Medicine deals, by necessity, in the reliable knowledge of a science-based discipline. So why did things go so drastically awry for the Tavistock clinic’s Gender Identity Development Service (GIDS). Back in 2005, psychiatrist David Taylor noted a disturbing lack of clarity about the clinic’s goals: was its purpose to treat children with gender dysphoria or did they identify as trans because they were distressed for some other reason? He was concerned too by the “onerous” pressure on staff from trans activist groups, and children themselves, to prescribe “untested and under-researched” puberty blockers.
Fundamental issues, one would think, but there would be no opportunity to address them. His report would be buried, not to be exhumed till 2020. During those crucial 15 years, the concerns he identified would be compounded beyond measure by a remorseless rise in the number of children referred – from 50 a year to several thousand – and the culture of denial epitomised by the fate of his report.
By way of context, back in the early 1990s transitioning was generally regarded as highly effective and non-problematic. In a consultation from around that time, so memorable I noted it down, a young university student in his late teens told me how, as a child, he would “lie in bed praying to God promising to do anything if He would just perform a miracle and make me into a girl”. Surreptitiously, he dressed in his sister’s clothes and yearned for the presents she received at Christmas. He had long anticipated he would only find fulfilment with reassignment surgery. Nonetheless, “I don’t resent nature having played a trick on me,” he ruefully observed, “I just need it to be put right.”
Completely persuaded, I duly signed the prescription for female hormones recommended by his psychiatrist and took up his suggestion to check out a recent paper on the results of reassignment surgery. This could scarcely have been more positive, the outcome reported as “excellent” when combined with supplementary procedures so as to achieve a truly feminine appearance. Nine out of ten patients claimed to be “very satisfied”.
Hannah Barnes’s “inside story” of the subsequent rise and catastrophic collapse of the GIDS clinic is a complex story, but three salient factors predominate, starting with the deceptive technical fix of those plausible puberty blockers. In 1998, a Dutch psychologist had suggested they might improve yet further on those already impressive outcomes on two counts: they would circumvent the psychological trauma of reaching sexual maturity “in the wrong body” while their suppression of secondary sexual characteristics (notably breasts in girls, facial hair in boys) would obviate the need for those supplementary feminising (or masculinising) procedures. In essence, the immensely influential “Dutch protocol” (as it would be called) allowed for a seamless transitioning pathway. It carried, however, a couple of highly significant caveats as to whom might be deemed eligible. They would have to have experienced gender dysphoria from early childhood and not be troubled by any psychological condition that might compromise its implementation.
But puberty blockers, it soon transpired, achieved considerably more than suppress those secondary sexual characteristics while allowing a young person “time to think” about the desirability of transitioning. They made it almost inevitable. Consider a teenage girl deprived of the pubertal surge of her own natural sex hormones. By age 16 she is psychologically and physically very different from her peers – smaller, sans breasts and pubic hair, with no experience of those early sexual yearnings and encounters that might prompt her to reconsider her wish to change gender. So though it was claimed the effects of puberty blockers were reversible with resumption of the normal trajectory of sexual maturation if discontinued, very few do so. Virtually all proceed to the next stage of the protocol with high doses of masculinising testosterone (or, for transitioning biological males, feminising oestrogen) in preparation for reassignment surgery.
The determining influence of puberty blockers in impelling children along the path to transition should have caused the advocates of the protocol to be more cautious. And perhaps some were. But they also had to contend with (or were persuaded by) the ascendant narrative about gender dysphoria – not a psychological state but rather the defining characteristic of yet another oppressed minority group, just as homosexuality had been in the past. Here the role of GIDS, it was argued, was to affirm, not question, a person’s self-identification as trans with the prescription of puberty blockers being “proof of solidarity with the plight of the person requesting it”.
Meanwhile, the demographic of those seeking referral to GIDS was changing dramatically. No longer, like my university student, predominantly young males with gender dysphoria from a young age who “just wanted it to be put right”. They were mostly girls in their early teens with no such history whose self-identification of being transgender was of sudden onset associated with social withdrawal and a marked hostility to those, especially parents, reluctant to acknowledge their new status. A disproportionate number had experienced troubled childhoods or were psychologically vulnerable. Thus, if paradoxically, most of those being treated with puberty blockers according to the Dutch protocol were precisely those for who, when originally formulated, it was deemed inappropriate.
This could only end badly, as indeed it did. But it took an astonishingly long time for the intellectual and therapeutic confusion that was the hallmark of GIDS’s clinical practice to unravel. There were dissenting voices, of course, and Barnes’s even-handed account is informed by those increasingly uncomfortable about the harms of, as one put it, “offering an extreme medical intervention as a first line treatment for distressed young people who may, or may not, turn out to be trans”.
By 2017, GIDS was no longer coping with the escalating number of referrals – recruiting psychologists with little clinical experience who were then expected to deal with astronomical caseloads. Ten staff members shared their anxieties with the senior psychoanalyst at the Tavistock, Dr David Bell, who agreed to compile (yet another) report that judged the needs of those attending the clinic were being met “in a woefully inadequate manner”. This was not well received but the publicity generated when extracts were published in the press a year later would initiate the long-overdue public scrutiny that would eventually lead to the clinic’s closure in spring this year.
We can know practically nothing of the consequences, for good or ill, for the thousands of children referred to GIDS because shockingly, if true to form, the clinic neglected to collect the data that would allow a reasoned evaluation on the effectiveness or otherwise of their experimental therapies. That reluctance is more understandable when reading the accounts of former patients describing their transitioning experience that Barnes includes in her story.
They include a couple of success stories, predictably in those who desired to transition from an early age. But set against these are the troubled adolescents for whom it did not work out: started on medication after a cursory exploration of their sexuality (“It was enough to say I was uncomfortable with my body”) and subsequently regretful (“My doubts started almost immediately after my double mastectomy”). Thankfully for troubled adolescents, wiser counsels now prevail.
Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children is published by Swift Press.
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