That bit about Bill’s rejection — the killer merely thinks he’s trans — is a relic from an earlier, hard-to-imagine age, when patients’ claims of belonging to the opposite sex were apparently subjected to rigorous scrutiny, rather than being readily affirmed. Yet the film’s dialog fails the test of verisimilitude in one respect. By the time the events in Silence of the Lambs take place, in the 1980s, Johns Hopkins University’s sex-change clinic had been closed down.

Dr. Paul McHugh, then head of psychiatry at the Hopkins School of Medicine in Baltimore, made the decision to shutter it in 1979. The move “wasn’t controversial” at the time, McHugh tells me in a Zoom interview this week. There were dissenters, to be sure, not least John Money, the sexologist who’d established the unit a decade and a half earlier. But “all the other people at the hospital, even including many of the plastic surgeons, agreed.”

A colleague’s systematic follow-up study found that subjects who’d undergone reassignment didn’t show much by way of improvement in their “interpersonal relations” and overall well-being. In those days, McHugh recalls, the specialists who pioneered trans surgery didn’t really imagine that they were “turning a man into a woman.” They simply thought they’d make life “easier, more comfortable” for the patient. 

But if the intended effects failed to materialize, what was the point? The enterprise, he reflected later, was akin to “collaborating with madness.”

In the ensuing years, McHugh maintained a distinguished career at Hopkins, even founded a program on human flourishing. Beginning in the late 1990s, however, gender-activist pressure mounted on medical researchers and practitioners across the West. The psychiatric field, in particular, was called to ratify a pair of highly speculative claims: that gender is largely a social construct, unmoored from biology; and that some people are “born into the wrong body.”

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Both can’t be true at once. The second claim rests on the idea of gender identity as a meaningful, immutable characteristic of which a person can have a deep inner awareness. How can it then simultaneously be socially constructed? Nevertheless, many in the medical profession forced their minds to submit, the Law of Non-Contradiction be damned. Paul McHugh refused. After his term as department chair ended, in 2001, he continued to critique the new gender science, both through academic research and popular advocacy.

McHugh paid a price. By the mid-2010s, he’d emerged as the trans movement’s Public Enemy No. 1. The Human Rights Campaign in 2017 launched an entire website to “debunk” his work. The advocacy group GLAAD created an “accountability” profile on him (complete with an unflattering portrait) that busted him for claiming, among other things, that “gender ideology harms children,” and that transitioning kids is akin to performing liposuction on anorexics.

In 2016, The Advocate, an LGBT publication, described McHugh as a “notoriously antitransgender psychiatrist,” singling out his statements that “‘sex change’ is biologically impossible” and that “People who undergo sex-reassignment surgery do not change from men to women or vice versa.” A 2017 Washington Post article cheered the resumption of reassignment surgeries at Johns Hopkins, under the headline: “Long Shadow Cast by Psychiatrist on Transgender Issues Finally Recedes at Johns Hopkins.” 

Then, in 2022, Johns Hopkins established a special board to rename programs and buildings that “recognize individuals whose legacies may now be considered antithetical to our values.” Soon enough, a postdoctoral fellow petitioned the board to rename the Paul McHugh Program on Human Flourishing on account of “his transphobic and homophobic views,” as a campus paper tsk-tsked.

But then, as the “peak-woke” fever broke, gender ideologues began to suffer setbacks. In Britain and across Europe, youth gender clinics have come under intense scientific scrutiny, in some cases leading the authorities to shutter them. Global athletic bodies, including the Olympic Committee, are rewriting rules that allow biological men to compete in women’s sports. 

McHugh’s public reception altered once more, in tandem with these developments. In 2023, the university’s president, Ron Daniels, intervened to preserve McHugh’s name on his legacy program. “‘You can’t take the name off a program [associated with] an active faculty unless he’s had some infraction,’” McHugh paraphrases Daniels telling the university community. McHugh had a spotless record. Then, on Wednesday, the 94-year-old McHugh received the Medal for Intellectual Freedom from the American Academy of Sciences and Letters.

McHugh has returned from the cold, in short. “In your mid-90s,” he tells me, “you expect people to not find you interesting. So the very fact that we’re talking is kind of fun for me.” 

When Paul McHugh entered psychiatry, the battle over evidence-based medicine took a very different shape. It was the mid-1950s, when an Americanized, and particularly dull, brand of Freudian psychoanalysis almost totally dominated the profession. At Harvard Medical School, he recalls, “the brightest classmates of mine were drawn into psychiatry, psychoanalysis in particular. And I wanted to be with the bright boys, so I went along.”

As with every other branch of medicine, psychiatric training involved the memorization of a mountain of facts — which in those days, he says, meant “psychoanalytic facts.” But a Harvard mentor urged him to go in a different direction. The Freudians, the mentor told him, “get so tied up with themselves. They don’t know anything about the brain. You know, the brain must have something to do [with mental illness].” 

McHugh was impressed enough to take a detour into brain science. He also had a stint at King’s College London, studying under the legendary psychiatrist Sir Aubrey Lewis, who “showed me exactly how to take a case … in such a fashion that you began looking for evidence to prove one thing right or wrong.” This, contra the Freudian method, which, he argues, starts with theory — the Oedipus complex, repression, and so on — and then searches for evidence in the case.

Upon returning Stateside, he became a champion of experimental, evidence-first psychiatry — and made enemies of swaths of the profession. “I began challenging things,” he says, “and people got really mad. I was surprised by the Freudian orthodoxy.” Each time he was up for a post, some half a dozen psychoanalysts would show up — in person — to militate against McHugh getting it. “Imagine giving up a day or two’s work to stop a guy from getting a job!”

He rose all the same. One early position was chairman of psychiatry at the University of Oregon, where he encountered his first trans cases. An Oregon colleague, Ira Pauly, a disciple of Money (who’d founded the Hopkins gender unit), was “encouraging sex-change operations out there.” Seeing the patients, McHugh says, “I thought they were caricatures of women. They were all men who wanted to be women.” His early conclusion: “I thought it needed research.” 

When the Hopkins chairmanship opened up, it offered an opportunity for just such research. Once more, his hiring faced ferocious opposition from the psychoanalysts. Yet when he got the job, it didn’t occur to him to “cancel” the Freudians. He continued to maintain a psychoanalytic presence in the department, and funded the expensive training analyses aspiring Freudian therapists must undergo. 

Beyond respect for differing scientific views, McHugh worried that if he ousted his intellectual opponents, the medical students he trained would come to suspect “that I had something to hide” — wisdom that would be lost on many others across academe in coming years, as censorship and cancel culture ramped up. 

It was one of the Freudians, an analyst named Jon Meyer, who did the follow-up study on the gender clinic, finding that transgender surgery didn’t noticeably improve the lives of the men who underwent it (the cases then were almost entirely male-to-female). Three decades later, a Swedish study discovered that, as McHugh summed up in a much-discussed Wall Street Journal op-ed, “beginning about 10 years after having the surgery, the transgendered began to experience increasing mental difficulties. Most shockingly, their suicide mortality rose almost 20-fold above the comparable nontransgender population.” 

Meanwhile, he conducted research in many other areas, including schizophrenia, pedophilia, and what used to be called multiple personality disorder, among other conditions. As the years wore on, experimental psychiatrists like McHugh would find themselves in a curious alliance of sorts with the Freudians, as both faced the fury of the anti-psychiatry movements promoted by the likes of Thomas Szasz in America and Michel Foucault and his disciples in Europe.

The idea was that mental illness is an invention of the institutions that treat the mentally ill and valorize themselves in the process. “Get rid of the psychiatrist, and you get rid of mental illness,” as McHugh sums up the anti-psychiatric creed, which he likens to the view that crime is a social construct used by the police and justice systems to maintain and expand their institutional power. 

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As he recounts in an essay published in the ’90s, McHugh encountered a medical student besotted with such notions. McHugh’s solution: he had the student spend half an hour with a patient diagnosed with schizophrenia. Afterward, the student sheepishly conceded that schizophrenia, and mental illness more generally, are very much real. 

Yet too many others in the profession, McHugh worries, have gone along with such trends, culminating in psychiatry’s near-total surrender to gender ideology in the last decade. Instead of challenging patients’ misperceptions regarding themselves — something that, to their credit, orthodox Freudians also insist upon — “affirming” psychiatry actively colludes in the delusion and even justifies radical bodily modification to give it a semblance of “reality.”

“It’s the idea,” McHugh tells me, “that if your sense of yourself and the facts about yourself diverge, it’s the sense of yourself that [the clinician] has got to go with.” He adds: “That’s a kind of old idea, too. It goes way back to the Gnostics” — the Late Antique heresy — “where it was in a sense the spirit, not the flesh, that mattered.”

But what specifically explains transgenderism — the radical disjuncture between bodily sex and the patient’s subjective sense of his gender identity? As might be expected from an anti-Freudian, McHugh resists accounts based on hidden or distorted sexual desires. As a clinician, McHugh prefers to deal with conscious-but-deluded ideas that grip patients’ minds — especially dangerous in a cultural context that actively encourages the drive toward unreality.

In the event, McHugh believes that medicine’s knowledge of human sexuality is still in its infancy. “That’s really the problem,” he says. “We don’t understand the connections that tie us one to the other…. We should be studying and debating these things. But, you know, there are a lot of answers people don’t want to hear, so they don’t ask the questions that need to be asked.”

Nothing could’ve been more harmful to this project than the anti-scientific moralism that took hold of elite institutions in the 2010s. “In the old days,” McHugh recalls, “I used to have conversations with people who thought I was wrong now and then. But at the beginning of the 21st century, it was no longer that I was wrong. It was that I was evil.” You didn’t debate evil during peak woke — you extirpated it.

Yet as the fog of gender fanaticism lifts, McHugh looks like the one who remained clear-eyed. His triumph is a testament to the enduring capacity of rigorous, pluralistic scientific inquiry to self-correct, adjusting course in the light of the evidence, and withstanding even the most intense ideological agitation. “I think that really is the only way to go,” he says. “Realism and the recognition that all this disdain for traditional facts, biological facts in themselves, is not going to get anybody anywhere.”

Correction: An earlier version of this essay misstated the organization that awarded the intellectual-freedom medal to McHugh, and the day on which the award was presented.

According to this account, feminist writers had devoted themselves to rooting out the scourge of “neurosexism”, and they had been all too successful. By rejecting the idea of inherent sex difference, writers such as Cordelia Fine (in Delusions of Gender) and Rebecca Jordan-Young (in Brain Storm) had effectively undone the very class they claimed to represent. The most appealing part of this story is, of course, that it takes a particularly virulent attack on women’s rights and pins the blame for it on women.

But it also has a germ of truth to it: there is a strand of feminism that has always seemed deeply uncomfortable with the idea of sex difference. “Born this way” might make strategic sense as a slogan for other civil rights movements, but for the women’s movement, it would have come close to an admission of defeat: born to be underpaid and sexually harassed. No wonder there was an insistent pull towards a form of blank slatism for some feminists.

At its most extreme, this becomes the “gender performativity” theory offered by Judith Butler in Gender Trouble, which claims that gender and sex are shaped by social influence. And it’s a theory that goes even further back. In the 1969 book Sexual Politics, for example, Kate Millett quoted approvingly from the work of sexologists to support the argument that “Psychosexual personality is… postnatal and learned.” Regrettably, the particular sexologist she was referring to in this section was John Money. And though Money was much cited and widely respected, he would also be entirely discredited before the end of the century.

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Money’s most influential work was probably the twin study now widely known as “John/Joan”. In 1965, a pair of male twins were born in the Canadian city Winnipeg, named Bruce and Brian Reimer. At seven months old, their mother noticed that their foreskins seemed to be closing up, and they were advised to have both boys circumcised. In the event, only one would be operated on: the first procedure was botched so badly that Bruce’s penis was entirely burned, and eventually (in the journalist John Colapinto’s account) “dried up and broke away in pieces”. Brian was left alone after that.

For the family, this was a dreadful event. For John Money, it was an opportunity. Money had already achieved some measure of fame as a pioneer of (what were then called) “sex change operations”, and also worked with (again, what were then called) intersex patients. In both cases, his aim was to use surgery and hormone treatments to bring about alignment between what he called the “psychological sex” and the “sex glands”.

Now Money had the perfect opportunity for a rare empirical study of his theories. The uninjured twin would be the control, while the injured twin would be the test. The baby was castrated and furnished with a rudimentary vulva, and the parents were given strict instructions on how to raise their newly-minted daughter as a girl. Brian would become Brenda. And, up until 1997, all the public knew of this experiment was that it had been a huge success — because all they knew was Money’s version. In his book Sexual Signatures, he described the case like this: “by the time the children were four years old, there was no mistaking which twin was the girl and which the boy. At five, the little girl already preferred dresses to pants, enjoyed wearing her hair ribbons, bracelets and frilly blouses, and being her daddy’s little sweetheart.”

It was, continued Money, “dramatic proof that the gender identity option is open at birth for normal infants”. It appeared to be indisputable evidence that the brain was plastic, and gender a work of culture rather than nature.

The real child had a very different experience. Far from the stereotypically girlish interests listed by Money, Brenda enjoyed playing with model aeroplanes and CB radios. By the age of 11, Brenda was struggling with anxiety and social isolation, and suffered (according to a clinician’s report) from “strong fears that something has been done to her genitals” and “suicidal thoughts”. As signs of puberty kicked in, other girls treated Brenda with suspicion and cruelty: they could tell this child was not like them. Compounding the trauma, Money forced the twins into sexual roleplay under the belief that this was necessary to gendered socialisation.

In 1980, Brenda was finally told the truth. He immediately made the decision to live as a boy, and adopted the name David. Money never reported that his experiment had been a failure. It wasn’t until 1997 that the sorry episode was added to scientific literature, in an article by Milton Diamond; this was followed by Colapinto’s Rolling Stone article (expanded into a book called As Nature Made Him in 2000), which brought the case to wider public attention. Gender plasticity was declared over. The harm to David Reimer was not: in 2004, he killed himself. His family squarely blamed Money’s experiment.

This awful episode perhaps demonstrates little except that sexologists should be treated with grave suspicion: it is so extreme and grotesque, it can hardly be treated as indicative of anything in normal childrearing. Certainly, if Money’s twin experiment had any influence on the development of gender identity theory, it surely ought to have been discrediting, given Money’s direct involvement in medical transition.

But instead, it seemed to sow the seeds of what was to come. The New York Times’ report on the 1997 revelations had ended like this: “And it is the head, Dr. Diamond added, that holds the primary sexual organ, the source of one’s identity, and the organ that does not lie.” In other words, gender is in your head. One reading of this was that the experiment on Reimer was not wrong because it mauled the body of a child; it was wrong because it put the brain and body out of alignment.

The Nineties were also a time of considerable public interest in the idea that “masculine” and “feminine” had a biological basis. John Gray’s blockbusting 1992 book, Men Are From Mars, Women Are From Venus had established a popular narrative of psychological sex difference as a kind of relationship self-help. (Men couldn’t help being inconsiderate — they were born that way!) In 2003, Simon Baron-Cohen’s The Essential Difference had brought a neuroscience gloss to the position. As he summarised it in his introduction: “The female brain is predominantly hard-wired for empathy. The male brain is predominantly hard-wired for understanding and building systems.”

The Noughties critics of neurosexism were not, or were not all, rejecting the idea of sex difference in totality. As Fine wrote in her 2010 book Delusions of Gender: “There are sex differences in the brain. There are also large (although generally decreasing) sex differences in who does what, and who achieves what. It would make sense if these facts were connected in some way, and perhaps they are.”

But the way in which they were widely claimed to be connected was, plainly, influenced by sexism more than science. Baron-Cohen’s questionnaires used items like “I enjoy participating in sport” and “I try to avoid doing household chores if I can” to establish someone’s “systematising quotient” — as though women had equal access to sports, as though there was anything “systematic” about not doing the washing up, and as though playing in a team didn’t demand a certain level of empathy.

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The ultimate implication of The Essential Difference was that men were designed for thinking, and women for caring. It is substantially the same vision of gender that you can see in the notorious Mermaids “Barbie to GI Joe” gender scale. And this is a very appropriate thing for feminists to critique, especially when the level of “empirical” evidence underpinning it is so flimsy. Applying a rigorous eye to the science of sex difference is hardly the denial of sex difference: you could even call it a systematising impulse.

Fine herself has written, in a 2021 article, about the threat that gender identity theory poses to women’s rights. Replacing the category of woman as sex class with the category of woman as gender essence potentially deprives women of “the concepts to explain the disadvantages they face in virtue of their sex, and a commitment to accurate data to test and understand it”. In other words, when you make the idea of sex taboo, you make sexism impossible to name, or to counter.

Jordan-Young, however, took a very different direction, and ended up arguing not only against the idea of men and women having different brains, but against sex categories altogether. In 2019, she coauthored an article arguing that Caster Semenya (who is chromosomally male) should be eligible for women’s competition, which stated it was “simply not true” that testosterone played any role in athletic performance — a position that not only stands in opposition to every race result ever recorded, but which is also belied by the observable outcome of doping regimens.

It is hard to understand how anyone could be at once so deeply in denial about reality, and so cavalier about fairness to female athletes. The answer, perhaps, is fear. Like Kate Millett, Jordan-Young correctly deduces that sex difference has been used as the alibi for sex discrimination; in order to prevent the discrimination, one must therefore deny the difference.

Or as the science writer Angela Saini (author of the book Inferior) put it in a 2019 radio discussion: “We have to be careful that we don’t treat women as categorically different, and the reason we have to be cautious of this is because in the past this is a stick that is used to beat women with.” There is logic here, but a fragile, partial kind. Turning away from science may be tempting after the ways science has been abused to further sexism, but if you base your claim to sexual equality on the idea that men and women have no meaningful differences, your claim will fail.

Gender identity theory required two parents. One of them, yes, is the fearful strand of feminism that tends towards science denial. But the other was the tradition of scientific chauvinism in which femaleness amounted to being “daddy’s little girl” or doing chores: a tradition in which sex is reduced to stereotypes. If the only lesson we learn from this century’s strange diversion into gender identity mysticism is that we should blame women alone, then we’ve learned nothing at all.