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Review of book by Hannah Barnes: ‘Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children’

By Stella O’Malley:-

When journalist Hannah Barnes carried out an exposé on the Tavistock for Newsnight in 2019, she was so shocked at what was uncovered that she took time out from working at the BBC to write her book, Time To Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children. This account of medical misadventure happening within plain sight at the Gender Identity Development Services (GIDS) in the Tavistock and Portman Trust in London demonstrates in explicit detail how none of this happened behind closed doors; indeed concerns were raised and a litany of reports made recommendations about GIDS from 2005.

The story begins in 1989 when a psychoanalyst called Dr Domenico di Ceglie became convinced there was a need for a clinic that focused on gender identity issues in children. . Whether GIDS operated within the framework of gender identity theory or a more developmental understanding of gender dysphoria never seemed to be properly clarified. This ambiguity seems to be a fatal flaw in the service as clinicians operated from different theoretical perspectives. 

The clinic operated out of a small office at the Tavistock, Although the numbers were miniscule, the cases were extreme and the work was difficult. The psychoanalyst Sue Evans first became worried in 2004 and raised concerns about the treatment provided to gender-distressed children in 2005. This was followed in 2006 by an extensive report made by Dr David Taylor, then the medical director for the Tavistock, who outlined the issues and made specific recommendations. His report was ignored.

Arguably, GIDS moved from being a disorganised, ill-thought out service to being the centre of a medical scandal when, in the 2010s, numbers grew exponentially. The demographics also changed –across the world – as there came reports of an unexplained rise of teenage girls presenting at clinics with gender-related distress. In the gender identity literature there had never been significant numbers of teenage girls; pre-pubescent boys had always been the largest proportion of the paediatric cohort. In addition, the cases of these teenage girls appeared to be complex, happening within the context of wider identity confusion. One Finnish study showed that “Thirteen per cent were in care or living independently, and well over half had been ‘significantly bullied at school. But close to three-quarters of those had been bullied before they came to think about their gender identity. Most startling was that the fact that 75 per cent of the young people ‘had been or were currently undergoing child and adolescent psychiatric treatment for reasons other than gender dysphoria when they sought referral’.”

As a result of the growth in numbers, the maverick GIDS rapidly became “a beast” that propped up less lucrative aspects of the Tavistock that has been recently operating at a deficit. GIDS’s income was 5.9 per cent of the Tavistock total in 2015/16, 10.4 per cent a year later, and then, in the draft Operational Plan for 2020/21, “gender services for children and adults were said to make up 28 per cent of the Tavistock’s income.” Senior employees at the Trust were asked to give up their offices to make space for GIDS and “because it was bringing in so much money they could not challenge it.” When Dr David Bell, the consultant psychiatrist and most senior psychoanalyst at the Tavistock, submitted a complaint about GIDS in 2018, he was rebuked by a colleague who said that the Tavistock would “go down” if GIDS closed.

In a bid to obtain some clinical evidence for the medicalisation of children’s gender identities, a study was commissioned by GIDS in 2011 to examine the outcomes of puberty blockers on children. Puberty blockers stop sexual development in a growing child, meaning the adolescent doesn’t experience a full sexual awakening. It can also create an out-of-sync feeling between the child and their genitals.

The first results emerged early in 2016. By then puberty blockers had become the “only real treatment” at GIDS for children with gender dysphoria – less invasive approaches such as talk therapy were typically deemed to be “transphobic”. The youngest child to have started on puberty blockers was just 10. In theory, puberty blockers promised “time to think”. However,  considering that every child on puberty blockers in the 2011 study subsequently moved on to cross-sex hormones, in practice this was exposed as a false promise. Puberty blockers turned out to be the first step in a medicalised identity and, it seems, rather than offering the opportunity to reflect, blockers effectively “lock in” children to a medicalised treatment pathway.

The results were not good; “the children’s gender-related distress and general mental health – when based on clinical measures of things like self-harm, suicidal ideation and body image – had either plateaued or worsened.” Moreover, “Researchers reported a statistically significant increase in those answering the statement ‘I deliberately try to hurt or kill myself ’ as well as a significant increase in behavioural and emotional problems for natal girls.” Even though there was no clinically measurable positive impact on psychological well-being, GIDS chose instead to focus on the children’s self-reports of being “highly satisfied with the treatment”.

Barnes describes how certain lobby groups such as “omnipresent” Mermaids used alarmist rhetoric to pressurise the GIDS management team to fast-track young and vulnerable children. Mermaids and ex-CEO Susie Green, a parent and computer consultant with no clinical qualifications, are singled out by Barnes as a heavy influencing factor in the rush to medicalise children’s gender identities. Accusations of “transphobia” became a way to ensure that the medical pathway was prioritised over less invasive options such as psychotherapy. Yet, there is no high-quality long-term evidence-base to support any paediatric medical transition.

Believers of gender identity theory are child-led rather than child-centred: they argue that if children want puberty blockers they should get them; many view them as a “miracle cure”. The GIDS leadership team didn’t seem very  sure what to do – had they been clearer about which model they followed perhaps they would have been firmer with parents like Susie Green, who, in exasperation with the slow pace at GIDS, took her child to the USA for puberty blockers, and then aged just 16 to Thailand for genital surgery so that her child could fully transition from male to female as young as possible. The relationship between GIDS and Mermaids has cooled recently. In November 2022, Susie Green stepped down as CEO and left Mermaids.

GIDS adopted its own separate branding, TV crews came to film documentaries and the leadership were often quoted in the media. None of this was common practice elsewhere at the Tavistock. Perhaps it  led the clinicians to feel like the movers and shakers of a new way of thinking? Certainly Barnes’ book makes abundantly clear that GIDS clinicians openly acknowledged that protocol was not followed. In 2015, the GIDS leadership team, Polly Carmichael and Bernadette Wren, told Parliament that the service had “no record of refusing anyone who continues to ask for physical intervention after the assessment period’”. This was repeated by Dr Wren in her oral evidence when she said that “‘anybody who wants it’ could have physical interventions.”

As numbers increased, the caseload per clinician increased beyond safety levels. In 2015, in an attempt to calm the over-worked clinicians, an organisational consultant was called in. The subsequent report warned that GIDS was “facing a crisis of capacity to deliver effectively on an ever-increasing demand for its service” and recommended immediate action to cap referrals. This was ignored by GIDS director, Polly Carmichael. The caseloads continued to rise, first 50, then 70, , 90 or 100 patients each. One clinician reported an astronomical caseload of 140 patients. With some caseloads comparative to the size of a small primary school it is little wonder that clinicians had difficulties recognising their patients when they arrived for their second appointment.

Staff seemed to be cowed by a fear of being accused of transphobia from their young patients, parents and lobby groups. Clinicians trying to explore children’s complex and difficult emotional histories were told that it was “transphobic” to ask thought-provoking questions. Long months passing over the course of a small number of sessions meant that client-therapist relationships were difficult to maintain. Barnes reports on how the research shows that females who transition to male show abnormally low bone density. A senior physician who spoke to Barnes was disconcerted by the lack of concern shown by his trans patient; “’The only thing that mattered was transition,’ the doctor explains. ‘If osteoporosis doesn’t matter to someone receiving puberty blockers, then they probably shouldn’t be receiving them.’”

In a dangerous sequence of buck-passing, Barnes demonstrates how junior clinicians were overawed by senior clinicians while the leadership team were intimidated by Susie Green. GIDS director, Polly Carmichael, in particular seemed to allow Susie Green and Mermaids to dictate policy at GIDS. Green became so involved that she would ring up to request another clinician on behalf of families who were unhappy because they hadn’t received a prescription for puberty blockers. And GIDS followed her instructions.

To this day, GIDS runs primarily using junior clinicians, and with new clinicians joining routinely; “GIDS staff had the potential to progress their careers quickly, without necessarily facing the same level of managerial or service responsibility that others would in the health service at similar grades. And they were paid comparatively well.” Barnes reports a high turnover of staff at GIDS where most of the clinicians quickly climb the career ladder and then, when they realised the problems, would raise concerns. Any challenges to the GIDS system were taken as a personal affront by management. It would be made known among the team that they had “made Polly cry”. Other responses to concerns were allegations of transphobia or else the clinician was “made to feel hysterical” and as if they couldn’t handle their work. Realising the lost cause, many left the service and focused hard on rebuilding their reputations after this difficult chapter in their working lives.

By 2017, there was already an extensive paper trail of concerns being raised and whistle blowers speaking individually to senior management. In August 2018 Dr Bell submitted an extensive report after ten clinicians had contacted him separately voicing their individual concerns. He branded GIDS “not fit for purpose”; by then, eleven clinicians had left in the previous six months because of ethical concerns. Details about the report were leaked to the newspapers. Marcus Evans, a governor of the Tavistock  (and husband to Sue Evans who first voiced her concerns in 2005) tendered his resignation with immediate effect.

Consultant social worker and child safeguarding lead at the Tavistock since 2009, Sonia Appleby also raised concerns. The hostile response from management to these led Appleby to lodge a whistle-blowing claim against her employers in November 2019. Appleby won her case in November 2021 and the judgement was highly critical of several Tavistock staff.

In July 2019, Dr Kirsty Entwistle, a psychologist who worked in the Leeds GIDS site, published a 2700-word open letter to GIDS director Polly Carmichael expressing her concerns about how “traumatised, deprived, and sexually or physically abused children” were referred for puberty blockers without acknowledgement of the complexity of their needs.

In December 2020, three judges from the High Court weighed the evidence provided by Mrs A, the parent of a gender-distressed child, and Keira Bell, a detransitioned woman and ruled that it was “unlikely” that under 16s could give informed consent to treatment with puberty blockers. Keira Bell had first attended GIDS when she was 15, been prescribed puberty blockers at 16 while living alone in a hostel, went on to testosterone at 18 and had a double mastectomy aged 20.  By the time she was 22 Bell regretted her decisions, stopped the medications and detransitioned. (Another detransitioner in the book describes how this process was like “waking up from a nightmare or regaining control of my mind after someone else took over”). Bell replaced Sue Evans as the lead claimant in a legal challenge against GIDS’s practices arguing that she couldn’t have consented to puberty blockers because she was too young to give informed consent. In September 2021, the Court of Appeal overturned the High Court stating that the decision was for doctors and not the courts but that clinicians need to be “alive to the possibility of regulatory or civil action”.

In January 2020 the Care Quality Commission (CQC) published their report on GIDS and rated the service “inadequate”, the lowest possible safety rating from the healthcare regulator. In a sample of records the CQC found that more than half the children at GIDS had references to autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD). In August 2021 the NHS established an external panel to review each proposed referral for children under 16 for puberty blockers.

In March 2022 Dr Hilary Cass’s independent interim report on GIDS was published saying that the current model was “not a safe or a viable option” for the long-term treatment of gender-related distress in children. Finally, in July 2022, 17 years after concerns were first raised, the NHS announced that GIDS would be closed down and replaced by regional centres with a greater focus on mental health. Since 1989 GIDS has seen roughly 10,000 children. Barnes notes that Sweden, Finland and France have also all concluded that the perceived benefits of puberty blockers do not outweigh the risks.

There is a huge challenge ahead. Barnes reports 7,500 children on the GIDS waiting list with some young people waiting four years to be seen. Lawyers are hoping to bring a class-action clinical negligence case against the Tavistock. Former clinicians believe they had “front-row seats on a medical scandal”.

The Tavistock was famed for its thoughtful, psychoanalytical approach. Indeed, a statue of Sigmund Freud sits outside. However, at GIDS some children were prescribed puberty blockers within the first twenty minutes of their first session and this once world-famous Trust has now become synonymous with gender. Barnes’ account of the downfall of GIDS is a horrifying story that shows how clinicians need to keep their focus on clinical care rather than caving to pressure from interested groups.

Stella O’Malley