In which Dr Paul McHugh's 2004 article
Surgical Sex is rebutted by.... Dr Paul McHugh's 2004 article
Surgical Sex.
Why did Johns Hopkins stop performing sex reassignment surgery? The obvious reason is that their surgeon left, and wasn't replaced. They now refer patients to other surgeons after assessing suitability. The surgery is now no longer a "research" effort, but part of mainstream medical practice.
But there's more to it than that.
From McHugh's work,
Psychiatric Misadventures :
I happen to know about this (sex-reassignment surgery) 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.
Verdict first, trial afterwards.
The Meyer study McHugh commissioned in support of his pre-determined aim, and used as the primary evidential basis for the conclusions in
Surgical Sex was, well, it has figures on a scale of -8 to 5 with values of 19. For a scathing critique of just some of the more obvious nonsense that means it should never have passed even the most cursory peer review, due to the ridiculous figures in it, see
Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991 Friedemann Pfäfflin, Astrid Junge (Translated from German into American English by Roberta B. Jacobson and Alf B. Meier),
specifically
Chapter 3: Follow-up studies in chronological order :
Meyer & Reter, 1979 Dept. of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
"The tables and figures shared by the authors do not seem serious because after the scoring table a maximum of only eight minus and five plus
points can be achieved, but in the results table (p. 1014) a range from -18 to +19 points is given. How these figures came about remains totally
in the dark....One asks the question how it came about that a renowned professional publication published such opaque figure material."
Junk Science from the "Dark Age of Psychiatry".
McHugh adduces in support of his secondary thesis, that genes determine sexual identity, an article by Reiner,
Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth by Reiner and Gearhart,
N Engl J Med. 2004 January 22; 350(4): 333–341.
McHugh writes:
"Reiner concluded from this work that the sexual identity followed the genetic constitution. "
Reiner did no such thing. He stated that sexual identity followed the hormonally-directed path in foetu.
1
in 300 men aren't 46,XY, they do not have a "male" genetic
constitution (as McHugh puts it). Some women do. Genes are only important in that they
*usually* (not always) cause a specific hormonal environment in the
womb.
It's
important to make the distinction because hormonal environment during
pregnancy can change, resulting in mixed anatomy, part female, part
male. It can also be completely out of synch with "genetic
constitution", resulting in XY females and XX males.
This
explains the situation, and why McHugh's claim that "genetic
constitution" dictates "sex identity" is very obviously a
misinterpretation of the evidence.
Sexual Hormones and the Brain: An Essential Alliance for Sexual Identity and Sexual Orientation Garcia-Falgueras A, Swaab DF Endocr Dev. 2010;17:22-35
The
fetal brain develops during the intrauterine period in the male
direction through a direct action of testosterone on the developing
nerve cells, or in the female direction through the absence of this
hormone surge. In this way, our gender identity (the conviction of
belonging to the male or female gender) and sexual orientation are
programmed or organized into our brain structures when we are still in
the womb. However, since sexual differentiation of the genitals takes
place in the first two months of pregnancy and sexual differentiation of
the brain starts in the second half of pregnancy, these two processes
can be influenced independently, which may result in extreme cases in
trans-sexuality. This also means that in the event of ambiguous sex at
birth, the degree of masculinization of the genitals may not reflect the
degree of masculinization of the brain. There is no indication that
social environment after birth has an effect on gender identity or
sexual orientation.
Note that McHugh got it partly right -
"Male hormones sexualize the brain and the mind."
Correct!
"Having
looked at the Reiner and Meyer studies, we in the Johns Hopkins
Psychiatry Department eventually concluded that human sexual identity is
mostly built into our constitution by the genes we inherit ..."
WRONG - this contradicts the previous statement, that it's hormonal environment that's the issue
" ... and the embryogenesis we undergo."
Correct again.
Moving
outside the field of psychiatry, let's look at physical anatomy. If
embryogenesis and hormonal environment rather than "genetic
constitution" is key, if "male hormones (in the womb) sexualise the
brain and the mind" as McHugh says, then there has to be physical,
objectively measurable evidence of this.
If
genetic constitution is key - as McHugh also says, contradicting
himself, it is impossible for "genetic males" to have female brain
structures.
If
hormonal environment is key, then we'd observe female brain structures
in all those with a female sex identity, and only those with a female
sex identity, regardless of genetic constitution.
The experiment to determine which is correct is simple.
A sex difference in the human brain and its relation to transsexuality. by Zhou et al
Nature (1995) 378:68–70.
Our study is the first to show a female brain structure in genetically male transsexuals and supports the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones
Note the date. 1995. Twenty years ago. Nine years before McHugh's article.
In terms of what this means for patients.... here's McHugh again.
"Proper
care, including good parenting, means helping the child through the
medical and social difficulties presented by the genital anatomy....
This effort must continue to the point where the child can see the
problem of a life role more clearly as a sexually differentiated
individual emerges from within. Then as the young person gains a sense
of responsibility for the result, he or she can be helped through any
surgical constructions that are desired. Genuine informed consent
derives only from the person who is going to live with the outcome and
cannot rest upon the decisions of others who believe they “know best.”
ABSOLUTELY!
This applies to both Transsexual and Intersex children. Those who
believe they "know best" because of religious conviction or whatever
should not be allowed to mandate un-necessary treatment, or prevent
necessary treatment. Moreover, as sexual identity is based on biology, and biology is anything but a strict binary, the sexual differentiation may not be binary either. Some will be most comfortable conforming to a binary model, while others will find that model neither comfortable nor appropriate. Similarly, surgical options should be offered, but never required. The patient may be fine with having unusual genitalia - their body, their choice.
Back to McHugh again...
"
I have learned from the experience that the toughest challenge is
trying to gain agreement to seek empirical evidence for opinions about
sex and sexual behavior, even when the opinions seem on their face
unreasonable. One might expect that those who claim that sexual identity
has no biological or physical basis would bring forth more evidence to
persuade others. But as I’ve learned, there is a deep prejudice in favor
of the idea that nature is totally malleable. "
Again, completely agree in all respects. The problem is that McHugh states that
- Sexual Identity results from hormonal factors (true)
- Sexual Identity instead results from "genetic constitution" (false)
and also
- Sexual Identity always without exception results from biological factors (true)
- Sexual Identity in Transsexuals is a "mental illness" with no physical basis (false)
Bottom line:
Male–to–female transsexuals have female neuron numbers in a limbic nucleus. Kruiver et al
J Clin Endocrinol Metab (2000) 85:2034–2041
"The
present findings of somatostatin neuronal sex differences in the BSTc
and its sex reversal in the transsexual brain clearly support the
paradigm that in transsexuals sexual differentiation of the brain and
genitals may go into opposite directions"
