EP 150: The Consumerism of Gender-Affirming Care with Leor Sapir

hi Stella hi Sasha uh i' I've been I've been told by our producer we should say our names and I've been actually avoiding saying your name for the last few weeks I have a secret so I'll tell you why well I realized with a shock and a horror that I'm kind of mispronouncing it because I you say Sasha well I just realized everybody American says Sasha as if it's an O So Lisa says hi Sasha everybody says Sasha and I say Sasha oh you Sasha and I just realized I'm mispronouncing her name because actually because I I remember it was a few weeks ago you call you said your name and I went oh is that how you said Sasha not Sasha so yeah I've been avoiding it so this is my little confession hey podcast co-host how are you well I I will reassure you that actually you can pronounce my name that way and as a matter of fact I'm thinking my father pronounces my name Sasha and my mom pronounces it more like Sasha and then some people say Sasha with like an oish sound so I think it's fine and if we have well first of all I mean most listeners will now know I am not Russian but my name is Russian that's right so if we have any Russian or Eastern European listeners who can correct us I believe the pronunciation in that part of the world this Sasha my way Sasha Sasha Sasha I think so Sasha it's so interesting because it came from my you know I often uh would be talking you know Carrie Mendoza and I call her Carrie and my husband was calling her Carrie and I was laugh at him I said that's like call him somebody Gary Gary not Gary it's Carrie Henry and I was I was completely full of myself Carrie and then Carrie said well it's Carrie and I was like oh so I like Carrie and Sasha I can call them Carrie and Sasha anyway that's I love how it sounds coming out of your beautiful accent so fine with it a stronger accent than I certainly thought anyway how's your life been Sasha my life has been well it's been good and uh yeah I really don't have too much to report I mean what I would have reported was a piece of news that came out towards the end of our podcast with leor about my deep dive into the memory ho podcast and repressed memories and the unbelievable number of parallels with what is going on today so when we talk to leor we end up discussing that and then that kind of also shifts into our um substack listener Community kind of exclusive content so it it was a great conversation and that's been on my mind a lot what what about you you have some updates and stuff going on your world I I listen to that podcast too I really recommend it to people really really interesting sad though it's a sad you know very good reflection of how especially girls can get caught up in a contagion and they can feel so serious looking for meaning and purpose looking for for often looking for a reason for distress that it's so easy to get caught up in um so yeah highly recommended looking forward to your videos and um I I I think there's so much going on it it makes me dizzy but we are at the moment collecting any submissions for dtrans awareness day so if any D transitioners or anybody who's been harmed by medical transition D awareness day it's very interesting it's only about three years old and it's on the 12th of March and um you know we've we've each year we've kind of let out different bits of material just to kind of raise awareness for D transitioners and people have been harmed by where do people go how do how do they they if they emailed info at J .org we'll we we take it from there but any sort of submission we pay a fee for anybody who wants to submit something and it gets published on D awareness day and we really try and help people they don't have to do it with their name attached they could just send an essay in or do a piece of audio there's lots of different ways you could submit a piece anything to raise awareness for it we already have a couple of kind of anyway you know things planned so you know it's it's just an extra yeah I we make sure to put that in the notes so that people can easily find the links and it's you know it's a while away from now but it's important to know that these events are coming anything to raise awareness to what's going down at the moment we can do our little bits with retweets and hashtags and stuff like that but today's conversation is with leor sapir we we had him on about 18 months ago and he was fascinating and he was fascinating yet again today really really good yeah so he's a researcher in political science um and he's you know the the best person really to talk about the way policy and legal changes stuff that feels very I guess like unsexy and behind the scenes because you know we talk about the cultural piece we talk about the media and that has a really kind of um glittery facade that it's easy to see but Lear is really good at explaining the way behind the scenes policies or like subtle changes in language of a law or a bill or whatever can have these Ripple effects and it's super interesting and today we talked about a lot of things including kind of like the the relationship the medical ethics relationship between consumer and doctor and institutions and the way especially in gender medicine every person in that kind of relationship keeps kind of dodging responsibility and leor points out that ultimately gender affirming care puts the onus on the patient even if the patient is only like 9 or 10 years old it was a really interesting discussion when we touched on that yeah yeah it was really really good yeah we um we talked a little bit about the bands uh here in the US and kind of Leo shared some of his thoughts about the way medicine is regulated so it was a broad ranging conversation we hope you will enjoy it and if you want to go back and listen to Lor's first episode it was episode 88 in September of 2022 ages ago so uh shall I read Lor's bio and then we'll jump in yeah leor seir is a fellow at the Manhattan Institute in his work Dr seir applies his research and academic experience to policy matters concentrating on issues of gender identity and transgenderism his inaugural essay in City Journal in the winter of 2022 explores a series of recent court rulings on transgenderism demonstrating how how bad ideas translate from Fringe academic theories into law and policy previous pieces for City Journal explored the evolving athletic guidelines and media coverage surrounding trans issues we hope you enjoy our very interesting conversation with Dr leor seir hi I'm Stella omali a psychotherapist in Ireland and I'm Sasha aad an adolescent therapist in the United States and this is gender a wider lens a podcast dedicated to the Shi in Concepts around gender in our contemporary culture through in-depth interviews personal stories and psychological exploration we seek to open up the discourse around this hot button issue join us as we look at gender from a wider lens hi Stella and welcome leor hi thanks for having me again glad to have you back you know so recently as as of recording this this conversation uh New York Times published a piece by Pamela Paul talking about um youth gender medicine and d transitioners uh I was interviewed for it s several other people we know of course were as well and I wanted to talk a little bit about that because it feels like a really big deal for the New York Times to publish something with this much kind of clarity about gender medicine and so you had made a tweet Thread about it kind of highlighting things that you thought Pamela Paul did well and then also a flaw that you had seen in the piece so I'm wondering if we could start there could you kind of like summarize what you uh were talking about in that tweet thread yeah I mean I think one thing to say just off the bat is um I think it's unfortunate that some of the New York Times best reporting on this issue has come in the opinions in the opinion section yeah I mean that that seems to be a point that you know activists who who were um outraged by the piece have latched on to that this is an opinion piece and not investigative journalism I think anybody involved in this piece from what I've heard you know the D transitioners that anybody who was interviewed um had to hand over uh mounds of documentation and evidence uh pamel Paul really went out of her way to make sure that her claims were defensible probably anticipating that you know they would get torn to shreds by activists online so um so the piece is actually deeply researched and I think it belongs honestly as an investigative piece regular reporting for the New York Times um but you know having it as an opinion piece I think also allows the New York Times to um to broach the topic in a slightly more critical way without really saying that they're broaching the topic um and could could we just say for anybody who hasn't read uh the New York Times and you know people from this side of the the pond what it was about you know if you could just say what the what what the piece was about cuz it it was a game changer right I mean the piece was ostensibly about D transitioners um and it profiled I think four D transitioners um but it used their stories as as a way to um to explore some of the um deeper questions and the research and the evidence or lack thereof Behind these um these interventions and so uh you know um uncharacteristic for an opinion piece uh um Pamela actually uh does site some of the research in there um she she goes into some of the uh you know what we do and don't know with regard to um regret detransition desistence things like that and it's a very measured moderate piece um you know not perfect and we can talk about that in a minute but but much better than um almost anything we've seen in the New York Times including you know the times have has had um two or three pieces in the last last few years that have also generated out outrage among activists um that for example called attention to the um uncertainties and potential harms of puberty blockers um but as is usual with these pieces they kind they they tend to miss the forest for the trees um and they they underplay the uncertainties and risks and they you know they kind of genuflect and say things like you know what most medical associations agree without really giving us the context of what that agreement is based on without really doing a deep dive into you know what evidence are they citing and whether it's credible um they they've barely touched on changes abroad um which I think is a is a a real Point against the New York Times is that it's you know with with a few exceptions it's by and large ignored the fact that the United States has become um maybe with the exception of Canada an outlier in this area of medicine um um and so you know pieces like the one that we saw from Pamela Paul are are a welcome addition to the reporting New York she did she did highlight the difference between the way the European countries are moving what direction they're moving and the US and so she first for the first time in the New York Times acknowledged this which seems to be such an important element to me so yeah keep going I mean I don't know if it was the the first time per se I think there was an acknowledgement in a few sentences in a previous article but um I mean if you if you understand what's going on in Europe and you care about evidence-based medicine the changes in Europe should be a story in their own right and maybe even several stories in their own right I mean that's a huge huge development in the area of pediatric medicine and the fact that the times has only um found it appropriate to cover in a few sentences over the past few years I think is is pretty outrageous but in any case um here we are we have this piece by by Pamela Paul um and as I said in my threat on on on X you know I think she got many things right and one thing wrong so let me just kind of go through what I think she got right first I think first of all she did mention or at least um hinted that you know the American Medical associations really are out of sync with um with a growing number of countries in Europe um and they're not really based on reliable evidence um so that I think it's it's important to acknowledge that that um there is consensus among medical professionals and health authorities on this issue um and that to the extent that there is let's call it a kind of a majority opinion um it's gradually shifting away from the approach taken by us medical groups so that that's you know that wasn't fully explored but it was at least hinted at that I think is is good number two um I think it's really important to emphasize that the D transitioners who were featured in this piece were deemed good candidates for transition by clinicians who practice the gender affirming model um and that's important because um gender clinicians who practice that model and activists who defend it are constantly telling us that they have um highly reliable ways to distinguish between those who are good candidates and those who are not those who know that they're Trends and those who who you know are passing through a phase um and I think that the the very existence of detransitioners suggest that that's not true or at least that you know that that they can't uh reliably distinguish between these two populations um and you know Paul noted in uh in a follow-up piece to her um to her piece from Friday that detransition rates or at least discontinuation rates of hormones according to one study might be as high as 30% um now I should point out that we don't have a good empirical picture of regret and D transition in fact fact those words themselves are contested there's different definitions for what regret is what D transition is those are important debates to have important discussions to have um we don't currently know how many um people who you know got medicalized as adolescents or young adults um regret their decision how many have detransitioned um and I think it's going to take us at least another decade until we have a better picture um I don't think we'll ever know with accuracy um the full picture yeah but I do think it's reasonable to assume that under the affirming protocol that is really you know at work in American clinics because that protocol um openly rejects any gatekeeping any questioning of a person's self- declared identity um I think rates of regret and detransition are going to be much higher than what activists tell us they are simply because there's absolutely no gatekeeping so that was the second the third point point that um Paul made that that uh that I think was good although I think it could have been developed a little bit further is you know she mentioned that rapid onset gender dysphoria is a contested controversial concept but um but that there is evidence for it and she cited number of sources including a recent letter to the editor that I co-wrote with Lisa Litman and Michael bigs where we used a uh the US transgender survey of 2015 which is a survey that is um highly biased against any finding of evidence for rogd and that is frequently used by activists researchers and clinicians like Jack turbin to um you know to launch their Crusade against rogd and we used that that survey and we said even if you look at this at this survey which is already biased against RG there's actually quite a lot of evidence for um experiences consistent with rogd in this survey um so you know I'm glad that that Pamela Paul all um highlighted the existing evidence that we have in favor of this hypothesis and I would point out that it is still a hypothesis right we're still accumulating evidence um um but but part of the hypothesis is that rogd exists um and I think it's it's be that's becoming increasingly hard to harder to deny um I think number four a really good point that came across in the article is that um this whole narrative that is now being promoted by Defenders of gender affirming care especially Democrats um that you know parents should be the ones to decide um ignores mounting evidence that skeptical parents are frequently bullied by gender clinicians by activists by activist organizations um and probably by people in their own um in their own social milu um to agree to these medical interventions on behalf of their kids um the idea that you have kind of in this you know ideal clinical scenario in which a doctor sits down and gives kind of a comprehensive assessment of what we know and what we don't know the risks the uncertainties all that kind of stuff you know gives that information to the parents and then kind of takes a step back and lets the parents you know consult among them and then they come back with questions and it's kind of a collaborative decision-making process everything I have seen and heard from the world of gender medicine um tells us that that is simply not true um from the moment the kid sets foot in the gender Clinic there's a tremendous amount of pressure on the parents to agree to uh medical interventions um even you know Jamie Reid in her uh you know account of what went on in the um now closed uh gender clinic in St Louis you know she said we were regularly bullying parents and and sidelining the skeptical parent which is usually the dad um and putting an enormous amount of pressure on the parents to to agree to hormones and I want to point out too you you've been talking a little bit about this idea that it should be the parents decision is also a way that clinicians and professionals can dodge their culpability and responsibility if somebody feels harmed by these interventions and this is a really important point because I I hear people on both sides of the political aisle use this phrase that like well it's up to the you know well they often say doctors and parents to kind of collaboratively decide just as you describe right but a lot of people are saying well this is up to the parents and it's kind of ironic I'm just thinking out loud we often say you know we believe that parents know their kids best in the vast majority of cases your parental Instinct blah blah blah but there is this coercion and sometimes there are parents who actually go into these clinics demanding the hormones and interventions and I think Hannah Barnes also kind of describes that in her book so it's very complicated and tricky because everybody's trying to kind of Dodge responsibility and put it on somebody else that's right and of course ultimately you know if you if you look at what gender clinicians the influential ones the ones who you know advocate in in in the public the ones who testify in court the ones who actually write the guidelines if you look at what they they themselves say um they are actually putting all responsibility on the kid right they're saying like Jason rafy and that interiew that he gave to Jennifer block that that was published in the Boston Globe you know he said the affirmative model is is a CH is child L it's oriented around a child's sense of reality those were his words and it's all about following the child where the child goes from start to finish meaning even if the child de Transitions and regret it regrets it detransition helping them through d-transition is itself part of gender affirming care right so it's all all the responsibility is placed on the kid that really shows that uh this model of care is being imported from the world of adult medicine where it makes more sense I'm not going to say it makes perfect sense but it makes more sense to just let adults dictate their own treatment decisions um but they're putting it on kids as young as 10 or 11 that's a totally different story so then the question is well what is the role of parents here and you know I think there's an understandable tendency among critics of gender medicine to try want to hold these parents accountable and maybe even demonize them um and say you know how could you possibly do this to your kid and look I'm not denying that there are parents that um that do this to their kids for reasons that are not you know legitimate for example meaning that they're not really trying to help their kid they're trying to help themselves in some way right so the kind of the munchow in syndrome by proxy and you know in Hannah barnes's book um the the the gids clinicians do describe that um that they've they've encountered some of these cases it doesn't seem to be a majority um but they do exist it's mostly women who do this um but it's pretty rare and and one thing that I've uh learned about from reading a little bit about um Munch Housen syndrome by proxy it's extremely difficult to diagnose yeah um and so taking all these things together the fact that it's rare the fact that it's very difficult to diagnose the fact that you know the entire medical establishment as reflected by the medical association um the Democratic party kind of left of center Legacy Media everybody is signaling to American parents to parents all around the world but but here to American parents that these U interventions are medically necessary um well evidenced and and life-saving my position has been and continues to be we need to lay off the parents we need to give them the benefit of the doubt um there go there is going to be a point in time in which I think the the evidence of institutional ideological capture is so overwhelming in which you know the New York Times has already reported enough articles about the dangers and the uncertainties behind gender firming care for kids there's going to come a point where yes we can and should start holding parents accountable too because parents have an obligation they have a moral responsibility to uh to make sure that their kids are not harmed um but I don't think we're there yet I don't think we've crossed that threshold yet and I think also for strategically reasons and this is what I've said publicly and what you referenced just a minute ago Sasha for strategic reasons I think it's it's it's wrong of us to focus on the parents and I and I think that because gender clinicians and activists um and and you know politicians who give them cover um they are the ones who are desperate to make this all about parents and what they decide because that offloads responsibility from uh gender clinicians and from the medical associations that Empower them um and so I don't want to see that responsibility being shifted in the public debate onto parents I want to see people focusing attention on the gender clinicians on what they say what evidence they site and what the medical associations are doing in many ways we've kind of moved it's it feels like it's moved from you know Medical Care to Consumer driven care and it feels like you know back in the day you know it was kind of eminence-based medicine where it was basically the doctors were in a position of expertise and their experience was was held kind of the most important voice in the room and then it's kind of it's moved into evidence-based medicine in general has moved into evidence-based medicine where it's the evidence the research will back up any any treatment and for in a whole lots of different you know areas um even Psychotherapy has been massively influenced by what is now arguably almost patient-based um health care or even you could call it experiential um health care it's like you know what I mean the the the voice of the patient has become like they might come to me saying for example I want some CBT I'm an integrative counselor so I I I could you know go Any Which Way but I'm thinking well actually it's my job to figure out what I think should be the treatment in this you know what I mean as opposed to they read it up online it's become this online Dr Google thing that's happened but the patient yeah it's the patient-based um medicine is actually it feels very empowering and it feels very given lots of authority to the patient but it's actually a ruse in many ways it's it's it's kind of allowing the patient to feel very powerful but actually it's giving away all your rights almost and when the patient is 10 years old it's it's now it's it's moved from being patient based to being child Le so it's moved from being child centered to being child Le it's moved from patient-based to being child Le and suddenly it's actually become a debacle it's a fiasco at this stage and you then go back to well what was the seven years training for what what is the high salary for if the doctor in the room can't take responsibility for all the decisions that are being made well then it feels like well why isn't this just a pharmacy do you know what I mean so it's it's kind of it's it's it's ducking from responsibility in a slate of hand that pretends to give the patient so much responsibility I know I haven't asked you a question but it makes me very angry no I I I agree with that I mean I think this distinction between patient centered and patient Le is crucial um and I think you know I'm not an expert in medicine broadly conceived um so you know there other people who are more qualified to comment that than on that than I am but I I do think we we're seeing more examples of this um this trend of letting of of you know casting doctors as vendors yeah and and and and their patients as consumers um I think the opioid epidemic is actually a pretty good example of that right the adoption of pain as a fifth Vital sign um you know there there were some good reasons to do that but at the same time I think that the tendency there was was clearly trying to make um the ex the subjective experience of the patient um factor in a lot more heavily into the U treatment decisions and um and that that paved the way to um the deadliest um iatrogenic epidemic we've ever seen um ongoing I should mention but look I mean when it comes to to gender medicine I think it's really remarkable sometimes when you when you read statements by by activists by um gender clinicians um especially when it comes to adults but you you are you're obviously seeing this kind of seep into pediatric care as well um that just cuts out the doctor um it almost makes the doctor an irrelevant um figure in this whole transaction right it's it's it's all about the patient and they want and what they believe is going to make them feel better as if the doctor um the doctor's only obligation is to write the prescription if the patient wants it and what I've been arguing you know for for quite a while is no doctors have a separate professional and ethical Duty that is independent of the patient desires and that in some cases can over um override the patient's desires yeah um and that is the duty to Do no harm um so doctors are not you know glorified shoe salesmen they are not you know just merely highly trained vendors of some consumer good um they they are professionals who practice a science but also in art and they are under separate moral oblig and professional obligations and sometimes that that obligation requires them to say no to patients and that introduces a certain element of paternalism the picture and that so that I think Stella is what you're what you're talking about that paternalism but that paternalism is essential to Medicine yeah you know we so I think you always want to try to balance right you want you have to balance that paternalism against the autonomy of the patient for sure and and medicine can become too paternalistic um but I think we've the the pendulum has swung in the opposite direction I think gender affirming care is a very good example of that we want to take a moment to thank our sponsors gen spect and therapy first gen spect is an international organization committed to fostering a healthy approach to sex and gender the team and members of gen spect strive to promote highquality evidence-based care for gender non-conforming individuals gen spect is pleased to offer a non-medicalized approach to gender with their recently published gender framework and they continue to hold conferences around the world visit gp.org to learn more therapy first is a nonprofit worldwide Professional Association of mental health providers who view Psychotherapy as the appropriate firstline treatment for gender dysphoria therapy first supports psychotherapists working with gender dysphoric Youth and Young adults and offers public education on mental health and Psychotherapy visit therapy first.org to learn more now back to the show you know sometimes I've compared the the shifts and gender affirming medicine to what we might expect from plastic surgery or a real kind of aesthetic consumer-based medicine but even since kind of making that point I've spoken with various uh surgeons and people within that aesthetic world and even they say if a patient comes in clearly with body dysmorphia disorder I have to turn them away I'm not allowed to do uh this augmentation or that procedure on a person who's clearly suffering from some sort of a mental illness and there are even within the field of those aesthetically oriented medical practices there are certain doctors who are known to do whatever the patient wants at any time irrespective of whether or not this seems good for the patient whereas other Physicians are having to practice based on those ethical standards so even in the most kind of consumer driven versions of medicine there are safeguards which the the doctor's resp responsible for keeping in place so there's just like so much here right that's a good point um yeah I I I don't have anything to add to that I mean it's I I I just think it's you know again we just have to constantly keep in mind that that there's this permanent tension that we have to understand between the kind of the paternalistic impulse and the autonomy respecting impulse and medicine and both are important but the pendulum can swing too far in each Direction I think with gender medicine it's swung way too far um in the direction of autonomy and um and it's not even a I think a sound reasonable definition of autonomy I think actually Roberto D'Angelo had a really good letter to the editor about this question of patient autonomy um recently um where he says you know precisely if you care so much about about the autonomy of patients um exploratory therapy is absolutely essential because because only with exploratory therapy can you help patients understand themselves better that's the role of a therapist right to just take what a patient says and their desires at face value especially when they're so when they're so clearly suffering from um various forms of distress um is not respect for patient autonomy that's just you know kind of unbridled consumerism yeah well in many ways you know therapy is is a good example of you say paternal I suppose it is paternal we all kind of eek around the word paternal but it it is quite paternal but maybe authoritative or certainly it has expertise involved and the expertise could be respected I I I do think that we need to have a public awareness campaign around this so that the public are aware that there's a there's there's a decision-making process happening and you know people I think might rely too much on evidencebased and it's all about the research and somebody else might rely too much on the doctor says the doctor says whatever the doctor says and other people would be completely I want it and therefore and it's it's actually a Triad it's the three it's it's a collaboration between the three is how we should arguably be coming to a decision with perhaps the most in my view the most responsibility as well as Authority with the actual Doctor Who was trained and is kind of has the moral responsibility not not to do any harm um do you see limitations in the evidence-based approach well so maybe before we get into that let's just finish the let's just finish the the Pamela Paul section because I do I do think we should get into that um because that's a big question okay if that's okay with you that's fine with me okay um so just I think one one last point that that Pamela Paul I very very thankful that she got right um and that is that you know there are problems um in terms of how the Democratic party and left of center journalism has covered this topic um the way you know her quote um from the pieces um uh the doctrinal rigidity of the progressive wing of the democratic party is disappointing frustrating and counterproductive one one senses you know more than a hint of statement here um and and it's true you know um the Democrats for uh for I think both ideological and um political reasons are deeply invested in gender affirming care and deeply averse to recognizing any of its problems um although we're starting to see change there um we now have about two dozen Democrats in state legislators who have either voted in favor of age restriction laws um or who have vot voted against um uh Sanctuary state laws for hormones um and you know two dozen Democrats is not nothing that's not nearly enough but it's not nothing and and I think this represents a growing Trend and I think by the end of 2024 um we'll see a lot more Democrats who are are willing to publicly Express doubts um but it's true that you know left of left of center media with some exceptions uh Reuters for example but with some exceptions left of center media have for long time ignored um the plight of D transitioners and maybe more importantly what the experiences of D transitioners can tell us about the realities of of gender medicine whether pediatric or adult so here's what I think Pamela Paul gets wrong and I think it's a it's a pretty major point to get wrong um I've tried to call attention to what what I've labeled the golden mean fallacy in left of center reporting on gender medicine I mean there have been um a few journalists who have done a really good job journalists on the left liberal journalists who have done a really good job kind of trying to report on the research on on the the practices on the ground without you know kind of getting dragged into the culture War aspects of this issue but oftentimes even in those articles you get a sense that there's this you know that that they're trying to stake out a middle position between on the one hand you know the Republican or conservatives who want to just ban it all yeah pediatric on pediatrics at least ban it all um and the Democrats and the progressive wing of the democratic party who want absolutely no restrictions and if anything to scale it up um and so these kind of you know journalists who are who are liberal will say something like um you know these laws are excessive they're cruel they go too far um but at the same time the Democrats are not willing to acknow the the risks and uncertainties and and and that the the pref the preferable approach would be let's say the approach being taken in Scandinavia right now right where a small number of of cases mostly adhering to the criteria of the Dutch protocol um are allowed to go through with hormonal interventions um and the golden mean fallacy is a fallacy because it it wants the reader to to think that the middle position is correct simply because it's the middle position between two extr um but that's not true right um extremes can be you know an extreme position can be correct um to give an obvious example um some people most people know that the world is round um some people how dare you you're alienating half of our audience right now just kidding I know going I know um some people believe the Earth is flat um those are two extremes and in the middle some people can say well the Earth is oval shaped um so that's you know that's a good example of of why the the the middle ground is not necessarily true just because it's the middle between two extreme positions um and I think here too if you look at the evidence and I think more importantly if you look at the conceptual framework for Pediatric gender medicine I think um it's pretty clear that that one of those two extremes is is is far more correct than the other yeah um because the evidence even for the supposedly conservative Dutch approach is severely lacking yeah um the the Dutch study which is widely cited as the best available evidence even WF considers it to be the best available research that's been done to date um the Dutch study is uh extremely weak methodologically it has a high risk of of bias um uh it does not furnish high quality evidence in any way shape or form and so we really don't have good evidence even for the most conservative approach to transitioning children um and when you think about the kind of the philosophical framework the conceptual framework for Pediatric transition um it kind of doesn't make sense right um and so in light of all of that I think the sensible position to take right now is that the path of least harm um is to delay these decisions until mature adulthood so I think that's that's one thing that Pamela uh gets wrong and I think that that leaving open the door for this claim that well certainly at least some kids would benefit from this even if you know gender medicine has gone off the rails even if there's no safeguards even if the medical establishment is refusing to acknowledge any of the harms can't we all just agree that at least some kids would benefit from this and that all we need really is you know therapists and endocrinologists who are extremely cautious and only transition the small number of kids who really need it no even that proposition requires evidence um and the evidence isn't there and so that I I wish that that Pamela Paul had had called more attention to that because as long as we leave the door open um it's going to be extremely difficult to bring this um what I regard as a medical Scandal to an end that's such a good point and St you and I were talking about something recently where like a person you encountered who's very very skeptical of this rush to affirm said something like but what about the real trans kids you know so I think you're right that there is this weird and sometimes I don't know how to assess this like is it that it's better for us to inch our way towards a more reasonable position or do we have to be really really hard line about the lack of evidence for any of it throughout the whole process because I I'm also aware having been doing this since 2016 because of the way there's this institutional capture and the mainstream narrative around this is so crazy a lot of people who first encounter our cautious position think that we are conspiratorial and nuts so I'm not always sure like strategically speaking because I'm just a therapist like I work oneon-one with people you know about their personal and emotional issues I don't know strategy on like big global scale so I don't know what's best for us to do and it's an interesting question and like this kind of makes me um think about another topic we'd love to ask you about which is the the kind of state-to-state bands because I feel really um again really confused and torn like you're saying leor I can't think of any situation where I think it is appropriate to medically transition a child I can't think of any scenario where I would think it's advisable on the other hand I know that bands in them in and of themselves the way they operate can be so inflammatory as to create like this secret underground demand for something so do you have thoughts about that I mean I I imagine you've thought and written a lot about this yeah I mean look let's set aside the issue of kind of the the black market the black market of hormones um because I think that that's that's an issue it's a very important question and there are you know online platforms like plume that are now um trying to to fill that Gap and there are organizations like Planned Parenthood that are also trying to fill that Gap um but let let's let's focus on the bands themselves you know okay look I mean you know we we live in a society that is extremely polarized politically ideologically um part partisan polarization in particular is very intense um there used to be overlap between the two parties meaning there used to be Republicans who are more liberal than the most conservative Democrats and vice versa that is almost non-existent nowadays the parties are are sorted and polarized so if you're conservative you're in the Republicans if you're liberal you're in the Democrats and that's that um and we're also extremely tribal um because of how information is um is consumed nowadays you know if you're liberal you're going to read the New York Times and slate and Mother Jones and you know Washington Post and whatever and if you're conservative you're going to read National Review and Fox News and so on and so forth and you know it's it's pretty rare to find you know the average American um reading across the aisle just to make sure that you know that they're not sinking into confirmation bias I think the vast majority of people consume information from from the sources they ideologically agree with and so um when when when you have laws that regulate an area of medicine as controversial as this one people are going to want to kind of fit it in to their to to the tribal Dynamic right and so if you're a Democrat if you're liberal and you see that these laws are supported by Republicans your natural instinct is to say well then I I oppose the law um and vice versa um and that's fortunate but that's kind of the reality in which we live um and so look I you know is it possible that these laws are producing a a you know a reaction among liberal Americans among Democrats to support gender firman care where otherwise they wouldn't um yeah of course there is um but I'm not sure there's a better alternative at the moment um you know because when the medical establishment this is argument I keep making right when the medical establishment is um promoting a harmful practice and refuses to regulate itself or even to allow scientific open-minded debate on this issue um and we know that kids are getting harmed um what choice do Regulators have other than to intervene and it's not as if lawmakers don't regulate medicine they do it all the time American Medicine even though it's it's correctly recognized as um you know kind of uh um it there there's a strong element of free market um exchanges of capitalism profit motives um these are one of the fundamental characteristics of American Medicine in contrast to let's say European medicine um but at the same time American medicine is heavily regulated especially after Obamacare especially after 2010 um there's there's almost no aspect of medicine that that doesn't have either the direct or indirect imprint of government um laws or uh rules regulations lawsuits um all those kinds of things so to to single this out and say you know this is a unique example of legislator stepping in and regulating the practice of medicine is obscene it's just not true um and not to mention the fact that you know on the other side of the issue activists have um have gotten the Democratic party to regulate to to ban to to ban conversion therapy as they call it yeah yeah um which in the case of gender identity means you know or has been interpreted to mean even exploratory therapy um so they're also trying to put their thumb on the scale um through a legislative action yeah it's crazy it's crazy the way the different concepts kind of come in and they stay you know what I mean because like affirmative therapy by calling themselves affirmative therapy effectively negated the previous 150 years of conventional therapy and it just with a phrase by by sticking affirmative onto it it it it wasn't therapy and it it should never have got past the gate as well as I bristle every time I hear exploratory therapy because I'm like it's conventional therapy it's it's it's 150 years it's it's it's a it's wellestablished therapy and we we feel I feel reduced when it's it's it's now it's turned into exploratory and you're right I know it's all therapy is exploratory and I know all that but it's just an off hand Point yeah and and you know I mean just to riff off of that just a little bit um if you listen carefully to what uh you know mental health professionals who practice the affirmative approach say in terms of you know what exactly is affirmative therapy because on the face of it it doesn't seem like there's a role for therapist at all right if all you're doing is agreeing with a patient's self- understanding and self diagnosis where do you come in as a therapist you know the session is over after 10 minutes um but if you listen to what they say about what they actually do um when they say things like mental health assessment they don't mean exploratory therapy what they mean is trying to understand how they can help the already affirmed clearly self-evidently transgender child cope with being Trans in a in a different domains of life so in Family Life at school yeah um if they have a job then then at work um wherever it is that's that's how they understand their role so it's kind of like uh self-help kind of you know kind of a new AG self-help right um instead of therapy being a mirror to help patients be become more reflective and ask themselves difficult questions and look a little deeper um into their feelings and experiences um the role of the therapist is reduced to kind of a a a popular self-help Guru who just helps the the the the kid the Adolescent who's already figured everything out um um figure out how to uh be his or her authentic self in different areas of life that's not therapy yeah you can call that whatever you want but that's not therapy and it's definitely not a mental health assessment yeah and it you go ahead it it it kind of takes the form of like a coaching on how to assert this identity which hasn't been explored it hasn't been examined it hasn't been assessed it hasn't been even thought about how do you assert this identity in every domain of life so like these therapists are often kind of helping Co the person on how to demand pronouns from people how to come out to your parents how to Advocate at the school so it really becomes kind of an action oriented kind of like coaching advocacy advocacy yeah yeah and one thing that I don't know that I would be curious to find out because you could see the potential for fueling narcissism here right you could see the potential for a therapist kind of inflating the sense of entitlement of his um Teenage P teenagers are already prone to a sense of entitlement and thinking that the world has to bow down before them right yeah um it seems like it would be very easy for a therapist an affirming therapist to kind of inflame that sense that you know everybody owes me um to understand my pronouns at every single moment to follow the the subtle fluctuations of my gender wherever they go um I would be interested to know as you know do affirming therapists ever say to clients um no you can't expect you know uh if if let's say it's a male to female you can't expect other girls to just accept that you'll that that you're going to use the locker room you can't accept other girls at school to accept to to accept that you know that that if you want to run on their track team that that that all of them should just be okay with it yeah um I I doubt it I doubt that they're that's a key Point that's how the the phrase has set it up to be anti- therapeutic because when you call it affirming therapy as soon as you say no you can't go and play basketball or whatever you know what you've just said there they'd say you're not affirming that's not affirmative so immediately you're you're you're kind of checkmated in in W paath uh there are standards of care 2012 sock 7 I suppose standards care 7 when they released that they moved they did an extraordinary shift and placed the therapist from the position of a therapist who could offer a therapeutic process to uh a therapist who's a facilitator yeah who is offering therapeutic support right which is and so this is that's a really good point so because this is this is consistent with kind of the role of let's say the prescribing physician the endocrinologist as a dispenser of pills right um so you're no longer that kind of paternalistic element that we were talking about earlier the gatekeeping function the you know the ability to say no um it if that has gone away at the level of MDS it's also going seems to be going away at the level of mental health um uh therapists and license clinical social workers and so on and so forth so um so yes I think it's across the board we're seeing that in this in this model of of care well I'm I'm even thinking about the way it's gone a step further at least here in the US I'm thinking about this APA position statement on the care of transgender and gender non-conforming people that I read and they they talked about things like CS heteronormativity and internalized transphobia and and the the bias of the therapist in the transphobia and so they're really kind of twisting up the mind of the practitioner in an even more disturbing way they're not only saying you can't challenge your patient they're saying if you consider that maybe a male patient shouldn't expect these things that's your own transphobia talking this patient is a girl and she deserves to be on the girl's te team so it's like a really twisted way of reframing and reorienting our perception of reality I mean I know that sounds so hyperbolic but it's right there in the position statement it tells you if you have any kind of qualms about this examine your own bias as a practitioner it's almost you know it's almost as if the roles are being reversed here that when a a a a trans identified kid comes into a a therapist office it's really the therapist who should be lying on the couch yes right it's really the therapist who's being put you know put through an examination of their own beliefs and experiences in order to bring about a psychological transformation in them yes um because of course the trans kid is is on a pedestal right there this is this is something special that's yeah so no I think you're probably right and and I think that tells you that level of projection among psychologist tells you more about psychologist and about the patients Stella our feels in a bad shape I've gone through a very interesting process in the last few years of just really really criticizing Psychotherapy as as an entire concept and you know looking at the evidence base and being unimpressed with it and looking at different kind of strands looking at the murky history I was actually at um Freud's house in London yesterday I visited it um and Anna Freud this where Anna Freud lived and where where Sigman Freud died in the actual room that he was in and you're just you're looking at the wall and you're reading all the crazy crackpot stuff that he came out with and you're thinking wow my industry really it began on on shaky science and it's it's continued on it's a good 150 years later and it's it's not doing great is it and you know well look I mean was all these bad therapists and now I think the therapists have just moved with the times and they're told airm we're told it's support forget about this process business now you're a supporter go and support I mean look I I wouldn't want to and I also don't have the knowledge to do this right I wouldn't want to just kind of dismiss all of therapy I mean maybe you know a lot more about it than I do but um I'm I I just personally know a lot of people who have benefited from therapy and you know there are therapists including ourselves who do wonderful work and really help people so I'm sure that there has been a lot of um Improvement and um and and benefit to um to our um to our society from from the advancement of therapeutic techniques but but yes I mean you can see that the potential for things going arai in this particular field partly because it's it's not an exact science um and and it's just prone to abuse heavily partly heavily reliant on the therapist heavily reliant on the right and partly because it's also just so susceptible to cultural Trends um you know I just got done listening to uh six uh six episode podcast on the recovered memory craze of the 1990s we're all about it Lear we're talking about all the time yeah I mean there's also there's a really good book that I'm that I'm almost done with right now um uh called making monsters that really gets deep into the into the weeds of what happened there and kind of the the the origins of the scientific theories and how they got popularized and I mean the the the parallels to what we're seeing with gender firman care are just remarkable um there are P there are entire pages of that book where you could just you know cross out recovered memory and write gender firming care and the meaning would be exactly correct totally as a matter of fact I am probably by the time this episode comes out it will be out but I'm producing two videos about the memory hold podcast and the parallel with gendering care concept and it is incredible I mean there there are so many things that even though I had studied this that keep kind of I keep discovering more and more parallels and you know to go back to what you we were talking about regarding therapy um one of the interesting episodes of the memory hold podcast they talked to a couple of researchers and scientists and neuroscientists who study how memory works and they were talking about how very precarious and subjective it is and even the way a therapist might ask a patient a question can elicit a Cascade of things to where they're trying to remember something that didn't actually happen and it's it may not be intentional on the therapist part but we're just very vulnerable to suggestibility all of us are and when you look at the kind of vulnerability of a child you know it's even more apparent that we have have a huge responsibility that should be taken seriously and we should be very sober about how we interact with kids who are distressed having mental health issues questioning their identity so it it's so important for people to kind of understand this isn't the first time that therapy has the potential to go off the rails that's right and I you know at at the at the risk of preempting some of the stuff that that you might say in your podcast pleas um I mean there are a number of really interesting parallels here if I could just mention a couple that really stuck out to me one is um that at the heart of the recovered memory memory theory is an unfalsifiable theory about how the memory works yeah it's unfalsifiable right because you only know about the memory once it's retrieved so how could you possibly test whether it exists in in in a state of rep repression um so it's unfalsifiable and in the same way the idea that all humans have an innate gender identity that's you know kind of intuitively known and blah blah blah that's also unfalsifiable yeah um so so that's number one um number two I think the mechanism um of uh of of of therapy here I think is really or of diagnosis is really interesting here right because you have a scenario or or or um you have a condition in which certain symptoms are known to be caused by a certain event in the case of let's say sexual trauma right if you were sexually traumatized as a child that can give rise to certain symptoms of you know maladjustment anxiety depression whatever later on but the move in the recovered memory movement was to go from symptoms to cause yeah and that's where all of the shenanigans came in right so if you have anxiety and depression then we can work backwards and find you know and use that as evidence for a repressed memory that can be retrieved through therapeutic sessions where patients were um were were're basically subject to the problem of suggestibility yeah and in the same way you know if you know that um that this experience of distress arising from being in a particular sex body let's call it gender dysphoria if you know that that gives that that causes anxiety and depression well then all of a sudden you get these teenagers with anxiety depression and you work your way back and you say oh well then maybe they have gender dysphoria yeah right and then the third thing that I found really interesting as a parallel there there was a moment in the podcast um and this also came up and there's actually a few books that I've read on recovered memory that are that are really good um yeah but I think this making monsters is probably the best but um but there there was a few passages in some of those books and one moment in the podcast where you had examples of therapists saying explicitly my job is not to discover the truth of what happened to a patient my job is to help them feel better uh it's therapeutic right my job is to help them uh uh uh cope better with her life circumstan she actually said my job is to create a safe space for her to recover her memories or at least to recover to to um to overcome the sources of distress and so on and so forth right so so it's like the the whether something actually happened becomes unimportant yeah right and in the same way I think you can see in the in the gender affirming field um there's almost a kind of a regard for I mean some some people actually believe in this theory of innate gender identity I'm sure a lot of people actually believe in it but to some extent I think it kind of doesn't matter yeah right because the the premise seems to be if it makes you feel better to be affirmed treated as a boy or as a girl then you are a boy or a girl right so it's it's the the therapeutic uh focus is is is primary and whether something is actually true or not is secondary um I I really would recommend that I listeners do go and take a break from our podcast check out the memory ho podcast it's only six six episodes and then you can go back to us it's phenomenal because she begins and it shows about the culture of the time that there was so much talk about incest and so much talk about child sexual abuse I remember it we're talking kind of like late 80s 90s everybody was talking about it was on all the TV shows it was in all the Soaps it was just in the air just like gender is today it's just in the cultural water as such and um this was a she was in her 20s or something like that and she forgot what she was going to say this is how the session or the first episode starts she forgot what she was going to say and her friends who were totally into whole recovered memory said oh forgetting what you're going to say is a sign of uh child sexual abuse that you've forgotten and she was like oh I don't think so I think I just forgot I stumbled and I forgot what I was going to say and they were like oh no and then they did this confence very Voodoo they started doing free writing in their opposite hand and I just remember and we're laughing at it because it's 30 years later but I I I remember the vibe of it you'd say something and somebody would say oh maybe it's maybe it's a hidden memory it was it was peppered in your speech back then and um you know it's it's it's a credit Paul McHugh who also exposed the work of John money in the 70s he's a doctor he was working in John Hopkins and ultimately you know when John Money Was Gone Wild in John Hopkins John's Hopkins isn't it called in in the 70s and he was transitioning people and doing very unethical things Dr Paul McHugh got it closed down in 1979 got that gender identity clinic closed down but he started the false memory syndrome foundation in the '90s this guy is a hero and four four years after he started the concept so they were coming in with the recovered memory syndrome he came in with false memory syndrome like this is a false memory and four years after he started his his or he and others I shouldn't just say him of course um he got it into the dictionary so it just shows that the culture of the times and I feel we're in the middle of this period of transition you know what I mean that it it where it was oh it might be your identity it might be your identity now people are saying oh hang on a second there's more to this yeah so well okay so so that's actually interesting right because I think there are can can we can we maybe take this conversation into our membership do CU I I really for now we want to say to our general audience we're so grateful to have had you on we're going to link to your letter to the editor to your writing at Manhattan Institute and of course to your Twitter account is there anywhere else we can send people to read more of your work all of my written work appears on my Mi profile my Manhattan Institute Prof profile okay that's great than for joining us again thanks very much leor you're on fire on Twitter these days yeah knocking it out of the park thanks Le thank you thank you thanks so much thanks for joining us this week on gender a wider lens if you enjoy the show please wrate and review us on Apple podcasts or Spotify and be sure to visit us on substack by going to wider lens pod.com there you can join our listener community access bonus content and resources plus learn about additional ways to support the show our discussions are for educational purposes and are not intended as a substitute for mental health [Music] services

Channel: Gender: A Wider Lens

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Id: i1_fjn90hKo

Length: 66min 42sec (4002 seconds)

Published: Fri Feb 16 2024