Nearly four decades after he derailed a pioneering transgender program at Johns Hopkins Hospital with his views on guilt-ridden homosexuals, psychiatrist Paul McHugh is seeing his institution come full circle with the resumption of gender-reassignment surgeries.
McHugh, the hospital's chief of psychiatry from 1975 to 2001, still believes that being transgender is largely a psychological problem, not a biological phenomenon. And with the title of University Distinguished Service Professor at Johns Hopkins Medicine, he continues to wield enormous influence in certain circles and is quoted frequently on gender issues in conservative media.
"I'm not against transgender people," he said recently, stressing that he is "anxious they get the help they need." But such help should be psychiatric rather than surgical, he maintains.
Hopkins, however, is moving beyond McHugh. This summer, it will formally open a transgender health service and will resume, after a 38-year hiatus, an accompanying surgical program.
Once at the forefront of gender-identity science - and site of the nation's first "change-of-sex operations," as the headlines announced in 1966 - Hopkins abruptly halted those surgeries in 1979.
The main trigger was a study by Jon Meyer, who ran the hospital's Sexual Behaviors Consultation Unit. In the study, Meyer concluded that although "sex-change" surgery was "subjectively satisfying" for the small sample surveyed, the operations they underwent conferred "no objective advantage in terms of social rehabilitation."
"With these facts in hand," McHugh later wrote, "I concluded that Hopkins was fundamentally cooperating with a mental illness."
Two months later, its gender-identity clinic was shut down.
Many scientists subsequently challenged the methodology behind Meyer's study, as well as his interpretation of the results, but in the decade that followed, other academic hospitals often cited the research when they discontinued their own transgender surgical programs.
The decision to restart operations initially was made public in July and then repeated in October on the health system's website in a letter titled "Johns Hopkins Medicine's Commitment to the LGBT Community." The letter stressed "strong and unambiguous" support of the LGBT community and made clear that when "individuals associated with Johns Hopkins exercise the right of expression, they do not speak on behalf of the institution."
At the same time, the letter emphasized a hallmark of American higher education: the freedom to express contrarian views. "Academic freedom is among our fundamental principles," it said, "essential to the self-correcting nature of scientific inquiry, and a privilege that we safeguard."
McHugh, many people assumed, was the unnamed impetus for both declarations.
Hopkins' shift not only reflects the public's far broader discussion about transgender rights and protections, but also the controversies that the discussion engenders. In February, the Trump administration revoked federal guidelines put in place under President Barack Obama that had directed public schools to allow transgender students to use restrooms matching their gender identity. And North Carolina passed its own restrictive "bathroom bill" for public spaces - legislation that drew such condemnation, especially from outside of the state, that lawmakers last week voted to repeal the law.
"Obviously there's a lot of apprehension and anxiety in the transgender community, because we don't know how health care is going to be impacted [by Trump's agenda], especially for transgender youth," said Paula Neira, clinical director of the new Hopkins program. "I think it shows that what we're doing is timely."
But as the plans for the transgender health service were coming together last fall, a 143-page report, titled "Sexuality and Gender," appeared in the New Atlantis, a science and technology magazine published by the Ethics and Public Policy Center, a conservative Christian think tank. It was authored by McHugh and Lawrence Mayer, a professor of statistics and biostatistics at Arizona State University and, at the time of the publication, a scholar in residence at Hopkins.
The pair contended that neither sexual orientation nor gender identity are biologically determined. Although the New Atlantis is a small publication, the report dismayed many in the Hopkins medical community and beyond. Those included Dean Hamer, a scientist at the National Institutes of Health for several decades and one of the first researchers to identify a genetic link to homosexuality. Hamer termed some of the authors' statements "pure balderdash."
The paper gained traction with conservative media, however.
"People began citing the New Atlantis article as a reason to support legislation against transgender people," said Tonia Poteat, a Hopkins epidemiologist who is an expert on transgender issues.
The result: In October, Poteat and a half-dozen colleagues at the university's Bloomberg School of Public Health denounced the report, writing that it "mischaracterizes the current state of the science on sexuality and gender." More than 600 students, faculty members, interns, alumni and others at the medical school also signed a petition calling on the university and hospital to disavow the paper.
"These are dated, now-discredited theories," said Chris Beyrer, a professor at the public health school and part of the faculty group that denounced McHugh's stance.
In an interview from his home in Baltimore, where he still sees patients, McHugh explained that the "duty of all doctors who propose a treatment is to know the nature of the problem they propose to treat. The issue of transgender [people] is, the vast majority coming for surgery now don't have a biological reason but a psychosocial reason."
While McHugh successfully lobbied for more than 30 years to keep gender-reassignment surgery from becoming a Medicare benefit, he supports the operation for those born with an intersex condition, which means having a reproductive or sexual anatomy that doesn't fall into the typical definition of male or female.
Most recently his name was prominent on an amicus brief in opposition to the case of Virginia transgender student Gavin Grimm. The teen sued his school district to be allowed to use the bathroom of his gender identity - an issue that until last month was headed to the Supreme Court.
"People with abnormalities of development should be helped to find their place as they see it best," McHugh said. "But they are a tiny number of the transgender population seeking and being given treatment."
Those involved in Hopkins's transgender health services disagree with his positions. But the 85-year-old doctor, who still teaches an occasional course, says he bears no animus toward them. In fact, he appreciated a visit made last fall by W.P. Andrew Lee, the head of plastic and reconstructive surgery at Hopkins. Lee wanted to tell the former psychiatry chief that the hospital would be resuming gender-affirmation surgeries, as they are called these days.
The visit was "a professional courtesy," Lee said in an email to The Washington Post. He declined an interview request.
McHugh elaborated a bit on their conversation and how the two had disagreed: "When I said [surgery] reduced options, he said he was thinking about the people who were pleased about the treatment."
Their stalemate, the psychiatrist knew, wasn't going to affect the hospital's decision.
So far, the new transgender health service involves 25 to 30 professionals across a number of departments, including plastic surgery, urology, endocrinology, nursing and social work. The surgeries will take place at Hopkins Hospital and possibly at some of the system's satellite centers.
Despite important gender research the university maintained over the years, it has ground to recover. The long break in its surgical program, coupled with McHugh's vocal positions on gay and transgender issues, caused Hopkins to lose standing within the LGBT community.
"It took an exceptionally long time," Beyrer said. "Too long."