Irreversible Damage? | Abigail Shrier | EP 159

[Music] Today I'm speaking with Ms. Abigail Schreier, who is a writer for the Wall Street Journal and the author of a recent book, which was named by The Economist as one of the notable books of 2020: Irreversible Damage: The Transgender Craze Seducing Our Daughters. Thanks for agreeing to talk to me today.

Thank you so much for having me on.

So, why did you write the book?

I wrote the book because a woman wrote to me. I had written a piece for the Wall Street Journal on our transgender pronoun laws that we have in New York and California now that assign criminal and civil penalties for failing to use someone's preferred pronoun. I pointed out that these laws are straightforwardly unconstitutional in the United States. A reader wrote to me; she read this, and she said, “Maybe you'll take up my issue.” But I'm a mom; my daughter had no symptoms of gender dysphoria throughout her growing up—gender dysphoria being the severe discomfort in one's biological sex. But she went off to college, had a lot of mental health problems, and with a group of girlfriends, they all decided they were transgender. She started a course of testosterone. I’ve had this problem with the epidemic of these young girls who are in a lot of very real pain deciding that gender must be their problem and very quickly obtaining hormones and surgeries. She told me that no journalist would take it up; she had written to many journalists. I tried to find her an investigative journalist who would write about this or at least investigate it, and when I was unable to find one, I finally, three months later, got back in touch with her and said, “All right, I’ll look into it.”

Okay, well, I can tell you that I have had some trepidation about even conducting this interview.

Yeah, well, it's because this is exactly the sort of issue that you can get pilloried for, and I've had a fair bit of that over the last number of years. I mean, I was very unhappy with the Canadian government's language law provision Bill C-16, and my comments about that caused a whole sequence of chain reactions, I suppose, that changed my life completely. I was concerned at that time that the movement—let's say the political movement of the political ideology—that I saw as driving the language legislation, Bill C-16, would manifest itself in psychological trouble for many people. I had read this book called The Discovery of the Unconscious by Henri Ellenberger, and he talked about psychological contagions and documented them going back hundreds of years, as a matter of fact. I was aware that such things occurred, and it struck me as highly likely that confusion about gender identity on the ideological end and categorical front would translate itself into confusion about gender among adolescents in particular who were just starting to catalyze their gender identity.

So you claim in the book that this is an epidemic, and one of the things I'm wondering about is what relevant stats do you have at your disposal and why language like that?

Well, I actually asked a bunch of—you know, I interviewed—I conducted nearly 200 interviews for the book, and I actually asked a lot of scientists. Once I had some numbers, I asked, “What do you call this? What is it when you have this giant demographic jump? We have a hundred-year diagnostic history of gender dysphoria, and it always afflicted boys and men. Now, for the very first time, in the last decade, there has been a giant surge in a different population claiming to be gender dysphoric. It has shifted from onset in young boys to teenage girls with no childhood history. It's shifted from men to women.” So I asked them, when you have a giant demographic jump, and all of a sudden they are, as these teenage girls, now the leading demographic—these are girls who, as a population, experienced virtually no gender dysphoria throughout history—suddenly being the leading demographic. I would ask them, “What do you call that? Is there a scientific term for this?” They would always all say, “Yes, epidemic.”

I see. Okay, so in your Wikipedia page—which I read this morning and struck me as a place where a battleground was likely taking place—occurring in the book, it says: "In the book, Schreier accuses social media of playing a driving role in girls' decisions to identify as transgender based on the unproven and contentious hypothesis of rapid onset gender dysphoria. She advocates for withholding gender-affirming medical care for transgender youth, a fringe position not currently supported by most reputable medical organizations."

Now, one of the things you do document in the book is the rapid move by organizations like the American Psychological Association and the American Psychiatric Association to change the wording that they've used surrounding the discussion on gender identity, correct?

Yes, that's right. They've changed the wording. But the bigger change, of course, is that they've gone to an affirmative care standard, which means that they no longer apply any medical judgment. They simply surrender all judgment and agree with or affirm the patient’s self-diagnosis.

Right, and along with that goes—the—and this is part of what made me nervous about talking to you, and I still probably am—is that as a medical practitioner, as a psychotherapist, psychotherapists are now bound, as far as I've been able to determine by examining the law, to adopt precisely this gender-affirming position. I believe that that's the case in Ontario. So I don't do adolescent therapy, but if I had a young adult, say 18 or older, come to me who was expressing confusion about their gender identity, let's say, or was gingerly testing the waters to determine if perhaps they were transgender, I believe that I'm required by law to adopt a position that would affirm that fundamentally, that's right, yes.

Sort of Damocles hangs over professionals’ heads now, and what it says is you must agree with the patient’s self-diagnosis. Put another way, it suggests that you should begin with the conclusion. Your conclusion must be that this person has gender dysphoria, and then you can, you know, go along from there and start prescribing treatments. That's not how medicine or any other area of therapy is practiced. You don’t begin with the conclusion; you investigate it.

Now you brought up my Wikipedia entry.

Oh, sorry. You know that. Go ahead.

I mean, obviously, it's—the number of lies that have been put into that. I didn't start the Wikipedia entry; others did, and there’s been, you know, back-and-forth fights with activists and so forth to rewrite it. But of course, I—I don’t, you know, advocate any. I mean, it's not true. I mean, so much of what has been said is not true. First of all, the affirmative care standard, that’s the problem. I don't advocate a particular method of treating transgender people. I don’t even advocate a method of treating transgender teenagers. All I'm pointing out in the book is that there seems to be a sudden rise in these teenage girls who are subject to pure influence—in social media influence—deciding they’re transgender, and there are no medical safeguards for these girls. There’s no means right now—and no one determining whether they actually have the correct diagnosis before proceeding to treatment. That's it.

Right, and so I guess the catch-22 here is that if the statement—“most reputable medical organizations affirm or put forward an affirmative care requirement”—then any position that questions that or objects to it is, in some sense, by definition, fringe.

Well, yes, I’m not saying at all that your position is a fringe position. It’s—it’s a matter. I don’t see how that can be avoided under the current circumstances because the laws and guidelines are written as if this is a fait accompli—that we understand transgenderism completely and gender dysphoria—and that, you know, all the answers are already in. I don’t think that’s true for any psychiatric diagnosis.

Yes, I would just say that it seems fringe—and so far, or it appears fringe—because all the doctors who disagree—and there are many—and they’re speaking up all the time—are silenced. They are told that they could lose their license if they don't immediately affirm the adolescent, no matter what her other mental health problems are, and immediately go along with facilitating her transition.

You talk about the occurrences at the mental health institute in CAMH in Toronto, yes?

That’s right. I mean, you had, you know, Ken Zucker, the truly a giant in the field of gender dysphoria, who actually oversaw the authoring of the definition of gender dysphoria. He was fired.

Right. Let’s talk about Ken Zucker for a moment or two. So, as you said, he occupied a very prestigious position in the world of transgender treatment and I think was universally regarded as the most outstanding and most objective scientist working in this field. I've spoken to him about it on some occasions—not publicly, ever—and he struck me as a dedicated clinician and researcher, and he advocates for—and still advocates for, as far as I know—a wait-and-see treatment method based on the presupposition that most children with gender dysphoria who have interests in transforming their body to that of the other sex should be encouraged to wait because, if a waiting technique—it’s not a technique, even, I suppose—if waiting, with sufficient patience, most of the children who manifest these concerns desist. I think it’s 70 to 80 percent of them. A certain percentage—fairly high—come to the conclusion that they’re gay, and it’s perhaps the case that that’s driving some of their early gender dysphoria, confusion about their identity.

And Zucker was fired from CAMH and also pilloried in a variety of newspapers and other publications as a consequence of what was essentially his mainstream stance. Now, I believe—and I haven't followed this up recently—but I believe that he was engaged in a number of court battles with the publications that had gone after him, and I believe that he won his legal cases.

He did. They had to apologize, and they settled with him. I mean, what they did really wronged him. Yes, I mean, that's what happens when professionals speak out on this issue, and of course, when I say speak out, all they’re expressing is concern that there is an overdiagnosis here. You're seeing young teenage girls who do not seem to have typical gender dysphoria nonetheless be immediately fast-tracked toward transition.

So I’d asked you a little bit earlier about numbers. Do you have any sense of how prevalent this is, and I’m also interested in—and I’m sure the listeners and watchers would be as well—rate of increase?

Sure. So, in America it’s a little harder to look at to come up with these numbers. Although I’ll tell you the numbers that I do know. It’s harder because we don’t have centralized medical care like they do in Britain. In Britain, where they have centralized medical care, they can tell you that the number of young women being referred for gender treatment has exploded over four thousand percent in the last decade. In America, we don’t have centralized medical care, and you don't even need a diagnosis of gender dysphoria to start treatment. You can start a course of testosterone without ever having received a diagnosis of gender dysphoria.

So, they’re a little harder to come back, but here’s what I can tell you. In 2018, two percent of high school students said they were transgender—so that’s two in a hundred kids. That’s an enormous increase over what was historically the rate of gender dysphoria in the population, which was 0.01 percent—so one in 10,000 people went from roughly one in 10,000 people to two in a hundred high school students. We also know that between 2016 and 2017, the number of females requesting gendered surgery in the United States quadrupled. So we know these are the exploding rates, and then, of course, you know I’ve interviewed many therapists, and Lisa Litman of Brown University did her survey. When you talk to therapists, when you talk to parents, you get the same thing over and over, and that is that the leading demographic asking for gender transition is teenage girls—teenage girls with no childhood history of gender dysphoria.

Now, here’s a contentious issue. So generally speaking, for the story of long-term gender dysphoria to be coherent, a girl would have to claim that she’d always known that she was in the wrong body—that she was a boy—and that that had been the case ever since early childhood. So maybe she’d be speaking as a teenager now. You make the claim in your book that girls who go online, who are searching for information about transgender identity, often encounter coaches who tell them to falsify their personal narrative and to claim that they’ve always been gender dysphoric, despite the fact that that’s not the case. Is that a reasonable summary of what you found?

Yes.

Yes, so you can see that it’s a complete diagnostic mess from a therapist perspective. Because—even from a conceptual perspective—because the people who are on the other side of the argument than you, let’s say, are going to claim that the reason that these rates have skyrocketed to the point where they’re at now is because there were always that many people who had gender dysphoria or who were transgender, but the weight of public opinion was held so strongly against them that they had to stay in the closet, essentially. And the claim is going to be made as well that you’re radically exaggerating the proportion of people who are putting themselves forward for transgender transition procedures, let’s say.

Right. So let me respond to a few of those things. First of all, I don’t think that’s right. I think that I agree with you that that’s what they would say, but here’s—I thought about that claim. Here’s what I would say in response: if this were just—as they say—a natural reversion, now that there’s greater societal acceptance of transgender people, that they would say, “Oh! You would expect to see a natural reversion to what we’re seeing now,” which they might claim is a normal base rate of transgender identification in the population. The problem with that is, number one, we’re only seeing this sudden spike among teenage girls. Where are the women in their 30s, 40s, 50s, and 60s who were denied the opportunity to come out as transgender? They should be coming out too, but they’re not.

Can you also point out, I guess, the other thing that you might conclude is that if the people—the bulk of the proportion of people who were claiming a transgender identity in the past were male, then release of the social strictures on identification should have produced an explosion in males. It’s not easy to figure out why there is an explosion in females.

Okay, so that leads us to another extremely troublesome topic, which is why the explosion in teenage females. Now, you do attempt to explain that in your book, and so maybe you could outline for the listeners exactly what your conclusions were.

Sure. Teenagers teenage girls are famous for falling for every hysteria. Right? We know that the way young women—and there are psychologists who’ve done wonderful work in this area—Amanda Rose is one at the University of Missouri, who I interviewed. Teenage girls tend to spread these psychic epidemics because their modes of friendship involve co-rumination—taking on their friends’ pain. They like to rehash their own pain, and they like to take on their friends’ pain, and they are even willing to suspend reality in order to sort of get on the team of their friend.

Okay, so I’m being a real son of a in this interview to some degree because I’ve been trying to think up all the objections I possibly could to your perspective because it’s so contentious, and so I’m going to put forward things that I’m thinking about that are critiques, and it’s not that I’m believing them, but they need to be brought forward. So a skeptic might say that you are relying on stereotypes of feminine behavior in adolescence to justify your claim that it's girls that are susceptible to a kind of hysteria, and that that’s an outdated and sexist hypothesis.

No, I’m not relying on stereotypes at all. I’m relying on evidence. If you look at the anorexia, it afflicts one population. If you look at bulimia, it afflicts one population, and it grows and spreads among friend groups, just as this does. It’s young women encouraging each other in self-harm. And if you look at cutting, same thing. And we know—clinicians have known for years that you cannot house anorexics together in a hospital ward without being very careful because they will encourage each other to learn more and more weight. We know that women, right? And you see that online with regards to anorexia, right? With the pro-anorexia and the pro-bulimia sites, right? It wasn’t men who came up with thinspiration, right? Inspiration to lose more and more weight; it was young women. Now, of course, men get involved in all kinds of, you know, bad behavior and encouraging each other in all kinds of bad behavior, but this kind of, you know, socially spread self-harm has proven over and over to be endemic to young women.

You can’t group antisocial males together when they’re teenagers because they get worse. So that's well-known, and in fact, if you take antisocial boys and you put them with pro-social boys, the pro-social boys become more antisocial. The antisocial boys don’t get better, and that was discovered back in the 1930s in the Somerville Study—the detrimental consequences of grouping antisocial boys together. It was a very large-scale study that was designed to reduce the risk of children boys at risk for developing criminal behavior and alcoholism and so forth. It was one of the first longitudinal studies. It was a complete failure in that the treatment group, who were subject to all sorts of benevolent, at least in principle benevolent, interventions, did much worse than the control group.

After much painstaking analysis and heart-rending doubt, the study’s authors concluded that housing the children together in the summer camps they put out for them to get them out of the inner city was actually the cause of their increased pathology in adulthood.

So it does happen among males. Now, Tumblr is also something that you discuss as a new mode of perhaps a new medium of social contagion, and as far as I know, that's also a social media forum that’s essentially female-dominated, is that correct?

I believe it is still, but though I have not kept up to date on the latest, you know, of who looks at Tumblr, but it always has been, yes, predominantly.

Right. So, all right, here’s another question: What made you convinced that you were qualified to do this? Because if I was a critic, again, I guess that’s the next place that I would attack, right? Because you’re not a mental health professional, and so it might be asked, “Well, what right do you have to investigate this?” Even that might be one question, but then also to draw conclusions.

Well, as you’ll—as I’m sure you saw if you, you know, when you read my book, I didn’t draw any medical conclusions. That is, I relied entirely on experts, and I do believe it is a journalist’s job to look into medical phenomena, including epidemics and so forth, and investigate them and rely on the medical judgment of experts. That is precisely what I have done. This isn’t my—you know, all I did was investigate a phenomenon with neither a particular hypothesis in mind but just being willing to listen to a lot of experts, and it was their testimony and their explanation that I put into the book.

Do you think that you were even-handed in your selection of experts? I mean, because one of the ways that you can bias an outcome, obviously—if you have a political agenda, you can bias an outcome by selecting experts that testify in one direction—and of course, the transgender activists and perhaps the medical and psychological associations themselves might regard people like Ken Zucker as experts who, you know, would appeal to someone of more conservative sensibilities, perhaps?

Well, sorry, I’m not—I think what you're saying is did I bias it by only looking at certain kind of experts? Will I say no, I didn’t. If you read the book, I interviewed experts of all persuasions. But more importantly, there are literally thousands, I believe, certainly hundreds of books celebrating immediate medical transition for teenagers. There is precisely one book that did an investigation of the risks and benefits and concerns that might be had around the medicalization of teenage girls. That’s it—one book. And the question is, so do all these experts have a voice? Of course! I don’t claim to have conducted my own scientific study. All I did was show a willingness to speak to the experts who are very, very concerned about what’s going on here.

Okay, so let’s dig even deeper, I suppose. Why the claim that you just made—for example, that there is a very large literature supporting the idea of medical transition and very small literature criticizing it—is striking. I don’t understand it. What’s going on? Like, what’s driving this? Why is it that the medical associations and the psychological associations have rushed so precipitously into gender identity affirmation when the cost of it, when it’s taken to its logical conclusion, is extraordinarily invasive surgical modification, which carries substantive risk and which I think it’s fair to say has disputable benefits? What—why is this happening?

Well, there are a number of reasons it’s happening, but if you’re asking why more medical—more doctors and therapists aren’t speaking out, I think the answer is because if even Jordan Peterson is concerned about having this interview with me and with all of your courage and all the stances you’ve taken, imagine what far less courageous doctors are willing to say.

It still strikes me as remarkable that this change has occurred over such a short period of time. I mean, one of the things you do in the book—and maybe you can talk about this—is document the nature of the treatment, the medical treatment for gender dysphoria when the treatment is gender transition. So you talk about the use of testosterone and its subsidy on university campuses, and then you talk about the more invasive surgical transformations: double mastectomies, phalloplasty—which is the creation of a new penis, if you use that word loosely. These are very—not minor procedures— including the use of testosterone. And it’s remarkable to me given how fast these guidelines for treatment have changed.

Well, I think you’re right. The medical— the activists have been very aggressive and very effective here in the medical accrediting institutions, but I think that at root of all of these changes is a series of polite lies that we were—that we swallowed, unfortunately, in the public sphere. So in the last week, for instance, the California insurance commissioner has said that for the purposes of insurance in California, that breast surgery, top surgery, double mastectomy on healthy breasts for even teenage girls needs to be regarded no longer as cosmetic but something that corrects abnormal structures, because if you’ve accepted the lie that a young woman who says she’s a boy truly is a boy, then healthy breasts become abnormal structures. This is the corruption of language, so you must remove them regardless of her age.

Yeah, well, language tends to be associated with action, and it was the corruption of language that I objected to, you know, four years ago, because it has consequences. Now, you made the strongest statement so far, I would say, that you made in our interview, which is that the lie that an adolescent girl who thinks she is a boy truly is a boy. I suppose it’s language like that that gets you in trouble to the degree that you get into trouble, because that’s a pretty strong statement.

The gender theorists who are driving this movement, I would say, put forth the proposition that, first of all, that an individual always knows what gender they are, even if that changes from day to day. There isn’t an authority outside the individual themselves that can opine on gender identity. That’s part of the philosophy that drives the gender affirmation movement, I would say, correct?

Right, that’s part of the philosophy. But unfortunately, there’s no biological or empirical means of verifying that. We have no means of establishing that a girl who believes she is a boy is truly a boy.

Well, it’s more—it’s more of a definition than anything else, right? It’s a place to start. It’s an axiom. The axiom is that the only person who can offer an informed opinion about their gender is the person themselves—no medical professionals, no parents, no loved ones, no one else—only the individual. And that’s even the case if it changes from day to day or hour to hour.

Right, exactly. You could begin with a conclusion, okay? And then the other claim—and this is the one that I have difficulty with logically—is that a girl who thinks she is a boy is, in fact, a boy trapped in a girl’s body, which seems to me—and that’s been the case ever since birth—and it seems to me that this is a form of biological essentialism that the gender theorists typically decry, proposing as they typically do that gender is a social construct. Now, it isn’t obvious to me how gender can be a social construct and be something immutable from birth that’s only known to an individual themselves, which sounds a lot more like a biological explanation to me.

So, right, right. I mean, I interviewed affirmative therapists, and I would say to them—and they would say, “Well, some kids are gender-fluid,” and I would say to them, “Well, then how can you recommend top surgery on a young woman who’s who maybe turn out to be gender fluid, meaning she decides at some point she isn’t—she was wrong, she isn’t a boy; she’s a girl?” And, you know, this response was essentially, “Well, only she can know her truth.” I mean, this is not medicine any longer; it’s closer to witchcraft.

So let me start at the beginning and outline the hypothesis of the book. So, over the last five years, there’s been a tremendous transformation in the language and the conceptualization that’s been applied by medical associations in relationship to gender. Gender is being defined as something that’s a personal choice, essentially, and that personal choice has been extended to the domain of physiological transformation, and medical professionals have been required—are now required to accede to any requests for physiological transformation on the part of their clients or patients. As a consequence of the mandates of their professional organizations, the consequence of that has been a shift in the transgender phenomenon from a tiny percentage of primarily males to a 1-in-50 percentage of primarily adolescent females, many of whom are undergoing the full physiological—or many of whom are undergoing at least part of the physiological transformation process. That sums it up, essentially?

I believe—I’m not sure I totally followed that, but I think so.

Okay, well, I probably should have asked you this at the beginning of the interview, but the basics—I was trying to outline the basic argument that you were making, right? The basic argument that I’m making is that girls— is that a lot—a large population of teenage girls who probably do not have gender dysphoria—they certainly have an atypical form of gender dysphoria—are able to quickly obtain hormones and surgeries. They’re very much, you know, they’re acting under social media influence and peer influence. We have numbers on that, certainly not my studies, but others have done studies on this, and they’re acting under the influence of peer influence and social media influence. They are quickly obtaining hormones and surgeries, and there is virtually no medical oversight of this process. That’s the thesis of the book.

Right, and so the alternating hypothesis are either that there’s been an explosion in transgender-identifying individuals because the social structures have been taken off the diagnosis, or that this is a form of psychological contagion.

Right, I don’t think it’s the former. I started to explain why. One of the reasons I said is you would expect, you know, a large rise in transgender identification across populations; it wouldn’t just be teenage girls. You would see women in their 40s, 50s, and 60s coming out as transgender. In comparable rates. But not only that, you’re seeing among this population—we know that rates of suicide and depression are rising as social acceptance of gender dysphoria is going, or transgender identification is going up, but we would have predicted that those things would be going down with social acceptance. Instead, it seems to be, you know, coincident and comorbid with teenage girls' mental health crisis, in which we’re seeing very, very high rates of anxiety and depression.

I have to think about—I have to think for a minute. Herein, I want to go back to why this is happening. So there’s been a political—arguably—not—I won’t say that. There’s been a transformation in the way that transgender identity is conceptualized and treated in the last five years. What’s motivating the people who have been behind this transformation? What’s in it for them?

Well, I think that there are, you know, people who are—there are a number of things. There’s a strong ideological and financial commitments and incentives for certain people to insist that transition on demand, regardless of age, context, or other mental health problems, be always immediately facilitated.

Right, well, it seems like that becomes necessary to prove something, it seems to me. And that’s what I’m trying to get at: it’s necessary to set up the medical system so that gender dysphoric, transgender-identifying teenagers have access to the full arsenal of medical transformation, and that helps demonstrate that some other axiom is true. What is that? Is it the—is the axiom that gender is, in fact, socially constructed? Do you see what I mean? Is that there’s—you said there’s an ideological reason. What I’m trying to do is to specify that reason. I’d like to understand that reason.

I don’t know that there is a larger sociological or ideological goal. I think they are ideologically motivated. So in other words, they have these commitments, but I don’t think that they’re trying to prove something, you know—except in the way that I suppose that they are saviors of some kind.

You know, look, that would be—that would certainly be something that would be motivating to prove. I mean, if you notice the doctors who are pushing this very often, we’re certainly seeing in the United States is a young generation of doctors and therapists who are activists first and doctors or therapists second. We’re seeing this across society in all kinds of, you know, professions. Their ideological commitments precede their professional investigation—they begin with their conclusions.

Yeah, well, the ideological commitment is the—I can’t wrap my head around it because the ideological commitment, if it’s that gender is socially malleable or a social construct, which seems to be that—seems to be a fundamental axiom that drives this kind of ideology, I can’t see how that can live side by side the proposition that the girl who’s trapped in a boy’s body has an immutably male identity.

Well, I think a lot of them—yeah, a lot of them just insist on the immutability. The problem is we know that’s not true.

Except that they also insist on gender fluidity.

Right, but they also insist on gender fluidity. I mean, I could answer your question this way: What is non-binary? Because right now in the United States and throughout the West—certainly true in Canada—you can get your breasts removed if you say you’re transgender. You don’t even have to say you’re transgender, but if a young woman, 16 or up, says she is non-binary, that’s enough to allow her, without a therapist note, to get her breasts removed. Now, we—how do we know that a non-binary person has no breasts? I know that a man has no woman’s breasts. How do we know that a non-binary person has no breasts? Well, that’s what we know.

See, that’s a very good illustration, I would say, of the mystery that I’m trying to nail down, is that your claim is that breasts or no breasts, it’s all the same to the non-binary identity, but that isn’t the way it plays out. The way it plays out is that the breast removal proceeds forthwith, and so that’s not—I don’t—I don’t understand that.

Well, there are no diagnostic markers at all or evidence of a non-binary identity, except the say-so of course. Part of it’s a matter of definition. Now, one of the things that you do in your book—I thought this was quite interesting—is make the claim that when gender theory is taught in schools, the classic binary genders are presented in a very stereotyped manner—very stereotyped, very unidimensional, unidimensional stereotype manner. And then any personal deviation from that stereotype is regarded as evidence for a non-binary identity. So that’s a matter of definition in some sense, right? Because you could say that the only genuine genders—and this would be the redefinition of the word gender in some sense—the only binary genders are the stereotypes, and if you are deviant from those stereotypes on any of the multiple dimensions along which they’re defined, then you are in fact another gender.

You can set up a definitional structure in that way and have it be coherent. The question is what are the consequences of that? So the consequences is a lot of confusion for young people trying to sort these things at who they are—out at a time when that’s typically done in adolescence.

I mean, do you think these—can you distinguish that from freedom? You know, because if I was going to take the perspective that was opposite to that, I would say, “No, no, what you’re doing by deconstructing the concept of gender itself is allowing adolescents much more freedom and exploration of their identities during a critical period than would otherwise be the case.”

Now, I would temperamentally tend to side with the confusion hypothesis. I think it’s a catastrophe to confuse adolescents with regards to their gender identity, just when they’re attempting to catalyze that identity, right? At the same time that hormonal transformations are at their peak and they’re undergoing a profound transformation in self to offer them a plethora—an infinite plethora—of ways to be, none of which have been tested, in some sense, in the world, seems to me a recipe for disaster. But does it look like freedom?

No, it doesn’t look like freedom, and I’ll tell you why. Because these girls are miserable. Just look at the number of young women on YouTube who regret their transitions already. They adopt behaviors after deciding online on some social media site that their true identity is non-binary. “Oh no, wait! I’m a two-spirit. Now I’m agender!” Once they go through these, they lead lives. I mean if you talk to them, talk to their parents, they are—when I—I wouldn’t—if these young women were flourishing, I wouldn’t have written the book. That’s not a sad story—they’re flourishing. But instead, they’re cutting off their parents, they’re dropping out of school, they have no meaningful employment, all their friends are only transgender, they hate all cis people. You see patterns that are desperately unhealthy.

Well, it seems to me, you know, and maybe this is a consequence of not taking the idea of a social role with sufficient seriousness, is that there’s a lot more to identity than your personal feeling. Identity is something that’s negotiated in the social community, and an identity is actually a tool that you use to adapt, so that if you have an identity that functions, we could say you managed to find a long-term stable mate, you managed to have children at some point in your life, you managed to have gainful employment so that you can support yourself in a meaningful and productive manner, you were able to use your own time outside of work and social obligations in a manner that’s meaningful to you, you regulate your use of drugs and alcohol so that you don’t fall by the wayside in that manner. So what it means is that an identity is partly who you think you are, but it’s also partly the manner in which you interact with other people. And if that identity is going to be useful, let’s say, if that identity is going to be valid, it has to provide you with a mode of being in the world. And part of the problem with this multiplication of gender identities is that it’s not obvious how you can manifest them in the world without transforming the entire world, which isn’t going to happen in your lifetime.

And so that’s—we did talk about what was driving this. Is that it’s some deep desire for a radical social transformation so that anything goes. And what would you call it? It’s pushing. Look, everybody feels to some degree the restrictive nature of social roles. You know, I just said that you have to adopt an identity so that you can get by in the world, but that doesn’t mean that there isn’t a fair bit of your individuality that’s squashed and crushed as you adopt that identity and become in some way like everybody else. And maybe this is a rebellion, at least in part, against that notion of having to become like everyone else.

The unfortunate reality is, though, that if you don’t—there’s no place for you.

I think that’s right. I mean, the young women who do—you know, these are overwhelmingly—and you look at Lisa Litman’s study and, you know, the number of women—I’ve seen my own interviews—the these women are overwhelmingly white, middle and upper-middle class, and they have no victim status. They have no easy victim status, and they need one. They need one to get by socially. They aren’t a minority in any sense, but this is the one status they can choose. See, they can’t always choose to be gay, you know, but they can choose to be trans. No one knows better than they do who their gender is, as is the saying goes.

So, another theme I would say that emerges from your book is the increasing social inacceptability among adolescents of what would have been more normative gender identities. This generation that you’re describing is also characterized, according to the research that you did in your book—and research that’s been put forward elsewhere—by a dearth of intimate relationships. And so it also seems to be, right? One of the things you pointed out was—I think it was—I don’t remember if you talked about 16-year-old girls or 18-year-old girls, but in the year and a half preceding being asked the question, half of them hadn’t had anything that resembled any aspect of an intimate couple's relationship. That seems to be a radical transformation. So is it also partly that the more traditional gender roles aren’t working?

No, I don’t know that they aren’t working. I don’t know that they’ve ever explored them. Look, these are young, very sheltered young girls. These are the generation that grew up with helicopter parents, and they have had barely ever had a kiss. They’ve never held hands. They spend all their time on their phone. They don’t know their own bodies and their own desires, and they don’t know—and they haven’t experienced romantic relationships with each other, so they don’t know who they are, and they don’t know what they want. And instead, they turn to the internet to answer all their questions.

What do you suppose has happened? I mean, I thought that the statistic that you put forward about the lack of intimate relationship—because those were population-based statistics, if I remember correctly, right? You weren’t looking at a small minority of teenage girls who were on the road to transition. This was that generation, right? Why aren’t these teenagers dating and engaging in intimate relationships when they’re teenagers like they were only 15 years ago or 20 years ago? What's failed? Like, do you see this as a consequence of technological transformation?

There are many, many things at play. One, they’re with mom all the time. These kids report being at mom, with mom. They don’t—they get a driver’s license until much later. They don’t spend time with each other; they’re with mom all the time. Even they talk to her all day, they text her all, you know, on a constant basis. So they don’t have freedom to be alone with each other. And then when they are alone with each other, rather than being intimate and sharing things and exploring each other, and even just in a verbal way or in any way, they’re on their phones.

So that’s at play. There’s also pornography. I mean we’ve seen, you know, there’ve been studies that show—there are statistics that show that young men are experiencing erectile dysfunction—young men under 30—at rates we’ve never seen before because of online porn. So basically, the one thing that biology evolved that men were evolved to be able to do—social media or online porn content has made it hard for them to do, you know, difficult for them to achieve. We’ve never seen, you know, these kinds of rewiring of human sexuality that’s going on, because people aren’t spending time with each other in person.

Okay, so part of—you do see at least part of this transformation as being driven by the phone, by the constant electronic tethering, let’s say. And part of that tethering is to the parent, and part of that tethering is to friends, but it’s mediated by electronic communication. And maybe that’s the case with the boys?

Yes, but the images that girls see online are just as frightening because they’re seeing violent porn at very, very young ages—women being choked within an inch of their life. This is what young girls think sex looks like with the opposite, you know, with the man, and they’re terrified of it. It doesn’t look anything to look forward to; instead, it looks like something to run away.

Well, it’s never presented regarding pornography. Sexuality is never represented as part of an intimate relationship, right? It’s its own thing. Sex—it’s not an integrated part of a loving relationship, which is what it should be under optimal circumstances. You don’t see that; that doesn’t attract widespread impulsive viewing, right? But it’s also violent, and that’s the—that and some—you’re right. There’s always been this porn that exists in Playboy and whatever— divorced from intimate relationships, fine. But what young girls at age 11 younger are seeing are violent, violent porn. That’s what they know of sex, and they’re seeing it at a very young age, and it’s terrifying.

Okay, so let me ask you about that. I mean, how confident are you in that proposition? I mean, we’re trying to determine why it is that there’s a generation of young women who are much less likely to engage in dating, intimate relationships of the classic teenage style. And it’s not like anybody knows the answer to this because it’s such a new phenomenon, and so are these tentative hypotheses that you’re putting forward, or do you have some—how solid are you in your belief that you’ve correctly identified the factors that are driving this?

Well, the core, you know, thing I look at in the book is, you know, what’s going on with why there is this epidemic—the sudden explosion—and what are the risks and benefits, and why, you know, are these girls thriving? Are they doing well? And should we be concerned and why?

Okay, now the part of this observation was to look at the culture and what was going on in the culture and observe the fact that young women are having sex and intimate relationships at much lower rates. That is not my research; that was done, you know, by Gene—there are a number of people who’ve been doing this. Kate Julian had a wonderful article in The Atlantic in which he interviewed many psychologists about this, but it’s been something that many psychologists have observed and studied—and a very unexpected development, right?

Right, not exactly; it’s not what you'd predict at all when all the social constraints or many of the social constraints have been removed from every possible form of sexual behavior. The consequence of that has been a precipitous decline in sexual behavior among adolescents. And I guess we didn’t talk at all about what the role of the boys might be in this. Like, are girls not dating, let’s say, and engaging in intimate relationships when they’re teenagers because of something that’s changed with them, or have the boys stopped asking?

You know, that’s a good question about whether so—I didn’t—what I was trying to say is I didn’t look into specifically or investigate why there’s this sudden drop in sexual activity or even intimate relationship activity among teenagers.

So there are things I can surmise from looking at the culture and writing about the culture as I do, but do I have studies on this? No, I don’t know; I don’t have, you know, a real answer that I’ve come across yet.

Well, the pornography question’s an open one, right? Because that’s a form of easily accessible gratification with endless novelty that’s never been—you know, it’s possible for a young man to see more beautiful nude women in one afternoon than any human being that ever lived before 1950 would have seen in his entire life, right? And right, and the problem with this, of course, is not that there’s so much pornography—I mean online—but of course, that we’re also seeing men be less inclined to engage in intimate relationships, less able to even perform—I mean these, you know, because of it. I mean, it’s the rewiring of young people so that they’re so incompatible with each other. That’s the real sort of disturbing part if these young people—and this applies to this young group of women who suddenly decide they’re transgender. If they were forming families and living good lives, that would be a success story. But that’s not the story; that’s not the story that I found in my book.

Right, unless you define success as being allowed to pursue whatever fragmentary identity occupies their consciousness at any given time, and you can define it that way, right? I mean, you're using—and I would use as well—I would say more conservative criteria for what constitutes a good life. You know, as a clinician, I I listed as a clinician; it struck me that you can assess someone's mental health with some degree of accuracy by looking at the success of their embeddedness within their social community. And that's why I outline markers of a good life—like gainful and meaningful employment and education to the extent of your intelligence, and the ability to form an intimate long-term relationship and children, and all these things that seem to make up the bedrock of life. But again, to some degree, that's a matter of definition, right? You could object to all of that and say, “Well, no, that’s a very 1950s or 1970s way of looking at the world, and that’s long gone.” And and now what we’re trying to do is facilitate people's—the broadest possible range of choices among people so that we have a world that’s much more diverse in its expression of identity.

It’s a very difficult argument to contend with, I think it’s deeply wrong. I think it’s too confusing for people, but I mean, except that a lot of these young women, their mental health after the trans identification deteriorated, so they’re not able to function.

Look, I have no—I’ve interviewed many transgender adults who are flourishing. They’re leading good lives. They’re in—they’re gainfully employed. They are happy. They’re socially connected. That is not a problem story. The reason that these young girls are the subject of my book is because they’re not flourishing; they’re not doing well. They’re not connected to friends and family; they’re not staying in school.

Do you think—and I don’t know the literature on this, and I guess it’s partly because it’s so soon after the phenomena emerged itself—do you know the literature on the relationship between mental health and movement through the transitioning process? It's tricky, because you point out in your book that if you're an anxious teenage girl or maybe even an anxious teenage guy, and you're given testosterone, at least in the short term, that can do wonders for your anxiety. And so whether or not mental health improves might depend very much on when you measure it. So if you’re anxious and your identity is chaotic and you take testosterone, the immediate consequence of that is that you’re going to be much less anxious, at least. And why wouldn’t you think immediately that that’s evidence that there was something astray with your identity that this magic hormone fixed?

You know, the time frame is a killer problem when you’re trying to assess mental health. So what studies are—or what data are you looking at when you generate the proposition that going down the medical transition road isn’t producing the positive outcome that it’s hypothetically designed to produce?

Well, first of all, I only say that it’s not producing that outcome for these teenage girls who I believe are misdiagnosing. Okay? So I don’t make a claim about transgender adults who went through therapy, arrived at this decision as mature adults, and are living a life as a transgender person. I never make a claim that that wasn’t a good or the right move for them.

Right, well, I don't and I don't know—I don't think that there is a reliable literature on the long-term outcome of gender transition surgery even in those cases, because the phenomena we’re discussing is much newer than that. So, the data aren’t—it’s very difficult for the data to be in yet, so I’m wondering again why you concluded that it’s not working.

Well, there are a number of reasons. First of all, you know, obviously, I used Lisa Litman’s study, which was the jumping-off point for my book, a Brown University public health researcher who looked into this. You’re also seeing clinicians report the same across the Western world that they’re seeing a sudden spike of gender dysphoria that seems to be pure motivated or claimed gender dysphoria that seems to be pure motivated and social media motivated.

Okay, it’s not an organic problem, and it doesn’t look like traditional gender dysphoria. You’re also seeing numbers of detransitioners explode on YouTube. So if you go to YouTube, week to week, the number of detransitioners—and you’re right about the timeline, by the way, of course that’s always going to be relevant. So testosterone does deliver a high, as you said, and it does suppress anxiety. So some women who self-medicated with it feel great after they’ve started a course of testosterone, but very often, if you listen to these transitional accounts—I’ve listened to many, many of them—they will report that then after that, you know, spike, their anxiety and depression came right back, and there’s a woman I recently listened to called Waffling Willow she goes by on YouTube, who did a 12-part series on my book. I never met her; I didn’t know about her until she did this, but she’s a detransitioner and did a 12-part session on my book in which she said, “Yes, this was totally her experience as a teenager.” She transitioned very quickly, and at first she felt great on the testosterone and then she realized that—and then she had basically a crash in which all of the other mental health issues that she had returned.

Yeah, well, that’s a good example of the difficulty in doing longitudinal mental health outcome studies, especially in an uncontrolled environment. Clinical studies are notoriously difficult to conduct, and the time frame problem bedevils them. And this is, this is a particularly nasty situation given that testosterone produces that initial high. So you can cherry-pick your data to some degree if you look early in the transition process; you might well see an improvement. And then you can argue about what’s contributing to that, you know, whether it’s just the pharmacological effect of the testosterone or if it is actually proof that the gender identity confusion in question was real.

There’s also, of course, the Tavistock report out of the gender clinic—the largest gender clinic in the United Kingdom—which showed that there was no mental health improvement, no improvement in suicidal ideation for young women who had been started on puberty blockers and then cross-sex hormones. So, you know, we aren’t seeing the improvement that was supposedly, you know, claimed as the rationale for starting young people on these treatments.

Yeah. I wonder—I’m going back to something that we talked about earlier when we were trying to pin down what the motivation for this ideology might be, like the notion that your identity is yours alone to determine strikes me as it’s profoundly—it's profoundly narcissistic. It seems to me to be predicated on the idea that you have the right to be master of your own domain, master of your own outcome, regardless of people around you. You’re the only person that has to be taken into account. So that would go along with the express claim that you’re the only person that can determine what your identity is. It seems to me to be a very infantile and narcissistic wish that that might be the case. You know, that you could decide who you were and that the world would be forced to bend around your will.

And I can understand that, again, as I said, because everybody fights a battle against society molding them and destroying their individuality while they’re socialized. It’s a—there’s something there that’s valid to rebel against. But generally speaking, as you mature, you start to understand that you have to negotiate your way through the world with other people and that the benefits of being acceptable to other people outweigh the costs to your own narcissistic self-determination. And it’s the desire to not have to contend with that compromise that drives, I believe, that drives the insistence that you are the only person that can determine your identity.

That's right. I think that the activists in this movement have a lot more in common with, say, the Black Lives Matter movement and others such, you know, so-called woke movements than they do with adult transgender people. When I talk to interview, you know, adult transgender people, they don’t insist that they were always girls or always boys. They don’t ask you to suspend reality. They say, “Look, I had gender dysphoria from the time I was a child. You know, I struggled with it for many years. As an adult, I went through therapy, and I realized this was the way to, you know, calm my gender dysphoria, and this is how I’m most comfortable presenting.” That’s not imposing anything on the world, really. But the group of insistent activists, many of whom are not transgender themselves, but insist that we suspend reality—that medical professionals agree with them, “Yes, you were always a girl, or you were always a boy”—this kind of stuff. This is an aggressive ideological movement that really has nothing to do with gender dysphoria per se.

Yeah, well, I’ve been trying to put my finger on, while I was reading your book, as well, what it is that’s the driving factor. And you know, if you look at—there’s broad philosophical streams like those that emerge from the writings of Rousseau that claim that human beings as individuals are essentially good and pristine in their fundamental nature and that culture is what corrupts them. You know, it’s a very one-sided view. You can take the Hobbesian perspective, which is exactly the opposite and say, “Well, people are self-interested, narcissistic, and malevolent, and it’s only society that makes them good.”

And I would say a balanced viewpoint emerges if you integrate both of those views—even though they’re paradoxical to some degree. You pay for your socialization and you benefit, and you sacrifice something of value, but you also gain. And that’s what you decide, if you’re mature. If you stay locked in the notion that social pressure in and of itself is the perverting force that destroys your soul and your psyche, then you’re going to be motivated to push as hard as you can to justify your claims that your identity is something that you yourself determine, and that no one has any right to interfere with that whatsoever.

And maybe if you have to sacrifice people in order to justify that claim, that’s okay, because the claim is important enough to you that those sacrifices are warranted. You know, I got a sense of horror, in some sense, from reading your book, especially when you started to describe the surgery. And so maybe we could walk through that a little bit.

Let’s say that you do decide to walk down the gender transition road as an adolescent female. You can look forward to a high that’s generated by testosterone, and maybe that’s something short-term and positive, but what else can you look forward to?

Well, I suppose then the next—what can you look forward to? No, I’m being facetious. Gotcha.

Yes. Well, the—the—so the testosterone delivers that, but it also comes with risks. I don’t know if you want me to talk about those.

Yes, I—and also the experience. You talk about voice deepening and hair development and all of that. Walk through it. What happens to a person if they if they go down this road for the—in the first few months on testosterone, at 10 to 40 times what a young woman's body would normally experience? Her voice will change and masculinize—that does not seem to go away. You know, her features will change; they will round; her shoulders will broaden, and it will redistribute fat. So if she’s concerned about her fat, all of a sudden, wow, she’s lost weight, and she can develop more muscle. The problem is that a lot of these changes are permanent: the masculinization of the facial features and whatnot. And also, that comes with a very big risk of cardiac arrest, and cardiac risk seems to be, you know, much, much higher than a woman would normally experience—even more than a man would normally experience, it seems.

And you also discussed the effects on fertility and sexual threat, right?

So, vaginal atrophy and uterine atrophy occur. There can even—it can be quite painful, and so in some cases making intercourse impossible if there’s enough atrophy. It’s quite painful, and because of the increased risk of endometrial cancer, doctors typically recommend that at five years on testosterone, a prophylactic hysterectomy. So even assuming that the testosterone doesn’t impact her fertility, which it may, the hysterectomy certainly will make that impossible. So, you know, those are some of the risks of testosterone.

But the biggest risk of all, of course, is that we have no idea all the long-term effects of what testosterone at 10 to 40 times what her body would normally happen will do to her.

Right, and that’s a long-term course of treatment, right? Because she can’t go off it, because if she goes off it at any point, she will—some of her changes will revert. She’ll go back to an in-between male and female look. So once you start, you become a permanent medical patient. And we just don’t know—we don’t have enough evidence of what this—what will happen, you know, to this patient population—all the problems they will incur in the long term. Then, of course, there’s double mastectomy, which is the only cosmetic surgery I’m aware of that you show up without a mental health professional’s note—even as a minor, you can have your breasts removed. It destroys biological function; obviously, it destroys all capacity for breastfeeding as well as erotic function very often. And, um—and you outline some of the potential side effects of that as well, um, the—I believe monthly engorgement of breast tissue and leaks and that sort of thing as a consequence of only partial removal of the breast tissue. I got that right, right?

And whether the testosterone is enough. I mean, you know, if you go off testosterone, your breasts may refill with milk even after they’ve been removed. You may have some drainage problems. I mean, drainage is another side effect that often happens very often. Women are unhappy with the look; they want a second surgery to repair the look of it. And why are they unhappy with the look? Because they’re—they’re chasing an asymptote; they’re running after a horizon—the final look of being a man, which is always a little bit out of reach.

I mean, I—I—some of the people I interviewed for the book were forensic anthropologists, because I wanted to know about skeletons. What—you know, are there skeletal differences between men and women? And it turns out there are—even the sloping of the forehead won’t be quite right; they’ll be smaller; they’ll have smaller hands; they’ll have differently shaped pelvises. No matter what other, you know, surgeries they get, they’re actually—their femurs will attach differently for a woman than they do for a man, right? And that accounts for the difference in gait. And there’s a difference in the angle of the forearm connection to the upper arm as well because of the difference in hip-to-waist ratio—all these subtle differences between men and women. It’s hard enough for a man to be an ideal man, much less a woman to be transformed into an ideal man. And if you’re an individual who has some questions about the acceptability of your physical appearance, then you can imagine that it’s quite likely that that’s going to be maintained as you make the transition to another gender.

Right, and there’s something else I asked one of the doctors about because I started looking at many pictures of the young women who had received a double mastectomy, and I noticed something. I said, “Wait a second, look at their hips. They have a woman’s hips, which become even more obvious once they’ve had their breasts removed.” So, you know, the doctor said to me, “That’s right, there’s a surgery; there’s another surgery they can get if they’re concerned that their hips are protruding too much.” So you see that there—that this is not an easy fix, and yet it’s being doled out, you know, quite casually.

Right, and by casually, you mean that there’s no screening in place, essentially, to stop women from beginning this transformation process and that also you point out that so many medical health insurance schemes, like those provided by universities, now cover the testosterone, certainly, but also the medical procedures themselves to reduce their costs to a point where they’re much more accessible than they would be otherwise.

That's right. I talked to a woman a week or two ago whose daughter suddenly decided she was trans at university. She was at a very top American university, and at university, she not only started a course of testosterone, but she was able to get her breasts removed.

Yes, well, that would be rather shocking news for any parent to contend with. So let me shift gears for a minute, if you wouldn’t mind. What has been the personal consequence for you of writing this book? I mean, I can’t imagine hitting a more active hornet’s nest. So is it okay that you wrote it? Do you regret writing it? And what’s happened personally to you because you’ve written it?

You know, it’s been something of a journey. You know, when I started this project, it was—so, you know, once I started, I was just in a sort of a constant state of shock and revelation, and I couldn’t really believe this was happening. And it struck me the more I investigated it. It struck me as such, so obviously madness that there would be no, you know, oversight and no, you know, guardians or gatekeepers in place that I just kept thinking at the end of this everyone’s going to be shocked and, you know, this will become a safer procedure or, you know, everyone will have to agree. I didn’t write the book for religious people; I didn’t write the book for conservatives. I just wrote it for common sense people who were interested in the number of teenage girls suddenly coming out as transgender.

And I was—I can’t even tell you how many parents have called me since the book came out, while the book was coming out, telling me that 20, 30, 40% of their, you know, whatever—very high—15, 20, 30% of their daughter’s seventh grade class suddenly decided they were transgender, sometimes at girls’ schools. The boys weren’t even relevant; it was at a girls’ school—or at least they weren’t around.

So on the one hand, I—and then, then, of course, in England, the high court came out and it came out with a decision that effectively verified everything I had to say in the book. They said—

Right—that was the case of the detransitioning girl.

I mean, I thought—five years ago, I thought—or more, I thought this will all come to an end when these adolescents hit adulthood and start to bring the lawyers into play for everything that was done for them, let’s say, when they were teenagers. And that high court case—do you want to just outline that briefly?

Sure. A young woman named Keira Bell brought a case against the—she brought a claim against the Tavistock Gender Clinic in England in which she said, “I was started on these treatments—hormone treatments. I was sure I was transgender. I started—I, you know, I had never had a childhood history of gender dysphoria, but as a teenager, I was very uncomfortable in my body and I decided I was transgender. And at 16, I was started on the course of puberty blockers and then cross-sex hormones.” She eventually went on to have her breasts removed, and she realized as a young woman in her 20s that she had gone down the wrong path—that none of this had made her any happier and that she wasn’t supposed to be transgender—she was a lesbian. And that was all, and she had no—and she was very upset that nobody had stopped her. Nobody had exercised any judgment. It had been a celebration-only zone from the moment—even from medical professionals and therapists—from the moment she decided she was transgender. And the court looked at this population of teenage girls and was horrified.

And if you read the decision, you know, as I have, and written about it, it just came out in December.

Right, right. They said that it’s basically, you know, young people under 16 should not be allowed to give informed consent. They can’t give meaningful consent to doing away with their future fertility, their children, and there’s, in no sense, is this informed consent for a possibility of a sexual life, because in many cases, they—this may lead to sexual dysfunction—they can’t foreclose sexual life, a healthy adult sexual life, and fertility as minors. You know, how many 19-year-old women who claim to not want children have children in the upcoming decade? I mean, I don’t know the statistics, but I do know that a very large number of 19-year-old women that I knew when I was 19 had decided that they weren’t going to have children, and all of the ones that I knew either eventually had children or were very unhappy that they didn’t, you know, by the time they had hit their mid-30s.

And so that’s right—I mean, we don’t know that much about our future selves, and the question is, under what circumstances should we be allowed to sacrifice them? You know, so that—that’s right. And that’s the problem. It’s not that these girls are having these feelings, but that our adults are immediately supplying the irreversible treatments without any medical judgment or differential diagnosis.

Well, you also—this is part of what’s horrifying about your book. We didn’t talk about some of the other surgical complications, for example, with regards to phalloplasty, which we might want to dive into just briefly, because I wasn’t aware of the mechanics of that particular operation, let’s say, and it’s enough to give you pause, I would say.

In any case, well, let’s do that now. Why don’t you talk about phalloplasty and describe that?

Sure. It begins with the de-sleeving of the forearm. They have to remove the fat and muscle from around the forearm. That’s what’s used as the shaft of the neophallus.

How much is removed?

Oh, gosh. Many inches. If you see young women’s videos, you can go online and see views of women who’ve had their forearms de-sleeved. It’s a long stretch of the forearm in order to get enough skin to form the neophallus. Then they have to transfer a peripheral artery and nerves to that area. They have to graft it. Obviously, it’s extremely difficult work. Future surgeries are needed if you needed to be able to—first of all, just making it able to have a urine stream without infection is extraordinarily difficult. Often that, you know, complications include urine that sprays rather than streams. It’s extremely difficult to achieve, and, and then, of course, having it harden at all is difficult. It requires a further surgery.

And what does the surgery entail for that? Is that inflatables?

Yes, that’s right. There’s some sort of inflatable thing put into what would be like the sort of the testicle—I mean the manufactured scrotum—so that to make it inflatable. But it’s very hard to get it hard. It’s very difficult to get it hard enough to penetrate for sex. And if you do get penetration, what’s the pleasure that, are they able to get the same amount of sexual—or the, you know, achieve orgasm?

Actually, that depends on—I don’t know how often they’re able to achieve any kind of sexual orgasm, but I do know that, you know, if they start out if their puberty is blocked by early on, and then they go to cross-sex hormones and then they have these operations, sexual dysfunction and inability to ever achieve orgasm becomes much more likely, because they never finished their, you know, all the Tanner stages involved in, you know, making a young person be able to eventually achieve orgasm.

So, um, there are a lot of problems. And but the biggest problem with the surgery, I’m told—you know, I’ve interviewed a lot of surgeons, and I’m told that surgeons who do this very well and are very skilled at this and very highly trained in this can do a pretty impressive phalloplasty. But the problem, of course, is these are big moneymakers, and for hospitals, there’s a lot of pressure to do this surgery. And I keep hearing from surgeons that the people who are doing these surgeries are very often not qualified. They’re not qualified to transfer peripheral nerves—each of these micro-surgeries involves a different separate fellowship, and they haven’t done those because the hospitals are so desperate to make this extra money that they’re not putting the safe—they’re not applying the traditional safeguards that they normally would.

It doesn’t take much imagination for someone who’s undergone surgery or who has witnessed someone who underwent surgery to imagine just exactly how complicated and difficult this is, especially to bring about anything approximating success.

So we didn’t finish our discussion of the impact on you personally. So you said that you were continually shocked. I imagine somewhat demanding psychologically to do the research that was necessary to write the book, but then there’s also the consequence of publishing it and the notoriety or unpopularity that that might have produced, right?

So I suppose, you know, I suppose I would fall into disagreeable as my personality category that I learned from you. In the sense that, you know, I’m not someone who—I—you know, things—lies really bother me. They just bother me on a moral, intuitional level. So I really sort of wrote this not looking to make friends but just because, gosh, the truth seemed obvious, and it was fairly horrifying. And it didn’t affect me personally or my family personally, so if it had, I think I would have had trouble writing it. I don’t think I would have been able to—women who’s—and fathers, mothers and fathers, who’ve watched their daughters go through this are absolutely devastated, and it’s not something I would have been able to do if this had been a personal issue. But I wrote the book; I thought it was a very fair treatment.

It makes you wonder, too, when you’re doing analysis of the outcomes of surgery if you take into account the effects of that on the immediate family members, if that’s a valid scientific question. You know what I mean? That, like, you could say, “Look, the only person who’s ever affected by a surgery is the person upon whom the surgery is performed,” and perhaps that’s the case, and perhaps that’s a reasonable perspective, but we are embedded in familial structures. And if a surgical procedure makes a person a temporarily happy or even maybe happy over the long run, but devastates five other people, it seems to me that it’s at least worth asking the question of whether that should be taken into account, especially when you’re talking about teenagers.

Right. I don’t think it’s that it devastates the parents because they can't stand the thought of having a transgender child, son or daughter. In fact, they were overwhelmingly politically progressive and supported, and they were big—they considered themselves allies long before gay rights was possible, you know—sorry, gay marriage was possible in America. So, the—it wasn’t that they were so miserable and so devastated because they thought their daughters were so miserable and likely to—and regretting this already or likely didn’t regret it because they saw the lives their daughters were leading. So I think while I was writing the book, I just thought this is so obviously true. You know, everything—there’s everything in the book is true. Nobody has pointed to a single factual error, and the book has been under a tremendous amount of fire now for six months.

So, and how have you withstood that?

So I think that the hardest thing about the fire—in a certain sense, is all the— to be honest, I—you know, it’s all the polite people out there who who won’t even, you know, who are willing to say, “Oh, you know, you’re effectively provi—well you wrote that provocative book.” As if they don’t—they almost don’t seem not to know that it’s a journalist’s job to go out and investigate phenomena, especially cultural ones that seem to be real. I didn’t go looking for trouble. Trouble is all around us in America today. I mean, you know, I mentioned the—you know, states are lowering the age of medical consent across the country so that kids can get all kinds of surgeries. I mean, in Oregon, the age of medical consent is 15. So a 15-year-old in Oregon can get her breasts removed without her parents’ permission. Now, you don’t need to be a religious person to find that disturbing or alarming. You don’t need to be conservative, for sure. But just a thinking person who says, “Gosh, that seems really young! I know I had a lot of crazy ideas at 15.” I’m glad no one would have given me that option.

Who do you want to read your book?

Oh, I—you know, I mean—and the book’s for anyone to read, but I suppose parents—parents have been very helped by it, or they felt, you know, they felt it was very useful, in just helping them sort of develop a, you know, sense that they’re not completely insane when they think this is a whole lot of kids suddenly deciding they’re transgender out of the blue. This can’t be right; there’s no oversight—you know, feeling that they’re not alone. But, you know, I’m happy for people who are affirmative therapists to read the book. I mean, I’m happy for anyone to read the book. You know, unlike those who have called for my book to be banned and burned, I, you know, I’m not in favor of those things. I’d be happy for anyone to read it, and of course I would never want another book banned or burned.

And so you remain pleased with your decision to write it?

The truth is, I’m not sure I could have done anything else. I mean, once I was aware of what was going on, I wrote an article about it for the Wall Street Journal, and it’s got a huge amount of traction. I mean, people were writing to me across the country, even across the West, to say, “Yes, this is going on in their daughter’s school. Yes, let me tell you my story.” I mean, I’m sure there are people who could have walked away from that, but I’m not one of them. I thought, “Gosh, there’s something worth investigating here,” and how could I just walk away from that and not look into it?

Well, you know, I think that’s probably a reasonable place for us to end. What do you think? Do you have anything else that you’d like to say?

Oh, no. I just thank you very much for having me on, and, you know, I’m a big admirer of yours, and I really appreciate the opportunity to talk about it.