Paul McHugh on transsexualism

Paul McHugh, M.D.is Henry Phipps Professor of Psychiatry and Director of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, and Psychiatrist-in-Chief of the Johns Hopkins Hospital. A member of the Institute of Medicine of the National Academy of Sciences, McHugh is currently co-chairman of the Ethics Committee at the American College of Neuropsychopharmacology. He also serves on the board of The American Scholar. His writings include Genes, Brain, and Behavior (1991) and essays on assisted suicide and the misuse of psychiatry.

From an article by Elizabeth Gilbert:

McHugh has always reserved special scorn for the practice of sex-change surgery on adult transsexuals. Classifying transsexualism as merely one symptom in a larger complex of personality disorders, McHugh had long believed that psychiatrists should treat such patients with the talking cure, not radical, irreversible surgeries. In a 1992 article in the American Scholar, McHugh lambasted transsexual surgery as 'the most radical therapy ever encouraged by twentieth century psychiatrists' and likened its popularity to the once widespread practice of frontal lobotomy.

From A Brief History of Transsexuality

In the late 1970s, however, the climate began to change. The first signs were seen at Johns Hopkins, where the chairman of the Psychiatry department, Dr. Joel Elkes, was replaced by Dr. Paul McHugh. McHugh saw SRS as unnecessary mutilation, and set out to kill the program. He assigned Dr. John Meyer to do a long-term follow-up study of 50 transsexuals who underwent SRS at Johns Hopkins. Meyer's report, issued in 1977, claimed that SRS confers no objective advantage in terms of social rehabilitation for transsexuals. Although the paper was widely criticized as flawed, it led to the October 1979 closing of the Johns Hopkins Gender Identity Clinic.

McHugh is frequently cited in anti-trans literature, as he is on the NARTH site or in Bailey pp. 206-207

Paul McHugh, chairman of the Department of Psychiatry at Hopkins University, used a more sophisticated version of that argument to close Hopkins's renowned gender identity clinic. McHugh objected that clinicians naively accepted transsexual patients' histories of having been quite feminine, when there was ample evidence in many cases that the histories were false (for example, a married man who presents as conventionally masculine). This objection is often correct, though it has no obvious relevance to the advisability of sex reassignment. Furthermore, and more importantly, McHugh argued that it is simply wrong for physicians to "mutilate" perfectly good organs because the transsexual patient's troubled mind wants this: "[The focus on surgery] has distracted effort from genuine investigations attempting to find out just what has gone wrong for these people--what has, by their testimony, given them years of torment and psychological distress and prompted them to accept these grim and disfiguring surgical procedures.

McHugh's concerns are worth taking seriously. Consider the case of the man erotically obsessed with having his leg amputated. Would it be advisable or even ethical to remove the leg? And McHugh is correct that interest in sex reassignment medicine has far exceeded interest in changing the minds of transsexual people so they do not want to change their sex.

Psychiatric Misadventures by Paul R. McHugh

via http://www.lhup.edu/~dsimanek/mchugh.htm

This interrelationship of cultural antinomianism and a psychiatric misplaced emphasis is seen at its grimmest in the practice known as sex-reassignment surgery. I happen to know about this because Johns Hopkins was one of the places in the United States where this practice was given its start. It was part of my intention, when I arrived in Baltimore in 1975, to help end it.

Not uncommonly, a person comes to the clinic and says something like, "As long as I can remember, I've thought I was in the wrong body. True, I've married and had a couple of kids, and I've had a number of homosexual encounters, but always, in the back and now more often in the front of my mind, there's this idea that actually I'm more a woman than a man."

When we ask what he has done about this, the man often says, "I've tried dressing like a woman and feel quite comfortable. I've eve made myself up and gone out in public. I can get away with it because it's all so natural to me. I'm here because all this male equipment is disgusting to me. I want medical help to change my body: hormone treatments, silicone implants, surgical amputation of my genitalia, and the construction of a vagina. Will you do it?" The patient claims it is a torture for him to live as a man, especially now that he has read in the newspapers about the possibility of switching surgically to womanhood. Upon examination it is not difficult to identify other mental and personality difficulties in him, but he is primarily disquieted because of his intrusive thoughts that his sex is not a settled issue in his life.

Experts say that "gender identity," a sense of one's own maleness or femaleness, is complicated. They believe that it will emerge through the step-like features of most complex developmental processes in which nature and nurture combine. They venture that, although their research on those born with genital and hormonal abnormalities may not apply to a person with normal bodily structures, something must have gone wrong in this patient's early and formative life to cause him to feel as he does. Why not help him look more like what he says he feels? Our surgeons can do it. What the hell!

The skills of our plastic surgeons, particularly on the genito-urinary system, are impressive. They were obtained, however, not to treat the gender identity problem, but to repair congenital defects, injuries, and the effects of destructive diseases such as cancer in this region of the body.

That you can get something done doesn't always mean that you should do it. In sex reassignment cases, there are so many problems right at the start. The patient's claim that this has been a lifelong problem is seldom checked with others who have known him since childhood. It seems so intrusive and untrusting to discuss the problem with others, even though they might provide a better gage of the seriousness of the problem, how it emerged, its fluctuations of intensity over time, and its connection with other experiences. When you discuss what the patient means by "feeling like a woman," you often get a sex stereotype in return--something that woman physicians note immediately is a male caricature of women's attitudes and interests. One of our patients, for example, said that, as a woman, he would be more "invested with being than with doing."

It is not obvious how this patient's feeling that he is a woman trapped in a man's body differs from the feeling of a patient with anorexia nervosa that she is obese despite her emaciated, cachectic state. We don't do liposuction on anorexics. Why amputate the genitals of these poor men? Surely, the fault is in the mind not the member.

Yet, if you justify augmenting breasts for women who feel underendowed, why not do it and more for the man who wants to be a woman? A plastic surgeon at Johns Hopkins provided the voice of reality for me on this matter based on his practice and his natural awe at the mystery of the body. One day while we were talking about it, he said to me: "Imagine what it's like to get up at dawn and think about spending the day slashing with a knife at perfectly well-formed organs, because you psychiatrists do not understand what is the problem here but hope surgery may do the poor wretch some good."

The zeal for this sex-change surgery--perhaps, with the exception of frontal lobotomy, the most radical therapy ever encouraged by twentieth century psychiatrists--did not derive from critical reasoning or thoughtful assessments. These were so faulty that no one holds them up anymore as standards for launching any therapeutic exercise, let alone one so irretrievable as a sex-change operation. The energy came from the fashions of the seventies that invaded the clinic--if you can do it and he wants it, why not do it? It was all tied up with the spirit of doing your thing, following your bliss, an aesthetic that sees diversity as everything and can accept any idea, including that of permanent sex change, as interesting and that views resistance to such ideas as uptight if not oppressive. Moral matters should have some salience here. These include the waste of human resources; the confusions imposed on society where these men/women insist on acceptance, even in athletic competition, with women; the encouragement of the "illusion of technique," which assumes that the body is like a suit of clothes to be hemmed and stitched to style; and, finally, the ghastliness of the mutilated anatomy. But lay these strong moral objections aside and consider only that this surgical practice has distracted effort from genuine investigations attempting to find out just what has gone wrong for these people--what has, by their testimony, given them years of torment and psychological distress and prompted them to accept these grim and disfiguring surgical procedures.

We need to know how to prevent such sadness, indeed horror. We have to learn how to manage this condition as a mental disorder when we fail to prevent it. If it depends on child rearing, then let's hear about its inner dynamics so that parents can be taught to guide their children properly. If it is an aspect of confusion tied to homosexuality, we need to understand its nature and exactly how to manage it as a manifestation of serious mental disorder among homosexual individuals. But instead of attempting to learn enough to accomplish these worthy goals, psychiatrists collaborated in a exercise of folly with distressed people during a time when "do your own thing" had something akin to the force of a command. As physicians, psychiatrists, when they give in to this, abandon the role of protecting patients from their symptoms and become little more than technicians working on behalf of a cultural force.

From the conservative Washington Times August 21, 2002

Strange bedfellows by Judith Reisman and Dennis Jarrard

If you found the clergy sex abuse scandal shocking, prepare for another jolt: the Catholic bishops are getting their "expert" advice on pedophilia from people who have covered up or even defended sex between men and children.

The bishops recently chose Dr. Paul McHugh, former chairman of the Department of Psychiatry and Behavioral Sciences at John Hopkins University School of Medicine, as chief behavioral scientist for their new clergy sex crimes review board. Yet Dr. McHugh once said Johns Hopkins' Sexual Disorders Clinic, which treats molesters, was justified in concealing multiple incidents of child rape and fondling to police, despite a state law requiring staffers to report them.

"We did what we thought was appropriate," said Dr. McHugh, then director of Hopkins' Department of Psychiatry and Behavioral Sciences, which oversaw the sex clinic. He agreed with his subordinate, clinic head Fred Berlin, who broke the then-new child sexual abuse law on the grounds that it might keep child molesters from seeking treatment.

Neoconservative/Catholic links

McHugh penned a piece for First Things, the neoconservative publication from The Institute on Religion and Public Life, "an interreligious, nonpartisan research and education institute whose purpose is to advance a religiously informed public philosophy for the ordering of society.”

Exerpts from Right Web on IRPL:

Both the institute and its journal function, in large part, as the institutional vehicles for the conservative religious philosophy of Richard John Neuhaus, a Catholic priest and neocon stalwart. In the early 1970s Richard John Neuhaus was a liberal, antiwar Lutheran minister, who became associated with the neoconservative camp by the end of the decade.

The Institute for Public Policy and Religion quickly established itself as staunchly neoconservative and recruited Midge Decter to serve on its board at about the same time that she was invited to join the board of the Heritage Foundation. In 1991 Neuhaus became a Roman Catholic priest.

The rise of the Institute on Religion and Public Life (and the absence of similar institutes controlled by traditional conservatives) illustrates the declining fortunes and influence of the Old Guard and demonstrates the neoconservative ability to integrate a traditional rightist position--the centrality of religion and ethics in politics and society--into the neoconservative ideological agenda.

In December 2004, McHugh wrote a rather revisionist history of transsexualism:

http://www.firstthings.com/ftissues/ft0411/articles/mchugh.htm

As with the "Psychiatric Misadventures" piece, McHugh takes credit for dismantling the gender program at Johns Hopkins, and for creating the idea of differential diagnosis. The article cites work done by Ray Blanchard at Toronto's notorious Clarke Institute. The Johns Hopkins people under McHugh were advocating a differential diagnosis many years before Blanchard gave it his name. JHU proposed for those who weren’t “classic” or “primary” that they were “transvestitic applicants for sex reassignment” [1] who are “aging” [2] and “distressed,” [3] suffering from “pseudotranssexualism,” [4] or a “non-transsexual” variant of “gender identity disorder” (GIDAANT). [5]

This letter was published in response:

http://www.firstthings.com/ftissues/ft0502/correspondence.html

Transsexual Truths?

In “Surgical Sex” (November 2004) Paul McHugh is certainly right to assert that sexual identity (or, as I prefer, gender) is not subject to change; it is most certainly inherent. About nearly everything else, however, Dr. McHugh is quite wrong. To begin with, I honestly have to wonder how many transsexuals Dr. McHugh has encountered, either before or after surgery. While some do match his descriptions, most of those I know have actually been quite successful in their transformation and are indistinguishable from other women.
Contrary to Dr. McHugh’s claims, many transsexual women show considerable interest in children and many mourn the fact that they will never be able to bear a child. I myself have cried bitter tears over this. And yes, some transsexual women do identify as lesbian—just like women who are not transsexual. Likewise, many transsexual men identify as gay. Such is to be expected if transsexualism is more than just a choice.

The report published by Jon Meyer (and cited authoritatively by Dr. McHugh) was met with considerable skepticism at the time it was published. It was widely criticized for methodological flaws, while other studies have shown that Meyer’s study was incorrect in its conclusions. Nevertheless, it was used by Johns Hopkins as an excuse to shut down its gender identity clinic. I also note that Dr. McHugh mentions the Clarke Institute. The fact is that this agency has a notorious reputation for mistreating transsexual patients, forcing them to meet unreasonable standards, and denying them the hormones needed to modify their bodies.

One wonders why Dr. McHugh would choose such a cruel approach to the treatment of transsexuals. Sex- reassignment surgery has proven to be the only successful treatment for these patients, and yet for some reason he wishes to deny this. He makes a rather clumsy attempt to justify his position by comparing the treatment of adults who are transsexual with the treatment of children who are intersexed. Ironically, the arguments for one contradict the arguments for the other. Children who are intersexed have traditionally been surgically altered in whatever manner is simplest. This has often resulted in a child who has a male brain being given a female body. As Dr. McHugh points out, such a child is tormented by the attempt to force him to live at odds with his natural inclinations. And yet, he cannot find the compassion to provide treatment to those who, for whatever reason, were born male but whose brains were not sexualized as male in the womb. Even though both groups face the same set of problems, Dr. McHugh sets out to protect one group while effectively punishing the other.

Jennifer Usher
San Francisco, California

Further reading

See Professor Lynn Conway's commentary on Paul McHugh.

References:

1. Wise TN, Meyer JK (1980). The border area between transvestism and gender dysphoria: transvestic applicants for sex reassignment. Archives of Sexual Behavior . 1980 Aug;9(4):327-42.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7416946

2. Lothstein LM (1979). Psychological treatment of transsexualism and sexual identity disorders: some recent attempts. Archives of Sexual Behavior . 1979 Sep;8(5):431-44
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=496624

3. Wise TN, Dupkin C, Meyer JK (1981). Partners of distressed transvestites. American Journal of Psychiatry . 1981 Sep;138(9):1221-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7270729

4. Wise TN, Lucas J (1981). Pseudotranssexualism: iatrogenic gender dysphoria. Journal of Homosexuality . 1981 Spring;6(3):61-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7341667

5. American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (DSM III-R).
http://www.amazon.com/exec/obidos/tg/detail/-/0871400499/qid=1094416834/sr=1-1/ref=sr_1_1/002-8778638-7938457?v=glance&s=books

Selected Bibliography

McHugh, Paul and Victoria McKusick. Genes, Brain and Behavior: Association for Research in Nervous and Mental Disease. Raven Press: 1991.

McHugh, Paul and Phillip R. Slavney. The Perspectives of Psychiatry. Johns Hopkins University Press: 1998.

Reading Paul McHugh: Politics, Psychiatry and the Response to Terror. (PDF: requires reader)
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