Hanna Barnes thinks long and hard about her answers. Some questions she rejects outright because she is not an opinionated journalist, politician or activist. For over 10 years, Barnes has worked as an investigative journalist only comfortable with confirmed facts. Her most recent story is about a well-intentioned health initiative that produced unforeseen impacts and forced healthcare professionals to stop and think. Now that it is winding down, there is much concern for the vulnerable people it served – individuals questioning their gender identity who need urgent professional help. Barnes recently spoke to a group of foreign correspondents in the United Kingdom about her new book, Time To Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children, available in British bookstores on February 23. The book expands on the author’s extensive investigation for the BBC’s Newsnight program, which won her the prestigious Royal Television Society award for television journalism. The Financial Times has already named it one of the books that will frame the public debate in 2023.
In mid-2022, after a rigorous internal investigation, the UK’s National Health Service (NHS) decided it would temporarily close (in the spring of 2023) the only center treating minors who question their gender identity. For over 30 years, Tavistock operated the Gender Identity Development Service (GIDS). The NHS report by Dr. Hilary Cass recommended that GIDS be moved to local health centers to mitigate “the lack of peer review” at Tavistock due to its limited “capacity to cope with increasing demand.” While the report stopped short of complete condemnation, it described a treatment center that skipped over any “open discussion” about the nature and causes of the “gender incongruence” of its patients before opting for the gender transition process.
“This is not a story which denies trans identities; nor that argues trans people deserve to lead anything other than happy lives, free of harassment, with access to good healthcare,” writes Barnes. “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”.
In 2007, a small group of psychologists, psychotherapists, family therapy specialists, social workers and nurses went from treating 50 children a year to becoming the entire country’s referral center for thousands of patients. The most striking thing about this expanding mission was not the numbers (which are vague because of poor record-keeping) but the diversity of the people who came for help. Most of the existing scientific literature is about children assigned male at birth who have suffered gender incongruence virtually all their lives. However, Tavistock’s GIDS office slowly filled up with unmanageable numbers of girls whose anxiety about their true gender identity had begun to emerge during adolescence. Barnes shies away from simplistic explanations that blame this trend on the influence of social media, although she does not deny that it is a factor. She interviewed dozens of patients, all of them different, and found multiple factors.
“Take someone like Harriet. She says, for her, for sure, there was a social influence element,” said Barnes. “She was struggling with her sexuality. She didn’t like the fact that she was a lesbian. She’s had a relationship with another girl and was made to feel ashamed about it. The idea [of transtioning] was becoming a quiet trend in her friendship group, and actually gave her a sense of social kudos to be non-binary and then trans.”
The mere mention of gender dysphoria is sure to cause controversy. Many people in the field refuse to label it a mental health problem because of the stigma it carries for people who want to self-determine their gender. The NHS has accepted the diagnosis for decades: the incongruence between a person’s biological sex and the gender with which he or she identifies. The World Health Organization (WHO) does not consider it a pathology and prefers to use the term “gender incongruence.” In practice, a professional will conclude that a patient suffers from gender dysphoria if experienced for more than six months.
In the book, Harriet tells Barnes, “I would have liked to be challenged on why I thought certain things were signs of gender dysphoria, such as not liking skirts or not liking my voice. They could have questioned why I changed identities so rapidly from non-binary to a trans boy to whatever else.”
Puberty blockers: time to think?
Patients who decide they want to undergo a medical gender transition process take their first steps at GIDS and then are referred to pediatric endocrinologists (specialists in medical diagnoses with hormonal causes) at NHS public hospitals. The first step is treatment with gonadotropin-releasing hormone analogs, known as puberty blockers. These are drugs commonly used for children with precocious puberty (before eight in girls and nine in boys). They directly affect the pituitary gland and prevent the release of sex hormones such as testosterone or estrogen. They have also been used for treating prostate cancer in men and even for the chemical castration of sex offenders. Still, their use in gender dysphoria does not align with the original purpose of these drugs. In simple terms, they slow the development of physical traits such as breasts in girls and body hair or Adam’s apples in boys.
GIDS was created to help young people and their families “develop their gender identity” through extended psychotherapy sessions. Puberty blockers were only prescribed when the adolescent was at least 16, and everyone involved was convinced that a gender change was the answer. Professionals believed waiting until the age of 16 was needed so adolescents could have time to form ideas about their developing sexuality. The concept was to give minors “time to think,” hence the book’s title. Another meaning of the title is that society should stop and reflect before designing responses to actual, urgent situations. Instead, puberty blocker treatment became a prelude to an irreversible process because the drugs became a sort of self-fulfilling prophecy – their effects confirmed the conviction to change gender.
“Evidence shows that this isn’t really how they work in practice,” said Barnes. “There was always this hypothesis, and it was no more than a hypothesis, that they provided time to think, time and space to think and to take away the distress caused by this developing body in a way that that young person didn’t want, and therefore allow them exploration. In theory, it makes sense. In practice, it doesn’t. Almost all – more than 95% – progress to the next stage…. The specialists began to suspect that, rather than helping them to think, what they were doing was cutting short this period of reflection, which had become the first phase of the transition process.” The NHS report prepared by Dr. Cass also called for “the need to better understand the reasons” why almost all the young people who began puberty-blocking treatments chose to proceed to the next phase of hormone replacement.
Many adolescents coming to GIDS had complicated family lives, financial difficulties and even sexually abusive situations. Many had eating disorders, self-harmed, suffered from depression or had symptoms of autism. Barnes questions how such diverse people were all given the same answer – puberty blockers.
When children with precocious puberty are treated with blockers, their bodies usually revert to natural biological development after treatment is stopped. But for children undergoing a gender transition, the treatment doesn’t stop until they go to the hormone replacement phase. The few medical studies on the subject are contradictory. Many of these children clearly gain some peace of mind and experience less anxiety due to the blockers. But some studies found changes in sexual functions, bone weakening and mood swings. People who switch to synthetic hormone replacement therapy have an increased risk of coronary heart disease. The third phase – surgical intervention – is virtually irreversible, and any hypothetical gender reversal procedure would undoubtedly be painful.
However, the potential side effects were not the main reason for the Tavistock shutdown. As the Cass report notes, the fundamental cause is that the institution never clearly established whether the gender incongruence detected in many young people “was an inherent and immutable phenomenon, for which the best response was a transitional treatment, or whether in some more fluid cases, temporary responses to a series of psychological, social or developmental factors were possible.”
The Tavistock story produces a flood of doubts and questions that Barnes’s book discusses with nuance and care. Why did a process with such enormous consequences proliferate so quickly and broadly? Why did it proceed based on such poor evidence and test results? Why was there no proper follow-up of all the people who went through Tavistock? Were there external pressures on the decisions of the center’s professional staff?
“They [GIDS staff] were not ideologues,” said Barnes. “They were mental health professionals who cared about young people. But the fear of being criticized was much stronger. We’ve had this shift in society, and rightfully so, of concern for the rights and just treatment of minority groups. I think there was a real fear of being branded transphobic…. It’s difficult to say how much influence groups like Mermaids [an organization that supports trans youth] had over clinical practices [at Tavistock]. I think there was undoubtedly a fear of how they would react if the clinic did certain things.”
The impending publication of Time to think has spurred conservative politicians and pundits to reinvigorate their culture war on the trans movement. On the other side are those who welcome the book, like university professor Kathleen Stock, who resigned from the University of Sussex (UK) after a campus smear campaign against her for questioning some of the trans movement’s approaches. Stock applauds Barnes for spotlighting the most urgent issue of the Tavistock shutdown: more than 7,000 young people in the UK have been left in limbo, awaiting help, diagnosis and care.
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