When a tiny specialist clinic opened at St George’s hospital, south London, in 1989, with just four referrals, few would have predicted what would happen in the next 35 years. Having grown to become the world’s largest children’s gender clinic, the Tavistock’s Gender Identity Development Service (Gids) will close its doors for good on 31 March. What has unfolded there over the past decade or so is quite exceptional. The service referred around 2,000 children under 18 for puberty-blocking drugs, without robust data to support that decision. When evidence emerged indicating that this medical intervention wasn’t benefiting many of the young people receiving it, the service did not change its approach. Nor did it follow up with any of its patients to see how they were faring. Faced with an exponential increase in referrals, and a fundamental shift in the demographics of those requesting its help, Gids ploughed on. However, it buckled under the pressure of growing demand. The leadership of the service – along with that of the NHS Trust that housed it – was inadequate and shut down the serious concerns of a growing number of their own staff.
All this happened under NHS England, which was ultimately responsible for the service. As I have written in my book, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children, this is not a story that denies transgender identities. “This is a story about the underlying safety of an NHS service, the adequacy of the care it provides and its use of poorly evidenced treatments on some of the most vulnerable young people in society. And how so many people sat back, watched and did nothing.”
The Gender Identity Development Service (Gids) was the creation of the child and adolescent psychiatrist Dr Domenico Di Ceglie. Inspired by a single case he’d worked on in the early 1980s of a teenager “who was claiming that she was a boy but in a female body”, he felt children with “these rare and unusual experiences” needed a service of their own.
The focus of Gids was never on changing a young person’s gender identity, but in supporting them and their families in whatever solution they settled on to best manage it. But Di Ceglie saw that, in some cases, by addressing other difficulties experienced by the child – perhaps abuse, trauma or low mood – the gender difficulties might be resolved too. Almost all young people referred were contending with other problems.
In those early days, the offering was largely therapeutic. It provided what might be termed now a “safe space” to talk. Di Ceglie commented to the Sunday Times in 1993 that only about 5 per cent of the young people seen at his clinic would “commit themselves to a change of gender”. And 60-70 per cent of the children were gay. Medical interventions were available in the 1990s to block puberty, but only if strict criteria were met. A young person had to be 16 and have undergone extensive therapy and thorough assessment. The distress they felt around their gender had to have continued throughout puberty, too. The drugs weren’t so much used to block puberty, therefore, but to prepare bodies for the start of cross-sex hormones. Back then, as today, the service didn’t prescribe medication itself; it referred its patients to endocrinologists linked to the clinic.
When Gids moved to its current home – the Tavistock and Portman NHS Foundation Trust in north London – in 1994, it was immediately unwelcome. Colleagues at the Trust felt unease at the model used by Gids, which was based initially in a broom cupboard inside the Portman Clinic. The Tavistock was internationally renowned for its commitment to talking therapies, or psychotherapy. Medication wasn’t ruled out, per se, but it was used only sparingly and where there was a robust evidence base. That just wasn’t the case for this area of care.
Formal concerns were first raised about Gids in 2005 by Sue Evans, a nurse specialist at the service and later psychoanalyst. She thought external patient support groups – the transgender charity Mermaids and the Gender Identity Research and Education Society – had undue influence (which they deny), but her main worry was how quickly some of her colleagues were referring young people for puberty blockers. While there was thoughtful work going on, she discovered others would refer after only four sessions. The cases being seen by the service, Evans says, were all complicated. It just wasn’t possible to meet someone on so few occasions and make such a serious decision.
The concerns were investigated – and written up – by the Tavistock’s then medical director. But that report and its recommendations to improve the service remained unimplemented and hidden from Gids staff – and the wider public – until 2020. It was reluctantly released following a lengthy freedom of information battle I launched, while at the BBC’s Newsnight, with the Tavistock Trust.
It would take a decade for another group of whistleblowers to emerge. By this time, the service had changed beyond recognition.
Gids was nationally commissioned by the NHS in 2009. Children could now be referred from anywhere in England and referrals, inevitably, grew. And grew. By 50 per cent each year between 2009-10 – when there were 97 – and 2014-15, when there were 697. They doubled over the next 12 months to 1,419.
It wasn’t just the numbers. The sex ratio of those being referred reversed too, from two-thirds natal male, to two-thirds female by 2015. On top of that, most were girls whose gender-related distress had begun after the onset of puberty – not in early childhood as had been the case before. And these girls often had complex needs – depression, anxiety, eating disorders, or histories of abuse and trauma. The changes were impossible not to notice, and Gids clinicians describe how the clinic’s waiting room would be filled with self-diagnosed adolescent trans boys all with similar stories and haircuts. Many had chosen the same name too, often that of their favourite trans YouTubers.
At the same time, what Gids offered young people under its care changed significantly, too. The service moved to being an assessment service – deciding if children met criteria to be referred for puberty blockers. That’s not to say all children, or even the majority, went down this path, but it was the only treatment on offer. That Gids didn’t provide therapy was something widely acknowledged by the team, including the service’s director Polly Carmichael (who replaced De Ceglie in 2009). Asked by the Tavistock’s governors in 2018 what Gids offered in terms of “face to face counselling and psychotherapy”, Carmichael reportedly replied that “the national service did not provide psychological support and that if required they would consult with the local psychotherapists to do the work through CAMHS [Child and Adolescent Mental Health Services]”. Assessments would typically take place over four to six appointments. Four was then reduced to three. Assessments could be extended in particularly complex cases, but also, it seems, reduced. In a small number of instances, children were referred for puberty blockers after just an hour or two. Having been a rarity in the 1990s, and only permitted after extended therapy, puberty blockers became routinely available after a matter of hours. And at ever-younger ages.
In 2011, Gids and its endocrine colleagues at University College London Hospital (UCLH) had embarked on a research study to look at the impact of blocking puberty in younger children, at the outset of puberty. The idea behind these drugs – gonadotropin-releasing hormone agonists (GnRHas), to give them their proper name – is to “pause” puberty, stopping the development of secondary sex characteristics such as breasts in girls, or facial hair and an Adam’s apple in boys. They act on the pituitary gland to switch off the release of sex hormones. This in turn gives the child who is distressed about their body “time to think” and reflect while their development is on hold. They were – clinicians insisted – completely reversible. Pause the developing of the body, stop the distress. That was the idea. But it was only ever a hypothesis. There was no evidence they actually worked this way, or that they were entirely reversible. It’s hard to imagine why it was thought that pausing one of the most significant stages in human development would have no consequences at all.
The drugs have never been licensed for this purpose. GnRHas are predominantly used to treat prostate cancer in men. They’re used in women with endometriosis too, and have also been used in the chemical castration of male sex offenders. They’re only approved by medical regulators for use in children with precocious, or early, puberty – before eight for girls, and nine for boys – where they work very differently. Not only are children much younger, but they only stay on the drugs for a short time before going through their body’s natural puberty. This doesn’t happen when used to treat gender dysphoria – when an individual’s gender identity doesn’t match their biological sex. One study suggested 95 per cent of young people don’t stop treatment, but simply then go straight on to cross-sex hormones to help masculinise or feminise their bodies. They never go through the puberty of their sex.
A team in the Netherlands pioneered the medical transitioning of children in 2000. Provided they had experienced gender dysphoria from childhood, were living in a supportive family setting and were free of any major mental health problems, children could receive puberty blocker injections from the age of 12. The Dutch researchers reported promising, cautious early results. Blockers appeared to relieve depressive symptoms and improve well-being, they said. The numbers involved were small, and the findings not robust; Gids wanted to conduct its own research to be sure. There had been mounting pressure on the service to follow the path of the Dutch throughout the 2000s. So, between 2011 and 2014, 44 children aged 12-15 joined the Gids/UCLH early intervention study.
It was what happened next that was so extraordinary. Gids did not wait for data to emerge from the study before rolling out early puberty suppression more widely. From the middle of 2014, puberty blockers became routine clinical practice. On top of this, the service moved from an “age” to a “stage” approach, whereby access to medical interventions would be dictated by an individual child’s stage of puberty – in this case Tanner stage 2 – not their age. Provided a child had reached this early stage of puberty they could potentially be referred for puberty blockers. “Twelve is an arbitrary age,” Carmichael told the press at the time. Those starting puberty “aged nine or ten” could be considered for treatment from now on.
If not data, what lay behind the decision? One clinician working at Gids at the time says it was based largely on two considerations: the Dutch team were doing it, and Mermaids wanted it to happen. Mermaids, together with the Gender Identity Research and Education Society, had lobbied hard for Gids to make blockers available at younger ages. A more charitable explanation given by Dr Natasha Prescott, who was also there at the time, is that it stemmed from a desire to help: there was a real empathy for these distressed young people and here was a potential solution to that distress. It was well-meaning, she said, but ill-informed.
But the young people being referred to Gids were not the young people of the Dutch studies – they would not have met the criteria to be received by them. The Gids leadership readily admitted this. Puberty blockers were available to those with “psychiatric difficulties, including young people with autism and learning disabilities, and young people who are looked after”, it explained. The service felt these children had the “right to be considered for these potentially life-enhancing treatments”. This was clinical practice dictated by feeling, not evidence-based medicine.
By 2016, those participating in Gids’ early intervention study had all been receiving puberty blockers for at least a year. “In terms of our early intervention I guess the other thing is that our results have been different to the Dutch… We haven’t seen any change in terms of psychological well-being,” Carmichael told trans health professionals. But by now it wasn’t just the 44 children on the study (who had largely met the Dutch criteria) who’d received blockers; another 162 under-15s had been referred.
The Gids team received a presentation on these findings around the same time. They learned that not only had the children’s well-being not improved – and for some it had got worse – but also that every single one who was old enough had chosen to continue on to hormones. For some, this exploded the idea that the blocker was providing time to think. As the clinical psychologist Dr Anna Hutchinson puts it, “What are the chances of 100 per cent of people, offered time to think, thinking the same thing?” To her and others it felt as if puberty blockers were not neutral, but rather the beginning of a pathway; they were not providing time to think, but rather the end of thinking and exploring.
At this point, there could have been a change in direction. But to quote a phrase used by so many former Gids staff I have spoken to: “Everything had changed, but nothing changed.”
While some individual clinicians began to practice differently, and more cautiously, there was no major service-level change. Staff began to worry more and more that they were placing vulnerable young people on to a medical pathway without exploring what else might be going on in their lives that could explain their gender-related distress. While a small number appeared to thrive on the blockers, staff saw the majority did not. For some children, their gender dysphoria appeared to have been immediately preceded by a traumatic event, the loss of a parent or a sexual assault, for example. For others, their trans identification had come after facing homophobic bullying and coming out as gay or lesbian. So common was this that Dr Matt Bristow, a clinical psychologist who worked there, and others came to feel that Gids was performing “conversion therapy for gay kids”. It’s a serious claim, but one that is supported in part by the little data that exists. When, in 2012, Gids asked older adolescents about who they were attracted to, almost 90 per cent of natal females for whom data was available reported that they were same-sex attracted or bisexual (67.6 per cent and 21.1 per cent, respectively). For the natal males, 80.8 per cent reported being same-sex attracted or bisexual (42.3 per cent and 38.5 per cent, respectively).
Gids clinicians were also concerned about the levels of autism and neurodiversity they were seeing in their patients, and wondered whether this too might be impacting on their trans identification. Less than 2 per cent of children in the UK are thought to have an autism spectrum disorder (ASD). Yet, according to Gids, “around 35 per cent of referred young people present with moderate to severe autistic traits”. There were even young people presenting at Gids who didn’t just identify as another gender, but as another ethnicity too. But they were assessed for their gender identity difficulties as if the other issues were not important, or an indication that perhaps this young person might be struggling more generally.
There was pressure from patient groups such as Mermaids, too, that staff say Gids was unable to stand up to. The psychotherapist Anastassis Spiliadis, for one, says the charity’s boss, Susie Green, would request that a child’s clinician be switched if they had not approved puberty blockers quickly enough – and that this would be agreed to. (Gids denies the group had any influence on clinical decisions.)
Staff shared their concerns in every forum they could. Clinicians such as Hutchinson, Bristow, Prescott, Spiliadis, Melissa Midgen, Kirsty Entwistle and others spoke out repeatedly over years (and for years after leaving the service), trying to get the leadership to act. There’s a paper trail that shows it. Two things would generally happen, they explain: there would be a lot of talk but no action; and those who raised issues were scapegoated and labelled troublemakers. Most who spoke out, and those who helped them or amplified their concerns, had to leave the Tavistock.
In 2018, ten clinicians – around a quarter of the London-based clinical staff at that time – shared their concerns with the adult psychiatrist Dr David Bell, in his capacity as staff governor. His report that summer laid them out in devastating detail and concluded that the care Gids provided wasn’t always safe. It was shared with the most senior figures in the Tavistock and the wider NHS, but fundamental reform didn’t follow.
The true story of Gids is known thanks to a small number of parents, former patients, individuals who have monitored the work of the service for a decade, and several brave whistleblowers who were prepared to go public with their concerns. Sue Evans launched legal proceedings against the Tavistock Trust in 2019. The case, which was taken over by Keira Bell, questioned whether children could properly consent to treatment with puberty blockers. Bell had received puberty blockers after three or four appointments, and later testosterone, while under Gids’ care. A double mastectomy followed in adult services. Aged just 22 she regretted it, and said no alternatives to her treatment had been explored by the service at the time.
The case ultimately lost on appeal, but it brought the attention of the world on to the clinic. It showed how, over 30 years, Gids appeared to have collected no meaningful data on its patients or its only treatment pathway. It could not tell the court how many young people had been referred for puberty blockers, how old they were, what sex they were, or if they had gone on to take hormones. With true British understatement, three High Court judges expressed their “surprise” at this.
Others went to the media, some of which listened. The Times and Sunday Times newspapers stand out among the print media, and for broadcast, BBC Newsnight, which made a series of films highlighting different aspects of the care being provided by Gids. Most importantly, how a number of clinicians had raised these very serious safeguarding concerns as part of an official review into the service by the Tavistock’s then medical director, Dinesh Sinha. He had heard from a sizeable minority of staff that Gids’ model of care was unsafe, and that some children were being harmed. Yet this testimony featured nowhere in the Trust’s final report. Instead, it told the public the review had not identified any “immediate issues in relation to patient safety or failings in the overall approach taken by the service”.
Change quickly followed, as clinicians’ concerns reached a wider audience. In September 2020, NHS England announced that Dr Hilary Cass – one of the UK’s leading paediatricians – would undertake an independent review of gender identity services for children and young people. The Care Quality Commission (CQC) inspected Gids the following month, triggered by the concerns reported by Newsnight. It rated the service inadequate. The resulting report is a damning read, and upheld most of the concerns clinicians had been raising for years.
Cass’s interim review, published in February 2022, marked the beginning of the end for Gids. The “single specialist provider model is not a safe or viable long-term option”, she wrote. “A fundamentally different service model” was needed. Cass identified the problem of “diagnostic overshadowing” – whereby even though many of the children and young people presenting to Gids had complex needs, once they were identified as having gender-related distress, those other important healthcare issues were sometimes overlooked. The report described how there were “significant gaps in the research and evidence base”. And how the existing weak evidence base did not apply to many of the young people, particularly “birth-registered females first presenting in early teen years”, being seen at Gids. The latter’s “clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced”, Cass concluded, nor had the service undertaken “routine and consistent data collection”.
When it came to the thorniest issue of all – the use of puberty blockers – Cass questioned their purpose and how they performed in practice: the “most difficult question” in this regard, she wrote, “is whether puberty blockers do indeed provide valuable time [to think]… or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminates in progression to… hormones by impeding the usual process of sexual orientation and gender identity development”.
On 28 July 2022, NHS England announced that it planned to close Gids. It would be replaced, initially, by two new regional services – one in London, the other in north-west England. These new services will follow a very different model of care to the past, offering more holistic treatment. In the service specification that will guide them, gone is any mention of the four-to-six-session assessment model. Instead, the document calls for “a range of pathways to support these children and young people”, something Gids clinicians had urged years previously. The primary intervention is “psychosocial” and “psychological support”, not medical. And NHS England confirmed on 12 March this year that there will be no medical pathways available from the new services at all, because there is not enough evidence to support their safety or clinical effectiveness. This followed a systematic review of the evidence base by the National Institute for Health and Care Excellence, which judged it to be of “very low” quality.
Puberty blockers will not be prescribed on the NHS, unless and until a research trial has been established. If the study is granted the relevant approvals, it may begin recruiting participants in late 2024.
The opening of the new services has been beset by delays. Initially planned for spring 2023, they have taken far longer than anticipated. The process hasn’t been helped by some bizarre decisions made along the way, largely by Great Ormond Street Hospital, which is to house the new London gender hub. In the meantime, Gids remained open, but haemorrhaged staff. By September 2023, there were around half the number of clinicians than there had been three years earlier. The same was true on the administrative side: Gids staff have been treated poorly by NHS England, which failed to provide timely and clear advice on what would happen to jobs when the service ended.
Gids struggled to cope with its existing caseload, and not a single young person has come off the ever-growing waiting list for care since October 2022. During this time, Gids has continued to operate under a model of care that has been found wanting by both the CQC and Cass’s review. It has also been allowed to refer more children for puberty blockers. In the year after July 2022, when NHS England first indicated its intention to provide blockers only in a research setting because of inadequate evidence, 123 more under-18s were referred by Gids to endocrinology teams at UCLH and Leeds General Infirmary.
Once the world’s largest children’s gender clinic, Gids will close its doors for good on 31 March. In the process, it may well have played a part in bringing down the globally renowned Tavistock. The Trust plans to merge with another health provider by next summer. It was always difficult for such a small trust to stay afloat financially, but the over-reliance on income from both children’s and adult gender services over the past decade left it especially vulnerable. The money received from the Gids contract alone amounted to 14 per cent of the Trust’s total income in 2022-23 – a hole that its CEO has admitted cannot be plugged.
The first two new gender identity services will open on 1 April. A third is being set up in the Bristol area, and over time it’s thought there may be up to eight operating in different regions of England.
But it won’t be easy. Great Ormond Street has found it so difficult to recruit staff to the new service that it took to offering a £500 “refer a friend” bonus as part of its most recent recruitment drive in early March.
There is little to smile about for the 6,000 or so young people on the waiting list for help. No one will be coming off the list soon, if ever. As John Stewart, NHS England’s national director for specialised services, conceded on 12 March, “Our two new providers on their own are not going to be able to make a significant dent immediately in that waiting list.”
Initially, the only children who will be seen by the new services will be those whose care is being transferred from Gids. But the new services won’t be seeing all of them – just 250. In a development not mentioned by NHS England before, any child already receiving puberty blockers or cross-sex hormones at one of Gids’ two linked endocrinology clinics, or who has been referred to endocrinology but not begun treatment, will not have their care overseen by the new services.
This is the majority of Gids’ caseload. NHS England has told me that it numbers around 400 children and young people. Around 190 are 17 and therefore eligible to be transferred to adult clinics. The remaining number are on puberty blockers or cross-sex hormones (having already been on puberty blockers beforehand). This group of around 210 will be eligible for a “wraparound service” being provided by Nottinghamshire Healthcare NHS Foundation Trust. There are few details – this has not been publicly announced before. However, several of the Nottinghamshire Trust’s services have been severely criticised in recent months, including findings of staff falsifying records and assaulting patients, and it has received highly critical CQC reports. NHS England did not provide details on how the Trust was chosen. I’m told that this “wraparound care” will be working to the same interim service specification as the new gender services, while “recognising that not all of it will apply to this patient cohort”. NHS England insists that these children will still receive psychosocial support.
The private sector has, inevitably, stepped into the void created by a lack of NHS care for gender-questioning children over the past few years. Recent Gids staff have been turned down for jobs in the new gender hubs. In order to keep practising, some have joined Gender Plus. Headed by the clinical psychologist Dr Aidan Kelly, who worked at Gids between 2016 and 2021, this private service – based above an east London fried chicken shop – lists at least nine other Gids workers, or those who have worked in endocrinology services connected to Gids, alongside him.
Gender Plus is predominantly aimed at the 16-25 age group, and goes further than the NHS ever has: prescribing hormones to 16-year-olds without the need for prior treatment with puberty blockers. Young people seen at Gids have only ever been able to access testosterone or oestrogen at 16 if they had been on blockers for a year beforehand. Kelly’s colleague, another former Gids clinician, Claudia Zitz, has said that Gender Plus would “definitely” assess 15-year-olds, “so that they can start kind of accessing medical treatment at 16”. The Gender Plus team has publicly stated its opposition to NHS England’s plans to end the routine prescription of puberty blockers.
The Gender Plus service isn’t cheap: under-18s will need to have around six appointments, spanning six months, before being eligible for hormones, with each hour-long “specialist gender assessment” appointment costing £275. Kelly has said “offering such a comprehensive, holistic kind of package of care, I suppose, does come with a cost”.
Under-16s can be assessed and receive “therapeutic support”. But while Gender Plus’s own hormone clinic won’t prescribe puberty blockers to under-16s, it will inform them of those that will. Responding to my questions in January, Kelly confirmed the company had and does refer under-16s to others for “age-appropriate medical gender treatment”. “When it has been indicated and [is] appropriate to do so we have signposted people to their options for treatment,” he said. “Those options have always been with fully registered and regulated professionals and in line with the best-practice guidelines (according to the NHS and WPATH [the World Professional Association for Transgender Health]).”
Hilary Cass’s long-awaited final report and recommendations on youth gender identity services will be published in April. That, along with NHS England’s announcement on puberty blockers and the new hubs, means there is an opportunity to change the way gender-questioning young people are cared for. To make it evidence-based, in line with other areas of healthcare. But activists and gender clinicians alike are already discussing how they can challenge the Cass Review, while private providers can sidestep the NHS’s more cautious approach. NHS England will have to do far better than it has in the past at providing oversight to ensure Cass’s recommendations are followed. But even then, that so many did so little, for so long, has meant there is a mountain to climb. With thousands of young people lingering on a waiting list wanting help, there will be no quick fixes.
The updated paperback edition of Hannah Barnes’“Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children” (Swift) is out on 28 March
[See also: No more puberty blockers for children, says NHS England]
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This article appears in the 20 Mar 2024 issue of the New Statesman, Easter Special 2024