Published by the Students of Johns Hopkins since 1896
May 26, 2020

Trans postdoc claims psychiatrists were biased against him

Does academic freedom clash with identity at Hopkins?

By RUDY MALCOM | May 5, 2020

hospital

PUBLIC DOMAIN / edited by David Hilden

Paul McHugh, former chief of psychiatry at Hopkins Hospital, believes that being transgender is a mental disorder.

Content warning: The following article includes topics some readers may find triggering, including transphobia and suicide.

“It was one of the first graduations Ron Daniels was at. I got to shake his hand. Underneath the cap and gown, I was wearing a dress. At another graduation, I was wearing a shirt and tie. It felt full circle. At Hopkins, I had gotten a bachelor’s degree and a PhD — and a new body and soul. Everything was possible here, but on the flip side, when I followed someone else’s advice blindly, it almost killed me.”

These are the words of a postdoctoral fellow at the School of Medicine (JHM), who graduated from there in 2017 and from the Whiting School of Engineering in 2010. Henry, who identifies as transgender, requested a pseudonym because he is not out to many people in his life. The News-Letter granted Henry anonymity to protect his privacy. 

He alleged that between 2015 and 2018, clinicians at JHM’s University Health Services (UHS) discriminated against him on the basis of his gender identity. 

In November 2019, after conducting a three-month investigation, the Office of Institutional Equity (OIE) found neither clinician guilty of violating University policy. Henry believes, however, that both clinicians had implicit biases from training as residents under Dr. Paul McHugh, Hopkins Hospital’s psychiatrist-in-chief from 1975 to 2001. 

“At first it seemed like all of this was accidental,” Henry said. “But the road to hell is paved with good intentions.”

McHugh’s views on gender affirmation surgery clash with a strong consensus in the peer-reviewed literature, along with every major medical association in the United States.

In 1979, McHugh shut down the Hospital’s program for gender affirmation surgeries, which had been the nation’s first. McHugh believes that being transgender is not a biological phenomenon but instead a mental illness. By contrast, the World Health Organization voted last year to stop classifying transgender people as having a disorder.

“I would’ve thought that, with the LGB community, we’ve had quite a good record. We were the first to absolutely insist in offering care to them when they were being treated like lepers.”


The Office of Institutional Equity (OIE) did not find a preponderance of evidence (a greater than 50 percent chance) that Dr. Paul Rivkin, one of Henry’s clinicians, shared McHugh’s views or that they affected the care he provided Henry. 

OIE did not investigate whether McHugh’s position on treating transgender patients influenced that of the other clinician, Dr. Elizabeth Kastelic, who was named a top therapist by the magazine Washingtonian in 2009.

In an interview with The News-Letter, McHugh described Kastelic and Rivkin, both influential psychiatrists, as “two brilliant doctors.” They declined to comment out of respect for patient privacy, which ethically and legally prevents them from sharing their version of events. 

McHugh argued in an interview with The News-Letter that his perspective should not affect the University’s standing in the queer community. He noted that, during the AIDS epidemic in the 1980s, Hopkins was one of the few psychiatric hospitals to admit HIV-positive patients. 

“I would’ve thought that, with the LGB community, we’ve had quite a good record. We were the first to absolutely insist in offering care to them when they were being treated like lepers,” he said. “The most important things that happened in my 26 years at Hopkins have very little to do with the transgender issue.”

Wendy Marie Ingram, a postdoctoral fellow in Psychiatric Epidemiology at the Bloomberg School of Public Health who studies LGBTQ mental health, criticized McHugh’s views on transgender care.

“It’s horrifying to me that this is still a belief being held and propagated by someone at an institution I’m at — in a department that I very much love, respect and appreciate,” she said.

Despite OIE’s findings, Henry asserts that McHugh’s views led Rivkin to prescribe him dangerously high doses of lithium. Though lithium is used to treat bipolar disorder, he noted that subsequent mental health professionals found that he does not have this condition. 

The first time Henry overdosed on lithium, he developed hypothyroidism. The second time, which was after he came out to Rivkin, he suffered from hallucinations and nearly attempted suicide. 

“He kept telling me, ‘It’s because you have a mood disorder that you feel this way.’ That was the rationale for each medication,” Henry said. “It turns out that you can’t just bounce back from those. My mind has never been quite the same.”

To this day, he suffers from the cognitive effects of lithium toxicity and often struggles to verbalize his thoughts. Altogether, he said, Rivkin prescribed him 11 medications.

In an interview with The News-Letter, Vice Provost for Student Health and Well-Being (SHWB) Kevin Shollenberger shared plans to expand unconscious bias training for SHWB employees. Henry and members of the Johns Hopkins Postdoctoral Association advocated for this in January. 

“We’re working with the offices who deliver those trainings to help develop a refresher that the current staff could take on a yearly basis,” Shollenberger said.

Shollenberger added in an email to The News-Letter that the Center for Transgender Health also facilitates Safe Zone trainings and cultural competency trainings for providers. 

The Center opened in 2017, 16 years after McHugh stepped down from his position, ending the four-decade hiatus from gender affirmation surgeries at Hopkins. Currently a University Distinguished Professor of Psychiatry, McHugh stated that he does not oppose the transgender community.

“I don’t think that anyone could believe for a moment that these matters of my opinion represent biases or hatred against anybody, but rather the point of view of a doctor who has a vast experience in psychiatric matters,” he said. “The transgender issue is still a fraught issue in medicine today... We’re still in the midst of the debate.” 

JHM officials announced their plans to open the Center in a letter that voiced their support of the LGBTQ community. They clarified that when “individuals associated with Johns Hopkins exercise the right of expression, they do not speak on behalf of the institution.”

While the University has affirmed its unequivocal support for LGBTQ students, including those who are transgender, Henry emphasized the potential risk of its support of academic freedom. The University protects freedom of inquiry and expression, he noted, but it does not guarantee the right to harass.

“The thing that I’ve always loved about Hopkins is that it’s the first research university in the U.S. Everything is about testing your hypothesis and having a debate,” Henry said. “But in psychiatry, when you’re a patient, you don’t have that same footing. You can’t go up against a physician.”

“I don’t want to be involved.” 

Henry first sought psychiatric help at UHS during the summer of 2014. Because he’d been avoiding seeing a specialist for stomach issues, his primary care physician suggested he address his anxiety. 

In the closet, Henry initially avoided discussing his gender identity with Rivkin.

“I knew that other trans people were even worried about coming out to the therapists and psychiatrists at UHS because of fear of what they would think of them,” he said.

During August 2015, Henry was hospitalized for depression. He decided he could no longer remain in the closet and, soon after, came out as transgender to Rivkin.

“The first thing the psychiatrist said was, ‘I don’t want to be involved.’ He said, ‘But I hope I can still treat you for your mood disorder,’” Henry said. “I tested his hypothesis for a long time that I was mentally ill, but then I started going off those medications... and I gradually felt better and better.”

OIE confirmed that Rivkin told Henry that he didn’t “want to be involved” and that he referred to Henry as having “gender identity disorder” rather than “gender dysphoria.” The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 2013, replaced “gender identity disorder” with “gender dysphoria” to avoid stigma and ensure clinical care for transgender and gender-nonconforming individuals.

However, Rivkin insisted that he wasn’t anti-transgender, Henry said.

“The question is, ‘When does neutrality become a bias if you stop taking into account someone’s full self?’” Henry said. “You could be on the rooftop of a parking garage, almost jumping, because you’re hallucinating from a medication you were over-prescribed — because a person wasn’t willing to believe that part of you exists.”

Henry’s stomach issues turned out to be endometriosis. Many undergo hysterectomies to alleviate the painful symptoms caused by the disorder, for which there is no cure.

“If OIE were to investigate a hate crime — if someone says, ‘I did the crime, but it didn’t come from a hateful place,’ then OIE would be like, ‘Okay, it’s not our jurisdiction.’”


Rivkin saw the hysterectomy, Henry claimed, as transition-related, even though it was meant to address a separate health issue, and told him that he’d regret the procedure because he would want to have children later. OIE confirmed that Rivkin discussed the reproductive implications of getting a hysterectomy. 

OIE also found that Rivkin made a remark about not being able to change the arm-length ratio in men as compared to women. Nevertheless, OIE found that Rivkin’s comments related to Henry’s gender identity did not meet the level of severity or pervasiveness required to hold Rivkin responsible for creating a hostile environment for Henry. 

“If OIE were to investigate a hate crime — if someone says, ‘I did the crime, but it didn’t come from a hateful place,’ then OIE would be like, ‘Okay, it’s not our jurisdiction,’” Henry said. “He told me once that there’s not enough evidence that transitioning helps people, and when interviewed by OIE, my therapist recently confirmed that that was his stance. However, he denied it, and OIE said, ‘There’s no evidence that he said that to you.’”

Henry added that Rivkin refused to write him a letter necessary to have his Employer Health Programs (EHP) insurance cover hormone treatment and gender affirmation surgeries. According to OIE, this was more likely based on Rivkin’s lack of subject matter experience than on Henry’s gender identity. 

Rivkin advised him, Henry said, to contact Sex and Gender Clinic, a specialty clinic at Hopkins Hospital.

“Transgender people who go there get the same evaluations as sex offenders and pedophiles... which is not a standard in the field,” Henry said. 

On its website, the clinic lists its primary areas of focus as “Intimate Relationship Issues (Sexual Dysfunctions),” “Gender Identity” and “Psychosexual Disorders.”

“We respect the dignity of every patient and the legitimacy of what each person is experiencing,” the website reads. “We provide a nonjudgmental environment in which individuals and their families are safe to explore the choices that they feel will be best for them.”

Vice Provost for Student Health and Well-Being (SHWB) Kevin Shollenberger and Interim Vice Provost for Institutional Equity Joy Gaslevic could not comment on the clinic’s patient evaluation methods, they explained in an email to The News-Letter, because the clinic is separate from the SHWB. 

OIE found that Rivkin’s suggestion qualified as a referral. However, Henry received no further information about the clinic from Rivkin, who had told him he didn’t “want to be involved” in his gender identity.

McHugh considered how such a remark could affect a doctor-patient relationship. 

“I’ve seen many patients who claim to be transgender, and if they’re adults and of clear mind, as far as I’m concerned, they can say whatever they want. I don’t object to them,” he said. “Doctors and patients have a perfect right to decide whether they’re a good fit or not.”

Henry noted, however, that to see a therapist at UHS, you must also see a psychiatrist. He liked his therapist but worried that if he stopped seeing Rivkin, EHP insurance would deny his claims. 

“As long as we didn’t talk about transgender issues, we got along pretty well. We shared a love of mathematics and logic. I always really liked him... But any time that we got on the topic of health care, I’d start getting upset. I’d have therapy sessions about my psychiatry sessions,” he said. “I was thinking, ‘Maybe I’m not severely mentally ill like he thinks I am.’”

While working on his thesis during the fall of 2017, Henry feared the opposite was true. Driving home, he discovered that his night vision was impaired. This led him to worry that Rivkin would prevent him from receiving gender affirmation surgery.

“I was used to being told all the time that something was wrong with me. One evening, as the sun was going down, I pulled up in front of my apartment complex door, which has a glass window. I saw the reflection of my car; one of my headlights was out,” he said. “That’s why I couldn’t see, but I thought it was me.”

Accountability

After graduating from JHM at the end of 2017, Henry hoped for a fresh start. He stopped seeing Rivkin and began seeing Dr. Elizabeth Kastelic. 

According to Henry, Kastelic refused to administer a new evaluation after he came out to her as transgender, recommended he go to a psychiatrist outside UHS if he disagreed with his diagnosis (of bipolar disorder) and told him that UHS “does not provide transgender treatment.” 

OIE did not find that these claims occurred as alleged and/or were based on a legally protected characteristic.

At the beginning of 2018, Henry left UHS. He explained that this allowed him to find LGBTQ-friendlier treatment elsewhere. During May 2019, a report was filed with OIE to investigate whether Kastelic and Rivkin engaged in discrimination or harassment. 

OIE decided to move forward with the case on August 22, 2019, the same day that McHugh submitted an amicus curiae brief to the U.S. Supreme Court in the R.G. & G.R. Harris Funeral Homes Inc. v. Equal Employment Opportunity Commission (EEOC) case.

“I told OIE that maybe Paul McHugh should be the epicenter of this investigation,” Henry said.

In his brief, McHugh characterized certain claims about gender identity as based not on science but on ideology.

While the EEOC maintains the Obama-era position that discrimination based on gender identity is considered sex discrimination, the Department of Justice under the Trump administration reversed this policy in October 2017, leaving transgender workers unprotected by federal civil rights law.

The EEOC case will determine whether Title VII prohibits discrimination based on gender identity. A decision is expected in the coming weeks.

“If you get harmed as a patient here, you have no protection.”


Henry called on OIE to devise explicit guidelines for what constitutes discrimination and harassment. He also highlighted the need for clarity on how to report medical malpractice, which OIE does not specifically include in its jurisdiction. 

On Jan. 23, Shollenberger convened a meeting where Johns Hopkins Postdoctoral Association (JHPDA) Co-President Kynon Jade Benjamin raised concerns about holding UHS accountable. Two weeks later, Interim Vice Provost for Institutional Equity Joy Gaslevic explained in an email to Henry that patients may file complaints about quality of care concerns, which OIE does not specifically investigate, through Patient Relations at JHM. 

Patient Relations told him to address his concerns with OIE this March, Henry said. At the end of April, however, Patient Relations began assembling a team to review Henry’s concerns. 

“Since 2015, no one ever mentioned Patient Relations... Maybe I should’ve gone to a lawyer right away, but I kept thinking that it would get better,” he said. “But it seemed like the more Hopkins knew about it, the more they tried to look the other way.”

In an email to The News-Letter, Shollenberger and Gaslevic detailed how the University handles quality of care concerns.

“[OIE] handles matters of protected status-based discrimination, harassment and retaliation... including matters that occur in a medical setting, but is not charged with handling patient quality of care concerns,” they wrote. “Student Health and Well-Being (SHWB) is actively working to clarify the avenue and process for addressing any quality of care complaints that may arise with SHWB services.”

Initially, Henry questioned how to report Kastelic, given that she, as JHM’s director of University Mental Health Services, would be the person to contact. 

This August, Shollenberger brought all nine divisions of the University under a single, centralized system for primary care and health and wellness programs. Henry characterized this as a step toward improved accountability.

Going forward, he would also like an internal mechanism for the University to pay for his cognitive-related medical care. A medical malpractice lawyer with whom he spoke described winning a psychiatric case against Hopkins as nearly impossible. 

“They said, ‘Hopkins has really good lawyers. If you try to go up against them, they’ll make your life miserable. They’ll try to attack your character. They’ll use everything in your life to discredit you.’ The University has all the resources. They can drag this on for years,” Henry said. “If you get harmed as a patient here, you have no protection.”

The future of LGBTQ care at Hopkins

At the same meeting in January, Benjamin proposed that UHS hire people with more LGBTQ-specific knowledge in order to help transgender patients understand how to access Employer Health Programs insurance. 

On Feb. 10, UHS Director Spyridon Marinopoulos emailed Benjamin and Henry, among others, informing them that student health insurance had been updated in October 2019 to make transgender health care more accessible. Henry noted that transgender patients had been unfairly charged copayments in the past. 

During the spring of 2019, the UHS website had listed transgender health care as an example of “a condition we do not have expertise or resources to treat.” 

This specification went online, Henry said, after a separate postdoctoral fellow demanded transparency upon being denied transgender health care. By the summer of 2019, though, it was removed from the website, Henry said. 

“Especially when it comes to psychological and psychiatric conditions, it can be really detrimental to the therapeutic alliance between a patient and their provider if they don’t get what you’re going through.”


Henry underscored the need for the University to expand its LGBTQ resources. Wendy Marie Ingram, a postdoctoral fellow in Psychiatric Epidemiology at the Bloomberg School of Public Health (JHSPH), agreed with Henry. 

Ingram, who studies LGBTQ mental health, noted that individuals from the LGBTQ community have higher rates of psychiatric conditions like depression.

“It’s not because they have this sexual orientation or gender identity; it’s the treatment that they experience from society, including from mental health and medical providers,” she said. “While LGBTQ individuals are an arguably small percentage of the Hopkins population, it stands to reason that they are going to be an over-represented group within those seeking psychological and psychiatric care. It absolutely behooves and is a responsibility of the University to know that and to invest in specialized care.”

Benjamin Ackerman, co-president of the JHSPH Mental Health Grad Network, echoed Ingram’s sentiments.

“Hiring providers who specialize in seeing patients with diverse backgrounds and diverse identities is important,” he said.

He noted that, in this way, undergraduate resources are more developed than those available to East Baltimore campus students. 

In an email to The News-Letter, Shollenberger agreed, sharing his plans to further improve SHWB services. Achieving this goal, he stated, could be delayed by the ongoing coronavirus (COVID-19) pandemic. Due to predicted large budgetary shortfalls, the University will severely restrict all faculty and staff hiring in the upcoming academic year.

“For Homewood and Peabody, we have a therapist who liaisons with LGBTQ Student Life and coordinates services for LGBTQ students providing both individual counseling and opportunities for support groups,” Shollenberger wrote. “As part of the reorganization of SHWB we are exploring how we can expand these services beyond the Homewood campus. Planned enhancements to SHWB services may be impacted due to financial constraints as a result of COVID-19. We nevertheless remain fully committed to meeting the needs of the community.” 

In a separate email to The News-Letter, he and Gaslevic stressed the University's efforts to promote inclusivity for members of the LGBTQ community. 

“For example, in the past year, the University has established support for preferred name use in university systems and continues to explore ways to further support pronoun use in systems,” they wrote. “Shollenberger... ensures that all SHWB providers stand ready to support LGBTQIA+ community members and provide individualized care to patients.”

Overall, Shollenberger has endeavored to reduce barriers to care since August, when he became the inaugural vice provost for SHWB. This year, he made SilverCloud and TalkNow, two online mental health resources, free and available to Hopkins students and trainees. 

Ackerman reflected on Shollenberger’s goal of implementing structural changes to health and wellbeing services. 

“There’s a lot of promise in Shollenberger’s vision to increase access to resources to students. It’s a really big endeavor, and there still remain some challenges in getting there,” he said. “But it’s certainly an effort that is very much needed. It’s great that the University is finally responding to the call for better and increased access to resources to address mental health.” 

These resources, Henry said, must evolve to serve the University’s increasingly diverse population. 

“At first I thought it just happened to me — that it wasn’t going to happen to anybody else, but then I started hearing other people’s stories, where medication was on the higher side. That’s when I realized that there was a pattern,” he said. “Maybe it wasn’t really so much LGBTQ-specific. Maybe there’s just a tendency to assume things about people without taking into account their life experiences.”

Ingram, who helped found the JHSPH Mental Health Grad Network, observed that in addition to members of the LGBTQ community, students of color and students with disabilities have faced similar struggles to Henry’s while seeking help. 

“Especially when it comes to psychological and psychiatric conditions, it can be really detrimental to the therapeutic alliance between a patient and their provider if they don’t get what you’re going through,” she said. 

Although McHugh acknowledged the importance of the therapeutic alliance, he argued that ultimately the physician’s role is to share their wisdom with patients.

“Many people are uncomfortable with opinions that doctors give them. The doctor’s job is to help them understand why the answer is for their benefit,” he said. “Lots of people hear bad news from doctors, don’t hear what they’d like to hear. Doctors are not here just to make people feel good after every interaction.”

During the August of 2016, McHugh co-authored an article in a conservative magazine arguing that the safety of puberty-blocking treatments for gender dysphoria had been insufficiently studied. McHugh also wrote in the report that children who identify as a different gender will likely grow out of it. 

“I tried to live with that hypothesis in mind. It never really worked out.”


Over 600 members of the Hopkins community signed a petition calling on the University to publicly disavow the report. Inspired by the petition, the Human Rights Campaign (HRC) deducted 25 points out of a potential 100 from Hopkins Hospital’s Healthcare Equality Index, which scores health-care facilities on their treatment and inclusion of LGBTQ patients. 

In April 2017, McHugh expressed his belief to The News-Letter that the HRC was disregarding his right to academic freedom by trying to push Hopkins to condemn his controversial paper.

Henry recalled attempting to apply the concept of academic freedom to his own life.

“In the research context, we’re always testing a hypothesis. We should be open to changing our model around the data. Back then, I felt the same way, where for the longest time in my life, I tried to live as a girl and follow what other people expected, like when I was told I had a mood disorder,” he said. “I tried to live with that hypothesis in mind. It never really worked out.”

His experiences at UHS, he maintained, are the legacy of McHugh’s views. As SHWB expands, Henry believes that Hopkins will need to reconcile a growing tension between academic freedom and identity. 

Since October 2019, the University has been searching for a permanent successor to its first vice provost for diversity and inclusion and chief diversity officer, who joined and left Hopkins in October 2017 and July 2019, respectively. 

“I do believe that the administration wants people’s lives to be better here,” Henry said. “But with the current system we have, I don’t think it can be done.”

Lists of transgender resources and of LGBTQ crisis hotlines and services are available at the Office of LGBTQ Life website and the Out in Science, Technology, Engineering, and Mathematics website.

Counselors at the Crisis Text Line can be reached anytime by texting HOME to 741741 .

If you or someone you know is suffering, the National Suicide Prevention Lifeline provides free, 24/7 confidential support through a toll free hotline at 1-800-273-8255.

Corrections: According to Henry, Rivkin told him “there’s not enough evidence” — not “no evidence” — that transitioning helps people.”

The original version of this article referred to the meeting in January with Shollenberger as the “JHPA meeting.” The correction abbreviation of the Johns Hopkins Postdoctoral Association is the JHPDA, and the meeting included other individuals involved with LGBTQ advocacy at Hopkins besides the JHPDA. 

The original version of this article incorrectly characterized the JHPDA’s efforts regarding insurance changes. They did not involve covering copayments.

The News-Letter regrets these errors.

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