"This is How Medical Institutions Became Captured!" | Joseph Figliolia
23 April 2026
With Joseph Figliolia
North America
The Cass Review concluded that UK medical guidance on paediatric gender treatment had developed without adequate evidence scrutiny. This episode, featuring Manhattan Institute policy analyst Joseph Figliolia, examines the mechanisms behind that failure through a US lens — showing how medical associations adopt positions by deferring to a narrow cluster of sources rather than conducting independent appraisal, a pattern the Cass Review's findings suggest is far from uniquely American.
Joseph Figliolia is a policy analyst at the Manhattan Institute whose work focuses on how professional medical associations form and communicate positions on contested clinical questions. In this episode he walks through his examination of the Texas Medical Association as a detailed case study in how a major medical body arrived at an institutional stance on paediatric gender treatment — not through its own appraisal of the clinical literature, but by deferring to a small number of organisations whose positions in turn referenced one another. Figliolia uses the term 'citation cartel' to describe this dynamic: a closed loop in which a handful of associations — including WPATH, whose Standards of Care have exerted significant influence on clinical practice internationally — cite each other's statements as though each represents an independent evidentiary anchor. The result is the appearance of broad professional consensus built on what is, on closer inspection, a much narrower and more circular base. He also examines the Tordoff study, one of the most frequently cited pieces of research in policy arguments for paediatric gender interventions, and the methodological questions that attend it. For those following the UK picture, the parallels with what the Cass Review documented are striking. The independent review, completed in 2024 after examining the evidence base used to justify treatment pathways at NHS England's Gender Identity Development Service, found that the quality of research underpinning clinical recommendations was consistently poor, and that professional guidance had been developed without the rigorous independent evaluation expected in any comparable area of medicine. NHS England subsequently suspended puberty blocker prescribing for gender dysphoria in under-18s, and the interventional pathway has since been subject to wholesale redesign. The episode also explores the internal mechanics of how medical societies process policy questions — specifically the role of reference committees, which filter and frame resolutions before they reach a full membership vote. Figliolia describes how this procedural layer can shape outcomes in ways that are largely invisible to the broader membership and to the public, concentrating effective decision-making power in a small number of hands. The framing of certain interventions as 'necessary' rather than 'elective' care also receives attention, with significant implications for the clinical and ethical arguments deployed in debates on both sides of the Atlantic. The relevance of this analysis extends well beyond Texas. UK professional bodies, including the British Medical Association and the Royal College of Paediatrics and Child Health, have faced their own questions about the robustness of the processes by which they adopted positions in this area. Parliament's scrutiny of NHS England's response to the Cass Review, and the sequence of legal proceedings — including the Bell v Tavistock case in the Court of Appeal — all reflect the same underlying question Figliolia raises: whether institutional positions represent genuine evidence appraisal or the amplification of a pre-existing consensus that was never as well-founded as its proponents maintained.
