In 1979 Dr. Paul McHugh closed the sex-change clinic at Johns Hopkins. In the ’80s he testified against phony ‘recovered memories.’ He hasn’t given up the fight.
You might have heard this joke: A man in a car gets a call from his wife. “Honey, be careful,” she says. “A car is going the wrong way on the highway.” He replies: “It’s not just one car. It’s hundreds of them!”
If it were a psychiatrist joke, Paul McHugh, 87, could be that driver. A professor at the Johns Hopkins School of Medicine and a tenacious skeptic of the crazes that periodically overtake his specialty, Dr. McHugh has often served as psychiatry’s most outspoken critic. Either he’s crazy, or all the other psychiatrists are.
The best-known, and most controversial, decision of his professional life is newly relevant—and recently reversed. In 1979, as psychiatrist in chief at Johns Hopkins Hospital, he shut down the Gender Identity Clinic, which performed sex-change operations. In his view, the hospital had “wasted scientific and technical resources and damaged our professional credibility by collaborating with madness rather than trying to study, cure, and ultimately prevent it,” as he wrote in 2004. In 2017 the clinic was reopened as the Center for Transgender Health, performing what it now calls “gender-affirming surgeries.” Its medical-office coordinator, Mellissa Noyes, told me “the demand is massive.”
Dr. McHugh is again on the outs with his profession. He doesn’t mind: “I’ve been there before,” he tells me as we sit in his book-laden Baltimore home, a white-brick American Moderne in the leafy Guilford neighborhood abutting Johns Hopkins, where he’s still a professor.
His contrarian roots runs deep. He was a diminutive boy in the 1940s, when psychoanalysts had popularized the notion that physical deficiencies—including short stature—produced inferiority complexes, especially in boys and men. He became a prime candidate for the experimental growth-hormone therapies rising to meet the demand from anxious parents. But Paul’s father, a schoolteacher, decided against the treatments recommended for his son. Shortness wouldn’t be the worst problem he’d have to face, the elder McHugh reasoned. As it turned out, the animal-derived pituitary treatments were ineffective; the human-derived form sometimes carried the infectious agent that causes Creutzfeldt-Jakob disease, an incurable degenerative brain disorder.
“I know my life would have been easier if I had had 4 or 5 more inches,” says Dr. McHugh, who now stands 5-foot-6. But his childhood experience taught him a lesson that helped make him a giant in his field: Sometimes psychiatry’s cure is far worse than the disease.
Dr. McHugh believes psychiatrists’ first order of business ought to be to determine whether a mental disorder is generated by something the patient has (a disease of the brain), something the patient is (“overly extroverted” or “cognitively subnormal”), something a patient is doing (behavior such as self-starvation), or something a patient has encountered(a traumatic or otherwise disorienting experience). Practitioners too often practice what he calls “DSM checklist psychiatry”—matching up symptoms from the Diagnostic and Statistical Manual of Mental Disorders with the goal of achieving diagnosis—rather than inquiring deeply into the sources and nature of an affliction.
“I came into psychiatry with the perception that it had not matured as a clinical science in which rational practices are directed by information on the causes and mechanisms of the disorders,” Dr. McHugh says. “Every other medical discipline has that.” He still regards psychiatry as badly in need of “organizing principles.”
That’s putting it mildly. Psychiatry has fallen under the sway of a dizzying number of crazes. They include imagined ailments like hystero-epilepsy, in which people who didn’t have epilepsy supposedly acquired symptoms from those who did—and conditions exacerbated by mental-health professionals, like anorexia nervosa and post-traumatic stress disorder. Treatment has often been grotesque—think frontal lobotomies, insulin shock therapy and primitive chemically induced seizure therapies.
Psychiatric enthusiasm has also led to gross miscarriages of justice. In the 1980s, Dr. McHugh became a leading opponent of so-called recovered-memory therapy, in which psychoanalysts claimed to have discovered the latent source of patients’ multiple-personality disorder. Dr. McHugh believes multiple-personality disorder is a phony ailment and recovered memories are iatrogenic—a Greek word meaning “brought on by the healer”—implanted by the therapeutic process that purports to discover them. Often the fake memories were of childhood abuse, and Dr. McHugh traveled to Rockville, Md.; Manchester, N.H.; Providence, R.I.; and Appleton, Wis., offering expert testimony to exonerate wrongfully accused defendants.
Given all this, does psychiatry have anything of value to offer? “I think it really has helped demonstrate that mental illnesses are real things . . . that need to be studied, and can be treated,” Dr. McHugh says. “I think that’s a tremendous achievement.”
But what are those “real things,” and how should psychiatrists treat them? Those are critical questions for a field that routinely administers powerful medications and sometimes recommends life-altering surgery, while the relationship between the brain and its elusive alter-ego, the mind, remains largely mysterious.
Dr. McHugh argues that the treatment of returning soldiers for the liberally applied PTSD diagnosis is another example of iatrogenesis. Such diagnoses are far rarer among Israel Defense Forces veterans, who experience plenty of trauma. Israelis “know that you can get a terrible psychological reaction out of a traumatic battle. And they do take the soldiers out, and they tell them the following: ‘This is perfectly normal; you need to be out of battle for a while. Don’t think that this is a disease that’s going to hurt you, this is like grief. You’re going to get over it, it’s normal. And within a few weeks, after a little rest, we’re going to put you back with your comrades and you’re going to go back to work.’ And they all do.”
By contrast, American psychiatrists say: “ ‘You’ve had a permanent wound. You’re going to be on disability forever. And this country has mistreated you by putting you in a false war.’ They make chronic invalids of them. That’s the difference.”
Dr. McHugh graduated from Harvard Medical School in 1957, when many of the brightest aspiring psychiatrists poured their energy into psychoanalysis. During his psychiatry internship at Boston’s Peter Bent Brigham Hospital (now part of Brigham and Women’s Hospital), the chief of psychiatry gave Dr. McHugh a bit of advice that set the course for his professional life: If you want to make a real contribution to psychiatry, avoid psychoanalysis and study the brain.
Dr. McHugh spent the next six years training under some of the world’s best neurologists, starting at Massachusetts General Hospital, where he met his wife, Jean, a British social worker visiting the U.S. on a Fulbright scholarship. It isn’t hard to imagine what she saw in the brilliant young neurology intern, a nice Catholic boy with courtly manners and aquamarine eyes like sea glass.
He focused his research on the physiology of appetite—the brain’s regulation of food intake. He eventually discovered and named two receptors for the digestive hormone cholecystokinin. He wrote 162 academic papers, and the National Academy of Sciences credits him with being the first to “describe increased cortisol secretion associated with depression, an accomplishment that led to the development of a test to identify serious depression by physical means.” This work taught him how to conduct rigorous scientific inquiry—and led him to believe many psychiatrists weren’t engaged in it.
In 1975 Johns Hopkins hired him as director of its Department of Psychiatry and Behavioral Science and the hospital’s chief psychiatrist. Hopkins was famous for pioneering sex-reassignment surgery: In the 1991 film “The Silence of the Lambs,” Dr. Hannibal Lecter, played by Anthony Hopkins, refers to Johns Hopkins as one of the “three major centers for transsexual surgery.”
As department head, Dr. McHugh encouraged a colleague to conduct follow-up research on patients who had undergone sex-change operations. The results disturbed him. Although most of the patients “were reasonably satisfied with the change, they hadn’t any improvement in any of their psychosocial issues that were the whole reason for doing it in the first place.”
Worse, some of the patients became “suicidal and depressed and regretful.” There was not enough good evidence to determine before the fact which candidates for surgery would fall into either group. With no way to predict which patients would be hurt by the operations, Dr. McHugh decided he could not allow them to continue. He says shuttering the clinic was a matter of adhering to the Hippocratic Oath and the scientific obligation to ground conclusions in empirical evidence.
“Everybody should agree” that sex-reassignment surgery is “an experiment right now,” he says. “We’re doing an experiment. We have lots of publications that are telling us that the evidence base for these treatments is very low-quality.” There are “not enough subjects, not enough good results—not enough anything. Not enough comparisons . . . that would make it evidence-based.” He says the Institutional Review Board should oversee all such surgery. It doesn’t.
Dr. McHugh believes the Johns Hopkins clinic’s reopening was motivated by economic and political factors, not scientific evidence. The complicated operations are big moneymakers for hospitals. That the new department’s name uses the politically correct designation “transgender,” not the clinical term “gender dysphoria,” and refers to the surgeries as “gender affirming,” seems to support the view that the doctors have formally embraced transgender ideology.
Dr. McHugh does not believe surgery cures gender dysphoria. He thinks that condition, along with anorexia and body dysmorphia, is a “disorder of assumption,” characterized by an “overvalued idea,” or a ruling passion that “fulminates in the mind of the subject, growing more dominant over time, more refined, and more resistant to challenge,” as he has written.
In the case of anorexia, the overvalued idea is that it’s good to be thin. The primary goal of the psychiatrist ought to be to help the patient change behavior. The prevailing standard of care for sufferers of gender dysphoria—“affirmative care”—is the opposite: It calls for mental-health professionals to accept both a patient’s self-diagnosis of gender dysphoria and the corresponding behavior.
The possibility that Dr. McHugh is wrong doesn’t trouble him. “Either the plastic surgeons and the transgender psychiatrists are right and I’m wrong—and if that’s the case, they will have done a lot of good by opposing me, and I will have been a drag on the system—or the opposite. Suppose they’re wrong and I’m right? They will have mutilated thousands of children, and I will look good. Who do you think is sleeping better at night?”
In fact, both parties seem to be sleeping fine—separately. Most current Johns Hopkins medical students, Dr. McHugh says, won’t talk to him. “They think that my views must be motivated by hatred,” he says, sounding baffled.
Dr. McHugh says he never went looking for these fights, but that’s not entirely credible. He is animated, even joyous, when assailing his opponents. If doctors can claim to have a professional calling, this has been his: to rail against what he considers the foolhardy passions of his profession, steering straight for the eye of the storm.
He quotes from the final stanza of Matthew Arnold’s poem “The Last Word”: “Charge once more, then, and be dumb! / Let the victors, when they come, / When the forts of folly fall, / Find thy body by the wall.” The lines speak of a tension between the impulse toward righteous opposition and the knowledge that there is also a time to surrender.
Dr. McHugh turns 88 later this month. For a moment, he seems to consider abandoning the fight. Perhaps he guesses what I’m thinking. Perhaps it occurs to him that his adversaries will read this article. He says, “I hope I’m still standing when these forts fall.”
Ms. Shrier is a writer living in Los Angeles.