The Broken Chain of Trust in Pediatric Gender Medicine

The below essay was originally published in the City Journal based on a series of videos first published by The Ben Shapiro Show. 

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The American Medical Association (AMA) is the largest and most powerful doctors’ organization in the United States. It has also consistently supported pediatric medical transition, or “gender-affirming care,” which includes puberty blockers, cross-sex hormones, and surgeries administered to minors. The AMA has passed a resolution promising to protect these procedures, joined an amicus brief in a lawsuit challenging a state age-restriction law, and written a letter urging state governors to veto similar legislation.

The AMA has done all this despite the findings from systematic reviews—the gold standard of evidence-based medicine (EBM)—of weak evidence for these treatments’ mental health benefits, and despite the corresponding health risks. In 2021, AMA board member Michael Suk publicly called pediatric transition “medically-necessary, evidence-based care.” He did so after health authorities in several European countries, including progressive Sweden and Finland, had already begun to change course and prioritize psychotherapy for pediatric gender dysphoria cases.

Skeptics of the AMA’s position have wondered how a professional medical organization could have ignored systematic reviews. New videos, one of which was published by the Daily Wire, provide a possible answer. The videos reveal the AMA’s president, the Michigan-based otolaryngologist Bobby Mukkamala, making false claims about pediatric gender medicine and demonstrating ignorance of basic concepts in EBM. Mukkamala appears to believe that only doctors involved in medical practice can be trusted to evaluate the evidence for the treatments they perform. Where EBM sees a potential conflict of interest, the president of the AMA sees a credible source of expertise.

In accordance with his belief about expertise, Mukkamala recommended that a legislator consult with one gender doctor in particular, fellow Michigander Jesse Krikorian. The Daily Wire videos also reveal that Krikorian, like Mukkamala, is unfamiliar with basic principles of EBM and with existing research on pediatric gender medicine.

Together, therefore, the videos illustrate the broken chain of trust in American medicine: medical group leaders place trust in conflicted “experts,” who—deliberately or out of incompetence—mislead their colleagues.

The videos published on Daily Wire were recorded by Representative Brad Paquette, a Republican in the Michigan House of Representatives who has opposed pediatric gender transition. The first video, published Tuesday, August 26, contains a conversation between Paquette and Mukkamala, which took place after the two discussed gender medicine at a Michigan House Subcommittee on Public Health and Food Security hearing on April 15. Paquette also invited Eithan Haim, the surgeon-turned-whistleblower who exposed Texas Children’s Hospital for performing pediatric transition procedures, to join the call.

The second and third videos feature conversations between Paquette and Krikorian, whom Mukkamala recommended to Paquette as a credible expert on the evidence for pediatric medical transition. Paquette recorded all three conversations without his interlocutors’ knowledge, which he could do legally because Michigan’s eavesdropping law exempts conversations in which the recorder participates.

The AMA president, who knew in advance that Paquette was calling to discuss pediatric gender medicine, made two noteworthy claims on the call. First, he asserted that the suicide rate— not suicidal ideation or attempts, but deaths by suicide—among people who identify as transgender is between “50 and 70 percent.” He was clearly implying that gender-transition procedures for minors are necessary to prevent these tragic outcomes.

RELATED: Leaked Footage Exposes Top Med Org’s Support For Trans Procedures On Kids: ‘I’m Not An Expert At All’

This claim is baseless. Indeed, even the most outspoken advocates of pediatric transition refrain from saying that suicide—as opposed to suicidal ideation or attempts—is this high among trans-identifying youth. The truth about suicide in this population is complex, and the research is often mischaracterized by both sides of the debate. Suicide does appear to be higher among youth with gender dysphoria than in the general population, but existing data from the U.K. suggest that it is below one-tenth of 1 percent, and no studies suggest that it is higher in the United States or elsewhere. Last December, ACLU lawyer and LGBTQ & HIV Project co-director Chase Strangio admitted in a Supreme Court hearing that “suicide, thankfully and admittedly, is rare” among trans-identifying youth.

The best available research also suggests that co-occurring mental-health conditions, common in youth diagnosed with gender dysphoria, likely explain the elevated risk. No credible evidence shows that medical transition resolves or lowers the rate of suicidal behavior, and some evidence suggests that suicide risk remains significantly elevated—though still nowhere near the figures cited by Mukkamala—following medical transition.

Mukkamala’s assertion about suicide is troubling not only because it is false but also because it defies evidence-based recommendations for preventing suicide, which is known to be a socially contagious behavior. Finland’s leading gender clinician has called the suicide narrative—the notion that absent pediatric transition, gender-distressed youths will escalate to suicide—“disinformation” and those who use it “irresponsible.”

Last year, the U.K.’s Labour government asked Louis Appleby, a professor of psychiatry with expertise in suicide research and prevention, to examine claims that the country’s restrictions on access to puberty blockers have led to increase suicides. Appleby reported that the available data “do not support the claim” and added that “[t]he way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide.”

Mukkamala’s second claim on the call is possibly even more troubling, given that it came from the president of America’s largest and most powerful doctors’ lobby. When Haim asked Mukkamala why the AMA continues to make claims about “gender-affirming care” that are negated by systematic reviews of evidence, Mukkamala refused to discuss the matter. He even seemed annoyed that Haim felt entitled to review the evidence himself. In a later email exchange, Mukkamala said that “we should defer to the people that take care of patients with these issues,” as “no one else is an expert.”

READ MORE: Leaked Footage Exposes Top Med Org’s Support For Trans Procedures On Kids: ‘I’m Not An Expert At All’

Mukkamala’s admonition runs counter to two foundational principles of evidence-based medicine: that systematic reviews sit at the top of the hierarchy of evidence, while individual clinicians’ opinions sit at the bottom; and that experts who are personally invested—professionally, intellectually, or financially—in a given treatment are unlikely to evaluate the evidence for it impartially.

As a leading textbook in EBM emphasizes, financial interests are only one potential conflict. Nonfinancial conflicts, including intellectual conflicts arising from, say, advocacy or publication, can bias an expert’s assessment of the evidence and recommendations at least as much as financial ones.

Health organizations have embraced these principles in the context of developing clinical recommendations—a process that, in EBM, requires a systematic appraisal of evidence. The National Academy of Medicine (NAM) recommends having “unconflicted methodologists” lead the development of clinical practice guidelines “in collaboration with clinical experts who may be conflicted to a degree that would not preclude them from panel participation.” The World Health Organization counsels that experts personally involved in a particular treatment should not constitute a majority of the panel that develops official guidelines for the use of that treatment. In 2022, the Endocrine Society embraced NAM’s preference for reducing conflicts of interest, “even if doing so means that fewer well-recognized experts will be on its [guideline development panels].”

By Mukkamala’s logic, none of this makes sense. But the field of EBM was conceived in large part to address the cognitive biases that impair the judgment of even the best doctors.

An entire body of academic literature discusses medical authorities’ failure to follow or even acknowledge the best available evidence when doing so threatens doctors’ or professional organizations’ interests. As one group of authors observes, “the coalition for evidence-based medicine is weak” because it “includes too few doctors and attracts too little energy and political entrepreneurship from policymakers.” And medical associations are known to buck evidence review when they perceive a threat to their own interests or those of their members. Medical associations are trade unions whose “primary function . . . [is] to protect the autonomy and advance the interests of their members.”

Put another way, Mukkamala confuses two distinct types of expertise. Clinical expertise involves applying a standard of care to a particular patient, taking account of that patient’s unique needs, wants, and vulnerabilities. When the standard of care itself is in question, a different form of expertise—that of the methodologist—is needed.

To be clear, none of this means that researchers or physicians with conflicts of interest will always reach incorrect conclusions. But it does mean that their judgment should not be taken on trust. Had Mukkamala understood how EBM works, he might have indulged Haim’s questions—or found another reason not to engage.

After Mukkamala recommended that Paquette speak with Jesse Krikorian, the latter two met virtually over two hour-long sessions. The recordings leave no doubt that Krikorian is badly misinformed about gender medicine research and, like Mukkamala, seems unfamiliar with how EBM works.

In their second call, Paquette asked Krikorian about systematic reviews of evidence and the umbrella review in the Department of Health and Human Service’s report on pediatric gender dysphoria, which they had agreed in advance to discuss. Regarding umbrella reviews, which are systematic reviews of systematic reviews, Krikorian said, “Honestly, it’s not a term that I come across very often . . . . It’s not a term I was taught in medical school.”

Paquette wanted to understand how systematic reviews of evidence “fit in” to EBM, especially because “the AMA points to gender-affirming care as evidence-based medicine” despite systematic reviews finding the opposite. Systematic reviews are considered the gold standard in EBM because, properly done, they use a transparent and reproducible methodology that minimizes author bias, and because they not only summarize the research on a particular question but also evaluate it for quality. Krikorian, by contrast, explained that systematic reviews are essentially reading lists, which doctors can consult before using their own subjective judgment to evaluate individual studies.

Paquette pushed further. “But isn’t the whole point of a systematic review to assess the quality of studies—all of them?” “There should be some attention paid to the quality of studies . . .” Krikorian conceded. “But in general, the goal of a systematic review is to get a bird’s eyes view of the landscape of research on that particular topic.” Paquette wanted to know if Krikorian was familiar with the systematic reviews on pediatric gender medicine. “I am sure I could find some, but systematic reviews are not my go-to. I go to the individual [studies] where I can assess the quality individually.”

This inverts the pyramid of evidence in EBM. After Jack Turban, a “gender-affirming” psychiatrist at the University of California, San Francisco, made a similar comment in a deposition, Gordon Guyatt, a founder of the field of EBM, said that “anybody who doesn’t recognize that a crucial part of a systematic review is judging the quality or certainty of the evidence does not understand what it’s all about.” Guyatt’s judgment would seem to apply with even greater force to Krikorian.

The consequences of Krikorian’s approach were readily apparent. Krikorian, for instance, cited a cross-sectional survey as “valuable” evidence for the mental-health benefits of hormones, and in response to Paquette’s office’s request for “long-term studies and literature that is used to inform practice” ahead of their conversation, provided citations for three studies—Tordoff et al. (2022), Chen et al. (2023), and Turban et al. (2020)—that have been found to have serious methodological problems that render their self-reported conclusions unreliable. Since Turban et. al (2020) is a cross-sectional survey, it is inherently incapable of discerning cause and effect; it has other problems, too. Nevertheless, according to Krikorian, the three studies provide compelling evidence that “gender affirming hormone therapy . . . really improves mental health. It improves social functioning. It improves suicide rates.”

Krikorian expressed other bizarre views on the calls. For instance: “When you’re doing a literature review, you look back maybe 10 years. You don’t look back farther than that.” While changing social or cultural context can be relevant in assessing research findings, when a study was conducted is far less important than how it was conducted. A 15-year-old, double-blinded randomized controlled trial will give you far more reliable information about a drug than a five-year-old, uncontrolled observational study of the same drug.

When discussing the risks of cross-sex hormones, Krikorian minimized the side-effects, or even cast them as desirable. “Most of the side effects are things people are looking for. They’re looking for beard growth . . . deepening voice, softer skin, more feminine distribution of fat.” Testosterone gives girls acne, “but acne is normal during puberty anyway.” For estrogen, “you may cry more during commercials, but for some that’s desirable.” Most disturbingly, Krikorian assured Paquette that “these are chemicals that half the population is making naturally . . . . These are chemicals that occur in 50 percent of bodies.”

This is dangerously misleading. The Endocrine Society recommends using drugs to achieve testosterone levels in females undergoing “gender affirmation” between 320 and 1000 ng/dL—at least six times higher than the normal range for pre-menopausal women (15-46 ng/dL). Side-effects of these treatments include vaginal atrophy, clitoral growth (which can lead to painful chafing), pelvic floor dysfunction, and mood disorders. Males who take estrogen face heightened risk of cancer, cardiovascular disease, and infertility. The evidence for these harms is growing. In effect, “hormone replacement therapy” in the context of “gender-affirming care” is a way to induce endocrine disorders.

Krikorian did not seem bothered by the risk of infertility, because “at 13 or 14,” adolescents “have some insight into the seriousness of whether or not [they’re] going to be able to have children.” (Last year, videos published as part of the “WPATH Files” revealed Dan Metzger, an endocrinologist, saying that talking to 14-year-olds about fertility is like talking to “a blank wall.”) Krikorian also insisted that 12-year-olds can anticipate what going through puberty will be like, falsely asserted that the regret rate for hormone use is between 0.5 percent and 2 percent (Mukkamala also repeated this unsubstantiated statistic), and assured Paquette that “most of Europe is moving toward easier access to intervention.”

When Paquette asked about the World Professional Association for Transgender Health’s suppressing evidence, failing to manage conflicts of interest, and eliminating age minimums under pressure when drafting its current “standards of care”—facts reported variously in the New York Times, the Economist, the Atlantic, and other major outlets—Krikorian responded, “I don’t have a New York Times subscription. They’ve had some pretty off-the-wall stuff on trans issues in general, so they’re not my go-to.”

Particularly jarring was Krikorian’s repeated use of “folks” when referring to children and young teens. This is standard practice in pediatric gender medicine and quite obviously is intended to obscure minors’ immaturity and inability to make autonomous choices. In no other context do adults carefully avoid using “children” or “teenagers” and instead refer to 11-year-olds as “folks.”

I don’t think that Mukkamala is an ideologue, though his lack of collegiality toward Haim, himself an AMA member, was unbefitting of a medical professional. Mukkamala’s motives are likely more prosaic. He is the newly elected president of the nation’s largest medical association, whose reputation he does not want to compromise at the outset of his tenure. He likely has career ambitions and does not want to be called “transphobic.”

Above all, Mukkamala seems sincerely to believe that doctors are the most trustworthy assessors of the evidence for their own practices. This belief, I have come to understand, is characteristic of many American doctors. It is also colored by self-interest. If Mukkamala defers to “experts” like Krikorian on gender medicine, then Mukkamala can expect similar deference from colleagues when questions arise concerning otolaryngology. But whatever his motives, Mukkamala has a duty to ensure his organization does not support harmful treatments that lack basis in science and medical ethics—something, so far, he’s failed to do.

Leor Sapir is a senior fellow at the Manhattan Institute. He holds a Ph.D. in Political Science from Boston College and completed a postdoctoral fellowship at the Program on Constitutional Government at Harvard University.

The views expressed in this piece are those of the author and do not necessarily represent those of The Daily Wire.