Why the First Hospital to Do Sex-Reassignment Surgeries No Longer Does Them

Greg referenced this article by Paul McHugh (former psychiatrist in chief at Johns Hopkins) on the show Tuesday, and it's worth posting an excerpt here, as well:

[P]olicy 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.

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….

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….

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.

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….

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.

Listen to what Greg had to say here (starts at 1:24:40).

Comments

[WillieR]

Sounds like proponents may have a faulty epistemology.

I wander what Boghosian would say?

[RonH]

There are a number of problems with McHugh's op-ed.

I will start with his abuse of the Swedish study.

The design of the study precludes using it to argue against (or for) SRS.

The control group was taken from the general population; it was not taken from non-SRS trans patients.

So the study has a bearing on how SRS patients do compared to the general population.

The study has NO bearing on how SRS patients do compared the non-SRS trans population.

The authors of the paper recognize this.

Read the 'Conclusions' section of the paper...

Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Clearly, the authors think SRS is good for trans people: it 'alleviates gender dysphoria'.
They don't say why they think this, but it's not because of the results of this study.
Their interpretation of the troubles SRS people have is that surgery isn't enough.

The choice of control group makes the study in capable of supporting a case against(or for) SRS surgery.

Combined with the premise (supported by other evidence) that SRS surgery is good for trans patients, the Swedish study can be used to test whether SRS is sufficient treatment for trans people. The authors conclude it is not.

McHugh abused this study in claiming it was evidence that SRS is bad for trans people.

[Pspruett.wordpress.com]

A "solipsistic concept" indeed. It is a sad and dangerous trend that our desires have come to trump reality, and if the physical world does not conform then it must be the thing to change. Look up "amputee wannabe" to witness one of the extremes of traveling down that road.

When did we stop questioning the integrity of our own minds?

One might say that secularism did this, but a purely material accounting of our selves would suggest that our brains could malfunction just the same as our bodies. I think that it is a cross between the nihilistic idea that there is no particular purpose to life and the hedonistic idea that happiness is the greatest good. The net result is a shallow form of "happiness" that seeks only the myopic gratification of physical and emotional desires. Consequently, it is completely immaterial whether transgender, homosexual, or amputee wannabe urges are pathologies, they are simply desires to be fulfilled in the pursuit of happiness. Even further, the philosophical freedom to pursue it has been elevated, in their mine, to a mystical "right."

The only limitation that those practitioners of this ideology apply is the minimalist ethic of "consent" and "no harm." But that is no hedge against those who happen to have desires that necessarily violate other people's consent and health, e.g., rapists, serial killers, pedophiles. And after all, if some are required to curb their desires then we admit the unflattering conclusion that some desires, no matter how urgent, are psychologically or morally defective.

The homosexual cannibal, Jeffrey Dahmer, sums up the problem nicely: "[I]f a person doesn't think that there is a God to be accountable to, then what’s the point of trying to modify your behavior, to keep it within acceptable ranges, that’s how I thought anyway."

So, next time you tell your child that you "just want them to be happy," make sure they have the proper worldview context through which to lens that statement.

[Phyte On]

Pspruett, very well said.

"One might say that secularism did this, but a purely material accounting of our selves would suggest that our brains could malfunction just the same as our bodies. I think that it is a cross between the nihilistic idea that there is no particular purpose to life and the hedonistic idea that happiness is the greatest good. The net result is a shallow form of "happiness" that seeks only the myopic gratification of physical and emotional desires. Consequently, it is completely immaterial whether transgender, homosexual, or amputee wannabe urges are pathologies, they are simply desires to be fulfilled in the pursuit of happiness. Even further, the philosophical freedom to pursue it has been elevated, in their mine, to a mystical "right"."

I might go a step further and say that the advocates of this LGBTQ world view force others to recognize homosexuality as virtuous. Those who hold to a Biblical (teleological) world view are pathological and must be marginalized to prevent harm to society. We are talking about an inversion of values not just a "right".

[David Fraser]

RonH makes some excellent points. It is discouraging to have to ferret through 'Christian' endeavours to use information propagandistically. The truth ought to be useful enough, without unfairly asserting facts or using them deceptively.

[Pspruett.wordpress.com]

Some have gone further yet to infer that homosexuality is actually an evolutionary leap beyond strict heterosexuality. The new uber-man, so to speak. Perhaps not a common belief, or often admitted one, but it is another idea that leading edge advocates are acting upon. And, after all, it's not the moderates of any given movement, that just want to be left alone to their private lives, who drive the train, is it?

[JulianH]

McHugh's citation of the Swedish study is accurate because the (mistaken) argument is being made by policy makers and media that the transgender condition should be given the same right as everyone else. That is, the right to have one's body match the gender identity of their mind.

I say it's mistaken because it seems to me that the body has a gender and the mind does not...

But if we allow their argument and say the transgender will be better off should their body match what they feel in their mind, the study shows they will be left disproportionately higher to harmful tendencies than every one else and that therefore this should not be an adequate treatment to be argued for or protected.

[RonH]

JulianH,

McHugh says the Swedish study (like the earlier JHU study* he mentions but doesn't clearly identify) is evidence of 'grim psychological outcomes' for SRS patients.

Based on the Swedish study, he claims SRS hurts patients.

Like I said above, the Swedish study simply cannot be used as evidence for that claim.

It wasn't designed to address the question: Does SRS surgery help/hurt patients?

The problem is that the Swedish study compares SRS patients to the general population. So it can be used to see how the SRS patients are doing relative to the general population - not relative to that non-SRS trans population.

A study designed something like the following could show that SRS hurts/helps patients.

Select 2 large groups of persons with gender dysphoria.
Make sure the 2 groups match each other as well as possible.
Same age distribution.
Same level of dysphoria.
Same health.
Same family history.
Same level of support network.
Same everything - as well as you can do.

Give one group SRS.

Now collect data on the two groups over time.
How long do they live?
How happy are they?
How healthy are they?
Etc.

Now you have a data that can be given in answer to the question: Does SRS surgery help/hurt patients?

RonH

*I think the JHU article is this one by Meyer mentioned here.

That JHU newsletter is well worth reading.

I haven't got the Meyer article yet.
So I don't know if IT might be useful for answering the question: Does SRS surgery help/hurt patients?

The abstract says there were two groups of 'SRS applicants'.
One group of 29 had surgery - according to the newsletter.
The other group of 21 did not.
These are NOT large groups for a medical study. That's strike one.

If I can get my hands on the paper, I will comment on whether the two groups were matched and maybe on other things.

The JHU newsletter also mentions another study McHugh doesn't mention in his op-ed.

Meyer’s study came after a study conducted by Money, which concluded that all but one out of 24 patients were sure that they had made the right decision, 12 had improved their occupational status and 10 had married for the first time. Beyer believes that officials at Hopkins just wanted an excuse to end the program, so they cited Meyer’s study.

[brianehunt]

Unfortunately RonH is relying on the "spin", I mean interpretation, of the authors of the study.

This is how the authors interpret their data: "Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group."

The data are data. They don't suggest anything. The authors should say that "we interpret the data…" To interpret these data in the particular manner these author's did one must assume that sex reassignment surgery is one step on the path to full recovery from transsexualism. It's based on an assumption that comes from one's world view. It's a bias. It may be accurate, or it may not be accurate.

What I do applaud RonH on is that he is willing to look at these data, from an imperfect study design, along with other data from imperfect study designs, and attempt to see if they seem to reflect a coherent biological and psychological reality.

Lastly, Ron, can you stop making statements like "these are not large groups for a medical study". That is an opinion, and you're welcome to yours. But you write as if you are declaring a truth. If you are going to criticize scientific research, then do it with some sophistication and accuracy, such as providing power calculation to back up your claims regarding sample sizes.

[RonH]

brianehunt,

Let me clarify.

The design of the study compared SRS patients to the general population (not non-SRS trans patients).

The study didn't collect data that would allow comparison between SRS patients and non-SRS trans patients.

You cannot report what you did not measure.

If you read the comments at the end of the JHU news letter, you will find one of the authors making this exact point.

The study was not designed to answer the question if gender confirming surgery imposed specific risks or benefits. Therefore the findings cannot be to argue for or against endocrine or surgical treatment.

She also says something that might make the point easier to grasp.

As pointed out earlier, the same type of outcome are observed for other diseases and no one would argue against treatment of cancer, diabetes or bipolar disorder; all demonstrate an increased overall mortality.

Would you argue against treatment of cancer because those treated didn't do as well as the general population?

That's the main evidence I offer in support of my argument.

I only mentioned the interpretation given by the Swedish study's authors to show that they don't make the same mistake McHugh made.

Yes, it's my opinion that the Meyer study was not large.

What do you think? Was it large?

RonH

[RonH]

brianehunt,

The Meyer study - the one I opine was not large - was not a controlled study.

The group that was compared to the SRS patients

had not met the criterion of a trial period and could not be considered for surgery

They were, by the study's own standards, different from the SRS patients in ways other than not having had SRS.

In the words of the Meyer the comparison group was

While not a rigorous control group, the provided the only available approximation to it.

What do you think of that?

RonH

[WisdomLover]

What the study found is that 10 people who'd undergone surgery out of 300+ died from suicide, 29 tried to commit suicide.

In comparison, 5 people of 3000+ in the general population died of suicide and 65 of 3000+ tried.

So the rate of suicide and attempted suicide is over 20x higher among those who underwent surgery vs. normal people.

That may not tell us what the rate would be for people who are gender-confused, but don't get surgery, but the suicide rate for terminally ill cancer patients is only about 2x that of normal people.

I think that works out to say that you're about 10x more likely to commit suicide if you are gender-confused and get surgically altered than if you are suffering from terminal cancer.

(Let the quibbling begin...)

So however effective surgery is for the gender-confused, it's kind of a joke as 'treatment', or would be if it weren't so tragic. Maybe we don't know whether the surgery makes things better or worse, but we do know it doesn't make things go from bad to good.

[LarryFarlow]

We can quibble over the study all day long but this is the bottom line:

"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."

We don't need a "study" to grasp this. A man with an amputated penis still has both X and Y chromosomes.

As the author points out, this is a failure to accept reality. It's no different than a man who believes he's Napoleon - only in that case we don't force people to conform to his distorted view by sending people to diversity training who refuse to call him "your majesty."

[RonH]

Look at the title of the OP.

Read the OP.

And read McHugh's op-ed.

And listen to Greg.

All claim that the science McHugh refers to confirms what Greg, Amy, and McHugh all believe about SRS for other reasons.

Answering that claim is not quibbling.

[Amy]

Ron, McHugh is clear about what the study was about: "Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population." There's nothing hidden here, so I'm not sure why you think you're revealing something.

He's also clear about why they stopped doing the surgery at Johns Hopkins: "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." Right there, he's saying the patient was "satisfied" (which could very well be more satisfaction than a non-transgendered person who didn't have surgery), and yet the still-poor results were enough to convince the hospital that surgery was not the way to go.

In other words, the fact remains that even after surgery, the results are not good enough to justify "amputating normal organs" (even if those patients are better in some degree than those who didn't have surgery—the bad results make that irrelevant to Johns Hopkins). So the comparison he is commenting on here is indeed between surgical patients and the "nontransgender population." And surgery does not achieve acceptable results.

His conclusion is merely that surgery is not the answer, and trusting in it as the answer is resulting in a shocking number of suicides later in life. Perhaps the non-surgical patients also have a rise in suicide later in life, but that's not the issue. The point is that treating surgery as the solution results in an unacceptably-high-suicide outcome, which indicates that it's not the right treatment.

Johns Hopkins is not exactly a hotbed of Christian activism. I have no reason to believe they did not truly think that this surgery wasn't a good idea for transgendered people because it didn't achieve acceptable results.

[RonH]

Amy,

What can and cannot be argued based upon the results of a scientific study is, in part, determined when the study is designed.

Doing the study may get you, depending on the results, Premise A, Premise B, or Premise C.

Then, you can use A, B, or C in any argument you want.

But once the design is done, the results, the numbers collected, however they strike you, can't produce some other premise, D.

The Swedish study can't serve as evidence that surgery is bad for patients because it was not designed in a way that could produce a useful premise in any such argument. No matter what results had come out of the Swedish study, it could never have been used that way.

Johns Hopkins is not exactly a hotbed of Christian activism.

Certainly not.

Here's a Hopkins web site indicating that Hopkins friendly to trans people and friendly to SRS. Nobody performs SRS at JHU. But JHU people refer patients elsewhere for it. I'm sure not everyone at JHU agrees. Nor did everyone agree with McHugh when JHU stopped doing SRS.)

I have no reason to believe they did not truly think that this surgery wasn't a good idea for transgendered people because it didn't achieve acceptable results.

I'll give you a reason to think, at least, that 'they' had other reasons as well.

First of all, 'they' is McHugh and his allies not JHU as a whole. McHugh had opposition.

McHugh quotes the (2011) Swedish study.

He quotes the Meyer (1979) study.

But, elsewhere he writes

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.

McHugh intended to 'help end' SRS surgery at Hopkins when he arrived in 1975 - four years before Meyer's study. Elsewhere he says he considered the surgery a 'misdirection of psychiatry'.

Why?

McHugh thinks that there is some bad cultural trend that ties together the closing of state psychiatric hospitals and SRS.

I think McHugh's mind was made up in 1975. Ignoring other studies, he used Meyer's study for ammunition and he acted.
-------------------------------
Y'all seem to think this is easy.

Suppose the brains of MTF transexuals turned out to have brains with female features?

[WisdomLover]

Y'all seem to think this is easy.

Suppose the brains of MTF transexuals turned out to have brains with female features?

Well, it is easy.

That doesn't mean that those foolish enough to disbelieve in God won't credulously say just about anything on this or any subject.

And as long as we're supposing things that there's no evidence for, suppose each cell is etched with the words "This is God speaking, I disapprove of mutilating men so that they can pretend to be women."

Then what?