead a part of one’s “nurture” proved to be false, and the actions taken as a result of Money’s theory altered the course of Bruce’s life.
Brenda renamed himself David Reimer and had a mastectomy, testosterone injections, and phalloplasty surgeries to rebuild a penis. He married and adopted children but remained tortured by what had happened and committed suicide in 2004, at 38 years old. Throughout this process, Money published articles extolling the success of the experiment, until the 1990s when the psychiatrist who treated Brenda exposed the truth about Money.
Money’s lack of knowledge (or more likely, his willful ignorance and refusal to accept that his belief was wrong) led to Reimer’s psychological torment and eventual suicide. Nutt thus shows the danger in the belief that one’s gender identity is socially constructed and changeable.
Gradually, it became more accepted that gender is innate, but Reimer’s case did not explain how there could be a disconnect between anatomy and gender identity. The idea that someone born a male would want to be female was (and often still is today) considered a psychiatric problem, not a medical one. Transgender people were regarded as “scientifically inexplicable.”
Nutt makes it a project of her book to prove just the opposite of Money’s theory: that being transgender does not have a psychiatric remedy, it requires medical treatment instead.
Only in the past decade has gender come to be regarded as a spectrum. The first institutions to adopt nonbinary gender classifications have been mostly academic. Yet despite gender being regarded as a spectrum, transgender people can still be firmly rooted in one gender identity or another. Transgender people “may agree that gender is a spectrum, but they also know exactly where they fall on it.” In a test meant to measure gender identity, there is no difference between the answers of transgender (biologically male) girls and cisgender (biologically female) girls.
This point serves as another culmination of Nutt’s arguments. Gender and sex are not always black and white, male and female, as the beginning of this chapter laid out very clearly. However, one’s sense of gender identity is usually innate and unalterable.
For transgender people, whose bodies are at odds with their ideas of themselves, the only way out of the alienation is to make the body congruent with the mind. But often in the past (and still today) doctors prescribe intensive therapy. Some parents, however, believe that forcing their child to go through puberty in a body that is foreign to them would be deeply damaging.
Nutt elaborates on how the problem is a medical one, not a psychiatric one. It is impossible to alter one’s gender identity, but it is not impossible to alter one’s own presentation or sexual anatomy to match that gender identity.
Prior to the 21st century, all sex reassignment surgeries were performed on fully developed men and women, and often the psychological consequences of doing so as a fully-grown adult can be devastating if the results do not meet expectations. On April 26, 2007, 50-year-old Mike Penner, a veteran sports journalist at the Los Angeles Times announced that he would be leaving for a few weeks’ vacation and would return as Christine Daniels. He confessed to his readers that he was “transsexual.”
Nutt demonstrates why transitioning as a person who has not yet reached puberty can be more effective than doing so as a grown adult, because that medical intervention is far easier. Christine’s tragic story indicates some of the struggles with transitioning late in life.
Although Christine’s public declaration was liberating, the adoption of a life as a woman was difficult. After Christine’s first appearance at a sporting event with her new identity, another journalist wrote in his own blog, “I hate to be judgmental about these things, but Christine is not an attractive woman. She looks like a guy in a dress, pretty much.” This was cruel and devastating to Christine.
Christine’s struggles not only stem from the medical hardships that come from transitioning, but also from the discrimination and judgment of others. The abuse that Christine endures at the hands of others makes it difficult for her to feel accepted as a woman.
Later, Christine agreed to do a story about her transition with Vanity Fair magazine. But when the photo shoot became a disaster, the reporter pulled the plug. Meanwhile, Daniels’ wife filed for divorce and she lost friends. Mired in depression, Daniels stopped taking female hormones and decided to revert to being male. Thus, it was as Mike, dressed in male clothes, that Penner took his life on November 27, 2009.
While this chapter focuses on a variety of different gender identities, Christine’s story is emblematic of the issues that transgender people specifically face. Her tragic outcome illuminates why individuals are often so intent on transitioning at a young age—they want to avoid the same ridicule and cruelty that drove Penner to take his own life.