1. Summary of the facts.
In 1965, the Canadian couple Janet and Ron Reimer had twin sons: Bruce and Brian. The boys were diagnosed with phimosis at 6 months old and circumcised at 8 months. Due to the cauterization method used by the urologist who performed the procedure, Bruce suffered severe burns to his penis, rendering the organ useless. Since it couldn’t be reconstructed, it was removed. Months later, concerned about Bruce’s future, his parents sought advice from Dr. John Money, a professor of pediatrics and psychology at Johns Hopkins University Hospital, whom they had seen on television advocating that gender and sexual orientation could be taught. He proposed a sex reassignment for the child. The conversion to a girl would involve another surgery to create a cosmetic vagina, hormone treatments, and psychiatric therapy, which Bruce would attend with his twin brother, who was designated as a control subject in the experiment. At 22 months old, Bruce’s testicles were removed, his name was changed to Brenda, and the truth was hidden from him until 1980. Over the next twelve years, he underwent additional surgeries and had several suicide attempts. At the age of 15, following a psychological treatment session that he was forced to attend, his father told him the truth. After this revelation, Brenda decided to undergo several sex-change operations and male hormone treatments, a process that took place over the next five years. His penis was reconstructed, although with limited function, and his name was changed back to David (in reference to the story of David and Goliath). In 1990, at the age of 23, David married a woman who was the mother of three children from a previous marriage. They were married for 14 years and separated on May 2, 2004. A few years earlier, in 1997, David had shared his story with Dr. Milton Diamond, a professor of anatomy and reproductive biology at the University of Hawaii, and months later with John Colapinto, a Canadian journalist for The New Yorker, who published an article about him that, in 2000, became a book titled “As Nature Made Him: The Boy Who Was Raised as a Girl”, in which David stated that he had never identified as a girl. This statement debunked John Money’s publications, which for years claimed the success of the sex reassignment.
In 2002, David’s twin brother Brian committed suicide by overdosing on antidepressants, which was not his first suicide attempt. According to sources, Brian suffered from schizophrenia and couldn’t overcome the guilt of having witnessed his brother’s suffering and the fact that he had emerged unscathed from the circumcision that both boys had undergone. After separating from his wife, his brother’s suicide, and facing severe financial difficulties, David committed suicide on May 5, 2004, by shooting himself in the head. He was 38 years old. His father, who had become an alcoholic, also committed suicide, and his mother required cyclical hospitalizations due to clinical depression.
2. Dr. Money’s Experiment
Dr. Money was a New Zealand psychologist who emigrated to the U.S. after World War II, specializing in sexology. His theories had a significant influence on the area of gender identity. Money believed that gender identity did not stem from birth but from socialization and education, provided that the individual’s genitals matched the male or female role in which they were raised. To prove his theories, he conducted an experiment that ultimately resulted in the patient’s death by suicide.
Before discussing Dr. Money’s experiment in more detail, it’s important to highlight a contrasting theoretical position held by Milton Diamond, a professor of anatomy and reproductive biology. Diamond asserted that individuals are born with a psychosexual inclination influenced by their genes and hormones. Therefore, according to him, gender identity was not linked to socialization but to anatomy and biology, specifically to one’s birth genitals. Both Money and Diamond used David Reimer to prove their theories.
Dr. Money’s experiment with David was unspeakably cruel, as David was a healthy child who had suffered a terrible accident but had no disorder or disease that would have prevented him from leading a relatively healthy life. However, disregarding all ethical principles and solely to prove his theories, Dr. Money violated rigor, truthfulness (as evidenced by his book Sexual Signatures: On Being a Man or a Woman, in which he falsely reported that Brenda was happily living her childhood as a true girl), as well as respect and the norms dictated by the professional code of ethics regarding research and experimentation on human beings.
The sex reassignment theory defended by Money, which could be summarized as “gender is not innate but acquired through education,” turned out to be an absolute failure.
What did the experiment consist of?
Money recommended the following to David’s parents:
👉 Surgery to remove the testicles, to which the parents agreed.
👉 Surgery to create an artificial vulva, which the parents refused.
👉 Hormonal treatment, which was accepted by the parents and administered to the child throughout childhood and adolescence.
👉 Psychological therapy, which the parents consented to, and Brenda (formerly Bruce) attended regularly, sometimes alone and sometimes with her twin brother. This included an annual evaluation session with Dr. Money for 10 years.
👉 Raising Brenda at home and at school as if she were a girl.
👉 Concealing the truth: Dr. Money ordered that the child should never be told the truth about her origins.
There is no documentation that the parents were informed or discussed the physical or psychological consequences of the reassignment. David would suffer sterilization, scars, infections, loss of sexual pleasure, the removal of natural hormones, dependence on medication, and an irreparable and constant sense of personal violation and disintegration of his identity. If the parents had known all of this, they probably wouldn’t have consented and would have sought other medical alternatives. However, the asymmetric relationship Money established with them, due to their ignorance, fragility, and vulnerability, made them dependent on the psychologist. This allowed Money to influence their decisions and commit many abuses.
But one might wonder why David’s case was so interesting to Dr. Money that he decided to use him for experimentation. The answer seems to rest on two reasons: the first is that David had a twin brother, making Brian a perfect control subject since they shared genes and a family environment.
The opportunity to observe two individuals with identical genetics has always been intriguing to science. Experiments with twins or triplets separated at birth and observed for years (for example, the case of the brothers Eddy Galland, David Kellman, and Robert Shafran narrated in Three Identical Strangers by Wardle in 2018) or the “Jim” monozygotic twins (Minnesota Study, 1979) are two examples of the scientific interest in studying the influence of genetic inheritance and environment. However, in the case of Money’s experiment, it was even more invasive as it involved sex reassignment.
The second reason for Money’s interest in the Reimers’ son was that David wasn’t an intersex child; he had been born with clear sexual differentiation. The only reason he had crossed paths with Dr. Money was the tragic result of the circumcision. Thus, David would be the first person not born with ambiguous genitalia to undergo sex reassignment, which, according to Money, would demonstrate the success and viability of his theory.
It was in 1997 that Diamond revealed that the reassignment had failed and that David had never identified as a woman.
The Reimer case (also known as the John/Joan case, as Manley called it) fueled the public debate between personal cost and scientific advancement. It influenced the reduction of sex reassignments in individuals diagnosed with micropenises or other types of malformations. In my opinion, it is crucial to include the voice of those who suffer in these debates. Additionally, this case helped improve the understanding of sexual biology and influenced various medical practices and paradigms, becoming a reference to avoid surgical intervention on minors’ genitalia. A more detailed review of procedures and ethics in human experimentation had precedents, such as the Tuskegee experiment carried out from 1932 to 1972, which led to the Belmont Report. Nonetheless, the torture David Reimer suffered throughout his life deeply sensitized public opinion and the medical profession.
3. The Fundamental Rights Violated and Their Breach in the Case
Starting from the premise that the right to health doesn’t only mean the right to avoid illness but also includes general physical, mental, and social well-being to allow the person to fully enjoy their personal development, I have divided the documents whose principles and articles mention the different rights that were violated in David Reimer’s case into three groups:
Group 1: International documents specifically addressing fundamental patient rights in the context of experimentation.
Group 2: Documents related to minors in healthcare procedures.
Group 3: International and Spanish documents related to gender identity.
Group 1: Patient’s Fundamental Rights
👉 EU Charter of Patients’ Rights (2002) outlines 14 universal and inalienable rights, of which, in my opinion, the following were violated in the Reimer case:
- Number 3: Right to Information.
- Number 4: Right to Consent.
- Number 5: Right to Free Choice.
- Number 6: Right to Privacy and Confidentiality.
- Number 11: Right to Avoid Unnecessary Pain and Suffering.
- Number 13: Right to Complain.
- Number 14: Right to Compensation.
👉 Nuremberg Code (1947): Principle 1 stresses the essential need to obtain voluntary consent from the subject of experimentation, who must have the legal capacity and freedom to provide it. Principle 3 requires the design and outcomes of the experiment to be based on prior animal experimentation, and principles 4, 5, and 10 stipulate that the experiment should have been halted when physical and psychological harm to David was observed.
👉 Declaration of Helsinki (1964, WHO): Informed Consent.
👉 Belmont Report (1979): Ethical principles and guidelines for the protection of human subjects of research. In David Reimer’s case, Dr. Money violated the Principle of Respect by failing to protect David’s autonomy and disregarding informed consent. He also violated the Principle of Beneficence by not minimizing the risks to David as a research subject.
👉 APA Ethical Principles of Psychologists and Code of Conduct: The principles of Beneficence and Nonmaleficence. It is evident that Money’s primary interest was proving his thesis, and he failed to prioritize his patient’s well-being.
Additionally, international documents such as the Universal Declaration of Human Rights (1948), American Declaration of the Rights and Duties of Man (1948), European Convention on Human Rights (1953, 1998), International Covenant on Civil and Political Rights (1966, 1981), American Convention on Human Rights (Pact of San José) (1969, 1981), and the World Conference on Human Rights (Vienna, 1993) were relevant to this case.
Group 2: Treatment of Minors in Healthcare Procedures
👉 United Nations Convention on the Rights of the Child (November 20, 1989), ratified by Spain on November 30, 1990, and the Spanish Organic Law on the Legal Protection of Minors (1/1996). Article 12 of the Convention states: “States Parties shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.”
👉 Patient Autonomy Law (Spanish Basic Law 41/2002) refers to the concept of the age of majority for healthcare decisions, set at 16 years. Therefore, mental health professionals must obtain informed consent from patients, and if they are unable to make a “conscious, voluntary, and free decision,” parental consent is required (Article 156 of the Civil Code). If one parent or legal guardian does not give consent, the intervention is suspended until judicial authorization or proper consent is obtained.
It is clear that due to David Reimer’s age (22 months when his testicles were removed and the reassignment process began), he was incapable of understanding or deciding any matter. As for his parents, they didn’t have the opportunity to make an informed decision due to the lack of information.
Group 3: Gender Identity
I found it relevant to add this third group of documents on gender identity rights because sex is a legally significant category, to the point where it is essential information required on all identification documents and is used to define or self-define us. From this perspective, it is understandable that Reimer’s parents were deeply concerned about finding a solution to David’s sexual identity, which, for them, likely meant an integral identity. From this position of vulnerability, Dr. Money abused his authority and technical power, influencing their decisions, first leading to traumatic castration and then to irreparable psychological and emotional damage.
The documents I selected for their relevance to gender identity are:
👉 Yogyakarta Principles (November 9, 2006, Indonesia), presented to the United Nations Human Rights Council on March 26, 2007, regarding Sexual Orientation and Gender Identity.
According to its definition, gender identity is “each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal experience of the body (which may involve modifying bodily appearance or function by medical, surgical, or other means, provided it is freely chosen) and other expressions of gender, including dress, speech, and mannerisms.”
Therefore, it can be stated that David Reimer was not given the right to freely choose his gender identity since he was a minor when others made a decision that would affect him for the rest of his life. Moreover, considering that the right to health implies full personal development related to one’s personality and dignity (López Galiacho Perona, 1998), we have further reason to assert that all actions carried out against him in the name of his health and well-being were not such and violated his rights. As he himself declared as an adult, he never identified as a woman, meaning his personality and dignity were disregarded.
👉 Law 41/2002, of November 14: In Spain, Article 8 of Law 41/2002 regulates patient autonomy and the rights and obligations regarding clinical information and documentation. This means that, in the case of a diagnosis of gender dysphoria, it must be issued by a doctor or clinical psychologist, and the duration of the medical hormone treatment must be at least two years. To register their new sexual identity, the person is not required to undergo sexual reassignment surgery. However, if the person, as an adult, decides to undergo surgery, a favorable diagnostic report is required, and their request must be explicit, signed by the individual, and made after a period of hormone treatment. The right to information and informed consent must be presented in writing, explicitly and individually. Therefore, based on this, in David Reimer’s case, even though it wasn’t a case of gender dysphoria, both his and his parents’ rights to information were violated. Medical personnel didn’t explain the process and its consequences, thus failing to uphold “informed autonomy” (Pérez Fernández-Figares, 2010). Moreover, consent was not obtained (he was a baby), no more than one doctor provided a diagnosis, and his general well-being was certainly not considered.
👉 Universal Declaration of Human Rights:
Article 1: “All human beings are born free and equal in dignity and rights.” Article 2 states that there should be no distinction based on race, color, sex, etc. The UN Mandate addresses the right to be protected from discrimination based on sexual orientation and gender identity. However, what happens to individuals like David Reimer, who didn’t conform to the binary male or female physical image? Although a person’s sex or gender, as established by the European Court of Human Rights (2002), is a psychosocial concept and not merely biological, we cannot ignore that a male or female classification still prevails today (man or woman), and human rights still operate within a framework where, in many countries, physical considerations take precedence over the person’s right or will to freely choose their gender determination if it doesn’t match their birth sex. In many societies and legal systems, free gender determination is not understood as part of the right to free personal development, and consequently, the rights to self-determination, dignity, and freedom are stifled.
👉 International Declaration of Gender Rights (Houston, 1993):
This declaration asserts the right to claim one’s gender identity, its free expression, the right to modify one’s own body, and the right to competent and professional medical services.
👉 Declaration on Violations of Human Rights Based on Sexual Orientation and Gender Identity (December 1, 2006, Norway):
It was ratified by 54 States in Europe, Asia, and America. Based on the principles of universality and non-discrimination, this declaration calls for issues related to sexual orientation and gender identity to be included and considered in the overall defense and promotion of human rights.
👉 OAS Resolution on Human Rights, Sexual Orientation, and Gender Identity: Approved by consensus of the 35 member countries in June 2008.
4. Was the behavior of the psychological professional ethical?
The short answer is NO.
The psychologist did not consider the best interests of the child, which should have been his primary consideration. Instead, his lack of ethics was consistently evident throughout the years.
The EFPA (European Federation of Psychologists’ Associations) emphasizes the role and responsibility of psychology professionals in protecting human rights. To fulfill this task, psychology professionals have various strategies and environments where they can carry out this defense, whether through therapeutic consultations directly with patients or through interventions in education, advocacy, and support of actions and measures that benefit prevention, resilience, and the integration of vulnerable or at-risk populations whose rights may be violated.
Dr. Money violated numerous rights outlined not only by the EFPA but also by the General Council of Official Psychologists’ Associations and the Code of Ethics.
Below, I list the articles of the Spanish Code of Ethics for psychologists that Money would have breached:
❗️❗️❗️ Article 6, regarding respect for the individual, protection of human rights, a sense of responsibility, honesty, sincerity towards clients, and prudence in the application of instruments and techniques. Let’s remember that Money also published reports and articles in which he falsified information and the results of the tests and evolution of the case, which he referred to as the “John/Joan case.” For years, he concealed the real data and falsified his reports, which he disseminated to both the scientific and academic communities as well as the general public.
❗️❗️❗️ Article 7, concerning the freedom and physical and mental integrity of individuals, as he directly participated in the cruel treatment and torture of his patient.
❗️❗️❗️ Article 8, referring to the obligation to report abuse to professional bodies, as he inflicted abusive treatment on both brothers in his consultations with degrading behavior.
❗️❗️❗️ Article 11, regarding the misuse of his position of power or superiority for personal benefit (which he did from the start by convincing the parents of what was later done).
❗️❗️❗️ Article 18, which refers to the obligation of the psychologist to inform clients that, in research cases, his techniques are unproven.
❗️❗️❗️ Article 25, about avoiding manipulation of individuals and the treatment of minors (he took nude photographs or had them perform sexual poses with their sibling, which could be considered sexual harassment and lead to criminal consequences today).
Regarding this article, the Hawaii Declaration (1977) of the World Psychiatric Association and its revision in Vienna in 1983 states that, among other duties, a psychiatrist must never allow personal beliefs or desires to interfere with treatment and must ensure the dignity of patients, including refraining from abusing their trust or crossing physical and emotional boundaries.
❗️❗️❗️ Article 32, regarding the creation of false expectations (information given to the parents) that he was later professionally unable to fulfill.
❗️❗️❗️ Article 33, concerning the communication of scientific knowledge and practices to students during teaching. Money continued to maintain the success of David Reimer’s case until the end of his life, despite all the tragic events that had been confirmed as a result of Money’s actions and interventions. He continued teaching until 2006.
❗️❗️❗️ Article 34, which prohibits the psychologist from causing “permanent, irreversible, or unnecessary harm to avoid greater harm” and the obligation to obtain explicit parental consent in the case of minors.
❗️❗️❗️ Article 37, which mandates respect for the dignity of individuals, particularly regarding their privacy and sexual behavior.
The evaluation sessions with Dr. Money, involving physical examinations, intrusive questions, and actions that David was forced to carry out with his brother, constituted a continuous lack of respect for his physical and psychological integrity. Moreover, being raised as a girl was a constant attack on his personal freedom and the expression of his true personality.
❗️❗️❗️ Article 47, which requires prior consent from the patient to be observed by third parties such as students in training or other professionals in development, a situation to which David was subjected on several occasions.
5. What other courses of action could have been possible?
It would have been necessary to demand evaluations from several specialists rather than relying on the opinion of just one professional, no matter how influential or publicly known they were. As long as the child’s overall health was good, given his young age, there would have been time to consult different hospitals and centers. Some physicians might have recommended delaying invasive surgical interventions on the child’s body, especially when it was mainly for aesthetic reasons. When the child was older, he could participate in the decision regarding his gender assignment. Perhaps other professionals would have recommended treating the case as if it were a diagnosis of micropenis and suggested hormone treatment because their focus would have been on assigning one sex or the other as soon as possible. In any case, and putting aside speculation about what other medical professionals might have recommended to the parents, the priority would always be the child’s well-being. Additionally, I believe the key would have been to provide the parents with exhaustive information so they could evaluate the consequences and decide whether or not to give their consent for certain procedures or treatments.
Today, it is not considered normal for a psychologist to conduct physical examinations unless they specialize in psychophysiology, neuropsychology, or somatoform disorders, and have provided the patient with a consent form that includes three sections:
- An explanation of the examination to be performed;
- The parts of the body involved in the examination; and
- The patient’s signed consent.
If the patient wishes, they may be accompanied by a family member or a nurse during the procedure.
On the other hand, authorizing the removal of the testicles would not have been an advisable course of action because it assumed the dissociation of biological sex from visible external appearance. Since it was an erroneous decision, it had irreversible consequences. This could have led to a legal claim or lawsuit by the parents for medical malpractice, and a court could have awarded financial compensation to David and his family.
It would have been very important for Money or the organization he worked for to take responsibility. If the family did not want to file a lawsuit, at the very least, a moral acknowledgment with an apology would have been advisable. In the U.S., there are “I’m sorry” laws in 36 states, which clarify that if a doctor apologizes to a family, it cannot be used in court as evidence of wrongdoing or medical negligence. However, the moral repair process for harm caused to victims requires acknowledging the damage and offering an apology.
Furthermore, it was NOT ethical for Dr. Money to remain employed by Johns Hopkins University Hospital after it was proven that his experiment had failed and that he had concealed and falsified information. He should have been expelled from the pediatric and psychology boards as well as the faculty, and a commission should have been established to investigate the previous cases he had handled and the information he had published.
Corporatism, self-protection, and underreporting of errors must be penalized because they increase future harm to other patients and also damage the profession by reducing patient trust in healthcare professionals.
Finally, if sensitivity had been shown to David’s vulnerability and he had been treated as a victim, whether by Johns Hopkins Hospital, the administration, or the relevant authority, a protection system could have been created in three areas:
a) Psychosocial: Providing resources for grief support and psychological therapy.
b) Legal: Offering legal advice, not only regarding his right to file a legal claim but also for the retroactive correction of documents he might need to rename, such as school certificates, property titles, bank accounts, identity documents, records, etc.
c) Socio-labor: Providing a job that would not only allow him to earn an income but also enable better social integration.
6. Final questions to reflect on:
💡 The speed at which society, the scientific-medical community, and language evolve is different. Actions related to what was once understood as pathologies have been criticized and rejected in different historical periods. Technological innovations and the speed with which we can now share thoughts, values, and judgments are greater than ever. This can have a significant impact on the de-pathologization and removal of stigmas associated with certain classifications or, conversely, could lead to their criminalization and discrimination. An example is the case of transsexuality, which the DSM-5 now refers to as “gender dysphoria,” instead of “gender identity disorder” as it was previously called. This means that the negative connotation of the word “disorder” has been removed, but it is still a concept found in a manual of mental disorders, so it remains a diagnostic classification. This is not the case with homosexuality. Most of Western society has accepted that homosexuality is not a disorder and that homosexual people have the same fundamental rights as heterosexuals. However, this is not the case in every country, where certain sexual orientations are still criminally persecuted. With transsexuality, the path is still being traveled, but at a slower pace. In Spain, Law 3/2007, Article 10 of the Spanish Constitution, and the European Court of Human Rights (ECHR) in Articles 8, 12, and 14 of the Convention on Human Rights (CHR) recognize the right to sexual or gender identity and cover the legal gap surrounding transsexuality. The ECHR recognizes transsexuals’ right to private life, to form a family, and to marry according to their gender identity, but it was the Supreme Court ruling of September 17, 2007, that eliminated the requirement of sex reassignment surgery. The question that might arise is: Who leads the impact on defending the equalization of human rights and its reflection in jurisprudence: social changes, scientific and medical discoveries, or language?
💡 Despite how utopian it may seem, I believe in the need for a standardized global code of ethics that ensures uniform principles of action and legislation related to healthcare. The adoption of specific normative instruments applicable to healthcare professionals that guarantee the integrity and well-being of patients should not depend on each state or the luck or misfortune of where a person is born or falls ill. The credibility and reputation of the healthcare profession, whether doctors, psychologists, or nurses, would be strengthened.
💡 Beyond the individual responsibility of each psychological professional, more attention should be paid by the government and institutions to the conditions in which mental health patients are treated. Compliance with the Universal Declaration of Human Rights goes beyond the respect that psychologists can individually exercise in their interventions; it also involves raising awareness of these rights, which can be supported through public demonstrations and denunciations of situations where equal treatment, dignity, and respect for people are not provided. Specifically, in the case of the poor conditions in which mental health patients are often found, Spain passed the General Health Law of 1986, which aimed to close psychiatric hospitals and change the healthcare model (referred to as the Avilés model). However, even today, there are still psychiatric hospitals, centers, and mental health units where unacceptable conditions have been reported in 23 reports issued by the Ombudsman’s Mechanism Against Torture since 2013. The most severe case is the psychiatric hospital of Conxo in Galicia, where the situations reported in 2017 persist, including overcrowding, patients hospitalized for 30 to 50 years without rehabilitation, overmedication, misuse of mechanical restraints, and lack of resources. These situations directly violate the fundamental rights of patients, in addition to the repeated complaints about the insufficient number of healthcare professionals, whether psychiatrists, psychologists, social workers, or nurses, who are unable to care for the number of existing patients.
Let us all defend mental health and the right of patients to be treated with the utmost respect, ethics, and professionalism.
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