The story about Viktor and Viktoria and the inborn gender identity

Viktor in 2010, photo: Dagbladet

Is your gender identity inborn, or is it not? Here is a story that explains why I believe there is a biological component to our sense of being male or female.

In 1985 a boy named Viktor was found in a basket on the stairs of a hospital in the capital of Quito, Ecuador. No one knows who had left him there, but one reason may be  his parents were poor (he was malnourished) and that he had ambiguous genitals.

XY does not a boy make

A genetic test told the doctors that he had male chromosomes (46 XY) and that the testicles were intact.

Still, the penis was shorter than the 1,94 cm needed to be considered functional by the medical establishment. In accordance with the ruling paradigm of the day, the doctors therefore decided to turn him into her.

The doctors believed that gender identity is something that is created throughout the upbringing. Since it is easier to create a vagina surgically than extending a penis, the doctors chose the easy way out, believing that Viktor would thrive as Viktoria.

John Money and the John/Joan case

This way of thinking had been strongly influenced by the famous psychologist John Money over at Johs Hopkins Gender Identity Center. He had studied a lot of intersex children who had undergone surgery, and had concluded that it was the upbringing that determined their gender identity, not biology.

(“Intersex” and "disorder of sex development" are terms used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. See ISNA.)

Some experts disputed this finding. Dr. Milton Diamond of the University of Hawaii had studied the sexual development of guinea pigs and found that they changed behavior according to the amount of testosterone they had been exposed to in the uterus.  He doubted that human beings were that much different.


John Money felt pressured by this criticism, but he managed to deliver what at the time was considered the ultimate proof:: the twins "John "and "Kevin", born in 1965.

An accident had given John serious genital burns after birth, and John Money used surgery to turn John into Joan. The parents raised Joan as a girl, promising  Money never to tell John the truth.

In 1972 Money presented the case for the public, describing the experiment as a huge success. It was this case that made doctors all over the world go for the easy option.

Viktor goes to Norway

At the age of three Viktor, now Viktoria, was adopted by Norwegian parents.

The parents consulted the local expertise and were told that it was important to strengthen "Viktoria's" identity as a girl. Because of this they raised him as a girl. They did not tell him the truth about what had really happened to him.

The problem was that Viktor never felt like a girl. He refused to wear girl's clothing. He wanted to play with the boys. In kindergarten, he was considered a problem child, acting out.

Meeting Diseth

In the early 1990's, at the age of six and a half, "Viktoria" was admitted to the National Hospital (Rikshospitalet)  in Oslo for cosmetic surgery. The idea was to feminize his genitalia even more.

Child psychiatrist Trond H. Diseth was asked to take a look at the "girl", as "she"  was reported to be "confused and disturbed".

Diseth had been told by his superiors that he should do anything he could to make these kids understand that they were girls, and to keep the real condition a secret.

Diseth asked "Viktoria" to make a drawing of herself. The kid did so, and the drawing made Diseth reconsider everything he had learned about sex and gender.

"Viktoria" explained the drawing to Diseth:

"This is a boy, but the boy is now dead. He had a big penis; it started to grow and came up into the mouth so that the boy could not eat. The boy had to be operated. The penis were cut off, but the boy died. The penis and the boy were buried separately. All the people came to the funeral for the penis, but none came to the funeral of the boy."

Like all children Viktor had made theories to explain what he did not understand. What was amazing about this theory, was that it at least partly reflected the true nature of what the boy had been through.

Diseth was not allowed to discontinue the feminization procedure, however, and Viktor was transferred to a child psychiatrist close to where he and his parents lived. Viktor had to stay a girl for the time being.

Joan became John again

In 1994 Diamond, the one who had criticized Money, managed to get in touch with "Joan".

It turned out that "Joan" had never been happy as a girl. "She" had always felt that she was a boy.

David Reimer. Photo: Reuters

John Money did not care about the information he got from the parents, though, and had  told them to stick to the original plan, and raise "Joan" as a girl.

In 1980 "Joan" violently opposed a new operation, arguing that he was boy. This made his mother tell him the whole story, and John was finally was accepted as a boy. When Diamond met John,  John had married -- as a man.

The real name of John was David Reimer. He committed suicide in May 2004.

John Money never admitted he was wrong

"He [Money] waffled," Diamond told Deborah Rudacille in 2003.

"He paid lip service to biology, but when push comes to show he made his money, his reputation, on the idea that sex is socially constructed. You put them in the pink room and they are a girl; put them in a blue room and they are a boy. And I think he did not want to lose his reputation."
(Deborah Rudacille: The Riddle of Gender, 2009)

Milton Diamond presented his findings in an article in 1997, an article which ultimately led to a change in hospital procedures in many countries..

Life as a girl

Diamond's work also helped Viktor in Norway.

Viktor says that he had come to accept that he was a girl when growing up. No one had told him otherwise. But he never felt like a girl. Still, he was unable to put this experience into words as a young child.

When his parents demanded feminine behavior, he protested loudly. He hated wearing a dress. His heroes were all masculine.

His misery intensified as he grew older. He wanted to play with the boys, but the boys didn't want to play with him. Nor did the girls, for that matter, as they sensed "Viktoria" was different. He fell in love with girls, and believed he was a lesbian.

Entering secondary education he became more isolated and depressed. The fact that they gave him estrogen made things worse. After an attempted suicide he got in touch with Dr. Diseth again.

Diseth makes a break with the past

Trond Diseth,
Photo: University of Oslo

Diseth had in the meantime found more and more intersex "girls" with psychological identity problems, many of them suicidal.

He had now decided to stop following the traditional procedure and wanted to help Viktor understand what had really happened to him.

He  replaced Viktor's estrogen-treatment with testosteron.

"Getting testosteron was an enormous kick," Viktor says. "I was felt happily intoxicated. Things fell more and more into place."

Viktoria change name to Viktor, and he and Diseth made plans for how he could find the way back to his original  sex.

Patric the ponyo

“I never felt like a girl," Viktor told the Norwegian newspaper Dagbladet in 2010:

"When I was little I played with boy’s stuff, and had male friends. Very early I had an imaginary friend, Patric, a male figure who has constantly been there for me as a role model. He gave me the motivation to live.I usually say I died when I was six months old, but the Patric figure stuck with me as a standard for the man I would once be. And with today’s surgery, that has largely come true. I feel like I’m 90 percent back to being a man, and the doctors say I will reach 95 percent. I do not know what the last 5 percent is. Perhaps it is psychological.”

I would guess that Patric represents a parallel to the kind of alternative personality complex -- or "ponyo", as I have called it -- that many transgender persons develop in order to handle the discrepancy between their official sex and their alternative identity. Patric helped "Viktoria" express the natural feelings of being a boy, in the same way a female avatar or cross-dressing persona may help a crossdreamer handle his or her conflict.

As for Viktor's idea of being 90 percent male, I guess this must be set up against a culture that  had asked him to be 100 percent female. Basically, we are all a mix of the feminine and the masculine.

New procedures

Diseth and his colleagues now make use of a completely different procedure when determining the real sex of a child with ambiguous genitalia. They try to find out how chromosomes, genes and hormones have influenced the development of the brain before birth.

When the sex has been determined, it is up to the parents to decide if surgery is needed.  This means that the default sex is no longer surgery to make an XY boy look female. They also try to reconstruct male genitalia.

Follow-up studies show that over 90 percent of the children treated in the new way thrives in the sex they have been assigned, something Diseth and his colleagues take as proof of them being able to determine the real inner gender identity of the child.

This is not necessarily in line with what Diamond and many intersex activists recommend, namely to leave the kids off the operating table until they are old enough to decide for themselves. They are in total agreement regarding the inborn component of gender identity, though.

Given that Diseth presented Viktor in his doctoral thesis, and that the reform has been strongly influenced by the collapse of Money's social constructivist approach, you might say that Viktor and David contributed significantly to a more humane treatment of intersex persons in Norway.

Brainwash, the TV program

Harald Eia. Photo: NRK

The story of Viktor was presented in a controversial Norwegian TV series made by the Norwegian entertainer Harald Eia in 2010.

Harald Eia has been trained as a sociologist, but had got tired of the social scientists' tendency to interpret everything as the effect of culture. He found that few, if any, Norwegian social scientist knew anything about biological research on sex and gender, and decided to demask them on prime time television.

Viktoria was presented in the final episode of the series "Hjernevask" (Brainwash).

Suddenly the whole country was debating  sociology and social biology, sex and gender, and the fate of intersex kids and transsexuals.I must admit I had never expected that to be even remotely possible.

I believe Eia was right in attacking the dominant social science paradigm in this way, and they proved his point with an embarrassing display of academic arrogance and ignorance.

Eia failed in one respect, though. He should have been equally critical in his approach to the evolutionary biology of scientists like  Simon Baron-Cohen. I guess the journalistic temptation toward simplification and conflict was just too strong.

I have included the final episode below, so you can see the interview with Viktor for yourself. The embedded version has English subtitles, as does the Vimeo version (without ads).

What can we learn from this?

For me the stories of John and Viktor are ample proofs of there being an inborn gender identity. Their stories, and the stories of thousand others, do not make sense without such an concept. There is a biological component to our identities as men and women, and the idea of the brain being nothing but a blank slate waiting to be filled with culture is simply wrong.

That does not mean that this biological core is not influenced by other factors, though: personal, cultural or environmental. And some brains seem to be more malleable than others.

For instance: The male gender identity has  not been equally clear among all of the intersex boys who have been turned into girls.

Although Diamond in 1997 argued that "there is no known case where a 46 chromosome, XY male, unequivocally so at birth, has ever easily and fully accepted an imposed life as an androphilic female regardless of the physical and medical interventio," there have been reports of XY kids who continue to live as women and who do not report gender dysphoria.

In 2005 Heino F. L. Meyer-Bahlburg published a review of several studies of "46,XY" intersex persons raised as women, and found that out of 51 patients, 33 were living as women, 7 as females with possible gender dysphoria and 11 as males. Of 15 that had been raised male, all lived as male.

Meyer-Bahlburg's concluded:

"These data do not support a theory of full biological determination of gender identity development by prenatal hormones and/or genetic factors, and one must conclude that gender assignment and the concomitant social factors have a major influence on gender outcome. On the other hand, a number of female-raised individuals did change gender to male and others developed a possible gender dysphoria, which indicates that gender assignment does not dictate gender outcome either."

But please note: The Meyer-Bahlburg's review does not in any way disprove the idea that gender identity has a biological component.The proportion of patients who report a male gender identity or gender dysphoria is highly significant. But it tells us that the development of our sense of being male or female is influenced by many factors, biological, environmental and cultural.

I suppose some of the intersex XY persons staying female may be lying to themselves or  to their kin, trying to protect the investments they have made into upholding a female persona. Or they may interpret their gender dysphoria as some different kind of depression or dysphoria. But I would not be surprised if many  of them feel truly at home in their female body This tells me that there are many shades of grey here as well.

The neuroscientist Lise Eliot puts it this way (in Lise Eliot: Pink Brain, Blue Brain: How Small Differences Grow Into Troublesome Gaps -- And What We Can Do About It,  2009):

"So while these cases clearly demostrate that prenatal testosterone is important for shaping play behavior and sexual preference, they also prove that it's not omnipotent. Rearing also matters in establishing a child's sense of gender identity and in the many other behaviors that accompany this potent piece of self knowledge."

Gender identity is not the same as gender expression

It should also be noted that the fact that John and Viktor had strong inborn male identities, and preferred male games and clothing, does not necessarily mean that gender specific behavior or personality traits are biological.

You might just as well imagine an inborn gender identity that seeks to express itself with the cultural expressions found locally. That is: I prefer rough and tumble play, not because my male body forces me to be violent, but because I am a boy and I want to fit in as a boy.

The jury is out on this one.

Are all trangender people intersex?

Men like David and Viktor are not transgender or transsexual. But their narratives are close to identical with the ones given by trans women and trans men. The confusion Viktor went through -- and his journey of self discovery -- is very similar to the one felt by many crossdreamers, as well. It is beyond unlikely that this is just coincidence. This means that what causes the different conditions must be similar.

This does not mean that we can say that all male to female crossdreamers have an inborn female gender identity, however, or that all FTMs are men.

Many MTF crossdreamers argue strongly that they identify as men, and that their crossdressing or crossdreaming does not make them transgender. Nor are they necessarily particularly interested in stereotypical female activities (but then again, nor are all women).

I believe some of these MTF crossdreamers misunderstand the term "transgender" (believing it to be synonymous with "transsexual"). Moreover, some of them have probably invested so much in their male facade that they refuse to even contemplate the idea of having a female self.

Nevertheless, there are far too many of them for this to be the final answer. It is clear to me that many MTF crossdreamers have  a clear  male gender identity, in the same way as many FTM crossdreamers have a clear female identity, which again proves that it takes more than one variable to make a man or a woman.

If Diamond; Diseth and their allies are correct in their assumption that gender identity development is at least partly dependent on the hormonal environment in the womb, we should actually expect this kind of diversity.

As David/Davida explained in the guest post on the causes of transgender conditions, hormones do not act as on/off switches, nor do they act on one personality trait only. The amount of hormones produced is important and may vary in quantity. At the same time the body's ability to absorb and make use of the hormones may fluctuate.

It should therefore not come as a surprise that the intensity of the gender identification will also vary. If you add environmental, epigenetic, psychological and cultural factors, the variation we see becomes very plausible.

Still, this does not change the fact that David and Viktor were born men, and deserved to stay male. What the medical establishment did to them was a crime. And if intersexed people can have such a strong inborn gender identity, it should come as no surprise that transgender men and women can have one too.

References

Harald Eia and Ole-Martin Ihle: Født sånn eller blitt sånn, Oslo 2010 (Born this way or become this way, a book based on the TV series Hjernevask/Brainwash)

You can watch the TV program, Hjernevask (Brainwash) that presented the story about Viktor over at Vimeo (password: hjernevask) with English subtitles. I recommend that you see the whole program, but if you are impatient and want to learn more about Victor, skip to 15:55 in the Vimeo version.


"Dagbladet: 'Viktor never let himself be brainwashed'”, translation of article in the Norwegian newspaper Dagbladet from Intersex in Australia.

Milton Diamond: "Sexual identity and sexual orientation in children with traumatized or ambiguous genitalia", Journal of Sex Research, 34(2), 199-222 (March 1997).

Milton Diamond:  "Sex Reassignment at Birth: A Long Term Review and Clinical Implications", Archives of Pediatrics and Adolescent Medicine, No. 151 (March 1997)

Heino F. L. Meyer-Bahlburg: "Gender Identity Outcome in Female-Raised 46,XY Persons with Penile Agenesis, Cloacal Exstrophy of the Bladder, or Penile Ablation", Archives of Sexual Behavior, Vol. 34, No. 4, August 2005, pp. 423–438 ( C 2005).

"Finner barnets egentlige kjønn", Newspaper article on Diseth and how to determine the sex of a child in Verdens Gang, September 14 2008. (In Norwegian)

"Gutt eller jente", by Charlotte Lunde, article in the Norwegian magazine A-magasinet, January 17 2007. Includes interview with Viktor. (Confusing Google Translation here)

See also David/Davida's guest post on the possible origins of transgender and transsexual conditions.

APPENDIX Diamond on "John"

Milton Diamond

Milton Diamond made the following conclusions regarding John (David Reimer):

"The sex reassignment of John to Joan only attended to the gender patterns, and gender roles to which he would be subject with the expectations his identity and other levels would follow. 

"Joan did indeed become aware of the social expectations concomitant with the female gender but these were not in keeping with those with which he felt comfortable. Standing to urinate, despite its housekeeping and social consequences is a dramatic display of preference. The sex reassignment thus obviously failed in the area in which it was most designed to succeed.

"But it failed in the other four levels as well. The contrast between the female gender-typical behaviors the child was being asked to accept and his inner directed behavior preferences presented a discordance that demanded resolution. Joan's analysis of the situation was that she best fit in, not as a girl but as a boy. Thus, despite her upbringing, Joan's sexual identity developed as a male. 

"Sex reassignment also obviously went against Joan's or John's reproductive character. Castration removed any reproductive capacity. Certainly unaware of this as a child, John very much resents this now and decries this loss. Castration also removed the androgen source for sex-typical mechanisms of sexual arousal and other physiological processes. His ability to ejaculate returned with androgen treatment. The castration and surgical scarring, however, has dramatically reduced erotic sensitivity to the perineum and subsequently reduced this option. 

"And significantly, as many studies strongly indicate, sexual orientation is prenataly organized or at least predisposed. The sex reassignment did nothing to effect sexual orientation. Joan remained totally gynecophilic despite being reared as a girl."

In other words: It did not matter how much "social construction work" doctors, parents, family, friends and the surrounding society did on John, neither his sex identity nor his sexual orientation could be adapted to the cultural norm.