Hi, welcome to Gender Analysis. Every so often, a particular bit of folklore pops up in the
media: the claim that transitioning doesn't actually help to improve transgender people's
health and well-being. News outlets like the Washington Times, the National Review, the
Daily Caller, the Christian Post, Fox News, the Wall Street Journal, and even the New
York Times have all promoted the idea that these treatments are ineffective for us. It's
an audacious claim, and you'd expect that it would be supported by some pretty persuasive
evidence. Yet in almost all cases, it can ultimately be traced back to two flawed and
misinterpreted sources. So where did these claims originate - and why do they get such
disproportionate attention?
Paul McHugh served as the psychiatrist-in-chief of the Johns Hopkins Hospital in Maryland
from 1975 to 2001. The hospital ran a Gender Identity Clinic beginning in 1965, and was
one of the first major institutions in the United States to provide transition treatments.
The clinic was closed in 1979, and McHugh has repeatedly claimed that this was based
on evidence showing that transitioning had no effect on trans people's psychological
and social functioning. McHugh related this story to First Things, the Witherspoon Institute,
the Wall Street Journal, and many other outlets which have cited this as proof that transitioning
is ultimately unhelpful. Given that many clinics and professional organizations still provide
and endorse transition treatments, McHugh's claims raise serious questions. Have all of
these professionals simply ignored the findings of a supposedly revelatory study from decades
ago? The study asserts that surgery made no difference in trans people's overall social
functioning, but it relies on criteria that fail to provide a useful measure of adjustment
before and after treatment. In "Sex Reassignment: Follow-up", the authors construct a single
"Adjustment Score" from several measures. Points were added or subtracted from each
subject's score based on their interactions with law enforcement, employment status, intimate
relationships, and use of psychiatric services. Many of the supposedly objective criteria
for these measures are in fact based on subjective value judgments. One point is deducted for
"nongender-appropriate" cohabitation, and two are deducted for "nongender-appropriate"
marriage, while one or two points are added for "gender-appropriate" cohabitation or marriage.
The authors explain that "gender-appropriate" would mean a trans woman cohabiting with or
marrying a man, and a trans man cohabitating with or marrying a woman. Using this scoring,
the authors considered trans people in same-sex relationships to be up to four points less
"adjusted" than the others. This isn't a measure of health - it's a measure of heterosexuality.
The authors also deduct one point for any "contact" with psychiatric services, two for
outpatient treatment, and three for hospitalization. By this measure, seeking psychiatric help
is considered indicative of lesser "adjustment". Current standards of care for transitioning
actually emphasize the importance of followup mental health care even for patients who have
completed surgery. Receiving this care isn't inherently negative. This simplified measure
also provides no details about any specific diagnoses these patients received, the severity
of any symptoms, or the duration of any treatment. For example, this scoring could assign a higher
level of adjustment to a person with schizophrenia who saw a psychiatrist once and pursued no
further treatment, and a lower level to a person with depression who chose to attend
regular therapy sessions. The legal category of the "adjustment score" is similarly vague.
One point was deducted for a subject who was arrested, and two were deducted for being
arrested and jailed. This measure does not consider the charges involved in an arrest,
whether those charges were substantiated, or how long a subject was jailed. This is
particularly relevant because trans people are often targeted by the police simply for
being trans. During the time this study took place, trans people still faced the threat
of arrest under various ordinances prohibiting "crossdressing", just for presenting as their
gender in public. Even today, trans women of color are profiled by police and arrested
on charges of prostitution for carrying condoms. Being subjected to transphobic harassment
by police says nothing about a trans person's own health and adjustment, and the scoring
fails to account for these scenarios. After the study was published in 1979, it was only
a year before other researchers noticed that the method of summing these scores was extremely
unclear. A subject receiving the lowest score in all four categories could only have negative
7 points altogether, yet the ranges presented show that some subjects scored as low as negative
18. This would require that the four measures were sometimes counted more than once. If
this is the case, these categories are even less useful as a measure of adjustment or
well-being. For example, a trans woman with a stable long-term marriage to a woman - minus
2 points - would score eight points lower than a trans woman with three shorter marriages
to men - plus 6 points. An alcoholic who was arrested three times for public intoxication
- minus 3 points - would score lower than a reckless driver who served a prison term
for manslaughter - minus 2 points. And marrying someone of the same sex is considered as indicative
of maladjustment as going to jail. That is the basis on which the study's authors concluded
that "Sex reassignment confers no objective advantage in terms of social rehabilitation".
Do their methods seem "objective" to you? This study was fatally flawed even in its
own time. But it did accomplish McHugh's goal. Quote:
"...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 began working at Hopkins two years before the results of this study were first
presented while he sought to end their transition services. But despite his stated motives,
publications continue to devote column inches to his claim that he closed the clinic on
the basis of these findings.
A more recent study followed 324 Swedish trans people who had genital surgery between 1973
and 2003 and has been frequently cited as evidence that transitioning doesn't help.
Paul McHugh refers to this study in the Wall Street Journal, claiming "after having the
surgery... their suicide mortality rose almost 20-fold above the comparable nontransgender
population", and Richard A. Friedman similarly claims in the New York Times that "transsexuals
had 19 times the rate of suicide and about three times the mortality rate compared with
controls". To say that the subjects' mortality from suicide "rose" after surgery is not supported
by the data, because the study did not compare outcomes among trans people before and after
treatment. Trans people who had already received surgery were the only ones studied, and they
were compared to a control group of cis people, who don't experience gender dysphoria and
have no need for these treatments. The authors themselves acknowledge this, saying:
"...the current study is only informative with respect to transsexuals persons health
after sex reassignment; no inferences can be drawn as to the effectiveness of sex reassignment
as a treatment for transsexualism. In other words, the results should not be interpreted
such as sex reassignment per se increases morbidity and mortality. Things might have
been even worse without sex reassignment."
Imagine if a study compared cancer patients receiving a new treatment to healthy controls
who did not receive it, and found that the cancer patients were more likely to die than
the healthy control group. Would this constitute evidence that the treatment is ineffective?
For the same reason, this study says nothing about how transitioning affects suicide rates,
except that this doesn't reduce its frequency to levels seen among cis people. And even
that conclusion is dubious - the study found that "the overall mortality rate was only
significantly increased" in subjects who had surgery before 1989, and a higher risk of
suicide attempts "was not statistically significant" for those who had surgery after this time.
In "How Changeable Is Gender?", Friedman offers no acknowledgement of these detailed findings,
and simply concludes that "the overall outcome with gender reassignment doesn't look so good".
It's hard to see what he would recommend based on his cursory interpretation of this study
- "don't be trans" isn't exactly a realistic treatment option.
Why are these two papers so frequently cited on the topic of transitioning and its relation
to trans people's health? They are not the only studies that have ever been conducted
on this subject. While these news outlets were busy fawning over two studies that they
didn't even read, they've ignored dozens of studies finding that transitioning is associated
with an improvement in health and functioning. A study from Belgium in 2006 found that trans
people's rates of suicide attempts dropped from 29.3% before surgery to 5.1% after. Another
study of 50 trans women who received genital surgery found that their physical and mental
health was not significantly different from samples of cis women. A 2013 study of 433
trans people in Canada found that 27% of those who hadn't begun transitioning had attempted
suicide in the past year, but this dropped to 1% for those who were finished transitioning.
And a 2010 meta-analysis of 28 studies showed that 78% of trans people showed an improvement
in psychiatric symptoms after transitioning, with a level of psychological functioning
similar to the general population and greater than that of untreated trans people. Several
additional studies have since confirmed that hormone treatment for trans people is associated
with reduced stress levels, a lower prevalence of depression, less anxiety, a reduction in
functional impairments, and a higher quality of life. There is no excuse for using a study
from 1979 and missing the entire body of evidence that's accumulated since then. Those who cover
this topic have a responsibility to do so accurately. Instead, too many of these stories
just tell readers what they want to hear. They offer a scientific-sounding excuse to
keep believing that the existence of trans people is itself wrong, reducing us to the
remnants of a long-debunked medical mistake. The public deserves a fuller understanding
of the science of transitioning. More importantly, they need to be prepared to accept that transitioning
works. Trans people are real, and the treatments that help us live as our genders are effective,
no matter how much this may defy common attitudes. We can look at the science in its totality
and see the truth that's continuing to emerge. Can you?
I'm Zinnia Jones. Thanks for watching, and tune in next time for more Gender Analysis.