original, p. 211, 212 113







I hold the Degree of Bachelor of Medicine. I am a Fellow of the Royal College of Surgeons of Edinburgh. I am a Member of the Royal College of Obstetricians and Gynaecologists. I am presently Reader in Obstetrics and Gynaecology at Sheffield University. In connection with that I hold Consultant posts in two hospitals, the Jessop Hospital for Women which is a part of the United Sheffield Hospitals, and the Northern General Hospital, part of the Sheffield Regional Hospital Board. In October I take the Chair of Obstetrics at London University. In that connection I will be attached to the King Charles Maternity Hospital and the Chelsea Hospital for Women.

Q.- Have you for some years been concerned with the study of inter-sex states in individual's?

A.-Yes, I have.

Q.- Particularly no doubt at the stage of birth?

A.- At all ages in fact and more commonly in babies, yes.

Q.- I think you have published certain literature on the subject?

A.- Yes I have.

Q.- Are you in the process of completing a book which deals with this matter?

A.- Yes, that is so.

Q.- Did you on the 24th January this year examine Dr. Forbes-Sempill, the Second Petitioner?

A.- I did.

Q.- Did you carry out a further examination last night?

A.- Yes, I did.

Q.- I wonder if you would be good enough to describe in detail the findings which you made as a result of your examinations - I don't want any conclusions, if you would restrict yourself at the moment to factual findings? A.- Factual findings concerning height and physique of all kinds?

Q.- Yes, if you please?

A.- Dr Forbes-Sempill is of fairly short stature, 5 feet 2 in height, he is of broad build, he is muscular more or less without the deposition of subcutaneous tissue that is commonly found in the normal female. He has a growth of hair on the face for which he finds it necessary to shave, he has a vigorous hair growth on the chest, limbs and to a lesser extent on the abdomen. He has a growth of pubic hair and a growth of axillary hair.

Q.- Is axillary hair, hair in the armpits?

A.- Yes. The proportion of limb span to height is normal for a normal individual. There is an abnormality in the development original, p. 212, 213, 214, 215 114 of the external genitalia.

Q.- Before we come to that, was there anything of any significance in relation to Dr. Forbes-Sempill's head hair?

A.- Dr. Forbes-Sempill has receding head hair similar to that which most men have.

Q.- Would you pass now to the genitalia?

A.- The genitalia consist of a phallic organ, enlarged phallic organ, this was when I examined him some two centimetres in length and perhaps one centimetre in thickness with for the size of the organ a substantial glans at its top, a very distinctive glans at the top, that is to say the portion of the phallus which is normally visible once the foreskin is retracted, it is not necessary in his case to retract the foreskin, it is completely visible without that. From the underside of the phallic organ there is a small amount of smooth red skin running backwards to an orifice on the perineum some two centimetres from the base of the phallus.

Q.- If I may interrupt you one moment. Would you describe to us what the perineum is?

A.- The perineum is the area of skin and other tissue between the anus posteriorly and whatever is anterior, the vagina in the female, the scrotum in the male. Some two centimetres posterior to the base of the phallus there is an orifice which on closer inspection in fact appears to be two orifices, the forward one is the urethra and the one behind this may well be a small external orifice of a vagina. The perineum itself is a larger one, that is to say it is projected further forward than the normal in female subjects.

Q.- Does that mean if you were to measure the length between the anus and the first hole that it comes further forward than you would find in the normal female?

A.- Yes, it would be longer, yes.

Q.- In the normal case is the perineum of a male longer than the female?

A.- Oh, a good deal longer, yes.

Q.- Thank you.

A.- On each side there are loose folds of skin which meet round about the phallic organ as I have described. At the top of the phallic organ there is a depression but no visible orifice.

Q.- That is to say in the glans itself there is a depression?

A.- Yes.

Q.- How does that, on looking at it, how does that glans with the depression compare from a visual point of view with the glans in a normal male penis?

A.- How does the depression compare?

Q.- Yes?

A.- It is superficially smaller, although, of course, it is only a depression and it is not an orifice.

Q.- Is the depression which you see in the position which in the normal male penis there would be the orifice of the urethra?

A.- Yes. On the second occasion on which I examined Dr. Forbes -Sempill there was a visible scar in the left groin, and on palpating this area there was a small amount of induration beneath this scar which is natural since it was the site of a original, p. 215, 216,

115 fairly recent operative procedure, and again beneath this there was a small palpable swelling which was not easy to define because it was beneath this slightly indurated area.

Q.- You used the word indurated, would you describe that for us?

A.- An unusually firm area such as forms under a scar having not the normal supple feeling of the normal skin and tissue.

Q.- Just if we may come back a moment to the folds of skin you have described which were adjacent to the phallus, are those folds of skin which in a female would be described as the labia majora and minora?

A.- In a normal female folds of skin in that position would be described as the labia minora. This bore certainly a superficial resemblance to that.

Q.- Were they identical to the normal female labia minora?

A.- No, I would not say they were identical, but they resembled it certainly.

Q.- Am I right in thinking that during the formation of the foetus the folds of the skin or the predecessors of the folds of skin which you saw in a normal individual either remain as folds to form labia for a female or join up in the centre to form a scrotum for a male?

A.- Yes, the tissues on the foetus may develop one way or the other, they depend upon the sex of the child.


Q.- At what stage does the change normally begin?

A.- It begins in early intra-uterine life, round about the 4th to the 8th week, that kind of time.

Q.- Can you tell me this, up to that stage the appearance of the foetus is precisely similar, is it?

A.- Yes, that is so, in the early stages the appearance is entirely similar, and from a young stage development in one direction or the other is made.


Q.- By what stage in foetal life are the sex organs normally formed to an extent where you can differentiate between male and female?

A.- Speaking in very general terms perhaps three months, this would be so, development would be complete by then.


Q.- One way or the other?

A.- That is so.


Q.- You told us that you were able to palpate a small swelling in the left groin?

A.- Yes.

Q.- Would you describe the position of that swelling in relation to the inguinal canal?

A.- It was roughly just at the external opening of the inguinal canal.

Q.- When you say the external opening do you mean the opening where a descending testis would come out of the inguinal canal original, p. 216, 217, 218


or where it would go into it?

A.- No, I mean where it would emerge.

Q.- What did you consider from your examination, considering only what you saw, was the likely explanation of the swelling?

A.- From what I saw only?

Q.- From what you saw only first of all?

A.- I would have said it was either a testis in this situation or perhaps an abnormal gonad like an ovotestis in this situation, or even perhaps a lymph gland that was not gonadal at all. I could not have differentiated between these three in examination.


Q.- I want to be clear about this, I understand it was on the second occasion, that is yesterday, that you palpated this?

A.- I should have made it clear that on the first occasion there was a plaster over the area, a piece of plaster over the area which had been I was informed the site of a recent operation, and was quite tender, and palpation in that area would have been fruitless on that occasion. I did gently palpate the area but in view of the tenderness that was present I could not make out anything.


Q.- Yesterday you were able to palpate. Is that correct?

A.- That is so.

Q.- And you saw signs of a scar?

A.- Exactly, yes.

Q.- Are you in a position to express any opinion as to the stage of development of the organ from which the testicular tissue was removed in the light of this report?

A.- I would have said that this organ shows a development which is compatible with testis in this situation. It is uncommon for testis in this situation to be probably completely normally developed, but it would roughly correspond to the development described in this Report.

Q.- The Report refers to the existence of hyperplastic Sertoli type cells with occasional but infrequent spermatogenic cells?

A.- Yes.

Q.- Did you draw any conclusion from the existence of these two types of cells?

A.- They are both normally found in normal testicular tissue, neither is abnormal.

Q.- What is the significance of a spermatogenic cell in a testis?

A.- Its significance is that the testis is capable of at least initiating the process of spermatogenesis, of going through the early stages of spermatogenesis.


Q.- What does that mean exactly?

A.- Spermatogenesis is a series of changes, going through perhaps three or four stages of cells of different appearance, and those described here suggested at least the early stage has been observed, but it is not specifically stated that the later stage has, apart from the reference here to a few

original, p. 218, 219, 220

117 sperm-like structures. If indeed those were sperms this confirms some of the sperms are completing maturation.

Q.- Could you describe in language that lay man understands the separate stages?

A.- The separate stages are the spermatogone is the initial stage which becomes a second which is called a spermacyte, this in turn becomes another spermacyte which in turn becomes a sperm, roughly four maturations. I find it difficult to describe it otherwise, four stages of development from a primitive stage to a completely formed sperm.

Q.- This is really cellular development?

A.- It is cellular development.

Q.- But I understand it is a different form of cellular development from the normal human cell?

A.- It is a very different form of cellular development in one particular respect in that during this process the number of chromosomes present is reduced to half, this is a most important matter, a fundamental matter.


Q.- But apart from that fundamental difference which you have described does this development result from separation of cells?

A.- Yes, addition and separation of cells.

Q.- But in a fundamentally different form in its effects from the normal human cell?

A.- Just so, yes.

Q.- If it were the case that the testis were still to some degree producing sperm do I take it that would mean that the four stages which you have described had in fact been completed?


Q.- And that the finished article, the finished sperm, was in fact being produced in some measure?

A.- In some measure it would.


Q.- And I understand the finished article is otherwise known as spermatozoa?

A.- Yes.

Q.- You call it sperm?

A.- I call it spermatozoa in fact, I don't think sperm was my word.


Q.- But may I take it that using the word loosely sperm and spermatozoa are synonymous?

A.- Yes, I would have said they probably were, but in fact I would prefer to call the finished product spermatozoa.


Q.- So the four stages would be so far as the terminology goes?

A.- Spermatogone, primary and secondary spermatocyte forms, spermatozoa. I must say that I am not personally an expert in this matter, but this is in fact in general what happens, the original, p. 220, 221, 222


outline of maturation of sperms.


Q.- I want you to assume that a biopsy has shown part of the ductus deferens of this gonad which contained seminiferous, to some extent seminiferous tubules. Am I right in thinking the ductus deferens is part of the excretory apparatus in the testes?

A.- You are suggesting that the biopsy contains ductus deferens and seminiferous tubules?

Q.- Yes?

A.- Yes, the ductus deferens is part of the excretory apparatus of the testes.

Q.- Assuming that those assumptions I put to you apply to the gonad in question, that is to say the assumption that Dr. Stalker's Report accurately sets out what he found and the assumption that ductus deferens with some seminiferous tubules were present, what would be your opinion as to the existing function of this testis?

A.- It is undoubtedly showing some spermatogenic function, I would not necessarily say it was performing a normal function, but it is certainly showing some function in this respect.

Q.- Apart from a spermatogenic function what other function do you imagine this testis could be performing?

A.- The androgenic function, masculinizing function, production of male hormones.

Q.- Am I right in thinking that the male hormones or androgens are the hormones which are normally responsible for the masculinization of an individual?

A.- That is so.

Q.- And conversely do the oestrogen's have a similar effect upon a female?

A.- They do, yes, the appropriate similar effect, yes.

Q.- Is there however an important difference in that the existence of oestrogen's is not necessary for an individual to develop a female form, the existence of oestrogen's in large quantities?

A.- That is so, yes.


Q.- Is this beyond question?

A.- Yes, in my view it is beyond question.

Q.- Is it an accepted medical fact?

A.- Yes, it is an accepted medical fact among those who have studied this particular problem. This is not a problem which is widely studied by doctors everywhere, because it is an uncommon one.


Q.- I wonder if we can take the matter a stage further. Am I right in thinking that just as the testes produce androgens to a fairly substantial extent so the ovaries produce oestro-gen's?

A.- Yes.


original, p. 222, 223, 224

119 Q.- Both being hormones I understand?

A.- Both being hormones.


Q.- But this is in fact the case that there are persons with a female form who have no ovaries at all?

A.- Yes, that is quite true. Perhaps I should make clear this, when I say female form I mean a primary female form without secondary sexual development, that would not occur unless there were some substantial oestrogen producing source of some kind.


Q.- You say primary female form without secondary sexual development?

A.- By secondary sexual development I refer to development of breasts, fat on the hips, and the normal female figure if you like to call it that, perhaps menstruation also.

Q.- And by primary female form you mean what?

A.- I mean someone who is showing what are the normal female external genitals with perhaps a uterus also and fallopian tubes also, but no secondary changes such as I have defined.


Q.- I wonder if you would just look a moment at No. 17 of process and Page 370. At the top of that page there is described a condition called pure or simple gonadal dysgenesis?

A.- Yes.

Q.- That appears to relate to what is described as "Tall eunuchoid apparent females in whom the external genitalia are normal female and who have a uterus but no gonads"?

A.- Yes.

Q.- So this would appear to be a practical effect of the situation you are describing, would it not, the development of a female form albeit there were no gonads to produce oestro-gen's?

A.- Yes it would.


Q.- That is no gonads either male or female, no testes or ovaries?

A.- In fact in this condition there are structures of tissue which are not identifiable as gonadal under a microscope, there is something there but it is not positively identified as gonadal in any way.

Q.- Where are they found?

A.- They are found roughly in the position of normal ovaries.

Q.- So that has to be done by operation?

A.- It has to be done by operation.


Q.- It appears to be assumed by the writer of this book that they fall to be treated as having no gonads?

A.- In the sense there is no recognisable specific gonadal tissue present, that is true.

original, p. 224, 225, 226


Q.- Is that accepted, you cannot assume any gonadal tissue in this condition?

A.- That is so.


Q.- How do you identify gonadal tissue?

A.- In a normal person you would probably be able to identify it without doubt by a simple inspection by operation, but to prove precisely which it was it would be necessary to take a piece of it and look at it under a microscope.

Q.- And microscopically you would find what?

A.- In an ovary?

Q.- Yes?

A.- You would find the typical supporting cells of an ovary, you would find developing follicles in the middle of which would be ova.

Q.- Whereas in a patient of the type described in this article if you examined the tissue found which is described what would you observe?

A.- You would probably see simple fibrous tissue which might have come from anywhere in the body.

Q.- Has this been established empirically?

A.- This has been established beyond doubt in a number of cases of patients with pure gonadal dysgenesis.

Q.- That is tissue has been examined?

A.- Histologically examined yes.


Q.- And to complete the matter is the situation very similar in the case of what is called Turner's Syndrome which is found at Page 357?

A.- The situation is similar in the genital aspect, yes, it is different as far as the patient's stature is concerned.

Q.- Certainly, but in Turner's Syndrome are you always able to find a measure of ovarian tissue or not?

A.- Always, no. There are variations in Turner's Syndrome, and occasionally there is recognisable ovarian tissue but more often than not there is no recognisable ovarian tissue.

Q.- And presumably there is no testicular tissue either?

A.- That is so.

Q.- And again do persons suffering from Turner's Syndrome develop with an external female form?

A.- They do indeed.


Q.- Can you tell me whether in this case any tissue was found in the position of the gonad?

A.- In most cases in Turner's Syndrome?

Q.- Yes?

A.- Yes, usually there is a whitish streak tissue.

Q.- With the same properties?

A.- Similar histologically to the pure gonadal dysgenesis, again there is some variation, but there is always a variation in biological matters.


original, p. 226, 227,228


Q.- But frequently you find simple fibrous tissue?

A.- yes.

Q.- Perhaps I should ask you is it correct that in addition to the ovaries there are or may be other glands in the body which produce some oestrogen's?

A.- Yes, this is almost certain, the adrenal gland.

Q.- But is it thought that the adrenal gland will oestrogen in comparable quantity to that produced by a normally functioning ovary?

A.- No, it is not thought that it will.

Q.- Would it appear from a consideration of the two syndromes which you have referred to, namely, Turner's Syndrome and Gonadal Dysgenesis, that in order to develop complete secondary female sex characteristics, gonadal tissue is a requisite?

A.- It would, yes.

Q.- If you look at the present case, can you explain how you think at the moment the androgens in the gonad are influencing the Second Petitioner?

A.- I think they are influencing him in the development of temporal recession of his hair, in the muscular development of limbs, the general belief in masculinity, the feeling of being male in all his ways.

Q.- It may be suggested to you that if the testis at some time in the uterine stage failed to complete its normal passage that it could not be achieving any function or any worth while function at the moment. Can you deal with that?

A.- I would not accept that as you have stated it, no.

Q.- Is there a reason for the fact that failure to descend in the uterine stage does not necessarily mean that the testis does not operate at a later date?

A.- I am sorry, I am not absolutely sure of the question.

Q.- Perhaps I put the question badly, can you describe what is the function of the testis in the uterus?

A.- I believe the testis in the early maturity has a most important function to perform. Broadly speaking it has two functions, one is to develop maleness, develop the male form, the external genitalia and at the same time its function is to inhibit primitive female structures which are always present in every embryo and which unless inhibited are capable of development, so it has those two functions, one to produce, the male organising function as it is called, to develop the maleness, and the other to inhibit femaleness.

Q.- Does your reference to the female primitive structure relate to what you were telling us a moment ago, namely that but for the existence of gonads the female structure would develop on its own?

A.- Female organs, the primitive organs would develop whether there were ovaries present or no ovaries present, but they are only inhibited if there is effective testicular action in early uterine life.

Q.- I think one has heard the expression basic female sex. What does that suggest?

A.- Basic female sex - I am afraid it does not suggest anything to me as such.

Q.- Take the case of an animal, if you were able to take an animal in the foetus at an early stage, what was going to be original, p. 228, 229 230 122

a male foetus, and remove its testes and then put it back again so that it was born in the normal way, in what sex would the foetus be born?

A.- The foetus would develop a female form, it would be born with a female form. This is possible and has been carried out?


Q.- With what animals?

A.- Rabbits.


Q.- Do I understand that you are referring again to the primary female condition?

A.- Primary female development.

Q.- So if there were no gonads of any kind exerting any influence on development the foetus would develop as a female?

A.- Exactly, yes.

Q.- If there were female gonads exerting an influence it would develop as a female with secondary female characteristics?

A.- Yes.

Q.- And therefore does that mean that a foetus can only develop as a male if there is in existence some organ which can exert an influence to overcome the natural tendency to develop as a female?

A.- Yes, it does.

Q.- And is that what you consider is one of the two functions of the testes in the uterus?

A.- It is indeed, yes.

Q.- Is that what is called the male organising function?

A.- Yes, certainly.

Q.- I was asking you as it were that although a testis might fail to exert the appropriate influence in the uterus whether it could still exert any influence in life?

A.- Yes, it can also up to a point, its intra-uterus failure is still compatible with effective androgen function at puberty, I would not say this would necessarily happen, but they are compatible, failure in one sense, function in the other.

Q.- To say that a testis has failed is not to say that it has failed completely?

A.- Not to say it has failed in all its functions or that it has completely failed in any of them.

Q.- From your examination of the Second Petitioner on the assumptions that the pathological report is correct what would you consider to be the likelihood with regard to intra-uterine failure here?

A.- I would have thought that it is likely that the testis of which this is a histological report has to some extent failed in its intra-uterine function which has permitted only partial male differentiation and has allowed the development of some female gonads.

Q.- When you say it has permitted only partial male differentiation do you mean to the extent that there is male differentiation the testis has been effective?

A.- It has been effective to the extent it has partially failed and/or partially succeeded, whatever you like.

original, p. 230, 231, 232

123 Q.- What would be your opinion as to the likelihood of ovarian tissue being in existence in the Second Petitioner?

A.- I think this is a possibility, it is very difficult to assess the extent of the possibility, but I think it is probably more likely than less likely, more likely there is ovarian tissue than there is not.

Q.- What form the ovarian tissue would take I suppose you cannot really say, can you?

A.- No, at this stage of life it would be comparatively atrophite.

Q.- Is that because the age of the Second Petitioner is past the age when the menopause would normally take place in a female?

A.- That is so, yes.

Q.- Are you in a position to express any opinion as to the extent to which any ovarian tissue there may be or may have been may have exercised an influence on the body of the Second Petitioner?

A.- It may have exercised an influence in producing some breast development which in fact I omitted when I was describing my findings before, I should in fact have included this, there is some breast development, and it may have been responsible for that. It appears not to have given rise to menstruation, it has certainly not given rise to normal development of the vagina, the vagina that I took to be present if it is indeed a vagina is small and atrophic.


Q.- Assuming there is ovarian tissue present, you see, in this patient, could you express any opinion as to how long it is likely to have exercised an influence?

A.- I don't think I could.

Q.- You see you said it had probably become atrophic now because the patient would be past the age of menopause in a normal female, I was wondering whether one can draw any conclusion?

A.- I was not necessarily meaning one could draw a conclusion, I was simply trying to answer the question as to what it would be like at this stage if it was present at all. If it was present one could take it, it had been responsible for the breast development, so it must have functioned for at least a period of time.

Q.- But you cannot express any opinion as to when it is likely to have become atrophic if present?

A.- No, I don't think I truly could.


Q.- Does it follow that because there is some breast development that this development must have been caused by the ovary or is it merely a possibility?

A.- It does not follow it must have been caused by the ovary, no, a breast swelling of this kind can sometimes arise when there is no ovarian tissue present.

Q.- Is there any particular situation where that occurs?

A.- It occurs in a variety of situations, one is in a condition called Klinefelter's Syndrome or a proportion of the original, p. 232, 233, 234 124

patients with Klinefelter's Syndrome, not all of them.

Q.- Look at Page 360 of No. 17 of Process, I think at 360 and 361 the author deals with the matter and shows a photograph of a patient suffering from Klinefelter's Syndrome?

A.- Yes.

Q.- Under the photograph it says in the first line "Chromatin-positive Klinefelter's Syndrome. Karyotype 47 XXY showing gynaecomastia, straight forehead hairline and level pubic hair". Is gynaecomastia breast development?

A.- Yes.

Q.- Is there any ovarian tissue normally found in a patient suffering from Klinefelter's Syndrome?

A.- No.


Q.- Is it sometimes found or has it never been found?

A.- It has never been found to my knowledge.


Q.- Does that mean then that all you can say is that it is possible that breast development results from the ovarian tissue?

A.- It is possible that this breast tissue has resulted from ovarian tissue, yes.

Q.- Yes, but do I understand it is also possible it may have resulted from some other cause?

A.- Yes.

Q.- If it did result from another cause what would be a cause which would produce such a feminine development?

A.- I don't think I can answer that, I doubt if the answer is known. It is an observed fact that it happens sometimes, but I am afraid I cannot explain it.

Q.- May I take it in the Klinefelter's Syndrome case you are unaware of any medical explanation for the development of breasts in such cases?

A.- I think there are theoretical explanations advanced, but the true explanation I think is unknown yet.

Q.- Consider then if you will the matters which you found on examination that you told us about, namely, the hair on the head, the body, the muscles, the genitalia, and the existence of this swelling in the groin, assume the biological reports relating thereto correctly set out the facts, what would be your diagnosis as to the condition of the Second Petitioner?

A.- I would think it probable that the condition of hermaphroditism existed, but not certain.

Q.- If you are not certain what would be the possible alternative?

A.- The possible alternative would be that the situation was similar to those of Klinefelter's Syndrome in which a Y chromosome had not been located on the chromosome analysis, or had been present for a short period of time and lost during development.

Q.- Assuming that the Second Petitioner was not a hermaphrodite and that the position was as you have described, Klinefelter's Syndrome, from the point of view of sex how would you describe the Second Petitioner in that situation?

original, p. 234, 235, 236


A.- Would you mind saying that again?

Q.- Assuming for a moment that the second alternative were the correct one, the diagnosis of Klinefelter's Syndrome?

A.- Yes.

Q.- From the point of view of sex how would you describe the Second Petitioner?

A.- As a male or a female you mean?

Q.- Yes?

A.- As a male.

Q.- And that alternative diagnosis proceeds I understand upon the assumption that no gonadal tissue exists?

A.- No ovarian tissue exists.

Q.- Assuming alternatively that the diagnosis of true hermaphroditism is correct?

A.- Yes.

Q.- And taking into account the factors which I have described as resulting from your examination and the pathological reports would you be prepared to say whether these characteristics predominate either towards masculinity or femininity?

A.- I am to assume there is no ovarian tissue present?

Q.- Indeed, assuming this is a case of true hermaphroditism and you have to consider the characteristics which I have mentioned?

A.- Then I think that masculine features predominate.


Q.- Could you elaborate that to indicate to me what the balance is in your opinion?

A.- I find it difficult to do this because it is not something that I would normally do under conditions of ordinary clinical practice, my concern would be different from this comparison that I am asked to make.

Q.- You would be concerned with treatment.

A.- I would be concerned with what is best for my patient rather than making a comparison of this kind, but in making this comparison I would be influenced by the fact that the external genitalia were as abnormal in the female sense as they are in the male sense, there is both ovary and testis present, but the testis appears to be exerting its androgenic influence to a much greater extent than the ovary is exerting its female influence, that there is evidence of temple hair recession, hair growth on the body, muscular development, and of course there is very strong evidence of the Petitioner's belief in his masculinity.


Q.- When I asked you the question a moment ago as to the characteristics I was asking you to confine yourself to the factors which you had already dealt with?

A.- Confine myself to those alone?

Q.- Putting aside any question of psychological consideration at the moment?

A.- The answer would be the same.

Q.- I wonder if you would just elaborate a little further when you said the androgenic influence of the testis appeared to be greater than any oestrogenic influence there may be from original, p. 236, 237, 238 126 ovarian tissue, could you perhaps specify the matters in which you considered that the androgenic influence of the testis is presently being exerted?

A.- In the normal physical sense, hair growth in various parts of the body and the disappearance of hair growth on the forehead, the need to shave regularly, the lack of the normal distribution of subcutaneous fat, the muscularity of limbs is evidence in favour of androgen function. So far as oestrogen function is concerned there is breast development which could be attributed to that, but there is no obvious development of the vagina which is a small atrophic organ, there apparently never has been menstruation, and if you are asking me to eliminate psychological matters completely.

Q.- Yes, I am.

A.- On the physical side those are the factors I would be influenced by.

Q.- I think we know that the chromosome karyotype of the Second Petitioner is 46 XX?

A.- Yes, within the limits of medical knowledge we know that.

Q.- If in relation to the factors, if you were to add the existence of an apparent 46 XX karyotype to the factors which you have just taken into account in expressing an opinion as to masculine or feminine predominance, if you were to take into account the 46 XX karyotype would that alter the answer which you have just given towards the predominance?

A.- I can only take it into account, but I would assess it clinically if in fact he was my patient, I would assess it as most unimportant.

Q.- Why do you say that?

A.- In my management of other patients in a similar condition I know that what is important in the decision as to the more appropriate sex of rearing and what the family happen to think is the matter of physical development and gonadal function and in no way is a matter of chromosomal structure.

Q.- Is it in your view that the existence of testicular tissue requires at some stage the existence of a Y chromosome?

A.- I don't know whether it does or not, it seems probable from consideration of many cases reported in the literature, but it remains to be explained why a number of patients who have testicular tissue have not shown Y chromosomes, on the other hand it is possible that there is Y chromosome tissue present which is not identifiable as such. I don't know what the answer is.

Q.- I understand that a chromosome test is not in all cases conclusive and exclusive?

A.- No, that is true.

Q.- There may I understand be questions of mosaicism and mosaicism is a very difficult thing to disprove?

A.- Yes.


Q.- Has it ever been established?

A.- Has it ever been proved?

Q.- Yes?

A.- Oh yes, many times.

Q.- You mean a very difficult thing not to prove as a theory, original, p. 238, 239, 240 127 but to disprove in a particular person?

A.- To disprove in a particular person, it is very hard to prove there is no mosaicism present, it may be quite easy to prove there is, but it may be extremely difficult to prove there is not.


Q.- Whether you prove it must be very largely a matter of luck?

A.- It would depend on all kinds of things, it would depend on the extent of the mosaicism, but if there was only a small number of cells of different chromosomal constitution present, only in one tissue, you may not of course examine this tissue, or the number may be so small it would be missed in the count. If you would like me to give an example, one hermaphrodite patient reported had an apparent XX karyotype on examination of skin, blood, fibrous tissue and gonadal tissue, but on a second examination of testicular tissue present some of the cells showed XY as well as XX, on a further biopsy examined later.

Q.- Was that a case in 1955?

A.- This is a case by two people called Barker and Inios.


Q.- That was a case of true hermaphroditism,was it?

A.- That is so, yes.


Q.- Are you in a position to form any view as to the likelihood of there being mosaicism or translocation in the present case?

A.- I don't think I am, no, it is a possibility, I don't think I could say it was likely or unlikely except in so far as the testicular biopsy is concerned, I think the presence of spermatozoa here would make me think that it was likely there were some Y chromosome tissue present.


Q.- Why do you say that?

A.- I find it difficult to believe that there would be adult sperm present in the absence of a Y chromosome. I don't know if I can explain why, I would find this difficult to believe, I would think it very likely there was some Y chromosome tissue.


Q.- Perhaps I can put this, have you any personal experience or any knowledge from literature of a true hermaphrodite with a 46 XX chromosome pattern where sperm to any extent has been found in testicular tissue?

A.- Adult spermatozoa you mean?

Q.- Adult spermatozoa?

A.- No.

Q.- Just to finish this matter, is it the case there are a number of patients who are male so far as gonads, genitalia and appearance are concerned but who have been found to have original, p. 240, 241, 242 128 46 XX chromosomes?

A.- Yes, there are certainly three reported in the literature, probably more.

Q.- And in such a situation would the chromosomes in your view have any influence on the treatment or management of such persons?

A.- No, none whatever.

Q.- I want you to consider if you will the question of orientation and thinking which has been generally described as psychological sex?

A.- Yes.

Q.- Assuming that you were required to assign an adult true hermaphrodite to one sex or the other sex would you consider that the behaviour and orientation in the individual was a factor to be taken into account.

A.- It is probably the most important factor to be taken into account.

Q.- Why do you say that?

A.- Because the belief of a person in their sex, the adjustment of the sex which they have been brought up would be, if they were completely adjusted to the sex in which they had been brought up, would be an overwhelming barrier towards successful readjustment in the opposite sex, and considered clinically it would be futile to make such an attempt if the person was well adjusted to the sex in which they had been brought up.

Q.- In your view is there any physical connection between the orientation of a true hermaphrodite and the hormones created by the gonads?

A.- Yes, I think it is probable that their orientation reflects the hormones created by gonads in many cases. This is not always so, but it is one of the factors concerned.

Q.- Have you considered at all what the orientation of the Second Petitioner is here?

A.- Oh yes, this is very markedly a man.

Q.- Are you in a position to express an opinion whether in this case there is a link between the orientation and the gonads?

A.- It is very likely there is.

Q.- Does that mean that androgens produced by the testis have their effect not only as you have described on the body but also have an influence on the orientation and behaviour as well?

A.- Oh yes.

Q.- So if that is correct would that mean that the psychological sex cannot be divorced from appearance, endocrinology, gonads and so forth in the case of a hermaphrodite?

A.- I think it probably can be divorced from that in some cases, I think it could be, if neither gonad had any predominant influence of any kind it might be an important matter simply the sex the child had been brought up in, and to be regarded as a member of that sex by other people, but if in fact there was a gonad present exerting a specific function I think it would probably be of more importance to overcome the sexual convention.

original, p. 242, 243, 244


Q.- Are you able to express an opinion as to whether the influence exercised by a gonad may vary throughout the patient's life - you understand what I mean?

A.- I understand what you mean, yes, I think it may vary, of course. It would not vary under normal circumstances, but if testicular atrophy occurred for some abnormal reason at an unusually early stage I think this might have the effect of reducing libido and masculinity in general terms.

Q.- What about the other side of the picture with ovarian tissue, are you able to express any opinion as far as that is concerned?

A.- Atrophy at an early stage of ovarian tissue would certainly have a physical effect, their menstrual periods would cease, their breasts would become slack and atrophied, and they would appear to age prematurely to some extent at any rate, it would probably have a physical effect and it would have a psychological effect on their belief in their active femininity.

Q.- Does the volume of creation of androgens and oestrogen's from the gonads in a normal case decrease after a certain age?

A.- Certainly in terms of oestrogen's it does, I am no expert on what happens to men in later life.


Q.- Am I right in thinking that a hermaphrodite is a person who has got gonads of both sexes?

A.- By my definition, yes.

Q.- Is that an accepted definition?

A.- The word is occasionally loosely used by Americans to apply to a person whose sex is in doubt, a number of American writers have used it in this loose sense.

Q.- So far as this country is concerned is it used in the sense in which you have used it?

A.- Usually, yes.

Q.- So that gonadically speaking, as you might say, a hermaphrodite is both female and male?

A.- Gonadically speaking that is true.


Q.- May I ask one question so that I have it quite clearly. A true hermaphrodite, as it has been called in this case, has gonads of both sexes?

A.- Yes.

Q.- That means a person may have testis on one side and an ovary on the other?

A.- He may have gonadal tissue disposed in that manner or he may have it disposed differently.

Q.- According to your knowledge what are the possibilities so far as different disposal is concerned?

A.- The possibilities are one may have one testis, the other may be an ovotestis, may be a joint gonad with both tissue present, the opposite one may be either a testis or an ovary, both maybe ovotestis, any combination you can think of.

Q.-You might have an ovotestis on one side and a testis on the other?

original, p. 244, 245, 246 130

A.- Yes

Q.- You might have an ovotestis on one side and an ovary on the other?

A.- Yes.


Q.- But however they were disposed you would describe the person with such features as a hermaphrodite?

A.- I would.

Q.- And you would say they were both female and male?

A.- No, I would not say that, I would say they were a hermaphrodite. Sorry, gonadically speaking, I would say that.

Q.- At what time is gonadal sex determined?

A.- Oh, in early intra-uterine life.

Q.- So when a baby is born with both ovarian and testicular gonads that baby could develop as either a male or a female?

A.- In the physical sense, yes, there could be development more in the one direction than the other, or vice versa, yes.

Q.- But at that point of time, the point of time of birth the baby has got female features and male features?

A.- Precisely.

Q.- Would those features be sufficiently evidenced to enable them to be distinguished by a doctor?

A.- Yes, as a result of careful examination, perhaps even including operation, yes. It is likely some features would be visible at birth.

Q.- If the external genitalia were more female than male at birth, if you see what I mean, the normal thing I suppose would be to register such a child as a female?

A.- I think if I may say so the correct thing to do would be not to register the child as either until a full inspection had been performed perhaps quite quickly.

Q.- That would only be if the doctor who brought the child into the world was in any real doubt?

A.- Yes, if he was in any real doubt then in my view that is the correct thing to do.

Q.- That would depend upon the particular features which showed themselves?

A.- Yes.


Q.- Would he look at anything else apart from the external genitalia to reach a conclusion?

A.- To reach an opinion, yes, a great deal would be necessary>

Q.- I am thinking of the normal doctor in attendance at birth who had to advise the parents in which sex to register the child, what would he look at?

A.- The normal doctor now if he delivered a child of this kind would initially be influenced by the appearance of the external genitalia, those may be sufficiently abnormal for him to say, "I don't know whether this child is male or female, further investigation is necessary", and it would be quite wrong for him to give the parents any opinion about which sex the child should properly be brought up in. It is possible that the apparent masculinity or apparent femininity may be so marked that he may not be in any doubt, although perhaps an original, p. 246, 247, 248 131 expert in a similar position might notice a small difference.


Q.- I am thinking of the ordinary doctor who would be bringing a child into the world today, he would simply look at the external genitalia and if their were no penis and scrotum that would appear to be female genitalia, and the doctor in broad terms would say "You have got a girl"?

A.- If the genitalia appeared normally female, of course he would, yes.

Q.- If they appeared more female than male due to the absence of a penis and scrotum?

A.- Yes, I cannot speak for what the average doctor would do, but I think nowadays with the publicity which has been given to the correct management, a departure from the normal would be noted and an opinion sought quickly.

Q.- Would the same apply to a person bringing a baby into the world in 1910?

A.- Oh no, by no means.

Q.- Are you able to express a view from your examination of the Second Petitioner as to what the likely appearance of the genitalia were at birth?

A.- I would think that they were likely to be as they are now, it is possible that they were slightly less female than they are now. I say that because it is known that some minor procedure on the genitalia was performed when the Second Petitioner was young, and although we have no means of knowing what this was I have an idea what it might have been.

Q.- Slightly less female than they are now?

A.- I think it is possible, I only said possible because of this procedure when something was done.

Q.- And I take it from that answer that the external genitalia now are predominantly female?

A.- No, I think the external genitalia now are neither normal male or normal female, I think they are as abnormal in the male sense as they are in the female sense.

Q.- I will come back to that when we go over the other features, but so far as birth is concerned as at that point of time chromosomal sex could be discovered?

A.- Not at this time, now, yes.

Q.- And in any event one knows at has been determined?

A.- Yes.

Q.- Whether it could have been ascertained by examination or not is another matter?

A.- It could not have been ascertained in the Second Petitioner's case at birth.

Q.- But it would have been determined nonetheless?

A.- It would have been determined, yes, it would have been established, I thought you meant determined by some other person, it would have been laid down, fixed, yes.

Q.- In any sense could chromosomal sex be described as the sex which the individual was meant to have, if you follow me?

A.- Yes, I think it might be so described, yes.

Q.- So presumably one could say that people with a chromosomal sex of XX were designed primarily by nature to be female?

A.- It would appear so, yes.

original, p. 248, 249, 250


Q.- Do either of those sexes, the chromosomal sex or the gonadal sex, both of which are established at birth, do either of them ever change?

A.- No.

Q.- I think various terms have been applied by various writers in the literature to other sorts of sex, one is phenotomical?

A.- Yes.

Q.- Is that a sex in respect of what a person looks like, their form and so on?

A.- Yes.

Q.- And in other words is apparent sex, physical sex?

A.- Yes.


Q.- I want to understand this, because these various phrases have been used from time to time, phenotomical sex you say is apparent sex in the sense of form and physical appearance?

A.- Yes.

Q.- Does that mean external purely?

A.- It does not mean external purely, but it is generally taken to mean the external physical characteristics.

Q.- Which may be affected by some internal condition, is that what you mean?

A.- I don't necessarily mean that, I think a phenotomical female is somebody who looks female, who has female external genitalia.

Q.- On clinical examination?

A.- On clinical examination. I doubt if it is always precisely used this word, but someone who is not operating on a patient at all and does not know what the internal organs are may use the word phenotomical to describe what he does know, which would only mean external form and external examination.

Q.- Or by palpation?

A.- Or by palpation. I doubt if it is always precisely used.

Q.- Phenotomical sex is the usual expression adopted?

A.- It is a common expression adopted.


Q.- And that would include sex determined by the appearance of the external genitalia?

A.- Yes.

Q.- The appearance of the structure of the body?

A.- Yes.

Q.- And as my Lord has said to you any evidence which could be obtained from palpation?

A.- Just so.

Q.- Does that sex ever change?

A.- To a small extent in respect the body form changes occasionally. The body form would change after castration.

Q.- Is operative treatment common in these circumstances?

A.- It would probably change if the patient agreed to castration, complete testicular atrophy, but in normal circumstances, no.

Q.- I am thinking of it in normal circumstances?

A.- No.

original, p. 250, 251, 252



Q.- What about ovarian atrophy?

A.- This would produce an effect, but it would not produce any marked effect in appearance, it would certainly produce change.


Q.- Would it permit of a greater appearance if any androgen was operating in the body?

A.- It might to a very small extent, yes, occasionally in very old women there is a small growth of hair on the chin.

Q.- I am thinking of a person such as a hermaphrodite who might have, by definition would have, both ovarian and testicular tissue?

A.- Yes.

Q.- And there was atrophy at a fairly early stage of the ovarian tissue, would the testicular tissue then take over and have a bigger impact than it would have done had the ovarian tissue not atrophied?

A.- Under the circumstances you outline I would think that to be likely, yes.

Q.- That is three types of sex we have dealt with so far none of which you have told me ever change, chromosomal, gonadal and phenotomical?

A.- Yes.

Q.- So far as I can discover, but you will be able to correct me if I am wrong, the remaining sex which has been considered in the literature is psychological sex or some such name?

A.- Yes.

Q.- Does that sex ever change in the course of a person's life?

A.- In normal circumstances no.

Q.- Just so we are quite clear about this, the first type of sex, chromosomal, can never change?

A.- No.

Q.- The second type of sex, gonadal sex can never change unless it is physically changed, if the testes were removed and the ovary were removed?

A.- It can never change from one to the other, no.

Q.- But the position at birth could be altered by operation?

A.- It could be altered by operation or a pathological process.

Q.- But the sex once established as at birth never changes?

A.- No.

Q.- And the same applies you say under normal conditions to phenotomical sex?

A.- Yes.

Q.- And also you told me to psychological sex?

A.- Yes under normal conditions.


Q.- What do you mean by under normal conditions?

A.- There are disturbances of the psyche which might operate and change a person's belief in their sex.

original, p. 252, 253, 254



Q.- Do you know of cases where persons have thought to put the matter broadly today they were a girl, tomorrow they were a man?

A.- Not in this particular sense of a volte face of this kind.

Q.- No, but to live for some time as a woman and then decide to live as a man?

A.- Yes.

Q.- That would be a change of psychological sex?

A.- Yes.

Q.- Because all the other sexes would be constant?

A.- Agreed.

Q.- But it would not necessarily follow from that, that the person had always been a man?

A.- I am sorry?

Q.- If a person changed their psychological sex, decided instead of living as a woman to live as a man, it would not necessarily follow that they were a man?

A.- no.

Q.- In the sense of either the chromosomal sex, the gonadal sex or phenotomical sex?

A.- In those senses, no.

Q.- So far as the Second Petitioner is concerned I think we know that chromosomally the sex is female with the reservation I appreciate that there may be some mosaicism?

A.- I would have said with that reservation, yes.

Q.- But I think it is the case that one can search for long enough for a Y chromosome without ever necessarily finding one?

A.- Yes.

Q.- And so far as gonadal sex is concerned I think you take the view - but I may be wrong - that there is both, probably both ovarian and testicular tissue present, or certainly has been both ovarian and testicular tissue?

A.- I would think it probably on balance, yes.

Q.- That the probabilities tilted in that way, in favour of that?

A.- Yes.

Q.- So that we get so far as gonadal sex is concerned the most probable picture in your opinion of a hermaphrodite?

A.- Yes.

Q.- And at that stage if you are going to put the weights into the pan the balance is slightly down in favour of a female, is it not?

A.- If you are going to assign one point for one and one for another, yes.

Q.- For what it is worth?

A.- For what it is worth, yes.

Q.- But I take it you don't consider that the weight is tipped either way on consideration of those two sexes, chromosomal and gonadal, or do you?

A.- Yes, I think it is tipped towards maleness on consideration of those in as much as I consider the chromosomal factors to be unimportant once they have developed and in as much as the appearance of testicular tissue is a presumption and the gonadal tissue which we know to be testicular appears to original, p.253, 254, 255 135 be exerting a specific function, I would think that this was on balance a male.

Q.- But I think that on a consideration purely of the gonadal position you consider the situation was equal?

A.- I said I thought it was probable that there was ovarian and testicular tissue.

Q.- But as I understood your evidence what you were saying was that you thought the testicular tissue had, had a greater influence on the development of the phenotomical sex?

A.- It is exerting a greater influence.

Q.- Is that right?

A.- Yes.

Q.- And is that why you say that you come down if forced on the side of male as opposed to female?

A.- Not altogether, no.

Q.- Leaving aside psychological sex?

A.- Yes, I am leaving that aside entirely. I am unable to consider the ovary or the testes as simply an anatomical entity without considering its function to some extent, I cannot consider them separately.

Q.- Would it have any effect in your view on this matter about whether the balance is tipped one way or the other when you are considering gonadal sex if you had understood that the Second Petitioner had menstruated?

A.- Yes, it would influence me if I knew this to be the case.

Q.- To what extent?

A.- I doubt if I could answer that, it would be another factor to be considered, I don't think I could go further than that. It would certainly be a factor in support of the ovarian function, it would be a factor in favour of its presence and its function.

Q.- Would it be a factor indicating apparent normal development as a female?

A.- It would be a factor, yes.

Q.- A significant factor?

A.- Yes, a significant factor.

Q.- I would like to go through with you the various features you discovered on your examination, but before we do so perhaps you could just tell me what you were asked to do, what were your instructions with regard to examining the Second Petitioner?

A.- I had no instructions at all, I was asked, I was told the problem existed, and I was asked if I could see the Second Petitioner to give my opinion of his sex in the medical sense.

Q.- What problem were you told existed?

A.- I was told the whole story, he had initially been assigned the female sex - you want me to go through it, the whole story as told, what had happened to him, he felt he was not truly a member of the female sex, that menstruation had not occurred.

Q.- Is this the history which the Second Petitioner gave you, you are talking about?

A.- I am discussing the history that he gave me, yes.

Q.- This information you are telling us about you ascertained from the Second Petitioner?

A.- The information I am telling you now, yes.

Q.- On examination?

original, p. 255, 256, 257 136 A.- On questioning.

Q.- I was wondering what you were asked to do, why you were asked to report and examine the Second Petitioner, were you asked whether you could reach one conclusion and if so what?

A.- I was asked if I could express my opinion about the Second Petitioner in a physical sense, to see whether it was possible for me to tell if he probably belonged to one sex or another, or if some pathological process existed, and what it was, but I was given a background which I subsequently elicited from questioning of him.

Q.- So far as his stature is concerned, it is small, and I suppose do you attach any significance to that in one way or the other?

A.- I don't think I attached significance to it, it is small for a male.

Q.- Smaller than the average male?

A.- I would say it was, yes.

Q.- You referred to the limbs being muscular without the subcutaneous tissue. What about the general form of the body?

A.- The general form of the body I would think was probably male, probably more than female in appearance.

Q.- Is the bone structure of the two sexes different?

A.-Yes, it is different.

Q.- Did you consider this when you were examining the Second Petitioner?

A.- Yes.

Q.- What conclusion if any did you reach?

A.- There was nothing very marked about this aspect of the case.

Q.- What do you mean by that?

A.- I mean that the body form was not the normal female form, it was a plump, muscular form much more resembling that of the male than the female.

Q.- What about the structure of the body, were you able to say whether the bone structure of the body was more male or more female than male?

A.- No, I was not able to say, I did not think it was a significant feature in this particular case, the difference is a small one, and I see many women in my practice who might be regarded as having a distinct male bone structure. I don't think it is such an important feature I would pay special attention to unless the feature was very marked and it was not so marked here.

Q.- Is this a factor which you do not consider significant?

A.- It is a factor which I consider but only to a small extent, I don't think it is a very important matter.


Q.- One sometimes hears evidence of corpses or skeletons having their sex identified fairly confidently by pathologists by such features as the supercilliary arches, to take an example?

A.- Yes, there are features which can be ascertained when one examines bone structure after death.

Q.- But it is not so easily determined with a living patient?

A.- Not, when they are covered with tissue, no.

original, p. 257, 258, 259 137 CROSS-EXAMINATION CONTINUED:-

Q.- Can it be determined?

A.- Can what be determined?

Q.- Whether it is female or male bone structure?

A.- On the living structure?

Q.- Yes?

A.- Well, no, I don't think it can, you can take an X-Ray of the pelvis, and you could say it was android which is the general form of the male pelvis, one of the normal forms of variation of female pelvis is android, so you cannot say definitely.

Q.- Is it the case that the general appearance of the male and female is different in respect that the female has got larger hips and a higher waist?

A.- This is usual.

Q.- Those are common and well known physical differentiating features?

A.- Yes.

Q.- Were those present or absent in the Second Petitioner?

A.- Although they are common features they are by no means universal features and it is not uncommon to find broad shouldered women with comparatively narrow hips, the features of the Second Petitioner were not sufficiently distinct to seem to me to be important in his case.

Q.- Is the result that those features I am talking about of physical appearance in the Second Petitioner could have been applicable to either a man or a woman?

A.- Yes, they could have fitted in broadly to either.

Q.- You could discount them, they might fall on one side of the line or the other. Is that right?

A.- Yes.


Q.- Can you tell me whether that is what you would expect with a hermaphrodite or is it contrary to what you would expect, or do you not expect anything?

A.- I don't know you would have particular expectations, I can recall one hermaphrodite who had a fairly female form in the general sense, I can equally recall another who was neither distinctive one way or the other - two adults, which is the only kind that would apply, because these changes in a child do not occur.


Q.- But so far as the physical appearance of the Second Petitioner was concerned it was quite typical of a hermaphrodite?

A.- I would not say it was typical, I don't think I would be prepared to say what was typical of a hermaphrodite.

Q.- It certainly was not atypical?

A.- No.

Q.- And so far as pointing towards male or female is concerned it really did not point in either direction?

A.- In the case of bone structure, yes.

Q.- What about pubic the hair, is there a difference between the pubic hair in a woman and the pubic hair in a man?

A.- There is normally a difference, yes.

original, p. 259, 260, 261 138 Q.- What is the difference?

A.- The normal difference is the majority of women have a straight line of pubic hair on the upper limit of it, and in men it commonly comes up towards the umbilicus to a point.

Q.- Which feature did the Second Petitioner have?

A.- It is comparatively flat in the Second Petitioner's case.

Q.- The pubic hair was female?

A.- Yes, but many women have the male form and some men.....

Q.- There will be a difference, everybody is not completely normal, but taking the normal standpoint the Second Petitioner was female as opposed to male in this respect?

A.- In this respect, yes.

Q.- And the axillary hair, the hair under the arms, could that have been applicable to either sex?

A.- Yes.

Q.- The receding hairline was a factor which I think you felt was indicative of masculinity rather than femininity?

A.- Yes.

Q.- When in your experience does such a feature emerge in a person who is a hermaphrodite?

A.- I can't answer that question in relation to hermaphrodites, I can't say when it emerges in relation to hermaphrodites as such, but I would expect it would emerge in one with androgen influences roughly at the time when it might emerge in a normal man, but this is an impression I am giving.

Q.- Is it a particularly significant feature?

A.- I would think it was a significant feature, yes.

Q.- And caused by what?

A.- I would be unable to say what was the specific cause of it, but it is generally assumed to be an androgenic influence which produces this.


Q.- At what age?

A.- This is a variable factor, of course, but in general terms it appears in later life in most people rather than earlier.


Q.- I think there were also present, and you did refer to it later on in your evidence, breasts?

A.- Yes.

Q.- Did you measure them?

A.- I did not measure them, no.

Q.- Were they obviously breasts?

A.- Oh yes, they were obviously the female form of breasts.

Q.- And the nipples, were they of female dimensions?

A.- Almost, not quite, but nearly, they were a little on the small side for female nipples, but they were getting that way.

Q.- And the areola?

A.- Again on the small side but they were getting that way.

Q.- You did not measure them?

A.- I did not measure them, no.

Q.- And then so far as the genitalia were concerned I understand you to tell us that there was what you described as an enlarged phallic organ which measured two centimetres by one centimetre?

original, p. 261, 262, 263 139 A.- Yes.

Q.- Would the size of that organ vary from time to time?

A.- Oh considerably, yes, I would think that there would probably be occasions when it was far larger.

Q.- And occasions when it was smaller?

A.- I would think that it might be a little smaller, yes, it was flaccid on examination.

Q.- It was one centimetre in diameter by one centimetre in length?

A.- A penis is a very difficult thing to measure, it merges into the body tissue.

Q.- This organ is in no sense a penis?

A.- This organ is penile in the general sense I find it impossible to give any specific name to it, it is a phallic organ which is as precise as I wish to be about this. I don't think that names always clarify the issue.


Q.- Just tell me this, because I want to understand the terminology, is the clitoris also referred to medically as a phallic organ?

A.- Not unless it is considerably enlarged. If a known female has an enlarged clitoris it would be described in general terms as a phallic organ measuring whatever it is.

Q.- It might be a term used for an enlarged clitoris?

A.- It might be a term used for an enlarged clitoris.

Q.- Medically?

A.- Yes medically.


Q.- And this organ, was it the same sort of thing as you could find in a female and describe as an enlarged clitoris?

A.- Yes.

Q.- So while it could be described with reference to an organ which is clearly female it could not, could it, be reasonably described as a penis in any sense of the term?

A.- Yes, I think it could.

Q.- In what sense of the term?

A.- If indeed the Second Petitioner has ovarian tissue present or if indeed he was what I would call an example of testicular female, if he was XY with some rudimentary tissue and this organ I don't think there is anything else you could call it, you could call it a small penis.

Q.- But it has no urethral tube running through it?

A.- I don't think that is a significant matter with respect.

Q.- I would have thought that was one of the features, it is the organ with which one urinates with if you are an ordinary male?

A.- The ordinary male does, yes.

Q.- And the ordinary male ejaculates seminal fluid through the penis, does he not?

A.- Yes.

Q.- And these are two things neither of which the Second Petitioner could have done because the organ would not permit it?

A.- Through the organ as such, no.

original, p. 263, 264, 265 140 Q.- And the emission of urine would come from where in the Second Petitioner?

A.- From the urethra which was as I described roughly two centimetres posterior to the base of this phallic organ.

Q.- Was that in the region where the scrotum would normally be in a male?

A.- It is in mid-line in the region of the scrotum, if you follow me, the rough piece of skin that roughly bisects the scrotum.

Q.- And that is the place from which the Second Petitioner would be able to urinate?

A.- Yes.

Q.- Would it be possible - I don't know whether you can tell me - for the Second Petitioner to urinate in the normal standing position of a man?

A.- I think it would be possible, yes.

Q.- At the comparatively normal type of urinal one finds in public places?

A.- I would not say I think it would be likely but I think it would be possible.

Q.- Possible but difficult?

A.- Yes.

Q.- So that it comes to this, does it not, that so far as the genital organs are concerned they a/typical of a male?

A.- Correct.

Q.- And in addition to that there is the absence of a scrotum?

A.- Yes.

Q.- And there is the presence of what I think you described as a narrow vagina?

A.- I think that is probable, yes, there was an orifice which seems to me as if it would lead into a narrow vagina, but it was too narrow for further examination.

Q.- Was it not possible to insert a finger or anything of that sort?

A.- No, you could not have inserted a finger.

Q.- Are you able to tell us whether or not there was a probability there might have been a uterus in the Second Petitioner?

A.- I think there could have been.

Q.- There might be still?

A.- If there was there would be now.

Q.- So that the probability is that the vaginal passage would lead to a uterus?

A.- I would not say it was probability, but it is certainly a possibility.

Q.- And that would be again an atypical male feature of the genitals?

A.- Yes, it would be atypical.

Q.- And atypical, although perhaps abnormally sized, feature of the female genitals?

A.- Yes, you describe it correctly.

Q.- The next feature to which you referred was the labia, which I think is a female feature, I think Mr Jauncey put it to you the labia would remain in a female but would form the bag for the scrotum in a male?

A.- Yes.

original, p. 265, 266, 141 Q.- There being no scrotum in the Second Petitioner the labia was still there?

A.- In the presence of an abnormality of this kind I am reluctant to give a specific name to an organ which is clearly not normal, but certainly there were loose folds of skin which closely resembled labia minora.

Q.- Another typical female feature in the genitals, and atypical of a male?

A.- Yes.


Q.- Did you find anything resembling the labia majora?

A.- There is tissue on each side, there is always tissue of some kind on each side, in the broad sense they resemble labia majora, yes.


Q.- When you were examined - I will just complete this area - you referred to seeing one scar when you were palpating in the inguinal region. Did you see only one scar?

A.- There was only one scar, although part of it looked as if it might have been a second incision over the original scar.

Q.- In the same place?

A.- in the same place.

Q.- Above or below the scar you saw?

A.- On it, on the line of it.


Q.- When was it that you observed this?

A.- The scar?

Q.- Yes?

A.- Yesterday.


Q.- Was this on your second examination that you saw the scar?

A.- Yes.

Q.- Was that the first time you had seen the scar?

A.- It was, a plaster was present on the previous occasion.

Q.- And the previous occasion was the 24th January, 1967?

A.- Yes.

Q.- There was then on the 24th January?

A.- A plaster in that area.

Q.- No plaster last night?

A.- No.

Q.- I don't know whether you can help us about this, but if there was a specimen taken from the region of the inguinal canal in January, 1967, which was not passed for examination to March what effect would the intervention of the intervening period have on such a specimen?

A.- None if it was correctly fixed in the meantime. If it was not correctly fixed it would have a considerable effect.

Q.- Would it have to be fixed in a laboratory?

A.- No, it could be placed in a bottle with a suitable fluid in it. Q.- Would that have to be done by an expert?

A.- Anyone.

original, p. 266, 267, 268 142 Q.- I could?

A.- Yes.

Q.- So long as I knew what fluid to use?

A.- Yes.


Q.- I wonder if you can assist me with one or two fairly elementary points. Could you give me indication of the dimensions of the penis of a normal male, or are there variations so great that it is not helpful?

A.- I certainly cannot give the normal variation, but certainly the alteration is very marked, since the organ is capable of becoming thoroughly distended with blood and emptied of blood.

Q.- But you can give me some sort of indication of the range of size in a normal adult male?

A.- If I did it would be purely a guess, I think it is possible in a normal adult male in certain instances the penis may be as short as an inch or an inch and a half in length.

Q.- And in centimetres that would be two and a half to four, an inch is 2.5, so it might be as small as that?

A.- I think it might be as small as that in some circumstances.

Q.- What I am really looking for is a sort of norm in a normal adult male?

A.-I think the conditions vary to such an extent one would be bound to put that within the normal limit of possibility for a normal person if there had been some physical exertion and the blood had been re-directed to other parts of the body the penis can be very small.

Q.- You cannot give me a figure?

A.- I cannot give a figure, no, I can just give you my impression.

Q.-The second question I would like to ask you which is also elementary, but may be difficult to answer, is where is the urethra normally found in a normal adult female?

A.- The urethra in a normal adult female is generally found in more or less the position of the Second Petitioner, it appears in front of the vagina and some distance from the base of the clitoris.

Q.- The third question I would like to ask you is something was said about the size of the vagina or at any rate of the orifice in this case, and I think you said you could not have inserted a finger. Is that right?

A.- Yes.

Q.- Can you give me any indication of the size of the vagina in the normal adult female so far as entry of a finger or fingers is concerned?

A.- In a normal adult female, an unmarried adult female, a finger can without difficulty be gently inserted into the vagina. The presence of hymen would perhaps make this rather uncomfortable, but nowadays it is common enough to be able to do so since so many women wear internal protection of some kind, so it would be at least the dimension of a fore finger and it is capable of far greater distension.

original, p. 268, 269 270 143 CROSS-EXAMINATION CONTINUED:-

Q.- I think you saw a Report by Dr. Stalker which is No. 12?

A.- Yes.

Q.- In that Report he says, "Cells in an early maturation stage". What do you understand him to mean by an early maturation stage?

A.- I would have thought he meant he had seen spermatogonia as it is called some of which had become primary spermatocytes, this is what I presume he meant.

Q.- But not spermatozoa?

A.- By that phrase I would not assume he meant spermatozoa.

Q.- You would assume, would you not, that Dr. Stalker had thought that the cells had not gone through all the stages which would result in final development in the producing of spermatozoa.

A.- By that phrase, yes.

Q.- This is what he says in his Report, does he not?

A.- Yes.

Q.- In his evidence what Dr. Stalker said was as it has been noted by my learned junior "Early spermatoblasts present in this testis, they divide into three or four stages, these are divided at the first stage". That is as we have noted it?

A.- This is I think probably another way of saying what I have just said, spermatoblast would precede this spermatocyte formation, it is a different terminology from spermatogone.

Q.- On Dr. Stalker's Report and assuming the evidence which I have read to you is correct it would appear, would it not, there had not been full development through all the stages of the spermatogenic cells in this particular testis?

A.- Not from his Report as such. There is a little later evidence which suggests there might have been full development in some of them. He says here "A few sperm-like structures are noted", which I take to mean he saw a few structures resembling spermatozoa.

Q.- Would you take from that Report that there was spermatozoa which had ben identified and that spermatogenic cells had gone through all their development stages or that the spermatogenic cells had not gone through their development stages?

A.- I would understand him to mean that some of them had gone through all the stages.

Q.- But not all?

A.- Not at all.


Q.- That is all four stages which you had previously described?

A.- This is so.


Q.- Is it your view that the testicular tissue which has been found to exist in the Second Petitioner has been producing some androgens which have caused such virilisation as appears from the Petitioner growing hair on her face and so on?

A.- This would be my view, that he had grown hair on his face as result of this and other features as a result of this.

Q.- Would the stage to which the testicular tissue had original, p. 270, 271, 272 144 developed have any effect on the amount of androgens it could produce?

A.- Yes, I think it would have that effect, yes.

Q.- Would there be much in the way of androgens being produced from what you saw in Dr. Stalker's Report No. 12 of process?

A.- From the Report I would think that this was compatible with a reasonably normal production of androgens, yes.

Q.- But not surely with a reasonably normal development of a testis?

A.- Reasonably normal, yes.

Q.- But wouldn't the normal male have a testis which had developed through all its stages, spermatogenic?

A.- The normal male with testes in the scrotum, would, yes. I think the normal male with a testis in this situation might have roughly this kind of thing.

Q.- Could the normal male have a testis in this situation?

A.- He could have one in that situation and one in the scrotum.

Q.- Could a normal male have one testis in this situation and no other testis?

A.- A normal male, in other respects normal, yes.

Q.- But he wouldn't be a normal male if he had a testis which had not come into the scrotum and only one, would he?

A.- If you care to define normal for me I will try and answer the question. If you mean no abnormality of any kind, well no.

Q.- A normal male, a large percentage of the population who are male have got a scrotum and two testes in the scrotum?

A.- Yes.

Q.- And as against that standard the person who had only one testis which had not descended and no other testis would be abnormal in this respect?

A.- Yes, they would be abnormal.

Q.- But would you expect on the definition I have given you of a normal male the normal male's testicular tissue to be developed to a greater stage than this testicular tissue clearly is?

A.- I would expect it to be developed to a greater stage.

Q.- And if it was developed it would be producing more androgens, would it not?

A.- I don't think so, since the androgenic function is largely the result of interstitial development and not tubular development.

Q.- In what particular feature does the androgenic substance manifest itself?

A.- In body features?

Q.- Yes?

A.- It manifests itself in muscular development, growth of hair, in development of the senses of being male, having a sex drive.

Q.- Are you able to express any view as to whether the testicular tissue and the androgens which you say it would generate would have operated during the whole of the Second Petitioner's life or only during part of it?

A.- I would have thought they had operated from puberty onwards.

Q.- So to come back to a subject we were discussing a little original, p. 272, 273, 274 145 while ago the male features as I understand your evidence to which you point in the Second Petitioner are the existence first of all of testicular tissue?

A.- Yes

Q.- And that I think is a feature which is common to a male and also a hermaphrodite?

A.- Yes.

Q.- And the other features you point to are associated with the testicular tissue, the receding hairline, muscular appearance and the body hair?

A.- Yes.

Q.- Is that right?

A.- Yes.

Q.- Does that exhaust the masculine features of the Second Petitioner to which you point?

A.- In the normal physical sense?

Q.- Yes?

A.- You are excluding however the masculinity, the sex drive, because he married.

Q.- Yes?

A.- No, it does not exhaust them, because there is a degree of male differentiation which is evident in the external genitalia.

Q.- Which particular feature of the external genitalia is male?

A.- The phallic organ is considerably enlarged for a female.

Q.- But did you not tell me that the phallic organ as you have described it is an enlarged organ of the female type, it is primarily a female organ which is enlarged?

A.- No, I don't think I said that. If I did I didn't mean that.

Q.- I think I put it to you and you said that this was an enlarged clitoris?

A.- I said it could be an enlarged clitoris.

Q.- And the clitoris is not a male genital feature?

A.- The clitoris is not a male genital feature, no.

Q.- So an enlarged clitoris could not be a male feature, could it?

A.- An enlarged clitoris could not be a male feature except in the sense that a penis is developed from precisely the same original structure as a clitoris is.

Q.- That applies to all the genitalia, don't they all develop from the same material, depending which way they go they are male or female?

A.- Yes, I don't think I said this was an enlarged clitoris, it is a phallic organ which is certainly far larger than one would expect in a normal female, and the additional feature is the raised perineum which has prevented the normal development of the vulva and has almost obscured the external orifice of the vagina.

Q.- That is the sort of thing you would expect to find in a male, is it?

A.- It is an early stage of what I would expect to find in a male.

Q.- Not completely typical?

A.- Not completely typical, no.

original, p. 274, 275, 276 146 Q.- Does that exhaust the features to which you point?

A.- In the physical sense it does, yes.

Q.- Are those features such that in your opinion they would permit the person concerned to live equally well as a female as a male in the physical sense?

A.- I think they are, yes, in a general sense, yes.

Q.- Physically?

A.- Yes, I don't think that in the female sense this could be done without a little further surgical treatment, I think this would be necessary, but it is possible this could be carried out.


Q.- What surgical treatment have you in mind?

A.- At the moment the orifice of the vagina is to a very small extent obscured by the perineum, the vagina is too narrow to permit normal intercourse as a female, and surgical enlargement of this would be necessary if one were to suggest living in the female sex.


Q.- Full life in the female sex with the possibility of intercourse with a male, I suppose?

A.- Yes.

Q.- So physically speaking I don't suppose you were surprised to know that for some 40 years the Second Petitioner did in fact live as a female?

A.- I am not surprised that he lived as a female for 40 years, but this would be, my main reason for saying that would not be a physical consideration, it would be because he had initially been placed in this sex and lived in it for a sufficient length of time that he himself had no control over the situation at all.

Q.- Are you just saying this, that the Second Petitioner is such a person as could accustom himself or herself to live in either sex?

A.- I am saying that he is the type of person who might, yes, as an individual plainly he did not, but he is the type of person who might.

Q.- And are you saying this when we start to consider psychological sex that the determining factor from the social point of view is the sex which the Second Petitioner wishes to assume because he could assume either?

A.- The determining factor could be that, yes.

Q.- And I think from your point of view I think you said it was the most important factor you thought in this case probably that the Second Petitioner wishes to live as a man?

A.- I think at the time I was answering a general question about the management of an adult who had a disability of this kind, and certainly so far as orientation is concerned the class in which they would wish to live and were living would be a very important matter indeed.

Q.- So actually the determination at the end of the day from the social point of view would be a subjective determination of the person concerned given the physical features of somebody like the Second Petitioner who could live as either?

original, p. 276, 277, 278 147 A.- Yes.

Q.- The final determining factor would be what they wanted to be?

A.- The final determining factor in the physical sense of my managing someone who was a patient, yes.

Q.- And when that decision had been made one would not be making a decision as to whether the patient was in fact a man or a woman, but would simply be making a decision that it is better for them to live as a man or a woman?

A.- This is the position as put to a doctor when he is confronted with an inter-sex state of one kind or another.

Q.- And that is all really you are saying with regard to the Second Petitioner, that having regard to his wish to live as a man and having certain characteristics which would enable her to do so, it is better he or she should?

A.- I have no doubt that this is so. I would not say that was all I was saying, but I am in no doubt that is true, what you did say.


Q.- Since you have used the expression, can you define what is meant medically by an inter-sex state?

A.- Initially just someone whose sex is clinically in doubt, because some discordant factor is present. There are very many degrees of this. In some instances the deformity is entirely an internal one, and the person concerned is chromosomally and gonadally perhaps female, in other instances there is conflicting gonadal function as there may be here. In some, for instance, there may only be testicular tissue of imperfect formation which has led to an imperfect development in the external genitalia, but it simply means in general someone whose sex cannot easily be defined as a normal male or a normal female.


Q.- Is there anything so far as you have been able to ascertain from your examination of the Petitioner on the assumption that she was brought up as a girl, went to parties as a girl, and had regular menstruation which would have prevented her continuing to live as a girl had she wanted to do so?

A.- That in fact was not my understanding of the history.

Q.- I am asking you to assume that is so?

A.- Assuming there was regular menstruation and being brought up as a girl for a period of time?

Q.- Yes?

A.- Is there anything to prevent?

Original, p. 278, 279, 280 148 Q.- Assuming that was in fact the history was there anything that you could see which would have prevented the person continuing to live as a woman?

A.- Yes, there is of course in this sense, that continued life as a woman demands that the person has an impression of themselves as clearly female, and with visible evidence of an abnormality the person concerned would be bound to question when they were old enough whether they felt a member of the

female sex or not.

Q.- Are you not surprised at somebody like the Second Petitioner who qualified as a doctor of all professions as a woman?

A.- Surprised - so many circumstances would influence this that I don't know I would be prepared to express surprise either way.

Q.- I thought you said that a person as they developed their life would have noticed and not gone on living as a woman?

A.- It is not to say they would be sufficiently influenced by noticing the abnormality that they would be able to bring themselves at an early stage to carry out this remarkable volte face, to join the opposite sex. They may live for years with doubts before they become crystallized.

Q.- As a doctor yourself does it not surprise you that somebody who has qualified as a doctor as a woman and continued to live afterwards as a woman to all outward appearances, does it not surprise you?

A.- No.

Q.- Somebody who you say is a man?

A.- I could not say that I admit surprise at this.

Q.- Would you think it was an unusual situation?

A.- Oh, it is certainly an unusual situation, of course.

Q.- Unique in your experience?

A.- Unique in my experience - no, not unique in my experience.

Q.- Have you known of other people who have qualified as doctors....?

A.- In this sense, I beg your pardon, it is unique in my experience.

Q.- You are concerned, I think, very largely in your particular work with adjusting people who are in this unfortunate condition of being neither one thing nor the other?

A.- I am not concerned very largely with this, it is not a very large matter, but it is a special study of mine, yes.

Q.- And is one of the real problems the problem of trying to get people adjusted to the way of life most suitable to them in whichever sex it may be?

A.- Starting as a baby?

Q.- If possible, I suppose, yes?

A.- No, this is not one of the problems, provided you do in fact investigate this matter fully in childhood and treat it correctly at the time, carrying out if necessary surgical treatment to underline the more appropriate sex, I would expect the person concerned to adjust to the sex in which they were placed well.

Q.- Does it become a problem if there is some doubt originally as to the sex to which they should be assigned?

A.- Unless there was some doubt originally the problem would not arise, it only arises when there is doubt.

Original, p. 280, 281, 282 149 Q.- Perhaps we are talking at cross purposes, it is probably my fault. I understand there is, happily with a few number of people, a problem today with which some people are trying to cope, namely, to assign them to the right sex because their sex is in doubt?

A.- Yes.

Q.- They were neither one thing nor the other?

A.- Yes.

Q.- When trying to solve that problem is the kind of consideration to try and see which sex they are best suited to from various points of view?

A.- In infancy, yes.

Q.- In later life as well?

A.- Yes, in later life, including the psychological aspect as well. In infancy this does not apply, you are concerned only with physical factors.

Q.- And it might be that a person who has lived a life as a man might find it better to continue as life in the guise of a woman?

A.- It might be that a person of this kind having been placed in the male sex might later have doubts about his true sex and wish to change to a woman, yes.

Q.- But such a person could have been at one stage in their life a perfectly well orientated male ?

A.- No, I think this is unlikely, not in the conscious sense of well orientated, I think if doubts of this kind, sufficient doubts to make a person change from male to female, arise at any time, I think it is unlikely the person concerned would ever have been an entirely well orientated male.

Q.- But a person who might well have been accepted as a male?

A.- Oh yes, perhaps someone who is accepted by others as male, had worn male attire and had been called a male name.

Q.- And with somebody like the Second Petitioner who has been brought up as a female there might be from your experience a time in their life when that was the right sex for them to be put in, although as time went on it might be better for them and their ego to be put in the other sex?

A.- You are asking me if it might at some time be right to place a person in the female sex who, having been placed there subsequently wished to become male?

Q.- No, I am not, I am sorry?

A.- I am just trying to find out what you are asking me.

Q.- I am sorry, it is my fault?

A.- It is a complicated question.

Q.- It is a difficult subject?

A.- I agree.

Q.- What I am trying to ask you is this, and you might not be able to answer it because it is a bit hypothetical, whether it may have been quite proper from the doctor's point of view to have been a girl to all intents and purposes for quite a large part of her life and equally proper for the doctor to be a man now to all intents and purposes - I mean the Second Petitioner when I say the doctor?

A.- I have no understanding of what you mean by proper in these circumstances, I don't think I can answer your question.

Q.- Well, the Second Petitioner is a person who has for 40 years Original, p. 282, 283, 284, 285 150 of her life been known as Elizabeth Forbes-Sempill and as a girl and was brought up as a girl as I understand it?

A.- Yes.

Q.- For at any rate part of that time, part of that 40 years may it have been the best thing, I think that is perhaps the fair word to use, the best thing for the Second Petitioner to have been presented to the world as a girl and live as girl?

A.- I understand what you mean.

Q.- Though now it might be better that the Second Petitioner should live and be presented to the world as a man. Is that quite a possible situation?

A.- I don't think it is so, I would not agree that it was likely to have been better for the Petitioner to have been brought up for a long period of time as a girl and now a man, I think it might have been more correct for him always to have lived in the male sex.


Q.- Why do you say that?

A.- I am looking at it with hindsight from all the facts that have emerged, but if someone has despite having been placed in the female sex and accepted as having been of this sex, has sufficient doubts about their true sex to change at this late stage then I think there must have been a considerable conflict initially which would have been better resolved by him living in the male sex all the time or from an early stage at any rate.

Q.- May I put this to you, it may be perhaps less hypothetical, you said, and I think this may necessarily be so, that in infancy in a situation of this sort you are concerned only with physical factors?

A.- Yes.

Q.- And of course, the number of physical factors is necessarily reduced, I take it, you don't have receding hair for example?

A.- No, the physical factors concerned are concerned with the genitalia only, internal and external, and nowadays chromosomes.

Q.- I understood you to say earlier in your evidence that even at this stage physically the Second Petitioner could live as a woman with perhaps some small matter of plastic surgery?

A.- I would not minimise it, with plastic surgery in the physical sense could live as a woman.

Q.- I understood from another part of your evidence that you could visualise the sort of baby that the Second Petitioner may have been as presented to the medical practitioner who delivered the Second Petitioner?

A.- Yes.

Q.- Can you give me any sort of indication as to what procedure would probably in your opinion have been adopted at the present day in the case of such an infant - I am assuming that the external genitalia presented the appearance which you have indicated, that is no scrotum, no testes to be seen, presumably that sort of thing, I was wondering what sort of procedure would be adopted at the present day in relation to such a case with the knowledge that we now have?

A.- What decision would have been made as to the more appropriate sex?

Q.- What practical steps would have been taken?

Original, p. 285, 286, 287 151 A.- The practical step would have been first and foremost to exclude the condition of adrenal hyperplasia which was for a period of time considered here, this would be the first and most important condition to eliminate, from this condition the patient might die. Having eliminated that one would make certain there was no evidence of androgenic influence having come from treatment the mother received in pregnancy, which so long ago can be discounted here for practical purposes. Then one would have to decide by operation precisely what organs were present, in particular what gonads were present.

Q.- By operation?

A.- It is the only way it could be done, to distinguish if testes alone or ovarian alone or ovaries and testes. having established all the facts those would have to be very carefully considered to decide in what sex it seemed more appropriate for the person to live.

Q.- From what point of view?

A.- From principally the point of view of the satisfactory sexual function in later life, the genitalia would be assessed, the external genitalia would be assessed to decide in which sex it seemed better that the individual should live from the sexual point of view, from being able to marry and have intercourse either way.

Q.- I take it you might discover, I don't say you would, you might discover by operation you were dealing with a true hermaphrodite. That is possible, is it?

A.- Yes.

Q.- Faced with the situation and with external genitalia such as you assume are present here at birth, what practical steps in your opinion would be probable?

A.- I think it would be probable that it would be judged wiser to accept the female sex. It is largely a surgical consideration, it is almost always surgically simpler and therefore safer for the individual concerned to convert the genitalia of doubtful sex into the female ones rather than into the male ones. The number of operations involved is small and their magnitude is smaller also, so I imagine that decision would probably have been arrived at, and having been arrived at, whichever in fact decision was arrived at, the inappropriate gonad would be removed to avoid the kind of influence that I visualise happened here, that the gonad in fact that was opposed to the chosen sex should later exert its influence, so you remove it in infancy so there is no possibility it ever will.

Q.- Would the chromosomal pattern have any bearing on the practical action?

A.- No, none whatever.


Q.- I think you dealt with this in fact in an article which you wrote along with Dr. Gordan?

A.- I have expressed this opinion many times in print.

Q.- Look at No. 18 of Process which I think is an article re-printed from Lancet of 27th October, 1962, "Ambiguous sex in the newborn by R.R. Gordan, Consultant Paediatrician, the City General Hospital, Sheffield", and yourself, and I think on Page 7 in the second paragraph you say "In hermaphrodite the suitable Original, p. 287, 288, 289 152 sex for rearing is decided on the functional possibilities of the external genitalia rather than upon anything else. If the size of the phallus is such that normal life as a male can be expected maleness may be chosen, and appropriate operations to prolong the urethra to the end of the phallus, if necessary, should be done. In addition, the uterus, if present, should be removed along with all ovarian tissue. In this way distressing heterosexual manifestations at puberty are avoided. Subsequent follow up will show whether androgen therapy is necessary or not. If the vagina is small, perhaps markedly so, the female sex should be chosen, the phallus amputated and the testicular tissue removed. The uterus and ovarian tissue should be preserved. Later if necessary the vagina may be enlarged"?

A.- Yes.

Q.- And I think you said to his Lordship it was the second you thought would probably have been adopted in this particular case?

A.- I think it probable, yes.

Q.- And if that sort of thing was done in a case where a hermaphrodite was recognised at birth this sort of question we are trying to decide would never ultimately arise?

A.- No, it would not.

Q.- Just a small matter, I think you said to my learned friend, and I think you also said to me, that the probable diagnosis you make here is hermaphroditism?

A.- Yes.

Q.- And you also said "Or Klinefelter's Syndrome", but it would appear from the book "Intersexuality" at Page 361 that Klinefelter's Syndrome would have certain features which are not present here?

A.- Here there are features which are not in Klinefelter's Syndrome, it is not typical, I don't think I said in fact Klinefelter's Syndrome, I said the conditions are similar to Klinefelter's.

Q.- I think your final diagnosis is hermaphroditism?

A.- My final diagnosis is not made at all, I would be unwilling to make my final diagnosis in the absence of all the facts, and they are not established.

Q.- So may I take it you are only reaching a conclusion rather than a final conclusion?

A.- Yes.

Q.- You are dealing with probabilities?

A.- Yes, just so.

Q.- On the matter of probabilities is there hermaphroditism for the Second Petitioner?

A.- On the matter of probabilities I would say that, yes.

Q.- And that would be somebody, if that is right, who had always been a hermaphrodite, because the sex is determined gonadally and chromosomally at birth?

A.- Yes.


Q.- Of course, you could only reach a firm conclusion on the question of hermaphroditism, I take it, if there was a laparotomy?

A.- Yes.

Original, p. 289, 290, 291 153 Q.- And that I think is a major operation involving opening up of the abdomen?

A.- Yes.

Q.- So that at the moment all we know as far as gonads are concerned is that there is tissue of a male gonad?

A.- Correct.

Q.- When you were describing the features which you found in the Second Petitioner you made reference to pubic hair. Did the Second Petitioner have any hair on the abdomen??

A.- Yes, there is a little.

Q.- Is abdominal hair normally found in a female?

A.- It is not uncommonly found, but more commonly it is absent than present.

Q.- And equally is it more commonly found in a male than being absent?

A.- yes.

Q.- You were asked about an organ, the phallus, which you said could be found in a female as an enlarged clitoris?

A.- Yes.

Q.- If that were so, if it were an enlarged clitoris what would be the cause of the enlargement?

A.- If the person would be otherwise female?

Q.- Yes.

A.- This would have to be some androgenic influence of some kind, most likely by far would be adrenal hyperplasia, another would be the presence of some other androgenic source whilst the baby was in utero.

Q.- Does that mean that you cannot find an enlarged clitoris in a female in the absence of androgenic source?

A.- I would think that there must be some androgenic source.

Q.- And therefore if you find an organ which can be described as an enlarged clitoris does it follow that the female in whom it is found cannot be said to be a normal female?

A.- It follows that they cannot, yes.

Q.- You remarked that the lack of a urethral passage was not significant?

A.- No.

Q.- Is there a condition in males called hypospadias?

A.- Yes.

Q.- What is it?

A.- It is a condition in which the urethra fails to traverse the whole length of the penis, but opens beneath it in one location or another.

Q.- And is the opening here in this case similar to what you might find in ceratin cases of hypospadias?

A.- Yes, this is rather like the appearance in what you would call perineal hypospadias.

Q.- Do you find perineal hypospadias in males who are in all other respects normal males?

A.- Yes.

Q.- Do I understand that your views on the external genitalia, as I think you said in examination-in-chief, are that they are neither typical male nor typical female?

A.- That is correct.

Q.- I am not quite sure whether there may have been a misunderstanding here, you were referred by his Lordship to the Original, p. 291, 292, 293 154 Report No. 12 of Dr. Stalker, the pathological report, and you made reference to the few sperm-like structures?


Q.- Do I understand that you said that the Report as a whole suggested that there were some cells which had gone through the complete cycle and reached the stage of producing sperm but that there were others in which only the primary or secondary stage of spermatogenesis had taken place?

A.- This is how I would define it, yes.

Q.- Not all the cells had gone through all four stages but some had?

A.- It appears that some have.

Q.- In examination-in-chief You made reference to the lack of subcutaneous body tissue as a factor, you did not mention it as far as I recollect in cross-examination as being a factor pointing towards masculinity. Was there any particular reason for that?

A.- No, except I probably forgot it, it is indeed a factor indicating androgenic influence.

Q.- And subcutaneous tissue is absent here?

A.- Yes, it is absent here.

Q.- It was put to you as I understand it that the matter really came to this, that in deciding in which sex this Second Petitioner should be placed you would have to take into account all the psychological considerations. Am I right in thinking that in so far as you were treating or managing a patient such as the Second Petitioner you would have regard to psychological sex?

A.- Oh. very much so.

Q.- I asked you in examination-in-chief whether you were in a position to state whether assuming this patient was a true hermaphrodite, and taking into account the physical factors which you have described, and assuming a gonad exists as reported in the pathological reports, you were prepared to say whether masculinity or femininity predominates in those factors?

A.- I think I replied that I thought that masculinity predominated.

Q.- And this is I understand irrespective of psychological considerations?

A.- Yes, I was considering physical factors.

Q.- What is the position if you take into account psychological considerations as well?

A.- It is much more so.

Q.- In relation to the procedure which would now be adopted if you had, had the care of the Second Petitioner as a baby do I understand assuming the Second Petitioner is a true hermaphrodite the principle reason governing your choice of female would be the safety of the patient resulting from the easier surgery operations required?

A.- Yes, and the greater degree of success that was likely to attend on female operations than male, the elongation of the urethra is a much more complex procedure.

Q.- Is it in fact possible to produce a urethra to the end of the phallic organ?

A.- Yes.

Q.- Is it possible to build up the phallic organ by plastic Original, p. 293 155 surgery? A.- It is possible to do it, yes.