How spotlight shone on a gender crisis in Britain

When journalist Hannah Barnes began looking at the British National Health Service’s flagship gender service for children, she started with a simple question: what’s the evidence base?

Investigative journalist Hannah Barnes outside the Tavistock Centre in London. Picture: Jon Attenborough

When British investigative journalist Hannah Barnes began looking at the British National Health Service’s flagship gender service for children, she started with a simple question, the sort of query that could reasonably be asked of any other health service: what’s the evidence base?

It was 2019 and Barnes was aware that some clinicians at the Gender Identity Development Service (GIDS), based at the Tavistock and Portman NHS Foundation Trust in North London, were worried that vulnerable and distressed children were having their puberty halted by medication after often rushed assessments that failed to explore other factors in their lives

She had read a leaked report from David Bell, a consultant psychiatrist at the trust, who described the care as “woefully inadequate’’. Some staff who had approached him were “extremely distressed’ and one “felt that they’d done damage”.

If this were any other health service, such as a paediatric cancer ward, media and political interest would have hit overdrive at this point. Children potentially being harmed by medical intervention is a big story by any measure.

But this wasn’t getting much attention and so Barnes, an investigations producer at the BBC’s Newsnight program, started asking questions, interviewing staff, patients and their families. She quickly learnt that this was no straightforward medical investigation. She had waded into a highly contested battleground.

“Every film we put out and every online article we published, we had complaints,’’ Barnes says. “Because it’s so hard to cover – you get grief and complaints all the time – it means that people haven’t looked at this area properly, and that’s part of the problem. Once this word ‘gender’ gets thrown in, it muddies the waters.”

Barnes pressed on, trying to ignore the growing personal attacks. “It’s not very pleasant being accused of wanting to kill children … But the reason our work at News­night was taken seriously by people in the healthcare sector in particular is because it was calm, thorough and evidence-based and we tried to take those external pressures out of our coverage,’’ she says.

She contacted close to 60 clinicians who worked at GIDS and collated a damning dossier that grew into a book, Time To Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children, a sober account of a medical scandal that’s been unfolding for years while authorities looked away.

Despite her meticulous work and the clear public interest, it was difficult to find a publisher willing to take it on – none of the big publishing houses would touch it.

But the power of the book is that she doesn’t rely on activists or fringe observers with an ideological bent. Well-meaning but often overwhelmed GIDS clinicians spoke to her of their regret in referring young people for puberty-blocking and cross-hormone treatment without solid data to support this pathway and in the absence of broader mental health assessments.

“These children often had a multitude of other issues they were dealing with: anxiety, depression, traumatic backgrounds in some cases, a high incidence of ­autism, homophobic bullying and sometimes very chaotic living conditions,’’ Barnes tells The Weekend Australian.

She notes that, as early as 2005, David Taylor, the Tavistock trust’s then medical director, wrote a report (that remained hidden for years) that raised a fundamental problem. Staff didn’t agree on exactly what they were treating. “Were they treating children distressed because they were trans, or children who identified as trans because they were distressed? Or a combination of both?’’

In the event, Barnes says GIDS wasn’t funded to provide the psychotherapies it was felt many of these young people needed. “Consequently, most of these young people would eventually proceed on to the medical pathway,’’ Barnes wrote. “If they met the diagnostic criteria for gender dysphoria, which they invariably did, then the only real treatment GIDS was commissioned to provide was a referral for puberty blockers.’’

GIDS was essentially providing a “one size fits all” intervention based on an affirmative model that viewed the young person as the ­expert on themselves when it came to gender, Barnes says.

“If anyone of any age self-identifies as the other gender, then they are affirmed as trans,” she says.

And while puberty blockers – administered to provide patients with “time to think” before embarking on irreversible treatment – were shown to help some children, they did not ease the distress felt by others.

“The evidence base isn’t strong; there’s pretty much universal agreement on that,’’ Barnes says. “Yes there are studies that show benefits to mental health but they’ve all been heavily critiqued … and once they’re scrutinised, they’re never shown to be as strong as claimed.”

Some studies have reported high satisfaction from children and their families. “The vast majority of clinicians I spoke to, even those most critical of the way the service was run, would say they did see young people thrive on the blocker,” Barnes says. “But it was overused and wasn’t appropriate for many other patients.”

She points to one internal study that identified no changes in psychological function, quality of life or degree of gender dysphoria in the young people prescribed ­puberty blockers. In some cases, gender-related distress and general mental health worsened.

And there were doubts around whether the treatment did provide the vital pause-time – in one internal report almost every patient who started on puberty blockers progressed to cross-sex hormones, a treatment with irreversible consequences.

Barnes stresses that this is not a story that denies trans identities nor suggests that trans people deserve anything other than to lead happy lives, free of harassment, with access to good healthcare. Being transgender is not in and of itself a mental illness.

“This is a story about the underlying safety of an NHS service, the adequacy of the care it provided and its use of poorly evidenced treatments on some of the most vulnerable young people in society,” she says.

Worrying trends

Burdened with exploding case numbers, clinicians at GIDS began noticing some unexplained trends as the service grew out of the small unit that began in 1989.

Where once it was mostly boys who were referred, by 2019-20 girls outnumbered boys by a ratio of six to one in some age groups, most markedly between the ages of 12 and 14.

In 2015, Anna Hutchinson, a senior clinical psychologist at the service, had noticed something else. She told Barnes that self-diagnosed adolescent trans boys – natal females – started to fill up the waiting room and they had similar stories, haircuts, even names.

“They’d talk about their favourite trans Youtubers, many having adopted the same name, and how they aspired to be like them in the future,” Barnes says.

“Given how complicated these young people appeared to be, could something else be going on that explained this, something other than them all being trans?”

Hutchinson said that from her earliest days working at the service she was struck by the incredibly complex cases that landed on her desk. She recounted the story of one young person who claimed not just to identify as a different gender to their sex, but also to have three different alter egos, two of whom spoke in an Australian ­accent.

“It later transpired that the young person had never visited Australia,” she said.

Clinicians were also concerned about the levels of autism and neurodiversity they were seeing. It wasn’t that anyone thought that it was not possible to be both autistic and trans, Barnes says, but clinicians openly questioned whether the over-representation of autistic young people in the service required further examination.

“Some staff feared that they could perhaps be unnecessarily medicating autistic children,’’ she says, noting that fewer than 2 per cent of children in the UK are thought to have an autism spectrum disorder yet at GIDS about 35 per cent of referred young people presented with moderate to ­severe autistic traits.

There were young people presenting to the service who didn’t just identify as another gender, but as another ethnicity too. “There were several cases in the service where a young person identified as a different nationality, usually East Asian, Japanese, Korean, that sort of thing,” according to former clinician Matt Bristow. They would have “quite specific ideas about transitioning and then taking on this East Asian identity as well as a different gender identity’’.

Despite the obvious complexity of all these cases “the answer was always the same,’’ Bristow said. “That the young people eventually get put on the blocker unless they themselves say they don’t want it.’’

Other concerns were also coming to the fore: overburdened staff taking on more and more patients (numbers increased at a rate of 50 per cent per year since 2009); staff who spoke up about being forced out; and what some felt was the undue influence of patient support groups on GIDS’s clinical practice.

Barnes says a significant number of clinicians were also worried that sexuality, like much else, wasn’t being adequately explored in assessments.

“I think there was a lot of ignorance about sexuality,” Hutchinson told her.

Homophobia on show

Matt Bristow was an openly gay man when he joined GIDS in 2013 and considered himself a trans ally. “I was very sympathetic,’’ he told Barnes.

But he soon came to view the service he was working for as “institutionally homophobic’’.

Another clinician, Anastassis Spiliadis, said the homophobia presented in different ways. “It could be completely silencing people who are gay,” he said. “It could be dismissing the reality that sexuality can play a role in how someone identifies.”

He told Barnes of families who remarked: “Thank God, my child is trans and not gay or lesbian.’’

Some young people were repulsed by the fact that they were same-sex attracted. “They did not identify as gay, because they did not see themselves as of their birth-registered sex,’’ Barnes says.

A large proportion of the teenage girls seen by GIDS were same-sex attracted. “Initially, some of them had identified as lesbian. And some of them had experienced a lot of homophobia and then started identifying as trans. It was almost like a stepping stone,’’ Spiliadis explained.

Barnes notes that some in the trans community find the suggestion that they might be gay, rather than trans, deeply offensive as it is for them to say how they identify. “Clinicians would never dream of telling a young person that they weren’t trans, or that they were gay instead,’’ she wrote.

“But where a young person had spoken explicitly about same-sex attraction or experiences, some felt it was only right to ask about this.”

Especially given that older studies of gender nonconforming children had “highlighted that the majority of young people would not medically transition but would grow up to be gay, lesbian or bisexual adults”,” she added.

“So it seems surprising that sexuality wasn’t at the forefront of GIDS clinicians’ minds as a possible outcome for the young people they were seeing.’’

Bristow told Barnes that some heterosexual members of staff didn’t realise that many gender nonconforming behaviours in childhood applied just as much to children who grew up to be gay, lesbian or bisexual, as to children who would grow up to be trans: things such as cross-dressing, feeling different, not necessarily fitting in with other children of their own sex, or having friends predominantly of the opposite sex.

“Some things which … are fairly normal for many LGB adults were read as being indicative of a trans experience,” Bristow said. Controversially, he came to feel that GIDS was performing “conversion therapy for gay kids”. Barnes notes this is a serious claim but said some clinicians had darkly joked “that there would be no gay people left at the rate GIDS was going’’.

“I don’t think that all of the children there were gay, by any means,’’ Bristow told Barnes. “But there were gay children there … who were being pushed down another path.’’

Hutchinson said: “Were people deliberately going into this field to convert gay people? Absolutely not. But the fact is the outcome might be the same.’’

Formal investigation

By September 2020, the bells were ringing so loudly that the NHS commissioned leading paediatrician Hilary Cass to review the service.

In March last year, her interim report found that the “single specialist provider model is not a safe or viable long-term option’’.

Four months later, the NHS announced that GIDS would close and be replaced by regional hubs staffed by doctors with a range of specialties and with a greater focus on mental health.

Other countries have made similar moves, Barnes says. Sweden is limiting access to puberty blockers for those under 18 to only “exceptional cases” and in research settings. In Finland, the guidelines state that psychotherapy rather than puberty blockers and cross-sex hormones, should be the first-line treatment for gender-dysphoric youth.

So nearly a year on from Cass’s report, how are things going in the UK, I ask Barnes. She lets out a long sigh. “No new service is up and running. GIDS is still open,’’ she says. “It was meant to close in June but that won’t happen because there’s nothing to replace it yet.’’

Meanwhile, more than 7500 young people are sitting on a waiting list where they will be likely stuck for years. “And that’s the tragedy,” she says.

“Wherever anyone stands on the best way to help them, no one can think it’s a good idea that thousands of young people sit on a waiting list getting no help whatsoever from anybody. It’s terrible.”