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The Technology of Gender

Examining an Unsettled Science

An Interview with Paul R. McHugh

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Future technologies, we’re told, will allow humankind to literally reshape who we are – for instance, by editing our own DNA or connecting our brains directly to computer networks. While such possibilities give ample cause for alarm, in fact we’re already using technology to modify human bodies: through sex reassignment. This package of hormonal treatment and radical plastic surgeries is finding ever-increasing social acceptance. But what’s at stake when we artificially alter a human being in regard to something as fundamental as biological sex? Plough spoke to Paul McHugh, professor of psychiatry at the Johns Hopkins School of Medicine, about his experience treating children and adolescents with gender dysphoria.

Plough: What has your research revealed about hormone treatments for children?

Dr. McHugh: We reviewed all the proposals and mechanisms about how these hormones might work in children with gender dysphoria, and there’s no evidence that this treatment leads to happy results. Experimental treatments like this ordinarily go with a set of standard accompaniments. First, they go through an Institutional Review Board (IRB). It became clear in the 1940s and 1950s that many hospitals were using patients as experimental subjects without their consent. To avoid that, IRBs were established. Patients need to give fully informed consent: the doctor needs to say, “we’re doing an experiment on you; we hope the results will be good, but we don’t know.”

Second, the treatment groups need to be checked against comparison groups. And finally, there needs to be detailed, long-term follow-up. But these hormone treatments are now considered standard of care without any of this being done. There is no good evidence that this is a beneficial treatment. There are testimonials, but that’s not the same. And at the moment there are no proper studies on it.

What can you tell us about the children who are seeking these treatments?

Many of these children have been drawn into this idea, that they are “really” the opposite sex, through the internet. They’ve got very vigorous social media support. They run on testimonials and trust. The young people are very vulnerable to that; they go on the internet and hear things they trust. They go to their parents and say, “I want to do this,” but this is the same age that you wouldn’t dream of letting anybody have a tattoo. It’s a craze-like phenomenon, and now it’s on the increase, especially among young women. It’s very much like anorexia nervosa or body dysmorphic disorder; they’re absolutely committed to living in this way and they resent anyone who doesn’t support them in it.

I’m beset with families calling me: “Where can we get someone to help us, given that we’re being asked to collaborate in making this permanent change happen?” They’re very distressed.

In 2016 you coauthored a 145-page study on gender and sexuality (see “Further Reading” below). How was the report received? It was controversial in the popular press…

On a scientific level, there was no explosive challenge. It almost sank without notice. You would think that people would respond with counterclaims, contrary research: that there is good evidence for these hormone treatments being beneficial. But that didn’t happen. Nobody said solid experimental evidence existed.

What are doctors’ responsibilities here?

Proposing a future different from what nature would recommend is a huge problem. Here’s something that’s so obviously against nature, and it fits into other things that are against nature, like assisted suicide. Doctors used to be in the position of helping nature, helping the body heal, but now it’s different. Political pressures are so great. We’re called transphobic: how could we be phobic toward these kids? The presumption is that we’re acting in bad faith for them. But we, and their parents, want to help them and benefit them; we don’t want to be responsible in the long run for injuries done to them.

What do you expect will happen with this in the future?

This is early times for us now. We expect that the regrets will start coming, but we’re not sure how to help. The best thing to do for these young people is to postpone any physical change, any physical intervention. Maybe the best course of action is to ask someone to live as the opposite sex without doing anything physical. But this is very difficult, and the children are so convinced that they want a sex change that they threaten to do themselves injury. It’s an unprecedented kind of treatment to be done on young people, because there’s no evidence that it has good long-term effects.

What do you know about long-term prospects of resolution for gender dysphoria if these hormone treatments aren’t administered?

Again, we know very little. University of Toronto researcher Dr. Kenneth Zucker worked with twenty-five girls who were experiencing feelings of gender incongruence, using family therapy among other things, and – ­crucially – treating co-occurring psycho­logical disorders that were contri­buting to these girls’ distress. He treated gender dysphoria as an idiom of distress, rather than an entity in itself, and sought to address any co-occurring psychological issues.

In a follow-up study after thirty years, twenty-three of the twenty-five girls had resolved their feelings of gender incongruence. Other studies indicate that these feelings resolve in 80 percent of cases as the young people grow up. But we just don’t really know, we don’t have good studies, and crucially, we are not doing comparative treatments. All we’ll have, in the next couple of years, is the outcome of this phenomenal experiment. And I expect that regret will run high.

Girl in high heels sitting on a windowsill and looking out.

Photograph by De Visu / Big Stock

For Further Reading

“Sexuality and Gender: Findings from the Biological, Psychological, and Social Sciences”

Lawrence S. Mayer and Paul R. McHugh

New Atlantis, Fall 2016, no. 50

What is sexual orientation? How do we understand transgenderism? And what is the role of medicine and biotechnology in addressing these issues? The answers to questions like these touch on some of the most personally and politically fraught issues of the day. In 2016, the New Atlantis, a journal of technology and society, published a lengthy report by Drs. Lawrence S. Mayer and Paul R. McHugh, both of Johns Hopkins University. This report approaches questions related to gender and sexuality by surveying available research across several disciplines. The authors’ conclusion? It’s complicated. The report challenges some of the dominant ideas surrounding these issues: sexual orientation is neither a choice nor a fixed and inborn trait, they say, with causes that are incompletely understood.

When it comes to transgenderism, the authors speak more strongly: the claim that a human being can change his or her sex “is starkly, nakedly false,” says Dr. McHugh. The practice of blocking puberty or administering hormones to children who identify as a member of the opposite sex, say Mayer and McHugh, has no therapeutic merit. The report concludes that “more effort is called for to provide people [who are personally wrestling with these issues] with the understanding, care, and support they need to lead healthy, flourishing lives.”
The Editors

Download the complete report at thenewatlantis.com.

Contributed By Paul McHugh Dr. Paul R. McHugh

A professor of psychiatry at Johns Hopkins University, where from 1975 to 2001 Paul McHugh was department chair as well as psychiatrist-in-chief at Johns Hopkins Hospital. Dr. McHugh is author of several books including The Mind Has Mountains: Reflections on Society and Psychiatry (Johns Hopkins, 2008).

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