Link Wednesday #2: Is Caitlyn Jenner Mentally Ill?

(~1350 words: analyzing Paul McHugh’s dealing with transgender issues)

Caitlyn Jenner’s last interview as Bruce Jenner occurred a little over a month ago. Then on June 1, 2015, she announced herself to the world with her new name and a cover shot. This prompted comments ranging from support to denigration.

So this link Wednesday has to do with one psychiatrist in particular who holds a lot of clout with conservatives who oppose to transgender persons (or what transgender people do, not their persons, according to the rhetoric).

1. “Surgical Sex” by Paul McHugh

Paul McHugh

Paul McHugh

Paul McHugh was the longtime chief psychiatrist, professor of psychiatry, and department head at Johns Hopkins University and Johns Hopkins Hospital. He has gained much publicity for his position against SRS. In this article published on First Things (see their About page here), he discusses why he opposes it. He primarily found the desire for SRS solely in men who could not deal with their own homosexual attraction and sexual experience. He wished to test his unease with these men by testing 1) if an operation resolved other “psychosocial issues” (“relationships, work, and emotions”) in them and 2) if operations performed on boys with abnormal genitals combined with raising the them as girls allowed them to be gender-adjusted in adult life as women.

Concerning his first inquiry, McHugh followed Jon Meyer’s research. Meyer had spoken with SRS patients years after their surgeries, finding that they were largely satisfied with their choice. McHugh inferred, though, that the surgery did not resolve other psychological issues present in them.

Concerning his second inquiry, he followed the research of William G. Reiner. First, Reiner used comparative anatomy to conclude that even if boys were surgically altered postpartum, they had still been exposed to testosterone in utero. These young children, though raised as girls, preferred “boy” play: “enjoying rough-and-tumble games but not dolls and ‘playing house.’” Reiner’s case study on 16 “genetic males with cloacal exstrophy” found that once the youths had learned about their birth sex:

  • 8 boys declared themselves male
  • 5 continued to live as females
  • 1 lived in sexual ambiguity
  • (2 had parents who had elected not to have the surgery performed on their children)

McHugh then concluded that gender identity flows not from socialization, but from genetics and intrauterine encounters with testosterone. I have two issues with McHugh’s inferences from the data and studies. The first has to do with the propriety of his first inquiry: is it appropriate to ask if SRS solves other psychological problems in a person? I’ll propose something and let you think about it: does gall bladder surgery have benefits for asthma sufferers? McHugh admitted that men who underwent SRS were satisfied with the results in the majority of cases. His contention is that it did not solve attendant psychological issues. Should that be expected? If I suffer from bipolar disorder, schizophrenia, and obsessive-compulsive personality disorder, will treatment for one diagnosis work for the other two? Some medications help multiple things. For example, Depakote can be used as a treatment for seizures, migraines, or the manic phase of bipolar disorder. But this isn’t always the case, and to expect one treatment to affect multiple issues doesn’t seem reasonable to me.

My second issue has to do with McHugh’s use of Reiner: “sexual identity is mostly built into our constitution by the genes we inherit and the embryogenesis we undergo. Male hormones sexualize the brain and the mind.” If effects in the uterus are primarily what account for sexual identity, why did nearly 43% of the boys operated on live as females—i.e., according to socialization—or ambiguously? Wouldn’t his claim call for a much higher ratio of “boyness” trying to overcome female socialization? Can a claim for naturalness/normalcy hold if it only accounts for roughly 57% of the sample?

2. “Transgender Surgery Isn’t the Solution”

(Google the title; if you click on this link, you have to subscribe in order to read the full article)

I came across this article when another article referenced it. That article had the catchy snippets in its title: “Johns Hopkins Psychiatrist: Transgender is ‘Mental Disorder;’ [sic] Sex Change ‘Biologically Impossible.’” (check out what the DSM-V says about it being a mental disorder; thanks to Brynn Tannehill; In the upcoming weeks, when I discuss the “institution” aspect of religion, I will discuss the politics of classification) While I read that article, I wanted to read the original. It is imperative in research to see what writers/speakers do with their sources in order to see if there are unstated motivations beneath their stated intentions.

I want to draw attention to one statistic provided by McHugh:

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.(Monte’s emphasis)

He also refers again to his reason for stopping sex surgery at Johns Hopkins: “surgically treated patients” were satisfied with the surgery, but didn’t experience relief from other “psychosocial” issues which he doesn’t detail here.

In this article, he produces a much more relevant study to his aims. The Karolinska Institute in Sweden conducted a 30+ year longitudinal study on over 300 people who had undergone SRS. He highlights two things. One, 10 years following the surgery brought about mental health issues, and two, the patients had a 20-fold suicide mortality rate when compared with the general population.

Concerning the Vanderbilt/Portman study, McHugh admits that no one knows for sure why gender dysphoria continues in 25% of individuals who experience it as children. With him, I don’t know what to do with this. It could have genetic or social contributors, or a combination of the two. We just don’t know. However, he’s the psychiatrist, and he doesn’t offer any alternatives to SRS (besides “devoted parenting” for children and adolescents) or help. If you’re a public intellectual offering your two cents, provide some solutions.

The second study concerns me. That suicide statistic is astounding. An article by Mari Brighe (about The Transadvocate here) critiquing McHugh’s op-ed detailed many of his misuses of data, including the following quote from the Karolinska study:

It is therefore important to note that 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. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit. (Monte’s emphasis)

Further links in the article cite differences in androgen receptors between transgender and cisgender men and a difference in brain anatomy between transgender women who haven’t yet undergone hormonal treatment (the article calls them “male-to-female (MTF) transsexuals”) and cisgender men.

What I take from this is that transgender persons need more access to mental health resources, but that a ban on SRS in itself would not “fix” them. With high suicide rates, abuse from families of origin, mistreatment by police and hospitals, and homelessness, exclusionary tactics like negative labels are not helpful. Labels more often than not serve to categorize a group as “Not us,” that can then serve as a shield of indifference to real complaints, issues, and needs.

So is Caitlyn Jenner mentally ill on account of being transgender? The DSM says no. I think the question might be missing an issue, though. My question is, do Jenner and people like her have access to mental health, relational, financial, occupational, housing, and other resources that I enjoy because no one is obstructing my access according to my appearance? I guess a person could say, “Stop trying to be something you’re not. Make your appearance more normal and you won’t have these problems.” To me that’s like saying, “Stop practicing Christianity, because it’s against your nature. You won’t have relational problems associated with being resisted because of your religious observance.”

Just How Biased Are You?, or Let’s Play a Game

I was going through a discussion forum today, and came across this list of cognitive biases. According to that list, there are 170 types of biases spread across three categories. Granted, this number is semi-inflated. Some items are



represented more than once, and not all of them could be called biases. But I went through the first 25 items, under the “Decision-making, belief, and behavioral biases” category, from the ambiguity effect to essentialism. I did this to see how many of biases I have had in the past or still have.

This exercise then prompted me to consider how these biases affect my stances on things religious and philosophical. When I go through the arguments for and against the existence of god, consider a religious experience, or evaluate other religions than my own, are there certain barriers in my mind that preclude a fair case? Here are some examples from my turn in the game:

  • Ambiguity effect– yes; now, since I am not absolutely sure god exists, or what is in the bible is god’s revelation to humanity, or that Jesus is the ultimate revelation of god, but I am sure I exist, I am absolutely more prone to use myself as the measuring stick to order my life than an external matrix I am unsure about
  • Attentional bias– yes; I have been a victim of something, and I can’t really attribute it to one thing. For example, in politics, or at least the kind I’m used to, only two positions are offered for public discourse, yes/or no on an issue. It’s a limiter on other possibilities, and then I find myself suffering from this bias in some areas of life and in others not. E.g., I know there are more theistic possibilities than mere “God exists: yes or no”; religion/philosophy runs along a continuum from strong atheism on one hand to strong theism on the other. In between are all kinds of options, like agnosticism, deism, pantheism, polytheism, monotheism, panentheism, etc. But then when it comes to contemporary political issues, I sometimes find myself narrowly focused: “Guns: yes or no” and no nuance.
  • Backfire effect– oh yah. My first read of Bertrand Russell’s Why I Am Not a Christian
    Source: Stanford Encyclopedia of Philosophy

    Source: Stanford Encyclopedia of Philosophy

    had the opposite effect than persuasion on me 🙂 Even some of his good arguments only reinforced what I saw as true.
  • Bias blind spot– haha, yes; when I first encountered rationalism in philosophy, I really ran with it. I took up the assumption I could remove all biases when looking at an argument, having pure objectivity. Too bad I didn’t understand the concepts of conditioning, context, place, and just the fact that no one is immune to bias.
  • Confirmation bias– I don’t think I know anyone who doesn’t do this. I’m sure they exist somewhere. Using myself as an example (this may be egocentrism, but I’m trying to be concrete), when I’d look over my life to note my tendencies, I would note particular episodes (like telling my mom when I was 10 that the bible was just stories invented by men) as indicative of my whole life. This obviously isn’t the case, since I also had episodes in life (which I’d conveniently forget when doing this exercise) where I was quite confident in the veracity of the Christian Scriptures.
  • Contrast effect– yes; as pertains to body image, I remember when I was in great shape. Then I would see another guy who was bigger and more ripped than me and would feel not in shape. But just because another guy was 8% body fat and had 10 more pounds of lean muscle did not mean my 10% body fat self was a chub.
  • Empathy gap– Yup. When I was studying to go into ministry, I assumed everyone should be doing what I was doing: reading about theology, biblical studies, church history, because that’s what Christians do, right? I didn’t understand different personality types, different time capacities. I thought my future church parishioners should go through the curriculum I went through, and with the same rigor, not realizing family, work, and other commitments they would have that I didn’t have at the time I was a single college student barely working 10 hours a week.
  • Essentialism– Oh yes. This one’s big and I think a lot of people play this game. For example, I saw the Christianity I grew up with as the true, authentic version. As I came to reject it, I believed I was rejecting Christianity. But as one of my friends pointed out (and something I should have remembered- dern you biases!), there are many branches on the Christian trunk. A mere perusal through the table of contents of Livingston’s Modern Christian Thought, here and here, shows a choir of voices singing sometimes strident harmonies, but the same song (though many in the same choir question others’ true membership). Essentialism tries to get at what is essential for one to be X, say human. A featherless biped which has the capacities of reason, relationship, and self-consciousness. What of the quadriplegic? What of those in a coma? Are these any less human than “normal folk?” or do essentials always fail, since the aberrations are still considered of the same kind, but we lack in language what we need to nail down what constitutes essence?

So out of these possible biases I played with, I’ve had or still have 9, have been unaffected by 8, and am unsure about 8, either because they were presented horrendously in Wikipedia, or I just won’t get them unless I plan on spending more time on them than I feel like doing. All in all, it was neat to see how fallible I am, and how I feel comfortable with that fact now. How do you fare in the bias game?