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[RUSH TRANSCRIPT BELOW] One of the first executive orders President Donald Trump signed after his inauguration last January was titled “Protecting Children from Chemical and Surgical Mutilation.” The order directed the Department of Health and Human Services (HHS) to produce a systematic review of pediatric transgender procedures and their impact on children within 90 days.

In May 2025, HHS published a more than 400-page review, titled “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices.” In November last year, an updated, peer-reviewed version was published with additional appendices and supplements.

Leor Sapir, a senior fellow at the Manhattan Institute, is one of the report’s main outside co-authors. In our in-depth interview, Sapir provides a detailed overview of the review’s findings and conclusions.

“We tried to be as factual and defensible as we possibly could,” he said.

The goal of the report, he says, is to “engage with people in the medical profession who may not be aligned with the administration, but who do care about questions of medical evidence and medical ethics.”

– The prevalence of sex-changing procedures in the United States, as well as the reversal in approaches in various Scandinavian countries and in the UK.

– How misleading and unscientific language was used by professionals across many fields to promote pediatric sex transitioning.

– The role of the organization, World Professional Association for Transgender Health (WPATH), in establishing “gender-affirming care” as the accepted standard.

– How clinicians, in his view, distorted the principle of patient autonomy to increase pediatric sex change surgeries.

There is one chapter in the report that everyone should read, Sapir said. And that is the chapter about ethics.

“The question on everybody’s mind is: Should we do it? That’s an ethical question. And medical ethics is, you would hope, [what] governs the field of medicine,” he told me.

Views expressed in this video are opinions of the host and the guest, and do not necessarily reflect the views of  NTD.

RUSH TRANSCRIPT
Jan Jekielek:

Leor Sapir, such a pleasure to have you on American Thought Leaders.

The term sex-rejecting procedures, it’s one that I hadn’t heard before, but it kind of makes a lot of sense to me. Where did this come from? It’s now largely used, actually, in this lexicon, particularly by HHS.

That’s right. The administration adopted this term in the last few months as an alternative to, certainly, as an alternative to the standard term in the field, which is gender-affirming care. Gender-affirming care is a euphemism, and it is essentially a marketing term. And so it was clear to the administration, in my view, that they didn’t want to use this term. There were a few other candidates, sex trait modification being one. But sex-rejecting procedures, the advantage of the term is that it conveys the intent behind the use of puberty blockers, cross-sex hormones, and surgeries to treat a condition known as gender dysphoria. And the intent is to reject one’s sex.

You played a significant role in this recent HHS [U.S. Dept. of Health and Human Services] report, which many people describe as groundbreaking and others really dislike. Tell me a little bit about this report and what it brings to the table that’s new, especially here in the U.S.?

The HHS report, Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices, was done pursuant to an executive order signed by President Trump in his first few days in office. The executive order tasked the Department of Health and Human Services to produce this report within 90 days. I got the phone call. I was asked to assemble the team and produce the report and deliver it on time. By the time we got going, we essentially had about eight or nine weeks to produce this report. By contrast, the Cass Review in the UK, which is the comparable review that was done and published in 2024, had four years. So we were working under a very, very tight deadline.

But luckily, I was able to recruit very, very good experts—medical doctors, bioethicists, researchers, people who know the field like the back of their hands and understand the principles of evidence-based medicine very, very well. They’re also well-published with a lot of scholarly articles. And so we were able to produce this report. It came in, I think, clocked in at just over 400 pages. We had a 170-page appendix with all of the data tables from our systematic review, which I’ll talk about in a minute.

Its central findings were substantially similar to those of every single systematic review done to date on this issue, which is that the evidence for benefit from the use of puberty blockers, cross-sex hormones, and surgeries as a treatment for gender dysphoria in minors is of very low quality, meaning there’s profound uncertainty about whether these treatments help.

At the same time, the evidence for harms—and this is one of the novelties of our report—the evidence for harms is stronger. And so one of the things that you have to do, of course, in medicine, especially with novel treatments, is you have to try to figure out what the risk profile, risk-to-benefit profile is. And one of the things that our report does for the first time in the context of a chapter on ethics is to try to balance the known benefits or lack of certainty of benefits against the higher certainty of certain types of harm.

You know, it’s interesting as you were describing, you know, you’re saying, you know, puberty blockers, surgeries. I kept thinking gender-affirming care, gender-affirming care, because I’ve been, you know, that’s the term that we’ve been using. And I always would say it in quotes because it’s not clear that it is care, I suppose, is the reason. But now, is the approach to try to get these sex-rejecting procedures to become the standard lexicon?

So we actually don’t use the term sex-rejecting procedures in the report. We use the term pediatric medical transition [PMT]. So that’s the term that we chose to use. There’s a reason behind it as well. This report was written in a style, in a tone that is markedly different from how the Trump administration has been talking about these issues. Partly, that’s a reflection of the fact that we are not partisans. And we are, you know, most of the authors of the HHS review are actually liberals who have voted Democrat their entire lives.

I would say most of it is motivated by the fact that we want to appeal to, and we want to engage with people in the medical profession who may not be aligned with the administration but who do care about questions of medical evidence and medical ethics, who care about, who may be interested in the history of this area of medicine and the clinical realities. We have a whole section of the report that talks about clinical realities and how this area of medicine actually operates in the United States and what’s been happening abroad and why. So the report is written in a tone and in a style that is trying to avoid being partisan, and really trying to just stick to the facts and look at the issue from a really neutral perspective.

So bottom line, now you’ve done this, the newest, I guess, systematic review. The bottom line is, what benefits are there?

First of all, what we did is not exactly a systematic review. It’s called an umbrella review. An umbrella review is a systematic review of systematic reviews. It gets a little bit technical, but I think that these details matter. So, in evidence-based medicine, you basically have what’s called a pyramid of information or a hierarchy of information.

At the very bottom, you have anecdotal case reports and the expert opinions of doctors. Those opinions may be based on their own experience treating patients, but they’re not based on systematic observation. If you go higher up the pyramid, you start getting cross-sectional research, you get observational research, uncontrolled observational research. At the top of the pyramid of research is, of course, the randomized control trial, of which none exist in this area. Then, at the very top, at the very pinnacle of the hierarchy of information, you have systematic reviews.

What a systematic review does is look at the entire body of evidence for a particular question, such as do puberty blockers cause mental health improvement and various metrics. They try to not only summarize and synthesize all the available evidence, but they also score it. They try to grade it. Is it credible? Is it not credible? What are the factors that determine that credibility? There have been many systematic reviews done on these questions in the last five or six years.

The first country to really do it was Finland in 2019, followed by Sweden and then the UK. Every single time a systematic review was done on this question, the answer came back exactly the same, which is that the evidence is of very low certainty because the studies are methodologically very weak. They’re incapable of determining a causal link between the use of these powerful drugs on the one hand and mental health outcomes on the other.

By the way, the outcomes are not always positive. In many of the studies, you see that the outcomes are mixed. In some studies, you actually see that the outcomes are negative. So, we did an umbrella review. Because there are so many systematic reviews, we didn’t need another systematic review. We needed to look at all these systematic reviews and score them for methodological quality. That’s what we did in this report. Just to get the details out there, because I think they’re important. So, we did an umbrella review.

Well, the bottom line is that there is no credible evidence that puberty blockers, for example, address anxiety, depression, suicidal ideation, and that they’re not needed to address those conditions. Now, you know, you also need to think about what the risks of these drugs are. And part of the problem in this field, in the field of gender medicine in general, and pediatric gender medicine in particular, is that the people who do studies in this area are typically gender clinicians, people who are invested in this type of practice, who believe in it for very, you know, sometimes very ideological reasons, sometimes financial reasons. Sometimes they have reasons, sometimes they just believe that they’re helping kids. And I think their belief may very well be sincere.

But, you know, we have plenty of evidence that these studies don’t try to track harmful outcomes. They’re usually very short-term. They have very high dropout rates. Even when the researchers are interested in registering and looking at potential harms, for example, the lack of bone density accrual or cognitive impacts or cardiovascular events, they don’t end up following up. They don’t end up publishing the results.

So to give one example, in 2024, the New York Times reported that a major NIH-funded study, $10 million, the lead researcher in that study, Johanna Olson-Kennedy of Children’s Hospital Los Angeles, or I should say formerly of Children’s Hospital Los Angeles, had the mental health outcomes from puberty blockers in the kids in her study, and she chose not to publish the results because they were unimpressive. And so she told the New York Times, I didn’t want this to be used by critics of this area of practice, to be cited by them. So she just didn’t publish the results. So this is fairly characteristic of the field. It’s dominated by clinicians who are deeply invested in this type of practice, and so that results in all types of biases and distortions.

And you can imagine, you know, the study design also is something that I did once in my life, and I was sort of struck by how easy it is to design studies to go in the direction of your favorite outcome to get closer or something like that. So I imagine that most of these studies, based on what you’re telling me, must be sort of set up for particular outcomes. And if they don’t get them, it’s almost like that itself is evidence, might be evidence. I’m just hypothesizing here, of course.

Yes. So just to give an example of what you’re talking about, one study that was published a few years back on the outcomes of mastectomy in girls, actually it was also led by Johanna Olson-Kennedy.They developed this tool for measuring outcomes. They called it the chest dysphoria tool. Basically, when you look at how they conceptualize chest dysphoria, it’s about whether you like the way your chest looks now after you’ve had a mastectomy. They asked all these girls a few months after they had the procedure, do you like how your chest looks now? Naturally, most of them said yes.

Okay, but what does that tell us? What does that tell us about their long-term mental health outcomes? What does that tell us about what’s going to happen when they’re in their 30s and they want to breastfeed and they can’t? Are they still going to be happy with their decision then? This study has no ability to give us any of that information. But, of course, the study’s results were applauded and spun as evidence that these procedures are medically necessary. So that’s a good example of what you’re talking about. You can design a study to show you something that you want it to show in advance.

Something that struck me about this report was that, I mean, I think you’re able to show that there’s a lot of misleading information being shared with parents systematically. I don’t know if that has been convincingly shown before.

It has definitely been shown, but I would say that it hasn’t been summarized in a way that’s accessible to both the medical community and lay readers, as we tried to make it. Sometimes that information is distorted, exaggerated, or misrepresented. We tried to be as factual and defensible as we possibly could. Just to give two examples, chapter two of the report has this whole introduction section, which discusses, after a brief introduction, the incidence and prevalence of these procedures. We discuss what’s been going on abroad, including the practice reversals in various Scandinavian countries and the UK.

One of the chapters in that section deals with language. We discuss how the core concepts that define this field are unscientific and misleading to patients, and in the case of minors, to their legal guardians, their parents. sex assigned at birth is an extremely common term in this field that pretty much every gender clinician uses. Sex is not assigned at birth; it’s determined at conception and recorded or observed at or typically before birth very accurately, with almost perfect accuracy. So sex is not assigned at birth, and to tell patients consistently in a medical setting where figures of authority wearing white coats come into the room and tell parents the sex that you thought your daughter or son is, is not their true sex, is fundamentally unscientific and misleading.

If you add to that the other core concept of the field, gender identity, another term that is ubiquitous but lacks a scientifically valid definition. It relies either on circular reasoning. A gender identity is a person’s internal sense of gender. What is gender? It’s an identity. That’s circular reasoning, right? Or it relies on stereotypes. A gender identity is, you know, your innate sense of wanting to be or be more masculine, be more feminine, according to socially accepted stereotypes.

If you tell parents that their child has this innate, immutable, gendered soul, and that, you know, they’re always going to have that soul, and it’s a real gendered soul, and that their actual sex is assigned, meaning it’s a social construct, and then you present them with medical options, irreversible hormone and surgical treatments, you are misleading parents and patients about the nature of their condition.

So we discuss some of these issues in a way that I think hasn’t really been done yet in a systematic, scientific manner. The other example I would give is in the section on clinical realities. This is part three of the report. We have one chapter there, chapter 10, where we summarize everything that we have discovered about the World Professional Association for Transgender Health [WPATH], which is kind of the trendsetter in the field. This is the organization whose recommendations it calls its recommendations the standards of care. The eighth version was released in 2022.

This is the organization whose recommendations are adopted across U.S. health care settings. Insurance companies kind of defer to its recommendations for what is and is not medically necessary. The Biden administration inscribed WPATH’s approach into its own policies. Hospitals follow it. And, of course, gender clinicians follow or claim to follow it. But in any case, WPATH, when it was developing its latest standards of care, commissioned systematic reviews of evidence, and when it discovered that those systematic reviews were not going to show what it wanted them to show, which is that there’s credible evidence of benefit, it suppressed their publication.

We know that because in a lawsuit in Alabama, WPATH was ordered by the court to turn over all internal communications that it had between its own clinicians and leadership related to the development of its standards of care. And it’s right there, clear as daylight. You see the clinicians admitting that they are suppressing evidence. You see them admitting that they are eliminating age minimums for hormones and surgeries due to political reasons, for political pressure. And a bunch of other things, like failure to manage basic financial conflicts of interest.

All of this has been public information. It was reported in the New York Times and The Economist. This is not some conspiracy theory. It’s right there for everybody to see. You can actually see the court documents. So we summarize all of these findings and kind of discuss their significance in Chapter 10 of our report.

And because of how ubiquitous WPATH is, and because of how much U.S. health care relies on WPATH, I think there’s a plausible case to be made that this is simply a case of medical fraud. Any patient who has consented on behalf of, or I should say, any parent who has consented on behalf of his or her child to these medical interventions when the doctors follow WPATH or claim that WPATH is the authority that publishes credible guidelines has fundamentally been misled if they’re not aware of the suppression of evidence and those other elements. So those are two examples of how, yes, fraud is not just a feature, or I should say it’s not just something that happens in this field. It’s almost fundamental to the field itself.

It is simple, but you have to make the case for it. You have to reason your way through it. You have to show the evidence. You have to discuss. Here’s another example. Medical societies say that these treatments are evidence-based and safe. What are they basing that on? We show in our review how groups like the American Academy of Pediatrics [AAP] and WPATH and the Endocrine Society cite one another’s guidelines as evidence. So there’s this kind of circular citations, and you might call it credibility laundering.

WPATH, actually, in those internal communications, its members explicitly discussed the importance of getting actual bona fide medical associations like the Endocrine Society, the AAP, and the American Medical Association [AMA] to endorse its guidelines, to give it the appearance of a credible medical guideline. Interestingly, not a single medical group agreed to do it. They simply didn’t criticize WPATH guidelines, but they didn’t endorse them either. But nevertheless, this is how this area of medicine operates. Everything is very secretive, behind the scenes, and by the time things come to light, there’s this kind of appearance of a consensus within the medical profession.

In Chapter 12 of our report, we also provide lots of evidence of how medical societies internally suppress dissent and questioning from their own members.The Endocrine Society has done this. The American Academy of Pediatrics has done this a lot over the last few years. Any time pediatricians would say, why aren’t we relying on systematic reviews of evidence? Why aren’t you, the leadership, allowing debate on this topic at our annual conferences? They would then find all of these clever, technical reasons to kill those resolutions, to suppress those questions and to marginalize and sideline the clinicians who say, we need to take a more scientific look at this.

So I was about to ask you about this, actually, because your report has been criticized by a number of groups, WPATH, and a number of professional organizations which have significant reputations in society and set a lot of effective guidelines for, for example, pediatric medicine.

Right. So the American Academy of Pediatrics criticized the report within hours of its initial publication in May. This is a 409-page report accompanied by a 170-page appendix with lots of data tables. I’m a little bit unsure that they were able to read the entire thing and really go through it and fact-check it within two or three hours. In fact, I’m confident that they did not.

What’s interesting about this report is that because of our very short deadline of 90 days, from the beginning, the plan was to have an extensive peer review process after the initial publication on May 1st. In the peer review process, our goal was to invite our strongest critics; the American Academy of Pediatrics, the Endocrine Society, and the American Psychiatric Association [APA] to review the report and tell us what we got wrong. What mistakes did we make? That’s what peer review is supposed to be all about.

The American Academy of Pediatrics, despite criticizing the report within hours of it coming out, initially agreed to do a peer review. And then at the very last minute, they pulled out. They just said, we’re not going to send you the review. The Endocrine Society from the beginning said, we’re not going to review it. The American Psychiatric Association, to its credit, agreed to review the report, but they overlooked the entire section on evidence.

They said, you didn’t disclose what your methodology is, even though it’s right there in the appendix. And they gave us a list of 16 studies that we failed to include or evaluate in our report. Twelve of those studies are not just explicitly included in the report. In some cases, we have elaborate discussions of those studies in the report. So clearly, they didn’t read it. And of the remaining four, the remaining four were either on adults, in which case they are irrelevant to pediatrics, which was the topic of the report, or in one case, it wasn’t even on gender medicine.

And because we didn’t get feedback from the AAP and the Endocrine Society, we said, we want to steelman this. We want to respond to the best available, the strongest possible criticism of our report. So we took two published critiques, published in peer-reviewed medical journals that kind of went point by point from our initial report. And these two papers were written by about two dozen of the top gender clinicians in the United States.

And we responded to all of their points, point by point, and showed why they’re simply mischaracterizing our findings; they’re overlooking very critical details. As I’ve been saying to people, don’t take my word for it. Go and read the supplement. There’s a document called the Supplement to the HHS Report. It’s on the HHS website, and that is where you can find all of the peer reviews and all of our responses to the peer reviews. It’s not that long. And so, you know, I’ve been telling people don’t take my word for it; go and read it, and you tell me who has the better argument.

But look, in addition to those three responses, the APA and the two peer-reviewed articles by the gender clinicians, we also got peer reviews from about half a dozen other experts who had a very positive assessment of the report. This includes a former president of the Endocrine Society. He’s a professor emeritus at the University of Virginia, and he said the report is overall solid. He specifically reviewed the section on all the harms that are likely to result from endocrine interventions, and he said this is a solid report.

We had two experts from the Belgian Center for Evidence-Based Medicine in Belgium, which is kind of its leading institution for ensuring that its own medical practices are based on the best available evidence. They reviewed our entire umbrella review of the methodology, that 170-page appendix. They said that our findings were robust and transparently reported, and they found no problems with it. We had a professor of pediatrics give a very favorable endorsement. We had a really prominent bioethicist say that our ethics chapter, which we should probably discuss because that’s another really important innovation in this report, was really, really good.

So with the peer review process, the bottom line is nobody was able to identify any significant errors in the report. There were a few minor errors that were pointed out, and some of the reviewers actually said we didn’t go far enough in criticizing certain practices in the field. So again, I encourage people to read the supplement and really see for themselves what were the criticisms made of the report and do those criticisms hold up.

Before we end up talking about ethics, I’ve looked at the report. I haven’t read it cover to cover, you know, appendix and so forth. But I am roughly familiar with the body of literature. I know which direction it goes. I appreciate you demonstrating that in this umbrella way, which is that that’s a very interesting distinction that I hadn’t fully grasped until you just talked about it. But major important medical institutions in this are deeply committed to saying that what you did is wrong and problematic. What’s going on?

Okay, so first of all, it’s three or four of the medical groups that have said that, right, out of dozens.

But incredibly influential and important ones.

Sure. There’s one medical organization called the American Society of Plastic Surgeons [ASPS]. It’s the largest medical group that represents surgeons. They actually, in 2024, broke ranks from other medical groups and said, no, actually, these practices are not supported by evidence. We need to rethink this. So that’s, I think, important to note as well. But if you’re asking specifically about the AAP, the American Academy of Pediatrics, the Endocrine Society, and WPATH.

WPATH is the easiest to explain, right? It’s an activist group that wants to present itself as a medical organization. By the way, a lot of its members are not even medical professionals. They can be lawyers. They can be just activists and advocates. But it’s an organization that’s devoted to promoting the medical model, eliminating any safeguards, any mental health assessments, and making sure that all of this can be obtained on the basis of insurance coverage.

But with regard to the AAP and the Endocrine Society, to some extent it’s anyone’s guess. I think it’s a combination of ideological commitments and sunk costs. Once these organizations committed themselves to the practice, even if they committed themselves out of good faith and trust in people they thought were experts, once they’ve committed themselves to this, because of the nature of these procedures, you’re talking about powerful, irreversible drugs and surgeries on kids. It’s very difficult for them to say, oops, we got this one wrong, even if they actually come to that realization. I think a lot of what’s going on in these groups…

Isn’t it harder to double down? You’re right, it’s hard, but doubling down seems somehow harder.

Well, I think it’s a matter of short vs. long-term incentives. So just to give an example, the presidents of these organizations have a tenure of one year, maybe two years. And so from their perspective, it’s probably easier to just kick the can down the road and let the next guy deal with it. So that’s one possibility. The other is what some of us call capture by committee, which is a phenomenon that we see in Congress. It’s a phenomenon that I think exists in any large corporation.

And that is when you have a small group of highly motivated, kind of ideologically cohesive activists within a particular committee or institution within an organization, and they promote one particular viewpoint. And those who prefer a different viewpoint are diffused; they’re not as organized, they’re not as motivated, maybe they’re looking at or thinking about other things, or maybe they’re afraid of sticking their necks out, as is the case in this area. It’s always the first group that’s going to prevail.

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