This is a very significant case. At stake is whether bans on sex discrimination in the United States also include discrimination on the basis of sexual orientation and gender identity. Dr McHugh's expertise is helpful in questioning a so-called scientific imperative for gender affirmation. (Footnotes and references have been removed and the text has been slightly abridged.)

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Sex refers to the two halves of humanity, male and female. It is well defined based on the binary roles that males and females play in reproduction. "In biology, an organism is male or female if it is structured to perform one of the respective roles in reproduction. This definition does not require any arbitrary measurable or quantifiable physical characteristics or behaviors, it requires understanding the reproductive system and the reproduction process."

The structural difference for the purpose of reproduction is the only "widely accepted" way of classifying the two sexes. "This conceptual basis for sex roles is binary and stable, and allows us to distinguish males from females on the grounds of their reproductive systems, even when these individuals exhibit behaviors that are not typical of males or females."

Sex is not and cannot be "assigned at birth," despite the assertions of the American Medical Association (AMA), the American Psychiatric Association (APA), and Respondents. The language of "assigned at birth" is purposefully misleading and would be identical to an assertion that blood type is assigned at birth. Yes, a doctor can check your blood type and list it. But blood type, like sex, is objectively recognizable, not assigned. In fact, the sex of a child can be ascertained well before birth.

"Gender identity" has no bearing on a male's or a female's sex. Stephens [legal team] maintains that, although in every biological and physiological way a man, Stephens is really a woman. Stephens felt a deep affinity towards things that are culturally and stereotypically associated with girls. But Stephens was not, and is not, a girl no matter how many of the stereotypes about girls Stephens adopts and no matter how deeply Stephens believes that affinity for those stereotypes about females transforms Stephens into a female.

A boy mind in a girl body?

The "popular notion regarding gender identity" that says a person has a "boy mind in a girl body" or vice versa is merely an idiom used by a person seeking to describe some type of distress to others. Just as we have seen before during the height of the discredited multiple personality disorder era, such testimonials are not truth, even if one asserts it as a truth claim. Such a "view implies that gender identity is a persistent and innate feature of human psychology." But based on "the neurobiological and genetic research on the origins of gender identity, there is little evidence that the phenomenon of transgender identity has a biological basis." There are problems with the methodological limitations of any imaging study that assesses "girl brain" and "boy brain" theories:

[I]t is now widely recognized among psychiatrists and neuroscientists who engage in brain imaging research that there are inherent and ineradicable methodological limitations of any neuroimaging study that simply associates a particular trait, such as a certain behavior, with a particular brain morphology. (And when the trait in question is not a concrete behavior but something as elusive and vague as "gender identity," these methodological problems are even more serious).

[Therefore] there are no studies that demonstrate that any of the biological differences being examined have predictive power, and so all interpretations, usually in popular outlets, claiming or suggesting that a statistically significant difference between the brains of people who are transgender and those who are not is the cause of being transgendered or not -- that is to say, that the biological differences determine the differences in gender identity -- are unwarranted. In short, the current studies on associations between brain structure and transgender identity are small, methodologically limited, inconclusive, and sometimes contradictory.

In short, science does not support the notion that gender identity is an innate, immutable physical property of human beings. One's sense of self and one's desire to present to others as a member of the opposite sex have no bearing whatsoever upon the objective biological reality that one is male or female.

Even if evidence existed that brain studies showed differences, which they do not, it would not tell us whether the brain differences are the cause of transgender identity or a result of identifying and acting upon their own stereotypes about the opposite sex, through what is known as "neuroplasticity."

Regardless of the extent transgender identities and aspects of the brain could correlate in some way, none of this speaks to the question of biological sex. Even if there was a biological basis for people to think they're the opposite sex, that does not make them so.

No matter how difficult the condition of gender dysphoria may be, nothing about it affects the objective reality that those suffering from it remain the male or female persons that they were in the womb, at birth, and thereafter -- any more than an anorexic's belief that she is overweight changes the fact that she is, in reality, slender.

Gender identity is not immutable, but is based on persons' beliefs associating themselves with whatever stereotypes they have about people of the opposite sex. It is a subjective perception not limited to the two sexes, but expands to categories other than male or female. Contrarily, sex is not a belief. It is an objective and scientifically demonstrable reality.

Stephens, as well as the APA and AMA, asserts that "everyone has a gender identity, which is 'one's internal, deeply held sense of gender.'" The APA's and the AMA's proffered descriptions of gender identity operate, in all essentials, analogous to a religious belief system. But neither the sincerity of a religious belief nor the sincerity of a person's beliefs about gender identity determine reality. Even the Sixth Circuit noted that gender identity has an "internal genesis that lacks a fixed external referent," and much like religion, should be "authenticat[ed]" through professions of identity rather than "medical diagnoses." But because it is more like a belief system, it does a great disservice to everyone, those suffering with gender dysphoria and others who are affected, to treat gender identity like sex. A person is either a man or a woman, regardless of what anyone -- including that person -- happens to believe.

Sex is not a social construct

Some of the errors described above may have led to the Sixth Circuit's mistaken conclusion that employers that have sex-specific policies based on their employees' sex instead of their gender identity "necessarily" rely on "stereotypical notions of how sexual organs and gender identity ought to align." However, the exact opposite is true. Gender identity is a social construct that stands in contradistinction to sex. The biological reality of sex is not a stereotype or social construct.

The irony of course is that labeling sex itself as an illicit stereotype turns everything on its head and actually elevates stereotypes as a reason to treat members of the same sex differently. An employer that has sex-specific policies would be treating all employees equally based on their sex. But, an employer who instead, had "gender identity-specific" policies, would by definition be treating employees of the same sex differently, and basing the different treatment on socially constructed sex stereotypes.

Sex matters in various contexts. Getting the definition wrong affects those areas. If the definition of "sex" is rewritten to mean "gender identity," doing so both deconstructs the meaning of "sex" and undermines the ability to account for those situations where the distinctions between the two halves of humanity matter.

In addition to bodily privacy in locker rooms, restrooms, and changing facilities (where sex distinctions are crucial based on the bodily differences between the sexes, which accounts for separate facilities in the first place) or the ability to maintain competitive athletic environments for females (again due to bodily differences), we must maintain both the language and the legal construct to recognize sex in other settings such as where strip searches must occur. An inability to do so will put those being searched -- including children -- in situations where a person of the opposite sex (who identifies with their sex) conducts the search.

Similarly, if we are to disconnect sex from our anatomical differences, other unreasonable demands will be made of persons, such as beauticians in the business of waxing being asked to wax the genitals of a man who identifies as a woman. Even our understanding of sexual orientation is based on sex, not gender identity. Because distinctions based on sex matter in myriad contexts (many of which may only be discovered as the consequences of this experiment unfold), this Court should be slow to muddle the definitions of sex and gender identity.

Treating gender dysphoria

While this case involves the question of whether the term "sex" in federal law means gender identity or includes gender identity, the AMA asks the Court to consider the policy implications, namely the notion that protections under Title VII are necessary to advance the treatment goals of those with gender dysphoria. It claims that science shows that transgender individuals benefit from being affirmed in their beliefs about their sex, from social transition, from hormonal interventions, and from surgeries.

However, these professional associations rely on mere testimonials rather than evidence-based medicine. They treat the supposed benefits of gender affirmation as fact, rather than a clinical judgment call. And we ought not make policy decisions in the name of science when the kind of evidence necessary to support these "treatments" simply does not exist. Instead, those who are affirmed in their gender beliefs progress from social transition to surgical interventions at their peril. Indeed, if the evidence shows us anything, it indicates that those who progress all the way through surgery fare poorly.

Gender affirmation and social transition

The AMA suggests that the many difficulties that are sadly experienced by those who identify with the opposite sex are caused by social stigma. What is necessary, they claim, is that those with gender dysphoria be affirmed in their beliefs. From there, the protocol calls for three phases: (1) social transition, (2) hormone therapy, and (3) surgical interventions.

However, subjecting gender dysphoric persons to this protocol is risky because there is little evidence that social transition is the panacea that the AMA makes it out to be. Often it is a self (or therapist) fulfilling prophecy. Worse, gender affirmation does not end with social transition, but leads to medical and surgical interventions. Even the World Professional Association for Transgender Health (WPATH) itself admits that "no controlled clinical trials of any feminizing/masculinizing hormone regimen have been conducted to evaluate safety or efficacy in producing physical transition."

Moreover, some patients wish to detransition, and "the potential that patients undergoing medical and surgical sex reassignment may want to return to a gender identity consistent with their biological sex suggests that reassignment carries considerable psychological and physical risk." This also "suggests that patients' pre-treatment beliefs about an ideal post-treatment life may sometimes go unrealized."

This protocol begins with the notion that gender affirmation is necessary in order to avoid social stigma. And while we should all agree that all persons should be treated with respect, blame should not be laid at the feet of friends, relatives, or co-workers who believe that social transition may not be in a person's best interest. In fact, even in environments that are fully supportive of transition, "a large number of people who have the surgery . . . remain traumatized -- often to the point of committing suicide."

The most thorough follow-up of sex reassigned people -- extending over thirty years and conducted in Sweden, where the culture is strongly supportive . . . documents their lifelong mental unrest. Ten to 15 years after surgical reassignment, the suicide rate of those who had undergone sex- reassignment surgery rose to 20 times that of comparable peers. Clearly poor outcomes cannot be blamed on lack of acceptance.

Contrary to what the AMA proposes, there is insufficient evidence that any phase of treatment is helpful. Instead, some studies suggest that not following the protocol may have more positive results. It is unacceptable to have lower standards of care for a group already at a far greater risk for psychological problems and suicide. Doctor Susan Bewley told the BBC in a Newsnight special that "We must not miss the opportunity to do good research now, helping . . . concerned clinicians actually deal with the uncertainty of what they're doing."18

Failing to address root issues

Previous editions of the American Psychiatric Association's Diagnostic & Statistical Manual of Mental Disorders, as recent as 2013, listed "gender identity disorder" rather than "gender dysphoria." And until recently, clinical distress was not a part of the diagnosis criteria, indicating professional concern for anyone who manifests an incongruence between biological sex and gender identity -- not just those who experience distress.

People who identify as transgender "suffer a disorder of 'assumption' like those in other disorders familiar to psychiatrists." "The 'disordered assumption' of those who identify as the opposite sex . . . is similar to the faulty assumption of those who suffer from anorexia nervosa, who believe themselves to be overweight when in fact they are dangerously thin."

Dr Anne Lawrence, who is transgender, has argued that body integrity disorder, which involves a person who identifies as disabled and feels trapped by a fully functional body, draws parallels to gender dysphoria. Dr. Josephson describes this type of phenomenon as a "delusion . . . [to] a fixed, false belief which is held despite clear evidence to the contrary."

To illustrate in another way, someone with anorexia may feel overweight and know that they are not. As a result, they struggle with their feelings until they come to believe that they are fat. Similarly, someone with gender dysphoria begins by feeling like they are the opposite sex but know they are not. They then struggle with those feelings until they come to believe they are the opposite sex and try to act accordingly.

Yet, just as you would not treat an anorexic person's delusion by helping that person to lose weight, it is unwise to treat a gender dysphoric person's delusion by encouraging them to indulge in that falsehood. When false beliefs about reality are not addressed by helping people come to accept reality, their false beliefs "are not merely emotionally distressing . . . but also life-threatening." Treatment should "assess and guide them in ways that permit them to work out their conflicts and correct their assumptions."

Instead, some in the scientific community want gender dysphoric individuals to "find only gender counselors who encourage them in their sexual misassumptions." Indeed, there are no other health issues where doctors modify healthy bodies to align with a mind's misperception or where they would call a healthy body a "birth defect" rather than working with the mind to accept bodily reality.

A more appropriate treatment would be to show gender dysphoric individuals that feelings are not the same as reality. "Psychiatrists obviously must challenge the solipsistic concept that what is in the mind cannot be questioned."

"Disorders of consciousness, after all, represent psychiatry's domain; declaring them off- limits would eliminate the field." Indeed, when treatment is focused on helping patients align their subjective gender identity with their objective biological sex by use of normal counseling methods such as talk therapy, gender dysphoria has proven to be significantly reduced.

Given the harms of the next two phases of the WPATH protocol, social transition should not be encouraged. Not only does it not address the root issues causing clinical distress, it also makes it more likely for patients to forge ahead into hormone therapy and physical alteration of their body.

The harm of hormone therapy

Hormone therapy has not been proven to improve the overall quality of life or reduce psychological symptoms or other negative outcomes. At best, the scientific data is inconclusive. At worst, it is harmful.

Hayes Inc., a company which focuses on "unbiased" "evidence-based assessments of health technologies and clinical programs to determine their impact on patient safety," gave the quality of evidence for hormone treatment its lowest possible rating. The Hayes Directory explains that some groups advocate for hormonal treatments as "medically necessary treatments." However, these treatments do "not readily fit traditional concepts of medical necessity since research to date has not established anatomical or physiological anomalies associated with [gender dysphoria]."

After reviewing 21 studies, the Hayes Directory concluded that the studies "were inconsistent with respect to a relationship between hormone therapy and general psychological health, substance abuse, suicide attempts, and sexual function and satisfaction." For quality of life, "[d]ifferences between treated and untreated study participants were very small or of unknown magnitude," suggesting little evidence of effectiveness.

Alarmingly, and contrary to the AMA's and the APA's narrative, the Hayes Directory reports that the studies show the prevalence of suicide attempts was not affected by hormone therapy.

Additionally, hormone therapy increased risk of cardiovascular disease, cerebrovascular and thromboembolic events, osteoporosis, and cancer. No proof of improved mortality, suicide rates, or death from illicit drug use was observed.

Similarly, in 2010, Mohammad Hassan Murad of the Mayo Clinic studied the body of research involving the outcomes of hormonal therapies used in advance of sex reassignment procedures. He found there to be "very low quality evidence" that hormonal interventions "likely improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."

Without well-designed studies that provide conclusive results that treatments designed to block natural maturation of the body are helpful, public policy should not be used to mandate the kind of gender affirmation that result in such treatments.

The harm of sex reassignment surgery

Scientific support for sex reassignment surgery is equally lacking. After one of the first studies addressing the efficacy of surgical transition occurred in 1979, Johns Hopkins Medical Center discontinued surgical intervention. A study performed by Jon K. Meyer and Donna J. Reter found that when individuals who underwent sex reassignment surgery reported improvement, it did not rise to the level of statistical significance, but those who opted not to undergo sex reassignment surgery showed statistically significant improvement. Those authors concluded that "sex reassignment surgery confers no objective advantage . . . ."

Other studies have shown negative consequences. In a study performed by Cecilia Dhejne with the Karolinska Institute and Gothenburg University in Sweden, it was found that "transsexual individuals had an approximately three times higher risk for psychiatric hospitalization than the control groups, even after adjusting for prior psychiatric treatment." "[M]ost alarmingly, sex reassigned individuals were 4.9 times more likely to attempt suicide and 19.1 times more likely to die by suicide compared to controls."

In 2009, a longitudinal study performed by Annette Kuhn in Switzerland found that over a 15-year period the quality of life for 55 sex-reassigned individuals was "considerably lower" than females who had pelvic surgery for other reasons. Moreover, "none of the studies included the bias-limiting measures of randomization . . . and only three of the studies included control groups." While the Mayo Clinic report indicated that 80% of sex reassigned patients reported improvement in gender dysphoria, 78% improvement in psychological symptoms, and 80% improvement in quality of life, none of the studies included the bias-limiting measure of randomization or control groups. Thus, the claim that improvement occurred after surgical transition is merely comprised of testimonials.

Another Hayes Directory report, this time addressing surgical interventions, concluded that there is not good scientific evidence to support surgical modifications. It concluded that the "evidence was too sparse to allow any conclusion regarding the comparative benefits of different [sex reassignment surgery] procedures."The "very low" quality of evidence was "due to limitations of individual studies, including small sample sizes, studies lacking evaluating any one outcome, retrospective data, lack of randomization, failure to "blind outcome," lack of a control or comparator group, and other problems. Unbiased assessment of the claims leads to the following conclusion:

The scientific evidence summarized suggests we take a skeptical view toward the claim that sex reassignment procedures provide the hoped-for benefits or resolve the underlying issues that contribute to elevated mental health risks among the transgender population. While we work to stop maltreatment and misunderstanding, we should also work to study and understand whatever factors may contribute to the high rates of suicide and other psychological and behavioral health problems among the transgender population, and to think more clearly about the treatment options that are available.

There is no good evidence that this dramatic surgery produces the benefits espoused by the AMA. There is, however, evidence that surgical modification poses health risks.20 Moreover, one unalterable consequence is that anyone who goes through with "sex change" surgery will be sterilized. Without firm scientific evidence, the medical and psychiatric community should not follow the WPATH protocol to progress from social transition, to medical interventions, and ultimately to surgery, which therefore calls into question the AMA's claim that government policy should require persons to affirm others' beliefs that they are the opposite sex.

Other procedures

Another Hayes Directory report reviewed all the relevant literature on ancillary procedures and services for the treatment of gender dysphoria, such as voice training, facial modifications, reduction of the Adam's apple, and other cosmetic surgeries to feminize or masculinize features. These too do "not readily fit traditional concepts of medical necessity since research to date has not established anatomical or physiological anomalies associated with [gender dysphoria]."

As with its conclusion on hormone therapies as well as surgical modifications, the Hayes Directory gave the scientific support for these treatments its lowest possible rating. The studies not only had limitations such as small sample sizes, separating procedures by category, and a lack of control or comparator group, they also measured "technical success and patient satisfaction" while ignoring "overall measure of well-being." In fact, the Hayes Directory found that the "overall individual well- being is unknown."

In conclusion, relevant to the Court's present concern, the AMA's suggestion that gender identity should be read into sex protections in furtherance of treatments goals for those suffering from gender dysphoria is misplaced. Given that the stated goal of transitioning people with gender dysphoria to their identified gender is to improve their overall well- being, altering a person's body, sometimes permanently, should not be done without solid scientific evidence of its benefits. Since the known studies only measure self-reported satisfaction with the aesthetic result, and not improved quality of life, mental state, or overall well-being, these procedures should not be recommended treatment.

How about children?

... If this Court, for policy reasons, were to redefine sex to mean gender identity, that definition will impact children in educational settings. Indeed, such an interpretation has been used to force some schools to open privacy facilities to the opposite sex. Such an approach not only subjects students to sexual harassment through the systematic loss of bodily privacy, but such treatment is actually contraindicated for those children who suffer from gender dysphoria.

Gender dysphoric children subjectively feel they are the opposite sex based on what they think it is like to be the opposite sex. Other than in this area, children who have persistent beliefs that do not conform with reality are not encouraged to persist in those beliefs. In the same way, counselors should assess and guide those with gender dysphoria in ways that permit them to work out their conflicts and correct their false assumptions.

Until recently when ideological imperatives took the place of scientific evidence, this is precisely what was done for gender dysphoric children. Dr. Kenneth Zucker, a leading authority on gender dysphoria, successfully helped children through psychosocial treatments like talk therapy, organized play dates, and family counseling. A follow-up study revealed that only 3 of 25 female children continued to struggle with gender dysphoria.

In contrast to the belief that we and our children are best served by observing and cooperating with our observable biological reality, the AMA and the APA say that children who suffer from gender dysphoria can relieve that dysphoria through social transition, puberty blockers, cross-sex hormones, and eventually surgically altering sex-based anatomy to look like that of the opposite sex. This progression, however, is unhelpful since children who identify with the opposite sex but who are allowed to go through puberty without puberty blockers and cross-sex hormones cease identifying with the opposite sex 70% to 98% of the time for males and 50% to 88% of the time for females.

Conversely, when children are encouraged to progress through social transition to puberty blockers, they tend to persist with their dysphoria. Yet no longitudinal, controlled studies support gender-affirming treatments for gender dysphoria. The problem is that while some persons who go through all these stages may report satisfaction with an eventual surgery, they may still suffer the same morbidities and experience startlingly high rates of suicide and attempted suicide.

Not only does the progression from affirmation to surgery result in increased psychological problems, but the evidence is insufficient to suggest that each step along the way is safe and efficacious. While affirming a child's gender identity may appear a compassionate way to help a child during a painful and confusing experience, it is not.

There is an obvious self-fulfilling nature to encouraging young [gender dysphoric] children to impersonate the opposite sex and then institute pubertal suppression. . . . All of his same-sex peers develop into young men, his opposite sex friends develop into young women, but he remains a pre-pubertal boy. He will be left psycho-socially isolated and alone.

Repetition affects the structure and function of the brain through what is called neuroplasticity. Thus, children who are encouraged to live as the opposite sex may be increasingly unable to live as their own sex. As a result, some children who would otherwise overcome their gender dysphoria may be unable to do so.

Puberty blockers pose other health risks. For example, they impair bone growth, decrease bone accretion, interfere with brain development, and impair fertility.

Rather than encouraging the progression through these stages, children would be better served at the very first stage by not encouraging their belief that they are the opposite sex. If they are allowed to progress through puberty, the issues of gender dysphoria naturally resolves the vast majority of the time. Therefore, a more cautious approach, supplemented by individual or family psychotherapy would be most compassionate. In short, the notion that science requires gender affirmation, and thus for policy reasons gender identity should be read into the word "sex" is misplaced.

Activism, not medicine

We should treat everyone with dignity and respect, but there is significant disagreement in the particulars of what is helpful to those identifying as transgender and what should be asked of others in the process. Though some research has been conducted regarding treatment of those who identify as transgender, when "research touches on controversial themes, it is particularly important to be clear about precisely what science has and has not shown."

As discussed above, the existing studies on treatment of and outcomes for transgender persons are poor support for gender affirmation or the progression to medication or surgery, yet the large medical associations like the AMA and APA ardently endorse these practices. Unfortunately, ideology rather than science is driving the support. And since dissent is systematically eliminated and those who disagree are loudly condemned, the kind of research necessary to inform the public debate is not occurring.

"Consensus" in the scientific community is more contrived than scientific. "Mainstream clinicians and scientists who consider gender discordance to be a mental disorder have been deliberately excluded in the makeup of the steering committees of academic and medical professional societies which are promulgating guidelines that were previously unheard of." Id. For instance, when the Endocrine Society created its guidelines, "the panel selected included only those who supported the emerging practices and attempts by many of the endocrinologists present to raise concerns were muted."

The American Psychiatric Association, in the most recent edition of DSM, removed gender identity disorder and replaced it with gender dysphoria.

"Changes in diagnostic nomenclature in this area were not initiated through the result of scientific information but rather the result of cultural changes fueling political interest groups within professional organizations." Naturally, considering identity with the opposite sex to be a mental disorder is incompatible with social affirmation. Therefore, the nomenclature was changed so that only the anxiety caused by the incongruity between sex and identification is considered to be a disorder.

Yet, since we would neither affirm a person who believed themselves disabled when they have a fully functional body nor suggest surgeries to disable such persons to conform their bodies to their beliefs, we should carefully consider the approach we take concerning persons' subjective beliefs about their sex.

Indeed, if something conflicts with our understanding of biological facts, is inconsistently applied, and defies common sense, we should demand more evidence to suggest that these factors are all pointing the wrong direction. The support for gender affirmation, medications, and surgery come from testimonials, but that is not evidence. It would be akin to asking consumers if they are satisfied with their vehicles, and publishing those testimonies, claiming it to be evidence of quality or reliability. It is not as if we do not know how to get good data, such as with control studies, but we refuse to conduct good science or follow the science -- and that has everything to do with activism and ideology -- not good medicine.

As confirmation of the power of activism over science, those who follow the science are often shut down. Consider Lisa Littman, Assistant Professor of the Practice of Behavioral and Social Sciences at Brown University, who coined the phrase "rapid onset gender dysphoria." She made the observation based on various parental reports that those who identify as transgender during or after puberty appear to have underlying and preexisting psychiatric conditions, and she called for more research. After members of the transgender community criticized the research, Brown quickly distanced itself. And ultimately, she lost a consulting job due to the research.

Jeffrey S. Flier, M.D., former dean of Harvard Medical School, wrote, "I have never once seen a comparable reaction from a journal within days of publishing a paper that the journal already had subjected to peer review, accepted and published. One can only assume that the response was in large measure due to the intense lobbying the journal received. . . ."

Similarly, Dr. Kenneth Zucker, a leading expert on gender dysphoria in children, who headed the Child Youth and Family Gender Identity Clinic in Toronto, was removed from his clinic on baseless charges and the clinic shut down. Zucker helped to write the "standards of care" guidelines for the WPATH and led the group that developed criteria for gender dysphoria used in DSM-5. But as others increasingly pushed gender affirmation and social transition, Zucker's clinic continued to be cautious, suggesting that it was better to "help children feel comfortable in their own bodies," since it recognized the malleable nature of gender identity in children and the likelihood that it will resolve. Activists saw this as a rejection of children's gender identities.

As a result, the parent organization running the gender identity clinic interviewed activists and clinicians critical of the clinic and fired Zucker and shut down the clinic based on false claims. Yet for the many families who benefited from Zucker's work and others who would benefit, "a sustained campaign of political pressure" took away their options to find help feeling comfortable with their own bodies.

This, of course, was not the first time science took the back seat in the practice of medicine. Trendy diagnoses and treatments have lead us astray in the past. The practices of eliciting alternative personalities from patients as well as lobotomy had many testimonials about their benefits to patients, but testimonials do not form the substance of evidence- based medicine. Thus we should be especially cautious when activism or ideology has the upper hand over science.

Ultimately, poor science exacerbated the suffering of those treated by lobotomy or diagnosed with multiple-personality disorders in the past, and appears to be doing the same with those suffering from gender dysphoria today.

As a matter of science, sex and gender identity are so distinct that gender identity cannot properly be read into or replace sex. And with regard to the underlying policy question, there is no reliable evidence that gender affirmation -- understood as asking or requiring persons to affirm others' beliefs that they are the opposite sex -- is efficacious.

The original text of Dr McHugh's essay may be consulted HERE.

Dr. Paul McHugh, M.D. is the University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine. From 1975 until 2001, Dr. McHugh was the Henry Phipps Professor.