Summary of the Argument

The District Court judge wrote that “Mr. Kluge believes that God created mankind as either male or female, that this gender is fixed in each person from the moment of conception, and that it cannot be changed, regardless of an individual’s feelings or desires.”¹ Plaintiff’s religious beliefs thus prohibit him from addressing a transgender student by their preferred name of by a gendered pronoun which does not correspond to that student’s sex. He is conscientiously unable, in other words, to lie, even at the price of his livelihood.

Amici take no position on divine causality. They write, not as theologians, but as men and women of science. And the scientific truth is just as Mr. Kluge describes: sex is binary, innate, and immutable.

To lay the groundwork for understanding the nature and risks of gender- affirming treatment, Amici first explain the incorrigibility of sex and its overriding importance to science and the practice of medicine. Next, Amici describe the concepts of “gender” and “gender identity,” and the problems caused by conflating them with sex. Finally, Amici detail the different methods of caring for children with gender dysphoria and outline the grave medical risks associated with gender- affirmative treatment.

To lay the groundwork for understanding the nature and risks of gender- affirming treatment, Amici first explain the incorrigibility of sex and its overriding importance to science and the practice of medicine. Next, Amici describe the concepts of “gender” and “gender identity,” and the problems caused by conflating them with sex. Finally, Amici detail the different methods of caring for children with gender dysphoria and outline the grave medical risks associated with gender- affirmative treatment.

Argument

This structural difference for the purpose of reproduction is the only widely accepted way of classifying the two sexes.

This definition of sex is clear and stable. It does not require any arbitrary measurable or quantifiable physical characteristics of behaviors to apply. It requires instead a basic understanding of the reproductive system and the reproduction process.

Human beings are either male or female.⁴ This characteristic is innate. “[I]n mammals the sexual fate of the organism is cast at fertilization.”⁵ The decisive event is the contribution by the father of an “x” or a “y” chromosome: an “X-carrying sperm produces a female (XX) embryo, and a Y-carrying sperm produces a male (XY) embryo. Therefore, the chromosomal sex of the embryo is determined at fertilization.”⁶ “Males have XY chromosomes, and females have XX chromosomes. Sex makes us male or female.”⁷ 

Although this sexual dimorphism is typically not apparent to observation until approximately twelve to fourteen weeks of pregnancy, the development of the human being as specifically male or female begins at the onset of life. Even though the very young embryo carries within it the primitive structure of portions of both reproductive systems, male embryos secrete testosterone from their testicles, which leads to the development of the male reproductive system. Embryonic and thereafter fetal development as male or female is directed from within, according to genetic information present in the zygote from the moment of fertilization. There are only and precisely two gametes, two sex cells —male and female. There is no third option, no middle way.

Contrary to an increasingly popular myth, no one can change his or her sex. Sex is, in other words, immutable.⁸ Some people have surgeries which they describe as a “sex-change” operation. Lately, these procedures have acquired in some ideological quarters the name, “gender-confirming” procedures. No matter what they are called, however, they never succeed in providing any patient with the sex organs or the reproductive capacity of a member of the opposite sex. Doing that is simply impossible: no man who “transitions” to female ever actually does so, and vice versa. All that these surgeries can possibly provide are poorly to non-functional pseudo-genitalia. These operations nonetheless invariably succeed in making anyone who undergoes them permanently sterile.

Even if modern medicine improved its capacity to engineer sex organs, these operations could still never “change” anyone’s sex. The reason is that no “sex- change” operation even touches the vast multitude of other sex-differentiated characteristics of the human body, psychology, and emotional make-up. The indelible biological differences between male and female go far beyond external genitalia. In fact, they inhabit every one of the human body’s trillions of nucleated cells. “Every cell in your body has a sex—making up tissues and organs, like your skin, brain, heart, and stomach. Each cell is either male or female depending on whether you are a man or a woman.”⁹  Sex is in this most profound way indelibly imprinted upon every part of our bodies.

There are many subsequent events in development that may alter the phenotypic expression of sex. None changes anyone’s sex.

II.  Science and Medicine Depend Upon a Correct Understanding of Sex.

That sex is binary, innate, and immutable is a fundamental reality that anyone doing basic or applied research in the biological sciences (or who teaches them), and anyone who practices medicine, including psychiatry (or who teaches it), presupposes, recognizes, uses, and applies. Keeping up a robust and uncompromised awareness of sex as binary, innate, and immutable is essential to successful work and ethical medicine in all these areas.

The reason why this clarity about sex is crucial can be simply stated: each person’s indelible reality as male or female pervades the body throughout the life of the individual and is essential for healthy maturation. Until recently, the role of the chromosomes that determine sex had been thought to be strictly limited to the development of reproductive tissues and organs.¹⁰ Now, “growing evidence attests to the fact that sex chromosomes exert their influence in every cell of the body, and every cell has a sex.”¹¹  Each and every cell of a woman’s body is female. Each and every cell of a man’s body is male. While the commonalities and similarities of men and women still far outweigh the differences, keeping in mind the differences are essential to sound research and competent clinical practice.

In an important 2017 journal article, Tracy Madsen and her colleagues wrote:

The completion of the human genome project in 2003 also influenced our understanding of the effects of sex on human biology and disease through the sequencing of all human genes, including those located on sex chromosomes. Understanding the location and function of genes located on sex chromosomes throughout the body’s cells, not just in reproductive organs, was critical to understanding that biologic sex not only affects human health and disease via sex steroids and reproductive organs but also affects cells in all organ systems.¹²

This now-universal recognition of sex differences realization goes beyond the truths that only women may develop ovarian cancer and only men, prostate cancer. This realization includes, but transcends, the easily noticed differences in the way that many other common ailments, such as autism and alcoholism, affect men and women. Some common respiratory illnesses, affecting millions of Americans each year, bear very differently upon women than upon men. For example, “genetics . . . play a significant role in the development of [Chronic Obstructive Pulmonary Disorder].”¹³ 

It is therefore unsurprising that the National Institutes of Health requires consideration of sex in its life sciences research proposals. The NIH states that “[t]here is growing recognition that the quality and generalizability of biomedical research depends on the consideration of key biological variables, such as sex.”¹⁴ “Failure to account for sex as a biological variable may undermine the rigor, transparency and generalizability of research findings.”¹⁵ 

The NIH sharply distinguishes sex from “gender.” It defines sex as “a biological variable defined by characteristics encoded in DNA, such as reproductive organs and other physiological and functional characteristics,” and “gender” as “social, cultural, and psychological traits linked to human males and females through social context.”¹⁶ The NIH also stresses the far greater significance of sex to “gender” in research. “Consideration of sex may be critical to the interpretation, validation, and generalizability of research findings. Adequate consideration of both sexes in experiments and disaggregation of data by sex allows for sex-based comparisons and may inform clinical interventions.”¹⁷ 

Ineradicable sex differences pervade human beings in ways that go beyond the natural science of our bodies. Research in and the practice of psychiatry and psychology depend upon undiminished clarity about the identity of a patient or a research subject as male or female, unchanged from the moment of conception. Clarity and consistency about sex is crucial in psychiatry and psychology for two connected reasons. First, each person’s indelible reality as male or female pervades the psyche, as well as the body, throughout the life of the individual. Second, there is overwhelming scientific evidence to suggest that men and women are markedly different across a whole range of cognitive and personality traits, elements of emotional make-up, and aspects of psychological well-being.

Among the most salient of these sex differences are those pertaining to sex. The social scientific evidence about frequency of masturbation and pornography use, the number of sexual partners, as well as more qualitative research into the nature of male and female sex drive and their preferred place of sex within the overall pattern of the relationship, confirms that nature, and not just nurture or socialization, explains differences between men and women.¹⁸ That the paraphilias listed in the DSM-5 are, with the partial exception of sadomasochism, almost entirely male phenomena, is further evidence.¹⁹ It is perhaps most striking that pedophiles are almost all men.

III.  Neither “Gender” nor “Gender Identity” is Sex and Conflating the Terms Causes Confusion.

Someone’s “gender identity” has no bearing on that person’s sex. Madsen and her colleagues (who argue—unpersuasively, in our view—for greater recognition of the “gendering” nature of disease and health) say that “gender” is a “psychological and social construct referring to the attitudes, feelings, and behaviors that a person and his or her culture associates with a person’s gender concordant with his or her sex at birth.”²⁰  The NIH defines “sex” as “a biological variable defined by characteristics encoded in DNA, such as reproductive organs and other physiological and functional characteristics. Gender [on the other hand] refers to social, cultural, and psychological traits linked to human males and females through social context.”²¹ 

Sex is innate, fixed, and binary. “Gender identity” denotes a subjective and fluid belief system based on cultural constructs. 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 either male or female. The difference between sex and “gender” (and “gender identity”) is parallel to the difference between ontological realism (the view that reality exists independent of anyone’s thoughts or feelings about it), and a pronounced solipsism: reality is what one thinks or wishes it to be.

The terms “sex” and “gender” and “gender identity” are therefore not interchangeable or functionally similar. They surely are conceptually unrelated, even radically different. Adopting ideological language about gender and sex causes confusion, and not only within science and medicine.

In the school setting, for example, increased emphasis on “gender identity” is sure to confuse children. Policies that permit students to use an opposite-sex bathroom or opposite-sex pronouns reinforce false ideas about the nature of sex. A girl who asks to be treated at school as a boy, to be called “he” and “him” and use the boys’ bathroom and locker room, will be led to think that she can change her sex. And her peers, seeing teachers and administrators “affirming” the girl’s false belief, will be taught the same falsehood.

While the concept that a child could be a “boy in a girl body” (or vice versa) is scientifically untrue, the expression of that feeling is not. It is an idiom used by a person seeking to describe some type of distress to others. There is a diagnosis for this—gender dysphoria.

IV. Placing Safeguards around Students’ Entrance into Gender Affirmative Treatment Promotes Their Health and Safety.

When a child suffers from gender dysphoria, there are three general approaches to treatment.²² One is psychosocial treatment that helps the child align their internal sense of gender with their sex. Another would be to “watch and wait.” This approach allows time and maturity to help the young person align sex and gender through natural desistance, while providing psychological support and therapy as needed and addressing comorbidities. Emerging practice guidelines recommend a version of this called exploratory therapy, which “does not favor any particular outcome” but “aims to address the distress of gender dysphoric youth rather than correcting any sense of misalignment.”²³ The third and most drastic option is starting “gender affirmative treatment.”

Gender affirmative treatment consists of four interventions. First, a child socially transitions. Second, he or she is given puberty blocking medications, which deliberately induce hypogonadotropic hypogonadism, a disease state where the pituitary gland does not send the hormonal signals to the sex glands, preventing them from making testosterone or estrogen. Third, a child is given very high doses of the opposite sex’s hormones. Finally, the child undergoes surgical removal of sex organs and genitalia, such as a double mastectomy for girls or an orchiectomy for boys.

The policy at issue in this case revolves around the first intervention in gender affirmative treatment, social transitioning. Social transitioning may involve a child changing her name, pronouns, and appearance to “present” in line with her gender identity. This is an active intervention.²⁴

In the case presented here, the teacher was primarily concerned with not violating his religious beliefs. But the record reveals as well that he was motivated to avoid the harms that Brownsburg School policies would visit upon students who were treated as if they were members of the sex that they imagined themselves to be.²⁵ His proposed accommodation to refer to all students by their surnames reflects his desire to avoid precisely those harms.

This approach to school children who would repudiate their sex is medically sound. Research shows that a very high proportion of children who experience gender dysphoria will eventually desist, i.e., come to experience a realignment of their internal sense of gender and their body.²⁶  There is no way to know who will desist: “There are no laboratory, imaging, or other objective tests to diagnose a ‘true transgender’ child.”²⁷

Because the social transition process may solidify a child’s belief that they are in fact the opposite sex, it can itself be considered a form of iatrogenic harm.²⁸ That is, this type of treatment for gender dysphoria, rather than alleviating the distress, can lock in the gender incongruence.

That is not surprising. It is understandable that a child “presenting” as the opposite sex and reinforced by authority figures like teachers would believe that he or she is destined to go through puberty of the opposite sex. And it would be quite frightening for a boy who believes he is a girl to be turning into a man with all of the adult features that accompany manhood. And the girl who has become convinced that she is a boy will be frightened by the physical changes brought on by womanhood. This fear only increases the distress the child feels and convinces them they are in fact “trapped” in the wrong body.

Another reason to approach school gender-identity policies with caution is the exploding rate at which young people, especially girls, experience what has been termed “rapid-onset gender dysphoria.”²⁹ As teachers and administrators uniformly use preferred first names and pronouns, gender dysphoria may become more prevalent as “a catch-all explanation for any kind of distress, psychological pain, and discomfort . . . while transition is being promoted as a cure-all solution.”³⁰ Moreover, policies that uniformly allow children to jump to social transition may result in the neglect of other problems that should be addressed head-on, such as underlying mental health or family issues.³¹ 

V. Policies that Facilitate Social Transitioning Lead Students to Serious Harms from Further Gender-Affirming Interventions.

Beyond the harms associated with social transitioning, the three following stages of gender-affirming treatment each pose additional, grave risks to children. These risks are relevant because each step a child takes down the gender-affirming treatment road makes it much more likely they will persist in their gender dysphoria and move on to the next intervention. Recent evidence shows that “of the adolescents who started puberty suppression, only 1.9 percent stopped the treatment and did not proceed to [cross hormones].”³² Put simply, once a child is placed on the gender-affirming conveyer belt, they are unlikely to get off. Puberty blockers, rather than being a “pause” to consider aspects of mental health, are all too often a pathway towards future sterilizing surgeries.

Each intervention carries with it its own harms. Puberty blockers induce a disease state called hypogonadotropic hypogonadism. For females, this stops the ovaries from producing estrogen. For males, this stops the testicles from producing testosterone.

The third stage of gender affirmative therapy involves using hormones of the opposite sex at high doses to attempt to create secondary sex characteristics in the person’s body. Females are given high levels of testosterone. This leads to a much higher risk of a heart attack.³³ They are also susceptible to erythrocytosis, a condition of high red blood cell counts, which is an independent risk factor for cardiovascular disease and coronary heart disease.³⁴ Other risks to females taking high-dose testosterone include irreversible changes to the vocal cords, hirsutism, polycystic ovaries, clitoromegaly, atrophy of the lining of the uterus and vagina, and potentially higher risks for ovarian and breast cancer.³⁵ 

Males on cross sex hormones receive high doses of estrogen. This “treatment” induces hyperestrogenemia, the condition of elevated blood estrogens. Long-term consequences include increased risk of heart attack and death due to cardiovascular disease.³⁶ Also, “[t]here is strong evidence that estrogen therapy for trans women increases their risk for venous thromboembolism over 5 fold.”³⁷  Venous thromboembolism is a blood clot that develops in a deep vein and “can cause serious illness, disability, and in some cases, death.”³⁸ Other risks of high-dose estrogen for males include a 46-times higher risk of developing breast cancer.³⁹ 

Next, the fourth stage of gender-affirmative treatment is surgical alterations of the body to mimic features of the opposite sex. For females, this may include mastectomies, the surgical removal of what are otherwise healthy breasts. This surgery results in a permanent loss of the ability to breastfeed and significant scarring. Other types of surgery for females include those of the genitalia and reproductive tract. For example, the ovaries, uterus, fallopian tubes, cervix, and the vagina may be surgically removed. Removal of the ovaries results in sterilization.

Some defenders of social transition policies say that doing so is necessary to lower if not eliminate the risk that a gender dysphoric child might otherwise commit suicide. The scientific evidence suicide. The scientific evidence does not support such claims. On the contrary, one comprehensive study in Sweden examined data from 324 patients over a 30-year time period who had taken opposite sex hormones and undergone reassignment surgery.⁴⁰ When followed out beyond ten years, the sex-reassigned group had 19 times the rate of completed suicides and nearly three times the rate of all-cause mortality and inpatient psychiatric care compared to the general population of Sweden.⁴¹ More recently, a study of 315 adolescents aged 12 to 20 years old who were taking high-dose hormones of the opposite sex noted “death by suicide occurred in 2 participants.”⁴²

Conclusion

The policies imposed by Brownsburg schools upon Appellant institutionalize an ideology which places children who experience a sex-discordant gender identification to serious risk of irreparable bodily harm.

These policies are, moreover, based upon a lie; in fact, two of them. One is that someone can be born in the “wrong body.” The other is that one can change one’s sex. The first is a basic metaphysical mistake, for each of us is our body: one can no more be “born in the wrong body” than one can be born as the wrong person. The second is and forever shall be technically impossible.

1. Doc. 191 at 3 (quoting Filing No. 15 at 6), RSA-004. ↩︎
2. Bronwyn C. Morrish & Andrew H. Sinclair, Vertebrate Sex Determination: Many Means to an End, 124 REPRODUCTION 447, 447 (2002). ↩︎
3. Dagmar Wilhelm etal., Sex Determination and Gonadal
   Development in Mammals, 87 PHYSIOLOGICAL REVS. 1, 1 (2007); see also American Psychiatric Association, DIAGNOSTIC & STATISTICAL MANUAL OF MENTAL DISORDERS829 (5th ed. 2013) (“DSM-5”) (defining sex as the “biological indication of male and female (understood in the context of reproductive capacity)”); Aditi Bhargava, Arthur PArnold, et al., Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement, Endocrine Reviews, Volume 42, Issue 3, June 2021, Pages 219–258 . (Available at https://doi.org/10.1210/endrev/bnaa034.) ↩︎
4. “Intersex” is not an additional category that erodes our understanding of sex as male or female based on reproductive roles. “Intersex” is instead an anomalous condition that in fact underscores the norm of male and female. ↩︎
5. Wilhelm et al., supra, at 1.  ↩︎
6. T.W. Sadler, LANGMAN’S MEDICALEMBRYOLOGY 40 (2004). ↩︎
7. National Institutes of Health (NIH), How Sex and Gender Influence Health and Disease. (Available at https://orwh.od.nih.gov/sites/orwh/files/docs/SexGenderInfographic_11x17_508.pdf.) ↩︎
8. See Stephen B. Levine, Informed Consent for Transgendered  Patients,  45  J. SEX  & MARITAL  THERAPY  218–229  (2019) (“Biological sex cannot be changed.”) ↩︎
9. NIH, supra. ↩︎
10. See Neil A. Bradbury, All Cells Have a Sex: Studies of Sex Chromosome Function at the Cellular Level, in PRINCIPLES OFGENDER-SPECIFIC MEDICINE: GENDER IN THE GENOMIC ERA 285
    (Marianne J. Legato, ed., 3d ed. (2017). ↩︎
11. Id. ↩︎
12. Tracy Madsen et al., Sex- and Gender-Based Medicine: The Need for Precise Terminology, 1 GENDER & GENOME 122, 123 (2017). ↩︎
13. Id. ↩︎
14. NIH, Consideration of Sex as a Biological Variable in NIH-Funded Research (Available   at   https://orwh.od.nih.gov/sites/orwh/files/docs/NOT-OD-15- 102%20Guidance.pdf.) ↩︎
15. Id. ↩︎
16. Id. ↩︎
17. NIH, NIH Policy on Sex as a Biological Variable (Available at https://orwh.od.nih.gov/sex-gender/nih-policy-sex-biological-variable.) ↩︎
18. See Mark Regnerus, CHEAP SEX: THE TRANSFORMATION OF MEN, MARRIAGE, AND MONOGAMY 22–23, 140 (2017);
    Norman R. Brown & Robert C. Sinclair, Estimating Number of Lifetime Partners: Men and Women Do It Differently, 36 J. SEX RES. 292, 292 (1999) (analyzing why men tendto report more sexual activity than women).  ↩︎
19. See DSM-5, supra, at 685–705.  ↩︎
20. Madsen et al., supra, at 122, 124.  ↩︎
21. Consideration of Sex, supra, at 1. ↩︎
22. See Kenneth J. Zucker, Debate: Different Strokes for Different Folks, 25CHILD & ADOLESCENT MENTAL HEALTH 36 (2020).  ↩︎
23. See Sasha Ayad, M.Ed., LPC et al., A Clinical Guide for Therapists Working with Gender-Questioning Youth 1, 34 (2022). (Available at https://www.genderexploratory.com/wp-content/uploads/2022/12/GETA_ClinicalGuide_2022.pdf.) ↩︎
24. See NHS England, Interim Specialist Service forChildren and Young People with Gender Incongruence 13 (June 9, 2023) (“While there are different views on the benefits versus the harms of early social transition, it is important to acknowledge that it is not a neutral act.”) (Available at  https://www.england.nhs.uk/wp-content/uploads/2023/06/Interim-service-specification-for-Specialist-Gender- Incongruence-Services-for-Children-and-Young-People.pdf.)
    ↩︎
25. See 2-ER-193. ↩︎
26. See Jiska Ristori & Thomas Steensma, Gender Dysphoria in Childhood, 28 INT’L REV. OF PSYCHIATRY 13–20 (2016) (61– 98% desisted by adulthood); Devita Singh et al., A Follow-Up Study of Boys With GenderIdentity Disorder, 12 FRONTIERS IN PSYCHIATRY 1 (2021) (87.8% desisted). ↩︎
27. Michael K. Laidlaw et al., Letter to the Editor: Endocrine Treatment of Gender-Dsyphoria/Gender- IncongruentPersons, 104 J. Clinical Endocrinology & Metabolism 686 (2019). ↩︎
28. See Zucker, supra, at 36–37 (“Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-upstudies of children with gender dysphoria who did not receive this type of psychosocial  intervention  and,  oddly  enough,  might  be  characterized  as
    iatrogenic.”).  ↩︎
29. See Lisa Littman, Rapid-Onset Gender Dysphoria in Adolescents and Young Adults, PLOS ONE (2018). (Available at https://doi.org/10.1371/journal.pone.0202330.) ↩︎
30. Id. ↩︎
31. See APA, APA HANDBOOK OFSEXUALITY AND PSYCHOLOGY 257 (2014) (“Premature labeling of gender identity should be avoided,” as “[t]his approach runs the risk of neglecting individual problems thechild might be experiencing.”); Elisabeth DC Sievert et al., Not Social Transition Status,but Peer Relations and Family Functioning Predict Psychological Functioning in a German Clinical Sample of Children with Gender Dysphoria, 26 CLINICAL CHILD PSYCH. & PSYCHIATRY 79 (2021)(Available at https://doi.org/10.1177/1359104520964530.) ↩︎
32. See Bell v. Tavistock & Portman NHS Found. Tr. [2020] EWHC 3274(Admin) [57] ↩︎
33. See Talal Alzahrani et al., Cardiovascular Disease Risk
    Factors and Myocardial Infarction in the Transgender Population, 12 CIRCULATION: CARDIOVASCULAR QUALITY & OUTCOMES (2019). ↩︎
34. See Milou Cecilia Madsen et al., Erythrocytosis in a Large Cohort of Trans Men Using Testosterone, 106 J. CLINICAL ENDOCRINOLOGY & METABOLISM 1710 (2021); David R. Gagnon
    MD et al., Hematocrit and the Risk of Cardiovascular Disease, 127 AM. HEART J. 674(1994). ↩︎
35. See Hembree, supra, at 3880, 3886–87, 3892. ↩︎
36. See Michael S. Irwig, Cardiovascular Health in Transgender People, 19 REVS. ENDOCRINE & METABOLIC DISORDERS 243 (2018).  ↩︎
37. Id. ↩︎
38. Center  for  Disease  Control  and  Prevention,  What  is  Venous Thromboembolism?, CDC.gov. (Available at https://www.cdc.gov/ncbddd/dvt/facts.html. ↩︎
39. See Christel J M de Blok et al., Breast Cancer Risk in Transgender People Receiving Hormone Treatment, 365 BMJ 1652 (2019). ↩︎
40. See Cecilia Dhejne, Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery, 6 PLOS ONE (2011) (Available at https://doi.org/10.1371/journal.pone.0016885.) ↩︎
41. Id. ↩︎
42. Diane Chen, Ph.D. et al., Psychosocial Functioning in Transgender Youth After 2 Years of Hormones, 388 NEW ENGLAND J. MED. 240 (2023). ↩︎