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Richard Helppie
Hello, welcome to The Common Bridge. I'm your host Rich Helppie. Today we've got a very delicate topic for this episode. It's about transgenderism. On the Common Bridge we strive to hear from all perspectives and we've gotten many invites out. We're going to hear from one perspective today with our guest Leor Sapir. Leor, welcome to The Common Bridge, thanks so much for being with us.
Leor Sapir
Thanks for having me, Rich.
Richard Helppie
Throughout history, there have been practices of gender switching, sometimes at a time of more defined gender roles as well as occasionally some dual-gendered or non-gendered people throughout history. It's very rare, but it's happened since the beginning of humankind and perhaps against their will; we had eunuchs and in recent times, Caitlyn Jenner, movies back in the 1950s - “Glen or Glenda,” “Myra Breckinridge” - and here in Michigan “Consider the Oyster” at the famous Purple Rose Theatre. So as we take on this most controversial and difficult topic, we invite anyone with a perspective to please let us know if you'd like to be on the show, we would like to have you. This issue is emerging at a time when deep platform censoring, doxxing and other forms of hate, have become tech enabled weapons of stifling dissenting viewpoints and dissenting facts. So looking for the middle ground, I want to start the discussion with our guest, Mr. Sapir, by suggesting that we can all agree that everyone desires a society and a world that is marked with compassion and kindness for everyone, freedom of choice, and freedom of expression for all competent adults, freedom from violence and freedom from harm and that children are precious, vulnerable, and must be nurtured, and finally, a shared commitment to science and truth however inconvenient or adverse to one's political view it might be. Leor, welcome to The Common Bridge, our audience likes to know a little bit about our guest so if you don't mind, where did you spend some of your early days, what your education and career arc been like? What are you up to today?
Leor Sapir
Sure. I got a PhD in political science at Boston College. I was very interested in American politics, political theory, and especially the role of the courts in our policy process. Right around the time [when] I was looking for a dissertation topic, the Obama administration handed down an administrative guidance document, telling schools that as a condition of receiving federal funds, they had to defer to how students identify themselves as male or female rather than their actual sex as male or female. I thought that this was very interesting especially because the Obama administration claimed, number one, that this was always the law, they weren't doing anything new - which I very quickly found out, it was pretty easy to show that that wasn't the case - but number two, and I think more relevant to our purposes here, the administration did this without providing any explanation for what human sex differences are based on and why. It just asserted a person's gender identity, [it] didn't even define the term in a coherent way, just that a person's gender identity is what makes them male or female. So I set about for the next few years trying to understand - using this episode to understand - how our system of government works and I very quickly became embroiled in these controversies over medicine. Because by and large, both the Federal courts and the Office for Civil Rights and the Department of Education were relying on medical rationales and deferring to medical associations. Towards the end of my doctoral work and into my post-doctoral work at Harvard I started really looking into tracing the footnotes in the citations but looking into the research behind so called gender affirming care. I found that it's really based on very little evidence, the evidence for it is extremely weak and unreliable but it was being presented to the public as settled science. Critics or even just skeptics - people who were just raising questions about this new experimental protocol - were being cast aside as bigots, anti-science, transphobic. I thought that this was a very unhealthy way to try to devise a new medical protocol, especially one that deals with children who are in various stages of development who are vulnerable. So in the last few years I've been focusing pretty much exclusively on the medical science question of pediatric gender medicine, but with obvious overlap to the legal and policy landscape, because I think that it's very difficult to separate those things, especially in the United States, maybe in other countries might be a little bit easier. So that's, generally by way of background. People constantly ask me, you're not a medical doctor, why should we listen to you? My answer to that is I'm not speaking as a medical doctor, I'm not giving diagnosis, I'm not giving medical advice. What I'm doing is basically examining the evidence that medical associations themselves cite in support of their protocols. If there's clear evidence that what they cite doesn't support their own conclusions, you don't have to be a doctor to appreciate, for example that a study that has no control group, it's impossible to make any causal claims about a particular treatment and whether it works or doesn't work. So I tried to help people understand what the studies did and did not do, what the strength of the evidence is. Why it is that over the last few years American medical associations have doubled or tripled down on a medical protocol that other countries - including very progressive European countries - have, in a serious way, started to back away from?
Richard Helppie
I think what's particularly interesting about this entire notion is how many of the guardrails in society have been cast aside in pursuit of a conclusion. I want to make it clear that we're talking about children here, in that a competent adult can make a competent adult decision. I've known people that have done that; there have been some good results and some other results. Then there are infants that are born with indeterminate genitalia or are hermaphroditic and such, and that is a small percentage, but we need to be able to treat that medically and compassionately. But when we're looking at the medicalization of young people some things seem to be tossed to the side, like the age of consent. If you want your ears pierced you have to be, I think, over 12 or have a parent [consent]. A tattoo is permanent, you've got to be over 21, beer in some places, even coffee, consenting to sex, joining the military, buying a gun, voting, seeing an R-rated movie; we set limits on this. Just over the weekend, I'm reading a story about a 14 year old mass murderer who planned and shot two people at a school; the debate was whether that young man should be released from prison. One of his proponents said that at his age his brain is about as developed as a turnip; that you really can't make decisions like that until you're 25. I thought to myself, you could be a depraved killer to shoot a six year old at the age of 14, but somehow at ten years old you're mature enough to make a decision about gender, it just doesn't seem to fit. What am I missing here?
Leor Sapir
Well, Richard, you're raising probably the most controversial aspect of this debate which is, to what extent do kids have the ability to consent or even just basically understand, grasp the gravity of the decision that they are trying to make. I've spoken with adults, including transsexual adults - they prefer sometimes to be called transsexual, not transgender - who say that going through puberty, as hard as it was, allowed them to mature into adults who can have kids, who are fertile - who can have kids - who are sexually functional, and that this is a very important part of their lives, and their lives would be miserable without their kids. But of course, as kids, if you had asked a 12 or 13 or 14 year old version of them do you think that you really want to be a parent in the future, they would have said...because what kid that age wants to have children of their own - it's not even remotely within the spectrum of things that kids care about. But let me say just a few things about this question of consent, which I think is, again, obviously central here. The first is that - what sometimes activists like to say - is that the kids who are agreeing to these treatments are providing assent and not consent. Meaning the fully informed consent is actually given by their parents, not by themselves; they assent to it, meaning they agree to it, but they don't provide the kind of legally relevant basis for medical interventions. We can get to what that means, we can get to why that consent by parents is - to say the least - questionable under the current affirmative protocol as it's practiced in the United States; I would just put that on the table. The second thing that I think it's important to understand is that unlike getting a tattoo or drinking beer or driving a car, according to advocates of the affirmative care model of treatment, these are not elective treatments, these are medically necessary. As they now like to say, “life saving” because they invoke the idea that kids will kill themselves if they're not given these interventions, meaning it's a medically necessary intervention for a medical condition. Of course, the kid doesn't have to agree to having a medical condition in order to be diagnosed with that condition. So in other words, what they're doing is they're using an approach that emphasizes the clinical benefits of these interventions, as opposed to an approach that we see is much more common among adults that relies on informed consent. If you want to get a boob job, you don't have to prove that it's going to - as a mature woman - you don't have to prove that there are clinical benefits associated with getting enhanced breasts. It's your choice. As long as you are appraised of the health risks involved you can give informed consent, but at the same time we recognize that that's a cosmetic procedure.
Richard Helppie
There are two things about about that; first of all, informed consent means there needs to be a medical standard of care. My understanding with these gender affirming treatments, as they're called, that there is not a standard of care. With breast augmentation, the first question the plastic surgeon is going to ask is what's your expectation of this surgery, and they are screening to make sure that there's a reasonable psychological expectation. My understanding, first of all, that we can't figure out what the parents responsibility is, and your kids are raised...the adult is trying to tell you, don't tell a secret; that's generally somebody that's not interested in your best welfare. Look at all the situations we've had with the priest abusing children and such; that was a secret to be kept from the parents.
Leor Sapir
Okay, you put a lot on the table, which I do want to kind of go back a little bit, because there was one additional aspect of the consent question, which I think is absolutely vital and maybe the most important of the three that I was going to mention. Then we can get back to standards of care, we can get back to social transition, which includes pronouns and all these kinds of things. I think at the heart of the argument for gender affirmative drugs and surgeries is the notion of the transgender child. What I mean by that is the idea that being transgender is something that you can be born as, and that this type of knowledge that I am, in fact, transgender is available to human beings from a very early age. It's not uncommon nowadays to read articles, including in peer reviewed journals, claiming that kids as young as two years old can know that they're transgender. So if you accept a notion that some kids simply are trans, in the same way that some kids are gay, some kids are left handed, some kids are tall, some kids are dark skinned, some kids are light skinned, and so on and so forth; if you accept that it's just a natural category of human life, it's very hard to then see why we shouldn't give transgender medicine to transgender children. So the practical consequence of accepting the notion of the transgender child is to reverse the burden of proof that normally exists in medical ethics. Because usually in medicine, if you are going to intervene in the human body, either with drugs or surgeries, or even with psychotherapy, there has to be a pretty compelling reason for you to do so. That's the practical consequence of taking seriously the oath, do no harm. So usually the burden of justification is on those advocating for certain treatments...or certain interventions, I should say, as treatments. But if you accept the notion of the transgender child, and if it seems intuitive to you that transgender children should get transgender medicine, then the practical consequence of that is really to flip the burden of proof so that now the burden of proof is on people like me to explain why transgender children should not receive transgender treatments; treatments that we give readily to transgender adults. So at the heart of this debate, I think, is the concept of the transgender child and the questions about [it] and further than that, philosophical questions about what is gender identity. Do all human beings really have it? How do we know that we have it? These are very complicated questions. But I think it's enough right here just to point out that we don't have evidence...put it this way, we don't have evidence that some kids are just born transgender. Let's start there.
Richard Helppie
Let's grab that a little bit. Because early on, you mentioned where's the control group. Again, I'm setting aside the percentage of babies that are born with indeterminate genitalia or they might have gonads and a uterus; this happens, okay. These are things that clearly call for some medical review and/or medical intervention. I'm talking about what we used to say; here is a boy, or here is a girl, not that you're sex assigned at birth. But you mentioned a control group, because if this has been a problem for so long, where are the 50 year old, 60 year old, 70 year old...there should be a large cadre coming to the fore saying, yes, I was transgender but I didn't have affirming care available to me, it's ruined my life. I'm listening for them and to date, I have not seen any evidence that there is a group of people out there that believe they missed the window to change their gender identity. Am I missing something? Is there something out there in the literature that says that there is a control group?
Leor Sapir
Well, I think you're definitely right to point out that we would expect to see a much larger presence and public discourse of older adults who say, if only I had these procedures available to me my life would have been immeasurably better. These individuals do exist but we also have a lot of older...again, I use the word transsexual, because that's usually the word that they use, they don't like the word transgender, they recognize it as kind of a new linguistic shift that brings in a lot of phenomena that they think is completely irrelevant and even harmful to what they regard as appropriate medical care. So let's leave that aside, let's just use the term that they prefer. A lot of these older transsexual adults, they recognize the fact that, again, having kids, having their sexual organs and functions intact coming out of puberty, with their bodies not having been flooded with synthetic hormones, not having had their breasts amputated or their penises inverted into neo-vaginas and so on and so forth, that this has actually been a real blessing to their lives, especially their ability to have kids and to have a family of their own. I think that to the extent that they know anything about pediatric gender medicine, they probably know that kids who go through these drugs and procedures from a very early age, from right around the cusp of puberty at Tanner Stage II, are unlikely to emerge from adolescence with their organs and functions intact. I think that a lot of these older transsexuals recognize that, at the very least, there's a real dilemma here. But I think a lot of them are actually against pediatric sex changes for exactly the reasons that I outlined. But again, getting back to the question of the transgender child trend, transgender is not a natural category; it's a social and political one. You could say that the natural category here or the clinical category would be something like gender dysphoria or gender incongruence. There's a debate within the clinical literature about whether for example, a very small subset of the population has a brain that is structurally and functionally typical of the opposite sex. That's the so-called Brain Sex Hypothesis; that transsexuals are, by definition, those who have the brain structure and function of the opposite sex. This is a controversial theory. There's a lively scientific debate about whether it's true or false, but regardless - and for the modern transgender movement and certainly for advocates of pediatric gender medicine - it almost doesn't matter. I say that because nobody is demanding MRI scans on the brains of children in order to determine whether they really are trans. Under the affirmative protocol, especially the one practiced in the United States as opposed to the one increasingly common in Europe, the medical protocol starts from the assumption that kids know who they are - specifically trans kids know who they are - from a very early age, from as young as age two or three, these kids can know that they are transgender. By that I mean that they are going to have a full human life as transgender, not just going through a phase. It becomes a kind of dogmatic ideological assertion, unproven and unprovable, in principle - one doesn't have to prove these things. If you peer into the circles of advocacy, including doctors, mental health professionals, who practice these things, you'll see them take it as just an article of faith that some kids are just transgender and that one can have intuitive knowledge - or as they like to call it “lived experience” - which is not objectively verifiable through any tools of scientific analysis or diagnosis, as opposed for example, to what you were mentioning earlier; the intersex are conditions or developed disorders of sex development. These are objective conditions that can be diagnosed objectively without just relying on a patient's say so. But in the case of transgenderism, that's just not true
Richard Helppie
To that degree about trying to put a diagnosis on it, in any other diagnosis the way that you might get to a diagnosis of gender dysphoria or transgenderism, transsexualism - I want to be sensitive to the right nomenclature - you'd rule out everything else. There have been two quite solid studies now with an undeniable link between autism and people that believe that they are of the opposite gender; the number of comorbidities of mental health conditions with people that think that they are in the wrong body is stark. There is no study that I've been able to locate, that says suicides and suicidal ideation is better post these massive medical interventions. In fact, threatening suicide is emotional blackmail in all circumstances; that the social influence that we are seeing is not a factor. Do you have any friends that say they are gender fluid or the opposite? How about the other people in your class? Then of course, there are parents that want to have a facetious disorder imposed on their child; they get attention for it. It seems to me that there's a lot to rule out before one comes into a life changing diagnosis. Giving credence [to the idea] that there are going to be a certain number of people - let's stipulate that that might be possible - but let's rule out everything else and see what can be treated before going to the big gun medicalization of minors.
Leor Sapir
That's right. What you're referring to is known as differential diagnosis, and that occurs in every area of medicine. So if you go to the doctor, and you say, hey, doctor, my back hurts, I think it might be the first symptom of cancer; the doctor is not just going to say, well, cancer people know who they are. They're going to do differential diagnosis, rule out other things that might be causing a symptom that is known to be common in certain types of back cancer. So we do differential diagnosis, and of course, in mental health it's tricky sometimes to do. In psychiatry, it's difficult sometimes to do differential diagnosis because you're treating diseases of the mind. You can't exactly just do a biopsy. So yes, there has to be differential diagnosis. One of the points that I've been trying to make in my writings, in my research and to convey to policymakers and especially to the medical community, is that the affirmative model that has taken root in the United States, if you want to kind of reduce it down to a slogan, it's basically: no differential diagnosis. We don't do that because differential diagnosis entails prolonged intensive psychotherapy, where you don't just take a person's trans-identification or desire to escape their body at face value. But in fact, you set it aside and you say, okay, I hear that you that you feel like you are the opposite sex, let's try to talk a little bit about your history or other mental health issues. Let's do a comprehensive assessment to see if there might be something else that's driving you to think about yourself in these terms, and to think that your life will be much, much better if you take these drugs and surgeries. You might think that that kind of intensive psychotherapy first approach is absolutely common sense; it's the least invasive way to treat kids in distress in these circumstances. In fact, that is what European health authorities are now recommending. But the affirmative model, as endorsed by American Medical Association, says that that form of exploratory therapy...they've called it “conversion therapy” and in doing so they're borrowing a term that has been used in another context, a context that is - if you're thinking about this as a scientist would - unrelated to the context of gender identity development, and I'm referring of course, to homosexuality. In American political culture, partly for strategic reasons, the “T” has been lumped together with the “LGB” as if it's all part of the exact same phenomena but in fact, these are very, very different things. It is true that in the context of homosexuality efforts to use psychotherapy or even harsher means to get people who are same sex attracted to not be same sex attracted anymore are almost always futile and worse than futile. They're almost always very damaging so they're greatly discouraged. But all of the available research that we have on childhood gender identity development shows that the vast majority of kids with cross gender identification desist from it by early adulthood. Puberty itself appears to be the factor that that helps clarify a person's sexual identity to themselves and that, more often than not, with psychotherapy they can come to terms with their body and they won't feel like they need to undergo risky transition in order to be who they think that they are. So I would say the affirmative model is really at odds with differential diagnosis. This is not just me making inferences. The American Academy of Pediatrics in 2018 published a position paper that explicitly said, any psycho-therapeutic approach that does not automatically and uncritically affirm - meaning agree with a child's self-diagnosis of being trans - is conversion therapy. This is a wildly irresponsible position to take; all of the evidence that they cited in that position paper actually supports the opposite hypothesis. That paper was written by a single medical doctor who was still in his residency and had virtually no clinical experience - he himself reviewed his own paper. It is a position undertaken by the American Academy of Pediatrics on the basis of one inexperienced doctor with virtually no input from the wider medical community. In the paper itself, they say, Dr. Jason Rafferty, who is the author of the paper, is accountable for this position statement, but he has not been willing to respond to or engage with critics ever since 2018. So it's a policy ungrounded in any scientific evidence, that has no guardrails or safeguards, as you put it earlier, and for which the AAP has been completely unaccountable to the public and to its own members.
Richard Helppie
I can see where the momentum starts with, we're not going through normal diagnostic procedures. The difference between a person that is born as a homosexual, and discovered that as their awareness increases, they could be a man who is attracted to, loves men, he's still a man, he's still not trying to medically change his body. But similarly with a woman that's attracted...and as we seen that people do change over time, there are people that are bisexual and asexual at different periods of their life or people who might come in and out of their lives, they may change who they're attracted to or who they're in love with but they remain their own biology versus something that's been contorted.
Leor Sapir
That's part of the problem. Sex used to mean something very specific, then the term “gender” entered into the lexicon for a variety of cultural reasons. Now the trans movement, over the last 10-15 years, has conflated sex and gender so that now we use the two interchangeably. There are two sexes - there are disorders of sex development - but there are two sexes. Gender; there are no genders. That doesn't exist. Gender refers to social and psychological understandings of sex. So in that regard, you can say that different cultures have different understandings of sex and that's it inarguably true, but it doesn't mean that there are more than two sexes. It certainly doesn't mean that there are more than two genders, unless, again, you're conflating the two terms. Then gender identity, what exactly is that? Well, that's a person's core sense of gender. But again, what is gender? So you have to come back to saying it's a person's core conception of their own sex. Well, that core conception can either be true or false but it can't replace, can't supplant a person's sex.
Richard Helppie
So when you think about this, we have diagnostic and treatment protocols for everything else. We have the Hippocratic Oath about doing no harm. We seem to be breaking through all of those guardrails and checkpoints. Who profits from this? Why is this being pushed so vigorously? There's so much noise around it. I will tell you, also part of my research and preparing for this talk today, there are really well funded not-for-profits out there that are clearly advocating to ask no questions, get to surgery as quick as we can. Why? Any sense for that?
Leor Sapir
I get this question a lot. I think Americans understandably, especially coming on the heels of the OxyContin scandal - opioid epidemic - where there were big pharma companies - Purdue Pharma, for example - standing to gain huge profits from getting Americans addicted to painkillers. I think there's understandable suspicion towards drug companies, maybe less so towards hospitals, but certainly towards drug companies, and to some extent, maybe insurance companies as well. I understand that, I'm sympathetic to that. But I think in this particular case, in the case of pediatric gender medicine, I haven't seen evidence that would convince me that the profit motive is the main driver [but] it is a factor. I don't think it's the main factor of why these protocols, why these procedures, have taken root and spread so quickly and so thoroughly. I think, by far and away, the most important factor is ideological. I think that a lot of the doctors who are doing this and the medical associations who are doing this are deferring to small and very vocal groups of activists from within their own ranks, are not doing it for profit, necessarily, or at least not primarily; they're doing it because they've drunk the Kool-Aid, so to speak. They believe wholeheartedly in the notion of the transgender child. They believe wholeheartedly that these interventions are safe, and that the clinical benefits are, if not proven, then at least extremely likely and that the risks are minimal if they exist at all. I think they have merged in their minds...they've merged a medical protocol with a civil rights cause to such an extent that they cannot even think about these two issues separately. They cannot...anytime they think about pediatric gender medicine, they're thinking about the newest civil rights frontier. Anytime they're thinking about the newest civil rights frontier, they're thinking about trans kids. So I think the driving factors here are primarily ideological; I think profit probably does play a role. But I think we need to know a lot more about exactly how much profit and what types of liability risks insurers and hospitals are accruing here. There's just a lot we don't know about the whole industry side of this, the profit side of this, before we can come to the conclusion that it's similar to other medical scandals like OxyContin.
Richard Helppie
When you talk about the civil rights frontier...probably leaning Libertarian here, but looking at an adult that wants to dress anyway they want to, great; a man wants to wear a dress, a woman wants to wear something that is typically identified with men – fine. The notion of going over into a space that should be safe for women, dressing rooms, and so forth with men that are both biologically male and behaving that way - I make that distinction - is grossly unfair to women and to girls, as is an athlete competing with biological women that has been through male puberty. Even Caitlyn Jenner, who was a world class athlete, saying, yeah, that's just not right, that's just not fair. I think people can see the common sense in this, but civil rights, we'd all defend any competent adult's right to dress and behave any way they choose, with the proviso it doesn't infringe on the rights of another person, period.
Leor Sapir
Yes, I think most Americans share your sentiments.
Richard Helppie
Societies need to look out for the most vulnerable and the most vulnerable are often our children and when I see items getting conflated, like, oh, people don't like drag shows - look, they've been around forever, the Kabuki theater in Japan...it's just, do we need them in a first grade classroom? That, to me, is getting down to ideology. Leor, neither one of us are doctors, but I've worked in medical records, I understand a little bit of - no clinical chops at all - a little bit of the lingo and obviously, you're well studied; the realities of the surgery don't seem to live up to the promise, they're fraught with risks. What do you know about that? What are you comfortable sharing?
Leor Sapir
I don't know too much about the full spectrum of complications, how common they are, to what extent and how they can best be managed, how they factor into mental health. What I can say is that we do know that the risk of complications is relatively high; I've seen figures somewhere in the range of 25 to 70 percent complications especially from genital surgery. I should mention that genital surgeries do happen in minors, they are extremely rare but they do happen; their numbers have been increasing. Double mastectomy, radical double mastectomies for teenage girls are far more common and increasing in numbers. There are complications; it doesn't seem like that risk of complication is as high as genital surgeries, but it is still a surgery and there are definitely complications. So we know that the rate of complications is high. We also know that from anecdotal stories of de-transitioners - these are young men and women who have undergone these surgeries sometimes as minors, sometimes as teenage adults, meaning ages 18-19, and have very quickly come to regret it - their stories are harrowing. They have severe medical problems. I'm not just talking about sexual dysfunction, it's sometimes things like incontinence and constant pain, excruciating pain. These are complications that they have to live with for the rest of their lives. We're learning other things as well. To give you an example, it used to be the case before - up until 15 years ago, outside of, let's say, the Netherlands - it was virtually impossible for kids to be able to access any of these drugs or surgeries. So if you want to transition, you have to do it as an adult. If you are a male undergoing vaginoplasty, going through that procedure of having come through puberty intact, your risk of complication is much, much lower than if you were a male who had his puberty stunted or halted by puberty blockers, in which case you have not had a chance to develop full male genitalia. That's relevant because in a vaginoplasty, they use the male genitals - the penis itself - they invert it into the cavity of the body, turning it into something that resembles a vagina. If they can't use the tissue from a fully formed adult sized human penis, they have to borrow tissue from elsewhere. The procedure as it exists today is typically to borrow it from the colon. Essentially you're taking part of the colon out, turning it into this new pseudo-vagina. That carries huge risk of complication, not just because the new organ that you're creating...you have secretions and smells and all these kinds of problems, but also because you're opening up a second surgical site which always carries a lot of risk. So for example, in the Dutch study, which is often considered the gold standard of medical research in this area, they had one death among their very small number of patients, and that death was because of a vaginoplasty in a male patient whose puberty was blocked and they had to borrow from the colon. So these are not negligible problems. They're enormous problems. Again, if you're talking about adults, let's say a 25 year old whose brain has fully developed - because we know that cognitive development happens until around age 25 - so if you're a 25, 26, 27 year old adult, you can fully grasp it. You're given all the relevant and accurate information about the chances of complications, the type of complications, what it would be like to live with those complications; you can make an informed decision. I think there still are some ethical issues of “do no harm” that have to be considered. I don't think that people can just consent away to anything they want, I think there should be some guardrails. Still, I do support adult transitions but not without some guardrails; at least you're able, you're capable of understanding what it is that you're agreeing to. The problem with pediatric transition is that we know, for example, that 93-98% of kids who go on puberty blockers go on to cross sex hormones. Once they're on cross sex hormones, the chances of them getting surgery also increase exponentially; because if your body is partly female, but you've been on puberty blockers followed by testosterone, your dysphoria could actually intensify. Because you are now in this in between category where your physical natural body is pulling in one direction and the synthetic body you're trying to give yourself is pulling in another direction that actually creates internal conflict so that can increase the likelihood that somebody like that is going to agree to surgery that that person might not otherwise agree to. And of course, the same goes for biological males. So putting kids on the medical transition path greatly increases the chance that they will end up on the surgical path as well. Even though when medical professionals are explaining this to the public, they tend to say that all these phases of treatment are totally separate and distinct and that you can agree to one and not even be bothered by the other until we have to cross that bridge; that's just not true.
Richard Helppie
I agree with that. From the reading I've done and the individuals that I've been able to contact, the treatment starts with let's change your pronouns and let's keep it a secret. Guess what? Everybody that tells Charlie that now your name is Sue, you're wonderful, but anybody that says the opposite is a hideous person gets reinforced. Then the puberty blockers, then the cross sex hormones, and the person is not any happier. Then it's the surgeries. These surgeries do come with infection, they come with functional arousal, erection, orgasm, menstruation but it's not going to turn you into the other sex. The form, it's not going to look real. I’d especially encourage those that are considering the phalloplasty to look at the outcome. You're still going to carry the same chromosomes, you're going to have lifelong maintenance and you're not likely to be able to reverse the surgeries. These are serious consequences for a small part of the population, but certainly not something for broad numbers of children. The closest parallel - I'm a believer in history, that if something's happening, something similar happened - if you look at other attempts to treat mental illnesses and mental maladies, emotional problems with medical treatment, lobotomies draw a strong parallel. Mostly it was children and women and those that were severely mentally ill that were being lobotomized and lobotomized without their knowledge. In Sweden there were 4500 lobotomies performed between 1944 and 1966. Most of the patients were women. Guess what? Parents, husbands and doctors were able to order the lobotomies without asking the person whose brain was about to be dismantled. So asking a minor, who would not be competent, is just another parallel. By the way, there were awards and international acclaim for people that practiced lobotomies and now we view lobotomy as a Frankenstein-like phenomena that never should have taken place. When I look to Finland, Sweden, the United Kingdom, backing away from their ardent pursuit of gender affirming surgery, I just have to wonder, are we on the front end because, again, I listened for that group coming to the fore saying, no, I missed the chance to do this transgender change or transsexual change when I was 12 and my life's not been good. But we're not hearing or seeing that. So again, it's a puzzlement to me. I do believe as a society, we want to be kind and compassionate to everyone. I think everyone needs to be able to earn a living, live in peace without violence but it just seems to me that - and I liked the way you put it - the conflating of civil rights with a fairly experimental medical procedure is not the way to get there. Leor, what didn't we talk about today that maybe we should have covered? Are there any ideas as far as like what good versus bad public policy might be?
Leor Sapir
Sure. I mean, there's plenty more that we could talk about. But let me maybe touch on two issues that I think are very front and center in the news, very controversial. One of them concerns the question of social transition you raised; pronouns and stuff like that. This is now happening in schools all the time, we get reports from parents, we see videos on social media being posted, that schools are not even hiding it anymore. They sometimes have the stuff written down explicitly in their own internal policies. Some schools have adopted what they call gender support plans, which is where they basically defer to the child no matter what the age, and they say, we will use your preferred name and pronouns, we will ask you if you want to share that information with your own parents. So let me just say a few words about that. I think, for the most part – there are exceptions here - but for the most part, teachers and school administrators who do this are doing it because they think they're being kind and inclusive. They're doing it for good intentions. I think what they don't understand is that this is actually a psychological intervention that is likely to do more harm than good. Interestingly, other countries have recognized this already. The Dutch have long recognized this, and again, the Netherlands is where pediatric transition comes from. The Dutch researchers have actually always recognized that social transition is not just a neutral act of showing respect but it's a powerful psychological intervention that can lock in a state of confusion or distress and turn it into a more permanent state of mind that would make medicalization more likely, whereas without the social transition, the child would come to terms with their body and their sex and, in all likelihood, come out as gay. In the UK recently, the National Health Service issued new draft guidance in October of 2022, strongly discouraging social transition in children and in adolescents, saying that social transition should happen only on the basis of a gender dysphoria diagnosis and with the supervision of a mental health professional and informed consent, which really shows you that the NHS is taking this seriously, that this is not just a neutral show of kindness but an active psychological intervention. Here in the United States, the picture is very different. For the most part, the people who run schools and dictate policy on this area are convinced...if I don't forget I'll circle back to this - don't let me off the hook - I can explain why they're convinced. They're convinced that this is a neutral act of respect and that parents should only be brought into the decision if the child agrees, if the child says yes, my parents are going to support this decision. If the child says no, my parents are not going to support it, that the school can and should hide it from the parents. But here's what we know based on research in over four decades. We know that in the vast majority of cases of children who have crossed gender feelings, behavior and identification, they grow out of it by early adulthood, something to the tune of 85% of them will come to terms with their body and their sex. A majority of those will realize that they're actually gay and that their feelings of cross gender identification were actually early signs of same sex attraction. In 2022, last year, there was a research paper published by Christina Olson, she's at Princeton, showing that kids at ages - I can't remember the exact average age, I think it was six to 11...it could have been three to 11, I can't remember the exact age of ranges - a range of ages, but kids who had crossed gender feelings and behaviors who are affirmed socially - meaning they were socially transitioned with new name, new pronouns and so on and so forth – five years later, 94% of those kids had not come to terms with their body and their actual sex, meaning they persisted in believing that they were either the opposite sex or some in between non-binary category.
Richard Helppie
Where would the support come from if they said that was a phase? Where could they turn to say, I was Carl and now I became Christina. Where's the backward migration path that says I've changed [my mind] I am not sure about this - there's no place to go.
Leor Sapir
Yes, I mean, especially in an affirming environment, where the idea is that if a child has regret or changes her mind or anything like that, that that's a telltale sign of what they call “internalized transphobia” as opposed to just kind of a natural course of progression of gender dysphoric behavior. But just to finish off the thought that I was starting earlier, the question is, okay, so what to do with the study, because it seems to contradict four decades of research. Eleven previous studies have found that the vast majority these kids dismissed it, and here's one study that comes along and says, no, actually, almost all of these kids persist. Of course, an activist in support of the model said, okay, because this study is more recent, it's supplants all previous research. Now, that's one interpretation, but it's by far and away not the most persuasive. Why? Well, the most important thing to know about these 11 versus one study was that, in this latest study by Christina Olson, the kids, as I said, were fully socially transitioned, whereas in the previous studies, they were not fully socially transitioned. One possibility - I think a much more likely possibility - is that kids persisted in identifying as the opposite sex because they were socially transitioned. So if you're looking at this without the critical distance that's required of a scientist, if you're looking at this as an activist who believes in the idea of the transgender child, and you believe that transgender children know who they are, then you're likely to say, of course, if a trans kid says I'm trans and you believe them and you offer them support as being trans, then five years later, those kids are still going to identify as trans. But if you're looking at this from critical distance, you say, well, if, in the vast majority of studies, these kids desisted and came to terms with their bodies and with reality, but in the one study, where they were socially affirmed as really being the opposite sex, they did not come to terms with their body, in reality then it's probably the social affirmation itself that's responsible for interfering with the natural resolution of gender dysphoria. I mean, that's just a common sense interpretation of how do you reconcile this one study against the previous 11. But that's not how it was reported, that's not what the authors said, that's not how journalists, this kind of left of center media, reported on this study. Instead they said, this is evidence that trans kids know who they are. So that's the state of the debate. Now, along with my colleagues at the Manhattan Institute, we recently authored an amicus brief for a lawsuit - for a couple of lawsuits, one in Massachusetts, one in Florida - dealing with secret social transition of children in schools. By secret I mean where the parents are either not informed, or they are informed and say no but the school goes ahead and does it anyway. What we're trying to get people to understand is that this, again, is not a neutral act of kindness or respect, this is an active psychological intervention that can change the course of a child's development and put them on a medical pathway, where otherwise they would not have to be on one. So it has potential to do enormous harm to children, to say nothing of the fact that it should be well within the right of parents to make mental health decisions affecting the well being of their children. That is not the role of the school. It's certainly not the role of the school where teachers, under extreme pressure from outside a lobby groups, think that it's their role to decide which kids are really transgender for life and which are not.
Richard Helppie
Well, to that point, a lot of that is into the political realm and this great divide that we have today in the country. In recent days, there's been an actress that's come forward and said, I have four children, one's gay, one's gender fluid, I think, and one's trans. I'm looking at that and saying that defies every statistical probability; this is not a naturally occurring event. To the point about the social transitioning, whether that's an act of kindness or it's an act of cruelty; it's an act of kindness if it's actually helping a person become who they are. However, if it's feeding into an underlying set of mental conditions, you're being cruel. A great example; I was in a group and they wanted all the introductions with your personal pronouns, I said, no, I just don't do that, one should be able to tell by looking at me. One person then identified...used to be a “her” now she's a “they,” said that's because she has overlapping disabilities. I thought, well, that's an interesting thing so I looked up overlapping disabilities. According to the VA, they don't exist, you can't have overlapping disabilities - basically, that's a function of my lay understanding - if you've got anxiety and it's because of PTSD, you can't also have the anxiety because of childhood trauma or something like that, it'd have to be from the separate incidents of PTSD. So I think we're in the realm of what good mental health is, as a starting point, versus in the realm of biology and medical diagnostics and treatment. I don't know how this ends. I don't know where this goes. But I am concerned for the young people that are swept up in it today.
Leor Sapir
I agree. Look, again, I'm not a medical doctor, I don't purport to offer medical advice. What I do is fact check the people who do make statements about the science and the research on pediatric gender medicine. You don't have to be a doctor. Again, if the citation that you invoke says the opposite of what you make it out to say, you don't have to be a medical doctor to call that out. That's exactly what's happened within the medical field. But yes, I think we are staring down the barrel of a huge mental health crisis. We know, based on data recently published by the CDC...There's a new book out by Jean Twenge, the social psychologist, called “Generations” where she documents a lot of the mental health collapse among Generation Z over the last decade and a half. I mean, it's staggering. We're seeing skyrocketing rates of anxiety and depression especially among teenage girls. We are going through a major mental health crisis in American youth. I think the transgender issue is very much downstream of that; it's a way for a lot of young people to try to make sense of the difficulty of growing up, of going through puberty, of being bombarded with pornography, or being sexualized. It's a coping mechanism in the vast majority of cases. The fact that our medical establishment takes those professions of being, so to speak, “born in the wrong body” at face value starts from the ideological premise that trans kids know who they are which is, frankly, a medical scandal; one of the worst, I think, that we've seen in recent memory. So you ask, where does it end? Usually with these things in the United States, in the court of law. It's going to end with a generation of kids who grow up to be young adults who are sterile, sexually dysfunctional, who have really bad health problems, whose mental health was not helped and probably harmed by being misdiagnosed as trans whereas in fact, they had other issues going on. It's a matter of time before these lawsuits succeed, there are already a few lawsuits underway. One of the problems that we're running into is that judges...like you asked earlier, what about standards of care; our standards of care are forged in litigation. One of the problems is that when a judge is faced with a claim of a de-transitioner - somebody who is harmed by these interventions - the judge will want to ask, okay, so what standards of care was the doctor following? Then you have most major medical associations, like the American Academy of Pediatrics and the World Professional Association for Transgender Health and The Endocrine Society, one by one lining up behind the doctor saying, no, no, this was completely legitimate and these procedures are science-based, evidence-based, and there's no problem with them. So one thing that that desperately needs to be done is to help judges understand why the policy statements and recommendations made by these medical associations are not based in science, that the evidence they themselves cite does not support their own conclusions and what European health authorities have done and why. It's just a matter of time before judges - who are, after all, intelligent people who live in this world with us - come to appreciate that, and when they do, I think it's enough that you'll see a small handful of these multi-million dollar lawsuits against these big health systems - I'm not going to say that pediatric sex changes are going to come crashing down - I think you're going to see the industry take up a serious blow; things are going to come to a grinding stop.
Richard Helppie
I just want to see that all human beings get the right compassion and care. It needs to be demonstrated that that it is the right compassion and care. Again, I invite anyone that would like to be a guest on our show to sit down and talk with us about why these pediatric sex changes or sex affirmations are an act of kindness and compassion in the best interest of the child. Leor, you've been a great guest today; so much to think about. Any closing thought for our listeners, readers and viewers?
Leor Sapir
I guess what I would say is this is a very - as you said at the beginning, in the introduction - it's a very heated issue. Passions run very high. I would just encourage your listeners to think about this, not just from a perspective of compassion and empathy, because as the word compassion suggests it's a passion; it's not always rational or reasonable or evidence based. Sometimes we need to rely on our reason and our understanding of the evidence to adjust our compassion and make sure that it's expressed in a way that's actually good for people and not destructive for the very people we're trying to benefit. So I would recommend anybody who's interested in this topic, that you really have a commitment to science, a commitment to evidence, to the scientific process of debate and inquiry, above all, and I think once we can get more people to be committed to the scientific process and scientific debate I think we'll see this issue get resolved sooner rather than later.
Richard Helppie
We've been talking today with Leor Sapir, on The Common Bridge, on the most sensitive topic, transgenderism, transsexualism and pediatric health care. This is your host, Rich Helppie, signing off on The Common Bridge.
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(Watch, Listen or Read) A Deep Dive into Transgenderism, Transsexualism, and the Ethics of Pediatric Care.