In a June 12th opinion article in the Wall Street Journal, well-known anti-transgender psychiatrist Dr. Paul McHugh attempts to make a case against supporting hormonal and surgical transition for transgender individuals. McHugh, professor of psychiatry at Johns Hopkins University, has been actively working against the medical treatment of trans people since the 1970’s. As the university’s chief psychiatrist, he was instrumental in closing the Johns Hopkins Gender Program in 1979, one of the first programs of its kind, citing the 1977 study by his Hopkins colleague Dr. Jon Meyer, which claimed that surgical intervention did not improve the psychological functioning of the individuals treated. McHugh himself admits to directing Meyer to conduct to further his anti-trans agenda in a 2004 article titled “Surgical Sex”. In the same article, McHugh also continues to preach the largely discredited “autogynephilia” theory of Ray Blanchard and J. Michael Bailey. McHugh is also known for filing an amicus curiae brief in Hollingsworth v. Perry, asserting that homosexuality is a choice, as well as for his participation of the campaign against Kansas abortion provider Dr. George Tiller– who was murdered in 2009 by an anti-abortion activist.
Dr. McHugh first attempts to draw a number of false and offensive parallels between gender dysphoria and conditions like anorexia, bulimia, and body dysmorphia in an attempt to demonstrate his assertion that gender dysphoria is not based in “physical reality”:
“This intensely felt sense of being transgendered constitutes a mental disorder in two respects. The first is that the idea of sex misalignment is simply mistaken—it does not correspond with physical reality. … The transgendered suffer a disorder of “assumption” like those in other disorders familiar to psychiatrists. With the transgendered, the disordered assumption is that the individual differs from what seems given in nature—namely one’s maleness or femaleness. Other kinds of disordered assumptions are held by those who suffer from anorexia and bulimia nervosa, where the assumption that departs from physical reality is the belief by the dangerously thin that they are overweight.”
Unfortunately, it appears that McHugh has decided to ignore the growing body of neurological and genetic research providing evidence of a biological basis for gender dysphoria. A 2009 study found a correlation between an increased number of a certain kind of sequence repeat in the Androgen Receptor gene and gender dysphoria. Another study in 2009 identified significant differences in cerebral grey matter structure in trans women who had yet to start hormone therapy when compared to cis men. In 2011, researchers noted that the structure of a sexually-dimorphic region of the brain, known as the intermediate nucleus, of trans women fell somewhere between cis men and cis women, while a similar difference was not noted castrated cis men. A 2013 functional brain imaging study of adolescents with gender dysphoria demonstrated a tendency for trans teens to perform more similarly to their identified sex (as opposed to their assigned sex) in a verbal fluency assessment, with similar correlation in brain activity during the assessment. Lastly, in 2013, a large study of monozygotic (identical) and dizygotic (fraternal) twins where at least one twin was transgender showed a far higher concordance of a diagnosis of gender dysphoria among monozygotic than dizygotic twins (33% vs 2.6%), which is strong indicator the existence of a biological factor in a trait. While much of the research into the biological aspects of trans people is still very new, Dr. McHugh’s assertion that no evidence for a biological basis for trans identities demonstrates a deplorable ignorance of current medical research.
McHugh then goes on imply that transgender surgeries do not improve the lives of trans people, and are actually causing harm:
“It now appears that our long-ago decision was a wise one. A 2011 study at the Karolinska Institute in Sweden produced the most illuminating results yet regarding the transgendered, evidence that should give advocates pause. The long-term study—up to 30 years—followed 324 people who had sex-reassignment surgery. The study revealed that beginning about 10 years after having the surgery, the transgendered began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population. This disturbing result has as yet no explanation but probably reflects the growing sense of isolation reported by the aging transgendered after surgery. The high suicide rate certainly challenges the surgery prescription.”
McHugh, again, appears to selectively reading the literature to support his own agenda. It is first important to note that Dr. McHugh is grossly misconstruing the findings of the Karolinska study. The study compared the mental health of post-surgical trans people with age-matched cisgender controls. The study itself posits absolutely zero links between gender-confirming surgery itself and the mental health of these people, and the authors themselves caution against interpreting the data in such a way:
“It is therefore important to note that the current study is only informative with respect to transsexuals persons health after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism. In other words, the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit.”
Again, returning to the available medical literature on the subject, research seems to actually indicate that medical transition (including hormone therapy) has positive effects on the psychological states of trans people. A study published earlier this year found significant reductions in all comorbid anxiety and depression, as well as lowered overall functional impairment in trans individuals just 12 months after initiating hormone therapy. A study released in late 2013 showed that individuals on hormone therapy have both lower-levels of self-reported stress and lower blood cortisol levels (a key physiological marker of stress). Given the known effects of stress on physical health, this could also translate to risk reduction for a number of chronic illnesses. Even breast augmentation, often maligned as a particularly “cosmetic” intervention, demonstrated significant increases in sexual and psychosocial well-being. Other studies in 2009 and 2011 have shown similarly positive responses in both trans men and trans women who underwent gender-confirming surgeries. While it might be understandable (though not excusable) for Dr. McHugh to be unaware of the genetic and neurobiological research on trans people, it is inexcusable for a lauded psychiatrist to be either so woefully ignorant or deliberately deceptive in his presentation of the state of psychological research regarding the transgender population.
Missing entirely from McHugh’s analysis is any understanding or even mention of the tremendous discrimination, harassment, violence, and economic stability faced by the transgender community. According to the National Transgender Discrimination Survey, 78% of trans students had experienced harassment at school, 90% of trans people have experienced harassment in the workplace, 26% had a lost a job due to being trans (which, in turn, leads to a 4-fold increase in risk of homelessness), 19% had experienced housing discrimination, 19% had been refused health-care, 22% had been harassed by law enforcement. Overall, 63% of trans people had experienced a serious form of discrimination, while 23% had experienced what the NTDS categorized as “catastrophic” levels of discrimination. It can come as little surprise that people struggling with a serious condition of body integrity who are then simultaneously subjected to massive structural discrimination with little in the way access to the usual safety nets would be so likely to attempt to take their own lives. These are not individuals for whom transition-related treatment has failed; these are individuals that our society and social justice systems have failed.
Perhaps most offensively, Dr McHugh then goes on to attempt to break down transgender individuals into three wide and poorly defined categories- with absolutely zero research or evidence other than his own personal say-so. In the first category, he both equates trans people with criminals and takes an unnecessarily person swipe at Chelsea Manning:
“One group includes male prisoners like Pvt. Bradley Manning, the convicted national-security leaker who now wishes to be called Chelsea. Facing long sentences and the rigors of a men’s prison, they have an obvious motive for wanting to change their sex and hence their prison. Given that they committed their crimes as males, they should be punished as such; after serving their time, they will be free to reconsider their gender.”
This short paragraph is so problematic that it’s difficult to figure out where to begin. Firstly, Chelsea Manning has completed a legal name change. She is not stating a preference- her legal first name is Chelsea. Phrasing her identity in this manner is blatantly dismissive. Furthermore, Manning’s struggles with gender identity began long before her trial or conviction, so to attempt to cast it as an attempt to avoid men’s prison is frankly absurd and amounts to little more than a personal attack tangential to McHugh’s entire piece. More pressingly, given that few prisons provide transition-related care to prisoners, and that trans prisoners are at far higher risk of rape and assault from prisoners and prison staff alike, it’s ludicrous to claim that any “advantage” is gained in coming out as trans while incarcerated. McHugh’s next category blames the internet for the existence of trans identities:
“Another subgroup consists of young men and women susceptible to suggestion from “everything is normal” sex education, amplified by Internet chat groups. These are the transgender subjects most like anorexia nervosa patients: They become persuaded that seeking a drastic physical change will banish their psycho-social problems. “Diversity” counselors in their schools, rather like cult leaders, may encourage these young people to distance themselves from their families and offer advice on rebutting arguments against having transgender surgery. “
Extensive scouring of the Internet via Google turned up zero sex education programs with an “everything is normal” mantra, though the phrase does turn up in a number of blogs advocating “abstinence-only” sex education, an approach shown to utterly fail to produce any positive outcomes. I could also find no evidence of the supposed “diversity counselors” he mentions, and his comparison of those who support young LGBT individuals to cult leaders is nothing more than tired repetition of the same conservative fear-mongering of the queer population that endures in right-leaning population. It’s political posturing that he’s attempting to disguise as legitimate medical opinion through the abuse of his MD credentials and title at Johns Hopkins. McHugh also continues his obsessive focus on “transgender surgery”, which born out in the rest of article. He appears to harbor the same misconception that most of the US population does, that transgender = surgery. The truth is, of course, that the majority of medical side of gender transition is hormonal treatment, and only a small minority of trans people will ever have surgery (whether by choice or lack of availability). His insistence on discussing surgery as the primary medical aspect of transgender care is just further evidence of how dangerous out-of-touch Dr McHugh is with the current state of medicine. In his last self-designed category, McHugh places young children:
“Then there is the subgroup of very young, often prepubescent children who notice distinct sex roles in the culture and, exploring how they fit in, begin imitating the opposite sex. Misguided doctors at medical centers including Boston’s Children’s Hospital have begun trying to treat this behavior by administering puberty-delaying hormones to render later sex-change surgeries less onerous—even though the drugs stunt the children’s growth and risk causing sterility. Given that close to 80% of such children would abandon their confusion and grow naturally into adult life if untreated, these medical interventions come close to child abuse.”
Here again, Dr McHugh appears to be warping and distorting medical reality to fit his own narrative and political position. McHugh is correct in his assertion that 80% of gender-nonconforming children do not go on to adult gender dysphoria. However, gender identity is far more firm in adolescents. Puberty suppression is NOT provided to prepubescent children- the current WPATH Standards of Care indicate that individuals should reach at least the Tanner Stage II of sexual development (meaning puberty has begun) before suppression can begin. Dr McHugh is drawing a false comparison, attempting to assert that the adolescents provided with puberty suppression are the same children of whom 80% will not have persistent gender dysphoria. They are, in fact, two very different and non-comparable groups. Furthermore, McHugh’s categorization of these treatments as dangerous (and constituting child abuse) is simply false. He provides zero evidentiary support for this statement, while medical research has established that delaying puberty is a safe intervention. Taken as a whole, it seems clear that Dr McHugh’s absurdly designed “categories” of trans people are little more than political grandstanding and fear-mongering created to smear and defame the whole of the transgender populace.
It is important to remember that the opinions of Dr. McHugh fly in the face of currently accepted medical practice and the positions of many major medical associations. The American Medical Association, the American Psychological Association, the American College of Obstetrics and Gynecology, the American Psychiatric Society, the American Public Health Association, and the World Professional Association for Transgender Health have all adopted positions supporting the medical necessity of transition-related care, including hormonal and surgical interventions, as well as expressing support for insurance coverage of these interventions. Despite his authoritative sounding title at a respected medical institution, Dr. McHugh’s opinions do not represent the views of the mainstream medical establishment, rather they are the erroneous, bigoted beliefs of a scientist who appears far too invested in his own antiquated, disproven theories and his anti-LGBT political position than the current state of medical affairs.
Dr. McHugh’s piece concludes with a firm assertion that trans people are nothing but mentally disturbed individuals:
“At the heart of the problem is confusion over the nature of the transgendered. “Sex change” is biologically impossible. People who undergo sex-reassignment surgery do not change from men to women or vice versa. Rather, they become feminized men or masculinized women. Claiming that this is civil-rights matter and encouraging surgical intervention is in reality to collaborate with and promote a mental disorder.”
In these final words, the true purpose of this missive appears to become clear. This appears to be a case of gaslighting in the most insidious and heinous of forms, that of a physician attacking a highly vulnerable minority that has already suffered for decades at the hands of the medical profession. His view of gender dysphoria as a psychological disturbance has been consigned to the wastebasket of medical history, much like hysteria, lunacy, and the disease view of homosexuality. However, it appears that McHugh’s ultimate goal here is to derail the ongoing press for transgender rights and equality by asserting that we’re all mentally ill, and hoping that his medical credentials will lend weight to that assertion. His reprehensible, dishonest misapplication of the current medical research to further his own political agenda is despicable, and it’s shameful that the Wall Street Journal would in such a piece.
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