Psychosomatic Medicine, Vol. 32, No.

5 (SeptemberOctober 1970) -449-454

Psychosomatic
Medicine

JOURNAL OF THE AMERICAN PSYCHOSOMATIC

SOCIETY
(Editorial Note:
The
following
paper
occasioned
considerable debate in the course of
editorial review and it was deemed
advisable that a critical review by Dr.
John Money and Dr. Zuger's reply to it
be published with the article. Dr.
Money added two footnote references
to his critique after reading Dr.
Zuger's rebuttal. These are crossindexed by Editor's notes in the
published text of Dr, Zuger's letter.
A second review (raising many of the
same issues) and the portion of Dr.
Zuger's rebuttal dealing with it have
not been included in this published
interchange.
MFR)
Gender Role Determination
A Critical Review of the Evidence from
Hermaphroditism
Bernard Zuger, MD
From the Department of Psychiatry and Neurology, New York University School of Medicine,
New York, and the Children's Psychiatric Clinic,
Greenwich Hospital, Greenwich, Conn. The
author has received helpful critical comments
from Drs. Rody P. Cox and Douglas G. Gilmour,
New York University School of Medicine; The

Psychosomatic Medicine, Vol. 32, No. 5 (SeptemberOctober 1970) -449-454

author has received helpful critical comments
from Drs. Rody P. Cox and Douglas G. Gilmour,
New York University School of Medicine New
York, NY.; from Dr. Bernard Benjamin, Brooklyn,
NY; and from Dr. Mack Lipkin. Received for
publication Jan 16, 1970.
Address for reprint requests: Bernard Zuger, MD,
Department of Psychiatry, New York University
School of Medicine. 550 First Avenue, New York,
NY 10016.
this paper examines the evidence for
the claim that individuals with ambiguous sex at birth will accept the sex
role of rearing over that indicated by
chromosomes,
gonads,
hormones,
internal or external genitalia. The
evidence as presented by the principal
proponents of this claim is found
wanting on methodologic and clinical
grounds. The conclusions drawn from it
are considered unacceptable.

Psychosomatic Medicine, Vol. 32, No. 5 (SeptemberOctober 1970) -449-454

Acquisition of gender role (sex identity) is
widely held to be the result of early sex
assignment and rearing. This belief has
important implications for normal and
deviant sex, as well as for the general
problem of environmental versus inborn
determination of behavior.
The evidence supporting this belief may be
divided into four kinds. First is the large
number of studies which seek correlations
between the child and respective parent as
regards one or other characteristic com monly
thought to be masculine or femi nineeg,
aggressiveness, predominant interests, etc.
Such correlations are not always found, or may
vary
depending
on
the
measure
or
methodology used (1-3). At best, they are
tangential to outright sexual identifi cation, and
their extrapolation to the latter can only be
hazardous. The interaction between child anti
parent, and later, the outside world, may be
successful in shaping its sex into socially
acceptable expression rather than altering its
basic masculine or feminine nature (1).
A second kind of evidence, closely related
to the fi rst, comes from studies purporting to
show a specific familial environment as
responsible for homosexualitynamely,
a
dom inating mother and an ineffectual and
rejecting father. To the extent that this may be
true, a genetic basis for such potential

Psychosomatic Medicine, Vol. 32, No. 5 (SeptemberOctober 1970) -449-454

characteristics of the parents, possibly as part
of a larger poly-genic constellation, would have
to be excluded in view of Kallmann's (4)
earlier twin studies on homosexuality. The evidence itself is retrospective. Direct evidence
available for the condition of effeminate
behavior (cross-gender identity) in young boys,
of
whom
a
large
percentage
become
homosexuals,
does
not
confi rm
the
presence of a specifically different familial
environment (5, 6).
A third kind of evidence centers around
homosexuality as a substitute for heterosexuality in the restrictive environments of prisons
and boarding schools. In the case of prisons, we
may be dealing with an increased number of
individuals
already
oriented
toward
homosexual practices (7); and in the case of
boarding schools, such practices may simply be
part of the experimental expression of the sex
of immature individuals before finding more
satisfactory outlets. Their temporary nature
would actually support the negative side of an
environmental determination of sex identity.
Akin to this kind of evidence is the oftquoted prevalence of and tolerance for
homosexuality in certain civilizations as indicative of an environmental influence.* Data
as to the precise nature and extent of such
homosexuality are lacking, and generalizations
made from such data could be as wrong as
would be generalizations made exclusively
from the character of the New York theatre or

Psychosomatic Medicine, Vol. 32, No. 5 (SeptemberOctober 1970) -449-454

ballet at certain times.f . A more important
criticism is that, even if
Gilbert Highet (8) , however, notes that ". .
homosexuality [was practiced in Greece]
although never (at least in Athens) accepted as
morally indifferent."
to similar point is made by Hooper (9) , who
says that ". . with respect to homosexuality [in
Greece] the available information is supplied
priZUGER
true, it no more supports an environmental
causation than it does a genetic one.
The evidence thus far considered is indirect
and inferential. This contrasts with the more
direct evidence obtainable from individuals
born with ambiguous sex. If it could be shown
that such individuals, regardless of biologic
variables, fully identified with the sex of
assignment and rearing, the environmental
nature of sex identification would receive
strong support.
THE EVIDENCE FROM
HERMAPHRODITISM
Two such attempts have been made: one by
Ellis (10) in 1945, and the other by Money
and the Hampsons (11) 10 years later.
Ellis collected from the literature 84 cases of
hermaphroditism, including 45 cases of
pseudohermaphroditism, and concluded that,
generally, the sex of rearing determined the
subsequent sex role. Ellis's material consisted of
patients studied before the availability of

Psychosomatic Medicine, Vol. 32, No. 5 (SeptemberOctober 1970) -449-454

nuclear chromatin or chromosomal sex typing,
and
before
better
differentiation
of
hermaphroditic types and the recognition of
variations among them in production and
utilization of the sex hormones. For these and
other reasons, the evidence presented by Ellis is
considered inadequate.
Money and his associates, who worked in a
children's endocrine clinic, avoided some of the
above objections but left others, partly
because knowledge of hermaphroditism had not
advanced to its present stage. They deserve
much credit for bringing modern psychologic
methods to the study of these children.
Their work has had great influence. It has
been the most frequently quoted evimanly by the intelligenstia ." ". . . it should be
stressed that there has always been a gap
between the occupations of the literati and
those of the man on the street."
450
Psychosomatic Medicine, Vol. 32, No. 5
(September-October 1970)

GENDER ROLE DETERMINATION

dente for the environmental determination of
sex identity (12, 13, 14). It has become an
important
consideration
in
the
clinical
management of sex change (15) and has
added to the belief that homosexuality is
experientially derived (16).
Only few exceptions have been taken to their
work. These include comments in reports of
successful sex change at a later age than their
theory would allow, and more extensive
criticisms by Cappon (17) and Diamond (18,
19).* Both have rejected the conclusions of
Money and his coworkers; Diamond, especially,
has rejected their basic conclusion that there
exists a state of sexual neutrality at birth.
The present paper particularly focuses on the
clinical evidence presented by Money and the
Hampsons, and after a detailed and systematic
analysis of their data, finds it unconvincing.
The argument underlying this conclusion will be
given in three parts. The first will deal with
some aspects of their methodology. A detailed
examination of their clinical data will follow. In
the third part, a series of cases from the litera ture will be presented from which conclusions
will be drawn contrary to those they drew from
their clinical material. (Some of these cases
have also been referred to by others.)
The Methodology of Money et at

Money and the Hampsons (11) found that the

gender role of a series of hermaphrodite
patients they studied was compatible with
their sex of assignmentC h ro m os o m es and
rearing,
although contradictoryGonads
to their chromosomal,
gonadal,
hormonal and
internal
or
externalH o rm o n es
genital
pattern. They reached Internal genitalia this conclusion
by
considering
each
factor in what
one may call a parallel
fashion, as in
the following diagram:
External

Diamond's excellent
papers
have
genitalia
received little notice
from clinicians
and have come to my attention only after the
completion of this study.
Variables Possibly Determining Gender Role
in Parallel Order
G
E
N
D
E
R
R
0
L
The question arises whether such a method
of dealing with the data is any more justified

Psychosomatic Medicine, Vol. 32, No. 5 (September-October 1970)

451

in hermaphrodites than it would be in normal

individuals. How can chromosomes function
except through gonads, and gonads except
through hormones? The relationship among
these variables should not be regarded in a
parallel manner but rather, more in a series,
as diagrammed below:
Variables Possibly Determining Gender Role
in Serial Order
Chromosomes.Gonads-----Mormones
__ 1
Internal genitalia
External
genitalia
Sex of assignment and
rearing
Gender role

ZUGER
A change or failure of
any one variable in the
series alters the whole
series. What is finally
evident is the result of
the
sequential
influences or lack of
influences
(as,
for
instance, in the failure
of
the
embryonic
gonadal male hormone
in the Jost syndrome)
of a number of factors.
The
result
may
become
evident
at
birth,
as
in
the
adrenogenital
syndrome, or not until
puberty,
when
the
whole series is called
into action, as in other
types of pseudoherma
phrodi tism.
Furthermore,
the
basis for snaking the
sex
assignment
in
these uncertain cases
before they reached the
notice of the inves-

tigators
must
have
been the appearance
of
the
external
genitalia. It would be
just as valid, therefore,
to say that gender role
was determined by the
appearance
of
the
external genitalia at
birth as by the sex
assignment
and
rearing. Cappon (17)
makes a similar point.
This is well illustrated
in the case of the
adrenogenital
syndrome.
Money
and
the
Hampsons
presented
42 patients with this
syndrome, 38 of whom
were
assigned
the
female role and 4, the
male role. Except for 1
patient assigned the
female
role
who
subsequently
was
bisexual,
they
all
stayed with their sex
assignment. But why
were the 4 patients

assigned
the
male
role?
Was
it
the
increased, and perhaps
earlier,
virilization,
evident in the external
genitalia, which led to
their male assignment?
The extent of fusion of
the labioscrotal folds
varies in different individuals
with
this
syndrome; in some, it
may
traverse
the
enlarged clitoris in its
entirety (14). The 2
groups given gender
roles according to their
external genitalia may
not,
therefore,
be
comparable
in
evaluating sex rearing.
Another methodologic
diffi culty in the paper
of
Money
and
the
Hampsons is that they
do
not
exclude
alternative possibilities
in
comparing
separately
each
variable
with
the
gender
role

assignment. To show,
for instance, that male
sex
assignment
is
dominant over female
"endogenous hormonal
sex" in a cryptorchid
male
hypospadiac
patient
with
breasts
(male pseudohermaphrodite) (Table 4) (11),
all the other variables
would have to be
female. That is not
the
case
in
this
example, nor is it
correspondingly so in
any of their other
comparisons.
In addition to these
objections, there were
factors
to
which
Money
and
the
Hampsons could not
give adequate consideration because these
factors
were
not
known at the time they
wrote their principal
papers.
These
are
452

Psychosomatic Medicine, Vol. 32, No. 5 (September-October 1970)

schematically

rep-

resented in Fig 1 and

most of them will be
referred to again below.
The Clinical Material
of Money et al
The 1955 paper of
Money
and
the
Hampsons (11) will be
the main basis for the
following analysis. It is
the most inclusive of
the
many
papers
dealing directly with
their clinical material
and referred to most
often. It is, however,
lacking in such data as
the
ages
when
individual cases were
first observed, their
subsequent course and
the part substitution
therapy
played
in
maintaining
their
gender role.
In
the
following
analysis, the same arrangement of cases, as
used by them, will be

followedie, according
to
the
individual
variables considered.
1.
Chromosomes
and
rearing
contradictory
(Table
1).* This group consists of 19 of the 76
cases with "somatic
ambisexual
development"
which
the authors give as
evidence
of
the
overriding influence of
rearing, compared with
the
influence
of
chromosomes
in
determining gen*Table 2 in the paper
by Money et al.

GENDER ROLE DETERMINATION

CHROMOSOMAL

GONADAL

---*HYPOTHALAMUS
Possible early1 ' Releasing
sexualization
f ,fa ctors
I --ANTERIOR
I
+ PITUITARY
I
HORMONAL
ADRENAL
Chromosomalmosaics
INTERNAL
GENITALIA
difficult
to
exclude;
EXTERNAL
GENITALIA
multiple tissues must
I
be examined.
SECONDARY SEX
CHARACTERISTIC
Gonadalunless
S
embryonic male hormone present, tendency for
develop. ment to proceed in female direction;
existence of a critical period for sexualization
of brain? Testes may secrete estrogens.
HormonalTestosterone levels may vary with
chromosomal constitution eg, extra X in
phenotypic males with low testosterone output.
Genitaliainsensitivity
of
cells
to
corresponding
hormoneseg,
testicular
feminizing syndrome.
Secondary
sex
characteristicsmay
at
puberty be opposite to earlier manifestations.

SEX ASSIGNMENT
and REARING
GENDER ROLE

Fig. 1. Some additional factors possibly

influencing determination of gender role in
individual case.
der role. Included are 11 cases of gonadal
agenesis (gonadal dysgenesis), which are
probably instances of Turner's syndrome.
These cases are called male because of the
absence of nuclear chromatin bodies, but
have since been found to have XO karyotypes,
or mosaics of various combinations of sex
chromosomes. Since these 11 cases were
raised as females, there is no contradiction
between their chromosomal pattern, as far as
we know it, and their gender role. Only 8
cases, therefore, require consideration.
Of the remaining 8 cases, 3 are called
simulant females but have since been put
into a category named the testicular feminizing syndrome. These individuals are
chromosomally male but have female habi tus
and body build, female external geni talia,
and
incomplete
expression
of
female
secondary sex characteristics. Internal genital
structures are absent or rudimentary fe male,
and the gonads consist of testes which may be
intra-abdominal, inguinal or labial. They
produce testosterone but its utilization is
impaired by some defect in the target
organs (20-23). It cannot therefore be said
that in these cases, chromosomes exert their
usual infl uence; it is obvious that they
cannot be relevant as a variable in
determining the behavior of such patients.
the 5
Psychosomatic Medicine, Vol. 32, No. 5 (September-October 1970)
453 Of
remaining cases, 4 are cryptorchid male
hypospadiac patients with male chromosomes
who have been assigned a female role. Of
these, 3 are reported as still

ZUGER
Table 1. Chromosomes and Rearing
Contradictory (19 Cases)*
Ass
Type of Chr
Ge No
ign
ambisexu
n
.
Gonadal om
M
F
F 11
agenesis
(dysgenes
Simulant
M
F
F
3
female
Cryptor
chid
True
hermaphr

Comment
Probably cases of Turner's syndrome
and of XO karyotypes (though may be
mosaics and of other karyotypes);
called males here because of absence
of nuclear chromatin; no contradiction
between chromosomes and gender
role
More recently called cases of testicular
feminizing syndrome; no failure in
testosterone production except in its
utilization by the target organs; chromosomes not a relevant issue
Three of these are called juveniles;
their subsequent acceptance of assigned gender role unpredictable
Gonads, hormones, internal and external genitalia indicated to be both
male and female

M, male; F, female.
* Table 2 in the paper by Money et al.
f Sex chromosome type inferred from
nuclear chromatin of biopsied skin.

being "juveniles" and therefore their later roles

must be considered uncertain. Of the 4, 1
presumably
made
an
adjustment
in
concordance with his assigned sex and in
contradiction to his chromosomes.
The remaining case is a true hermaphrodite
with a female chromatin pattern, who has been
assigned a male role. Gonads, endogenous
hormonal sex, internal accessory organs and
external genital morphology are both male and
female. This is another instance in which
chromosomes as a variable in determining
gender role may be irrelevant.
In the entire group of 19 cases, there is thus
only 1 case with some evidence that eff ective
chromosomal sex did not preclude an opposite
gender role.
2. Gonads and roaring contradktory (Table 2).* In this group, Money et al
assembled 20 cases whose gender role was in
contradiction to their gonadal sex, but
compatible with their sex of assign ment and
rearing. According to the table, 6 had ovaries
but assumed a male role, while of the 14 with
testes, 11 were successfully reared as
females. The authors do not state how they
determined gonadal sex, which is sometimes a
diffi cult task. Gonads cannot with certainty be
labeled male or female apart from their
microscopic structure and the nature of their

secretions. Gonads which are structurally

male may secrete estrogens (24). Functioning
testes may secrete testosterone to which the
target cells do not respond (testicular feminizing
syndrome). The problem is further comTable 3 in the paper by Money et al.