Religion is a Mental Illness

Eager to ‘Affirm,’ Yet Unwilling to Debate

A prominent South Carolina doctor and transgender rights activist has made a great show of calling England’s Cass Review “a sham at best”—bu

Quillette

In April, Dr Hilary Cass, a former president of Britain’s Royal College of Paediatrics and Child Health, published the most comprehensive scientific analysis of paediatric sex-trait modification procedures to date. These procedures, often described as components of “gender-affirming care” (GAC), serve to align a child’s physical features with his or her claimed “gender identity” through (typically irreversible) hormone regimes and surgeries, which often lead to sterility and other serious medical side effects. The Cass Review, as it is commonly known, reported that the evidence base supporting the use of such procedures was “remarkably weak.” Moreover, while it’s been widely claimed that hormone treatments reduce the elevated risk of death by suicide among trans-identified children, Dr Cass found that the available evidence “did not support this conclusion.”

The response to Dr Cass’s findings has been dramatic. England’s National Health Service, which commissioned the report, expressed gratitude to Dr Cass and committed to implementing her recommendations. These include prioritising psychotherapy for gender-distressed youth, and phasing out the use of puberty blockers as part of England’s publicly funded healthcare system. Following the publication of the Cass Review, Scotland and Wales joined numerous other European jurisdictions—many of which have conducted their own reviews, and reached similar conclusions—in restricting the use of puberty blockers and cross-sex hormones to treat minors. Several international bodies have also issued policy statements praising the Cass Review for its thoroughness and lack of bias.

However, while these international authorities are reforming their policies in accordance with the latest scientific evidence, medical organisations in North America have generally remained steadfast in their support of GAC. The American Academy of Pediatrics and the Endocrine Society, for instance, both recently issued statements defending their support of GAC practices as “grounded in evidence and science,” and “based on a thorough review of medical evidence, author expertise, rigorous scientific review, and a transparent process.”

Despite these assertions, however, no major medical organisation or scientific publication has (to my knowledge) published a detailed rebuttal of the findings contained in the Cass Review. The only ostensible exception is an article from the International Journal of Transgender Health‚ the official journal of the World Professional Association for Transgender Health (WPATH), whose author, Cal Horton, is a self-described “researcher & intersectional feminist… upholding a defiantly non-binary reality (they/them),” as well as a “specialis[t] in trans inclusion and Applied Trans Studies.” By means of what is grandly presented as a qualitative “inductive and deductive reflexive thematic analysis,” the author denounces the Cass Review as “an example of cis-supremacy, within a cis-dominant healthcare system lacking accountability to trans communities.” Interpret that as you will.

As the global trend shifts away from “gender-affirming care,” one might expect that proponents of GAC would be eager to publicly defend their practices, and to set out the facts and arguments that, as they see it, Dr Cass and her many international counterparts have ignored or misinterpreted. Specifically, one might imagine that they’d revisit the policy of “no debate” that has long been enforced within the trans activist community (typically on the stated grounds that the very act of debate would serve to invalidate, or even threaten, the existence of transgender individuals).

And yet, this hasn’t happened. Just the opposite: It appears that the definitive nature of Dr Cass’s report has caused defenders of GAC to become even more skittish about publicly defending their practices.

Last week on X (formerly known as Twitter), South Carolina-based doctor Michael O’Brien dismissed the Cass Review as a “sham.” As a paediatrician and outspoken advocate of GAC who’s made a name for himself on X by aggressively criticising anyone expressing divergent views, he may be fairly described as an influential American voice when it comes to treating gender-distressed youth—and therefore a worthy candidate for inclusion in any debate on the subject.

Following Dr. O’Brien’s outburst, I joined with my Manhattan Institute colleague Dr Leor Sapir, a gender-medicine expert, in inviting Dr O’Brien to participate in a good-faith scientific exchange on my Substack, Reality’s Last Stand, which provides regular editorial coverage of the issues Dr Cass examined. We offered to donate $250 to a children’s hospital of Dr O’Brien’s choice if he agreed to participate in the discussion. Our hope was that he would elaborate on his claim that Dr Cass had produced a “sham,” complete with data and scientific citations.

Dr O’Brien responded as follows: “I help kids and families with shared, evidence-based, complex medical decisions. [Dr Sapir is] a non-expert corporate pawn looking to make a quick buck. My answer is: f*** no.” He then blocked us both from seeing any of his future posts, and continued to justify his refusal to engage in the discussion on the grounds that it would somehow benefit us financially. (Since this time, Dr O’Brien has switched his X account to protected mode.)

This effort at deflection is nonsensical for several reasons. Firstly, as noted above, Dr Sapir and I had each pledged $250 of our own money to a children’s hospital in return for his participation. Secondly, I promised that the written debate would not be published behind a paywall, so as to ensure it received the largest possible audience without providing me with any direct financial benefit. I also indicated that I would donate any incidental revenue from new Substack subscriptions, as well as donations related to the debate, to the children’s hospital of Dr O’Brien’s choice. 

As our public exchange garnered attention, other X users started making their own financial pledges to encourage scientific debate on this issue. Dr Eithan Haim, a Dallas-based surgeon, pledged $500, for instance. Dr Emma Hilton, a developmental biologist at the University of Manchester (and Quillette author), pledged £100.

As I saw this as an important opportunity to open up a dialogue on this subject, in defiance of trans activists’ oddly dogmatic “no debate” policy, I even started a GoFundMe campaign to raise funds for the children’s hospital of Dr O’Brien’s choosing. The stated condition was clear, however: Dr O’Brien would provide a detailed critique of the Cass Review, outlining his reasons for dismissing it as “a sham at best,” and engage with at least one rebuttal from Dr Sapir.

Launched on 23 May, the GoFundMe campaign attracted more than $5,000 in pledges in just two hours. By the morning of the 24th, contributions had exceeded $10,000. That evening, a surprise $5,000 donation from J.K. Rowling, coupled with her encouragement to others to contribute, propelled the total beyond $20,000. On 29 May, we reached our goal of $30,000.

That’s over $30,000 to a children’s hospital of Dr O’Brien’s choice if this paediatrician agrees to engage in a scientific discussion about the Cass Review and GAC—a discussion that one might expect Dr O’Brien to regard as an urgent imperative given his fervent advocacy of GAC, his (presumably informed) opinion that the Cass Review is “a sham,” and his (presumed) fear that “trans kids” (as he describes them) are at mortal risk of being denied GAC on the basis of Dr Hilary Cass’s views. Assuming Dr O’Brien is able to debunk the Cass Review (in keeping with his sweeping denunciation of its validity), what would be the downside—for him or anyone else?

Although the fundraiser has garnered significant attention (one presumes he is familiar with Rowling as both an author and advocate), Dr O’Brien has yet to revisit his previously stated refusal to participate. Alas, today I will therefore be forced to refund over $30,000 in donations that would otherwise go to a children’s hospital so that children of all types, including those “trans kids” Dr O’Brien purports to care so deeply about, can receive better medical care. To do otherwise would violate the representations I made as part of the GoFundMe campaign.

However, I strongly encourage donors to consider personally reallocating their contributions to a children’s hospital of their choice—or to one of several organisations working diligently to inform doctors, parents, and policymakers about the risks associated with GAC. Among the organisations leading these efforts are the LGBT Courage Coalition, the Society for Evidence-Based Gender Medicine, Genspect, Do No Harm, and Therapy First.

I believe that all children and adolescents, gender-distressed or otherwise, deserve evidence-based care. And I’m sure Dr O’Brien shares this goal. I hope that this fundraiser will prompt gender-affirming doctors to reassess the logic of their extreme “no debate” policy, and ultimately abandon it. Open discussion of the science is the only way to ensure children receive the evidence-based care they need and deserve.