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Foreign.
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Welcome back to another episode of the City Journal podcast. I am your host, Raphael Mangual, and thrilled to be joined by my brilliant colleague, Lior Sapir. Lior, welcome to the show. Is this your first time on the podcast?
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On this podcast.
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Amazing. Amazing. Well, I am so glad to have you. I'm really excited for the conversation that we're going to have today and for our audience. For those of you who don't know, Lior Sapir is a senior fellow at the Manhattan Institute. I'm sure you have read his stuff in City Journal. If not, you absolutely should. But, Lior, you are perhaps the most, if not one of the most important and influential voices in our ongoing debates about gender ideology in this country and medicalization of gender ideology. And, you know, in addition to regularly commenting on these issues in places like the Wall Street Journal and the Free Press and, of course, City Journal, you also have a voice in the sort of academic realm of this debate. You are a co author of an important HHS report that recently came out entitled Treatment for Pediatric Gender Dysphoria, Review of the Evidence and Best Practice, which is something I want to talk about later on in our conversation. But I think the best place for us to start here is just to get a sense of how it is that you arrived at the place that you are. I mean, how do you go from, you know, a PhD from Boston College to a think tank where you are now kind of one of the leading national voices on gender ideology? Walk us through that, that journey.
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Sure. It was a very unexpected journey. I would never have predicted, let's say in 2015, 2016, that I would have ended up where I am. I wrote my dissertation on Title 9, the Federal Law that prohibits discrimination on the basis of sex and education. And I wrote specifically on the way in which the Obama administration and the federal courts had implemented a regulatory apparatus that expanded the common, conventional understanding, understanding of Title 9 with regard to how schools were expected to accommodate students who identify as the opposite sex. And I thought it was a very interesting puzzle to try to solve for two reasons. One being just the underlying issue is very interesting. And, you know, the Obama administration didn't really have a good sense of why it was doing what it was doing. It couldn't really define key concepts like gender identity, and it couldn't explain why, as it, as it said at the time, sex is a stereotype. It called kind of the conventional understanding of sex a stereotype. It couldn't understand. It couldn't explain this, and it didn't even bother to try. And I thought that. That in itself was interesting to me. But secondly, you know, it was interesting that the Obama administration said, this has always been law. What we're doing is nothing new, and therefore we don't have to go through all these regulatory hoops like notice and rulemaking process. And it just kind of tried to introduce all these new policy changes through unilateral guidance letters. So I thought it was an interesting case to try to understand how American government works nowadays. It's no longer the Schoolhouse Rock version of how laws are. Right. Exactly, exactly. It's a very convoluted, complicated process that involves, let's call it less democratic features of American government, meaning courts, litigation, administrative procedures that are largely controlled by interest groups, by insiders within government, by litigants, and largely insulated from public input or scrutiny. So I focused on this issue because I thought it was. It would, you know, it would. It would teach me a lot about American government. Towards the end of that process, I finished my dissertation. I defended in 2020, actually did a postdoc after that for a year as well. But around that time, two things happened. One is I started to notice. I mean, I should have noticed this earlier, to be honest, but it took me a while to notice that the arguments for these policies were largely meta, meaning that plaintiffs and, you know, agency officials and judges were not making the kind of traditional civil rights arguments about equality, about what it means to be equal citizens and so forth. They were saying things like, well, we have to implement these policies or we have to interpret the law this way because, you know, mental health considerations were. Can you give us a sense of.
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What those policies were? Exactly, and some examples of the sort of medicalized arguments that were being made to advance.
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Absolutely. So maybe one of the most visible cases at the time was Gavin Grimm vs Gloucester County School Board. This was a case out of the 4th Circuit in Virginia that involved a biologically female student who, identified as a boy, wanted to use the boys restrooms and so forth. And. And so the, you know, the plaintiff, I think he was represented by the aclu. And the plaintiff's lawyers were largely relying on expert declarations, expert witnesses that were citing mental health literature, that were citing medical literature that were saying, you know, health care authorities say that if you. If schools don't treat girls who identify as boys as boys, then they are going to, you know, become suicidal. They're going to have their. They're going to be depressed. And. And of course, that also has. According to their argument, that also has implications for equal educational opportunity because, you know, when students are depressed or feel excluded, they can't enjoy the full, full access to educational benefits. So there was a kind of link to the kind of traditional arguments about Title ix.
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A lot of categorical statements have been made this morning in argument and in the briefs about medical questions that seem to me to be hotly disputed, and.
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That'S a bit distressing.
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One of them has to do with the risk of suicide.
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Do you maintain that.
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The procedures and.
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Medications in question reduce the risk of suicide?
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I do. Justice Alito maintain that the medications in question reduce the risk of depression, anxiety and suicidality, which are all indicated indicators of potential suicide.
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Do you think that's clearly established?
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Do you think there's reason for disagreement about that? I do. I do think it is clearly established in the science and in the record. I think, as with all underlying questions of looking at evidence, there can be disagreement. I don't dispute that. But here, and sort of going back to questions about the cast review, for example, the cast review only looked at studies up until 2022. Well, I don't regard the cast review.
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A
As necessarily as the bible or as something that's true in every respect.
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But on page 195 of the cast report, it says there is no evidence that gender affirmative treatments reduce suicide. What I think that is referring to is there is no evidence in some in the studies that this treatment reduces completed suicide. And the reason for that is completed suicide thankfully and admittedly is rare. And we're talking about a very small population of individuals with studies that don't necessarily have completed suicides within them. However, there are multiple studies, long term longitudinal studies that do show that there is a reduction in suicidality, which I think is a positive outcome to the, this treatment.
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Everything seemed to depend on the mental health argument. The therapeutic framework was really dominant and very powerful. And there were many of these cases across the country. And so I did what any kind of, you know, nerdy aspiring scholar would do, and I decided to look behind the curtain and actually look at the literature they were citing because I thought it was kind of important. If they're saying that, you know, that there's a medical consensus that's well grounded in evidence that social transition as the case may be, and even medical transition, because I think that the plaintiff, most, most of the time plaintiffs in these cases were already on hormones, that these interventions are, are grounded in good science, I thought, well, then certainly it should be possible to see that in the, in the literature. And so I started looking at the literature, and as so many people across the country over the next five, six years, once you start looking, you can look away. Because the way in which this literature is represented, sometimes by the authors of the studies themselves, bears very little relation to what, you know, what the science actually shows and what they themselves actually find in their own studies. So I thought this was very interesting. This was a case of healthcare authorities misleading the public, misleading regulatory agencies, misleading judges, sometimes in good faith, by the way. Right. They weren't necessarily lying. They, they sincerely thought that this is what the medical literature shows. Um, and the more I started looking into it, the more I realized that this is really a case of kind of broad dynamic institutional capture. That's a, a word I've been using a lot. A term I've been using a lot. And I don't mean that in some kind of conspiratorial, nefarious way. I simply mean that there are all these kind of incentive structures that determine how organizations act. For example, collective action problems where you have a small, organized, attentive and highly motivated committee in a medical group that wants a particular policy, and against that committee, you have a kind of a diffuse, less attentive, less organized, and let's say, risk averse membership that might outnumber the committee 10 to 1. But if they're not paying attention or they don't care as much, or they're risk averse, then the committee gets its way. Right. And these problems of collective action happen in private and public organizations and they're very common. So that's kind of the stuff that I was starting to look at and think about during that time, during my postdoc year. But you asked how I ended up where I am. I mean, the short answer is, you know, towards the end of my postdoc at Harvard, I realized, you know what? There's just no future for me in academia. My topic is way too toxic. This was 2021. So, you know, it was kind of the high growth, as they say, peak woke, as they say. It was very much peak woke. And this was still also, you know, that was layered on top of a very, very bad academic job market. So it was made clear to me in more ways than one that no one would hire someone like me, given my topic, given my approach. Did you get any of that?
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I certainly were selecting your dissertation topic that this might have an adverse effect on your future career prospects.
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I should have known. I should have known better. Yes. Look, I mean, the truth is, I was so fascinated by this topic and it was so relevant at the time. It was, you know, actually the very week that I did my comprehensive exams in 2016, the Obama administration issued its infamous Dear Colleague letter on transgender students. It was the same week. So that really crystallized to me, like, this is a very important topic. And of course, nobody else, I may. I don't know, dispositionally, what was the interview that.
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B
Your colleague letter, that 2016 legend.
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Oh, that. That's the letter that kind of. Right. So that's the letter that crystallized the administration's approach that, you know, that the conventional understanding of male and female is, as they were calling it, a stereotype, and that this has always been what federal law requires schools to do. So, you know, looking back, I think. I mean, I know that I'm dispositionally, I'm a bit of a contrarian when everybody says, don't, don't look that curtain. You know, I want to look behind that curtain, and I do. And so the fact that I saw that this was important, this was becoming a major issue, and nobody wanted to touch this with a 10 foot pole made me want to look into it even more. And that's what I did. So, you know, eventually after the. Towards the end of my postdoc, through a friend of mine, I was introduced to the Manhattan Institute. And, you know, I had never really considered going into the world of think tanks. It just wasn't on my radar.
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But.
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But I'm so glad that I did.
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As are we.
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Oh, yeah. Well, thank you. I mean, it really is the case, I mean, certainly since 2020, 2021, that as academia was becoming so hostile to anybody who doesn't toe the line to orthodoxy, it really became the case that think tanks were doing the job that academia once did. Um, you know, I. Sometimes it feels like there's more diversity of opinion at a place like the Manhattan Institute than I would have encountered in pretty much any academic department that I would have been in. Um, and there's serious scholarship going on there too. Um, so the more I, you know, the more I started working with mi, the more I realized, wow, this is a really, really great environment and institutional home for me to do the kind of work that I want to do.
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B
Well, I know that the Manhattan Institute is absolutely glad to have you. I mean, I think the work that you're doing is so important in part because I think an issue like this, you know, I mean, it's no secret to anyone that it's, you know, a third rail, if there is any in our national politics. And I think that requires not Just, you know, a sound, analytical approach, but also, you know, a sober disposition. And I think that you have kind of mastered both, which is one of the reasons why I was so eager to have you on the show to talk about this stuff. I mean, I want to go back to something that you mentioned a couple times already, which was, you know, the Obama administration's claim that, you know, we. The gender identity was essentially rooted in stereotypes. And, you know, what I want to ask you about is, look, I mean, I live in New York, you know, born and raised in New York City. I have seen, quote, unquote, transgender people, you know, my whole life. You know, it's. It's not something that's super common, certainly, but, you know, I had exposure to individuals who did not clearly identify with the gender that they would have been, quote, unquote, assigned at birth. And in every one of those cases, the person who is adopting a different gender expression than the one that aligns with their sex is kind of acting out a stereotype. Right? I mean, if it's a male transitioning to, you know, an outward female expression, you know, they have long hair in a ponytail and they wear dresses and, you know, lots of pink and, you know, and vice versa.
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Right.
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Since it's the other way around, you see lots of flannel shirts and short haircuts and, you know, I mean, do.
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You see a kind of tension there? Absolutely. And this is one of the problems with the Obama administration's approach and more broadly, of course, with the. Let's call it the kind of the social movement advocating for transgender rights over the last decade, decade and a half. And we should talk about this, because it has a lot to do with how the meaning of the term transgender has changed. But, yes, I mean, of course, that's a key difficulty. And we discussed that, for example, in the HHS report, that the term gender identity itself, which is such a key concept here, you know, you would think that if you are proposing, you know, medical interventions or frankly, even social interventions, like social transition for vulnerable people, like children, you would have, you know, a definition of key concepts that is neither circular nor incoherent nor reliant on what you yourself consider to be stereotypes. And yet that's not the case here. And it is true that, you know, the people who are promoting these ideas in medicine and education, it's not just that they don't. It's not just that they try and fail to define these key concepts is that they don't want to. You know, I was recently on a call with three gender affirming social workers who are, of course coming at this from a very different perspective than I was. Um, and when I asked them to define some of these key concepts, they, they, they thought I was, I was just saying the most horrific thing possible. I, I, all I did was ask them to define, define their terms because I wanted to know what they meant by them. And they said things like, well, it's not for me to define, it's for my patients to define for me. And I said, okay, but, but how do you understand it? Or, or at least like, what have your patients told you? And they just didn't want to, they just didn't want to engage on that level at all. And that's really one of the most bizarre characteristics of this entire movement is the way in which kind of these fundamental questions, I mean, if you ask somebody, like, what does it mean? What is a gay kid? A gay kid is a kid who's attracted to members, sexually attracted to members of his or her own sex. It's not a difficult thing to define. So, yes, there were these internal tensions and contradictions within the Obama administration guidance, but of course it didn't matter to them at all. And the same thing goes for, even more problematically for courts in a lot of these court rulings, sometimes in some cases, the defendants themselves would say, you know, that the plaintiff's theory doesn't hold up because their own definition of gender identity relies on the very thing they claim is legally provided, namely stereotypes. And the judge would, I mean, I think there was one case where the judge actually acknowledged that that was true and nevertheless ruled in favor of the plaintiff.
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B
So that actually brings to mind a recent oral argument before the Supreme Court. I think it was just about a week and a half or two weeks ago, and there was a kind of really just astonishing exchange between one of the justices, I think it was Justice Alito and one of the litigants from the ACLU where the litigant was just asked to define, you know, what a woman is. Because, I mean, at the core of the legal question was sex discrimination. It's like, well, first we have to define this term. And I think a lot of people would. You know, it was almost like a scene out of that documentary that Matt Walsh had put together, what is a woman? Except, you know, it played out in real life in an incredibly high stakes legal dispute. I mean, did you, did you catch that? And what was your reaction to.
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Yeah, it was a quite surprising moment, maybe not surprising, but, you know, the police came out first. Can you walk us through what that.
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Case was about first?
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Oh, yes. This is the. It was a consolidation of two cases, I believe, dealing with sports. So, you know, whether states can pass laws that limit participation in female sports to females, to girls and women. And there was a moment where, you know, Justice Alito asked, how do you define sex? Why sex? And the lawyer. I don't think it was the aclu.
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B
Niles guy and that kid. Apologize, aclu.
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A
No, no, no. It was. It was the plaintiff. It was the. That side's lawyer, but it wasn't aclu. But there was one moment in which she basically said, we don't need to have a definition. We don't have a definition, and by implication, we don't need to have one to win this case, which is surprising. If you're alleging sexist woman, you can't define the very term that you say is being discriminated on the basis of which. So. So, yeah, I mean, but look, this is very kind of on brand, right? That these terms and concepts that do so much of the work of the heavy lifting of policy and institutional change are just left completely vague or with circular reasoning, right? So take the term gender identity. It's commonly defined as a person's innate sense of gender. Well, what is gender? It's obviously not meant as a synonym for sex in which. Because if. If that were the case, then a gender identity would simply be an error, a mist. Right? If. If we understood a man who has a gender identity of woman and woman refers to his sex, then clearly the person is simply mistaken about his sex. And that, by the way, is the original meaning of the term gender identity. So in its original sense, you know, everybody has a gender identity in that sense, in the sense of being able to recognize what sex you are. So that's clearly not what's meant nowadays by gender identity. Um, and so the. It becomes circular, right? It's. A gender identity is a person's sense of gender. What is gender? It's an ident. What's gender identity? A sense of gender. It just goes on and on and on like that. And eventually, when. When they are willing to define it a little bit more, they define it in terms of stereotypes. So a person who has a male gender identity as a person is a kid who's, you know, who. A girl, let's say, who wants to play with trucks and, you know, climb on trees instead of playing Barbie dolls. You know, we were told for decades that these are pernicious stereotypes, and now all of a sudden, they are sacrosanct. And part of it is some kind of innate gendered soul that must never be questioned. It must be affirmed and allowed.
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B
I find this incredibly shocking every time I hear it, although maybe I shouldn't be surprised anymore. But I was watching an interview not long ago, I think it was on some news program where a mother was saying with full confidence that I knew that my son was really a girl when he was 2 years old because he used to put on his sister's dresses. And I just thought, like, right. You know, I mean, the idea that that is somehow not incongruous with the objection to gender stereotyping which is found, you know, it was bizarre to me. It was like, wait a minute. You're going to medicalize your own child and put them on hormones and hormone blockers simply because they wore a dress a couple of times? I mean, that seems to me to be very much intentioned with what, you know, seems to be at root. At the root of this ideology, which is a rejection of gender stereotypes. It's like, you can't have both mix.
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A
Right, Right. That's right. You know, they would come back and say, well, it's not based on the fact that this kid wore a dress a few times. It's because. Or. Or it's when they're being insistent, consistent, and persistent in saying that they really are a girl. But, you know, the question, of course, is, what do you make of these types of behaviors? And to what extent do the adults in a child's life, you know, kind of determine the epistemological framework within which these kids are trying to understand how. How to interact with toys and their environment? And it becomes very clear very quickly that when kids tell you that they are trans or when they assert insistently, consistently, and persistently that they really are a girl, if they're boys, um, that doesn't come out organically.
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B
Right.
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A
And that's not being asserted against culture that tells them otherwise. It's being asserted consistent with a culture that tells them that that is how they should interpret their feelings and experiences. But, you know, think about. Just to think for a second about the implication here. I like to tell people that if you think for two seconds about what these terms mean in practice, it turns out that pretty much everybody is transgender. Because think about it this way. The most common definition of trans nowadays, and again, I emphasize that this is not what used to be meant by the term. The most common definition nowadays is a person whose sex assigned at birth is different from their gender identity. Okay? Gender Identity, we now know, is defined in terms of adherence to or your acceptance of certain stereotypes. And so it stands to reason, therefore, that a person who does not, who is non conforming to their sex, and we can sharpen that even more and say to the most rigid kind of, you know, platonic ideal or not ideals, but platonic stereotypes of their sex, is by definition transgender. So if you're a boy and you're not like GI Joe, the epitome of manliness, you're true.
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B
If I employed the series Gilmore Girls, I'm. I'm also trans, then. Okay, well, right.
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A
And if you're a girl and you don't, and you're not like the spitting image, a two dimensional stereotype of a, of a Barbie doll, then you're trans, but by the very terms that the movement proposed.
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B
I want to just key in on something that you said just a few seconds ago, which is, you know, this idea that when these kids are making these assertions that they are not actually going against the grain, but rather are conforming their own speech to the inputs coming from the adults in their life. And it reminds me of a discussion that I saw Jordan Peterson, the psychologist, having on a podcast somewhere where he was recounting this story of a woman listing all the ways in which her several children deviated from gender norms. And she would say, I have two trans kids and I have pansexual kid. And you know, with this kid, and he said, well, you know, what are the statistical likelihood given the distribution of those phenomenon in society, of all of those kids having those conditions within the same family is like, you know, exponentially more remote than winning, you know, the Powerball are on. So what are the chances that that's the case versus the chances that all of those kids have, you know, and unbearably ideologically possessed mother who is imposing all of this on them?
- [27:00]
A
And well, it doesn't even have to be the mother. I mean, in many cases it is, but it doesn't have to be. It could, it could be the cues that these kids pick up through osmosis in the culture that they're in, you know, in schools, through the culture, the TikTok videos they're watching, whatever it is, everybody is telling them that gender nonconformity is a sure sign that something is wrong, quote unquote, and that identifying as transgender is the path back to self understanding and self acceptance. You know, this is maybe a good place to plug our colleague Hollywright's really excellent Wall Street Journal op ed. I think it's called something like every tomboy is tagged transgender because the girls who used to simply be non conforming girls tomboys, now they have been provided with this new heuristic to understand their feelings and experiences through a new lens. And so there's no tomboys anymore. They're all just prize boys. And that, you know, that would, we would all just shrug that off if it didn't have serious psychosocial and medical implications.
- [28:06]
B
And I want to get into that because I do think that that's really kind of where the rubber hits the road in this debate. I often hear people ask, you know, what does it matter to you if this kid identifies as the opposite sex? Why are you so worked up about this? Why do you need a policy intervention to get in the way of this person just being who they feel they are? And I think the most compelling answer to that, but maybe I'm wrong, is that because it's not just that kid, you know, acting in a way that, you know, acting in accordance with their new identity, but rather the medicalization of those claims that has lifelong consequences.
- [28:54]
A
Yeah, I mean, the medicalization, I think is the most obvious manifestation, or I shouldn't say manifestation, but it's the most obvious way in which that identity can, can actually do lasting harm to a kid. But you know, even if you don't go to medicalization, is it really good for kids, young kids, to be told by every figure of authority in their lives for years that they really are the opposite sex and that it's unjust and unscientific for other people to deny that? Is it good for them psychologically, emotionally, developmentally? I would argue that, no, it's not that. These kids need, kids need to be grounded in reality. That is a core part of the responsibility of adults is to, is to introduce kids to reality and to ground them in it as a, as a condition for them becoming mature and responsible? And we also see some very serious implications. I mean, you know, you see some of these very tragic cases of boys, young boys, almost certainly gay, who, you know, behaved very effeminately as proto as prior to puberty and they were affirmed as being girls. And once they cross the threshold of puberty, you know, they've never known anything else. For them, their entire world is constituted by the thought that they are girls. And it's, they, they almost can't even understand why somebody would treat them otherwise. And, and it's a sincere thought on their part. Right. Because that's how adults have been reflecting back to them the reality of who they are for. For years. And so the problem, of course, here is that nature eventually takes its revenge and reality eventually hits. And these kids, you know, they. Their body is not going to cooperate with their internal sense of who they are. And so now they face a very significant dilemma. Do they undergo these very invasive, very risky medical interventions that, as far as we know, based on many systematic reviews, have no credible evidence for mental health benefits? Or do they realize that everything about them and everything their own parents and their teachers and all the adults of authority in their lives have been telling them, it's a lie? That's an extremely stabilizing thing for a kid to have to go.
- [31:19]
B
I couldn't agree more. And I wanna. You kind of hinted at it already, but I want to just get a sense of why it is that you think that the adults in the room are pushing kids in this direction. And I suspect that it has something to do with the mental health issue that you just alluded to. But I mean, is that right? I mean, what, what is the explanation for why adults are so willing to sort of defy reality or at least tell their children that they can defy reality? What, what's behind that? What's driving this? Is it a fear, these underlying mental health issues, or.
- [32:00]
A
It's a great question, and I don't think there's one kind of one size fits all answer to it. I think different parents have different motives. But you do see kind of certain motives reoccur. You know, the common explanation that you sometimes hear among those who criticize gender transition in kids is it's all just kind of Munchausen by proxy moms. I mean, the reality is, you know, this is typically infrared. That isn't familiar with. Yeah, Munchausen by proxy syndrome is basically, you know, making somebody else who is supposed, supposedly in your care making them sick in order to, you know, generate sympathy for you. But. And there is a little bit of evidence for that. It's very hard to study Munchausen by proxy. But, you know, the clinicians at the JIDS clinic in the uk, that was the, the biggest gender identity clinic there, they said that they definitely saw some cases of mothers with Munchausen syndrome by proxy. It affects pretty much exclusively women. And it's also true. I mean, you just see once you're kind of immersed in this topic enough, you see that mothers are heavily overrepresented among the parents who affirm their kids as trans and agree to medical interventions. It's not that fathers never do it, but it's Very skewed towards women. And that, I think, is an interesting question in itself. It is a very controversial question. There's a lot of feminists who do not want that being discussed or have a different take on it. I think it's almost incontrovertible at this point, and it's a question of why that's the case. But I guess what I'm trying to get at is that's not the only way that this happens. That certainly happens. But I think when you're dealing, for example, with prepubertal children, especially boys who are effeminate, you know, there may be parents who are genuinely concerned because they don't want to have a gay kid. They don't want their kid to be effeminate. They want them to be, you know, boyish and later manly. And so for them, this is kind of an escape hatch. And they can have a girl now, and the effeminate behaviors don't matter anymore. Um, and this is the kind of thinking that fuels, for example, how, you know, authorities in Iran think about Iran.
- [34:21]
B
Right.
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A
Talk about that a little bit. Yeah, well, we don't know much about that, or at least I'm not terribly familiar with. With kind of the. The. The on the ground realities and epidemiology of what goes on in Iran. But it's. It's. It's pretty well known. I would say that in Iran, sex changes not only happen, but, you know, are. Are encouraged and even mandated by the authorities there to. Correct, so to speak, effeminate.
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B
And mostly because homosexuality is not just frowned upon. Right. But. But legally prohibited.
- [34:52]
A
Well, it's. It's. You can. Yeah. And punished by death.
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B
The argument is that rather than risk punishment for homosexuality, they allow transitions for people to sort of witches. Seems very progressive for a theocratic state like Grant.
- [35:14]
A
I know, right? I mean, we're. We're smiling and laughing, but it's, of course, not funny. It's. It's. It's horrific. And in other countries as well, you know, transgender advocates like to say, oh, you know, the hijras in India, and look how much tolerance they have for gender nonconformities. Yeah, okay. But also, you know, to some extent, this is a kind of a coping or survival mechanism for effeminate and gay men in a society that does not accept that kind of gender nonconformity. But in any case. So that's kind of one. You know, that's one reason why parents might want to do this. In the last decade or so, we've seen, of course, the rise of a very different demographic, which is teenage girls who had no history before puberty of gender nonconformity and who all of a sudden, kind of out of the blue say, I'm a real, I'm really a boy, or I'm non binary. And those two things are different. But let's just group them together for a minute. And I, you know, I'm transgender. And if you don't affirm me, if you don't accept me as I am, I'm going to kill myself. That's a different scenario. And in that scenario, you know, I have a lot of sympathy for parents. I don't agree with them, of course, but I have a lot of sympathy for parents who knew nothing about this topic. And then all of a sudden, out of the blue, their teenage daughter who was going through puberty and hates herself and hates her body and all of her friends are doing the gender stuff, you know, and they've, the parents have no idea what the, what the girl is watching on social media. And all of a sudden she comes at them with this, with this statement, and she says, I'm going to kill myself if you don't, you know, treat me as a boy and use this new name for me and send me to the gender clinic. And the parents, if they haven't been paying attention, what's natural for them to do? Well, to Google, right? Google, is my daughter trans? And the kind of. The highways of information in Western societies have been so clogged for years with misinformation on this topic, with activist talking points, heavily filtered information.
- [37:22]
B
Can we dig into one of those activist talking points, which is one that I can't even count how many times I've heard, which is this. It's presented in the form of a question, right? Which is, would you rather have a trans daughter or a dead son?
- [37:35]
A
Why is that so? The, the, the suicide narrative. So let, let me just, if we could just put a picnic for that, for just one minute. I, I just want to complete the thought which is parents, you know, they seek information on the Internet as usual, and then who do they turn to? They turn to their pediatrician, they turn to a mental health professional. They turn to the expert experts. But if you know anything about this topic, you know that the experts are going to give them either one of two answers. Either, hey, this is not my, not my wheelhouse, not my area of expertise. Go talk to the gender clinicians. They're the experts, right? It's in their title. Or if they themselves are gender clinicians or Kind of ideologically on board with kind of the new understanding of gender nonconformity as evidence of a transgender identity. They will say, you can know that your daughter is trans, or rather, you can know that your son is trans because he tells you he's trans. And that's how, you know, trans kids know who they are. That's a mantra. That's a talking point. And parents, everywhere they turn, they see authorities, not just healthcare authorities, but legal authorities and educational authorities and journalistic authorities, especially if they live in these kind of, you know, silos, blue bubble silos of information, which is a lot of parents. So I have sympathy for parents who are faced with that situation. Even if they end up making the wrong decision. They are the victims of what I've been calling and others have been calling a broken chain of trust. Right? They trust their doctors, they trust their. Their educators and so forth. And those doctors sometimes trust other experts in turn, and everybody's trusting everybody, and nobody's actually looking to see what's. What's behind the curtain. But to get back to your question about the suicide narrative, this is a narrative that seems to have become popular in the United States more than in other countries. I'm not exactly sure why I have my speculations, but it became very common here, especially in the last few years of the 2010s and early 2020s, especially as criticism started to mount about gender transition in childhood. Because this is a way to basically say to parents, ignore all the uncertainties, minimize all the risks. The one risk you should be concerned, concerned with is the most dire, you know, terrifying risk of all, which is that your kid will commit suicide. And faced with that narrative, if parents even remotely think it's credible, and if it's given to them by, you know, a man with a white coat, a white lab coat, it's very often very. Is credible. There's almost nothing they won't agree to. It really is emotional extortion and manipulation in the most egregious possible way. And we know of many examples of parents who have faced this threat. We've seen doctors like Johanna Olson Kennedy, one of the most famous gender clinicians in America, say on camera, tell. Yes, I think it was 60 minutes a few years ago that this is what she says to parents. So we know that it happens. Now, what is the evidence for it? There is none. The suicide issue is more complicated than people on both sides of the debate tend to allow. What we know is that kids who have gender dysphoria or struggle with their identity or identify as trans. However, you want to conceptualize that we know that they are at higher risk for suicidal ideation, which is not the same thing as suicide, and it's not even the same thing as suicide attempts. And we know also, or we have some evidence that there are higher rates of suicidal attempt and even suicide among that population. But the question is how to understand that. And so, first of all, the actual risk of suicide, of death by suicide, is still very, very low. So, for example, in the UK between 2010 and 2020, the data from their centralized gender service showed that there were four suicides, representing 0.033% of all patients referred either being currently being seen or on the waitlist jids, you know, that's not, you know, would you want to have a dead daughter or alive son? That is a very, very small risk. Not nothing, but it's very, very small. And I think it's significant that the lead kind of ACLU trans litigator, Chase Strangio, admitted that the suicide risk, the suicide narrative is basically false. The oral arguments in the SKRE into 2024. So, so that's, that's number one, the risk is, is very, very low, even though it is slightly elevated compared to match controls.
- [42:16]
B
Number two, that slight elevation.
- [42:19]
A
Hmm. So in the UK study, I think it was five and a half times elevated relative to kids who were not diagnosed with gender dysphoria or being seen at the JITS clinic. Right. So even though the risk is still extremely low, it is still elevated relative to adolescents of a similar age in the general population.
- [42:40]
B
So what, what, what could be causing that if not.
- [42:44]
A
Ah, that's the golden question. Right. So what is, what's responsible for this higher rate, though still very low, but this higher rate of suicidal ideation attempt and even completion? Um, the only study to even try to parse that question came out of Finland in 2024 and it found that when kids with gender dysphoria or adolescents with gender dysphoria are matched to aged match controls with similar mental health problems. Also health comorbidities who are, who are not gender dysphoric or not transgender, they have the same levels of suicidal behavior. So it's actually the mental health comorbidities, the depression, anxiety, adhd, autism, all these kind of very common psychiatric problems that we know occur in, you know, over half, sometimes 2/3, even 3/4, depending on which studies you look at, of gender dysphoric youth. It's the comorbidities that explain the elevated, though again, still low rates of suicide and suicide attempts. And if that's the case, then the question becomes what is the best treatment for depression? Right. Is it steroids? Sorry, Is it testosterone and maurectomy? Or is it cognitive behavioral therapy?
- [43:57]
B
Right. And so, I mean, walk us through what the evidence says. I mean, is there any evidentiary support for the claim that the kind of medical treatments and interventions being pushed by, you know, gender ideologues actually reduces that risk of suicide or mental health along some other metrics?
- [44:21]
A
No, because the studies that could prove such a thing don't exist. There are no randomized control trials, which is the only methodology that can give you evidence of, I should say, high quality evidence of cause and effect. The studies in this area are observational and even within the category of observational studies. So they're not randomized and not well controlled. And even within the category of observational studies, they are very, very poor. Meaning you could have even better observational studies than the ones that exist. And yet even those, if they were better, even they would not furnish the kind of high quality evidence that would allow you to say that hormones and surgeries are necessary for preventing or reducing suicide risk. So what do I mean by that? I mean, the studies are, you know, there's multiple confounding variables. For example, kids get hormones, but they also get psychotherapy. So how, you know, so if they do better, and in some studies they actually do worse, or their mental health stays the same. But even, even if you're only looking at the studies where they, their mental health improves, how can you know it was the hormones versus psychotherapy or a phenomenon called regression to the mean, which basically just means that kids show up to receive care when they're at their worst, and over time they just naturally get better. It could be psychotropic medications, ssri, whatever. Right? There could be many reasons why they're getting better. So these studies are very poor. They cannot give anything remotely close to cause and effect evidence of benefit. And then on top of that, we also have some research that shows that adolescents and adults following gender transition interventions, hormones as well as surgeries, still have very high rates of suicide side. So, for example, there's a study that was published in Sweden based on 30 year longitudinal data from their national registry that came out in 2011 that showed that people who had undergone what they call sex reassignment surgery were still 19.1 times more likely to die by suicide relative to matched controls. There's the famous NIH study from here in the United States. $10 million study the largest, oh, I should say say the best funded so far that had, out of 315 kids who were being treated with hormones, two committed suicide within the first year. That's a rate of suicide far, far higher than what you would find in the general population. Now, I should just caution, because sometimes people on the critical side of this debate cite those studies to say, see the hormones and the surgery is actually cause suicide to increase the risk. No, that's not what we can know based on these studies either. All we can say is that the suicide risk did not come down as one would expect or hope for interventions this, this drastic in life.
- [47:15]
B
Is this the kind of evidence that you and your colleagues reviewed in this new HHS report? And if so, can you tell us a little bit about how that came? To be.
- [47:25]
A
Sure. So, yeah. So should we talk about the report? This is kind of. It caught me by surprise, to be honest. I was asked a few weeks after the. So, okay, so let me backtrack a little bit. January 28, 2025. This is about a week after the Trump administration came into office.
- [47:45]
B
Almost a year to the day.
- [47:48]
A
Oh, yeah, yeah. Well, almost. Yeah, yeah. I didn't even think of that. President Trump signs an executive order. I think it's called something like stopping chemical sterilization and mutilation of children, something like that. So, you know, very subtle and very modest in its rhetoric.
- [48:10]
B
On.
- [48:10]
A
On Brand. And one of the.
- [48:12]
B
On Brand.
- [48:14]
A
On Brand, exactly. We expect nothing but subtlety from our president. And one of the provisions there instructed HHS to produce a report on evidence and best practices within 90 days. Now, I understand the urgency. Whoever inserted the 90 day clause there, he or she and I are going to have to have a conversation later. But I mean, just by contrast, like the CAS review, which is the equivalent of what we did that came out of the UK took four years and we had to do it in 90 days. It was actually less than 90 days because by the time I got the call from the government asking if I would lead up this initiative, and by the time I assembled the team, we basically had about eight weeks, nine weeks, something like that, to produce this report. Now, you know, luckily I know, you know enough people, serious academics, serious researchers who know this topic like the back of their hand. They're well published in this area. They know the history, they understand very, very well principles of evidence based medicine. And so what I did was I said, all right, first and foremost, we need people who just know the literature and the history extremely well and can write this in A competent way that is credible and that can survive peer review. Because we knew that it was going to be peer reviewed, we wanted it to be peer reviewed. We were hoping that it would be peer reviewed by advocates of gender transition, by the most prominent advocates. I'll get to that in a few minutes. But so that was kind of one constraint, right? I needed to work with a team that could produce a report like this in eight weeks. The other constraint was I didn't want this to be perceived as some hit job by a bunch of MAGA aligned conservatives. Not that conservative doctors and researchers can't write with great integrity. There are many people in this field who are conservative, who are phenomenal researchers and writers and very committed to evidence based medicine. But it was important to me, for obvious reasons, that the authorship, the team of authors reflect a broad, a much broader, have a much broader representation of political leanings and opinions. And I wanted there to be liberals, I wanted there to be some kind of strong left leaning researchers and, and authors alongside conservative ones. And so that's kind of, those are the two constraints that I had in mind. And I think I assembled a great team, if I do say so myself. I mean, my co authors, I have nothing but the greatest respect for them. We have an endocrinologist, we have internal medicine folks, we have psychiatrists, we have bioethicists, we have an expert in evidence based medicine trained at McMaster University. We have a philosopher from MIT who is really good at kind of parsing out these terminological and conceptual issues. And then I contributed what I could from the kind of policy perspective and we put together this report and the original version of it, the first version of it was published on May 1. It would have been better if we could have been given nine months or even a year and then we could have done the peer review before the initial publication. But that's, you know, we were operating under constraints that we didn't choose. And so the initial report came out on May 1st. And then we started with a peer review process. The Department of Health and Human Services invited a bunch of stakeholders, including the Endocrine Society, which is, you know, maybe the most important medical group, bona fide medical group that has been promoting and supporting pediatric medical transition to participate in the peer review. You know, they asked them like, please review the report and tell us what we got wrong and don't hold back.
- [52:24]
B
Well, I'm curious to hear what their reaction was. But before we get there, how were you able to convince your co authors who maybe don't share the same level of comfort, you know, that others might associating with this administration to participate in this project.
- [52:44]
A
That's a great question. You know, every, every one of those co authors had his or her own motivations. What I can say is that I think, I don't think I know that all of them saw this as a kind of a civic duty. They knew that there would be a massive target on their back the moment they, their name was known, but they saw it as a duty. They know maybe better than anyone how the information highways of science have been corrupted, clogged up. They know better than anyone how the medical associations have been misinforming the public and they felt that it was their duty to be the ones to try to set the record straight. And then I think secondarily and also important is they knew that if it was not them, it might be somebody else who might be more heated, less judicious in how they interpret evidence. And they wanted to make sure that it was done right. And that's why I asked them, because I know that they are going to be judicious in how they treat the evidence and how they treat questions of medical ethics and the history and what we know and don't know about the clinical realities in America. So they wanted to make sure that it's done right and they appreciated that I wanted to make sure that it's done right and they trusted me enough to agree to.
- [54:11]
B
Well, I mean, I think that speaks to the integrity that you've displayed throughout the years and the work that you've done. So give us kind of the top lines of that report, like what are the sort of main takeaways?
- [54:22]
A
Sure. So the most important takeaway, which is also the least surprising because it's the best well known, is that the evidence supporting the claim that these interventions are safe and effective for improving mental health is just not there. What we did is instead of yet another systematic review of the evidence. And I can explain what you want if you want. I can explain what that means.
- [54:44]
B
Yeah, I think our audience that.
- [54:45]
A
Yeah, okay. Okay. So evidence based medicine, kind of the core concept in evidence based or the core idea animating evidence based medicine is that there's hierarchy of information. Some information is simply more reliable than others. Right. So a randomized control trial is much more reliable than observational studies, certainly more than cross sectional or surveys or clinical anecdote. So there's a kind of this pyramid of information where at the bottom you have the anecdotal experience or expert opinion of physicians that's based on their own, you know, what they see in their own office. And that's the least reliable. It's not unimportant, but it's the least reliable. Then you have kind of cross sectional or survey designs and observational studies that are uncontrolled and non randomized. Then you have randomized control trials at the top, that's the highest quality evidence you can get. But at the very top of the pyramid, there's something called a systematic review and meta analysis. And a systematic review, what it does is it says, all right, let's look at the entire body of evidence for a particular outcome. Let's say, you know, what is the effect of puberty blockers on depression? Okay, So a systematic review will take a look at the entire body of evidence on this question. And what's valuable about a systematic review is that it doesn't just summarize what these individual studies themselves report. It actually looks at the underlying methodology of the, of these, those studies to see, you know, if researchers said we gave kids hormones and they did better, therefore the hormones are responsible for them doing better, does their methodology support that conclusion? And if the answer is no, then those studies are, in EBM technical terms, they're called at high risk of bias. And so if you have a situation in which all of the available research that claims to show benefit is at high risk of bias, which is what we have here, then the evidence is of very low quality or very low certainty. Low certainty evidence, meaning we simply can't know if the interventions are what produce these effects. And a systematic review will also, what makes it especially valuable is the fact that it's transparent and reproducible. So the methodology is carefully spelled out such that any researcher, regardless of what political or ideological biases they bring, any researcher who applies the same methodology to the same body of research will arrive at the same conclusion. Okay? Now, there have been 17 systematic reviews to date done on puberty blockers, cross sex hormones, mastectomy, social transition, and psychotherapy for gender dysphoria. Let's set the psychotherapy issue aside for a minute because it's a little bit more complicated. But all of those systematic reviews have come up with the same conclusion, which is that there is certainly no credible evidence that these interventions are needed or cause mental health improvement. And so because those systematic reviews exist, because they're transparent and reproducible, there really was no need for us to do another one. That would have been completely unnecessary. So what we did, specifically our methodologist, our expert in evidence based medicine, and methods. What, what, what he did was something called an umbrella review. An umbrella review is a systematic review of systematic reviews. So a systematic review now become, rather than individual studies, systematic reviews become the individual units of analysis. And so what he did is he looked, he applied a methodology that's, that's widely used in these types of reviews to the systematic reviews themselves to try to figure out are they high quality, low quality or whatever. And sure enough, the conclusion was that, yeah, you know, these reviews, these systematic reviews reliably show that the quality of evidence is very, very low. We simply can't say much of anything about whether these interventions produce mental health benefits. So that's the central finding of the review. It's totally unsurprising to anybody who's been following this. We had, in the context of the peer review process, we had two experts in evidence based medicine at Belgium's center for Evidence Based Medicine. So this is their kind of, you know, their institution that is responsible for assessing the quality of evidence. We had them look at the, at our umbrella review and they, they said it's great, no problems whatsoever. So that.
- [59:25]
B
What was the feedback like from, you know, like the endocrine society and some of these other groups that have been kind of involved in pushing this ideology?
- [59:34]
A
Okay, so do you want to pivot to that and then come back to the final review? Because there are other.
- [59:39]
B
Finish the findings of the review first.
- [59:41]
A
Yeah, okay, so. Okay. So that's the kind of, the not surprising what this review did that other reviews haven't done. For example, the CAS review is first of all look a little bit more closely at the question of harms, because one of the problems in the field is that harms have basically not been studied. With a few exceptions, especially in the United States. The people doing these studies are by and large gender clinicians who are invested in these treatments ideologically, professionally, in some cases financially, and they simply don't study harms. Or if they say they're going to study them, they incompletely report them. And so when you use a systematic review to try to figure out if there are harms, the systematic review is only going to reflect what if research actually exists. And so the systematic reviews come back and say there's no good evidence for harms either. That doesn't mean that there aren't harms. In evidence based medicine. You have to rely on the best available evidence. And so if harms have not been studied, you can't say that. Right. So absence of evidence is not evidence of absence. And so what we did in that chapter of harms on harms is that we relied on our knowledge from basic physiology, human development and pharmacology, the known mechanisms of, of drugs, right? So once you take those things into account, you realize that there are actually harms that are known and there are also harms that are strongly anticipated, credibly anticipated. So a known harm, for example, if you block a kid's puberty at 10 or stage 2 right at the onset of puberty, especially boys, right. If you block a boy's puberty at the onset of puberty and follow up with cross sex hormones, you're sterilizing them, they're right. Their gamma gametes have not matured, they will be sterile. That's a harm. We know, for example, that sex steroid hormones are responsible in the context of puberty for bone mineralization, bone density, accrual. And so if you administer puberty blockers to kids, you're preventing their bones from becoming tough and they're going to have brittle bones, they're going to have osteoporosis and all these, all these bad conditions, even when they're 20 or 30 years old. You know, it's been said, for example, that okay, but if they follow up with cross sex hormones, they'll regain all of that bone density. That's not true. The existing evidence shows that there remain deficits. So that's a harm. Cognitive impacts, there's reasonable grounds to believe it's not high quality evidence, but there's reasonable grounds to believe that these hormonal treatments will result in IQ deficits. That needs to be studied more. And in fact, that's one of the things that the UK Puberty Blocker trial plans to, to study, as far as I know. So there are harms of sexual dysfunction and all of the impacts of that and quality of life. There are harms here. Okay, so that's kind of one of the key findings of this report. Then the next step that you have to do is to do a weighing of risks and benefits. And believe it or not, this is, I think, one of the first reports that's ever done that. Because ultimately what you want to know is, you know, what is the risk, benefit profile of one treatment modality versus another treatment modality, let's say hormones versus psychotherapy. And this kind of weighing of benefits and risks has to happen within an ethical framework, right, where you're taking into account the cardinal principles of medical, which is first, do no harm, number one. Number two, that doctors are ethically required to benefit their patients. The principle of Autonomy is very important here. Although as we explain in detail, it's been totally misinterpreted by those who say that kids should have the autonomy to choose whatever they want. And then there's a principle of justice that you don't want to disproportionately harm a vulnerable group. And that's what's happening here, especially with regard to gay kids. So the ethics analysis is another thing that was pathbreaking in this HHS review. And it was very important to the two bioethicists on our team, who, by the way, come from very different idea, you know, political perspectives. But it was very important for them to not reach for some, you know, esoteric academic theory, but to rely on very well accepted, very basic, very standard principles of medical ethics. And that's exactly. I'd say chapter 13 on ethics is maybe the most important chapter for anybody who has not read the report to read. And then finally, or then we had a whole section on clinical realities, what we know about the lack of the complete dismantling of safeguards and assessments in the United States and all that kind of stuff. WPATH and how it hid systematic reviews that were unfavorable to its approach and that stuff. And at the end we have a chapter on psychotherapy. What do we know about psychotherapy, its effects on gender dysphoria, its effects on depression, and to what extent can we say that it's a safer alternative than hormones? So that, in a nutshell, is.
- [64:38]
B
And the reaction war report, particularly from the groups that have been pushing gender ideology and have been pushing these medical interventions. I mean, it sounds like what you're describing is an incredibly comprehensive and, and sort of scientifically sound piece of literature worth engaging. Did you get that engagement and what was that engagement like?
- [65:07]
A
So, you know, the report is 400 pages long and has a 170 page appendix, which is where we summarize all the data tables and the methodology of the umbrella review. So it's a lot to get through, but it's written in a way that appeals simultaneously to kind of very scientific minded people and also to lay readers who can read it and understand certainly most of it. So, you know, as I said, it was very important to us and to the Department of Health and Human Services that, that those who have been aggressively advocating for these interventions, that they review the report and participate in the peer review process. And so HHS invited the Endocrine Society. Endocrine Society refused from the get go. It simply said, nope, not going to participate in the peer review process. It invited the American Academy of Pediatrics, which has again, been kind of at the forefront of promoting these interventions. Interestingly, the AAP, within hours of the report coming out on May 1, issued a strong statement condemning the report as unscientific and all that kind of stuff. Wow.
- [66:08]
B
Yeah. It was 400 and some odd pages.
- [66:12]
A
Right. Somehow they read 570 pages within two hours or three hours, managed to digest all the information. Don't ask me how they must be. There must be geniuses over there. But. So HHS said, okay, well, why don't you review the report and give us a detailed analysis of what we got wrong here? They actually initially agreed to do it, and at the last minute, they refused to submit their analysis. Why? I don't know. Your guess is as good as mine. My sense is maybe they just. Either they didn't want to give it public credit or they realized that they don't actually have a very good robust.
- [66:50]
B
So it's growing on eight months now since the report came out. Is that right? Have there been any attempts to comprehensively rebut the substance?
- [67:00]
A
Yeah. So. So, so, so the last kind of antagonistic group, so to speak, that HHS asked was the psychiatrist, the American Psychiatric association, another group that has been very aggressive in promoting these interventions. And that is obviously important to this field because they are the ones who hold the keys to the alternative. Right. They're the ones who can credibly say mental health counseling should not be offered to these kids, rather, they should be getting hormones and surgeries. So to their credit, the APA agreed to participate, which we thought we were actually quite surprised by. But. Okay, great, Ralph. They submitted a review in which they overlooked the entire section on evidence. They simply didn't see it. They said, here, you forgot, you know, your conclusions are incorrect because you. You overlooked. And then they gave us a list of 16 studies that we allegedly overlooked. 12 of those studies are explicitly included in the review. And in fact, in some of those cases, we have long, detailed discussions of those studies and why they're flawed. They, of course, didn't engage with any of that. Of the remaining four studies, three of them were on either adults or didn't concern. I might be getting my. I might be mixing up the three and the one. But the bottom line is they were either on adult or they didn't have anything to do with gender transition. So I think one of them actually came out after the initial report was published, and it's the same type of. So they clearly didn't read it. Right. And I Think this was a monumental embarrassment that they didn't read it. What's interesting is that when the news reported on this, even places like Washington Post, they mentioned the APA's review and they mentioned the kind of the top line conclusions that the APA stated. They never mentioned our rebuttal to them. They never mentioned that they, for example, they completely overlooked the entire evidence section. They left that part out as if it's irrelevant. So that's why I've been encouraging everyone to go to the supplement which is now on the HHS website. We called it the supplement to the HHS review, which is where all of the, there's seven or eight. I can't remember how many reviews all of the reviews are. You can find all of the reviews and all of our responses to those reviews. So those were. There's really one kind of critical review from the medical groups. Because it was very important to us to engage with our critics. We actually took two peer reviewed papers that appeared in medical journals that criticized the May 1 report and we went point by point answering their criticisms and we showed that there really is nothing left there. They didn't have one substantive criticism of any major point of the review. It really is astonishing. And again, I just want to emphasize, don't take my word for it, go to the supplement, read it for yourself and make up your own mind. You'll see for yourself. We were also very fortunate because all the other reviewers, who included, for example, a former president of the Endocrine Society, experts in evidence based, experts in evidence based medicine, methods professors of pediatrics, a very well respected and renowned bioethicist, they reviewed the report and they said it was very good. You know, they had some minor corrections that they suggested, but nothing that spoke to the major issues. And they praised the report. And in fact, in some cases they said we didn't go far enough in criticizing the field and how it operates. So again, I strongly encourage people to actually start from the supplement and see how the kind of the people who are invested in this area of treatment, how they've responded to it and whether their arguments.
- [70:53]
B
So I wish I could talk to you for another two hours about all of this. But I want to ask you a couple more quick questions. I mean, one is where is your hope for the report's impact? What is your sense of what its impact is going to be?
- [71:13]
A
I mean, so look, I mean, obviously the administration did not commission this report because, and I should say that one of the conditions that I posed to HHS when they chose I posed two conditions. One is, I get to choose the team. And the other is, you don't interfere with how we read the report. We're going to produce the report and submit it to you. And they were, to their eternal credit, they were very, very respectful of those boundaries. So obviously the administration did not commission this report to hang it on the wall and look at it right there. They wanted to be able to cite it in their regulatory actions. And they've already done that. They've already started to do that. So that's number one. It's obviously going to be a central justification in the administration's various actions on this issue. What my hope is that this will help change hearts and minds within the medical community, medical and mental health communities. And, and that's tough. It's tough because people who are not maga, you know, they understand, like, I get it. I'm not naive, I'm not an idiot. I get it. They say, okay, this report was produced by an admin by the Trump administration with RFK Jr. At the head of HHS. Why on earth should we take it seriously? Why should we even read it? So one of the chief challenges that's facing us in the months ahead is to get people to say, all right, maybe I don't agree with the administration on everything else, but at least on this one issue, this report is solid. And, you know, the editorial board of the Washington Post endorsed the report. The Economist endorsed the report. It's not like, you know, prominent left leaning intellectual organs have all unanimously condemned it. Not, not at all. So that's one, that's, I think the major thing that I hope is to change hearts and minds within the medical community by simply getting them to read and engage with the report. The second thing is I really want this report to outlast this administration. And again, that's not, you know, that's a tall order because given the Democratic Party and its incentives and how it, how it's been operating on this issue, at least right now, it's highly likely that the moment a Democrat comes into the White House, they're going to flip a switch and just go back to the status quo ante and this report will just go out the window. From a, from a regulatory perspective, right, it's always going to exist, but from regulatory perspective, it simply won't matter anymore. And so we want to try to prevent that from happening.
- [73:43]
B
So, I mean, I suspect that we won't have time to really get into it. But I wanted to ask you about the idea of social contagion and all this because you mentioned earlier that what we're seeing in terms of new cases is an overrepresentation of teenage girls, which suggests that something is going on in that is influencing these outcomes from the outside, from a social perspective. And I wanted to get your sense of whether you buy that or whether you think there's something else driving these changes. And just if you could describe quickly for us how much more, if at all, common, are these kind of self diagnoses of trans identity?
- [74:24]
A
Yeah, I mean, so the term social contagion is very contentious. And of course, a lot of people don't like it because it suggests that trans identity is a kind of a disease. Right. It plants that idea. But social contagion is actually a very common term. So girls who, you know, adopt what's now known as tick tock tics, anorexia, bulimia, a lot of behaviors, unhealthy behaviors that are transmitted, especially among young. Young adolescent girls, and even young women are known to transmit through these type of social contagions. So it's not controversial in that sense. You know, the ev Put it this way. The etiology, the pathways to trans identity and gender dysphoria diagnoses are not well studied. There is, of course, some evidence that a lot of these teenagers have been adopting trans identities out of maladaptive coping mechanisms because of their underlying mental health issues, to gain social prestige, whatever it is. But I think more research on that would be helpful. But also, I think we have to. At some point, science is supposed to be a corrective to common sense, Right. If we only relied on common sense, we'd think that the sun revolves around the Earth because it rises on one side and sets on the other. So science is an important corrective to common sense, but common sense is also a good corrective to science. And when you're told. And these are facts, right? When you're told that in the space of a few years, transgender identification rose among adolescents by 35 to 50%. Sorry, 35 to 50 fold. And when you're told that previously it was a tiny number of prepubertal boys, the vast majority of whom would desist and come out as gay. But nowadays, it's almost all teenage girls with mental health problems and social struggles. And when you kind of consider these facts in an age of social media and the broader context of plummeting mental health among adolescents, you know, common sense tells you that, of course, there's a social contagion here. Of course, transgender identity is a heuristic that's that's kind of transmitted from. From friend groups and within school districts and online. And it would be irrational, frankly irrational, to assume otherwise.
- [77:00]
B
Well, there's one last question I want to ask you, which I hope will be an easy one, but it seems to have given a lot of people a ton of trouble. Can you do us all a favor and just define the term woman?
- [77:15]
A
Adult, human, female? Yeah.
- [77:18]
B
Well, you know, I hope if nothing else, people will take that away from this conversation.
- [77:25]
A
Honestly, Ralph, I don't think most of the people who pretend that they can't define woman, they know exactly what a woman is. They know it through experience, through everyday encounters. They know exactly what a woman is. And more importantly, they know what a woman resembles. When they say things like, I'm not a biologist, or, you know, it depends on who. Depends on X, Y and Z. What they're doing is they're trying to evade having to define it for their own professional reasons.
- [77:51]
B
I think that's right. Well, Lior Sapir, Senior Fellow at the Manhattan Institute, I cannot describe how proud I am to call you a colleague. I think the work that you're doing is so incredibly important, and I'm so glad that we were able to get you in for this new podcast series, who We Are, which I hope you all watching and listening have found as informative as I have. Thank you so much for joining us on the show. Thank you all for watching. Please do not forget to, like, comment, subscribe, ring the bell, do all the things for the algorithm. Really, really excited for all that we have in store for you, Lior. Thank you so much, much, and we will see you all again soon.