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Sex and gender are not the same thing. Sex is a biological activity, gender is a person's identiication as male or female. Those are technical definitions; in popular writing the word sex is often employed as a synonym for gender (e.g. referring to same-sex education if a class or a school is all male or all female).

What is the difference between sex and gender?

For the first two-thirds of the 20th Century, Western psychologists tended to be strong situationalists. They thought environmental influences and learning were dominant in shaping behavior.

Gender identity was thought to be the result of social forces, a response to relentless pressure to conform to social norms. There is more than a grain of truth to that; we saw in Chapter 15 how powerful the urge to conform can be.

Many parents in the 1970s and 1980s arranged to have all types of toys available (both dolls and cars, along with other options). However, most children nevertheless selected gender-typical toys, when given a free choice.

By the 1990s, more evidence accumulated that gender-stereotyped behavior came from the inside. One influential case involved a boy who was raised as a girl.

The Boy who was Raised as a Girl

Doctors at Johns Hopkins Hospital accidentally damaged an infant boy's penis during a circumcision operation. The penis was badly burned, and the doctors said it was damaged beyond repair. They removed it and told the parents to raise the child as a girl.

The child took female hormone treat­ments to encourage normal female development. A well-known authority on sexual behavior, John Money of Johns Hopkins Medical Center, interviewed the child annually.

Money wrote journal articles about the anonymous subject of this operation, confirming the bias of most American psychologists toward environmental explanations of behavior. He reported the boy was developing normally as a girl.

What is the famous story of "the boy raised as a girl"? What was the outcome of the story?

In reality, the boy raised as a girl had many difficulties. In 1997 he went public with his story.

It turned out he had always felt like a boy on the inside. He wanted male toys and wanted to dress like a boy. He even felt it was natural to urinate standing up.

By the age of 16 he had learned the truth about his situation and reverted to a male appearance. He married to a woman whose children he adopted.

However, he was bitter about the experiment which had been conducted on him without his consent, as a child. He frequently made public statements to the effect that his life was ruined.

In the end, he committed suicide. His testimony showed that, certainly for him, sex role identity came from the inside.

A second case, similar to the boy raised as a girl, had a similar outcome. The genetically male patient, being raised as a female, became a tomboy interested in male toys as a child.

However, this patient accepted female sex assignment after finding out about it during adolescence. She completed reconstructive surgery and eventually married a man. The marriage did not work out, and the patient's second marriage was to a female, in a lesbian relationship.

Doctors at Johns Hopkins Hospital did gender reassignment routinely on male babies born without penises. The results over many years were clear, as CNN reported in 2000:

Researchers tracked the develop­ment of 27 children who had been born without a penis, a rare defect known as a cloacal exstrophy. The infants were otherwise male with normal testicles, male genes and hormones.

Twenty-five of the children were sex-reassigned -- doctors castrated them at birth and their parents raised them as girls.

But over the years, all of the children, now ages 5 to 16, exhibited the rough-and-tumble play of boys. Fourteen declared themselves to be boys, in one case as early as age 5, said Dr. William G. Reiner, a child and adolescent psychiatrist and urologist at the Hopkins Children's Center.

"These studies indicate that with time and age, children may well know what their gender is, regard­less of any and all information and child-rearing to the contrary," he said. "They seem to be quite capable of telling us who they are."

The two children who were not reas­signed and were raised as boys fit in well with their normal male peers and were better adjusted psycholog­ically than the reassigned children, Reiner said. ("Study of children born without penises finds nature determines gender," May 12, 2000)

The conclusion of experts in trans-gen­dering is that a person's inner feelings must be taken into account when there is gender ambiguity. These feelings may have little to do with external factors like clothing and parental influences.

When Feelings do not Match the Body

Scientists now believe that gender identity is programmed in the womb at a different time from sexual preference or the biological construction of genitals. Therefore the three do not always match.

Gender dysphoria is distress and dissatisfaction with one's outward gender. It may start early in life with a strong feeling of having a gender identity that does not match the body. People who feel such a mismatch strongly in childhood have the best record of successfully adapting to gender reassignment.

What sorts of people have the best success with gender changes?

Among male transexuals, there are at least two different types. The distinction was originally proposed by Blanchard (1985). It is controversial because Blanchard felt that one group was homo­sexual at root and the other was not, and some people disagree. Leaving aside that issue, the general distinction is this:

  1. Boys who feel like girls on the inside, so are mismatched to their bodies
  2. Men who love the thought of themselves as women, and are attracted to that image

The first category corresponds to the popular idea of transexualism as "being born in the wrong body." This is typically explained as resulting from brain circuits developing at different times in the womb, with gender identity developing differently from the body.

The second category, which Blanchard called autogynephilia, is familiar to those in the transgender community. It is characterized by an attraction toward the idea of oneself as a woman.

What are two different types of transgender males?

An expression of the second type is found in the song, "For Today I am a Boy" by Antony and the Johnsons. Antony Hegarty, who later completed sex-reassignment surgery and now calls herself Anohni, sang about how "Today I am a boy" but "One day I'll grow up, I'll be a beautiful woman/One day I'll grow up, I'll be a beautiful girl."

This shows the elements the led Blanchard to coin the term autogyne­philia. There are three roots in that word: auto (self), gyne (female) and philia (love).

This type of transgender person is a genetic male who has a love for a female image of him/herself. That seems to be different from "growing up thinking I was in the wrong body."

Disorders of Sexual Development (DSD)

Some people are born with mixed gender characteristics. The term disorders of sex development (DSD) is applied to individuals with an atypical combinations of chromo­somes, genital characteristics, and body characteristics.

DSDs are "a broad group of complex disorders" (Rawal and Austin, 2015). They lead to "significant angst and concern for both parents and physician, as they frequently lead to questions with regards to gender assignment, surgically corrective options, long-term outlook regarding gender identity, and repro­ductive potential."

Varieties of DSD are described in neutral terms by physicians, often with references to the genetic mechanisms affected. People with DSD sometimes prefer to adopt other labels such as genderless or intersex. Surgical interventions in cases of DSD may or may not be appropriate, de­pending on the genetic type and indi­vidual feelings.

Jaruratanasirikul and Engchaun (2014) reported on clinical results with 117 DSD patients encoun­tered over a 20 year period in southern Thailand. Patients with the genetic variants 46,XY and 46,XX all did well with sex assign­ment as girls, and 100% were re-assigned as females.

People with a different form of DSD, called mixed gonadal dysgenesis and ovotesticular DSD, could be assigned to either gender. In those cases, doctors "postpone any final decision regarding surgical gonadal removal and recon­structive surgery for 5-6 years (or until the patient reaches an age when they are old enough to be aware of the issues)." This allows time "to explore the patient's perception of gender identity" before surgery, a crucial step.

Surgical interventions a few decades ago were commonly made by con­sulting parents but not the patients, who were still babies when the surgery was carried out. That had some tragic conse­quences when people decided later in life they had been assigned to the wrong gender.

Why did doctors in Thailand wait 5-6 years before any surgical intervention for some people with DSD?

Specialists in DSD say that "many patients have concerns that arise from past incorrect treatments that were founded on the traditional binary concept of the sexes" (Hiort et al., 2014). Peer counseling with other people who have DSDs can be helpful. "Most importantly, dealing with DSDs requires accept­ance of the fact that deviation from the traditional definitions of gender is not necessarily pathologic."

Options for Transgendered Individuals

During the 1960s and 1970s the first sex-change operations were performed. A person who switched from one gender to the other was called trans­sexual.

Now the term transgendered is prefer­red, and surgery is called sex-reassign­ment surgery. Hormone treatments are more common than surgery, to add breast development for an outwardly female appearance or body hair and beards for a male appearance.

What is a transsexual or transgendered person?

The pitch of the voice cannot be changed without surgery, because this depends on the structure of the voicebox. A few clinics specialize in this surgery, which is complex, and they do a brisk business with male-to-female transgendered individuals who wish to sound more feminine.

Mannerisms characteristic of the oppo­site sex are easily cultivated. Historically, transsexuals often adopted exaggerated, sexually stereotyped behaviors. One study showed male-to-female trans­sexuals were more likely to use feminine mannerisms, posture, and movement than a control group of women "selected for their feminine appearance" (Allgeier and Allgeier, 1988).

A person who receives a sex-change operation sometimes presents a convincing appearance as an individual of the opposite sex. Some never do. The surgeries are generally irreversible, so the result of an unsatisfactory attempt at physical reconstruction can be despair or suicide risk.

Johns Hopkins University Medical Center, which pioneered sex change operations in the 1970s, did a long-term follow-up study in 1979 comparing 29 transsexuals who had received sex-change surgery with 21 gender dysphoric individuals who did not have surgery. Years after the surgery, the two groups did not differ in educational attainments, job stability, or adjustment to marital relations (Restak, 1979).

The research showed that sex-change patients who opted for surgery were were often dissatisfied with the results. Given the expensive and irreversible nature of the changes, Johns Hopkins stopped doing the surgery in 1979.

They changed their policy in 2016, issued a public letter declaring support for the LGBT community, and prepared to resume some sex change operations in 2017. Their letter read, in part:

We have committed to and will soon begin providing gender-affirming surgery as another important element of our overall care program, reflecting careful consideration over the past year of best practices and the appropriate provision of care for transgender individuals. (Rothman and Peterson, 2016)

Why did Johns Hopkins start discouraging sex change surgery? What change occurred in 2016?

Notice the wording: "gender affirming surgery." This conveys the new Johns Hopkins policy. When feelings of gender are firmly established, they should be affirmed.

That could include surgery where desired and appropriate. In other cases, individ­uals might prefer to dress and act the role of the opposite sex without surgery.


Allgeier, A. R. & Allgeier, E. R. (1988) Sexual interactions. DC Heath.

Blanchard, R. (1985). Typology of male-to-female transsexualism. Archives of Sexual Behavior, 14, 247-261.

Hiort, O., Birnbaum, W., Marshall, L., Wunsch, L., Werner, R., Schroder, T., Dohnert, U., & Holterhus, P-M. (2014) Management of disorders of sexual development. Nature Reviews Endocrinology, 10, 520-529. doi:10.1038/nrendo.2014.108

Jaruratanasirikul, S. & Engchaun, V. (2014) Management of children with disorders of sex development: 20-year experience in southern Thailand. World Journal of Pediatrics, 10, 168-174. Retrieved from:

Rawal, A. Y. & Austin, P. F. (2016) Concepts and updates in the evaluation and diagnosis of common disorders of sexual development. Current Urology Reports, 16, 83. doi:10.1007/s11934-015-0556-0

Restak, R. M. (1979, December). The sex-change conspiracy. Psychology Today, pp.20-25.

Rothman, P. B. & Peterson, R. R. (2016, October 7) Johns Hopkins Medicine's Commitment to the LGBT Community. LGBT Resources. [Blog] [No longer online]

Study of children born without penises finds nature determines gender. (2000, May 12). CNN. Retrieved May 12, 2000, no longer online.

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