Leor Sapir and Rafael Mangual dive into one of the most polarizing issues of our time: gender ideology. They explore how gender discourse evolved over the past decade, including cultural and policy shifts during the Obama administration, and how these developments reshaped institutions, media narratives, and social norms. A major focus of their conversation is the medical treatment of gender dysphoria in youth.
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Audio Transcript
Rafael Mangual: Hello and 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, Leor Sapir. Leor, welcome to the show. Is this your first time on the podcast?
Leor Sapir:
On this podcast, yeah.
Rafael Mangual: 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, Leor 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 Leor, 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 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 a PhD from Boston College to a think tank where you are now one of the leading national voices on gender ideology? Walk us through that journey.
Leor Sapir: Sure. It was a very unexpected journey. I would never have predicted, let's say in 2015, 2016, that I would've ended up where I am. So I wrote my dissertation on Title IX, 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 of Title IX 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 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 said at the time, sex is a stereotype called kind of the conventional understanding of sex a stereotype.
It couldn't explain this and it didn't even bother to try. And I thought that in itself was interesting to me. But secondly, 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 a notice and comment 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 create.
Rafael Mangual: “I’m just a bill.” Right.
Leor Sapir: Exactly, exactly. It's a very convoluted, complicated process that involves, let's call it less-democratic features of American government, 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 would teach me a lot about American government. Towards the end of that process, I finished my dissertation. I defended in 2020. I actually did a postdoc after that for a year as well. 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 met, meaning that plaintiffs and 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 mental health considerations…
Rafael Mangual: Can you give us a sense of what those policies were exactly and some examples of the sort of medicalized arguments that were being made to advance them?
Leor Sapir: Absolutely. So maybe one of the most visible cases at the time was Gavin Grimm v. Gloucester County School Board. This was a case out of the Fourth Circuit in Virginia that involved a biologically female student who identified as a boy. And so 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 healthcare authorities say that if schools don't treat girls who identify as boys as boys, then they are going to become suicidal, they're going to be depressed. And of course, that also has, according to their argument, that also has implications for equal educational opportunity because when students are depressed or feel excluded, they can't enjoy the full access to educational benefits. So there was a kind of link to the kind of traditional arguments about Title IX.
Justice Samuel Alito: 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 that's a bit distressing. One of them has to do with the risk of suicide. Do you maintain that the procedures and medications in question reduce the risk of suicide?
Chase Strangio: I do, Justice Alito, maintain that the medications in question reduce the risk of depression, anxiety, and suicidality, which are all indicators of potential suicide.
Justice Samuel Alito: And do you think that's clearly established? Do you think there's reason for disagreement about that?
Chase Strangio: 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 Cass Review, for example, the Cass Review only looked at studies up until 2022. Well,
Justice Samuel Alito: I don't regard the CAST review as necessarily as the Bible or as something that's true in every respect, but on page 195 of the Cass report, it says, "There is no evidence that gender affirmative treatments reduce suicide."
Chase Strangio: What I think that is referring to is there is no evidence 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 this treatment.
Leor Sapir: 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 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 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 of the time plaintiffs in these cases were already on hormones, that these interventions are grounded in good science. I thought, well, then certainly it should be possible to see that 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't take away because the way in which this literature is represented sometimes by the authors of the studies themselves, there's very little relation to 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. They weren't necessarily lying. They sincerely thought that this is what the medical literature shows. 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 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 diffused, less attentive, less organized, and let's say risk averse membership that might outnumber the committee 10 to one, but if they're not paying attention or they don't hear as much or they're risk averse, then the committee gets its way.
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, 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 is 2021. So it was the high…
Rafael Mangual: Peak work, as they say. Peak woke.
Leor Sapir: It was very much peak woke. And this was still also, 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.
Rafael Mangual: Did you get any advice when you were selecting your dissertation topic that this might have an adverse effect on your future career prospects?
Leor Sapir: 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 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 that this is a very important topic. And of course, nobody else dispositionally…
Rafael Mangual: What was in that Dear Colleague letter, that 2016 letter?
Leor Sapir: That's the letter that kind of ... Right. So that's the letter that crystallized the administration's approach 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 looking back, I think, I mean, I know that I'm dispositionally am a bit of a contrarian when everybody says, "Don't look behind that curtain,” 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 eventually towards the end of my postdoc, through a friend of mine, I was introduced to the Manhattan Institute and I had never really considered going into the world of think tanks. It just wasn't on my radar. I'm so glad that I did.
Rafael Mangual: As are we.
Leor Sapir: Yeah, thank you. I mean, it really is the case, certainly since 2020, 2021, that as academia was becoming so hostile to anybody who doesn't toe the line, the orthodoxy, it really became the case that think tanks were doing the job that academia once did. Sometimes it feels like there's more diversity of opinion at a place like the Manhattan Institute than I would've encountered in pretty much any academic department that I would've been in. And there's serious scholarship going on there too. So 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.
Rafael Mangual: 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, I mean, it's no secret to anyone that it's a third rail if there is any in our national politics. And I think that requires not just a sound analytical approach, but also 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 the Obama administration's claim that the gender identity was essentially rooted in stereotypes. And what I want to ask you about is, look, I mean, I live in New York, born and raised in New York City. I have seen quote unquote “transgender” people my whole life. It's not something that's super common certainly, but I had exposure to individuals who did not clearly identify with the gender that they would have been "assigned at birth." And 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. I mean, if it's a male transitioning to an outward female expression, they have long hair and a ponytail and they wear dresses and lots of pink and vice versa. If it's the other way around, you see lots of flannel shirts and short haircuts. I mean, do you see a kind of tension there?
Leor Sapir: Absolutely. And this was one of the problems with the Obama administration's approach and more broadly, of course, with the, let's call it 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. We discussed that, for example, in the HHS report, that the term gender identity itself, which is such a key concept here, you would think that if you are proposing medical interventions, or frankly, even social interventions like social transition for vulnerable people like children, you would have 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 the people who are promoting these ideas in medicine and education, it's not just that they try and fail to define these key concepts, it's that they don't want to. 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. And when I asked them to define some of these key concepts, they thought I was just saying the most horrific thing possible. All I did was ask them to define their terms because I wanted to know what they meant. 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 how do you understand it? Or at least what have your patients told you? " And 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 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. And a lot of these court rulings, sometimes some cases, the defendants themselves would say 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 prohibited, namely stereotypes. And the judge would ... I mean, I think there's one case where the judge actually acknowledged that that was true and nevertheless ruled in favor of the plaintiff.
Rafael Mangual: 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 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 were ... It was almost like a scene out of that documentary that Matt Walsh had put together, What Is A Woman?, except it played out in real life in an incredibly high stakes legal dispute. I mean, did you catch that and what was your…
Leor Sapir: It was a quite surprising moment, maybe not surprising, but the plaintiffs were-
Rafael Mangual: Can you walk us through what that case was about first?
Leor Sapir: Oh, yes. It was a consolidation of two cases, I believe, dealing with sports. So whether states can pass laws that limit participation in female sports to females, to girls and women. And there was a moment where Justice Alito asked, "How do you define sex? What is sex?" And the lawyer, I don't think it was…
Leor Sapir: No, no, it was the plaintiff. It was the that size 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 sex discrimination, if you can't define the very term that you say is being discriminated on the basis of which. So yeah, but look, this is very kind of on brand that these terms and concepts that do so much of the work, the heavy lifting of policy and institutional change are just left completely vague or with circular reasoning. 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, because if that were the case, then a gender identity would simply be an error, a mistake. 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, 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. And so then it becomes circular, right? Gender identity is a person's sense of gender. What is gender? It's an identity. What's gender identity of sense of gender. It just goes on and on like that.
And eventually 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 is a person is a kid who, a girl, let's say who wants to play with trucks and climb on trees instead of play Barbie dolls. We were told for decades that these are pernicious stereotypes and now all of a sudden they are sacrosanct and part of some kind of innate gendered soul that must never be questioned and must be affirmed and allowed to-
Rafael Mangual: 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 two years old because he used to put on his sister's dresses. And I just thought, I mean, the idea that that is somehow not inconguous with the objection to gender stereotyping, 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 in tension with what seems to be at the root of this ideology, which is a rejection of gender stereotypes. It's like you can't have both ways.
Leor Sapir: Right, that's right. They would come back and say, "Well, it's not based on the fact that this kid wore a dress a few times or it's when they're being insistent, consistent, and persistent and saying that they really are a girl." But 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 determine the epistemological framework within which these kids are trying to understand 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, that doesn't come out organically. That's not being asserted against a 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 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. Gender identity we now know is defined in terms of adherence to or acceptance of certain stereotypes. And so it stands to reason therefore that a person who is non-conforming to their sex, and we can sharpen that even more and say to the most rigid kind of platonic ideal, or not ideal, but platonic stereotypes of their sex, is by definition transgender. So if you're a boy and you're not like G.I. Joe, the epitome of manliness, you're trans.
Rafael Mangual: So if I enjoyed the serious Gilmore Girls, I'm also trans then.
Leor Sapir: And if you're a girl and you're not like the spitting image, a two-dimensional stereotype of a Barbie doll, they're trans, by the very terms that the movement proposed.
Rafael Mangual: Yeah. I want to just key in on something that you said just a few seconds ago, which is this idea that when these kids are making these assertions that they are not actually going against the green, 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 a pansexual kid with this kid." And he said, "Well, what are the statistical likelihood given the distribution of those phenomena in society of all of those kids having those conditions within the same family is exponentially more remote than winning the Powerball." So what are the chances that that's the case versus the chances that all of those kids have an unbearably ideologically possessed mother who is imposing all of this on them?
Leor Sapir: 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 be the cues that these kids pick up through osmosis and the culture that they're in and 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. This is maybe a good place to plug our colleague college Colin Wright’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 trans boys. And we would all just shrug that off if it didn't have serious psychosocial and medical implications.
Rafael Mangual: 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, "Well, 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 kids acting in accordance with their new identity, but rather the medicalization of those claims that has lifelong consequences.
Leor Sapir: Yeah. I mean, the medicalization I think is the most obvious manifestation, or I shouldn't say manifest, but it's the most obvious way in which that identity can actually do lasting harm to a kid. But 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 to be grounded in reality that is core part of the responsibility of adults is to introduce kids to reality and to ground them in it as a condition for them becoming mature and responsible. And we also see some very serious implications. I mean, you see some of these very tragic cases of boys, young boys, almost certainly gay, who behaved very effeminately as prior puberty And they were affirmed as being girls. And once they crossed the threshold of puberty, they've never known anything else. For them, their entire world is constituted by the thought that they are girls. And they almost can't even understand why somebody would treat them otherwise. And it's a sincere thought on their part because that's how adults have been reflecting back to them the reality of who they are for years. And so the problem of course here is that nature eventually takes its revenge and reality eventually hits. And these kids, 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, everything their own parents and their teachers and all the adults of authority in their lives have been telling them is a lie. That's an extremely destabilizing thing for a kid to have to go through.
Rafael Mangual: I couldn't agree more. And 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 is the explanation for why adults are so willing to defy reality or at least tell their children that they can defy reality? What's behind that? What's driving this? Is it a fear of exacerbating underlying mental health issues?
Leor Sapir: 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 certain motives reoccur. 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 that…
Rafael Mangual: Can you just explain for our listeners what that is for those who aren’t familiar.
Leor Sapir: Munchausen by proxy syndrome is basically making somebody else who is supposedly in your care, making them sick in order to generate sympathy for you. And there is a little bit of evidence for that. It's very hard to study Munchausen by proxy. But the clinicians at the GIDS Clinic in the UK, that was 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 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 pre-pubertal children, especially boys who are effeminate, 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 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. And this is the kind of thinking that fuels, for example, how authorities in Iran think about it.
Rafael Mangual: Right. Talk about that a little bit.
Leor Sapir: Yeah. Well, we don't know much about that, or at least I'm not terribly familiar with the on the ground realities and epidemiology of what goes on in Iran. But it's pretty well known, I would say, that in Iran, sex changes not only happen, but are encouraged and even mandated by the authorities there to correct, so to speak, effeminate, mostly…
Rafael Mangual: Because homosexuality is not just frowned upon, right, but legally prohibited.
Leor Sapir: But yeah, and punishment by death.
Rafael Mangual: The argument is that rather than risk punishment for homosexuality, they allow transitions for people to sort of ... Which seems very progressive for a theocratic state like Iran.
Leor Sapir: I know, right? I mean, we're smiling and laughing, but of course it’s not funny, it's horrific.
Leor Sapir: And in other countries as well, transgender advocates like to say, oh, the hijras in India, look how much tolerance they have for gender nonconformities. Okay. But also, to some extent, this is 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 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 conformity and who all of a sudden out of the blue say I'm a really a boy or I'm non-binary and those two things are a bit different, but let's just group them together for a minute and 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, 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's going through puberty and hates herself and hates her body and all of her friends are doing the gender stuff and the parents have no idea what the girl is watching on social media. And all of a sudden she comes at them with this statement and she says, "I'm going to kill myself if you don't 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. Google “Is my daughter trans?” and 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.
Rafael Mangual: 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, which is, would you rather have a trans daughter or a dead son? Why is that?
Leor Sapir: The suicide narrative. So if we could just put a tip for just one minute, I just want to complete the thought, which is parents, 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 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 wheelhouse, not my area of expertise. Go talk to the gender clinicians. They're the experts. It's in their title." Or if they themselves are gender clinicians or ideologically on board with 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. 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 authority, educational authorities and journalistic authorities, especially if they live in these kind of 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. They trust their doctors, they trust 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 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 criticisms 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 with is the most dire, 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 a man with a white coat, a white lab coat, it very often 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, 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. 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 0.03% of all patients referred, either be currently being seen or on the wait list at GIDS. That's not, “would you want to have a dead daughter or a live 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, in the oral arguments in the Skermetti case in 2024. So that's number one. The risk is very, very low, even though it is slightly elevated compared to matching controls.
Number two…
Rafael Mangual: What would explain that slight elevation?
Leor Sapir: 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 JIDS Clinic. So even though the risk is still extremely low, it is still elevated relative to adolescents of a similar age in the general population.
Rafael Mangual: So what could be causing that if not?
Leor Sapir: That's the golden question, right? So what's responsible for this higher rate, though still very low, but this higher rate of suicidal ideation attempt and even completion? 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 matched controls with similar mental health problems, mental health comorbidities who are not gender dysphoric or not trans-identified, 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 over half, sometimes two thirds, even three quarters, 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? Is it steroids? Sorry, is it testosterone and hysterectomy? Or is it cognitive behavioral therapy?
Rafael Mangual: Right. And so, I mean, walk us through what the evidence says. Is there any evidentiary support for the claim that the kind of medical treatments and interventions being pushed by gender ideologues actually reduces that risk of suicide or mental health along some other metric?
Leor Sapir: 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, there's multiple confounding variables. For example, kids get hormones, but they also get psychotherapy.
So if they do better, and in some studies they actually do worse or their mental health stays the same, but even if you're only looking at the studies where their mental health improves, how can you know because 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. 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, or I should 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. And 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 surgeries actually cause suicide to increase. 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 this drastic and life-changing.
Rafael Mangual: 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?
Leor Sapir: Sure. So should we talk about the report? It caught me by surprise, to be honest. I was asked a few weeks after the ... Okay, so let me backtrack a little bit. January 28th, 2025, this is about a week after the Trump administration came into office.
Rafael Mangual: Almost a year to the date?
Leor Sapir: 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 very subtle and very modest in its rhetoric.
Leor Sapir: What was that? On brand. 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 Cass 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, luckily, I 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. So that was kind of one constraint. 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, 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 authors alongside conservative ones. And so 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 was 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 1st. 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 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 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. They asked them like, "Please review the report and tell us what we got wrong and don't hold back."
Rafael Mangual: 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 that others might associating with this administration to participate in this project?
Leor Sapir: That's a great question. 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 their name was known, but they saw it as a duty that 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 the 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…
Rafael Mangual: 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. What are the main takeaways?
Leor Sapir: 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.
Rafael Mangual: Yeah, I think our audience ... Yeah.
Leor Sapir: Okay. So evidence-based medicine, the core concept in evidence-based more, the core idea of animating evidence-based medicine is that there's hierarchy of information. Some information is simply more reliable than others, right? So a randomized controlled trial is much more reliable than observational studies, certainly more than a cross-sectional or surveys or clinical anecdote. So there's 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 practice, 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 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, what is the effect of puberty blockers on depression? 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 those studies to see 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.
Now, there have been 17 systematic reviews to date done on puberty blockers, cross-ex 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 simply 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've been completely unnecessary. So what we did is specifically our methodologist, our expert in evidence-based medicine and methods, 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 methodology 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, 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.
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 institution that is responsible for assessing the quality of evidence. We had them look at our umbrella review and they said, "Great, no problems whatsoever." So that's the central finding.
Rafael Mangual: What was the feedback like from the Endocrine Society and some of these other groups that have been kind of involved in pushing this ideology?
Leor Sapir: Okay. So do you want to pivot to that and then come back to the final review?
Rafael Mangual: Finish the findings of the review first. Yeah.
Leor Sapir: Okay. So that's the not surprising. What this review did that other reviews haven't done, for example, the Cass 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 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 the 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. Absence of evidence is not evidence of absence. And so what we did in a chapter of harms on harms is that we relied on our knowledge from basic physiology, human development and pharmacology, the known mechanisms of drugs. 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 Tanner stage two, right at the onset of puberty, especially boys, if you block a boy's puberty at the onset of puberty and follow up with cross-sex hormones, you're sterilizing them. Their 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 bad conditions even when they're 20 or 30 years old.
It's been said, for example, 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 study, as far as I know. So there are harms of sexual dysfunction and all of the impacts of that on quality of life, there are harms here. So that's kind of one of the key findings of this report. And 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 what is the risk benefit profile, 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, taking into account the cardinal principles of medical ethics, 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 political perspectives, but it was very important for them to not reach for some esoteric academic theory, but to rely on very well accepted, very basic, very standard principles of medical ethics. And that's exactly that. 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 the report.
Rafael Mangual: And the reaction 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 sort of scientifically sound piece of literature worth engaging. Did you get that engagement and what was that engagement like?
Leor Sapir: So the report is 400 pages long. It has a 170 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 as I said, it was very important to us and to the Department of Health and Human Services 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, "No, I'm not going to participate in the peer review process." It invited the American Academy of Pediatrics, which has, again, been at the forefront of promoting these interventions. Interestingly, the AAP within hours of the report coming out on May 1st issued a strong statement condemning the report as unscientific and all that kind of stuff.
Rafael Mangual: I don’t know how they did it. You just said it was 400 and some odd pages.
Leor Sapir: Somehow they read 570 pages within two hours or three hours and managed to digest all the information. Don't ask me how they must be. There must be geniuses over there. 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 rebuttal.
Rafael Mangual: We're going on eight months now since the report came out. Is that right? Have there been any attempts to comprehensively rebut the substance?
Leor Sapir: Yeah. So the last kind of antagonistic group, so to speak, that HHS asked was the psychiatrists, 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. 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 your conclusions are incorrect because 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 either adults or didn't concern ... I might be mixing up the three and the one, but the bottom line is they were either on adults or they didn't have anything to do with gender transition. And I think one of them actually came out after our initial report was published. And it's the same type of ...
So they clearly didn't read it. 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 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 could find all of the reviews and all of our responses to those reviews.
So 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 1st 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 on 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 medicine methods, professors of pediatrics, very well-respected and renowned bioethicist, they reviewed the report and they said it was very good. 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 people who are invested in this area of treatment, how they've responded to it, and whether their arguments hold.
Rafael Mangual: 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, what is your hope for the report's impact? What is your sense of what its impact is going to be?
Leor Sapir: 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've posed two conditions. One is I get to choose the team and the other is you don't interfere with how we write their report. We're going to produce the report and submit it to you. And 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. 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 central justification in the administration's various actions on this issue. What my hope is, is that this will help change hearts and minds within the medical community, medical and mental health communities. And that's tough. It's tough because people who are not MAGA, they understand. I get it. I'm not naive. I'm not an idiot. I get it. They say," Okay, this report was produced 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 the editorial board of the Washington Post endorsed the report. The Economist endorsed the report. It's not like prominent left-leaning intellectual organs have all unanimously condemned it, not at all. So 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 a tall order because given the Democratic Party and its incentives and 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 regulatory perspective. 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.
Rafael Mangual: 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 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?
Leor Sapir: 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. It plants that idea, but social contagion is actually a very common term. So girls who adopt what's now known as “TikTok ticks,” anorexia, bulimia, a lot of behaviors, unhealthy behaviors that are transmitted, especially among 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. 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-fold. And when you're told that previously it was a tiny number of pre-pubertal 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 consider these facts in an age of social media and the broader context of plummeting mental health among adolescents, common sense tells you that of course there's a social contagion here. Of course, transgender identity is a heuristic that's kind of transmitted from friend groups and within school districts and online, and it would be irrational, frankly, irrational to assume otherwise.
Rafael Mangual: 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. Could you do us all a favor and just define the term woman?
Leor Sapir: Adult, human, female. It's not hard.
Rafael Mangual: Yeah. Well, I hope if faces nothing else, people will take that away from this conversation.
Leor Sapir: Honestly, Ralph, I don't think… Most of the people who pretend that they can't define a 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 isn't. When they say things like, "I'm not a biologist," or, "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.
Rafael Mangual: I think that's right. Well, Leor 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. Folk 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. Leor, thank you so much, and we will see you all again soon.
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