The John/Joan Case: Another perspective

Milton Diamond, Ph.D.

Mr. Jack Heidenry, Editor in Chief of the Internet site, ThePosition, published a screed against Mr. John Colapinto and his book As Nature Made Him: The Boy who was Raised a Girl (2000). In so doing he published many false accusations about me. Apparently his writings had no editorial or fact checking. Nevertheless, there are too many unfounded assertions to let matters lie. Mr. Colapinto, I'm sure, is more than adequately prepared to defend his work and his integrity. Since Mr. Heidenry's writings, however, happen to malign me, I will address some of his assertions. To correct all his allegations about me would take too much time. He gets paid for writing time, I don't.

Mr. Heidenry accuses journalists of being less than professional in not digging deeper into the topic being discussed. Perhaps Mr. Heidenry would have done well to also interview others and dig deeper. For instance he never tried to contact me nor many others to check out points. He had obviously all the input he wanted from his previous meetings with Dr. Money who is on the Advisory Board of his web site, The Position and selected others. Many journalists have given Dr. Money the opportunity to be interviewed and openly present his perspective of events and he has repeatedly declined.

I will address Mr. Heidenry points as they are presented:

Accusation (Part I. Section 1. Page1): Diamond attempts to destroy John Money's reputation. (Also Part III, Section 1. Page 1)

Response: Heidenry gives not a single example of such. Indeed, in the dozens of interviews and writings I had regarding Dr. Money's work, I have never made a single statement against his character nor motivation, nor reputation. Indeed, many reporters tried to bait me into doing so for their use in quotes or sound bites. My typical response to such questions is that I think Dr. Money was mistaken, not malicious. I have even written to reporters who did not interview me but who maligned Dr. Money's character and discussed my role in the John/Joan case. I suggested to them that it was Dr. Money's ideas on sexual development which were to be criticized, not the individual. And Mr. Colapinto, in his book, reports that was my feelings during his interviews with me.

This is in distinction to Dr. Money in his own self-assumed rivalry with me. He has more than once in print challenged my (as well as others such as Dr. Julianne Imperato-McGinley and Dr. Bernard Zuger) character and abilities without documenting any reason for such charges. For instance in one of his latest insults he intimated to a reporter from New Zealand (New Zealand Listener, 1998) that a motive for my research on the John/John case was financial gain. In fact, my research on that case (airfare, hotel, meals, etc.) was funded from my own pocket. I have, to date, not received a dime for any of that work. While Dr. Money obviously used the case for his own publications, did he interview the twins for free? I doubt it.

Had I wanted to impugn Dr. Money's reputation as a person or clinician in ways other than in regard to his theory of sexual development, I could have, in my writings, included mention of his use of sexually explicit materials with John/Joan and his brother. They had told me of their exposure to such materials. And so did others of Dr. Money's previous patients who have contacted me. I pointedly omitted any mention of such because I wanted the focus of my writing to be on the substance of the scientific argument and not be a dispute about character. And I recognized that, in the eyes of the general public or medical community, use of such materials with children would raise concern.

Further, in this regard, it was Dr. Money, who on many occasions tried to reduce my reputation by, for instance (according to three of his former students who mentioned it to me) forbidding them from referencing any of my work in their articles.

As Mr. Heidenry recognizes, it is the way of scientific discourse, to critique the arguments or theses with whom one is in scientific disagreement. When it comes to so doing against the thinking of Dr. Money, however, Mr. Heidenry considers this an effort to harm an individual's reputation. No, the target is the theory not the reputation.

Accusation (Part I. Section 2. Page 4) That it is my view that "a person's identity and behavior could be explained exclusively in terms of biological factors and genetic inheritance."

Response: Mr. Colapinto says nothing like that in his book and obviously, either Mr. Heidenry has never read any of my writings on the topic or didn't understand what he read or has been misinformed. In my first major critique of Dr. Money's approach (Quarterly Review of Biology, 1965) I wrote as follows: " . . . in sexuality, as in so many other areas, the human being is extremely flexible and his behavior is a composite of prenatal and postnatal factors superimposed on a definite inherent sexuality." And I have continued that theme of interacting influences in every subsequent discussion and publication on the topic. My writings have consistently said that I believe a person's sexual behaviors are the result of an interaction of environmental (social, cultural, religious, etc.) influences superimposed on an inherent predisposition due to biologic factors such as genetics and endocrine influences. Recently, in an invited address to the American Academy of Pediatrics, and in a publication for them last year (The Journal of Urology; special issue for pediatrics, 1999) I repeated my thesis: "In every individual . . . the [five major components of an individual's] sexual profile are evaluated to integrate best personal needs with abilities, which is typically a compromise that melds genetic endocrine forces with social and cultural conditions."

Mr. Heidenry continues this false accusation in Part 1. Section 4. Page 1 where he states that I thought that children were born "wired from birth to be either male or female." He is wrong again. I have written that I think that all people are biased in their behavior by their biology and that intersexed individuals usually have more flexibility than others do. But here again the same forces of nature and nurture interact. Mr. Colapinto correctly reports that as my thinking.

Accusation: (Part II. Section 3. Page 1) That I, in an interview with the BBC (Open Secret, Williams and Smith, 1980), asserted that "individuals are hard-wired as male or female, and that this biological determinism is resistant to the combined efforts of medical, surgical, and social efforts to change gender identity."

Response: There is nothing like that in Mr. Colapinto's book or in my copy of the BBC tape. See above. What I did on that program was cast doubt on the efficacy of the treatment imposed on the twin and, indeed, even the value of looking at this single case -as was being done in medical and psychological texts-- as a model for all such treatments.

In addition, some might be interested to know, that at the time of my publication regarding the BBC interview, I suggested to the journal editor, Dr. Richard Green, that Dr. Money be invited to simultaneously write his view of the BBC production. I also wrote to Dr. Money at the time suggesting this. In addition, in a letter to Dr. Money, I encouraged him to write a follow-up to the twin case since there was much in the literature based on the original writings. Dr. Money declined and even intimated legal action should the journal (Archives of Sexual Behavior, 1982) and I continue with publication.

Accusation: (Part III. Section 1. Page 4) That there are, according to Dr. James Weinrich, "lots of cases in his [Dr. Money's] files of adult men with micropenis who tell him (and the media) in no uncertain terms that they wish they had been castrated and reassigned as girls when they were very young." Mr. Heidenry himself claims to have interviewed such a gentleman.

Response: The implication is that the management of the twin was correct or at least could have been. If such data do indeed exist, there has been no peer-reviewed publication of such. While sex change may be the wish of some, it is certainly not the norm. Dr. Suzanne Kessler (Lessons from the Intersexed, 1998) writes of a study she conducted among college men. She reports that the men in her study "did not think that having a micropenis would have had a major impact on their sexual relations, peer or parental relations or self-esteem." Only a minority thought they might elect sex change as a solution. Also, electing a sex reassignment procedure is different from having one imposed without informed consent.

As far as I can determine, there has still not been reported a single case of a typical, nonintersexed male being successfully and happily reared to be an adult woman sexually attracted to men.

Accusation: (Part III. Section 2. Page 3): The reasons the long term follow-up study of John/Joan by Dr. H. Keith Sigmundson and myself was turned down by the New England Journal of Medicine and the Journal of the American Medical Association was because it was "not up to snuff."

Response: The main criticisms of our article by the reviewers were that the article did not have a discussion of the Freudian interpretation of the issue, the article was too long for the journal's format, and the topic was not thought of sufficient interest to the total scope of medicine. The controversy was that our interpretation did not cover a psychodynamic discussion that would offer a different view of how things developed. We did not at the time, and still do not think, that such an approach to the case is warranted. We also did not want to shorten the paper since we thought it contained material that justified the length. We then turned to the specialty medical publication The Archives of Pediatrics and Adolescent Medicine (1997). This journal has a primary interest in children and adolescents; the time of most significance relevant to the John/Joan story.

All three journals were satisfied that we had the permission of the individuals concerned (we submitted copies of written permission) and our use of the pseudonyms John/Joan would protect the subject's privacy.

Accusation: (Part III. Section 3. Page 1 & 2): Mr. Heidenry writes "Colapinto refers to Money's advocacy of the primacy of nurture over nature, or social environment over biology, though without ever directly quoting Money himself."

Response: For those who want to read Dr. Money's direct quotes in this regard they could, of course, read his papers for themselves. For those who would prefer a summary view, however, I recommend to them an exchange between Dr. Kenneth Zucker and myself regarding sexual development (Journal of Sex & Marital Therapy, volume 22,1996,). I don't know if Mr. Heidenry knew of these publications. They contain more than a half dozen of Money's quotes from many publications, not just one book or article, to the effect that learning and the environment over-ride biology. The JSMT articles also contain comparisons of Dr. Money's and my interpretation of the interaction of nature and nurture by such leading researchers as Masters and Johnson and Robert Kolodny (Human Sexuality, 1982) and Frank Beach (Human Sexuality in Four Perspectives, 1976). The material provided offer more than sufficient justification for the conclusion of Mr. Colapinto, and I that Dr. Money regarded pre-birth biological influences secondary to the power of post-birth environmental factors.

If Dr. Money at present has modified his original thesis to include biological factors as perhaps more important or as equally important as environmental ones, he should now get credit for that shift in thinking.

Accusation: (Part III. Section 3. Page 3): That Diamond (and others) "have done their level best to discredit Money's life work."

Response: My attention has only been focused on one aspect of Dr. Money's work; that related to his ideas on sexual development. On many other aspects of his work, I either agree with his ideas or have no interest in them. However, as I believe Mr. Heidenry would agree, it is part of a scientist's responsibility (and that of journalists) to challenge important questionable assumptions, statements and conclusions. That has been what I have been doing. If my work discredits this aspect of Dr. Money's thinking it has not been my intention to color other areas of his work nor his character. To infer, as does Mr. Heidenry, that criticism of Money has been premeditated by several of his critics, is ludicrous.

Accusation: (Part III. Section 3. Page 4): That I wrongly called the John/Joan case an experiment and Dr. Money never regarded it as an experiment.

Response: The definition of an experiment in medicine comes from The National Commission For The Protection of Human Subjects of Biomedical And Behavioral Research (The Belmont Report, 1979) and the handbook for Evidence Based Medicine (1997) by Sackett et al. A procedure is essentially considered an experiment when the results can not be predicted on the basis of past results. The result of the twin's treatment could not have been predicted since such a case had never before been reported. It was thus an experiment.

I have limited my remarks to the most salient criticisms or innuendoes that relate to me personally in Mr. Heidenry's articles. But a last comment is in order. I have never considered myself, as implied in several places, Dr. Money's rival for anything. He has nothing I either want or need nor are ours goals the same. I never have and do not now consider him an enemy as some might assume as a subtext in Mr. Heidenry's writing. If Dr. Money feels that I am some sort of rival or enemy that is his own thinking. Indeed, I applaud many of the things that he has done. But his dealing with the John/Joan case and his failure to allow David to be himself rather than, as he, Dr. Money would have him, is something I think seriously amiss. And too many children have had their lives adversely effected by his reluctance to admit this error. The John/Joan case was probably one of the most celebrated cases known in the medical, psychiatric, and psychological communities and many in these professions continued to believe that the treatment was a success. We are all entitled to make mistakes, but to keep the mistakes hidden when revealing them would save human misery is wrong. For Dr. Money to suggest his reluctance to reveal the failure of John/Joan's gender shift was to "chose the higher road of silence" and save David's privacy seems ingenuous when he was quite willing to tell the story when he thought things were going well. Also, I know at least for Mr. Colapinto's book, David Reimer told me he had granted Dr. Money written permission to discuss his case and that he thinks the book about his life accurately presents his recollections and views.

Mr. Heidenry might claim all of his writing were based solely as a review of the book As Nature Made Him: The Boy Who Was Raised As A Girl. However, since he has mentioned things about me that were never in the book there must have been more involved in his writings than a simple book review. The tone of his articles and the implications and statements applied to me, regardless of their origin, lead me to request this response be published.