Leor Sapir joins John Hirschauer to discuss his article from the Winter issue, “Gender Medicine on the Ropes,” and the growing legal and cultural opposition to sex-change medical procedures for young people.
Audio Transcript
John Hirschauer: Welcome back to the 10 Blocks podcast. This is John Hirschauer, Associate Editor at City Journal. Joining me on today’s show is Leor Sapir. Leor is a fellow at the Manhattan Institute where he researches education and medical policy, particularly as they relate to pediatric gender medicine. He writes frequently for City Journal and has been published in several other publications, including the Wall Street Journal, Tablet, and The Hill. He’s also testified before legislative health committees in several states. Today we’re going to be discussing his recent essay from our winter issue of City Journal, “Gender Medicine on the Ropes,” which chronicles the increasing pushback against medical sex change treatments. Leor, thanks for joining the show.
Leor Sapir: Thanks for having me on, John.
John Hirschauer: So your piece, of course is titled “Gender Medicine on the Ropes,” and that reflects a really remarkable development. I mean, gender ideology went from being the sort of thing you only heard about in college seminars to infiltrating public elementary schools in almost every facet of public life in America. And so before you delve into your reporting and the potential demise of transgenderism, I wonder if you could sketch for us the rise of gender ideology in the United States, how did we get here?
Leor Sapir: That’s a great question, and it’s a very complicated one to answer, but in very broad strokes, obviously some of this originated in the academy, in parts of the academy that are known for critical theory, but also for sexology, sex-related research, research on sex development and of course, the legal academy. In the United States in particular, the law has been a very powerful and influential instrument that the advocates of gender ideology in various forms have used in order to smuggle their concepts into a wide range of institutions, including medical ones. And I don’t want that to sound too intentional because often as is the case in public policy, you have a wide range of actors and institutions that take what they think are small steps, but what amount in hindsight to a string of events that lead inevitably to certain results that maybe nobody anticipated or hoped for. And so obviously, other institutions played a very important role too, the Democratic Party, at both the state and the federal level, as I mentioned earlier, medical associations. The media has played an absolutely vital role here in its refusal until very recently to scrutinize the claims of gender activists in a variety of institutions. So it’s always a complicated question of how we got here and the way out of where we are is going to be equally complicated.
John Hirschauer: And one of the things that you point to in the piece as potentially being a tipping point away from gender medicine’s ascendancy in the culture has been what to some might seem like an obscure document from the United Kingdom called the Cass Review. It’s something you’ve reported on extensively for City Journal in the past, and you chronicle it again in your latest feature. I wonder if you could tell our audience what that document is and what it found.
Leor Sapir: Sure. So just to give some context here, my article essentially argues that 2024 was a pivotal year in the pushback against so-called “gender-affirming care” for kids, and that we had a series of events that have really put the gender medicine industry on the defensive, and I think we’re seeing the fruits of that right now in the Trump administration’s executive orders. But the first of these events that I document in the piece, it was not the first event of 2024, but it was the first notable one that I document in the piece is the publication of the Cass Review in the UK. So this is a multi-year investigation of the UK’s Gender Identity Development Service, which is its centralized gender clinic. It was initiated in 2020 after a series of public disclosures and legal actions put this issue on the public agenda. The NHS tasked the former president of the College of Royal College of Pediatricians and Child Health, Dr. Hilary Cass, who’s a very widely respected clinician in the UK, tasked her with leading this multi-year investigation, with commissioning systematic reviews of evidence on a wide range of topics related to pediatric gender transition.
The interim report was published a couple of years ago, but the final report was published in 2024, in April of 2024. And it changed fundamentally the landscape of the scientific and medical debate over these treatments. I’ll mention a few words about why that is. So first of all, the report is very comprehensive. I mean, it starts, for example, with a few sections explaining how evidence-based medicine works, how evidence-based medicine is different from consensus-based medicine, which is very much what we have in the United States, at least on this topic, the pyramid of evidence, different levels of quality, all these kinds of things. And then it goes on to do a survey of the history of gender medicine, how we got to where we are, and then it goes through the diagnostic procedures and the care pathways, what we know and don’t know, the possible harms, different guidelines from different countries, what their strengths and weaknesses are.
So it’s extremely comprehensive. It’s a 388-page report, and the report finds that the evidence base for these treatments is extremely low, and that is due to the fact that the research that has been done in the last 20 to 30 years suffers from very significant defects, high risk of bias due to selection bias, high rates of dropout, no controls for confounding factors and so on and so forth. And of course, there’s also very, very little research on harms, which makes sense because the people who do the research are gender clinicians who are very, very adamant about its use. And so the Cass Review identifies all of these problems and says, “Look, we’ve let the horses escape the barn here. This could have been done in a more experimental controlled way,” but what ended up happening is that it was proposed as a medical experiment, and then it latched onto these arguments about human rights and civil rights, and it, so to speak, escaped the lab, to mix my metaphors. And it grew internationally in the United States and other countries to the point where now it’s offered as a routine treatment. This is the finding of the report at least.
And so Cass says the evidence base is very low, the ethical risks are very high, and recommends that these treatments be confined to experimental settings, which is where they are right now in the UK. And yeah, I mean, it was a very, very influential comprehensive report. Now, I would argue that the reason why this report is so important is because it made it impossible for journalists, especially left off center journalists in the United States, medical institutions, doctors to continue to pretend and I think by 2024, they were pretending, to continue to pretend that this is a debate between the scientists on one hand and evil conservative politicians on the other hand. That is simply false. This is a debate within the medical community, among scientists and the Cass Review makes that very clear. And so it created a new permission structure for discussion of youth gender medicine in the United States. Now, that doesn’t mean that medical groups necessarily took that as a cue to start to facilitate debate on the topic they have long avoided.
In fact, as I document in the piece, a few medical associations, specifically those associated with the American Psychological Association explicitly shut down any discussion on their listserves of the Cass Review. They didn’t even permit clinicians to mention the Cass Review for fear that it would harm their LGBT members, meaning hurt the feelings of their transgender members. Nevertheless, we saw the New York Times and NPR and later the Washington Post use the Cass Review in order to say, “This is an alive scientific debate and let’s not pretend that it’s not.”
John Hirschauer: And it was something that came in such stark contrast to the proclamations of consensus that we heard from the media and the scientific community that, oh, the science is settled. We know what works for kids who identify as transgender and like you say, it really pierced that narrative. I wonder, and I’m sure our listeners are variously skeptical of the peer review process because they are probably variously skeptical of academics in general, but how could the truth about pediatric gender medicine have basically evaded academic scrutiny for so long? How could this facade of a consensus among professionals in the field have persisted for so long?
Leor Sapir: Yeah, I would identify three institutions or three organs responsible for that. The first is medical associations, the second is medical journals, and the third is mainstream media at large, so let me just touch on each one of them. With regard to medical associations, I think this is very much a case of a broken chain of trust. And what I mean by that is the medical profession, like other professions that have a very high barrier of entry in terms of information and sophistication, relies on a heavy division of labor, meaning high level of specialization. And so doctors constantly defer to their colleagues who they perceive are specialists in a certain subfield of which they lack knowledge. And that’s how it should be. You cannot have... The modern practice of medicine requires this kind of division of labor, and thereby also trust, fundamentally, norms of trust between colleagues and between doctors and their professional associations.
And so what happened is in the mid-2010s, a number of these organizations convened committees on LGBT health. And these committees were staffed by gender clinicians so young, usually very ideologically motivated doctors who strongly believed in these interventions, which by then were still not front and center in the public debate. And they wrote guidelines, made statements, made recommendations in support of these interventions. And I think by and large, their colleagues just deferred to them saying, “You know what? I don’t know anything about this area. There must be a whole body of research. What do I know? I’m just going to defer to them.” The problem, John, is that by the time it became public knowledge, or should have been public knowledge, that these small committees led by these ideologically motivated doctors were misleading their professional associations, were writing papers based on very inaccurate, sometimes outright false citations as in the case, for example, of the American Academy of Pediatrics, it was too late. The medical associations had already said, “Our experts have spoken. Anybody who disagrees is denying science or worse, potentially a bigot.” And for them to now back down from that narrative is extremely costly in terms of their reputation and potentially also legal liability.
So the medical journals, I think, waded into this controversy, into the scandal, I would argue, potentially for understandable reasons, but it’s hard for them to back down from it because of their own organizational self-interest. So that’s in terms of the medical associations. The medical journals are critical here because they are essentially the gateways of scientific information. They’re the gatekeepers, right? They’re the ones who supposedly are supposed to tell us what types of medical claims have evidence and what kind don’t have evidence. And the problem with the medical journals is that they, leading up to 2020, they had already started to express, especially during the Trump years, they had already started to express a broader commitment to social justice. It started with race, it then turned into gender, and that meant that they were inclined to publish articles that agreed with a certain narrative and to reject articles or even criticisms of articles that disagreed with that narrative.
And that dynamic that was already underway got supercharged in the wake of the death of George Floyd in the summer of protest of 2020, when large swathes of medical profession openly and explicitly profess their commitment to social justice, in many cases above scientific rigor. So we’ve seen many examples of this from the medical journals where they just publish just garbage research stuff, that never should pass peer review, but it supports politically fashionable narrative, so they do.
And then the last thing is the mainstream media. And here you can think of if the journals are the information highways, the science journalists technically are supposed to be the policemen, they’re the ones patrolling the streets, making sure that nobody speeds. They haven’t been doing that. And you see in many of these outlets, journalists who are themselves very aligned ideologically with social justice causes, you see even very reputable magazines like Scientific American who have explicitly devoted themselves to the promotion of social justice, simply refusing to publish anything that doesn’t toe the line on, in this case, gender-affirming care, pumping out one article after the other of misinformation, refusing to fact check.
I mean, I have spoken with some of these journalists. They have called me and I walk them through the evidence. We go through some of the studies together just to make sure I hold their hand through the studies. They know that the studies don’t say what they claim they do, and then they just hang up the phone and write the article anyway, pretending that they never learn this stuff. And so this has become quite common, less so in the last year, I think that’s partly as a result of the Cass Review and some of the other events that I described in my piece. But these really are the three main factors for the manufactured consensus, the medical association, the medical journals, and the mainstream media.
John Hirschauer: Yeah, I mean, and it’s overwhelming. One thing that... So a friend of mine, Michael Brendan Dougherty, made the point a long time ago that the thing that he thought would bring down this gender medicine industry in the United States would be the inevitable legal backlash, right? People who are grappling with the long-term effects of these surgeries finally saying, “I’m going to sue the person who did this to me. I could not have consented at that age.” And in your piece, you outlined two lawsuits, one before the Supreme Court in this upcoming term, US versus Skrmetti, and another Boe versus Marshall, in which I guess we had some really remarkable revelations during the discovery phase. So could you just sketch those two cases and what their impact might be going forward on the gender medicine industry?
Leor Sapir: Sure. So there’s actually two categories of lawsuits that are really important here. There’s a third category, but I won’t get into that one. But the two main categories are lawsuits involving red state bans, meaning age restriction laws, and the second category is lawsuits filed by former patients against their doctors, these patients being detransitioners, meaning they now want to reverse the effects of the medications or the surgeries that they have received, having regretted them. So the two lawsuits that you mentioned, Skrmetti and Boe versus Marshall are both within the first category. These are both lawsuits that deal with state age restriction laws, and these are the two most important lawsuits. The Skrmetti case, US versus Skrmetti, arises out of Tennessee. It’s a challenge to Tennessee’s ban. The District Court initially sided with plaintiffs. The Circuit Court reversed that, and then the Department of Justice and the ACLU, this was the Biden Department of Justice, appealed to the Supreme Court, which agreed to grant cert to hear the case on the relatively narrow question of whether this law violates the equal protection clause.
So there, we’re likely to get a good ruling. Is it going to be 6/3, 5/4? Unclear. Nothing is guaranteed. The court could surprise us all inside with the ACLU and the Department of Justice, assuming the Trump administration leaves its predecessors legal position to stand, which by the way, I hope they do. But that’s the Skrmetti case. And the outcome from Skrmetti will essentially settle the legal battles over the 26 red state laws that impose restrictions on minor access. And it’s also going to have, of course, ramifications for the new executive orders issued just the other day by President Trump, which also seek to restrict access to these interventions in various ways. The Boe versus Marshall case from Alabama is probably the most significant legal event in the last five years. I would argue that that lawsuit is the biggest mistake that the gender medicine industry ever made, is to file a lawsuit against Alabama.
Because what happened there is that due to the sophistication and really a good preparation on the part of the Alabama Attorney’s General’s office and the law firm, Cooper and Kirk, that they were working with, they managed to get the judge to authorize disclosure, a subpoena basically, of internal communications from the World Professional Association for Transgender Health or WPATH. WPATH is the organization whose standards of care shape the entire field of gender medicine, both for minors and adults, and the Biden administration, the ACLU, all the medical associations were essentially arguing in the legal context that WPATH sets the tone. So Alabama comes along and says, “All right, well, let’s see how the sausage is made. Let’s see how you came up with these guidelines. Show us your work.” And so a massive amount of information was disclosed, I think it was up to 2 million emails or email communications.
And what was uncovered was really the smoking gun evidence of a massive medical scandal. I mean, I won’t get into too many details, but just to tease the audience, I mean, WPATH commissioned systematic reviews of evidence and then suppressed them when it learned that it didn’t yield the result that it had wanted. It consulted what it called “social justice lawyers” to help it shape its medical recommendations in order to make them politically and legally palatable. It only enlisted people with significant conflicts of interest, both financial and intellectual to write the standards of care, and only people who were in advance committed to the medical pathway and on and on and on. I mean, all this information came out of the Alabama lawsuit, and of course it’s going to serve us very well for the few years ahead. So those are the two lawsuits most important in the field dealing with state age restrictions. With regard to the medical malpractice lawsuits filed by detransitioners, there’s roughly 20 in existence right now.
Some of these are very high profile, some of them are less so. These are very difficult to win, and that is simply because judges have to ask the question, what is the standard of care? And they usually get the answer to that question from the consensus of medical groups. So the big challenge in these lawsuits is to get judges to second-guess that consensus and look behind the curtain and see what exactly is the basis for that consensus and why it differs so dramatically from what’s happening in other parts of the world.
John Hirschauer: You mentioned President Trump’s executive order. Sometimes it’s funny, I think when I read the executive order and I saw that it was the official policy of the United States to affirm that there are only two sexes, male and female, I imagine explaining that to my grandfather 10 years ago or 20 years ago, and the look on his face when I would say that. But I’m curious what you make of the executive order. How do you think advocacy groups are going to respond and mobilize? Is there anything they can do? Does the order go far enough? What are your thoughts?
Leor Sapir: Yeah, I mean, so there have been a few executive orders touching on this issue, right? There’s the executive order, I think that came out day one, defining sex in the way that we all understand it to be, and that’s scientifically accurate. There’s the executive order on prisons, there’s the executive order on gender medicine. So there’s a number of them, and there’s going to be more. But look, I mean, the bottom line is these are executive orders. There are essentially instructions to the federal bureaucracy. So they don’t necessarily merit challenge on its face. It could be that legal groups, it seems like, legal groups are planning to challenge every aspect of them, but only when they’re actually translated to rules or policies. So we already have, for example, a lawsuit over the prison executive order, the prison part of the executive order, and lawsuits about the youth gender transition, of course.
So yeah, all of these things are going to get challenged in the courts. And I want to say your guess is as good as mine in terms of what the outcome of those lawsuits is going to be. I think the Skrmetti case is going to shape the legal environment to a very significant degree, which is why I really hope the Trump administration doesn’t back out of that lawsuit. But other lawsuits are going to get at this issue with judges trying to do everything in their power to avoid weighing in on these scientific issues, because of course, judges are lawyers in black robes and they know that they don’t have any special authority to weigh in on scientific debates and so they will use, and lawyers will, crafty lawyers will offer them any plausible excuse to rule on a case without having to pretend that they are scientific authorities on something. That is one of the challenges of making policy through the courts in the United States, is that you’re essentially asking lawyers to settle scientific debates when they really don’t want to have to do that.
John Hirschauer: So final question here, as someone who’s edited your work, followed your work, really appreciated your work, I’ve always been interested in your approach to this issue, which I mean, again, obviously been tremendously effective. You engage with these gender medicine professionals on their own terms. You read the studies, you delve into the literature. You point out how the science really isn’t on the activist side, and obviously, I mean, there’s a lot to be said for that, but sometimes personally, I wonder why even go there? A man can’t become a woman as a matter of principle, and we’re dealing with something that no randomized control trial or white paper finding is going to change. And so I’m just curious why, and you’ve obviously had so much success, why you think it’s so important to engage with the gender medicine literature when in effect we’re really talking about something that’s entirely fictitious?
Leor Sapir: Yeah, I mean, it’s a great question. I guess one answer is because science remains the best way for human beings to try to discover truth. And so if we have a good sense that truth is on our side, if we want to rely on our intuition and say, “There’s only two sexes, male and female, it doesn’t matter how you identify, you’re still only one or the other,” that’s great but precisely, if we believe that science is the most powerful tool yet conceived for humans to discover truth, we should not be shy, not be afraid to use scientific reasoning, scientific analysis, scientific debate to clarify those truths. But I think, of course, from a more strategic perspective, I don’t want gender medicine to go the way of abortion, where it’s a red versus blue issue, it’s just a matter of philosophical differences. And then some states will do this, and other states will do that.
No, the default in medicine is you don’t cut into somebody’s body, you don’t give them drugs that disrupt their endocrine systems unless you have plausible evidence that doing so is net beneficial. And so the burden of proof is on those who propose interventions, and they are the ones who have to carry that burden of proof through rigorous well-controlled, well-conducted studies. Well, if you have doctors claiming and medical journals claiming that they have done that research and they have found that these drugs and these surgeries work, that they are net beneficial, that the benefits outweigh the risks, that’s going to be compelling to people who care about science, to policymakers, to elites, American elites. And so that argument needs to be engaged on its own terms. We can’t just wave it away and say, “Nope, we’re just going to use the power of government to shut this whole thing down,” because you are not going to settle a scientific debate by exercising power alone. Power is important and it needs to be exercised in the right way, and we can definitely use the levers of government to advance scientific arguments. But at the end of the day, this debate needs to be settled in the arena of science and medical ethics.
John Hirschauer: Well, thank you Leor for that, and we really appreciate you coming on taking the time on the 10 Blocks podcast today.
Leor Sapir: Thank you.
John Hirschauer: Check out Leor Sapir’s work on the City Journal website and his remarkable essay, “Gender Medicine on the Ropes,” in the most recent print issue. You can find those on his author page, which we’ll link to in the description. You can find Leor on X @LeorSapir. You can also find City Journal there @CityJournal and on Instagram @CityJournal_MI. If you like what you’ve heard on today’s podcast, please give us a five star rating on iTunes or wherever you listen. Leor, again, thank you.
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