Paul McHugh and the Johns Hopkins gender clinic: The perils of cherry-picking (More Trans, module 2-1)

More Trans is an ongoing Gender Analysis project to apply the philosophical insights of Less Wrong to transgender topics.

Previously: Paul McHugh is wrong: transitioning is effective

How many times have you heard some variation of this statement?

‘Sex reassignment doesn’t improve the lives of transgender people. At Johns Hopkins Hospital in the 1970s, chief psychiatrist Paul McHugh studied the outcomes of trans people after they transitioned. McHugh, a leader in the field of psychiatry, decided to close the gender clinic after studies found that transitioning didn’t help their patients become any healthier or more functional.’

As a trans person, I’ve heard this thousands of times. It’s a remarkably enduring claim that’s very frequently repeated by transphobes, who appear to believe that this conclusively refutes any justification for medical transition. The story has a number of features that have helped it persist for decades: perceived authority of recognizable institutions, specific details such as names and years, an assertion that this is based on scientific evidence, and some actual connection to the truth no matter how thin or tenuous. All of these aspects combine to make this claim appear to be legitimate, and many people find it very persuasive.

But how many times have you heard a statement such as this one (which, by the way, is completely accurate)?

‘In 2016, officials at Johns Hopkins announced that they would resume providing surgery to transgender patients, which they consider appropriate, evidence-based, and a best practice. In response to recent controversy over Paul McHugh’s claims, they clarified that individuals such as McHugh “do not speak on behalf of the institution”.’

Well, that should settle it. Johns Hopkins has decided to begin providing transition treatments again, on the basis of their careful examination of the evidence. That means transition works. Right?

It is so tempting to say this to every transphobe who has ever told me their thoughts on Johns Hopkins and Paul McHugh. But something feels wrong about this – and it should. What is that feeling?

It’s when you start to question whether the evidence base and efficacy of transition really does depend entirely on if this one particular hospital offers these treatments at any given time. Obviously it does not – this isn’t a convincing argument at all. Transphobes cherish their Johns Hopkins factoid because most have little or no familiarity with any transition-related literature or studies that have been published in the following decades. In reality, the evidence that medical transition significantly improves trans people’s health is overwhelming and has been replicated in dozens of rigorous studies spanning decades – and most of the population is entirely unaware of this.

The average person doesn’t read many books about transness, if any at all. They almost never bother to seek out and read academic papers that provide actual evidence regarding transition. In that vacuum of knowledge, a well-known name such as Johns Hopkins stands out as a decisive authority. To them, Hopkins is a reputable institution that can generally be trusted to offer reliable medical expertise, and if Johns Hopkins says transition doesn’t work, then transition doesn’t work.

Clearly, there are some deficiencies that come with just stopping at that point. Transphobes generally get the broad strokes right: Johns Hopkins had a gender clinic that performed transition procedures in the 1970s; at least one study was conducted on their trans patients during this time; Paul McHugh was the chief psychiatrist and cited the study’s results in his decision to close the gender clinic.

But that’s pretty much all they get right. If we ask them for details of how the study was conducted or what its quantifiable results were, they likely won’t be able to tell us. If we were to ask them the title of the study or the names of its authors, they generally wouldn’t even know that. That’s a problem, because these details are extremely relevant to the claims they’re making.

As it turns out, the study of patient outcomes used an entirely new scoring system that had never been validated. This measure was straightforwardly homophobic: same-sex relationships deducted from a patient’s score and were considered indicative of poor adjustment (Meyer & Reter, 1979). Receiving psychiatric care would also deduct from a patient’s score of well-being, despite the fact that routine counseling is now considered advisable throughout the process of transitioning (Coleman et al., 2011), and has been for decades. These measures appear to be simply arbitrary and almost wholly unexplained. The tabulation of these scores into a single overall measure was so confusing and unclear that this was already pointed out in literature just a year after the Johns Hopkins study was published (Fleming, Steinman, & Bocknek, 1980). Overall, the methodology of the legendary Johns Hopkins study is clearly a complete joke, and its findings are not reliable or useful in any sense.

Oh, and Paul McHugh later admitted in print that he took over the gender clinic with the intention of closing it – years before the study that supposedly justified this decision (McHugh, 1992).

Unfortunately, transphobes typically don’t know any of that. McHugh himself refrains – wisely – from discussing the study in any meaningful detail, and instead prefers general statements about whether these patients were “better” or “worse” after transitioning. That’s the extent of what a transphobic audience is learning from such a distorted and incomplete recounting of what happened at Johns Hopkins.

This is not serving them well. They are learning what is essentially a myth as if it were fact, and this is often all they know about the science surrounding this topic. The problem with hitching your supposedly “scientific” arguments to such a limited example as Johns Hopkins is that this can easily come back to bite you. As of October 2016, Johns Hopkins has indeed planned to resume performing transition surgeries on the basis of medical evidence. They’ve also strongly indicated that they disavow McHugh’s recent anti-trans, anti-gay publication in a religious conservative journal.

So what happens for those who espouse the transphobic Johns Hopkins/Paul McHugh argument when not even Hopkins can support this anymore? If they consider Johns Hopkins to be authoritative, does that authority still hold when Hopkins declares that transition works? If they consider McHugh to be an authority, does that authority still hold when he contradicts Hopkins on transition care?

Transphobes might begin to see something amiss with their argument once it’s turned against them by Johns Hopkins itself – but they should have seen these flaws much earlier. On what basis do you make the choice to believe Hopkins or believe McHugh? If you lack the necessary familiarity with the evidence to make that decision, why would you think you knew enough about the evidence to side with either of them in the first place?

A genuine interest in scientific evidence will lead a person to seek out research beyond the vague assertions of a fringe psychiatrist who cites unreliable data to support a conclusion he’d already decided upon. That research is not even especially difficult to find. It’s telling that most transphobes do not do this – even the flaws in the single study they typically cite are almost always news to them. For those who rely so heavily on Paul McHugh, this is clearly not a matter of evidence at all, but of the perceived authority that they’ve deliberately chosen to believe. Resolving the conflicts that arise from reliance on perceived authority alone requires the insight that much more is needed here – and that an arbitrary choice of authority is entirely inadequate for this purpose. ■

References

• Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232.
• Fleming, M., Steinman, C., & Bocknek, G. (1980). Methodological problems in assessing sex-reassignment surgery: a reply to Meyer and Reter. Archives of Sexual Behavior, 9(5), 451–456.
• McHugh, P. (1992). Psychiatric misadventures. The American Scholar, 61(4), 497–510.
• Meyer, J. K., & Reter, D. J. (1979). Sex reassignment: follow-up. Archives of General Psychiatry, 36(9), 1010–1015.