Friday, June 13, 2014

Really, Dr. McHugh?

For reasons somewhat beyond my comprehension, the Wall Street Journal has decided to give Dr. Paul McHugh another podium from which to spew his nonsense.  "Transgender Surgery Isn't The Solution" is yet another attempt by McHugh to justify his hostility towards providing transsexuals access to gender reassignment surgery.  

I've taken McHugh's previous writings apart in Debunking Dr. Paul McHugh, but this is a new column, and he's tried to throw a few new angles in.  Unlike most anti-trans writers, McHugh tries to actually use some objective research to support his position ... like a lot of such people, he tries to twist it to suit his ends.
Yet policy makers and the media are doing no favors either to the public or the transgendered by treating their confusions as a right in need of defending rather than as a mental disorder that deserves understanding, treatment and prevention. 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 second is that it can lead to grim psychological outcomes.
For all that many in the Trans* community direct their ire at CAMH's Dr. Zucker, they should be at least somewhat thankful that it was Zucker not McHugh sitting on the DSM V Gender Issues committee.  I fear the results of McHugh being on that board would have been far, far worse.

McHugh's comment about gender dysphoria "not corresponding with physical reality" is interesting.  It is perhaps more revealing of how long he has been out of clinical practice than any actual understanding of things.  The text of the DSM IV recognizes the very objection that McHugh is raising, and explains why his claim is erroneous:  (Note:  I do not have a copy of the DSM V at hand ... yet, so I apologize for using a somewhat older reference)
Insistence by a person with Gender Identity Disorder that he or she is of the other sex is not considered a delusion, because what is invariably meant is that the person feels like a member of the other sex rather than truly believes that he or she is a member of the other sex.
McHugh's second claim seems to be picking up on Walt Heyer's oft-repeated claims of how bad it is to be transgender.  I'll come back to this a bit later in my analysis of McHugh's article.
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.
Referring back to the DSM IV quote above, there is an enormous difference between the degree of awareness involved.  Where a transsexual is usually quite clearly aware of the distinction between reality and their inner world, someone with anorexia does not demonstrate the same sense of clarity and comprehension of reality.

It is not, as McHugh asserts, a "disorder of assumption".  Further, there is a considerable and growing body of evidence that supports the notion that transsexuals actually do have brain structures consistent with their desired gender.   Of course, McHugh has never made any secret of the fact that he had a specific agenda where treatment of transsexuals is concerned.  (He took on the position at Johns Hopkins with the specific intent of shutting down the gender clinic)

But it gets better.
With this argument, advocates for the transgendered have persuaded several states—including California, New Jersey and Massachusetts—to pass laws barring psychiatrists, even with parental permission, from striving to restore natural gender feelings to a transgender minor. That government can intrude into parents' rights to seek help in guiding their children indicates how powerful these advocates have become. 
How to respond? Psychiatrists obviously must challenge the solipsistic concept that what is in the mind cannot be questioned. Disorders of consciousness, after all, represent psychiatry's domain; declaring them off-limits would eliminate the field. Many will recall how, in the 1990s, an accusation of parental sex abuse of children was deemed unquestionable by the solipsists of the "recovered memory" craze.
Of course, what McHugh is referring to is "reparative therapy" - an approach that has been tried with homosexuality for ages, and about the only outcome seems to have been guilt-ridden, traumatized homosexuals who spend the next decade or so of their lives trying to recuperate.  

I cannot dispute the reality that children are naturally going to experiment.  That is normal development.  As various papers have pointed out, there is a dearth of long term research on the outcomes for children who transition early in life.  Given that so many transsexuals very clearly know at early ages (often among their first memories), one would expect that we will know more when the current generation of transsexual children reach adulthood.  While I have concerns about treatment for transgender youth, I do note that the WPATH Standards Of Care is appropriately cautious, recommending that irreversible changes be delayed until the child is old enough to make that decision for themselves.  The WPATH SOC v7 states:

Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success (Gelder & Marks, 1969; Greenson, 1964), particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical. *emphasis added
McHugh's claim that being transsexual is a solipsism similar to the "recovered memory" thing in the early 1990s is questionable indeed.  To make such a claim, McHugh has to fundamentally reject not only the transsexual's personal narrative, but also has to ignore the clarity with which the transsexual is able to articulate the distinction between their inner reality and the physical reality they have lived with.
You won't hear it from those championing transgender equality, but controlled and follow-up studies reveal fundamental problems with this movement. When children who reported transgender feelings were tracked without medical or surgical treatment at both Vanderbilt University and London's Portman Clinic, 70%-80% of them spontaneously lost those feelings. Some 25% did have persisting feelings; what differentiates those individuals remains to be discerned.  That justifies denying treatment to those whose cross-gender identity is persistent how?  Again, this speaks to the wisdom that is subtly embedded in the WPATH SOC v7:

An important difference between gender dysphoric children and adolescents is in the proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood does not inevitably continue into adulthood.5 Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6-23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12- 27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008). 
In contrast, the persistence of gender dysphoria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents who were diagnosed with gender dysphoria and given puberty suppressing hormones, all continued with the actual sex reassignment, beginning with feminizing/masculinizing hormone therapy (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2010). 
Appropriately, the SOC go on to urge caution for partially reversible and irreversible interventions with respect to youth.  Again, I must emphasize that McHugh is being quite deliberate in ignoring not only the body of evidence that WPATH affiliated researchers and others have put together.  This is intellectually and professionally irresponsible on McHugh's part.
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.
I am going to rant here.  McHugh is claiming "victory" of a sort with respect to the appallingly biased research that he used to justify shutting down the program at Johns Hopkins.  What he fails utterly to recognize is that treating someone's transsexuality only addresses that aspect of their lives.  It does not, for example, help them deal with other ongoing psychological issues or the blunt reality of life as a transsexual person.  Discrimination is rampant in society, hostility is pervasive.  These all produce a significant amount of long term distress for clients.

For McHugh to argue that the societal hurdles that transsexuals face justify denying treatment is professionally unacceptable, but it speaks to a degree of maliciousness on his part that I find appalling.  He is failing to recognize the validity of addressing a transsexual patient's distress with respect to their body not because there is a reasonable alternative, but because of the fact that society seems to have problems with the concept.

Fortunately, the Karolinska Institute study is publicly available in full.  Instead of backing up McHugh's position, it actually makes a very reasonable recommendation:

This study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalisations in sex-reassigned transsexual individuals compared to a healthy control population. This highlights that post surgical transsexuals are a risk group that need long-term psychiatric and somatic follow-up. Even though surgery and hormonal therapy alleviates gender dysphoria, it is apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons. Improved care for the transsexual group after the sex reassignment should therefore be considered. *Emphasis Added
McHugh then goes on to try and erase transsexuals by carving out "groups" that he thinks don't deserve treatment at all:
There are subgroups of the transgendered, and for none does "reassignment" seem apt. 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 is a very nasty form of erasure.  McHugh is essentially making diagnostic calls about people that he has never met.  Whether Chelsea Manning is transsexual or not is a discussion between her and her therapist.  Is she motivated by a desire for "less harsh" treatment in prison?  Somehow I doubt it.  I can't imagine a more difficult environment to transition in than a prison.  Much less a male dominated prison.  McHugh's accusations here are cruel and unjustified.
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. 
Wow.  The old "collaborate with madness" routine.  Not surprising.  It was at the heart of his arguments in the 1970s, and apparently he has never let go.  Nobody should undergo GRS (or even HRT) without a full and clear understanding of the limitations of the treatment.  However, the limitations of the treatment are not sufficient reason to deny the intent of that treatment to those who need it.  Does GRS make it possible for a transwoman to become pregnant?  No, but then again, since when did pregnancy define what it is to be a woman?  (Or, for that matter, the ability to make a woman pregnant define manhood)

Fortunately for transsexuals in this world, far more objective research than Paul McHugh's opinions exists and it supports the reality that transsexuals exist, and need appropriate treatment and support.

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