THE CASE OF JOHN/JOAN
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Her case was referred to the unit’s head of psychiatry, Dr. Keith Sigmundson, an amiable, self-deprecating 34-year-old whose career ascent had been rapid. “Because I was just ahead of the baby boomers, I got a position that I was too young for and probably didn’t deserve in the first place,” he says. From his very first meeting with Joan, Sigmundson was struck by the child’s appearance. “She was sitting there in a skirt with her legs apart, one hand planted firmly on one knee,” Sigmundson says. “There was nothing feminine about her.” But despite strong misgivings, he decided that in overseeing Joan’s psychiatric treatment, he would support the process that Money had begun. It had gone too far to turn back, Sigmundson decided, so he attempted to persuade the child to accept herself as a girl and to submit to vaginal surgery. To increase Joan’s female identification, he referred her case to a woman psychiatrist, Dr. M.

As Dr. M.’s clinical notes reveal, early in her sessions Joan voiced her conviction that she was “just a boy with long hair in girl’s clothes” and that people looked at her and said she “looks like a boy, talks like a boy.” She also opened up about how she dreaded the trips to Baltimore, where people looked at her and “a man show[ed] her pictures of nude bodies.” But the psychiatrist reassured Joan that she was, indeed, a girl and impressed upon her the necessity that she undergo surgery on her genitals.

Troubled nonetheless by the case, the psychiatrist wrote to Dr. Money and told him of Joan’s emotional difficulties and school problems. Money wrote back in January 1977 that he was very pleased that Dr. M. was willing to become involved in treating Joan. He explained that the second stage of Joan’s vaginal surgery had not yet been performed due to the child’s “fanatical fear of hospitals” – a fear, Money wrote, “that I have encountered on only one other occasion in 25 years of work at Johns Hopkins.” He added that mention of hormone treatments or surgery induced in Joan a “panic so intense that it’s impossible to broach any conversation on such matters without the child fleeing the room, screaming.” Nevertheless, Money continued, there was now an “urgency” that Joan’s fears be overcome, because the need for hormone therapy and surgery was rapidly increasing with her approaching adolescence. “It will be one of the best things you can do for her,” Money wrote to the psychiatrist, “if you can help her break down this extraordinary veto.”

Despite all efforts, Joan continued to hold out against surgery. Nine months passed, and she remained unmovable – refusing even to permit her pediatric endocrinologist to conduct a physical exam of her genitals. Then, in the late summer of 1977, when Joan turned 12, she suddenly had to fend off an attack on another front. On her last several trips to Baltimore, Dr. Money had spoken about the medication she would soon need in order to become a “normal girl.” He was talking about estrogen, the female hormone needed to simulate the effects of female puberty on Joan’s broad-shouldered, narrow-hipped boy’s physique. Like vaginal surgery, the prospect of developing a female figure struck Joan as nightmarish. So she was suspicious when, one day, her father produced a bottle of pills and told her to start taking them.

“What’s this medicine for?” Joan asked.

Frank, struggling for the best way to put it, finally came up with: “It’s to make you wear a bra.”

“I said, ‘I don’t wanna wear a bra!’ ” John recalls. “I threw a fit.”

But after repeated entreaties from her parents and the endocrinologist (not to mention the threat, which Dr. Money had introduced, that she would grow disproportionate limbs if she failed to take the drugs), Joan finally, and with great reluctance, began to take the pills.

It was around this time that Dr. Money authored another update on the twins. The report would appear in a 1978 journal. Once again, the outlook was sunny. “Now prepubertal in age, the girl has . . . a feminine gender identity and role, distinctly different from that of her brother,” he reported. Perhaps forgetting what he had told Joan’s parents four years earlier about her sexual orientation, he wrote: “The final and conclusive evidence awaits the appearance of romantic interest and erotic imagery.”

Though Joan often only pretended to take her estrogen pills, by May 1978, three months prior to her 13th birthday, the effects were visible. A pair of small but distinct breasts had appeared on her chest, along with a padding of fat around her waist and hips. But she remained stubbornly opposed to further surgery – a fact that became dramatically clear during her visit that spring to Johns Hopkins. It would prove to be the last time Joan would ever consent to go to Baltimore.

That something remarkable had occurred during Joan’s visit is obvious from a letter that Dr. Money wrote in August 1978, some weeks after the encounter. He said that Joan was still determined to avoid talk of sex or surgery and, when she was pressed on those points, she left the room to join her brother. “I followed,” Money wrote, “and, in bringing the session to a close, put my hand on her shoulder in what most youngsters would accept as a reassurance. She fled in panic.” Money then described how one of his students followed Joan to help her recover her composure. “They walked, saying little, for about a mile.” In concluding his oddly elliptical-sounding account of these events, Dr. Money referred to the student as a woman.

What he did not mention was that the woman had begun life as a man. She was a male-to-female transsexual one of many readily available from the Johns Hopkins Gender Identity Clinic. She had apparently been enlisted by Money to speak to Joan about the positive aspects of surgical construction of a vagina.

“Dr. Money said, ‘I’ve got someone for you to talk to who’s been through what you’re going to be going through,’ ” John recalls.

Joan was then ushered into the presence of a person whom she immediately identified as a man wearing makeup, dressed in women’s clothing, with a woman’s hairstyle. When the person spoke, it was in a breathy, artificially high-pitched voice.

“He’s telling me about the surgery,” John says, “how fantastic it was for her and how her life turned out beautifully.”

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