Paul McHugh is wrong: transitioning is effective (Gender Analysis 10)

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Hi, welcome to Gender Analysis. Every so often, a particular bit of folklore pops up in the media: the claim that transitioning doesn’t actually help to improve transgender people’s health and well-being. News outlets like the Washington Times, the National Review, the Daily Caller, Breitbart, the Christian Post, Fox News, the Wall Street Journal, and even the New York Times have all promoted the idea that these treatments are ineffective for us.

It’s an audacious claim, and you’d expect that it would be supported by some pretty persuasive evidence. Yet in almost all cases, it can ultimately be traced back to two flawed and misinterpreted sources. So where did these claims originate – and why do they get such disproportionate attention?


Paul McHugh and the Johns Hopkins study

Paul McHugh served as the psychiatrist-in-chief of the Johns Hopkins Hospital in Maryland from 1975 to 2001. The hospital ran a Gender Identity Clinic beginning in 1965, and was one of the first major institutions in the United States to provide transition treatments. The clinic was closed in 1979, and McHugh has repeatedly claimed that this was based on evidence showing that transitioning had no effect on trans people’s psychological and social functioning:

We at Johns Hopkins University — which in the 1960s was the first American medical center to venture into “sex-reassignment surgery” — launched a study in the 1970s comparing the outcomes of transgendered people who had the surgery with the outcomes of those who did not. Most of the surgically treated patients described themselves as “satisfied” by the results, but their subsequent psycho-social adjustments were no better than those who didn’t have the surgery. And so at Hopkins we stopped doing sex-reassignment surgery, since producing a “satisfied” but still troubled patient seemed an inadequate reason for surgically amputating normal organs.

McHugh related this story to First Things, the Witherspoon Institute, the Wall Street Journal, and many other outlets which have cited this as proof that transitioning is ultimately unhelpful. Given that many clinics and professional organizations still provide and endorse transition treatments, McHugh’s claims raise serious questions. Have all of these professionals simply ignored the findings of a supposedly revelatory study from decades ago?

The study asserts that surgery made no difference in trans people’s overall social functioning, but it relies on criteria that fail to provide a useful measure of adjustment before and after treatment. In “Sex Reassignment: Follow-up”, the authors construct a single “Adjustment Score” from several measures. Points were added or subtracted from each subject’s score based on their interactions with law enforcement, employment status, intimate relationships, and use of psychiatric services.

Scoring of marriage and cohabitation

Many of the supposedly objective criteria for these measures are in fact based on subjective value judgments. One point is deducted for “nongender-appropriate” cohabitation, and two are deducted for “nongender-appropriate” marriage, while one or two points are added for “gender-appropriate” cohabitation or marriage. The authors explain that “gender-appropriate” would mean a trans woman cohabiting with or marrying a man, and a trans man cohabitating with or marrying a woman. Using this scoring, the authors considered trans people in same-sex relationships to be up to four points less “adjusted” than the others. This isn’t a measure of health – it’s a measure of heterosexuality.

Scoring of psychiatric care

The authors also deduct one point for any “contact” with psychiatric services, two for outpatient treatment, and three for hospitalization. By this measure, seeking psychiatric help is considered indicative of lesser “adjustment”. Current standards of care for transitioning actually emphasize the importance of followup mental health care even for patients who have completed surgery. Receiving this care isn’t inherently negative. This simplified measure also provides no details about any specific diagnoses these patients received, the severity of any symptoms, or the duration of any treatment. For example, this scoring could assign a higher level of adjustment to a person with schizophrenia who saw a psychiatrist once and pursued no further treatment, and a lower level to a person with depression who chose to attend regular therapy sessions.

Scoring of legal troubles

The legal category of the “adjustment score” is similarly vague. One point was deducted for a subject who was arrested, and two were deducted for being arrested and jailed. This measure does not consider the charges involved in an arrest, whether those charges were substantiated, or how long a subject was jailed. This is particularly relevant because trans people are often targeted by the police simply for being trans. During the time this study took place, trans people still faced the threat of arrest under various ordinances prohibiting “crossdressing”, just for presenting as their gender in public. Even today, trans women of color are profiled by police and arrested on charges of prostitution for carrying condoms. Being subjected to transphobic harassment by police says nothing about a trans person’s own health and adjustment, and the scoring fails to account for these scenarios.

Composition of “Adjustment Score”

After the study was published in 1979, it was only a year before other researchers noticed that the method of summing these scores was extremely unclear. A subject receiving the lowest score in all four categories could only have -7 points altogether, yet the ranges presented show that some subjects scored as low as -18. This would require that the four measures were sometimes counted more than once. If this is the case, these categories are even less useful as a measure of adjustment or well-being. For example, a trans woman with a stable long-term marriage to a woman – minus 2 points – would score eight points lower than a trans woman with three shorter marriages to men – plus 6 points. An alcoholic who was arrested three times for public intoxication – minus 3 points – would score lower than a reckless driver who served a prison term for manslaughter – minus 2 points. And marrying someone of the same sex is considered as indicative of maladjustment as going to jail.

That is the basis on which the study’s authors concluded that “Sex reassignment confers no objective advantage in terms of social rehabilitation”. Do their methods seem “objective” to you? This study was fatally flawed even in its own time. But it did accomplish McHugh’s goal:

…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.

McHugh began working at Hopkins two years before the results of this study were first presented while he sought to end their transition services. But despite his stated motives, publications continue to devote column inches to his claim that he closed the clinic on the basis of these findings.


The Karolinska Institute study

A more recent study followed 324 Swedish trans people who had genital surgery between 1973 and 2003 and has been frequently cited as evidence that transitioning doesn’t help. Paul McHugh refers to this study in the Wall Street Journal, claiming “after having the surgery… their suicide mortality rose almost 20-fold above the comparable nontransgender population”, and Richard A. Friedman similarly claims in the New York Times that “transsexuals had 19 times the rate of suicide and about three times the mortality rate compared with controls”.

To say that the subjects’ mortality from suicide “rose” after surgery is not supported by the data, because the study did not compare outcomes among trans people before and after treatment. Trans people who had already received surgery were the only ones studied, and they were compared to a control group of cis people, who don’t experience gender dysphoria and have no need for these treatments. The authors themselves acknowledge this, saying:

…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.

Imagine if a study compared cancer patients receiving a new treatment to healthy controls who did not receive it, and found that the cancer patients were more likely to die than the healthy control group. Would this constitute evidence that the treatment is ineffective?

For the same reason, this study says nothing about how transitioning affects suicide rates, except that this doesn’t reduce its frequency to levels seen among cis people. And even that conclusion is dubious – the study found that “the overall mortality rate was only significantly increased” in subjects who had surgery before 1989, and a higher risk of suicide attempts “was not statistically significant” for those who had surgery after this time. In “How Changeable Is Gender?”, Friedman offers no acknowledgement of these detailed findings, and simply concludes that “the overall outcome with gender reassignment doesn’t look so good”. It’s hard to see what he would recommend based on his cursory interpretation of this study – “don’t be trans” isn’t exactly a realistic treatment option.


Facing the science on transitioning

Why are these two papers so frequently cited on the topic of transitioning and its relation to trans people’s health? They are not the only studies that have ever been conducted on this subject. While these news outlets were busy fawning over two studies that they didn’t even read, they’ve ignored dozens of studies finding that transitioning is associated with an improvement in health and functioning.

  • A study from Belgium in 2006 found that trans people’s rates of suicide attempts dropped from 29.3% before surgery to 5.1% after.
  • Another study of 50 trans women who received genital surgery found that their physical and mental health was not significantly different from samples of cis women.
  • A 2013 study of 433 trans people in Canada found that 27% of those who hadn’t begun transitioning had attempted suicide in the past year, but this dropped to 1% for those who were finished transitioning.
  • And a 2010 meta-analysis of 28 studies showed that 78% of trans people showed an improvement in psychiatric symptoms after transitioning, with a level of psychological functioning similar to the general population and greater than that of untreated trans people.

Several additional studies have since confirmed that hormone treatment for trans people is associated with reduced stress levels, a lower prevalence of depression, less anxiety, a reduction in functional impairments, and a higher quality of life. There is no excuse for using a study from 1979 and missing the entire body of evidence that’s accumulated since then.

Those who cover this topic have a responsibility to do so accurately. Instead, too many of these stories just tell readers what they want to hear. They offer a scientific-sounding excuse to keep believing that the existence of trans people is itself wrong, reducing us to the remnants of a long-debunked medical mistake. The public deserves a fuller understanding of the science of transitioning. More importantly, they need to be prepared to accept that transitioning works. Trans people are real, and the treatments that help us live as our genders are effective, no matter how much this may defy common attitudes. We can look at the science in its totality and see the truth that’s continuing to emerge. Can you?

I’m Zinnia Jones. Thanks for watching, and tune in next time for more Gender Analysis.

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A PDF version of this episode is available.

About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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