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In 1966, Johns Hopkins opened the first gender surgery clinic in the US. Thirteen years later, a single study shut it down. We examine what the research said, what it didn't say, and how new standards of care emerged from the ashes.
Publication Date: 05/04/2026
Duration: 13 minutes, 09 seconds
Transcript:
KELLIE NEWSOME: Before the modern era of gender-affirming care, similar clinics flourished in the 1970s under the leadership of Johns Hopkins. Today, we look at what brought them down.
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.
KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. Let’s start with a preview of the CME quiz. You’ll find the full quiz in the show notes, and the answer at the end of the podcast.
1. Which medication reduced methamphetamine use in a large, phase III trial?
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.
KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. Let’s start with a preview of the CME quiz. You’ll find the full quiz in the show notes, and the answer at the end of the podcast.
1. Which medication reduced methamphetamine use in a large, phase III trial?
A. Atomoxetine
B. Methylphenidate
C. Lithium
D. Mirtazapine
CHRIS AIKEN: Last week, we covered a controversial study that found little change in children's mental health after taking puberty-suppressing hormones for gender dysphoria. The author of the study worried that the results would be weaponized against patients, but as I read the study, I wondered what Dr. Olson-Kennedy was afraid of. Negative studies are common in psychiatry, and one study is not going to rock the boat when there are dozens to pool together in a systematic review. And anyway, no one expects gender transition to cure all mental woes. Simply resolving the gender dysphoria ought to be enough. But I was wrong. Gender dysphoria isn't like other psychiatric conditions, where we carefully weigh the accumulating evidence. This is a field where politics can overpower science, and a single study can bring the house down. That is what happened in 1979, when a paper appeared in the Archives of General Psychiatry titled Sex Reassignment: Follow-up.
KELLIE NEWSOME: To understand that paper, we need to go back to November 1966. In England, the Beatles began recording Sgt. Pepper's Lonely Hearts Club Band, featuring a song about a woman named Rita who pays for her own dates and looks “a little like a military man.” In California, Ronald Reagan is elected Governor, promising to restore law and order to the student protests at UC Berkley. In China, the Red Army is rooting out class enemies of the Cultural Revolution, including gay and transgender people whom they attack as "bourgeois degenerates." And in Maryland, Johns Hopkins opens the first center for gender affirming surgery in the U.S.
CHRIS AIKEN: At the press conference inaugurating the opening, plastic surgeon John Hoopes declared that psychiatrists had "tried repeatedly to treat these people without surgery, and the conclusion is inescapable that psychotherapy has not so far solved the problem — perhaps we should consider changing the body to fit the mind." Applications from prospective patients poured in, but the clinic was selective — only about 3% of applicants were approved for surgery. Psychiatrists served as gatekeepers. And one psychiatrist was determined to lock the gates entirely.
KELLIE NEWSOME: In 1975, Paul McHugh moved to Johns Hopkins to chair the department of psychiatry. He came with the expressed purpose of bringing down the Gender Identity Clinic, accusing them of “cooperating with a mental illness.” And in that effort, he found an unlikely ally: John Hoopes — the same plastic surgeon who had opened the clinic a decade earlier. Hoopes had grown disillusioned. He began describing patients as "hysterical masochists" and the surgery as an artificial façade. McHugh echoed that sentiment, writing that the surgery only turned them into “caricatures of women,” as if the true measure of success was whether these post-surgical patients conformed to the doctor’s ideal of a woman. Together, McHugh and Hoopes commissioned a study to prove the surgery didn't work.
CHRIS AIKEN: The study compared patients who applied for surgery but were declined by the examining committee to those who received the operation. It’s an unfair comparison, but one that likely favors the ones deemed mentally healthy enough to go through the operation. But about half of the ones who were sent away by Johns Hopkins went on to have the surgery somewhere else, creating a third group for comparison, as well as a testament to their determination. The study was small. They followed 50 patients for two to five years, measuring what the researchers considered markers of psychological adjustment: arrest records, employment history, how often they changed residences, psychiatric treatments, and whether they went on to marry a "gender-appropriate" partner. Yes, you heard that right. These were male patients who transitioned to female. In the eyes of these researchers, they were healthy if they went on to marry a man. Back then, transition was viewed through a strict binary lens of male and female. No room for non-binary. And the drive to transition was seen as a kind of sexual fetish, rather than an identity. Paul McHugh wrote in 2006 that there were only two kinds of transgender men. Some were, in his words, guilt-ridden homosexuals who thought they could have sex with men with a clear conscience they became a woman. The rest were heterosexual men who saw themselves as lesbians and fantasized about having sex with a woman as a woman.
KELLIE NEWSOME: The researchers did not look at subjective outcomes like depression or anxiety. In their view, distress about gender was not the problem. It was their inability to conform to society’s norms, and that is how they judged the success of surgery. If these measures seem archaic, the scoring system was more so. Patients lost the same number of points for going to jail as they did for starting outpatient psychotherapy.
CHRIS AIKEN: Here's what they found. At first glance, the surgery seemed to work. All groups improved with time, but the ones who transitioned saw greater improvements on this roughshod scale. But that didn’t pass statistical tests. The confidence intervals were too wide in the group that transitioned – meaning the outcomes were all over the place, even if they looked good on average. In the end, the only group with statistically significant improvements in adaptation were the ones who didn’t transition. But the bigger take-home in this blur of data is that it’s impossible to draw conclusions from a poorly controlled study with an unvalidated rating scale, a small sample size, and a 50% drop out rate.
KELLIE NEWSOME: But for the authors, the results were definitive. Dr. Meyer told the New York Times that "surgery is not a proper treatment for a psychiatric disorder," and that transgender people have "severe psychological problems that don't go away following surgery." Shortly after the study was completed, the Johns Hopkins board voted to ban gender-affirming surgery at the hospital in 1979. The building was demolished. In its place, Dr. McHugh oversaw construction of a psychiatry-neurosciences tower. But as the walls were crumbling, something else was taking place in California that would build them back in a different form.
CHRIS AIKEN: While Johns Hopkins was closing its clinic, delegates were gathering in San Diego for the Sixth International Gender Dysphoria Symposium. There, they ratified the first formal guidelines on gender-affirming care — what we now know as the WPATH guidelines.
KELLIE NEWSOME: WPATH worked with the DSM committee to introduce a new diagnosis for the 1980 edition: Gender Identity Disorder, hoping that this formal diagnosis would improve access to treatment. In 2013, the DSM committee changed name to Gender Dysphoria, making it one of the only entries in the DSM without the word "disorder" in the title. This was a radical idea – that the problem was not in the person’s identity, but in the distress they felt by being in the wrong body. From that viewpoint, the goal is not to change the mind but the body. Psychotherapy is not necessary. And that is how the WPATH guidelines stand today – they no longer require psychotherapy before transitioning.
CHRIS AIKEN: That isn't just a philosophical position, it's grounded in evidence, though the evidence is not robust. Psychotherapy may reduce associated symptoms of gender dysphoria like depression and anxiety – the results are mixed here, and the studies are few. But the bigger point is that psychotherapy doesn’t change the person’s identity. And some studies point to worse outcomes when patients are encouraged to accept their assigned gender.
LINDSEY SPERO: “ I lived 20-plus years in a home and within a family that not only did not affirm me, but I knew that I was the last thing from safe to come out to. And after, several, several rounds of conversion therapy and, and several years of a lot of that, I was kicked out, without access to gender-affirming care, without a community who affirms me, I don't think I would still be alive. I felt like at multiple times within those 20 years that I could not go on anymore, and I did attempt to take my own life.”
CHRIS AIKEN: That was Lindsey Spero, who transitioned from female to male after going through conversion therapy in his youth. Next week, we'll take a closer look at the science of gender identity and what the current WPATH guidelines say about assessing patients before transition. And now, a research update.
KELLIE NEWSOME: Today's study is the first large, phase III trial of mirtazapine in methamphetamine use disorder. Two earlier trials were small and focused exclusively on men who have sex with men. That’s a shift – usually we have to wait to see data in under-represented groups. This time, it’s the other way around. The study was published by Rebecca McKetin and colleagues in JAMA Psychiatry, funded by the Australian government, whose country has the highest per-capita methamphetamine use in the world. The US follows closely, with particularly high rates in West Virginia, the Appalachians, and the Sunbelt states.
CHRIS AIKEN: Three hundred thirty-nine Australian adults with methamphetamine use disorder were randomized to mirtazapine 30 mg daily or placebo for three months. The results favored mirtazapine, which resulted in few days of use by 7 out of 28 days as opposed to 5 out of 28 days. It’s a modest but meaningful difference for a population with few treatment options. The benefit was independent of mirtazapine's antidepressant or sedating effects. How does it work? Likely by easing withdrawal symptoms and modulating reward pathways. What are the risks? Weight gain – 10% of patients in this trial – and sedation.
KELLIE NEWSOME: If you like this podcast, leave us a review in the Apple store. Or subscribe online with the promo code PODCAST to get $30 off your first year's subscription — and help us stay among the small number of publications, like Current Affairs, New Philosopher, and Practical Farm Ideas, that operate without commercial support.
CHRIS AIKEN: Last week, we covered a controversial study that found little change in children's mental health after taking puberty-suppressing hormones for gender dysphoria. The author of the study worried that the results would be weaponized against patients, but as I read the study, I wondered what Dr. Olson-Kennedy was afraid of. Negative studies are common in psychiatry, and one study is not going to rock the boat when there are dozens to pool together in a systematic review. And anyway, no one expects gender transition to cure all mental woes. Simply resolving the gender dysphoria ought to be enough. But I was wrong. Gender dysphoria isn't like other psychiatric conditions, where we carefully weigh the accumulating evidence. This is a field where politics can overpower science, and a single study can bring the house down. That is what happened in 1979, when a paper appeared in the Archives of General Psychiatry titled Sex Reassignment: Follow-up.
KELLIE NEWSOME: To understand that paper, we need to go back to November 1966. In England, the Beatles began recording Sgt. Pepper's Lonely Hearts Club Band, featuring a song about a woman named Rita who pays for her own dates and looks “a little like a military man.” In California, Ronald Reagan is elected Governor, promising to restore law and order to the student protests at UC Berkley. In China, the Red Army is rooting out class enemies of the Cultural Revolution, including gay and transgender people whom they attack as "bourgeois degenerates." And in Maryland, Johns Hopkins opens the first center for gender affirming surgery in the U.S.
CHRIS AIKEN: At the press conference inaugurating the opening, plastic surgeon John Hoopes declared that psychiatrists had "tried repeatedly to treat these people without surgery, and the conclusion is inescapable that psychotherapy has not so far solved the problem — perhaps we should consider changing the body to fit the mind." Applications from prospective patients poured in, but the clinic was selective — only about 3% of applicants were approved for surgery. Psychiatrists served as gatekeepers. And one psychiatrist was determined to lock the gates entirely.
KELLIE NEWSOME: In 1975, Paul McHugh moved to Johns Hopkins to chair the department of psychiatry. He came with the expressed purpose of bringing down the Gender Identity Clinic, accusing them of “cooperating with a mental illness.” And in that effort, he found an unlikely ally: John Hoopes — the same plastic surgeon who had opened the clinic a decade earlier. Hoopes had grown disillusioned. He began describing patients as "hysterical masochists" and the surgery as an artificial façade. McHugh echoed that sentiment, writing that the surgery only turned them into “caricatures of women,” as if the true measure of success was whether these post-surgical patients conformed to the doctor’s ideal of a woman. Together, McHugh and Hoopes commissioned a study to prove the surgery didn't work.
CHRIS AIKEN: The study compared patients who applied for surgery but were declined by the examining committee to those who received the operation. It’s an unfair comparison, but one that likely favors the ones deemed mentally healthy enough to go through the operation. But about half of the ones who were sent away by Johns Hopkins went on to have the surgery somewhere else, creating a third group for comparison, as well as a testament to their determination. The study was small. They followed 50 patients for two to five years, measuring what the researchers considered markers of psychological adjustment: arrest records, employment history, how often they changed residences, psychiatric treatments, and whether they went on to marry a "gender-appropriate" partner. Yes, you heard that right. These were male patients who transitioned to female. In the eyes of these researchers, they were healthy if they went on to marry a man. Back then, transition was viewed through a strict binary lens of male and female. No room for non-binary. And the drive to transition was seen as a kind of sexual fetish, rather than an identity. Paul McHugh wrote in 2006 that there were only two kinds of transgender men. Some were, in his words, guilt-ridden homosexuals who thought they could have sex with men with a clear conscience they became a woman. The rest were heterosexual men who saw themselves as lesbians and fantasized about having sex with a woman as a woman.
KELLIE NEWSOME: The researchers did not look at subjective outcomes like depression or anxiety. In their view, distress about gender was not the problem. It was their inability to conform to society’s norms, and that is how they judged the success of surgery. If these measures seem archaic, the scoring system was more so. Patients lost the same number of points for going to jail as they did for starting outpatient psychotherapy.
CHRIS AIKEN: Here's what they found. At first glance, the surgery seemed to work. All groups improved with time, but the ones who transitioned saw greater improvements on this roughshod scale. But that didn’t pass statistical tests. The confidence intervals were too wide in the group that transitioned – meaning the outcomes were all over the place, even if they looked good on average. In the end, the only group with statistically significant improvements in adaptation were the ones who didn’t transition. But the bigger take-home in this blur of data is that it’s impossible to draw conclusions from a poorly controlled study with an unvalidated rating scale, a small sample size, and a 50% drop out rate.
KELLIE NEWSOME: But for the authors, the results were definitive. Dr. Meyer told the New York Times that "surgery is not a proper treatment for a psychiatric disorder," and that transgender people have "severe psychological problems that don't go away following surgery." Shortly after the study was completed, the Johns Hopkins board voted to ban gender-affirming surgery at the hospital in 1979. The building was demolished. In its place, Dr. McHugh oversaw construction of a psychiatry-neurosciences tower. But as the walls were crumbling, something else was taking place in California that would build them back in a different form.
CHRIS AIKEN: While Johns Hopkins was closing its clinic, delegates were gathering in San Diego for the Sixth International Gender Dysphoria Symposium. There, they ratified the first formal guidelines on gender-affirming care — what we now know as the WPATH guidelines.
KELLIE NEWSOME: WPATH worked with the DSM committee to introduce a new diagnosis for the 1980 edition: Gender Identity Disorder, hoping that this formal diagnosis would improve access to treatment. In 2013, the DSM committee changed name to Gender Dysphoria, making it one of the only entries in the DSM without the word "disorder" in the title. This was a radical idea – that the problem was not in the person’s identity, but in the distress they felt by being in the wrong body. From that viewpoint, the goal is not to change the mind but the body. Psychotherapy is not necessary. And that is how the WPATH guidelines stand today – they no longer require psychotherapy before transitioning.
CHRIS AIKEN: That isn't just a philosophical position, it's grounded in evidence, though the evidence is not robust. Psychotherapy may reduce associated symptoms of gender dysphoria like depression and anxiety – the results are mixed here, and the studies are few. But the bigger point is that psychotherapy doesn’t change the person’s identity. And some studies point to worse outcomes when patients are encouraged to accept their assigned gender.
LINDSEY SPERO: “ I lived 20-plus years in a home and within a family that not only did not affirm me, but I knew that I was the last thing from safe to come out to. And after, several, several rounds of conversion therapy and, and several years of a lot of that, I was kicked out, without access to gender-affirming care, without a community who affirms me, I don't think I would still be alive. I felt like at multiple times within those 20 years that I could not go on anymore, and I did attempt to take my own life.”
CHRIS AIKEN: That was Lindsey Spero, who transitioned from female to male after going through conversion therapy in his youth. Next week, we'll take a closer look at the science of gender identity and what the current WPATH guidelines say about assessing patients before transition. And now, a research update.
KELLIE NEWSOME: Today's study is the first large, phase III trial of mirtazapine in methamphetamine use disorder. Two earlier trials were small and focused exclusively on men who have sex with men. That’s a shift – usually we have to wait to see data in under-represented groups. This time, it’s the other way around. The study was published by Rebecca McKetin and colleagues in JAMA Psychiatry, funded by the Australian government, whose country has the highest per-capita methamphetamine use in the world. The US follows closely, with particularly high rates in West Virginia, the Appalachians, and the Sunbelt states.
CHRIS AIKEN: Three hundred thirty-nine Australian adults with methamphetamine use disorder were randomized to mirtazapine 30 mg daily or placebo for three months. The results favored mirtazapine, which resulted in few days of use by 7 out of 28 days as opposed to 5 out of 28 days. It’s a modest but meaningful difference for a population with few treatment options. The benefit was independent of mirtazapine's antidepressant or sedating effects. How does it work? Likely by easing withdrawal symptoms and modulating reward pathways. What are the risks? Weight gain – 10% of patients in this trial – and sedation.
KELLIE NEWSOME: If you like this podcast, leave us a review in the Apple store. Or subscribe online with the promo code PODCAST to get $30 off your first year's subscription — and help us stay among the small number of publications, like Current Affairs, New Philosopher, and Practical Farm Ideas, that operate without commercial support.
