Transgender Medicine: Abigail Schrier and Paul McHugh

Sometimes things just coalesce.  

Some weeks ago, the Phantom attended his annual Endocrine Society meeting and underwent his ritual plunge into icy water, and this weekend he read Abigail Shrier's most excellent WSJ piece on Paul McHugh.  Then a twitter post by Paul Krugman and the lightbulb went off above his head: Even in dark times, a conflagration can sometimes, for all its destruction and despair, clear a field so new growth can occur.

Dr. Paul McHugh

First, the meeting. 

Every year the Phantom attends sessions on his favorite hormones for updates from leaders in research and clinical practice.  He attended one session on "Androgen Abuse Update," where a man who runs a clinic at the University of Michigan described the patients he sees and the Phantom recognized these patients immediately, as he sees many similar folk in his clinics in Massachusetts and New Hampshire: They come to the clinic looking like Arnold Schwartzenager, huge trapezius, pectoralis, biceps, asking for prescriptions for industrial doses of testosterone.

They are never big enough. Never the incredible hulk they want to be. Of course, their testes have shrunken to the size of raisins, but that does not bother them. They are in pursuit of bigger deltoids.

The lecturer showed a cartoon of a heavily muscled man looking in a mirror seeing a skinny 98 pound weakling. 

"These men are like the anorexia nervosa patients who see themselves as fat and can never get thin enough," he said. 

A doctor from the Netherlands got up and told about his clinic where psychiatrists and endocrinologists work together with the patients, who are treated very much as people addicted to heroin are treated, with programs to taper them down and off the agents to which they are addicted. 

"Wow," an America doctor said. "I wish we could do that here. But we have to worry about the FDA and lawyers."

"Well," the Dutch doctor replied, "Everything is easier in the Netherlands."

Which is likely true, except when money is involved. Cash does grease the wheels in America.

The next session, which the Phantom makes himself attend every year was on "Transgender Medicine" where the heads of some of the biggest "Transgender Medicine" clinics report on their experience and practices and present cases to illustrate various clinical problems.

At a glance, it was clear these programs, which involve patient visits, prescriptions and often complicated surgeries, are big business at the institutions where they thrive. Careers are made and hospital budgets balanced.

One of the experts on the stage mentioned the doses of testosterone he uses to achieve the results the patient is looking for, in some cases, two or three times the usual dose used for replacement in men who lack testosterone.

On the other hand, the expert said, he had some patients who were not looking for increased musculature or facial hair, but just a deeper voice, so he "touched them up" with lower doses of testosterone. A sort of Botox approach to medical care: show me where you want that wrinkle dissolved and I'll deliver that. 

" I know in some cases these doses and blood levels  are higher than what androgen abusers attain," said the director of the transgender clinic, "But we need these to achieve results in our patients."

The Phantom, sitting in the audience,  quickly emailed the University of Michigan professor who had given the session on "androgen abuse" with what the transgender doctor had said.

 "Are we, in transgender medicine, not inducing androgen abuse in our patients?" the Phantom asked.

The professor replied, "In this case, the higher doses are used to achieve gender affirmative therapeutic goals." 

In other words, as an Endocrine Society approved expert, he was not about to criticize standard practice in transgender medicine circles.

"So, if a man who is not transgender requests an  industrial dose of testosterone so he can see bigger muscles, that is abuse. But if a transgender person requests industrial doses of testosterone so hair grows on an XX lip, well that's just 'gender affirmative'?" I asked the professor. 

One year, long ago, the Phantom had stood up in the audience during the transgender session and asked: "What is the suicide rate among your transgender clinic patients?"

The speaker blandly replied, "About forty percent," as if that were just another statistic. (The Phantom did not remark: "One death is a tragedy; a million deaths is a statistic," showing uncharacteristic restraint.) 

But the Phantom had persisted, "Suppose you had a cardiology clinic which did some procedure and it reported a 40% mortality rate. How long do you think that clinic would be allowed to stay in business?"

A blizzard of resentment and loathing swept from the audience toward the microphone where the Phantom stood, and the Phantom slunk back to his seat, chastened, not having the courage or the folly to persist.

Portrait of an Artist: Abigail Shrier

Paul McHugh on the other hand, saw what the Phantom saw and he did not slink away.

 As Abigail Shrier reported, at Johns Hopkins, where McHugh is a professor, medical students will not speak to him. 

"They think that my views must be motivated by hatred," he says.

In this one paragraph Shrier speaks volumes about where we are in "transgender medicine." The very people who ought to look at problems dispassionately, who should ask the hard questions, fail to do so. When it comes to "transgender medicine" all rational thought goes out the window. Suddenly a medical problem has been politicized and emotion rules, even among medical students, at Johns Hopkins School of Medicine. And in the audience at the Endocrine Society.

Schrier has done the journalistic equivalent of painting St. George and the dragon.

McHugh arrived at Hopkins in 1975 as chief of psychiatry, and was asked to coordinate the participation of psychiatry with urology and endocrinology and plastic surgery in the Hopkins transgender program. 

Being an actual physician and scientist he asked the requisite questions: What is the success rate of the clinic? What are the goals? How do you measure the achievement of these goals? And what are the risks? 

What he found was a 40% suicide rate among patients in the transgender clinic.

He thought of the dictum every medical student learns first day: Primum non nocere (First, do no harm.) 

He closed the clinic. In 1979. He did not do this immediately. He took time to gather facts. Facts he could not avoid. Facts are stubborn things. What he did had to take courage. So many jobs and dollars depended on that clinic. But he slew the dragon. And he has been paying for it ever since. 

He was trying to protect patients, but he was accused of hating the patients, of not accepting them as suffering human beings who needed care. 

In fact, he asked, at least by implication, "Would you respond to patients with anorexia nervosa by trying to help them find ways to lose more weight?"

But we all agree anorexia nervosa is a disease, that is, we agree the patients are wrong in their assessment of what they need. And we agree that heterosexual men who seek high doses of exogenous testosterone are wrong to do so. In fact, our state legislatures have called them not just wrong, but criminal for doing so. Testosterone is now classed with codeine as a drug with abuse potential in the criminal code. (Unless, of course, you are using it for "gender affirmation.")

McHugh has suggested in some cases, anorexia nervosa for sure, and very likely "gender dysphoria" have a disorder of an "over valued idea." For the anoretic, that idea is thinness. For the gender dysphoria patient, it may be that if only the right gender could be found, all would be right again.

A year ago, after one such Endocrine Society transgender session, the Phantom emailed Dr. McHugh about a case which had been presented. A male to female transgender had a lesbian partner and they wanted to have a baby. 

The male to female transgender had not had surgery, only estrogen therapy, but the estrogen therapy had reduced the sperm count.  They sought in vitro fertilization (IVF). The clinic was moving ahead with IVF just as soon as they could be sure insurance would pay for it.  The Phantom asked McHugh if this did not sound somehow wrong.

McHugh replied, "You have to ask, what sort of sex, exactly, is this couple having?"

That had not actually occurred to the Phantom. If the male to female was having erections, it was possible they were having penis in vagina intercourse, so why would they need IVF? Just reduce the estrogen, allow the sperm count to rise.

This year, another case presented:  A female to male transgender with an intact cervix and uterus on testosterone therapy was still menstruating and likely ovulating and the clinic thought an IUD would work best. But objections were raised that offering an IUD to this female to male person would be "emotionally traumatic" because it would remind the patient of her persistent female organs, and would not be "gender affirmative."

The Phantom thought of Dr. McHugh's email and emailed him again. 

"This couple is clearly having penis in vagina intercourse, and the female to male is receiving this penis, which is somehow not destructive of her 'gender affirmation' and yet an IUD would be?"

This time Dr. McHugh did not reply.

He may not have got the email.

Or maybe, at age 87, he had wearied of the battle or at least wearied of the questions from an exasperated Phantom.

Or maybe he just thought it's time for some other saint to slay the dragon.

As pernicious and nasty as Trump and his willing accomplices have been, it is possible a brush clearing fire might be possible. Trump is clearly hostile to the whole idea of transgenders, and has rescinded military codes in their respect. Would his FDA now be willing to look at these "transgender clinics" and all those who profit from them: the endocrinologists employed there, the plastic surgeons, the urological surgeons, the nurses, ancillary staff, the hospitals all of whom profit from this transgender industry? It may be that, at least in this one area an ogre will do the right thing.