91Èȱ¬

The Boy who was Turned into a Girl
91Èȱ¬2 9.00pm Thursday 7th December 2000

NARRATOR (DILLY BARLOW): In August 1965 in the small Canadian town of Winnipeg Janet Reimer gave birth to twin boys, Bruce and Brian. Her twins would form the basis of one of the most controversial case studies in the history of science, a study that is still having repercussions to this day, because by the time they were two years old, before they were even out of nappies, Brian would be a happy, bouncing boy and Bruce would have been turned into a girl called Brenda. For many years science has believed it could turn a boy into a girl. Not just make a boy look like a girl but make him think like a girl, feel like a girl, be a girl, to turn a boy's brain into a girl's brain.

DR WILLIAM REINER (Johns Hopkins Medical Institution): The idea of being able to turn a genetic male into a female is a, a tenet of our training, of dogmatic teaching and it's one of those that we accepted. We questioned many others and none of us seemed to question that.

NARRATOR: To do this science would have to override the very blueprint of nature - our genes. The theory was that although the genes on the X and Y chromosomes and our hormones turn us physically into males and females in the womb, they don't irrevocably shape our minds. Scientists believe that what happens in our brains to make us think, feel and behave differently as boys and girls, to give us what's called our gender identity is shaped by a force perhaps more powerful than nature - nurture, our upbringing. In theory, the key to our gender identity is that we are taught it, by things like the toys we're given, the clothes we wear, whether we're encouraged to behave in male or female ways.

PROF. MILTON DIAMOND (University of Hawaii): So to make it simplistic if you put a child in a blue room it'll be a, become a boy and if you put it in a pink room it'll be a girl.

NARRATOR: If this was true then it would theoretically be possible to turn a boy into a girl, to make a boy feel like a girl, think he was a girl by, amongst other things, carefully raising him as a girl. This theory would end up influencing the treatment of thousands of children.

PROF. MEL GRUMBACH (University of California, San Francisco): So it gave us confidence that, you know, on the basis of this well that, you know, this child could be raised as a, as a female just as well as a male.

NARRATOR: And dramatic proof of this theory was said to be the case of Bruce Reimer. It all began on a summer's morning in 1965 when Janet Reimer was granted her dearest wish.

JANET REIMER: When I was a little girl I used to dream about having twins and I always thought I would never be lucky enough to have twins, I wasn't the lucky kind and I had twins.

NARRATOR: Janet called her identical twin boys Bruce and Brian.

JANET REIMER: We were so pleased and so proud and we settled right into our little one room apartment.

NARRATOR: But within six months events would take a dramatic turn.

JANET REIMER: Bruce and Brian both started having trouble urinating. The doctors suggested circumcision.

NARRATOR: On 27th April Janet left her twins at the local hospital in Winnipeg. Circumcision was a straight-forward procedure and she expected to pick up her boys the next day, but early the next morning she got a call from the hospital.

JANET REIMER: When we first heard that there had been an accident we thought well, what kind of accident could there be? We went to the hospital and then the doctor said the penis has been burnt off from sic, circumcision and I could not comprehend what he was talking about because you see I thought they were going to use a knife. I didn't know there was electricity involved.

NARRATOR: Strangely, the doctors had chosen an extremely unconventional method of circumcision. Bruce's penis had been completely destroyed.

JANET REIMER: Daily I was crying. Every time I changed his diaper I'd cry. I was in shock for a while. I guess about a year I was in shock.

NARRATOR: Janet and her husband took their twin babies home and shut out the rest of the world. She had a little boy with no penis and didn't know where to turn. Months past.

JANET REIMER: Then we saw this show on TV. We just happened to be watching TV.

TV PRESENTER: Dr John Money, a psychologist at Johns Hopkins is one of the leading advocates of sex change operations. Dr Money is in the bear pit tonight with Alvin Davies.

NARRATOR: On television that night was a brilliant young psychologist. John Money was a pioneer in the astonishing new field of sex change surgery.

ALVIN DAVIES: Dr Money, it's still a pretty drastic procedure isn't it?

JOHN MONEY: Well it's a drastic procedure by your standards and mine, but for the people who are living in desperation perhaps the best way to understand it is that it seems no more drastic to them than circumcision.

JANET REIMER: Dr Money was on there and he was very charismatic, he was very, he seemed very, highly intelligent and very confident of what he was saying.

NARRATOR: Janet thought that there might be a chance that he could help her son by changing him into a daughter. Within weeks Janet Reimer had taken her son to the prestigious Johns Hopkins University in Baltimore where John Money ran a world famous unit. There, Money's team explained to her how to turn her little boy Bruce into a little girl, make him think and act for the rest of his life like a female. The reason the team felt this was possible was because they believed they had made a new discovery about human psychological development. Traditionally it had been thought that all children had an inborn sense of being a boy or girl, a natural instinct towards male and female behaviour, that before birth our gender identity is programmed by our genes and hormones and that it's unchangeable. If this was true then Bruce Reimer already had his male gender identity biologically fixed in the womb and he could never be turned into a girl, but John Money didn't think things were that simple.

JOHN MONEY: We've been stereotyped in, in our view of male and female, male and female behaviour. I suppose primarily because it's been that way for literally centuries and probably hundreds of centuries.

NARRATOR: The Hopkins team believed that the main key to how we develop our gender identity was not genetic or hormonal. It was how we were raised. A child might be born with some innate sense of its gender, but this could be overridden by upbringing, but nurture could override nature. A child taught to behave in a masculine way would grow up thinking and feeling like a boy. Raising a child like a girl - for instance giving it dolls to play with - would encourage it to develop a maternal instinct and a feminine way of behaving. If this theory was true, it could be used as the basis for raising Bruce successfully as a girl.

JANET REIMER: It made sense at the time that he became a daughter because we thought well maybe it can work, maybe it is a matter of nur, nurture over nature.

NARRATOR: John Money and the team at Hopkins had reached their ground-breaking theory about nurture and gender identity while they were trying to help people born with a rare and distressing condition. Historically called hermaphrodites, these were people born with genitals that were neither fully male nor female. In medicine they're known as intersex.

WILLIAM REINER: I think it's important to understand that John Money here at Johns Hopkins was a pioneer in this field and, and one of the very few, and probably at the beginning, almost the only person exploring these areas and in trying to understand the conditions and to understand the children and the adults with these conditions.

NARRATOR: Intersex cases are caused by an imbalance of hormones in the womb. All embryos start life as female with internal female organs, but from six weeks if the baby is to be a boy the genes on the Y chromosome cause the foetus to develop testicles which then produce the male hormone testosterone. It's this testosterone that makes the male organs grow. If, however, something goes wrong with the delicate balance of hormones in the womb the child's genitals won't develop fully and can be ambiguous. Intersex covers a wide range of complex conditions. For instance, this baby girl has been exposed to too much testosterone in the womb and so her genitals appear masculine, but she is genetically female. This boy did not receive enough testosterone in the womb and so he was born with a tiny penis that could be mistaken for a clitoris. Because mistakes were made when looking at their genitals, babies like this were often brought up in the wrong sex. In the 1950s John Money studied intersex children who'd been born genetically one sex, but raised by mistake as another.

JOHN MONEY: You find, for example, once in a while, not very often, but you do indeed find a person who is chromosomally a female, who has two ovaries inside, a uterus, who with appropriate treatment could in fact get pregnant and carry a baby, but that same person is born not with a clitoris but with a penis and I mean a regular type little boy's penis.

NARRATOR: The astonishing thing that Money found was that if a girl like this was raised as a boy she would fully believe that she was a boy, even though she was born genetically female. Likewise, a boy born with a tiny penis could be raised successfully as a girl and believe himself to be a girl. From studying these intersex children, John Money and his team came to a ground-breaking universal theory about all human development. The theory was that we were all born with such an unformed sense of being male or female that for up to two years after birth all babies' brains were malleable. There was a window of opportunity when you could train any baby to believe itself to be either a boy or a girl, but only if you started early enough and provided the right support. It meant up-bringing could override whatever effects genes and hormones had had in shaping our gender identity in the womb, but after two years this malleability ended and the child's gender identity would be for ever fixed.

MEL GRUMBACH: The theory that had emerged at, at Hopkins was that you were really neutral at birth, you were neither male or female and how, how you, your environment determined whether you were a boy or a girl.

NARRATOR: This became known as the Theory of Neutrality. For those dealing with the complex problem of intersex, Money's work offered hope. He advised doctors to pick whichever gender seemed most suitable and assign the baby accordingly, importantly before it was two years old. This decision would often mean performing surgery to alter the genitals of the child.

WILLIAM REINER: It allowed me as a surgeon to be able to deal with parents of a child who was a genetic male, but who had no penis and feel comfortable in saying we have a, a surgical solution because we have a psychological solution and that surgical solution is going to coincide with the psychological solution. We can rear the child as a female, we can construct the child as a female and your child will grow up and be a successful, happy girl, or woman.

NARRATOR: This meant that boys born with a tiny penis were often surgically transformed into girls and raised as girls.

MEL GRUMBACH: They were castrated and their external genitalia were surgically modified along female lines.

NARRATOR: It may sound brutal, but many doctors who deal with the deeply complex problems of intersex see this as the best solution. Over the years thousands of children have been treated this way. Today, here at Great Ormond Street Hospital intersex children are treated along similar lines. This baby did not receive enough testosterone in the womb. It is genetically male, but was born with a tiny penis, undeveloped testicles and some internal female organs. This child has not been fully masculinised before birth. Surgeon Philip Ransley believes that turning this child into a girl offers her the best future.

PHILIP RANSLEY (Great Ormond Street Hospital, London): This child would have gone through childhood with an extremely tiny phallus and would have had a very small phallus in adult life. the psychological burden that he would have carried as a male would have been enormous. There was no difficulty in this case in everyone agreeing that the appropriate sex of rearing was female and she was gender assigned female.

NARRATOR: Once the baby's gender is assigned, the next step is surgery to make her genitals as like a girl's as possible. No further surgery is likely to be needed, though the child and her family will be helped with continued medical and psychological support. At puberty, she will be given female hormones to develop the external appearance of a woman.

PHILIP RANSLEY: This child will not suffer a significant problem from very abnormal external appearance of their genitalia and therefore are not likely to suffer from psychological difficulties at school. I think the stage is set for this child to have an extremely successful life as a female.

NARRATOR: Back in the early 60s gender assignment surgery had only ever been performed on intersex children, but Money's ideas went beyond the specific problem of intersex. He had devised, he believed, a universal theory about gender identity that we are all born with an unformed sense of being male or female, so theoretically any boy could be raised as a girl, even if he'd been born completely normal. Then, in 1967, John Money became involved with the baby boy, Bruce Reimer. Bruce was not intersex. It was the first time that Money's theories would be used to help a completely normal boy.

JANET REIMER: Dr Money felt that it was going to be helpful to change Bruce into a female because he knew of the heartbreak and horror Bruce would have to go through living as a male when at that time there was no possibility of enhancement surgery for men.

NARRATOR: On 3rd July Bruce Reimer was surgically castrated. He was 22 months old. From now on, Bruce would be Brenda. She would be raised as a girl, treated as a girl, encouraged to behave as a girl. She would receive psychological support and at puberty she would be given female hormones. It seemed the ultimate test that nurture could override nature. If it worked, Brenda would grow up not only with the body of a woman but with the mind of a woman as well. Meanwhile, one scientist had been constructing a theory that seemed to contradict John Money's one. If he was right, then it could spell disaster for Brenda.

MILTON DIAMOND: My immediate reaction to the thesis was it was simplistic. I thought humans were a lot more complicated than just being a product of their upbringing.

NARRATOR: Milton Diamond is a biologist. He believes that just as animals are born with an instinctive set of behaviours to act like males or females, so are humans.

MILTON DIAMOND: I saw no reason for humans to be that different. Certainly we're influenced by our society, certainly we're influenced by our leaning, but our basic inclinations, our basic framework or predispositions we have have to come from biology.

NARRATOR: Diamond had become obsessed with the idea that it was the hormone testosterone that held the key not only to our physical gender but also to our gender identity, to what makes us feel like men or women. As a student in the 50s, Diamond was involved in a series of ground-breaking experiments that began to uncover the secrets of testosterone's power. Pregnant laboratory animals were injected with testosterone. That testosterone in the mother made its way through the umbilical cord into the babies in her womb. When the litter was born the females' genitals looked almost male. The testosterone pumped into them before birth had transformed their bodies, but the big question was: would this same testosterone affect their minds, their instincts, make these females behave like males? The answer was yes. The females who had received testosterone in the womb even attempted to mate as if they were male. It seemed that testosterone had programmed these females' brains to give them the instincts and behaviour of males and it all happened before birth.

MILTON DIAMOND: So in other words here's an intervention during their embryonic life which affected their adult life, so those type of experiments showed, at least for animals, that this was possible.

NARRATOR: But what affects animals does not necessarily affect humans. To prove that testosterone in the womb irrevocably defined a human's gender identity, Diamond would need far more evidence, so when he attacked the Theory of Neutrality in the 1960s nobody listened.

MILTON DIAMOND: My view was a minority view because the Hopkins group had a great status and my ideas were relatively out of the ordinary.

NARRATOR: Meanwhile, John Money was closely monitoring the progress of the twins. He felt Brenda was growing up successfully as a little girl and had adopted a female gender identity. By 1972 Money believed that he had enough evidence to announce to the medical community that he had changed the gender identity of a child born a perfectly normal boy. The case was published in textbooks, discussed at conferences, even reported in Time magazine. It became an international, scientific sensation. It seemed dramatic proof that John Money was right, that we all have an unformed gender identity at birth that we learnt to feel like men or women. Whatever was in our genes could be overridden by upbringing.

MEL GRUMBACH: It was the ultimate test of John Money's hypothesis that all of these influences in prenatal life - sex chromosomes, hormones, gonadal development - could be overcome by socialisation.

WILLIAM REINER: I think it was certainly used as very strong evidence that children are a blank slate, newborns are a blank slate and that we can impose a gender identity on a newborn.

MEL GRUMBACH: The twins' case, what we knew about it really so reinforced the, Money's hypothesis that it was very hard to challenge.

NARRATOR: If John Money's theories had worked in such an extreme case as Brenda, then any doubts that doctors had about reassigning the sex of intersex cases vanished.

MILTON DIAMOND: Here was an unambiguous true-to-life etc, etc. male that was switched to be a true to life female. That made a significant impact on the clinical treatment then. It was like everybody was saying on wow, really, then we can do this.

NARRATOR: But just as John Money was announcing the success of the twins' case, in a laboratory in Los Angeles another discovery was about to be made that would cast further doubt on the whole idea of gender neutrality at birth.

DR ROGER GORSKI (University of California, Los Angeles): My interest in research is what's going on in the rat, in a, a species that we can manipulate, species that we can understand.

NARRATOR: Gorski and his team believed that the difference in behaviour between males and females must be caused by some physical difference in the brain and Gorski was determined to find this difference. The team set about comparing the brains of male and female rats in minute detail. Slice by slice, millimetre by millimetre, they compared every area of the brain hoping to spot even the smallest of differences, but after years of searching they found nothing. Then out of the blue one of Gorski's students claimed to have found something - a tiny area of the brain that seemed to be different in males and females.

ROGER GORSKI: I had a graduate student in the laboratory and he announced to the lab group that there was a marked structural sex difference.

NARRATOR: The student claimed that the difference in this area of the brain was blatantly obvious. No-one in the laboratory believed him.

ROGER GORSKI: And so he arranged for a meeting in a, in a conference room. Had two projectors side by side and one he put the slice of male brain and another he put the slice of the female brain.

NARRATOR: Deep in the centre of the brain in an area known as the hypothalamus, Gorski's student had found what they'd been looking for.

ROGER GORSKI: There was this dramatic difference that just jumped out at us.

NARRATOR: The male brain on the left had an area twice as big as the female brain on the right.

ROGER GORSKI: None of us believed it until we saw it and then we couldn't disbelieve it.

NARRATOR: This is the actual part of the brain that they isolated in a male rat. They called it the sexually dimorphic nucleus, or SDN, and here it is in the female rat. Nobody knew what this part of the brain did, but it was the first proof that there was a difference in the brains of male and female rats.

ROGER GORSKI: When we first discovered the sexually dimorphic nucleus of the rat I was very much interested in is it sensitive to hormones, when does it develop, what does it do?

NARRATOR: Gorski knew that testosterone caused all the physical changes in the body of a male rat, but could testosterone be turning the brain male? The team repeated Diamond's early experiments by injecting a pregnant rat with testosterone. As before, the females of the litter behaved like males. Then Gorski examined their brains. The SDN had been transformed by testosterone while the rats were still in the womb. The female rats had the brain of a male before they were born.

ROGER GORSKI: This particular area of the brain appears to be totally dependent on the hormone environment.

NARRATOR: What this meant was that in rats at least male and female brains were physically different at the time of birth and the difference was caused by the hormone testosterone in the womb and Gorski suspected the same difference would be apparent in the brains of humans. At this stage no one could say how this difference might affect behaviour, but it was the first hard evidence that leant support to the idea that we are not born neutral.

ROGER GORSKI: Given the fact that the general view in the clinical world was that nurture was by far the more important, I think our demonstration that hormones played a role, at least in my mind, challenged that view.

NARRATOR: Back in Winnipeg, Brenda was growing up out of the public eye. She was making her way through school. By now John Money had written another book describing the twins' case as dramatic proof of his theory about gender identity, but far away from the textbooks the family were dealing with the reality of the situation. Bringing up Brenda was not always easy.

JANET REIMER: I could see that Brenda wasn't happy as a girl, no matter what I tried to do for her, no matter how I tried to instruct her, she was very rebellious, she was very masculine and I could not persuade her to do anything feminine. Brenda has almost no, no friends growing up. Everybody really killed her, called her cave woman. She was a very lonely, lonely girl.

NARRATOR: At about this time the local psychiatrist looking after Brenda wrote to John Money about the concerns she had with Brenda's development. Brenda was showing clear signs of being deeply disturbed and unhappy. John Money didn't publish this. When Brenda was 13 the Reimer family decided to stop seeing Money. From then on nothing would be heard about Brenda for 15 years. During this time most of the scientific community continued to believe that the case was a success, dramatic proof of the whole idea that you could change the gender identity of a perfectly normal boy. But now biologists were closing in on one crucial new piece of evidence about the brain. Although a difference had been found in the brains of male and female rats, scientists had, as yet, been unable to find a difference in the human brain, but one team in Amsterdam was looking.

PROF DICK SWAAB (Netherlands Institute for Brain Research): it took some time to make the leap from Gorski's rat into the human brain because in the first place you need the right material. Post-mortem material of human beings without brain disease is very hard to get.

NARRATOR: It took them five years to collect enough human brains for their research. Then the painstaking work began. Just like with the rats, slice after slice of male human brain was meticulously examined and compared to an identical slice of female brain.

DICK SWAAB: Ultimately I think maybe I measured over 100 brain samples. The difference between the male and female brain became incredibly apparent.

NARRATOR: they had finally found the sexually dimorphic nucleus in human brains. In the male brain on the left the SDN is twice as big as it is in the female brain on the right. Over the years four more types of SDN, different in males and females, were found clustered together. Could this be where our gender identity lies? The part of the brain that makes us feel male or female. To answer this question the team in Amsterdam turned to a unique set of individuals. Emma Martin is a transsexual. Physically she was born a normal boy, but she's spent her whole life feeling like a woman.

EMMA MARTIN: When I was four years old something happened which I guess was the starting point of, of my realisation that, that I was different from other people. I was playing in the back garden in my pedal car and I suddenly realised that there was a little girl in the garden next door basically doing the same thing, just going up and down the garden on a tricycle, and I saw her through the fence and I just realised that they'd made a mistake, that, and I couldn't understand why, I couldn't understand why my parents were treating me as a boy.

NARRATOR: Emma's case seems to go against the very idea that nurture can override nature. She was brought up as a completely normal boy, yet something inside her brain appears to have overridden this.

DICK SWAAB: Transsexuals don't describe themselves as having a female brain. They describe themselves as being female, but of course this strong feeling to be a female should come from somewhere and we are certain it's not coming from the heart, it's coming from the brain.

NARRATOR: In the 1990s Prof Swaab's team began the first ever study of transsexual brains to see if there was some physical reason for transsexuals unusual gender identity. Swaab was convinced that the answer must lie in the cluster of sexually dimorphic nuclei. If he could prove this, it would be the first evidence that gender identity was linked to a specific part of the brain. After years of painstaking investigation he found a key new SDN. The picture on the left shows that particular SDN in a normal male brain. The picture on the right shows the same SDN in a male transsexual like Emma. It's the same size as that of a woman. The eleven male transsexual brains Swaab studied showed this SDN to be the size of a woman's. It seemed clear to Swaab that this cannot be coincidence, that this particular SDN must be important in defining our gender identity. Other preliminary studies seem to suggest that this difference in the brain between men and women happens before birth and if so, it may be that our gender identity is already so established in the womb that it cannot be overridden by upbringing.

DICK SWAAB: I think if we look to the entire set of data it's clear that we are not born neutral, that our sex difference is present already very early in developments.

NARRATOR: The big question was: what had happened to Brenda Reimer and in 1995 she was tracked down. The girl who had helped to make John Money world famous was living anonymously in Winnipeg and it was time to go public.

DAVID REIMER: I didn't like dressing like a girl, I didn't like behaving like a girl, I didn't like acting a girl.

NARRATOR: Brenda Reimer, the boy who was turned into a girl, was living as a man.

DAVID REIMER: I wore dresses on occasion and I never played with girls stuff. I usually got stuck with dolls or something like that for my birthday or Christmas and they sat in a corner collecting dust. Played with my brother's things. Wasn't too happy about sharing, but share with my brother or I don't have anything.

NARRATOR: For almost 14 years David has lived as Brenda and for most of this time he had been unhappy.

JANET REIMER: During the early years I thought we had made the right choice and it would work out. Dr Money kept saying it would work out and I thought well, he should know.

NARRATOR: But by the time Brenda had become a teenager her life had become so difficult she had become a virtual recluse.

DAVID REIMER: I was so pitifully lonely and I tried to put make-up on, but I looked like Bozo the Clown. You ever can imagine a guy trying to put make-up on himself. After, after a while trying I just gave up, says what's the sense of trying. No matter how much I, I put out in effort it's never going to work. There's, there's no way of, of knowing whether you're a boy or girl 'cos nobody tells you. You don't wake up one morning and say oh I'm I'm, I'm a boy today, you know. You know. It's, it's, it's in you, you know, it's in your genetics, it's in your brain, you, nobody has to tell you who you are.

NARRATOR: When Brenda was 14, after years of unhappiness, her parents revealed her true sex at birth. Within a few months Brenda had decided to become David.

(ACTUALITY CHAT)

For the last 20 years he has been married and living in Winnipeg with his wife and her three children. He has undergone surgery to have his penis reconstructed.

DAVID REIMER: Make sure the cow won't move.

NARRATOR: Unaware of the significance his case had had to science, David had never realised how important it might be to go public.

DAVID REIMER: By me not saying anything the medical community was under the impression that my case was a success story and I was shocked when I heard that people thought that my case was a success story.

NARRATOR: In 1998 John Money, now in semi-retirement, published ten reasons why Brenda's case might have failed. These included the possibility that the surgical reassignment at 22 months had been performed late, that having an identical twin brother could have heightened Brenda's sense of being abnormal, and that the trauma caused to the parents by the entire event would have adversely affected Brenda's development. These were problems that Dr Money had never emphasised before, but for many people it was much simpler. The gender reassignment of a perfectly normal boy hadn't worked.

MEL GRUMBACH: Many of us were completely in the dark about, you know, what had happened. We heard in the early 70s what a success this had been. Until this denouement we had really no, no knowledge of how the twins were doing and so this led to major disaffection and what was disappointing in all of this, in, in, more than disappointing, I mean what was, what hurt a lot of us is that there'd been no word that this wasn't working out the way it had been first suggested. We'd been let down by somebody who we respected.

NARRATOR: With the most dramatic case of gender reassignment a failure controversy has also arisen in the field of intersex. Some patients and doctors had begun to question gender assignment surgery for intersex cases even before David went public.

WILLIAM REINER: I would recommend to the parents that surgery had great risks for children with intersex of being the wrong surgery and that the children may well reject that surgery at a later time in life because they may choose the gender identity that was not assigned.

NARRATOR: But many surgeons and psychologists believe David's case has no bearing on intersex…

DAVID REIMER: I'm not done yet.

NARRATOR: …because he was born a normal boy, unlike intersex children who receive an imbalance of hormones in the womb and their brains may well reflect this. For many who have to deal with the complex problems of intersex, the wider body of John Money's work is still highly valued and he remains respected in the field. Indeed while the guidelines for treating intersex have evolved continuously since the 1960s, they have not altered as a result of David's case. Many experienced surgeons continue to believe that intersex children do genuinely benefit from gender assignment surgery.

PHILIP RANSLEY: We have to perform our surgical task with what we believe to be the best interests of that child at heart and that is what we do and we would not undertake surgical intervention if we were not convinced completely that this was the correct course of action.

NARRATOR: The fact is that neither the case for or against assignment surgery for intersex is proven. There simply is not enough evidence. Over the last 40 years because of the sensitivity and complexity in tracking patients there have not been sufficient long-term follow-up studies to fully judge the outcome of gender assignment surgery for intersex. Many doctors who continue to have contact with their patients say most are happy in their assigned gender, but it will continue to be difficult to gain independent evidence of this.

PHILIP RANSLEY: The, the scientific data that we would love to have to tell us whether the, the decisions we're making in infancy were correct or not, this data does not exist. Therefore in this field medicine has to remain a mixture of science and art.

NARRATOR: Whatever it means for intersex, David's case has also caused the medical community to re-examine another belief. The theory that we are all born neutral is now being questioned by many.

MEL GRUMBACH: In the 21st century we can say that the theory of gender neutrality was wrong, that there are important biological factors that play a role. What the mixture is between environmental and biological factors is going to take us a long time to sort out.

DAVID REIMER: I was never happy as Brenda, never. I'd slit my throat before I'd go back to that. I'd never go back to that. It didn't work because that's life, because you're human and you're not stupid and eventually you wind up being who you are.

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