Notes on a medical scandal

We may never know how many children in Britain have been damaged by thoughtless, if well-intentioned, gender-affirming medicine

In 1998, Dutch clinicians revealed the existence of “B”, a “female-to-male transexual” who, at the age of 13, had her puberty blocked by drugs prescribed by a paediatric endocrinologist and who was now, at the age of 16, demanding sex reassignment surgery. As Hannah Barnes relates in “Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children”, “This was the first known case of a young person having their puberty blocked before 16 for the purposes of treating gender-related distress”.

“When” as the Dutch put it, “no psychological obstacles remained” B was deemed eligible for cross-sex hormones as a precursor to sex-change surgery. Aged 18, B began taking hormones and subsequently had her breasts and ovaries removed. A year later, the Dutch reported that B reported “no gender dysphoria at all” and “never felt any regrets about his decision and had never contemplated to live as a girl”.

By the turn of the century, B’s experience had become a prototype for treating young people experiencing distress caused by or related to their gender identity. If a person suffered from “extreme gender dysphoria” - the mismatch between a person’s physical reality and their conception of themselves - and was “psychologically stable” and benefitted from a supportive home environment, they could receive puberty-blocking drugs from the age of 12, cross-sex hormones at 16, and surgery at 18. Thus was born the so-called “Dutch protocol” which would, with startling enthusiasm, be adopted by gender clinicians across much of the western world.

Including by doctors at the Gender Identity Development Service (GIDS) at the Tavistock and Portman clinic in London. Over the following 20 years, the number of children referred to GIDS multiplied nearly 30-fold and thousands of children were put onto a medical pathway of uncertain safety. The impact of puberty blockers on a young person’s body was, and is, largely unknown. There are concerns blockers - designed as a short-term remedy for people with precocious puberty - reduce bone density and may have an impact on brain development. Much remains unknown but we do know that at GIDS almost everyone prescribed puberty blockers went on to take irreversible cross-sex hormones. Some of them now regret this.

This is the story Hannah Barnes, a veteran investigations editor at the BBC, tells in her book. It is a story of and for our time.

No fewer than 22 publishers passed on the opportunity to publish “Time to Think” and there is little need to spend much time speculating on the reasons for their doing so. Too difficult. Too much controversy. Too much hassle. It is worth congratulating Swift Press, a small independent publisher, for their fortitude in taking Barnes’ book on. It is not just one of the most important political and medical books of the year, it is one of the best too. 

Almost every page contains something noteworthy. Barnes is scrupulously fair, though she cannot avoid noticing that those GIDS clinicians most supportive of the service are also those least likely to allow her to use their names. It is not her fault that Polly Carmichael, the GIDS head of service, declined to be interviewed for her book, though it is typical of the approach Barnes takes that Carmichael is afforded the opportunity to respond to criticisms made of her leadership. 

It is also important - extremely important - to note that for some children the service delivered precisely what they needed. The testimonies from former patients make it clear that while GIDS may be a scandal in the round, for particular children it was also a lifeline. It is hard to read the accounts of former patients without feeling deeply moved by them. These are questioning, intelligent, articulate young people: individually they are impressive and it is hard not to admire their collective bravery. 

And yet, time and time again the testimony from former clinicians forces the reader to ask the same questions Barnes addresses: how did this happen and why was it permitted to happen?

Some statistics are shocking. No more than two percent of children in the UK have some kind of autism yet at some points more than a third of children referred to GIDS were also on the autistic spectrum. At no point does this appear to have been something which warranted proper exploration. 

Nor was much time spent wondering why referrals to GIDS increased so rapidly or, pertinently, why a service once slightly more likely to be used by gender-questioning boys became one dominated by girls disgusted with their own bodies. 

The rate of increase was remarkable: 97 referrals in 2009/10 became 2,748 in 2019/20. The number of girls referred grew from 40 to 1,892 in the same period. GIDS were not just seeing vastly more children, the type of children they were treating was also very different. Assumptions based on a tiny number of, often, male children continued to be treated as though they were equally applicable to a hugely higher number of patients, most of them female. 

Once in the system, everyone was deemed capable of understanding, or at least consenting too, the treatment offered them: out of 1,089 patients analysed for a paper published last year, just one was “judged to lack the capacity to consent to treatment”. 

Paraphrasing a clinician’s remarks, Barnes explains the fundamental issue: “Were children ‘born’ with something, possibly genetic, that ‘rarely changes’ and credits they will be happily trans forever? Or could it be that sometimes other life events might contribute to gender-related distress in a child - for whom the best solution might not be to transition?” Over time, this clinician argues, GIDS moved closer and closer to the former position. If so, it may because concerned staff left, while those keenest on the “affirmation” model remained in post. 

Experienced clinicians report that the children they were seeing often had other problems: eating disorders, depression, a history of self-harm, chaotic family backgrounds. Many were bullied at school. Some came from families with a record of sexual abuse. Others had parents who found it easier to have a trans-but-straight kid than a gay one. 

One clinician at GIDS’ northern outpost in Leeds had a caseload, Barnes writes, which “included children with parents who’d been long-term psychiatric patients, families where the mother had accused the father of rape, a number of children who had only ‘minimal verbal communication skills’, and ‘many’ who had witnessed domestic violence. Three percent were families where a parent was a registered sex offender”. (On that latter point, in England and Wales around 0.3 percent of adult males are registered sex offenders.) 

How could it be that so many children presenting with such varied causes of distress could all be treated in the same way? Amidst so much tumult, why was gender the sole, constant, variable whose “fixing” would by magic relieve all other problems? The questions were always very different but the answer was always the same. 

How many children have been put on puberty blockers? The Tavistock does not know and nor does anyone else. The lack of accurate record-keeping and data-collection would be a scandal of its own. As it is, it merely compounds a story of malpractice. I have been following this story for some years and while a good portion of what Barnes reveals was already in the public domain she adds an enormous quantity of new evidence and testimony in a book which already feels like a definitive account. I have not the slightest hesitation in suggesting it would be a more than worthy winner of the Orwell Prize for political writing. 

Again, it is necessary to note that clinicians did not see their patients as material for medical experimentation. They believed they were doing good work in extraordinary - and often extraordinarily difficult - circumstances. But good intentions were accompanied by a staggering lack of interest in outcomes. There was almost no long-term tracking of patients. One small study, concluded in 2014, found that while children were happy to be on puberty blockers - this was what they wanted from GIDS, after all - taking the blockers was not associated with any improvement in their mental health. They were just as unhappy, just as prone to suicidal thoughts, as they had been before they started on the only treatment GIDS provided them. There was no alternative to the medical pathway. 

In 2000, Dr Bernadette Wren, later the head of psychology for the Tavistock Trust, acknowledged “There is little evidence about the long-term effects of this intervention”. Twenty years later - I repeat, twenty years later - Wren conceded that “studies are still few and limited in scope” and “at times, contradictory or inconclusive on key questions”. Yet despite accepting the experimental, unproven, aspect of the treatment, little to no substantial research was done to discover the actual impact of medicalising children in this fashion. This lacuna seems scarcely credible and yet, there it is. Medicine, especially when involving children, is often plagued by uncertainty but few attempts were made, in this area at least, to resolve or reduce that uncertainty. 

One clinician tells Barnes that she could not think of any instance in which she recommended blockers “with a real sense that this is 100 per cent the right thing to do. Because how could you?” Even when it was demonstrated that everyone who took the blockers progressed to cross-sex hormones, there was no change in view. “I didn’t really see it as my job to know or to be sure. Because how could I? And how could anybody? I know that sounds really extraordinary, but what’s the nature of expertise in this field? Given the state of research, nobody’s got a clue really about what the life course of any of this is.” 

There was a clinician-lottery too. Some were much more cautious than others. According to one, some were “very pro-physical intervention” and a minority - albeit a significant one - of staff could make their more cautious peers “feel transphobic” for insisting upon a longer consultative process and a greater degree of questioning patients who, however sure they might be of their own status and feelings, might not actually always be as sure or certain as they seemed. 

Once more, perspective is important. Barnes writes that she has not found GIDS to be “in the grip of an ideology”. The staff was too heterodox for that. Nonetheless, Bernadette Wren, the service’s former associate director, is all on record as saying that “GIDS, from its modest start, was a justice project as well as a therapeutic project”. It “aspired to widen the circle of people whose experience of the self is listened too with respect”. There is a distinction, though, between listening with respect and affirming everything you hear. 

“So many former GIDS clinicians I have spoken with have used the same word to describe the service and their time there: mad.” Plainly, this is meant colloquially but it is revealing nevertheless. According to Dr Will Crouch, a psychologist and psychotherapist who worked at GIDS a decade ago but left before the great explosion in referrals, being over-worked and struggling to deal with increased caseloads - many clinicians were responsible for more than 100 patients - cannot explain all the service’s struggles. A wider, deeper, phenomenon is apparent: “organisations helping a certain group of people will develop symptoms that are related to the work that they do”.

Past decisions inform future choices. Once a pathway has been established, convictions it is the best, and perhaps even the only, way forward harden. Alternative approaches are discounted and a closed-loop is established: we do it this way because in the past we also did it this way. Questioning the past undermines the present - and consequently the future, too. 

Other symptoms of this kind of capture may be discerned. GIDS had a strikingly strong relationship with external lobby groups such as Gendered Intelligence and Mermaids. In the latter case, Mermaids would sometimes even demand individual children be seen by clinicians more likely to accede to their demands for puberty blockers as a precursor to cross-sex hormones and then, when they were adults, major invasive surgery. 

Over time, mission creep became a feature. In 2000, Mermaids’ website acknowledged the complexity of gender identity issues and was frank that “only a small proportion of cases will result in a transsexual outcome”. Some gender issues “can be caused by a bereavement, a dysfunctional family life, or (rarely) by abuse”. Correctly, Mermaids suggested these kids needed “sympathetic and non-judgemental” support. 

A decade later, Mermaids had changed. As Barnes puts it, “Their position appeared to be that there was only one outcome for these children and young people - medical transition”. One insider recalls that meetings between GIDS staff and Mermaids became unpleasant: “I didn’t ever want to go… You’re going to these people who are really slagging you off and saying, ‘Why don’t you give medication, you’re killing our children’”.

Though Barnes does not say so explicitly, some clinicians and some lobbyists plainly considered themselves members of the same team. They - and they alone - understood the kids and they drew validation from their suspicion the outside world neither cared for, nor was interested in learning more about, these children. 

According to Barnes, gay clinicians concerned that GIDS was, doubtless inadvertently, latently homophobic “were told they were ‘too close’ to the work and, according to one former senior clinician, anyone who spoke out was ‘made to feel hysterical’ in some way.” This witness says that “The more anxious and worried you became, the more it was framed that you weren’t really someone who could handle it.” This was “a brilliant way to divert it away from what we’re actually doing, which was changing children’s bodies”. 

What data there is endorses the view GIDS attracted children who were mostly gay. Perhaps gay and trans but certainly gay. Ninety percent of natal girls and 80 percent of boys referred in 2012 reported being same-sex attracted or bisexual. One clinician recalls families who said, “Thank god my child is trans and not gay or lesbian”. Some of the children agreed: “I had kids telling me, ‘When I hear the word lesbian, I cringe. I want to die’” one doctor tells Barnes. “Initially, she of them had identified as lesbian. And some of them had experienced a lots of homophobia and then started identifying as trans. It was almost like a stepping stone.” Another doctor concurs: “In my view, I think there were gay children who were being pushed down another path”. 

Barnes acknowledges that this is not a view universally accepted at the Tavistock. Other doctors argue that “It wasn’t ‘converting gay kids’ but accepting reality”. One psychologist recalls a case of a young person from a rural area deprived of “liberal wokery”. 

“There was a strong sense in which in a different world in a different place, this person could have lived happily as a gay man” the doctor says, “But they didn’t live in a different world. They lived where they did, and they didn’t want to move. And they were quite happy in their community and very accepted as a trans girl”. You could spend a lot of time unpicking the assumptions in that appraisal, couldn’t you?

According to this psychologist, questions are not really the point. “Are they really gay? Or are they really trans? Or is that a really unhelpful way of thinking about it? And for me, it’s an unhelpful way of thinking about it.” Insert “whatever” and “shruggie” emojis here, I guess. 

Perhaps that was the right approach for that child. For others, the question “Am I really gay or am I really trans?” was actually rather important. 

Harriet, a former patient who once thought she was a trans boy but has since changed her mind, now says: “I think I needed a much deeper examination of just why I felt so disgusted with myself at age 15, that I was convinced I needed to be replaced by this new male persona for the rest of my life. My gender dysphoria diagnosis was based on, essentially, two years of my life”. Two years during which, she now says, she was “a repressed lesbian at a girls’ school”  at which, moreover, “it was becoming somewhat trendy to be non-binary”. Harriet also says her enthusiasm for computers was portrayed as evidence she was interested in “male” pastimes. 

If this appears a thin basis for puberty blockers, it should be remembered that for all its imperfections GIDS was better than some other affirming providers of gender healthcare. In the United States, for instance, 13 year old girls have received double mastectomies on the basis of their professed “trans ness”. 

In this country, too, some providers have behaved with ultra-shocking carelessness. Dr Michael Webberley, who co-founded GenderGP, a private company, with his wife Helen, was struck off the medical register last year after the Medical Practitioners Tribunal Service documented a “catalogue of failings” in his practice. In one case, Barnes writes, Webberley “prescribed puberty-blockers to a nine-year-old, following a Skype call lasting 20 minutes, with him ‘actually having spoken to Patient V [the child] for only ten minutes’”. That child had gone to Webberley because they had been told there would be a five-month wait to be seen by GIDS. Helen Webberley’s license is also currently suspended. 

In autumn 2020, the Care Quality Commission inspected GIDS and rated the service “inadequate”, its lowest safety rating.  To some extent - and as the review into GIDS written by the eminent paediatrician Dr Hillary Cass confirms - this may be because the service was simply incapable of dealing with the increased number of referrals. (Cass recommended that the Tavistock clinic be closed, replaced by a series of regional centres which will operate on a much more holistic - ie, very different - basis.)

But the was “inadequate” for other reasons too. At the time GIDS was still claiming on its website that “the blocker is a physically reversible intervention” even though NHS England had officially updated its guidance to note that “little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria”. 

GIDS was also receiving patients from the Republic of Ireland, where there is no suitable or even comparable children’s gender identity service. So many Irish children began to be referred to the Tavistock that, instead of the patients flying to London, GIDS clinicians would go to meet them in Dublin. Doctors with extensive experience of adult transition in Ireland - and hence clinicians with no predisposition to question the reality of gender dysphoria - were appalled by the assessments conducted by GIDS. 

“There is a chance it’ll be fine. There’s a chance it will be a disaster” says Professor Donal O’Shea, a consultant endocrinologist in Dublin. “Some of the worst outcomes I’ve seen in my career have been [transition] done badly”. By “badly” he means “too quickly” or “in a person where it isn’t gender dysphoria - it’s a sense of not belonging”.

“There aren’t any easy answers” Bernadette Wren has said. “You can’t plausibly develop a foundational theory of gender identity in which to ground the work.” Asking “why” a child might feel trans is pointless. “You’re better off trying to help people to live well, rather than trying, probably fruitlessly, to establish the story of how they came to feel that way”. 

For some kids, this may be right. One such example is Phoebe, who was 15 when she was first seen by GIDS in 2009. Phoebe’s “desire to live as a woman wasn’t about who she was attracted to. ‘It wasn’t at all sexual’, she says. It was about who she was. ‘I literally used to go to the bathroom and I was repulsed. I was physically sick at times over what I saw in the mirror”. At 16, she started on puberty blockers; at 19 she had surgery. “I do feel, like, that really, those doctors gave me my life”. 

But it seems worth observing that Phoebe was seen every six weeks for more than a year at a time when GIDS was not overwhelmed by referrals. Later patients might be put on the medical pathway after just four, and sometimes only three, assessment sessions. Phoebe, now 28, “had a really positive experience” even though, looking back, she was often frustrated by how long it took. “I would have had the surgery at 13!” she says. “But obviously now what I say to people is the rules are there for a reason. Detransitioning is a thing.”

On the recommendation of the Cass Review, GIDS has been closed and Barnes’ book provides ample evidence demonstrating GIDS was both overwhelmed and unsustainable. In common with new guidance issued in countries such as France, Sweden and Finland, the use of puberty blockers in otherwise healthy young people is to be restricted. A medical pathway may still be appropriate for some but it will no longer be the default approach taken to questioning children.

“Are we hurting children?” Dr Anna Hutchinson, one of Barnes’ chief sources, asked her superiors in 2017. She now believes the answer to that question is “yes”. The next, still more dreadful question, is one with which Barnes concludes her book: “How many?”

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