ExclusiveHow the Gender Industry Suppressed Evidence of Harm: Leo Sapir

The UK has now banned puberty blockers. Probably will ban cross-sex hormones, too, is my prediction in the next few years. Lear Sapir is a fellow at the Manhattan Institute, where he's been following the massive increase in children identifying as transgender and undergoing what's known as gender-affirming care treatment, from puberty blockers to double mastectomies. Any way you look at it, WPATH greatly deviated from how responsible, trustworthy medical guidelines are supposed to be developed. And they suppressed this information and tried to conceal it from the public. His current area of focus is the pushback to gender interventions for minors, including state bans, lawsuits, and the landmark case now at the Supreme Court. This case has tremendous consequences for what's going to happen in the 26 states that have banned these interventions in minors. This is American Thought Leaders, and I'm Jan Jekielek. Lear Sapir, such a pleasure to have you on American Thought Leaders. Thanks for having me. Tennessee has banned what's dubbed gender-affirming care type treatment for children experiencing gender distress. This is in front of the Supreme Court right now. With this new Trump DOJ coming in, they could just walk away from this case and let that Tennessee law stand. You're arguing against that, though. Explain that to me, please. That's right. So the Trump DOJ could, in theory, let this case, or I should say back away from the case, drop it. And I argue that they shouldn't do that. I think the facts of the case, and more importantly, the arguments of the case, are heavily on the side of Tennessee. And the court, being a conservative majority court, is likely, some would argue almost certain, to rule in favor of Tennessee. And this case has tremendous consequences for what's going to happen in the 26 states that have banned these interventions in minors. Before I get you to talk about the evidence, maybe tell me a little bit how you've come into being an expert on this question. I stumbled into it, frankly. I wrote a dissertation on Title IX, the federal law that prohibits discrimination on the basis of sex in education. And I wrote on how the Obama administration and the federal courts had changed the meaning of Title IX to require schools to defer to students according to their gender identity, the way in which they self-defined, self-identified as male or female. And what I started to notice, actually, during my postdoc year, is that the arguments being made by advocacy groups like the ACLU were medical. These were medical arguments citing medical professionals, medical associations, and medical literature. And so I started looking at that literature. And once you look, you can't look away. Because the reality of the situation is that these interventions, including social transition in school, are said to be based on credible science, credible research over the years. And there just isn't that kind of evidence to support it. And I found it fascinating that you have this consensus has formed around these types of interventions, psychological as well as physical. In the absence of any credible evidence, school personnel and advocacy organizations believe, sometimes sincerely, that they are just following the best practices as announced by the medical community. It can be very difficult for people to believe that a whole, that the entire medical community, or maybe not the entire, but the decision makers in the medical community have adopted something that you're suggesting actually doesn't have a basis in medical evidence. That's right. And that's usually the first hang up when you talk to people who know maybe a little bit about this topic. They'll say something like, look, this is the consensus of medical authorities. And by medical authorities, they mean professional medical associations, the American Medical Association, the American Academy of Pediatrics, the Endocrine Society, and so on and so forth. So I think a few things here need to be said. First of all, if the standard is consensus of medical associations or medical bodies, there is no consensus even by that standard because numerous European countries, health authorities in several European countries, after conducting systematic reviews of evidence have backed away from these treatments, recognizing that, in fact, they lack credible evidence of benefits. And they have a real potential to do harm. So there's no consensus regardless. Even if you look only at the United States, the medical associations don't all march in lockstep on this issue. For example, last year, the American Society of Plastic Surgeons broke with the consensus and said, we recognize that there's really no good evidence for this in minors. But the more important point, of course, is that consensus-based medicine is not the same as evidence-based medicine. That is a very important distinction. And in fact, the field of evidence-based medicine, which came into its own during the 1990s, was created precisely in order to create this distinction between what doctors say is good treatment and what the evidence actually supports. And so you have to recognize, you have to acknowledge that, yes, there is a kind of a pseudo-consensus, and I'll say it a minute while it's a pseudo-consensus, but that doesn't mean that these are evidence-based treatments. That just means that medical groups say they are. To take that one step further, if you actually look at how these treatments ascended to the level of a consensus among medical associations, first of all, these are professional trade unions. It's important to recognize that. They exist to protect doctors and promote the interests of doctors, first and foremost. But more importantly in this case, they have oftentimes subcommittees that specialize in a certain area of care. So the American Academy of Pediatrics, for example, about a decade ago, convened a special working subgroup on LGBTQ health, and appointed, I think it was six clinicians to that subgroup, who were all kind of ideologically on board with gender transition treatments for kids. And the rest of the leadership of the AAP deferred to their colleagues in the specialized subcommittee on the assumption that they know what they're talking about, they're the experts in the field, and what do we know? And what you see, Jan, is that in a field as advanced in terms of scientific knowledge as medicine, where there is high levels of complexity and division of labor, you have to have that in order for these types of human endeavors to be possible. There's a great deal of trust and deference between medical professionals. And that trust can be exploited and has been exploited. So that's kind of the backstory to how we got to the pseudo consensus. You had the leadership of these medical associations said, look, we're not experts, but these people claim they are, so we're just gonna defer to them. There was a recent lawsuit in Alabama that in the process of discovery, they basically put into the discovery. As far as I'm aware, that is the most detailed compendium, up-to-date compendium of evidence that I'm aware of. And maybe you can speak to it. Sure, I mean, in a way it's unfortunate that the case before the Supreme Court is the Tennessee ban. And one of the reasons the Biden administration decided to appeal that ban is precisely because the evidence record in that case is incomplete. The Alabama case has by far the most complete evidence record. And so that's, there's a good reason that the Biden administration decided not to appeal from there. But look, I've said this before, and I continue to believe it. I think the greatest mistake the gender industry in the United States ever made was to sue the state of Alabama over its ban on youth transition. What happened is that the attorney general of the state of Alabama secured subpoenas from the judge in that case, Judge Lyle Burke, to have the World Professional Association for Transgender Health, whose Standards of Care Version 8 control the entire medical field in this area in the United States, to subpoena all their internal emails related to the development of Standards of Care 8, SOC 8. And what those emails have revealed has been nothing short of shocking. Those emails contain the smoking gun evidence of medical scandal. And so here's kind of in a nutshell what they found. WPATH commissioned systematic evidence reviews as part of the process of developing SOC 8. When it found out that the evidence reviews specifically for minors were unimpressive, did not get them the results that they wanted, that would support their medical approach, they suppressed them. They basically instructed the researchers at Johns Hopkins University who were doing these systematic reviews to not publish them. And then they also claimed in SOC 8, they said systematic review of evidence for minors is not possible, even though they themselves had commissioned one and suppressed it. More than that, they also spoke to what they called in internal emails, a social justice lawyer. And that lawyer told them, according to these emails, that having these types of systematic reviews would actually be bad for WPATH since it would compromise its ability to win lawsuits. And it would also place clinicians who provide these treatments at legal risk for malpractice. So it killed the evidence reviews and claimed that they're not possible. Beyond that, WPATH also, in a move that surprised a lot of us, a few days after it published SOC 8 in 2022, it issued a correction in the medical journal in which SOC 8 came out. And it said, we're now eliminating all age minimums for medical interventions for kids with the exception of phalloplasty, right? So all surgeries, all hormones, puberty blockers, all, none of that have any age minimums from now on. And it turns out that they did that not for any clinical reason or because of evidence, but they did that under pressure from Dr. Rachel Levin, who is the Assistant Secretary for Health in the Biden administration, who expressed concern that having age minimums, specified age minimums in SOC 8 would draw political controversy. And it turns out the American Academy of Pediatrics, which told WPATH, we're not going to endorse this. In fact, we're gonna actively oppose it if you specify age minimums, so you've got to get rid of them. And we have other things that have come out of that discovery that are no less concerning. For example, the lead author of SOC 8 admitted in a deposition in this case that conflicts of interest, both financial and intellectual conflicts of interest, were simply overlooked in the process of recruiting people to work on SOC 8. In fact, having a conflict of interest was deemed to be a prerequisite to being on the SOC 8 committee, which is really shocking. It violates every tenet of how responsible guidelines should be developed. Just clarify that for me. It didn't say having a conflict of interest was a prerequisite, what do you mean? Right, so what happened was, this came out of the deposition of Eli Coleman, who's the lead author of SOC 8, and also of Marcy Bowers, who was then the president of WPATH and also a co-author on SOC 8. Coleman was asked explicitly, were you aware that most of the people on the SOC 8 development committee had conflicts of interest? And he said yes, he was aware. And yet, if you look at the disclosure section, it says no conflicts of interest. Marcy Bowers said that being a proponent of the medical gender-affirming approach was a prerequisite to being invited to participate on the committee. So the WPATH leadership has admitted this under oath in the deposition. What do I mean by financial and intellectual conflicts of interest? A few of the developers of SOC 8 were expert witnesses in cases in which what SOC 8 would have said would determine whether their side in the lawsuit ends up winning. So they stand to gain financially from SOC 8 saying certain things and not others. Marcy Bowers, the president of WPATH, said in a deposition, admitted to making over a million dollars in 2023 from performing gender surgeries. Most of the other clinicians on the SOC 8 development team also made money, had professional appointments, gained professional reputations from performing these procedures or at least endorsing them. And those are considered financial conflicts of interest. And of course, intellectual conflicts of interest, if you become a public advocate, if you write in favor of a certain position, you're less likely to evaluate impartially the evidence base for a treatment. So the key thing here is that the U.S. Institute of Medicine in 2011 announced standards for the development of what they called trustworthy medical guidelines. And WPATH claimed that they were following these standards. In fact, Eli Coleman himself claimed that those standards were controlling. But if you look at those standards, they clearly and explicitly say you cannot have people with conflicts of interest dominating the process of developing a medical guideline. Any way you look at it, WPATH greatly deviated from how responsible, trustworthy medical guidelines are supposed to be developed. And they suppressed this information and tried to conceal it from the public. WPATH basically is the standard that a lot of these professional organizations have followed, right? But WPATH isn't per se a medical organization as I understand it. So how did WPATH rise to prominence? You know, I mean, it's a situation, again, in which you have a specialized group of clinicians and activists. And it's true that WPATH is, even though it calls itself the Professional Association for Transgender Health, it's an activist group made up of lots of, you know, disparate elements. Not all of them are doctors, not all of them are mental health professionals. Some of them are journalists, run-of-the-mill activists, some of them are social workers. But they have positioned themselves as the experts. And, you know, nobody really questions that in the medical field, although now they do. And certainly in Europe, European countries completely reject WPATH. I think the director of Belgium's Center for Evidence-Based Medicine said he would throw WPATH's guidelines in the dustbin. So there are no fans of WPATH there. But here in the United States, they are de facto the authorities in the field. In the absence of other organizations issuing guidelines, and there's one exception, the Endocrine Society did issue a guideline. But in the absence of other organizations saying, no, we're gonna issue our own guideline and take a different approach, WPATH has emerged as the de facto leader in the field. WPATH did not immediately respond to a request for comment. So, and how is it that Europe has taken, in, you know, writ large, right, has taken, you know, really looked more systematically at the evidence? How do you explain that exactly? You know, it's a great question, and it's one that concerns me a lot. So first of all, just to, you know, so listeners are aware, the UK has now banned puberty blockers. Probably will ban cross-sex hormones too, is my prediction in the next few years. Surgeries are almost never performed outside the United States, extremely rare. Lior, before you continue, maybe just lay out to me what this gender, as quickly as possible, what this gender-affirming care approach is, because you mentioned a few elements of it, but I'd just like to offer a picture. So according to kind of the, you know, the standard protocol as developed in the Netherlands, as soon as a kid reaches Tanner stage two of puberty, which is kind of the early development of puberty, the first stage is puberty blockers, which, as the name implies, block puberty from going into effect. Initially, these drugs were intended to kind of provide a window of time for kids to figure out whether to continue with transition. Now we know, based on research, based on the expertise of clinicians involved in the field, that that is simply not the case, because almost 100% of kids who go on puberty blockers end up going on to cross-sex hormones. So blockers very likely lock in the gender distress that would otherwise, in most cases, you know, evaporate as the kid goes through puberty. So the first step has gender distress, not sure, you know, whether they're male, female, or something else. Yeah. And then the next step is? Well, I mean, according to the traditional protocol, they had to be quite sure that they are, in fact, the opposite sex. And so they would be given puberty blockers to figure out, time to figure it out. And almost all of them would, of course, figure out that, in fact, they're trans, they want to proceed. And so the next step is cross-sex hormones. So testosterone if you're a boy, if you're a girl, estrogen if you're a boy. And whereas puberty blockers prevent the body from developing through its endogenous puberty process, cross-sex hormones are meant to induce the appearance of sex characteristics that mimic the opposite sex. So, you know, in girls who take testosterone, for example, their voice will get lowered, and that could actually be irreversible. And then the final stage, in the United States, at least, surgeries. And for boys, this is much, much more rare, but for boys, it could involve a vaginoplasty, a surgical inversion of the penis, or if they went on puberty blockers and their penile tissue didn't develop, the surgeon will borrow tissue from the colon and create kind of a semblance of a vagina with the colon tissue. In Europe, these surgeries are usually only offered after age 18, but in the United States, they are offered to minors as well. So that's the full protocol. Now, you know, there's deviations from it. Some kids only want, in the United States, gender-affirming care is typically more a la carte. It's whatever the kid wants, right? So if they want just the cross-sex hormones, that's what they get. If they want just the surgery, that's what they get. And now, also within the last five, six years, we've seen the rise of so-called non-binary procedures, which unlike the Dutch protocol, the non-binary procedures are really just meant to allow kids to pursue whatever, as the clinicians call it, embodiment goals they want. So if they want, you know, a little bit of body hair and to also have breasts and all that kind of stuff, they can kind of mix and match their drugs and surgeries to produce idiosyncratic body types that are not found in nature. So in Europe, you were starting to say, when I stopped you, and in the UK, they banned puberty plockers. So that basically stops this whole process. The UK and Finland and Sweden have recognized, based on systematic evidence reviews, that these treatments are fundamentally still experimental. You know, Norway has significantly scaled back. Denmark has significantly scaled back. Medical authorities in Germany and France have issued stern warnings about these procedures in Italy. Why is it that these countries have managed to do this, whereas in the United States, you know, things have gone totally off the rail and there seems to be, other than kind of political pushback through Republicans, there seems to be nothing to stop it? It's a complicated question. I think a large part of the answer has to do with how our health system works compared to their health system. So in Finland, for example, or Sweden, these are government-run health systems. So the government pays for insurance, but also runs the hospitals. And what happens there is that government has a fiduciary responsibility to taxpayers to use finite resources in a responsible way to promote the health of the public. And that means that they have a strong incentive to make sure that they're allocating resources to treatments that are really evidence-based, that are effective. And so these countries have agencies. In Finland, it's called the Council for Choices on Healthcare. In Sweden, it's the SBU. In the UK, it's the National Institute for Health and Care Excellence. These are agencies, government agencies or public agencies that have the responsibility to evaluate impartially the evidence base for medical treatments. And every single agency in Europe that has done that has come to the exact same conclusion. There is no credible evidence that these treatments are safe and effective. In the United States, things are very different. We don't have universal government insurance, and we have private insurance companies that can recoup their costs. So if Blue Cross or UnitedHealthcare or whatever pays for these interventions, they can just raise premiums across the board and recoup their costs without considerations of fiduciary obligation to taxpayers. More than that, because we as Americans have a kind of a healthy distrust of centralized power and centralized government, medical policymaking is de facto done in the States. And even more de facto is controlled heavily by medical boards and professional medical associations, who are, as I said earlier, essentially trade unions, that advocate on behalf of doctors and doctor interests. And so we have plenty of examples throughout American medical history of medical associations learning that the evidence doesn't support a certain treatment that their members perform and make money from, and yet opposing any efforts to impose restrictions. Good example is arthroscopic knee surgery, where a double-blinded randomized control trial found that in the vast majority of people who get them, over half a million people get them every year, they're no better than what's called a sham surgery, meaning a placebo surgery. So CMS wanted to cut off a lot of these surgeries, and the association that is essentially the home of surgeons who perform these procedures, they said, no, sorry, we don't accept the findings of this systematic review, please interpret it very narrowly and don't issue any correction to current practices. So that's just one example, and there's many I could give, but the bottom line is we have this kind of highly decentralized healthcare system where the financial interests and professional interests of doctors, of medical associations, of drug companies have a very heavy role. Now, I should mention one last thing, which is we do, in fact, have agencies that are counterparts to the ones I mentioned in Europe. We have PCORI, the Patient-Centered Outcomes Research Institute. We have AHRQ, which sits within the HHS government department and these are agencies tasked with assessing the evidence base for medical interventions. The problem is that in the wake of the Affordable Care Act being passed in 2010, Republicans neutered them. Republicans went to war with these agencies and basically said, in cooperation with medical associations and drug companies, and basically said, we don't want these government agencies or publicly funded agencies to dictate healthcare decisions. And probably not expecting this as an outcome. Yeah, I mean, it's a good example of the unintended consequences of policy decisions. Another very systematic, detailed review of the evidence was this Cass Review in the UK, which led to this outcome that you described. That's right. If someone is interested in understanding sort of the body of actual evidence around these types of procedures, where's the best place someone can go to kind of dig deep a little bit and understand that? Well, the Cass Review is not a systematic review per se. It's a almost 400-page report based on a multi-year investigation of the UK's Gender Identity Development Service, which has since been discontinued, but it's based on seven new systematic reviews of evidence and guideline quality that were commissioned for the purpose of the review itself. And so there have been, a number of these systematic reviews have appeared. In the UK, a few were done in Sweden and Finland. One was done by McMaster University in Canada, which is the home of evidence-based medicine, commissioned by a Florida healthcare agency. Is there one place where all of this appears? I'm not sure. You kind of have to look for it. You have to know what you're looking for. The Cass Review is a good place to start. It's a very long document. Unfortunately, it's written in the language of gender ideology. I think that was intentional to get buy-in from kind of people on the other side of this issue, but it does discuss the evidence, the ethical problems, what we know, what we don't know, the clinical practices that have come into being in the last decade or so, and it creates a pretty damning picture. It's proven to be hugely transformative in this field. It has made it impossible for American medical groups and gender clinicians to continue pretending that anybody who disagrees with their radical approach is an ideologue who hates people who identify as transgender. I don't think anybody can take that argument seriously anymore. Well, and so let's actually build on that a little bit here, right? There's been this huge issue in the last few years about parental rights, that parents should ultimately decide, but what if parents decide that this is a good course of treatment? Yeah. Right? Yeah, so I mean, that does present a certain dilemma because those of us who have been trying to push back against this medical scandal and expose it, in the context of education in schools, we've been making arguments about parental rights. Schools should not perform social gender transition on kids behind parents' backs. There are serious consequences to that. Parents should be involved. Parents have a right to know, to decide. But in the medical context, those who advocate for the gender-affirming care pathway are the ones claiming parental rights. They say states should not ban it. Let parents make the decision. These decisions should be between parents on behalf of their kids and doctors. Here's why I think that's wrong. I think it's wrong for a number of reasons. First of all, parents don't have a right to dictate medical treatment. They have a right to choose from among the treatments that doctors can responsibly and ethically offer to them. The doctors have the primary responsibility to only offer treatments that are within the standard of care, that are evidence-based, and that are net beneficial, or at least reasonably assumed to be. So medicine is not consumerism. It's not as though a parent can walk into a clinic and just pick and choose whatever they want. So the question of parental rights is, first of all, I think the most important thing to say, it's logically secondary to the question of what doctors should be offering and why. But beyond that, if you actually have seen what happens in a gender clinic, if you've seen the consent forms, if you've spoken to people like Jamie Reed, who have worked in these clinics, and I know that you've interviewed Jamie, parents are almost never given the full unvarnished picture of what we know and what we don't know about these interventions. Sometimes they're given a very incomplete story. Sometimes they're outright lied to. For example, we have numerous examples of parents being told by the gender clinician, sometimes in front of their own kid, that if the kid doesn't access these treatments, he or she will kill herself. There's no evidence that that's true. And in fact, it's a dangerous thing for a clinician to say, especially in front of a kid. Under those circumstances, what parent would not agree to these treatments? If the alternative is death, any risk is worth it. And then on top of that, we also see many of these cases of parents disagreeing with each other. It's almost always the mom who wants to do it and the dad who is skeptical, which I find that's pretty interesting. I've spoken to journalists who have interviewed many parents associated with particular clinics, and they've said, yeah, that's pretty much what we observe too, it's almost always the mom. But regardless, what happens when the parents disagree? So in Jamie Reed's clinic, the practice was, you go at the parent who agrees, and you lie to the parent who disagrees. You just kind of, you get them out of the picture as fast as you possibly can. I remember watching a training session, I think it was at the Cleveland Clinic, where the gender clinicians there said, if the parents disagree, we just have to keep working with them until they agree. So even if you buy the parental rights argument and ignore the more important responsibility of clinicians not to offer these treatments in the first place, parents are very often lied to, misled, and bullied into submission in order to agree to these interventions. And once they agree, they cross a Rubicon. Once you agree to medical interventions that have irreversible consequences for your kids, including sterility, possible sexual dysfunction, cognitive impairment, it's very difficult for any parent to say, actually, this was the wrong thing for me to do. I harmed my kid. And so that's why I've always been very sympathetic to the parents who agree to these medical interventions. I've always been very against activists who are kind of pushing back against gender medicine, who want to demonize parents, who want to try to cast them as abusers of their own children. Because in the vast majority of cases, these parents were lied to. They were misled, they were bullied. They don't deserve to be demonized twice. They're suffering enough on account of what happened to their kid. So we need to be able to provide them with off-ramps to recognize that this was not the right decision and to figure out a way back to restore their kid's health. There's always kind of a cost-benefit. Is that how you think about it? That you have to kind of look at it from a cost-benefit perspective? Yeah, I mean, so let's break this down into kind of two buckets. In one bucket, we have the question of clinical outcomes. What do we know about the benefits and harms, the benefits and risks of social transition and medical intervention, medical transition? And on both of those fronts, I think so far the evidence quite clearly says there's no credible basis to believe that these are beneficial and the risk of harm is real and substantial. And so therefore, there's kind of a very compelling argument to stave off these interventions as long as is possible and let the kid mature, let them get psychotherapy, let them figure things out. Most of these kids, or at least a lot of them are gay and will realize that about themselves. So that's kind of one approach. Let's call it the clinical outcomes approach. The other approach is to question the very conceptual basis of these interventions for kids. What is it exactly that we're treating here and why? If you give insulin to a kid, it's probably because the kid has diabetes, right? You can test for diabetes. There's an objective test that is high on specificity, meaning you're not gonna have false positives. And you can know that you are giving them a life-saving intervention for an objectively diagnosable medical condition. That doesn't exist here. The basis for intervention is subjective. It's a kid's feelings. And feelings, of course, have multiple causes. They're likely to change. But more importantly than that, the modern practice of gender medicine, unlike 15, 20, 30 years ago, rests on a series of pseudoscientific claims about the human person. That sex is assigned at birth, meaning a social construct. That's not true. That all humans have an innate gender identity that they can know from very early in life infallibly, and that will never change, although somehow it's also said to be fluid. And that kids can know with absolute certainty. That's what the AAP says. No basis to believe such a thing. That is pseudoscience. That's not science. And so if you look at these young kids who are suffering on account of something, and you say, oh yeah, this boy is really a girl who has assigned the wrong sex at birth, that's a completely different conceptual framework from what existed 20, 30, 40 years ago where transsexual was understood to be a biological man who, for whatever reason, would feel more comfortable going through life appearing as and being seen by others as a woman. Doesn't mean he really is a woman. It just means he would feel more comfortable that way. And so still there was a kind of a hold, a grasp on biological reality, and that hold has loosened to a great degree in our medical profession today. And so the conceptual basis of these interventions is already highly dubious, even before you get to the question of clinical outcomes. So you're saying that even thinking cost-benefit in this case is not actually useful. We can say with reasonable certainty that some of these kids may go on in adulthood to experience severe distress, and they will associate it with their bodies. And some of them will say, I started feeling this way as a kid, as a teenager, right? I don't have a basis to doubt that. Maybe some people do. For me, that seems like a good starting point for a conversation. These cases are extremely rare. They are often driven by unresolved struggles, mental health problems. They could be a result of a sexual paraphilia. There's the concept of autogynephilia that I think more and more Americans are beginning to understand. And some people with autogynephilia talk about it openly. But- Just very briefly. Yeah, autogynephilia is erotic attraction to the thought of oneself as a woman. You're attracted to, as a man, you're attracted to what you would be like as a woman. And you want other people, when other people see you as a woman, or you think they see you as a woman, that causes a kind of erotic feelings, right? So if you set aside the conceptual framework, and you're looking at from a clinical outcomes perspective, I think you can say, reasonably, the vast majority of these kids will come to terms with their sex, and will realize that their problems are best resolved not through dangerous drugs and surgeries. A few of them might come to that conclusion that nothing else will help them in adulthood. We have no way to know who these kids are. No way. And clinicians, mental health professionals, who say we're very cautious and conservative, and we do extensive mental health assessments, are deluding themselves. There is no mental health assessment that will tell you this because that kind of clarity about your identity, relative clarity, is the consequence of going through puberty, is a consequence of reaching mature adulthood. And so there really is no way for clinicians to be able to say, you are going to be a future transsexual, and you are not. And given the absolute moral hazard here, and the potential to hurt so many kids irreparably, I think by far the safest course of action is to not do it in kids. And even I, increasingly of the view, even young adults, the 18 to 25 cohort, I think we have research showing that the brain doesn't stop maturing until around age 25. Especially with this generation, kids are growing up immature. They're taking longer to reach that point where they can make rational decisions. And so I think there's a good case also to restrict it in young adults. Because the argument you hear, and I think you've spoken eloquently about this, the argument that you hear is if they're not able to realize their true selves early enough, there will be great suffering later in life, right? Yeah, I mean, so that was the original justification for the Dutch approach. And they were the pioneers just for the benefit of the audience of this whole thing. That's right, the Dutch were the pioneers. They observed, based on their clinical experience, that the adults, adult transsexual men, men who identified as women, said that they were subjectively satisfied. But if you actually look at their objective life metrics, their psychosocial adjustments, their ability to have relationships, hold down jobs, function in life, they were not doing well. And so the theory was, the hypothesis was, they're not doing well because they don't pass as women. And if they pass as women, then all these other problems would go away. The effects of testosterone on male puberty are irreversible. It's extremely difficult for a man who goes through endogenous puberty to pass as a woman. And so the theory was, let's bypass puberty in order for these kids to be able to pass later on as adults, as women. If they pass as adults, pass as women, they'll have a happier life. They'll be better adjusted. And also, they will be prevented from developing what the Dutch thought were psychopathology that resulted on account of going through the, quote unquote, wrong puberty. And so that was kind of the original hypothesis that launched this medical experiment in the first place. It is true that for some adults, especially men, who are unable to pass as women, that's agonizing for them. It doesn't follow that we should be bypassing the puberty of kids, subjecting them to medical experiments and chopping off healthy body parts. Not every problem has an obvious technological solution, certainly not one that doesn't carry moral risks that make the intervention really scandalous, as it does in this case. Essentially, you're in favor for banning this whole approach entirely, because there's some arguments that would say, well, maybe just a little bit of it. Yeah, in kids, you mean, yeah. Would be okay, right, right, right, exactly. Yeah, I mean, so it's interesting. You're starting to see some gender clinicians and advocates of medical transition agree that things have gone off the rail, that the massive exponential rise in the number of kids identifying as trans, especially girls, and seeking medical interventions, and getting them with virtually no safeguarding, no gatekeeping, that there's something that has gone terribly wrong there. But these clinicians or these activists will say, but what about the true transgender kids, for those who really need it? There's no such thing as those who really need it. You have to be able to establish that with evidence and reasoning, and that hasn't been done. So if you look even at the Dutch protocol, which is supposed to be the conservative approach here, the Dutch protocol would automatically exclude the majority of girls who are today presenting for medical transition. Even if you do it according to the Dutch protocol, the Dutch protocol lacks credible evidence. The papers that launched this experiment have been critiqued ruthlessly in the peer-reviewed medical literature. I highly recommend that people read one paper in particular called The Myth of Reliable Research. It's a fascinating peer-reviewed article showing the high risk of bias, the huge methodological problems that went into the original Dutch experiment. So again, looking at this from a clinical outcomes perspective, or kind of a clinical reasoning perspective, there's no evidence that any kid benefits from this, or that gender clinicians can reliably pick out any kid who will likely grow up to have this lifelong, agonizing suffering. There are some kids who are going to grow up and experience distress that they associate with their body. That's true. But what does it even mean to say that some kids are just trans? That what, that they were born in the wrong body? That's absurd metaphysical speak. When I talk to people about this issue who are kind of undecided, the first thing that I ask them to do is to define what they mean by a transgender child. And they usually twist themselves into a pretzel because they don't want to say a child who has the wrong body. That's absurd and it's the wrong message to send to kids. They can't say a child who is going to grow up to be a transsexual because how would they know? And so they end up resorting to something like, well, a kid who knows that he's transgender, but how does a kid know he is transgender? What does it mean to know that? If you don't have conceptual clarity about the basis of health and disease, about why it is that you're intervening in the body of healthy kids, these are physically healthy kids, you cannot perform these interventions. In most cases, again, from the literature that I've looked at, they will desist over time if just kind of left, in some ways, just left to their own devices. Right, so the literature about pre, that's the literature on prepubertal children does show that the vast majority of them desist and a large number come out as gay. The theory among the Dutch was, okay, but for those who cross the threshold into puberty and their gender, as they called it back then, the gender identity disorder, the gender confusion, did not go away. In fact, it intensified. These are the candidates for the medical intervention. But crucially, and I can't emphasize this point enough, when they said these kids are eligible for puberty blockers, they thought that puberty blockers were a completely reversible intervention that do nothing but buy time for the kid to figure out whether to proceed with transition. Meaning, even according to the Dutch, puberty blockers are a diagnostic tool. Meaning, even the Dutch don't know that these kids, didn't know that these kids were likely to grow up to be transsexual. They thought it's possible, it's maybe even likely, but they weren't sure. And that's why they said puberty blockers are part of the diagnostic process. We now know that they're not diagnostic. They lock in the medical pathway. They're the first step on a pathway to full transition. We talked a little bit about what you're hoping the incoming Trump administration will do. One is keep this Supreme Court case alive. If you had a wish list for what you would like to see this incoming administration do with respect to this issue. Yeah, I mean, there's more things that I could possibly list now, but maybe some highlights would be, HHS needs to deprogram itself from gender ideology. It needs to get rid of all the ideological language, all the directives. The NIH, for example, needs to stop pumping money, hundreds of millions of taxpayer dollars into research whose only purpose is to promote these interventions. I actually think that instead of shutting off the valve, NIH should reorient itself and devote money to studying the harms, which are not studied. Nobody's studying harms because the gender clinicians doing the research don't wanna know. They're only studying benefits and then they're spinning the results of their studies. We need evidence on detransition and regret, which are real and growing phenomena. I would also like to see the agencies within NIH responsible for evidence reviews, step it up. Do the evidence reviews if you need to, or at least acknowledge the evidence reviews performed by other countries. It would be nice to see the Surgeon General issue a warning about off-label use of puberty blockers. At the Department of Justice, I would like to see an immediate stop to the persecution of whistleblowers, specifically Dr. Eitan Haim from Texas who blew the whistle on Texas Children's Hospital. He's been subject to a ruthless political persecution by the Biden administration to try to shut him up and deter other whistleblowers. That has to stop. There's a lot of things that an incoming Trump administration can do on the executive side alone to say nothing of what Congress can do through its powers of investigation, of appropriations, even legislation, although that's going to be very difficult. There's a lot that can be done over the next four years. And so what about on the executive side? So, you know, the Biden administration on day one in office issued executive orders on trans issues and has issued others too. A good first step would be for President Trump to just rescind the executive orders of the Biden administration on this particular issue. That's easy to do, right? Stroke of a pen, you can do it. Stroke of a pen, you can undo it. So I'm not sure there's a whole lot else to be done through executive orders simply because executive orders can be undone by the next incoming Democratic president and will be undone by the next incoming Democratic president. We need to, we need the federal government to use its powers to investigate how the American medical profession went off track here and what can be done to restore us to a place of evidence-based ethical medicine. Well, Lierre Sapir, it's such a pleasure to have had you on. Thanks so much, Ian. Thanks for having me. Thank you for joining Lierre Sapir and me on this episode of American Thought Leaders. I'm your host, Jan Jekielek.