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A man's brain in an ambiguous body: a case of mistaken gender identity.

Chief complaint: “I feel like I have the brain of a man. Am I crazy?” On her first visit to a psychiatrist ( J.M.B.), “Ms. C,” a 48year-old woman, asked this question about her confused gender identity. Having also discovered a primary sexual attraction to women, Ms. C was having difficulty reconciling her church’s injunctions against sinful homosexual activities with her sense of herself as fundamentally male. She was dressed in a subtly frilly blouse and leather jacket she called “my leather-and-lace look.” Encircling each wrist were tattooed bracelets, traceries of curlicues and rosebuds that gently contradicted pearl earrings and a delicate gold locket. Born in the early 1950s and raised resolutely as a girl, Ms. C did not learn until she was 23 and married the unusual circumstances of her birth. Her mother finally divulged that she had entered the world with strange-looking genitals—neither male nor female. Doctors told her parents it was best to remove the odd tissue, fashion what remained to look female, and raise her as if nothing unusual had happened. At 6 months, surgeons removed both external tissue and presumed intra-abdominal testicular tissue and fashioned labia around the vaginal entrance she had always had. In grade school, she was told her large abdominal scar resulted from herniorrhaphy. At 12, after starting daily estrogen pills to induce puberty, she developed breasts and feminine curves, although without menarche or an increase in height beyond 5 feet. Her mother said she could not have children but did not explain why. She recalls being a tomboy who preferred boys for playmates. Because of her small stature and feminine appearance, however, boys were not particularly comfortable hanging out with her. Then, as now, she identified with the way males think rather than a sense of being physically male. She dated boys in high school, had a sexual experience with a woman during college, and married a man with whom she enjoyed satisfying marital relations for nearly two decades until they experienced a menage a trois. Her husband fell in love with the other woman, and she kindled awareness of her greater attraction to women than men. The marriage ended, and she embarked upon two long-term lesbian relationships and a struggle with alcoholism. Ms. C found sobriety and her church while that second relationship was unraveling. Welcomed and spiritually nurtured by church members, she felt happy except for increasing discontent with her pastor’s insistence that homosexual desires were her “cross to bear” and her options were either heterosexual marriage or celibacy. On one hand, her personal theology concurred that homosexuality was against God’s plan. On the other, she struggled with identifying herself as either man or woman, a dilemma her pastor could not solve. Ms. C’s childhood medical records had been lost. The psychiatrist asked if she had been karyotyped, given her unusual birth. She did not know. When she was born, chromosome testing was not routinely available. Given medical advice to raise her unquestioningly as a girl, the issue had not resurfaced. The psychiatrist suggested the test, and when results revealed 45,X/ 46,XY chromosomes, 75% the latter, the fragments—the childhood operation, hormones, her short stature, “brain of a man”—fell into place. She immediately reported feeling “less of a freak” now that she had a name—“intersexual”—for her condition.