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Nearly two years ago, I wrote a rebuttal to a Wall Street Journal Op Ed piece by Dr. Paul McHugh. It continues to be one of the most frequent search items and reads on my site. About two weeks ago, someone supportive of Dr. McHugh posted a comment worthy of reply. And reply I have!

Here is the unedited comment. The link to my original post is contained in the first line:

Marshall commented on My rebuttal to Dr. Paul McHugh’s Wall Street Journal Op Ed

On June 12, 2014, an Op Ed article by Dr. Paul McHugh was highly critical of the prevailing trends in the treatment protocols …

You say: …”why 25% of those tracked in the Vanderbilt and Portman studies would persist in having transgender ‘feelings’. Could it be that the subjects know who they are?”

It’s far more likely that, as with other psychiatric conditions like Anorexia, the “feelings” are simply wrong. There’s no reason to believe transgender is different from the numerous other conditions whose root symptom is the same: a mental rejection of the physical reality. This is a huge problem for the “transgender as identity” movement and why it relies on emotion-based justifications like the one you make that the earnestness and “realness” of the transgender “identity” separates it from other delusional conditions. Yet patents with other conditions like BDD and schizophrenia are just as convinced that their perception is absolutely real. Transgender has no corner on realness.

Moreover, the thought that someone can actually know what the other gender feels like makes no more sense than someone knowing what another species feels like because you can’t experience something you aren’t. Whatever experience there is is entirely the result of BEING that thing, not imagining it.

Whether SRS is better than psychotherapy or hormone therapy or a combination… science just doesn’t have enough data for consensus, but again – when transgender is viewed in the light of similar delusional conditions, the idea of altering the physical body to fit the mental perception is dangerous. You wouldn’t indulge an Anorexic by administering liposuction. SRS has severe drawbacks and potential complications and is the only treatment that’s essentially irreversible. Science doesn’t yet have a cure for transexual – there may not even be one – we just don’t know. But the lack of a cure doesn’t mean SRS is the best treatment, nor that those who recommend against it like Dr. McHugh are out to get transexuals. Someone truly interested in helping transexuals accepts the science over the emotion.

paul-mchughFinally, brain studies do nothing to refute the fact that gender is purely a biological construct. Schizophrenics, Anorexics and people with BDD all have have been shown to have brain abnormalities which, while potentially valuable in assisting treatment, don’t substantiate the reality of their delusions.

And here is my reply:

Hi Marshall,

First of all, your comparison of transgender to anorexia (or the more general BDD) shows how little you understand the nature of transgender.  No matter how thin anorexics become, even to the point of skin and bones, they remain obsessed with losing weight.  Many will continue to see themselves as overweight even when dangerously underweight.

Transgender people, on the other hand, are all too aware of the reality of our bodies. Some of us may loathe them, but we acknowledge them.  Often, we go the opposite direction and enhance the features of the gender assigned at birth in an effort to cure.  For example, an MTF will grow facial hair and/or develop a muscular, athletic build.  That is totally opposite what an anorexic would do.  It is totally opposite what your assertion would predict.

We are under no delusion as to what our faces look like, how much hair we have, what our breasts look like and what our genitalia is comprised of.  That knowledge is very real and accurate.  And whatever each one of us chooses to do, we do it knowing that the physical transformation isn’t perfect.  But it almost always helps. 

What we attempt to do is deny our mental reality, not our physical one.  But if we live long enough, that attempt will inevitably be in vain.  Furthermore, once we reach the point where we begin physical transformation to our innate gender identity, it is a rare case when we don’t reach a point of relative satisfaction.  Yes, we have the common human trait of wanting to look attractive to others.  But obsession with continually becoming more feminine (in the case of an MTF) or more masculine (in the case of an FTM) is rare and it isn’t a trait confined to transgender people.  We have certainly read of cisgender people who undergo surgery after surgery to look like Barbie or Ken or their favorite movie star.

Transgender isn’t so much a matter of our body being wrong, but our conviction that our minds are right.  Yes, we transform for our own sense of what we want to look like.  But just as much, we transform so that others will identify us consistent with the person we are inside.  It isn’t enough that I know that I am female. I want others to see me as female, too.  Fortunately for me, that seems to be how everyone sees me.

In my case, I was in denial of how feminine (or at least androgynous) I was in appearance.   As to how attractive I am, others may judge (my Links page has a link to my Flickr page).  But when I tell people that one of my reasons why I waited so long to transition was concern that I couldn’t look female enough, most of them are incredulous.

I also find your argument on this point somewhat disingenuous.  First of all, if we didn’t transform physically at all (at least in our presentation), the authenticity of our gender identity would be severely questioned.  Second, many people in our culture are unhappy with their appearance and go to various lengths to do something about it: everything from diet and exercise, to body sculpting and body building to plastic surgery to supplements (ranging from the mild to the extreme).  When people do these things in a healthy way, there is nothing wrong with it.  When it becomes an obsession or is taken to an extreme, then there is indication of a psychological issue.  Similarly, some obsessive people may be transgender, but most transgender people are not obsessive about appearance.

To compare transgender brains with schizophrenic brains, as you then proceed to do, is not only disingenuous, it is insulting.  The brain abnormalities in schizophrenics include significantly lower amounts (up to 25% less) of gray matter, particularly in the temporal or frontal lobes, and significantly lower levels of activation in the middle frontal cortex and the inferior parietal cortex compared to mentally healthy people.  It is these abnormal deficiencies that cause the problems that schizophrenics have with hallucinations and dealing with reality.

On the other hand, the so-called abnormality of transgender brains is that various studies have shown that transgender people tend to have brains more like their innate gender than their gender assigned at birth.  But these brains all lie within a male-female spectrum.  So unless you are claiming that either male brains or female brains are somehow deficient or diseased in and of themselves, your argument doesn’t bear up to scrutiny.

You state that it is not possible for someone of one gender to know what the other gender feels.  On face value, I can accept that statement for the sake of discussion. But then you take it someplace beyond facts in evidence.  You have made the assumption that every person’s gender identity must automatically be consistent with their genital anatomy, and that anything else is “wrong”.  What is this based on?  How do you propose to prove this to be so? 

You are aware, are you not, that the brain and the genitalia are differentiated at different stages of fetal development?  Why is it so difficult to conceive of the possibility that in a small percentage of cases, the baby received predominantly testosterone at one of those stages and predominantly estrogen at another?  And if anatomy automatically determines gender identity, then what gender are Intersex people?  Are they automatically non-binary?  Some are and some aren’t.  Are they automatically consistent with the predominant characteristics?  Some are and some aren’t.  What about people who have both XX and XY?  What about people who have neither?  What do you do with people who suffer from various hormone based syndromes?  The bottom line is this: how can you judge the wrongness of someone’s gender identity without knowing either their physical or mental situation?

True, I have no idea what the other gender feels like.  That “other gender” for me is the male gender.  By virtue of having spent a great deal of time in men’s only spaces (athletic team locker rooms, college dorms, men’s ministry meetings, men’s bathrooms), I have a pretty good idea of what men are likely to do.  But I have little clue as to why they do things the way they do and how it feels for them when they do it.  I generally felt like an interloper at men only gatherings, but I am now right at home in women’s Bible study or women’s only social gatherings. 

Now as far as your statement about lack of evidence: seriously?  I can easily find at least hundreds of people who transitioned to live a successful, satisfying life in their innate gender.  Undoubtedly many more are successfully living post-transition out of the public eye.  And in the 2011 Karolinska Institute study that Dr. McHugh misconstrues, he blithely ignored the preponderance of patient satisfaction with the results of transition that includes surgery.  Isn’t that one of the goals of treatment, that the patients are satisfied with the results?  Furthermore, he totally ignored the Institute’s conclusion: inadequate follow up care for post-GCS transgender patients impedes progress in their post-operative mental and emotional health.

Meanwhile, where is the parade of transgender people who have been “cured” by methods espoused by Dr. McHugh?  Surgery as a possible treatment for transgender people is no more than 85 years old and extremely rare until 50 years ago.  For the vast majority of that time, most mental health professionals were treating transgender patients in the general manner endorsed by Dr. McHugh: psychotherapy and pharmacology to attempt to rid the patient of their transgenderism.  And there are still doctors using these methods.  Where are there success stories?  Surely they aren’t all in stealth mode.  There should be thousands more than those reported by those who transition to their innate gender.  Their absence shows that there was no significant success with these methods when they were the mainstream practice and there is no significant success with these methods now.

For a moment, let’s imagine we are talking cancer rather than transgender.  If faced with two possible treatments, one with a success rate comparable to those who physically transform in some way, shape or form, the other with a success rate comparable to methods espoused by McHugh and others who still follow that methodology, you would be a fool not to choose or recommend the first method in a heartbeat.  And I will tell you unequivocally that if social stigma against transgender people was a thing of the past, that success rate would soar much higher.

We now have two studies, one in Ontario and the other in the State of Washington, that show a high correlation of life success for transitioning youth with a high degree of parental support.  If transgender were merely a delusion, should such a correlation exist?  In fact, shouldn’t supporting a delusion be more harmful?  That’s what you and McHugh are claiming, no?

And we now have a better grasp of why many gender variant youths revert back to their birth-assigned gender.  Those who are exploring and experimenting with gender roles before puberty overwhelmingly tend to revert.  But those who prior to puberty know with confidence that their innate gender identity is incongruent with their genitalia overwhelmingly tend to persist in their transgender identity for life.  But when you lump the two groups together to get a larger sample size, it gives the erroneous impression that most transgender children revert and that there is no predictor of which children will persist.  The experimenters and explorers should not be considered part of the transgender population.

I can accept that gender is purely a biological construct: once we factor in that the human brain is an organ and biological part of the human body.  In fact, it could be reasonably argued that the brain to be the most significant sexual organ in the body.  Where do attraction, desire and arousal begin, in the genitals or in the brain?

Furthermore, if transgender gender identities were so “wrong” and “delusional”, then one could not expect to find very many successful post-transitional transgender people, certainly few who could handle careers that call for mental acuity.  And yet there are many transgender people who are college professors in both the arts and sciences, many who have high level positions (and some with PhD’s) in STEM fields, high ranking military officers, airplane pilots, financial professionals, salespeople, successful entrepreneurs, high ranking government officials, attorneys, medical doctors, architects, and the list goes on.  (My professional and personal accomplishments were mentioned in my original blog post about Dr. McHugh’s Op Ed, and can also be found on my LinkedIn page.)  Considering the discrimination that most of us faced during and after transition, this is a remarkable list.

Marshall, you keep going back to basing gender identity on feelings rather than knowledge.  So how do you know your gender identity?  (For the sake of the post, I am going to assume that Marshall is male name with apologies if I have misgendered Marshall.  I ask that when this section is read, the reader substitute the appropriate gender term for their situation.)  Do you feel male?  How do you know that is the way males feel in general?  Do you have discussions with other males at the golf course, bar, office, locker room or men’s organization meeting?  (I am trying to picture that discussion!  I’ve been in those types of situations many times and never once did I witness such a discussion.)

Or do you assume this is how males feel because of what you see when you look between your legs and because your parents, teachers, etc. told you that you are a boy and you blindly accepted it?  Or perhaps you answered a series of questions as part of a test (if such a test exists) to accurately assess your gender and it came out “male”.  If such a test existed, I took it and it came out “female” would you then accept my female gender identity as genuine?

Well, I can offer a test: the real life test.  I have been presenting as the female that I know myself to be for a little over 3½ years now.  I have dealt with four distinct test groups: those who knew me before transition; those who I met after transition to whom I have come out; those who only know me as Lois to whom I have not come out; strangers in public.

The vast majority (sometimes 100%) of every one of these groups see me as female.  I have had no negative moments from strangers.  People who have been willing to stay in my life accept me as female, although some had to overcome their prejudices first.  About 30 people who I have come out to in my new church accept me as female, as well as the dozens more who I have not come out to.  More than physical characteristics are involved here, although they help.  But it is also mannerisms, speech patterns, body language, fashion sense, comportment and a host of little things that clue a person as to whether they are dealing with someone male or female.  I am successful and happy over an extended time period.

Even more important, mentally living as a female is authentic and relatively effortless compared to having tried to act like a guy for decades.  For the most part I pulled off the charade and no one ever accused me of being effeminate.  But inside, it was often a struggle to be something I’m not.

In my previous blog post, I never accused Dr. McHugh of being out to get transsexuals or transgender people.  What I accuse him of is having an agenda, for whatever his reason, and that it leads to bad science.  A neutral scientist will seek to test a hypothesis by designing an experiment or study that is as unbiased as possible to come up with a valid result and then having it peer reviewed.  McHugh is on record as having sought his position at Johns Hopkins in part so that he could shut down the Gender Identity Clinic.  He promoted a study that would produce the desired result. 

I now quote from the Johns Hopkins News-Letter, a story written by Rachel Witkin on May 1, 2014:

In 1979, SBCU [Sexual Behaviors Consultation Unit] Chair Jon Meyer conducted a study comparing 29 patients who had the surgery and 21 who didn’t, and concluded that those who had the surgery were not more adjusted to society than those who did not have the surgery. Meyer told The New York Times in 1979: “My personal feeling is that surgery is not proper treatment for a psychiatric disorder, and it’s clear to me that these patients have severe psychological problems that don’t go away following surgery.”

After Meyer’s study was published, Paul McHugh, the Psychiatrist-in-Chief at Hopkins Hospital who never supported the University offering the surgeries according to [Chester] Schmidt, shut the program down.

Meyer’s study came after a study conducted by [John] 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. [Dana] Beyer believes that officials at Hopkins just wanted an excuse to end the program, so they cited Meyer’s study.

A 1979 New York Times article also states that not everyone was convinced by Meyer’s study and that other doctors claimed that it was “seriously flawed in its methods and statistics and draws unwarranted conclusions.”

However, McHugh says that it shouldn’t be surprising that Hopkins discontinued the surgeries, and that he still supports this decision today. He points to Meyer’s study as well as a 2011 Swedish study that states that the risk of suicide was higher for people who had the surgery versus the general population.

Beyer, however, cites a study from 1992 that shows that 98.5 percent of patients who underwent male-to-female surgery and 99 percent of patients who underwent female-to-male surgery had no regrets.

“It was clear to me at the time that [McHugh] was conflating sexual orientation and the actual physical act with gender identity,” Beyer said.

As I stated in my previous post, it is also clear that McHugh errs horribly by comparing the histories of transgender patients with the general population.  The comparison is invalid due to the overwhelming prejudice that we face in society.  Marshall, try living for a couple of years with what most out transgender people face: higher murder victim rates, higher victim of violence rates, rampant job discrimination, significantly higher incidence of UIT’s because most of us rather “hold it in” than risk using public bathrooms, significant rates of discrimination in basic health care including outright refusal to provide any care at all (2% of transgender people report having been assaulted at medical facilities), frequent rejection by family, frequent rejection by one’s faith community … I submit that it is a testimony to the mental health and strength of transgender people that so many of us have achieved any success at all after transitioning to live in our innate gender.  Yet we have achieved far more than the bare minimum.

You say that “science doesn’t yet have a cure for transexual [sic]”. The evidence is in and mounting. We don’t need a cure. We just need to be believed. 

They that sow in tears shall reap in joy. – Psalm 126:5

God bless,