City Journal Audio – "Who We Are: Gender Ideology"

Host: Raphael Mangual
Guest: Lior Sapir, Senior Fellow at the Manhattan Institute
Date: February 12, 2026

Episode Overview

This episode features an in-depth conversation between Raphael Mangual and Lior Sapir, examining the origins, logic, and consequences of contemporary gender ideology, especially as it relates to children and the medicalization of gender dysphoria. They discuss Sapir’s personal and scholarly journey, the recent HHS report on pediatric gender dysphoria, contradictions within gender policy debates, the misuse of evidence in medical literature, and societal and policy ramifications.

Key Discussion Points & Insights

1. Lior Sapir’s Unlikely Scholarly Journey

• Background: Sapir recounts his progression from a Title IX-focused PhD to a leading critic of gender ideology.
  • He initially studied how the Obama administration and federal courts expanded Title IX regulations via unilateral guidance (without public regulatory input), focusing on transgender student accommodation.
  • Surprised to find “meta” arguments dominating (i.e., medical/therapeutic rationales rather than civil rights/equality ones).

    "Plaintiffs...were not making the kind of traditional civil rights arguments about equality...They were saying things like, ‘We have to implement these policies...because of mental health considerations’.” — Sapir [05:00]

• Turning Point: Realized that academics, courts, and agencies were increasingly relying on low-quality or circular medical evidence, with “therapeutic framework” arguments (e.g., unaccommodated trans students are at high risk for suicide).

2. Scrutinizing the Medical Evidence

• Initial Motivation: Sapir’s academic curiosity led him to examine the scientific literature cited in support of medicalized gender interventions.
  • Found large discrepancies between what studies claimed in summaries/press and their underlying data.
  • Detected a pattern of institutional and organizational “capture,” where small, highly motivated groups push policy, while broader, less engaged membership acquiesces.
  • “This was really a case of broad dynamic institutional capture...I don’t mean that in some kind of conspiratorial, nefarious way...There are all these kind of incentive structures that determine how organizations act.” — Sapir [09:21]
• Academic Obstacles: The topic, considered “toxic,” shut down Sapir's prospects in academia, pushing him toward the Manhattan Institute.

3. The Conceptual Incoherence of Gender Ideology

• Self-Referential Definitions: Key terms like “gender identity” are left undefined, circular, or are built on stereotypes.
  • Sapir describes clinicians refusing to define foundational terms, leaving them to self-assertion by patients.
  • “When I asked [gender-affirming social workers] to define some of these key concepts, they thought I was just saying the most horrific thing possible...They said things like, ‘Well, it’s not for me to define, it’s for my patients to define for me.’” — Sapir [16:00]
• Stereotypes Reinserted: While the movement claims to oppose gender stereotyping, in practice, medicalization is triggered by stereotypical gender nonconformity in minors.
  • “The idea that [putting on a dress is] somehow not incongruous with the objection to gender stereotyping…you can’t have both.” — Mangual [22:30]
  • Sapir observes: “If you think for two seconds about what these terms mean in practice, it turns out pretty much everybody is transgender…If you’re a boy and you’re not like GI Joe, you’re trans.” [24:11]

4. The Medicalization of Gender Nonconformity and Its Dangers

• Social Pressures: Societal and parental cues, as well as internet/social media influences, may prime children to interpret normal developmental discomfort or gender nonconformity as a transgender identity.
• Child Vulnerability: “Kids need to be grounded in reality—that is a core part of the responsibility of adults.” — Sapir [29:30]
• Medical Risks: Medicalizing gender discomfort can impose irreversible, poorly evidenced, and potentially harmful treatments on minors (sterilization, bone density loss, cognitive effects, sexual dysfunction).
  • “We know…that [puberty blockers and cross-sex hormones] sterilize [minors]…Their gametes have not matured. They will be sterile. That’s a harm.” — Sapir [59:41]

5. Suicide Narrative and Evidence

• Activist Rhetoric: The “affirm or suicide” trope is described as emotional extortion.
  • “There’s almost nothing [parents] won’t agree to. It really is emotional extortion and manipulation in the most egregious possible way.” — Sapir [38:59]
• What the Data Actually Shows:
  • Elevated suicidal ideation and attempts are observed, but suicide completion is very rare.
  • Risks track with mental health comorbidities rather than gender issues per se.
  • “When kids with gender dysphoria are matched...[with] similar mental health problems...they have the same levels of suicidal behavior.” — Sapir [43:00]
  • No RCTs support a suicide-reducing effect of medical transition for youth. Systematic reviews consistently find the evidence is poor quality and inconclusive.

6. HHS Report: “Treatment for Pediatric Gender Dysphoria, Review of the Evidence and Best Practice”

• How It Came About: Commissioned under Trump’s 2025 executive order; Sapir assembled an ideologically diverse team of top experts under tight deadlines (8 weeks).
• Methodology:
  • Instead of a new systematic review, the team conducted an “umbrella review”—an analysis of all existing systematic reviews of the evidence.
  • Systematic reviews are the gold-standard in evidence-based medicine, weighing the reliability and methodologies of existing studies.
  • “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.” — Sapir [55:00]
• Key Findings:
  • No credible evidence for mental health benefit of interventions like puberty blockers, cross-sex hormones, mastectomy, or even social transition for minors.
  • Known and anticipated harms include sterilization, bone density deficits, cognitive effects, sexual dysfunction.
  • Ethical framework: Current US practices violate key principles of medical ethics (do no harm, benefit patients, justice, properly understood autonomy).
• Reception:
  • Medical organizations declined, stonewalled, or superficially criticized the report; few engaged its substance.
  • “The Endocrine Society refused...AAP [pediatrics] condemned it within hours without reading. The APA [psychiatry]…overlooked the entire section on evidence.” — Sapir [65:06]
  • Supplement provides point-by-point rebuttals to critics, showing “nothing substantive remains.”
  • Praised by independent experts in EBM and some previous advocates (“some said we didn’t go far enough”).

7. The Problem of Broken Institutional Trust

• Parents & Professionals: Many parents want authoritative, evidence-based guidance but receive only ideologically driven talking points or referrals.
  • “Parents...are the victims of what I've been calling…a broken chain of trust. They trust their doctors, their educators...and nobody’s actually looking to see what’s behind the curtain.” — Sapir [37:35]
• Regulatory & Political Risk: Sapir hopes the report influences policy and persists beyond a single administration, but acknowledges the risk of reversal under political change.

8. The Social Contagion Debate

• Epidemiological Shift: Pre-2010s, most gender dysphoria cases were young boys, now the majority are adolescent girls—this abrupt demographic shift correlates with social media and peer group effects.
  • Sapir: “When you’re told that in the space of a few years, transgender identification rose among adolescents by 35 to 50 fold...common sense tells you that, of course, there’s a social contagion here.” [74:24]

Notable Quotes & Memorable Moments

• On Institutional Capture:

  "This was really a case of kind of broad dynamic institutional capture...It's not conspiratorial, there are all these kind of incentive structures..." — Sapir [09:21]

• On Gender Stereotypes:

  "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." — Mangual [15:40]

• On Medicalization:

  "If you block a boy’s puberty at the onset...and follow up with cross-sex hormones, you’re sterilizing them." — Sapir [59:40]

• On Suicide Evidence:

  “What is the evidence for [the suicide narrative]? There is none. The suicide issue is more complicated than people on both sides allow…What we know is kids are at higher risk for suicidal ideation, which is not the same as suicide, not even the same as attempts.” — Sapir [39:35]

• On Defining 'Woman':

  “Adult, human, female.” — Sapir [77:14]

Timestamps for Important Segments

• Sapir’s Professional Journey & Title IX Focus: [01:49–13:15]
• Medicalization & Institutional Capture: [05:14–13:15]
• Circular Definitions & Stereotypes: [15:46–25:46]
• Medicalization of Gender Nonconformity: [27:00–31:18]
• Parent & Societal Pressures, Munchausen by Proxy: [32:00–34:46]
• Suicide Narrative and Evidence: [37:21–47:15]
• HHS Report: Genesis, Methodology, Key Findings: [47:24–64:37]
• Peer Review and Medical Organization Responses: [64:37–70:53]
• Report’s Potential and Institutional Legacy: [71:12–73:42]
• Social Contagion and Epidemiology: [73:42–76:59]
• Defining ‘Woman’—Closing: [77:14–77:50]

Conclusion

This episode presents a rigorous critique of the conceptual and empirical foundations of current gender ideology discourse and practice, especially as it relates to youth. Lior Sapir details pervasive issues with the relevant science, policy, and institutional dynamics, challenges the dominant suicide-prevention narrative, and underscores the urgent ethical imperative for clarity, evidence, and prudence in treating vulnerable children.

For Listeners Seeking More

• HHS Report Supplement: Includes all reviews and rebuttals discussed
• Chapters recommended by Sapir: Chapter 13 (Medical Ethics)