One of the hottest of hot potatoes, transgender people’s place in society is under constant debate. And when it comes to the medical treatment of children and young people, it’s a nightmare of conflicting possibilities.
BC Newsnight journalist Hannah Barnes has researched the recent controversies surrounding the UK’s Gender Identity Development Service (Gids) — commonly referred to as ‘the Tavistock’, called after its host organisation, the Tavistock and Portman NHS Foundation Trust. It treats children and young people diagnosed with gender dysphoria, a condition that can be loosely described as distress arising from a person’s sense that their innate gender does not match their physical characteristics.
Last year, following much controversy and a review by consultant paediatrician Dr Hilary Cass, it was announced that the Gids centre at the Tavistock will close this year and be replaced by a network of regional centres.
Though Gids is a British institution run by the NHS, Irish youngsters were able to use its services under the Treatment Abroad Scheme, in conjunction with Crumlin Children’s Hospital. My daughter was one of them. Hence I read this book with a particular personal interest.
Barnes’s book, Time to Think, is meticulously academic, thoroughly footnoted and referenced. There are dozens of people and papers cited, and it’s full of detailed allegations of professional difficulties and conflicts, including parliamentary inquiries and employment tribunal hearings.
It’s a dense, clotted read — the material demands it. Several of the 21 chapters have more than 60 endnotes. The studious material is interspersed with seven slim pen-portrait chapters about individual young people who were treated by, or interacted with, the Gids provisions.
Barnes points to three major problems.
The first is rapid expansion: over Gids’ 30-year existence, the number of referrals increased exponentially from a handful in the beginning to almost 100 in 2009/10 to more than 2,700 in 2020. There was a distinct change in the profile of these referrals: a huge growth in teenage girls experiencing gender dysphoria. The service was constantly running to catch up and did not respond well either practically or scientifically to this changing demographic.
There was also an absence of data collection: during this major expansion, there was no proper parallel research project to capture data on patients’ treatments and outcomes. There are very few verifiable figures on anything — success rates, failure rates, numbers prescribed for blockers, co-morbidity, suicides, de-transitions.
The third significant issue was the poor response to staff who expressed concerns and queries about their work. The uncertain and evolving science behind this field of medicine meant there were sincere disagreements about different approaches.
What Barnes describes is a workplace where clinicians’ concerns appeared to be listened to, but no action ever followed. Deep divisions, mainly ideological, found no easy resolutions.
She paints a picture of a system that had a leadership going in one direction, but also a cohort of clinicians who formed an internal informal dissenting subgroup. Barnes uses the views of one of these former Gids employees, senior clinical psychologist Dr Anna Hutchinson, as a frame around which to present her arguments.
The interviews are almost exclusively with these dissenters. Barnes says it’s hard to get people to go on the record with more positive perspectives because the subject is so controversial — to raise your head above the parapet on this is to invite pot-shots, and the discourse surrounding this subject is deeply unpleasant in tone, from both sides.
It may also have been difficult for Barnes to get co-operation from more positive-minded people, as she would have been perceived as hostile and adversarial. But that’s what journalists are supposed to do: ask the tough questions.
Barnes has her well-argued position, and the questions she raises are legitimate. However, the result makes the book feel very one-sided. All the clinicians talk about how they harmed children. There is very little mention of how any clinician might have ever helped anyone.
The book occasionally slides into innuendo, with statements like: there was “generous funding for staff to attend international conferences on transgender healthcare, not just in Europe but as far afield as Buenos Aires”. Staff had the “potential to progress their careers quickly” and were “paid comparatively well”. It “more closely resembled a tech start-up than the NHS”; there is mention of away-days in London hotels. The implication here is that staff were on a sort of cushy number. These parts of the book are a pity, because they make Barnes sound biased.
One thing that surprised me was the allegation that the service was latently homophobic. There is the suggestion that homophobic parents are pushing their kids into being transgender rather than gay. This sounds unlikely. Most parents these days are relatively unfazed by their teenagers turning out to be gay — everybody now has gay family members or neighbours. But being trans is a different matter, with its need for interventions of some sort, and it seems unlikely people would prefer it in any significant numbers. This was, for me, one of the most surprising things suggested in the book.
A key aspect of transgender youth care is the prescription of puberty blockers, a hormonal treatment that stops puberty when prescribed early, and reduces the end stages of puberty when prescribed late in the cycle. The idea is that the delay of puberty allows the young person “time to think” before they take any further steps. Barnes contends that everyone who takes blockers goes on to take cross-sex hormones later on. So it is not really a neutral, inconsequential step; it is the first leg of a journey. And this is probably the nub of her argument — too many young people are being sent in this direction — though we don’t know how many because of the absence of data.
As Cass, in the context of her 2021 report, says of the need for proper research, “the evidence gap will continue to be filled with polarised opinion and conjecture, which does little to help the children and young people, and their families and carers, who need support and information on which to make decisions”.
Barnes suggests that sometimes clients are recommended for hormones on only two meetings and children are often fast-tracked into medicalisation.
This was not my experience. My daughter had six meetings over nine months — three in London, three in Dublin. The clinicians she saw were sober in their approach, and she was constantly urged to slow down, to try gender-neutral options in clothing and so on. In my limited, very personal experience, I thought them slow-moving and conservative-minded — this was also our approach as parents.
Barnes says clients are told that the blockers are completely reversible. My daughter was distinctly told that while blockers were physically reversible, they would have significant psychological impacts.
Before being referred to Gids, my daughter had been in the care of a clinical psychologist here in Dublin, and had the support of this psychologist throughout the process. This therapeutic relationship is still ongoing many years later. This was privately arranged, and not everybody has it, but most parents will put all available resources into finding the best way to treat their child.
There were very few child psychologists in Ireland with the expertise to take this on at the time — this was in the mid-2010s. From what I hear, it’s not much better now. And the reality is, for parents of a young person exhibiting acute distress, the Tavistock provided us with a lifeline.
My daughter is now in her 20s and an exemplary and cheery member of society with a busy social and student-professional life — a long way from the distraught 14-year-old who was frozen in what they considered to be the wrong body.
Our satisfactory experience with the Tavistock doesn’t mean I don’t agree with many of the criticisms in this book. There needs to be more research data, more psychotherapy, more listening to staff, more questioning of the exponentially growing patient base. But the overall tone of the book is so hostile that it is likely to become another weapon in the unfortunately loud and bitter war over this subject.
The tone of the debate is such that it may well be impossible to attract staff to a new service; who wants to get involved in such a pilloried professional field? In the words of clinical psychologist Bernadette Wren, one of the leaders of Gids, “it 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 to with respect”. And when, as a parent, you’ve dealt with a child struggling in this regard, you are grateful that someone was able to meet them in this difficult, distraught space.
What emerges to replace the Tavistock remains to be seen. In the meantime, young people and their families are doing their best to carve out a way forward in a difficult world made much worse by aggressive and toxic debates.
‘Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children’ by Hannah Barnes will be published by Swift Press on February 23