How Medical Authorities and Activists Created a Pseudo-Consensus on Gender: Leor Sapir

[RUSH TRANSCRIPT BELOW] “The UK has now banned puberty blockers—probably will ban cross-sex hormones too, is my prediction, in the next few years,” said Leor Sapir, a fellow at the Manhattan Institute.

He has 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.

“[The World Professional Association for Transgender Health] commissioned systematic evidence reviews as part of the process of developing [Standards of Care Version 8]. When it found out that the evidence reviews, specifically for minors, were unimpressive and 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,” said Sapir. “Any way you look at it, WPATH greatly deviated from how responsible, trustworthy medical guidelines are supposed to be developed.”

His current area of focus is the pushback to gender interventions for minors, including state bans, lawsuits, and a 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,” said Sapir.

Views expressed in this video are opinions of the host and the guest, and do not necessarily reflect the views of The Epoch Times.

RUSH TRANSCRIPT

Jan Jekielek:
Leor Sapir, such a pleasure to have you on American Thought Leaders.

Leor Sapir:
Thanks for having me.

Mr. Jekielek:
Tennessee has banned what’s dubbed as 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.

Mr. Sapir:
That’s right. The Trump DOJ could in theory back away from the case and drop it. I argue that they shouldn’t do that. The facts of the case and, more importantly, the arguments of the case are likely, and some would argue almost certain, to rule in favor of Tennessee. This case has tremendous consequences for what’s going to happen in the 26 states that have banned these interventions in minors.

Mr. Jekielek:
Before we talk about the evidence, how have you come to be an expert on this topic?

Mr. Sapir:
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, 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. I found it fascinating that 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.

Mr. Jekielek:
It can be very difficult for people to believe that a whole, that the entire medical community, or maybe not the entire, but the, you know, sort of the decision makers in the medical community have adopted something that
you’re suggesting actually doesn’t have a basis in medical evidence.

Mr. Sapir:
That’s right. And that’s usually the first hang up when you talk to people who know a little bit about this topic. They’ll say something like, look, this is the consensus of medical authorities. By medical authorities, they mean professional medical associations, the American Medical Association, the American Academy of Pediatrics, and the Endocrine Society. A few things need to be said here.

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.

You have to recognize, you have to acknowledge that yes, there is a kind of a pseudo-consensus. 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.
You can 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, oftentimes they have subcommittees that specialize in a certain area of care. The American Academy of Pediatrics [AAP], for example, about a decade ago convened a special working subgroup on LGBTQ health and appointed six clinicians to that subgroup, who were all kind of ideologically on board with gender transition treatments for kids. 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?

In a field as advanced in terms of scientific knowledge as medicine, where there are 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. That’s the backstory to how we got to the pseudo-consensus. The leadership of these medical associations said, look, we’re not experts, but these people claim they are, so we’re just going to defer to them.

Mr. Jekielek:
There was a recent lawsuit in Alabama that, you know, 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.

Mr. Sapir:
Sure. In a way, it’s unfortunate that the case before the Supreme Court is the Tennessee ban. The Biden administration decision 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. 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.

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 Judge Liles Burke to have the World Professional Association for Transgender Health [WPATH], whose Standards of Care 8 [SOC-8] control the entire medical field in this area in the United States, to subpoena all their internal emails related to the development of SOC-8.

What those emails have revealed has been nothing short of shocking. Those emails contain the smoking gun evidence of a 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 and did get the results to support their medical approach, they suppressed them. They basically instructed the researchers at Johns Hopkins University doing these systematic reviews to not publish them.

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. 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. 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, in a move that surprised a lot of us, a few days after it published SOC-8 in 2022, WPATH issued a correction in the medical journal where SOC-8 came out and said, we’re now eliminating all age minimums for medical interventions for kids with the exception of phalloplasty. All surgeries, all hormones, puberty blockers, all, none of them have any age minimums from now on. 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.

It turns out the American Academy of Pediatrics, which told WPATH, we’re not going to endorse this. In fact, we’re going to actively oppose it if you specify an age minimum, so you’ve got to get rid of them. 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.

Mr. Jekielek:
Please clarify that for us. It didn’t say having a conflict of interest was a prerequisite. What do you mean exactly?

Mr. Sapir:
Right. This came out of the deposition of Eli Coleman, who’s the lead author of SOC-8, and also of Marci 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? He said, yes, he was aware. 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. The WPATH leadership has admitted this under oath in a 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 by saying certain things and not others. Marci 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.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 impartially evaluate the evidence base for a treatment.

The key thing here is that the US Institute of Medicine in 2011 announced standards for the development of what they called trustworthy medical guidelines. 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 deviates from how responsible, trustworthy medical guidelines are supposed to be developed. And they suppress this information and try 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. How did WPATH rise to prominence? It’s a situation again in which you have a specialized group of clinicians and activists.

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 disparate elements. Not all of them are doctors, and not all of them are mental health professionals. Some of them are journalists and run-of-the-mill activists. Some of them are social workers. But they have positioned themselves as the experts. And nobody really questioned that in the medical field, although now they do.

Certainly, European countries completely reject WPATH. The director of The Belgian 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 going to issue our own guideline and take a different approach, WPATH has emerged as the de facto leader in the field.

Mr. Jekielek:
WPATH did not immediately respond to a request for comment. Why has Europe looked more systematically at the evidence? How do you explain that?

Mr. Sapir:
That’s a great question, and it’s one that concerns me a lot. So, first of all, just 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.

Mr. Jekielek:
What is the gender-affirming care approach? You mentioned a few of its elements.

Mr. Sapir:
According to the standard protocol as developed in the Netherlands, as soon as a kid reaches Tanner stage 2 of puberty, 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 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. Puberty blockers very likely lock in the gender distress that would in most cases evaporate.

Mr. Jekielek:
A child shows up, has gender distress, and is not sure whether they’re male or female. What is the next step?

Mr. Sapir:
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. The next step is cross-sex hormones, testosterone if you’re a girl, estrogen if you’re a boy.

Puberty blockers prevent the body from developing through its endogenous puberty process, when cross-sex hormones are meant to induce the appearance of sex characteristics that mimic the opposite sex. With 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.

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 a semblance of a vagina with 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. That’s the full protocol.

Now. there are deviations from that. 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 to 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. If they want 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.

Mr. Jekielek:
In the UK, they banned puberty blockers, so that basically stops this whole process.

Mr. Sapir:
The UK and Finland and Sweden have recognized, based on systematic evidence reviews, that these treatments are fundamentally still experimental. Norway has significantly scaled back. Denmark has significantly scaled back. Medical authorities in Germany, France, and Italy have issued stern warnings about these procedures. Why is it that these countries have managed to do this, whereas in the United States, things have gone totally off the rails. Other than political pushback from 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.

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 government insurance, universal government insurance, and we have private insurance companies that can recoup their costs, right? So if Blue Cross or United
Healthcare or whatever pays for these interventions, they can just raise premiums across the board and recoup their costs without considerations 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, right, 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.

A 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. The association that is essentially the home of surgeons who perform these procedures 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.

That’s just one example, and there’s many I could give. But the bottom line is we have this kind of highly decentralized health care 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. 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 intervention.

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 in cooperation with medical associations and drug companies, and basically said, we don’t want these government agencies or publicly funded agencies to dictate health care decisions.

Mr. Jekielek:
And probably not expecting this as an outcome.

Mr. Sapir:
Yes, it’s a good example of the unintended consequences of policy decisions.

Mr. Jekielek:
Another very systematic, detailed review of the evidence was the Cass Review in the UK which led to this outcome. If someone is interested in understanding the body of actual evidence around these types of procedures, where’s the best place someone could go?

Mr. Sapir:
The Cass Review is not a systematic review per se. It’s an almost 400-page report based on a multi-year investigation of the UK’s Gender Identity Development Service, which has since been discontinued.
It’s based on seven new systematic reviews of evidence and guideline quality that were commissioned for the purpose of the review itself.

There have been a number of these systematic reviews that 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, and was commissioned by the Florida Healthcare Agency.

Is there one place where all of this appears? I’m not sure. You have to look for it, and 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 people on the other side of this issue.

But it does discuss the evidence, the ethical problems, and what we know and don’t know about 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.

Mr. Jekielek:
There’s been this huge issue in the last few years about parental rights, and that parents should ultimately decide what is best for their children. But what if parents decide that this is a good course of treatment?

Mr. Sapir:
That does present a certain dilemma for those of us who have been trying to push back against this medical scandal and expose it. Schools should not perform social gender transition on kids behind their parents’ backs. There are serious consequences from that. Parents should be involved. Parents have a right to know and to decide.

But in the medical context, those who advocate for the gender-affirming care pathway are the ones claiming parental rights. They say that the 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, you know, 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.

The question of parental rights is 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, 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, you know, any risk is worth it.

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?

In Jamie Reed’s clinic, the practice was that you go for the parent who agrees. You lie to the parent who disagrees and get them out of the picture as fast as you possibly can. I remember watching a training session 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, 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.

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 pushing gender medicine, who want to demonize parents, and 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. 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.

Mr. Jekielek:
There’s always a cost-benefit analysis. Is that how you think about it, that you have to look at it from a cost-benefit perspective?

Mr. Sapir:
Yes. Let’s break this down into two buckets. In one bucket, we have the question of clinical outcomes. What do we know about the interventions as long as possible and let the kid mature, let them get psychotherapy, you know, let them figure things out. A lot of these kids are gay and will realize that about themselves. That’s one approach, and 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. You can test for diabetes. There’s an objective test that is high on specificity, meaning you’re not going to have false positives. Then you 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 all about a kid’s feelings. Feelings, of course, have multiple causes. They’re likely to change. But more importantly, the modern practice of gender medicine rests on a series of pseudoscientific claims about the human person. It says that sex is assigned at birth, meaning it is a social construct. That’s not true.

Gender medicine thinks 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, that kids can know with absolute certainty. That’s what the AAP says. But there is no basis to believe such a thing. That’s not science. That is pseudoscience.

If you look at these young kids who are suffering from something, and you say, this boy is really a girl who was assigned the wrong sex at birth, that’s a completely different conceptual framework from what existed 20, 30, to 40 years ago. Then a 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.

It doesn’t mean he really is a woman. It just means he would feel more comfortable that way. There still was a hold on biological reality. That hold has loosened to a great degree in our medical profession today. The conceptual basis of these interventions is already highly dubious, even before you get to the question of clinical outcomes.

Mr. Jekielek:
In this case, is even thinking about cost-benefit not actually useful?

Mr. Sapir:
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. Some of them will say, I started feeling this way as a kid, as a teenager. I personally don’t have a basis to doubt that. Maybe some people do. To 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 sexual paraphilia. There’s the concept of autogynephilia that I think more and more Americans are beginning to understand. Some people with autogynephilia talk about it openly.

Autogynephilia is erotic attraction to the thought of oneself as a woman. If you’re a man, you’re attracted to what you would be like as a woman. If people see them as a woman, it causes a kind of erotic feeling. If you set aside the conceptual framework and look at the clinical outcomes, you can reasonably say 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.

Clinicians and mental health professionals who say that they do and are very cautious and conservative and 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. There really is no way for clinicians to be able to say, you are going to be a future transsexual and you are not.

Given the absolute moral hazard here and the potential to hurt so many kids irreparably, by far the safest course is to restrict this, even for young adults, the 18 to 25 cohort. 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. There’s a good case also to restrict it in young adults.

Mr. Jekielek:
The argument is if they’re not able to realize their true selves early enough, there will be great suffering later in life.

Mr. Sapir:
Yes, that was the original justification for the Dutch approach.

Mr. Jekielek:
They were the pioneers of this whole thing, right?

Mr. Sapir:
That’s right. The Dutch were the pioneers, based on their clinical experience that the 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.

The theory was, let’s bypass puberty in order for these kids to be able to pass later on as women. If they 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 from going through the, quote, unquote, wrong puberty. That was 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.

Mr. Jekielek:
Essentially, you’re in favor of banning this whole approach entirely. There’s some arguments that would say, maybe just a little bit of it would be okay.

Mr. Sapir:
You’re starting to see some gender clinicians and advocates of medical transition agree that things have gone off the rails. With the massive exponential rise in the number of kids identifying as trans, especially girls, who are seeking medical interventions and getting them with virtually no safeguarding, no gatekeeping, something has gone terribly wrong. But these clinicians or these activists will say, but what about the true transgender kids, 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. If you even look at the Dutch protocol, which is supposed to be the conservative approach here, it would automatically exclude the majority of girls who are today presenting for medical transition. Even if you do it according to the Dutch protocol, that 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, and the huge methodological problems that went into the original Dutch experiment.

Again, looking at this from a clinical outcomes 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 and 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?

So they end up resorting to saying, a kid 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.

Mr. Jekielek:
In most cases from, 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.

Mr. Sapir:
Right. The literature on pre-pubertal 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 crossed 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, 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, maybe even likely, but they weren’t sure. 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.

Mr. Jekielek:
We talked about what you’re hoping the Trump administration will do. One is to keep this Supreme Court case alive. What is your wish list for what you want this incoming administration to do with respect to this issue?

Mr. Sapir:
There are 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, you know, hundreds of millions of taxpayer dollars, into research whose only purpose is to promote these interventions. I actually think that instead of cutting off, instead of shutting off the valve, NIH should reorient itself and devote money to studying the harms which are not studied.

Nobody is studying harms because the gender clinicians doing the research don’t want to 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. Eithan 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.

What about on the executive side? 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 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.

Mr. Jekielek:
Leor Sapir, it’s such a pleasure to have you on the show.

Mr. Sapir:
Jan, thanks for having me.