Money is the Root of All Evil

Written By Antonia Beevor-Martinez

For decades, many young children, some still infants, have undergone cosmetic genital surgeries, with very little public outcry. These children are intersex: they have rare conditions that affect not only their reproductive organs, such as their genitals, but also their genes and hormones.¹ Historically, the treatment of intersex infants focused on identifying the most appropriate sex for the child, and this was supplemented by hormonal treatment and cosmetic genital surgeries. But the outcomes of these surgeries were often unfavourable, and left many children with unnecessary medical trauma. Most disturbingly, the academic theories supporting these surgeries were based on unethical experiments conducted on a set of twins, and had been discredited in the late 90s. New recommendations in 2006 warned the medical community against early cosmetic genital surgeries and many intersex adults have spoken out about the suffering this treatment caused them, but in spite of this, the surgeries continued. 

This approach was heavily influenced by the - now largely discredited - work of John Money, a psychologist and sexologist. He argued that a child required “unambiguous genitalia and unequivocal parental assurance of the chosen gender" to achieve a stable gender identity. ² Many of these theories were created through experiments on a set of non-intersex twins, the Reimer’s. Following an unsuccessful circumcision performed on one of the boys, Money instructed his parents to allow cosmetic genital surgery on their child and that he be raised as a girl, alongside other medical treatment (such as feminising hormones). This case was reported by him as a success, with the child, Brenda, identifying as a girl. 

This was presented as pivotal for the treatment of intersex children, as it demonstrated that cosmetic genital surgery could successfully “treat” the issue, and the child could grow up unaware of their medical condition. In practice, Money’s theories led to early genital surgery, often occurring before 18 months, that focused on “early cosmetic appearance of the genitals”. ² In many cases, diagnoses were concealed from the child, as were the true purpose of these surgeries. 

In reality, the experiment was not the success Money claimed it to be. As a young child, Brenda often refused to take the hormones prescribed to her and did not wish to undergo further genital surgeries. Money saw the twins often in order to continue his experiment, subjecting them to sexually abusive behaviour, unbeknownst to their parents. At age 14, Brenda’s parents revealed the truth of her condition, who changed their name and from then on, identified as male, taking the name David.³ John Money fraudulently reported his theories as successful, leaving a lasting impact on the medical community’s treatment of intersex children, with devastating consequences for the twins, who both eventually took their own lives. 

The 2006 consensus statement on ‘the management of intersex disorders’ marked an attempt to reform the historic treatment of intersex children. It recommended that multidisciplinary teams (MDTs) lead the treatment of intersex children, and it cautioned against cosmetic surgery during a child’s first year of life.⁴ The previous support for the surgeries had only been supported by “a number of unsubstantiated claims”.⁵ But the medical community seemed to ignore these recommendations. One study found that clitoral operations in under-14s had in fact increased in the UK since 2006.² While some surgeries for intersex children address life-threatening complications of their conditions, many of the early genital surgeries performed are cosmetic.  These procedures are often performed in infancy, so the parents, rather than the patient, provide consent. 

It is not only through unwanted surgeries that the medical community has enforced its preferred treatment on intersex people. The 2006 consensus statement influenced the decision to rename this group of conditions in the ICD-11 under the umbrella term disorders in sex development (DSD). This name was introduced as the old term, intersex, was said to have pejorative connotations to some patients.⁴ However, the new name did little to address this issue, and objections to this term have continued to this day; the pathologising term disorders is often imposed upon intersex people who do not find this reflective of their lived experience.⁷ As a result, many members of the community choose to reclaim the label intersex, while some medical professionals use differences in sex development (also abbreviated to DSD) as a less stigmatising option. ⁸

As for why the surgeries continue to occur, the answer may lie in the enduring influence of the Western gender and sex binary. This binary enforces expectations that XX chromosomes will create bodies that present, identify and ‘act’ as females, and the same is expected of XY chromosomes and males.⁹ Deviance from this norm can lead to punishment or, in this case, medical correction. As Morgan Carpenter, an intersex activist, states, the presence of abnormal external genitalia may serve as a reminder to parents of their child’s nonconformity and “medical interventions on often healthy bodies…[address] perceived familial and cultural demands,”¹⁰ allowing for better integration into society. 

This binary is not only socially upheld, but also legally. In the UK, births must be registered within 42 days and only male and female sexes are recognised.^11,12 This requirement could pressure parents into making an irreversible medical decision on their child’s behalf, without allowing them to explore alternatives.¹³ Furthermore, the Equality Act does not consider intersex as an explicit protected characteristic, and therefore intersex people are afforded no specific protection from discrimination. These factors may encourage parents to consent to these surgeries, out of concern for the future stigma their child may face.

Most importantly, the question of what constitutes “normal” genitalia must be addressed. If intersex people’s genitalia are considered abnormal, and require corrective surgery, then upon what do we base “normal” genitalia?¹³ A person’s perception of “normal” genitalia is highly dependent on their cultural context. In recent years, the UK has seen an increasing number of women undergoing elective genitoplasty; the desired appearance of genitals was often drawn from advertisements and pornography, which do not reflect the normal variation of human anatomy.¹⁴ Medical professionals are not immune to this either. The lack of varied examples of female genitalia in medical textbooks could also lead doctors to use “personal experiences and popular culture”¹⁵ to inform their clinical practice. These examples reflect how perceptions of “normal” genitalia can be influenced by limited, and edited, sources, rather than by the wide range of natural anatomical variation. The cultural taboo around discussing genitalia, especially with young children, may also create an environment where parents feel less comfortable advocating for their child. Parental concerns are reinforced by clinicians’ framing of genital difference as urgently requiring correction rather than providing reassurance about natural diversity.

These surgeries are not without risk. One study found that many of those who underwent childhood genital surgery required further treatment later in life, and the outcomes of surgery were often much worse than previously reported.¹⁶ Feminising surgeries may require further corrective operations to allow tampon use or penetrative sexual intercourse. These operations may also leave patients with difficulty with orgasms. Importantly, this study also states that most vaginal surgery can be delayed if there are no contraindications, potentially leading to fewer surgeries and complications. 

In addition to the physical risks, the mistreatment of intersex people also carries psychological consequences. Despite a shift towards informed patient-centred care, the paternalistic legacy of the NHS continues to affect intersex patients. According to an intersex support group, the practice of withholding diagnoses from intersex patients had continued until at least 2012,¹⁷ leaving some patients to discover their recorded diagnoses much later in life. Intersex patients may also have “a history of repeat intimate medical examinations, medical photography and exposure”,⁵ experiences that can be distressing and invasive. Unsurprisingly, intersex people experience higher rates of mental health issues, such as anxiety and depression, than the general population.¹⁸ Surgical scars from repeat childhood procedures can lead to body image issues which can affect later intimate relationships. Some intersex children have their gonads removed, resulting in permanent infertility and denying them reproductive autonomy later in life. When the sex and gender of an intersex child is decided for them, there is no guarantee this choice was “correct”. The sex of rearing chosen by parents and clinicians may not align with a child’s future identity. One paper found that 7.1% of intersex patients later had a different gender identity than that assigned at birth,¹⁹ a much higher percentage than the rest of the population (typically less than 1%).²⁰ Transition under the NHS is often a years-long and difficult process, which has its own ramifications on mental and physical health, in addition to the difficulties intersex people may face in childhood. 

The goals of these surgeries have often been to produce genital appearance congruent with gender identity and to ensure future sexual and reproductive function.²¹ Yet these aims themselves may reflect cultural assumptions. Kate Wood, a social work researcher, discusses how current medical practice is “underpinned by the need to maintain heterosexuality”. These surgeries privilege “penetrative sex above sexual pleasure”, ²² centering penile-vaginal sex above other kinds. When some intersex children have had surgeries involving removal of the clitoris, it is difficult to argue that this is done to preserve their sexual function in adulthood. Rather, it shows the true nature of these surgeries: aesthetics above all. Wood also uses the social model of disability as a reference for framing intersex rights. She argues that society should see intersex conditions as natural variation rather than a disorder, as the current term DSD posits, that must be “repaired”.²² 

Following this model, the variation in intersex patients does not have to be pathologised. Indeed, there are cases where medical intervention has led to harm rather than social integration. As for the legal barriers intersex people may face, one proposed solution is multi-gendering, i.e. including other categories in addition to male and female. Thekla Morgenroth, a psychological sciences professor, describes how it forces individuals to question a long-entrenched binary, but may also be less threatening than de-gendering, as it “provides another category without necessarily changing the meaning of existing categories”. ⁹ This issue has reached the attention of international human rights advocates. In 2024, the UN Human Rights Council published a resolution aimed at combatting discrimination and harmful practices against intersex people, expressing concern about practices, such as cosmetic genital surgery, being performed without the informed consent of the person involved.²³ Delaying surgeries when possible, to allow intersex individuals to participate in decisions about their own bodies, could prevent unnecessary medical trauma, and help maintain patient autonomy.

Ultimately, to achieve fair and ethical treatment of intersex children, medicine must shift its perspective. Rather than consider these conditions as issues that need correction, treatment must remain medically necessary and conservative, and efforts must be made to leave permanent decisions to intersex adults. This would also require changes to the law to more accurately express the biological diversity of sex, as well as improved social support for families of intersex children. Medical education must also evolve, incorporating awareness about intersex patients to ensure that future clinicians give compassionate and competent care. Only by recognising these conditions as natural variation in human biology can we reach ethical and patient-centred treatment of intersex people. 

Read the rest of the edition here.

References

1. NHS (2017). Differences in sex development. [online] NHS. Available at: https://www.nhs.uk/conditions/differences-in-sex-development/.
2. Creighton, S. and Minto, C. (2001). Managing intersex. BMJ, [online] 323(7324), pp.1264–1265. doi:https://doi.org/10.1136/bmj.323.7324.1264.
3. Colapinto J. As Nature Made Him. Harper Collins; 2002.
4. Hughes, I.A. (2005). Consensus statement on management of intersex disorders. Archives of Disease in Childhood, [online] 91(7), pp.554–563. doi:https://doi.org/10.1136/adc.2006.098319.
5. Creighton, S.M., Michala, L., Mushtaq, I. and Yaron, M. (2013). Childhood surgery for ambiguous genitalia: glimpses of practice changes or more of the same? Psychology & Sexuality, 5(1), pp.34–43. doi:https://doi.org/10.1080/19419899.2013.831214.
7. Carpenter, M. (2018). Intersex Variations, Human Rights, and the International Classification of Diseases. Health and Human Rights, [online] 20(2), p.205. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC6293350/ [Accessed 25 Oct. 2024].
8. This Is Intersex (2021). Intersex is not DSD. [online] Thisisintersex.org. Available at: https://thisisintersex.org/advanced/intersex-is-not-dsd/#1 [Accessed 31 Dec. 2025].
9. Morgenroth, T., Sendén, M.G., Lindqvist, A., Renström, E.A., Ryan, M.K. and Morton, T.A. (2020). Defending the Sex/Gender Binary: the Role of Gender Identification and Need for Closure. Social Psychological and Personality Science, [online] 12(5), pp.731–740. doi:https://doi.org/10.1177/1948550620937188
10. Carpenter, M. (2016). The human rights of intersex people: addressing harmful practices and rhetoric of change. Reproductive Health Matters, [online] 24(47), pp.74–84. doi:https://doi.org/10.1016/j.rhm.2016.06.003.
11. UK Visas and Immigration and Home Office (2024). EU Settlement Scheme interim guidance: gender identity and sex markers on documents (accessible). [online] GOV.UK. Available at: https://www.gov.uk/government/publications/eu-settlement-scheme-caseworker-guidance/eu-settlement-scheme-interim-guidance-gender-identity-and-sex-markers-on-documents-accessible

12. GOV.UK (n.d.). Register a birth. [online] GOV.UK. Available at: https://www.gov.uk/register-birth.
13. Horowicz, E.M. (2017). Intersex children: Who are we really treating? Medical Law International, 17(3), pp.183–218. doi:https://doi.org/10.1177/0968533217726109.
14. Liao, L.M. and Creighton, S.M. (2007). Requests for cosmetic genitoplasty: how should healthcare providers respond? BMJ, 334(7603), pp.1090–1092. doi:https://doi.org/10.1136/bmj.39206.422269.be.
15. Andrikopoulou, M., Michala, L., Creighton, S.M. and Liao, L.-M. (2013). The normal vulva in medical textbooks. Journal of Obstetrics and Gynaecology: The Journal of the Institute of Obstetrics and Gynaecology, [online] 33(7), pp.648–650. doi:https://doi.org/10.3109/01443615.2013.807782.

16. Creighton, S.M., Minto, C.L. and Steele, S.J. (2001). Objective cosmetic and anatomical outcomes at adolescence of feminising surgery for ambiguous genitalia done in childhood. The Lancet, 358(9276), pp.124–125. doi:https://doi.org/10.1016/s0140-6736(01)05343-0.
17. Kirkland, D.F. (2017). Intersex patients ‘routinely lied to by doctors’. BBC News. [online] 22 May. Available at: https://www.bbc.co.uk/news/health-39979186.
18. Zeeman, L. and Aranda, K. (2020). A Systematic Review of the Health and Healthcare Inequalities for People with Intersex Variance. International Journal of Environmental Research and Public Health, 17(18), p.6533. doi:https://doi.org/10.3390/ijerph17186533.
19. Arzu Jalilova, Samim Özen, Deniz Kızılay Özalp, Begüm Yuluğ Taş, Aslı Ece Solmaz, Hanife Gül Balkı, Tekin, A., Arslan, E., Atik, T., Kübra Gülpınar, Özgür Çoğulu, Gökçe Ünal Kocabaş, Burcu Özbaran, Hüseyin Onay, Ulman, I., Ferda Özkınay, Füsun Saygılı, Damla Gökşen and Şükran Darcan (2025). Transition from assigned sex at birth to individual gender identity in cases of differences of sex development. The Journal of Sexual Medicine, [online] 22(11), pp.2154–2156. doi:https://doi.org/10.1093/jsxmed/qdaf254.
20. Office for National Statistics (2023). Gender identity, England and Wales - Office for National Statistics. [online] www.ons.gov.uk. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/genderidentity/bulletins/genderidentityenglandandwales/census2021.
21. Creighton, S., Ransley, P., Duffy, P., Wilcox, D., Mushtaq, I., Cuckow, P., Woodhouse, C., Minto, C., Crouch, N., Stanhope, R., Hughes, I., Mehul Dattani, Hindmarsh, P., Brain, C., Achermann, J., Conway, G., Liao, L.M., Barnicoat, A. and Perry, L. (2003). Regarding the Consensus Statement on 21-Hydroxylase Deficiency from the Lawson Wilkins Pediatric Endocrine Society and The European Society for Paediatric Endocrinology. The Journal of Clinical Endocrinology & Metabolism, 88(7), pp.3455–3455. doi:https://doi.org/10.1210/jc.2003-030127.
22. Wood, K. (2025). Bridging the gap: De-medicalizing intersex and the role of social work practice. The British Journal of Social Work, [online] 55(7). doi:https://doi.org/10.1093/bjsw/bcaf164.
23. UN Human Rights Council (2024). Combating discrimination, violence and harmful practices against intersex persons: Resolution . [online] United Nations Digital Library System. Available at: https://digitallibrary.un.org/record/4045699?+v=pdf&v=pdf [Accessed 31 Dec. 2025].