Symptoms of Unknown Origin: A Medical Odyssey

Chapter 6. The Woman Who Believed She Was a Man

40 6 The Woman Who Believed She Was a Man Despite my periodic contact with patients with multiple unexplained symptoms, most of my time was spent with patients with well-defined endocrine disorders. One such patient riveted my attention . I first saw Eugene when he was under general anesthesia in the operating room of a large teaching hospital in the community. The surgeon and the consulting gynecologist had called me to come across town to the operating room to help them figure out what they had encountered in a routine operation for acute appendicitis. By this time, I had developed a reputation locally as a specialist in the field of disorders of sexual differentiation. Most of these were endocrine problems that involved the testicles, ovaries, or adrenal glands and all were congenital. When I finally got to the operating room after stopping to mask up, put on greens, paper boots, and a cap, I found the surgeon and the gynecologist sitting on stools and leaning against the wall. They pointed to the table, where the patient was still under general anesthesia. They wanted me to look in the abdomen and give them some explanation for what they had found. Both regowned and I joined them at the operating table. Apparently the surgeon had begun operating for acute appendicitis on what he thought was a young man. When he got into the abdominal cavity, he found not only acute appendicitis but all the Meador฀pagesFeb15.indd฀฀฀40 2/17/05฀฀฀5:34:58฀PM The Woman Who Believed She Was a Man 41 internal organs of a normal female. He then called in the gynecologist , who called me. There they were—ovaries, fallopian tubes, and a fully developed uterus. I scrubbed and gowned up so I could palpate the organs and get more direct information. I could feel the uterine cervix at the end of the uterus and below it what I thought could be the upper vaginal vault. I asked them to undrape the patient so I could examine the external genitalia. I saw what appeared to be a perfectly normal penis. Despite all efforts, I could not find any masses that might represent testicles in the external areas of his skin. There are patients who are called “true hermaphrodites.” These people have both testicles and ovaries and all sorts of combinations of internal and external genitalia —a very rare condition, but frankly, it was my first bet. I asked the surgeon to tell me what he knew. He knew the man not only as a patient but also as an acquaintance. The patient was prominent in the northern part of the state in business and politics. Thirty-five years old, he had married his high school sweetheart and they had adopted a boy and a girl. Both the surgeon and the gynecologist had played golf with him. I suggested they do several things. First, complete the appendectomy to reduce the chance of infection. I asked them then to biopsy what I thought were ovaries and have the pathologist call me when he had the frozen sections ready. I needed to know if there was any hint of testicular tissue present, if these were just ovaries, or both. The surgeons should then continue with a complete hysterectomy and remove all internal genital tissue. At that point, we huddled for a very confidential talk. The situation was extremely delicate. I had a tragic experience with another adult patient, who committed suicide when some insensitive physician had told the person outright that “he” was actually a “she.” I didn’t want to see something like that happen again. It was not going to be easy to keep the facts quiet, but I thought it essential to protect the patient from the cruel and unneeded harm Meador฀pagesFeb15.indd฀฀฀41 2/17/05฀฀฀5:34:59฀PM 42 Symptoms of Unknown Origin that would come if any of the findings leaked out. The three of us took a vow to cover up all the findings once we figured out what was going on. An emerging literature also confirmed the great harm and suicides that can be triggered by bluntly telling people reared in one sex that they are the opposite sex. The literature of that time indicated that forced switches in gender after the age of two years were more often harmful than helpful. (I am...