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The Evidence of Harm: What the Data Really Show About Pediatric Transgender Procedures | Leor Sapir
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- [00:00]
A
She said, we're giving out puberty blockers like candy. You're talking about powerful, irreversible drugs and surgeries on kids. It's very difficult for them to say, oops, we got this one wrong, even if they actually come to that realization. What 12 year old can possibly understand what it means to never be able to have children in the future?
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In this episode, I'm sitting down with Leor Sapir, a Manhattan Institute's senior fellow and one of the co Authors of the 400 page HHS review of pediatric Gender Medicine.
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A
Sex is not assigned at birth. And to tell patients consistently in a medical setting where figures of authority wearing white coats come into the room and tell parents the sex that you thought your daughter or son is, is not their true sex is fundamentally unscientific and misleading.
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B
This is American Thought Leaders, and I'm Jania Kellock. Leora Sapir, Such a pleasure to have you on American Thought Leaders.
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A
Thanks for having me back.
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B
The term sex rejecting procedures, it's one that I hadn't heard before, but kind of makes a lot of sense to me. Where did this come from? It's now largely used actually in this lexicon, particularly by hhs.
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A
That's right. The administration adopted this term in the last few months as an alternative to, certainly as an alternative to the standard term in the field, which is gender affirming care. Gender affirming care is a euphemism and it is essentially a marketing term. And so it was clear to the administration, in my view, that they didn't want to use this term. And there were a few other candidates, sex trait modification being one. But sex rejecting procedures, the advantage of the term is that it conveys the intent behind the use of puberty blockers, cross sex hormones and surgeries to treat a condition known as gender dysphoria.
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B
And.
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A
And that the intent is to reject one's sex.
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B
You played a significant role in this recent HHS report, which many people describe as groundbreaking and others really dislike. Tell me a little bit about this report and what does it bring to the table that's new, especially here in the U.S. sure.
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A
So the HHS review on Pediatric Gender Dysphoria Evidence and Best Practices was done pursuant to an executive order signed by President Trump in his first few days in office. The executive order tasked the Department of Health and Human Services to produce this report within 90 days. I got the phone call. I was asked to assemble the team and produce the report and deliver it on time. By the time we got going, we essentially had about 8, 9 weeks to produce this report. By contrast, the CAS review in the UK, which is the comparable review that was done and published in 2024, had four years. So we were working under a very, very tight deadline. But luckily I was able to recruit very, very good experts, medical doctors, bioethicists, researchers, people who know the field like the back of their hands and understand the principles of evidence based medicine very, very well. They're also well published with a lot of scholarly articles. And so we were able to produce this report. It came in, I think, clocked in at just over, and we had a 170 page appendix with all of the data tables from our systematic review, which I'll talk about in a minute. And, you know, its central findings were substantially similar to those of every single systematic review done to date on this issue, which is that the evidence for benefit from the use of puberty blockers, cross sex hormones and surgeries as a treatment for gender dysphoria in minors is a very low quality, meaning there's profound uncertainty about whether these treatments help. At the same time, the evidence for harms, and this is one of the novelties of our report, the evidence for harms is stronger. And so one of the things that you have to do, of course, in medicine, especially with novel treatments, is you have to try to figure out what is the risk profile, risk to benefit profile. And one of the things that our report does for the first time in the context of a chapter on ethics, is to try to balance the known benefits or lack of certainty of benefits against the higher certainty of certain types of harm.
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B
You know, it's interesting, as you were describing, you know, you're saying, you know, puberty blockers, surgery. So I kept thinking gender affirming care, gender affirming care, because I've been, you know, that's the term that we've been using. And I always would say it in quotes because it's not clear it's care, I suppose, is the reason. But now is the approach to try to get this sex rejecting procedures into becoming the standard lexicon.
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A
So we actually don't use the term sex rejecting procedures in the report. We use the term pediatric medical transition, pmt. So that's the term that we, that we chose to use. There's a reason behind it as well. This, this report was written, you know, in a, in a style, in a tone that is markedly different from how the Trump administration has been talking about these issues. Partly that's a reflection of the fact that we are not partisans and we Are, you know, most of the authors of the HHS review are actually liberals who have voted Democrat their entire lives. But part of it is also, I would say most of it is motivated by the fact that we want to appeal to, we want to engage with people in the medical profession who may not be aligned with the administration, but who do care about questions of medical evidence and medical ethics. Who care about, who may be interested in the history of this area of medicine, in the clinical realities. We have a whole section of the report that talks about clinical realities and how this area of medicine actually operates in the United States and what's been happening abroad and why. The report is written in a tone, in a style that is trying to avoid being partisan and really trying to just stick to the facts and look at the issue from a really neutral perspective.
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B
So bottom line, now you've done the newest, I guess, systematic review. Bottom line is, what benefits are there?
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A
Well, so first of all, what we did is not exactly a systematic review. It's called an umbrella review. An umbrella review is a systematic review of systematic reviews. It gets a little bit technical, but I think these details matter. So in evidence based medicine, you basically have what's called a pyramid of information or a hierarchy of information. At the very bottom, you have kind of anecdotal case reports and the expert opinions of doctors. And those opinions may be based on their own experience treating patients, but they're not based on systematic observation. If you go higher up the pyramid, you start getting cross sectional research. You get observational research, uncontrolled observational research. At the top of the pyramid of research is of course, the randomized control trial, of which none exist in this area. Then at the very top, at the very pinnacle of the hierarchy of information, you have systematic reviews. What a systematic review does is look at the entire body of evidence for a particular question, such as, do puberty blockers cause mental health improvement? Various metrics. They try to not only summarize and synthesize all the available evidence, but they also score it, they try to grade it. Is it credible? Is it not credible? What are the factors that determine that credibility? There have been many systematic reviews done on these questions in the last five or six years. The first country to really do it was Finland in 2019, followed by Sweden and then the UK. Every single time a systematic review was done on this question, the answer came back exactly the same, which is the evidence is a very low certainty because the studies are methodologically very weak. They're incapable of determining a causal link between the use of these powerful drugs on the one hand, and mental health outcomes on the other. And by the way, the outcomes are not always positive. In many of the studies, you see that the outcomes are mixed. And in some studies you actually see that the outcomes are negative. We did an umbrella review because there are so many systematic reviews. We didn't need another systematic review. And so we needed to look at all these systematic reviews and score them for methodological quality. And that's what we did in this report. So just to kind of set the. To get the details out there, because I think they're important. Sure. So we did an umbrella review.
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B
So what's the bottom line then?
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A
Well, the bottom line is that there is no credible evidence that puberty blockers, for example, address anxiety, depression, suicidal ideation, that they're not needed to address those conditions. Now, you also need to think about what are the risks of these drugs. And part of the problem in this field, in the field of gender medicine in general and pediatric gender medicine in particular, is that the people who do studies in this area are typically gender clinicians, people who are invested in this type of practice, who believe in it for sometimes very ideological reasons, sometimes financial reasons, sometimes they just believe that they're helping kids. I think their belief may very well be sincere, but we have plenty of evidence that these studies don't try to track harmful outcomes. Usually the studies are very short term. They have very high dropout rates. Even when the researchers are interested in registering and looking at potential harms, for example, the lack of bone density, accrual or cognitive impacts, or cardiovascular events, they don't end up following up, they don't end up publishing the results. So just to give one example, in 2024, the New York Times reported that a major NIH funded study, $10 million. The lead researcher in that study, Johanna Olson Kennedy of Children's Hospital Los Angeles, or I should say formerly of Children's Hospital Los Angeles, had the mental health outcomes from puberty blockers in the kids in her study. And she chose not to publish the results because they were unimpressive. She told the New York Times, I didn't want this to be used by critics of this area of practice, to be cited by them. So she just didn't publish the results. This is fairly characteristic of the field. It's dominated by clinicians who are deeply invested in this type of practice. And so that results in all types of biases and distortions.
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B
And you can imagine the study design also is something that I did once in my life and I was sort of struck by how easy it is to design studies to go in the direction of your favorite outcome to get closer or something like that. So I imagine that most of these studies, based on what you're telling me, must be set up for particular outcomes. And if they don't get them, it's almost like that itself is evidence. Might be evidence. I'm just hypothesizing here, of course, but.
- [11:43]
A
Yeah, I mean, that's. So just to give an example of what you're talking about, one study that was published a few years back on the outcomes of mastectomy in girls, actually, it was also led by Johanna Olson Kennedy. They developed this tool for measuring outcomes. They called it the chest dysphoria tool. And basically what this tool, essentially when you look at kind of how they conceptualize chest dysphoria, it's do you like the way your chest looks now after you've had a mastectomy? And they asked all these girls a few months after they got the procedure, do you like how your chest looks now? And naturally, most of them said yes. Okay, but what does that tell us? What does that tell us about their long term mental health outcomes? What does that tell us about what's going to happen when they're in their 30s and they want to breastfeed and they can't? Are they still going to be happy with their decision then? This study has no ability to give us any of that information. But of course, the study's results were applauded and spun as evidence that these procedures are medically necessary. So that's a good example of what you're talking about. You can design a study to show you something that you in advance want it to show.
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B
So something that struck me about this report was that, I mean, I think you're able to show that there's a lot of misleading information that's being shared with parents systematically. And I don't know if that has been convincingly shown before.
- [13:09]
A
Hmm. It's definitely been shown, but I wouldn't. But I would say that it hasn't been summarized in a way that's accessible to both the medical community and lay readers in a way that we tried to make it. And sometimes, you know, that information is distorted, exaggerated, misrepresented. We tried to be as factual and defensible as we possibly could. And so, you know, just to give two examples, chapter two of the report, we have this whole introduction section which discusses, after a brief introduction, discussing the incidents, the prevalence of these procedures, and we discuss what's been going on abroad. The practice reversals in various Scandinavian countries in the uk One of the chapters in that section deals with language. We discuss how the core concepts that define this field are unscientific and misleading to patients and, in the case of minors, to their legal guardians, their parents. So sex assigned at birth, an extremely common term in this field that pretty much every gender clinician uses. Sex is not assigned at birth. It's determined at conception and recorded or observed at or typically before birth, very accurately, with almost perfect accuracy. So sex is not assigned at birth. And to tell patients consistently in a medical setting, where figures of authority wearing white coats come into the room and tell parents the sex that you thought your daughter or son is, is not their true sex is fundamentally unscientific and misleading. If you add to that the other core concept of the field, gender identity, another term that is ubiquitous but lacks a scientifically valid definition. It relies either on circular reasoning. A gender identity is a person's internal sense of gender. What is gender? It's an identity. That's circular reasoning, right? Or it relies on stereotypes. Gender identity is, you know, your innate sense of wanting to be or be more masculine, be more feminine according to socially accepted stereotypes. If you tell parents that their child has this innate, immutable, gendered soul, and that they're always going to have that soul, and it's a real gendered soul, and that their actual sex is assigned, meaning it's a social construct, and then you present them with medical options, irreversible hormone and surgical treatments. You are misleading parents and patients about the nature of their condition. So we discuss some of these issues in a way that I think hasn't really been done yet in a systematic, scientific manner. The other example I would give is, you know, in the section on clinical realities. This is part three of the report. We have one chapter there, chapter 10, where we summarize everything that we have discovered about the World Professional association for Transgender Health, which is kind of the trendsetter in the field. This is the organization whose recommendations.
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B
Wpath.
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A
Wpath, that's right. This is the organization whose recommendations. It calls its recommendations the standards of Care. The eighth version was released in 2022. This is the organization whose recommendations are adopted across US healthcare settings. Insurance companies kind of defer to its recommendations for what is and is not medically necessary. The Biden administration inscribed Wpath's approach into its own policies. Hospitals follow it, and of course, gender clinicians follow or claim to follow it. But in any case, wpath, when it was developing its latest standards of care, commissioned systematic reviews of evidence. And when it discovered that those systematic reviews are not going to show what it wanted them to show, which is that there's credible evidence of benefit, it suppressed their publication. We know that because in a lawsuit in Alabama, WPATH was ordered by the court to turn over all internal communications that it had between its own clinicians and leadership related to the development of its standards of care. And it's right there, clear as daylight, you see the clinicians admitting that they are suppressing evidence. You see them admitting that they are eliminating age minimums for hormones and surgeries due to political reasons, for political pressure, and a bunch of other things like failure to manage basic financial conflicts of interest. All of this has been public information. It was reported in the New York Times and the Economist. This is not some conspiracy theory. It's right there for everybody to see. You can actually see the court documents. So we summarize all of this, all of these findings, and kind of discuss their significance in chapter 10 of our report. And because of how ubiquitous WPATH is and because of how much US healthcare relies on wpath, I think there's a plausible case to be made that this is simply a case of medical fraud. And any patient who has consented on behalf of, or I should say any patient who has consented, or any parent who has consented on behalf of his or her child to these medical interventions, when the doctors follow WPATH or claim that WPATH is the authority that publishes credible guidelines, has fundamentally been misled if they're not aware of the suppression of evidence and those other elements. So those are two examples of how, yes, fraud is not just a feature, or I should say, it's not just something that happens in this field. It's almost fundamental to the field itself.
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B
So it's fraud. Yes, it's just that simple.
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A
It is simple, but you have to make the case for it. You have to reason your way through it. You have to show the evidence. You have to discuss. I mean, here's another example. Medical societies say that these treatments are evidence based and safe. What are they basing that on? And so we show in our review how groups like the American Academy of Pediatrics and WPATH and the Endocrine Society, they cite one another's guidelines as evidence. As evidence, Right. So there's this kind of circular citations and you might call it credibility laundering. WPATH actually in. In those internal communications, its members explicitly discussed the importance of getting actual bona fide medical associations like the Endocrine Society and The AAP and the American Medical association to endorse its guideline, to give it the appearance of a credible medical guideline. Interestingly, not a single medical group agreed to do it. They simply didn't criticize WPATH guidelines, but they didn't endorse them either. But nevertheless, this is how this area of medicine operates. Everything is very secretive behind the scenes. And by the time things come to light, there's this kind of appearance of a consensus within the medical profession. And in chapter 12 of our report, we also give lots of evidence of how medical societies internally suppress dissent and questioning from their own members. So the Endocrine Society has done this, the American Academy of Pediatrics has done this a lot over the last few years. Anytime pediatricians would say, why aren't we relying on systematic reviews of evidence? Why aren't you, the leadership, allowing debate on this topic at our annual conferences, they would find all of these kind of clever technical reasons to kill those resolutions, to suppress those questions, and to marginalize and sideline the clinicians who say we need to take a more scientific look at this.
- [20:57]
B
So I was about to ask you about this actually, because your report has been criticized by a number of groups, WPATH and a number of professional organizations which have significant reputation in the society and set a lot of effectively, guidelines, for example, pediatric medicine, right?
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A
So the American Academy of Pediatrics criticized the report within hours of its initial publication in May. This is a 409 page report accompanied by a 170 page appendix with lots of data tables. I'm a little bit unsure that they were able to read the entire thing and really go through it and fact check it within two or three hours. In fact, I'm confident that they did not. What's interesting about this report is that because of our very short deadline of 90 days from the beginning, the plan was to have an extensive peer review process after the initial publication on May 1st. And we wanted to, our goal was to invite in the peer review process, to invite our strongest critics, right? The American Academy of Pediatrics, the Endocrine Society, the American Psychiatric association, to invite them to review the report and tell us, what did we get wrong, what mistakes did we make? That's what peer review is supposed to be all about. The American Academy of Pediatrics, despite criticizing the report, within hours of it coming out, they initially agreed to do a peer review. And then at the very last minute, they pulled out. They just said, we're not going to send you the review. The Endocrine Society from the beginning said, we're not going to review it. The American Psychiatric association, to its credit, agreed to review the report, but they overlooked the entire section on evidence. So they said, you didn't disclose what your methodology is, even though it's right there in the appendix. And they gave us a list of 16 studies that we failed to include or evaluate in our report. Twelve of those studies are not just explicitly included in the report. In some cases we have elaborate discussions of those studies in the report. So clearly they didn't read it. And of the remaining four, the remaining four were either on adults, in which case they're irrelevant to Pediatrics, which was the topic of the report, or in one case it wasn't even on gender medicine. And because we didn't get feedback from the AAP and the Endocrine Society, we said, you know what we really want to respond to kind of we want to steel man this. We want to respond to the best available, the strongest possible criticism of our report. And so what we did is we took two published critiques published in peer review medical journals that, you know, kind of went point by point of our initial report. And these, these two papers were written by about two dozen of the top gender clinicians in the United States. And we responded to all of their points point by point and showing why they're simply, they're mischaracterizing our findings. They're overlooking very critical details. You know, as I've been saying to people, don't take my word for it, go and read the supplement. So there's a document called the Supplement to the HHS Report. It's on the HHS website and that is where you can find all of the peer reviews and all of our responses to the peer review. It's not that long. And so, you know, I've been telling people, don't take my word for it, go and read it. And you tell me who has the better argument. But look, I mean, in addition to those three responses, the APA and the two peer reviewed articles by the gender clinicians, we also got peer reviews from about half a dozen other experts who had a very positive assessment of the report. This includes a former president of the Endocrine Society, he's a professor emeritus at the University of Virginia. And he said the report is overall solid. He specifically reviewed the section on all the harms that are likely to result as a result from endocrine interventions. And he said, this is a solid report. We had two experts from the center for Evidence Based Medicine in Belgium, which is kind of its leading institution for ensuring that its own medical practices are based on the best available evidence. They reviewed our entire umbrella review of the methodology, that 170 page appendix. They said that our findings were robust and transparently reported and they found no problems with it. We had other professor of pediatrics give a very favorable endorsement. We had a really prominent bioethicist say that our ethics chapter, which we should probably discuss because that's another really important innovation in this report, was really, really good. So the peer review process. The bottom line is nobody was able to identify any significant errors in the report. There were a few minor errors that were pointed out and some of the reviewers actually said we didn't go far enough in criticizing certain practices in the field. So again, I encourage people to read the supplement and really see for themselves what were the criticisms made of the report and do those criticisms hold up.
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B
Before we end up talking about, about ethics? I've looked at the report. I haven't read it cover to cover, you know, appendix and so forth. But I, I am familiar with the, roughly familiar with the body of literature. I, I know which direction it goes. I appreciate you, you know, demonstrating that in this umbrella way, which is, that's, that's a very interesting distinction that I hadn't fully grasped until you just talked about it. But major important medical institutions in this country are deeply committed to saying that what you did is wrong and problematic. What's going on?
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A
Okay, so first of all, it's three or four of the medical groups have said that, right?
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B
Out of dozens, but incredibly influential and important ones.
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A
I mean, sure, there's one medical organization called the American Society of Plastic Surgeons. It's the largest medical group that represents surgeons. They actually, in 2024, they broke ranks from other medical groups and said, no, actually, these practices are not supported by evidence. We need to rethink this. So that's, I think, important to note as well. But if you're asking specifically about the aap, the American Academy of Pediatrics, the Endocrine Society and wpath. WPATH is the easiest to explain. Right. It's an activist group that wants to present itself as a medical organization. By the way, a lot of its members are not even medical professionals. They can be lawyers, they can be just activists and advocates. But it's an organization that's devoted to promoting the medical model, to eliminating any safeguards, any mental health assessments, and to making sure that all of this can be obtained on the basis of insurance coverage. But with regard to the AAP and the Endocrine Society, you know, to some Extent, it's anyone's guess. I think it's a combination of kind of ideological commitments and sunk costs. Right. Once these organizations committed themselves to the practice, even if they committed themselves out of good faith and trust in, you know, people they thought were experts, once they've committed themselves to this, because of the nature of these procedures, you're talking about powerful, irreversible drugs and surgeries on kids, it's very difficult for them to say, oops, we got this one wrong, even if they actually come to that realization. I think a lot of what's going.
- [28:45]
B
On in these Isn't it harder to double down? You're right, it's hard. But doubling down seems somehow harder.
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A
Well, I think it's a matter of short versus long term incentive. So just to give an example, the presidents of these organizations have a tenure of one year, maybe two years. And so from their perspective, it's probably easier to just kick the can down the road and let the next guy deal with it. So that's one possibility. The other is what some of us call capture by committee, which it's a phenomenon that we see in Congress. It's a phenomenon that I think exists in any large corporation. And that is when you have a small group of highly motivated, kind of ideologically cohesive activists within a particular committee or institution within an organization, and they promote one particular viewpoint. And those who prefer a different viewpoint are diffused. They're not as organized, they're not as motivated. Maybe they're looking at thinking about other things, or maybe they're afraid of sticking their necks out, as is the case in this area. It's always the first group that's going to prevail. And so if you're the leadership of one of these organizations, you know, your incentives are to defer to the small, vocal, highly attentive, highly motivated group, because the diffused larger group that's not as motivated and not as attentive is not going to have your back. So there's these collective action problems that occur naturally in organizations, and I think that that goes a long way towards explaining what's going on here. But I'd say one last thing is what I and others have been calling the broken chain of trust. Medicine is a profession characterized by a high level of information asymmetry and specialization. And that means that if you're a doctor in contemporary medicine, you know a lot within a very small silo of information, and you defer to colleagues who are specialists in other areas of medicine, and you expect in turn that they'll.
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B
Defer to you and you expect that there's competence.
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A
Exactly. And so there's a chain of trust without which medicine cannot work. Without that chain of trust. That chain of trust is deference in the medical field is extremely important. Right. If you take your kid to a pediatrician and they have some bone problem, it could be a fracture, let's say, in their spine or something like that, you're going to send them to an orthopedic surgeon, you're going to send them to somebody who's a specialist for that particular problem. And you need to be able to trust your colleagues. And so I think that the reason why it's not just in the United States, I think the reason why health authorities abroad as well, initially adopted these practices kind of, you know, the medical transition of children, is because they thought, look, there are these people who call themselves experts in gender medicine. They claim that they've looked at the evidence and evaluated. They claimed that their own clinical experience confirms that these procedures are beneficial. I'm a pediatrician or I'm a family physician, or I'm an endocrinologist. What do I know about these things? I'm going to defer to them. Once it becomes clear, once it became clear that the people who are most involved in promoting this field and turning it into what we know today, that they are either incompetent and I mean that literally, they don't know how to read scientific studies. I've seen examples of this. Or dishonest, or they are kind of siloed in an echo chamber in which they only hear their own views being reinforced. That's the typical WPATH conference. There's not a single voice of dissent at those conferences. I've watched many videos of their panels. These people truly believe that what they're doing is beneficial. Once you understand that you have been misled, that the chain of trust has been broken, that's a pretty sobering realization. And for medical group leaders, it's going to take a long time for them to kind of figure out how to deal with this. One last thing I should say it's not uncommon in American medicine for practices to be revealed as unsupported by evidence or negated by evidence and yet persist on. I mean, I can give many examples of this one being arthroscopic knee surgery for arthritis of the knee. There was a double blinded, believe it or not, randomized controlled trial done in 2002 that found that for the vast majority of patients who get these types of knee surgeries, they were happening at about 650,000 of these procedures per year. For the vast majority of patients getting them, they were no better than placebo. Now, did that mean that orthopedic surgeons just kind of stopped doing it on most patients for whom it was not beneficial? No. What happened was that medical associations that represent the interests of the surgeons lobbied the Centers for Medicare and Medicaid to adopt an extra extremely narrow interpretation of this double blinded, randomized control trial so that they wouldn't limit Medicare coverage of these procedures so that the surgeons could continue performing them. These types of. The AAP had a recommendation against peanuts for pregnant mothers and young children. 17 years that recommendation was on the books, leading to a skyrocketing of peanut allergies in kids. It took them some 17 years to reverse that recommendation.
- [33:57]
B
Yeah, I learned about that in now FDA Commissioner Marty Makary's book. Actually, I'm just like, astonishing. And I think there's a heck of a lot of people that don't know this yet. And this happened a while ago. Right, Right. I mean, this is, I think, the perfect foray into the chapter on ethics. Why did you include that?
- [34:18]
A
Yeah, one reason is that it seems so intuitively obvious that this is ultimately an ethical debate. Right. The questions of evidence are obviously important. They're front and center. But the question on everybody's mind is, should we do it? That's an ethical question. And medical ethics is, you know, you would hope that it's. That it governs the field of medicine. So that's one reason it was just obvious that we had to do it. The other reason is, believe it or not, there's. There's an. Until we published the report, there was no English language, rigorous scholarly analysis of medical ethics. In this context, ours is the first to do it. We had two bioethicists on our team, both of them very well established academics. Interestingly, they come from different sides of the political spectrum. What they did was they applied basic principles of medical ethics. This was not reaching for some bizarre interpretation. No, this was the most basic interpretation that any bioethicist would agree of the kind of the four cardinal principles of medical ethics. So the principle of beneficence, that the doctor has to benefit their patient, non maleficence or non maleficence, I should say what we know as first do no harm, the principle of autonomy and the principle of justice. These are the four cardinal principles of medical ethics. They applied them to what we know about this field, specifically what we know about the evidence. Evidence for benefits and evidence for harms. And I would recommend that anybody who doesn't have time to read the whole HHS report, if there's one chapter you should read, read chapter 13, the ethics chapter. It really is, I think, a tour de force of how to think about this issue from an ethical perspective. So to give you an example, within the context of an ethics chapter, we had to balance what we know about the risks with what we know about the benefits. That's not always done in this field, believe it or not. And the risk to benefit profile is, of course, unfavorable. And so then the question is, what do you do about that? Right. We don't make policy recommendations, but we do want people to have to grapple with that fundamental reality. The other, I think, really important analysis in this chapter is on the principle of autonomy. Because if you follow this issue and how it's being debated not just in the United States, but abroad, and how certain clinicians talk about the justification for what they do, it's always an appeal to patient autonomy. Let patients choose. Let parents choose on behalf of their kids. Don't tell doctors what to do. That's a problem, as we explain in this chapter, because the principle of autonomy in medicine is not a blank check for patients to demand anything they want from their doctors. You know, think about the opioid epidemic, right? Imagine patients going into their doctor and saying, you need to give me whatever I want, whatever pain medication I want. You can imagine kind of a mentally disturbed parent who wants to make their kid sick. This is sometimes called Munchausen syndrome by proxy. Going into a doctor's office and saying, I want you to prescribe chemotherapy to my kid. Because they won't say this out loud, because I want the sympathy points. I want them to be sick so I can have sympathy points. Or maybe the kid will get sympathy for being on chemotherapy from their friends. Doesn't mean the doctor's gonna do it if the kid doesn't have cancer, right? So patients don't get to demand treatments from doctors. Doctors have a professional ethical obligation to only prescribe things that are more likely than not to benefit their patients and not likely not to harm them. But in the context of gender medicine, the principle of autonomy has been reinterpreted to mean the doctors have to give patients what they want. And so we explain why that's not how the principle of autonomy works. It's a shield against unwanted interventions. For example, we give the example of the Tuskegee air experiment.
- [38:11]
B
Right? Right, exactly. Maybe just remind people what happened.
- [38:15]
A
Oh, that's a It's an experiment on, on, I think it was 600 African Americans that, you know, it was a fundamental violation of their autonomy. They were, they were misled and harmed in the process. But look, I mean this is the stuff that comes out of, you know, World War II era conventions about medical ethics. The patients can, cannot be given experimental or even non experimental drugs, procedures against their will. That's a fundamental commitment, ethical commitment of any doctor. But it's been again distorted to mean that patients can demand anything they want from their doctors. That is not what the principle of autonomy says. The justice principle is interesting in this context because we know based on research that a significant portion of these kids, if not socially and medically transitioned, will actually come out to be gay later on in life. And so there seems to be a disproportionate harm visited here upon the bodies of proto gay youth. Another thing that we do here is talk about a little bit about regret and how to think about regret in the context of this care. I know that you had Chloe Cole on detransitioners. Of course the question of regret is really important. But what we argue in this chapter is that it's actually not fundamental to an ethical analysis of this field because presumably you can have patients who regret beneficial interventions and patients who don't regret non beneficial ones. The question of regret really doesn't even come in until after you've done that initial risk benefit calculation. And then finally we added a section on research ethics. Anticipating that as ended up happening, that the UK was going to go into propose a clinical trial for puberty blockers, we raised the question, what can we say based on principles of research ethics. What can we say about doing clinical trials in this area? Here again we said there is a problematic, it's problematic from an ethical perspective. You really need to be careful here given everything that we know well.
- [40:27]
B
And just when this gender affirming care model, right, as I've learned, right the moment there's a hint of suggestion there might be some sort of dysphoric thinking or proto gender dysphoric thinking, the procedure is affirm, affirm, affirm, affirm, affirm and almost. So I'm thinking about how you were describing the principle of autonomy. Then the you know, child apparently ostensibly wanting this could be for all sorts of reasons, could be peer pressure, could be anyway, there could be many reasons. But it becomes a kind of manipulation of sorts because now everybody in the system is basically telling the kid, well you're probably, you know, you're probably not what you thought.
- [41:14]
A
Right, right.
- [41:15]
B
And just sort of reinforcing that because they're, they have a. Either an ideological commitment or they've been taught that and that maybe that's why they have the ideological commitment. And so, I mean, where does autonomy sit there? And of course, with kids, again, how could they even have any sense of the future and what to expect, what not to expect?
- [41:40]
A
That's a great question. And autonomy, I think we've always understood autonomy in the context of child development as an attraction, achievement of adolescence, rather than something that's kind of just posited at its very beginning. Right. That's why we don't let kids take out credit cards, buy guns, drive before they're, you know, whatever, 16, 17 years old. We recognize that they are not mature, they're not responsible, they make rash decisions and so forth. In this context, I think there has been, we actually discussed this a little bit in chapter two as well, on language. There is a conscious, deliberate, systemic effort in this field, in the field of pediatric gender medicine, to treat children, even very young children who are not even in puberty, as if they're mature adults. And so terms like children, kids have been almost purged from the field. If you watch grand rounds given by gender clinicians, which I have, if you watch WPATH panels, which I have, if you read the way they talk about their patients in their articles and their interviews, they use terms like folks to describe 11 year olds, young people is a very common term. Young people to describe kids as young as 5. Who talks about 11 year olds as folks? Who refers to kids that way? Well, the answer is people who want to try to kind of minimize what we all know with perfect clarity, which is that kids are not adults. There's differences between them. So getting back to the question of autonomy, the correct standard, as we discuss again in chapter 13, the ethics chapter, the correct standard is best interests. Parents have to make decisions in the best interests of their children, not based on the supposed Autonomy of a 12 year old who doesn't even understand what it means to give up their future fertility, which is what they're often doing in this context. What 12 year old can possibly understand what it means to never be able to have children in the future. So, I mean, just to give you an example, and we discussed this in a chapter on clinical realities, chapter 11, where we kind of talk about how the gender clinicians themselves explain what they're doing. So the author of the American Academy of pediatrics policy statement, Dr. Jason Rafferty, he gave an interview to Jennifer Block for the. It was published in the Boston Globe. And he said to explain what he means by the gender affirming model of care. He said, and this is almost a direct quote, he said, it's a model of care that's oriented around a child's sense of reality. So the treatment decisions are based on a child's sense of reality. And, you know, to people like us, we hear that and we say, whoa, this is. Something is really screwed up here. But to them, it's. It seems completely natural and normal because they have this belief that kids can know that they're transgender from a very early age. They can have this infallible knowledge of being transgender, and you must never question it. And sure enough, you know, the Boston Children's Clinic, the GEMS Clinic at Boston Children's Hospital, the director of that clinic was seen on a video, and we mentioned this, too, on a training video. I think it was a training video. She said, Jeremy Carswell is her name. She said, we're giving out puberty blockers like candy. Her words like candy. So this is not, you know, they say this themselves. We just document what they say in the report.
- [45:13]
B
Thank you. I mean, I think you've given us a really good picture of what's been accomplished here. And, I mean, as we finish up, what are the next steps? How is this being implemented? I mean, there's been a whole shift in this whole area of medicine dramatically since this administration came on very quickly. But where are we at now? And what are, you know, where are things heading?
- [45:38]
A
Yeah, so you're right. There has been a dramatic shift. The administration has made this one of its top priorities. You know, I don't think everything that it's done has been great, but it certainly has done quite a few things that have really moved the needle in a very positive way and drawn attention to the problems in the field and so forth. And they're trying to hold people accountable. They're going after insurance fraud, which is ubiquitous in this area. I've written about that. But what we really need right now, frankly, is more medical professionals to become aware, to educate themselves on this issue, and to stop blindly deferring to people they believe are experts. And we've seen a tremendous awakening of medical professionals over the last few years. More and more of them are willing to speak out and say, this is not right. And by the way, they're not all conservative by any stretch of the imagination. Many of them are very liberal, and they say, you know, my tribe got this one wrong, and we need to be able to talk about it and say that I would like. As one of the co authors of this report, one of my goals is to have people read it and engage with it. And I understand that's a tall order because it's a long report and doctors are very busy. So I would hope that people at least read sections of it or read it over a long period of time. That's fine, too, or reach out to us with questions if they have any. But you really need to understand the issue well if you are going to have an informed opinion on it. And I think this HHS report, not to pat ourselves on the back, really is the best thing that has been written in the English language on this topic. So I hope that people will, you know, read it, engage with it, let us know if they, if they disagree with it and why. But I hope it forms the basis of a, of a conversation within the medical community, not just during the Trump years, but after President Trump is gone.
- [47:26]
B
And they can at least start with the ethics chapter.
- [47:29]
A
I think that's a good place to start for people who don't have the time to read the whole thing that we have an executive summary that's a couple pages long can definitely start with that, just to see kind of what the whole report is all about. I think the ethics chapter is great. And I think if you want to add something to that, read the parts of the supplement where we respond to critics, read the critics what they say and then read our responses. And if that doesn't trigger your interest in the topic, I don't know what will.
- [47:54]
B
Well, Liryre Sapir, it's such a pleasure to have had you on.
- [47:57]
A
Thanks so much. I appreciate it.
- [47:58]
B
Thank you all for joining Lear, Sapir and me on this episode of American Thought Leaders. I'm your host, Janje Kelik.