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Clinically Insane

In the debate over medical treatment for children struggling with gender identity issues, who is watching out for the child patients? This question is one of several Hannah Barnes raises in Time to Think, her new book about the rise, decline, and fall of Britain’s Tavistock Gender Identity Development Service (GIDS) for children with gender dysphoria.

GIDS, the only gender clinic for children accredited by England’s National Health Service, was founded in 1989 by child psychiatrist Domenico Di Ceglie as a counseling service designed to help and support children struggling with gender identity issues and their families. Barnes, a BBC journalist and investigative reporter, follows the clinic’s transformation from a counseling service in the 1990s to a pill mill for puberty blockers and cross-sex hormones in the 2010s and beyond.

Barnes describes how, along that path, the tiny clinic’s mostly male patients—many of whom had exhibited opposite-gender behaviors from an early age—grew exponentially over the course of almost 30 years. The patient profile changed dramatically, and the service began receiving many more natal girls whose gender dysphoria had emerged as they neared puberty. Over a 10-year period between 2009 and 2019, Barnes writes, the gender clinic reduced requirements for psychosocial assessment of patients, reduced the age for prescribing puberty-blocking drugs, and became a major revenue source for the Tavistock and Portman health trust with which the clinic was affiliated.

Barnes’s book shows how groupthink creates blinders for even the brightest and most well-intentioned professionals. As clinicians in the Netherlands and United States began prescribing puberty blockers to children with gender dysphoria, GIDS came under greater and greater pressure to follow suit. Groups such as the Mermaids support group for families of transgender children and the Gender Identity Research and Education Society put political pressure on GIDS doctors to refer younger children for puberty blockers and hormones. Agency leaders enjoyed the positive press the clinic received and the revenue it generated. The clinic’s “gender-affirming” approach brought accolades from transgender activists.

But as the number of referrals grew, so did concerns regarding the children. While puberty blockers were originally regarded as fully reversible, researchers began questioning their effects on bone density and brain development in minors. In many cases, patients presented at the clinic with a recent history of gender dysphoria and also histories of parental conflict, time spent in foster care, suicidal ideations, extreme anxiety, obsessive-compulsive disorder, and sexual abuse. Often, parents or children came to the clinic pushing for an immediate referral for puberty blockers. A few parents expressed opinions that they’d rather have a trans child than a gay child.

Many GIDS staff raised questions. Were the children’s gender identity issues causing their co-occurring mental health issues, or vice-versa? Were some youth identifying as trans because they were ashamed of a same-sex attraction? Were young children truly able to give informed consent to procedures that would affect their adult sex lives at a time when they had no idea what that meant? Or as the judge in the Keira Bell case challenging the ability of children to give informed consent to these treatments put it: “How is it possible to have an age-appropriate discussion about the loss of orgasm with a young person who has never had one?”

Soon it became apparent that almost all children who were put on puberty blockers went on to receive cross-sex hormones, leading the clinic’s director to ask—but not answer—an important question: Were puberty blockers truly giving these children “time to think” or were they pushing them down a road inevitably leading to cross-sex hormones and surgery? Recognizing that many children with gender dysphoria adjust to their bodies and their sexuality as they become young adults, professionals at GIDS expressed concern that they might be harming children. At the same time, Barnes estimates that at least 70 percent of young teens were being referred for puberty blockers.

Those who spoke up were ignored or labeled transphobic. A court later found that GIDS executives instructed staff not to report any child protection concerns to the official responsible for child safeguarding.

Following investigations by BBC journalists, critical court decisions, and finally an NHS-instigated inquiry by preeminent pediatrician Dr. Hillary Cass, the Tavistock gender clinic is closing. But Barnes’s work raises significant lingering questions. The book paints a politically charged environment in which activists push to medicalize gender treatment for children; parents suffer seeing their children in distress; young patients threaten self-harm if not prescribed puberty blockers; and medical providers have financial incentives to provide a medical option. Given those circumstances, whose job is it to ensure that decisions are taken in the child’s best interests?

In the Keira Bell case that brought much attention in Britain to the issue of transgender medical treatment for children, the trial judge ruled that a court should make the decision regarding whether a child has the capacity to give informed consent to such treatment. That ruling was overturned on appeal. More recently, however, NHS created a multi-disciplinary group to fully review the circumstances of children under 16 who might be candidates for puberty blockers. The reviews are intended to ensure that children are safeguarded from harm and that their best interests are made a priority.

Events at Tavistock mirror what is happening in the United States. Trans activists push to shut down any questioning of medical intervention for children with gender dysphoria. When the New York Times published a series exploring both sides of the issue, GLAAD and other activists, including many Times staffers, complained that the coverage was transphobic. The reports of Jamie Reed, the whistleblower who worked at the child gender clinic at Washington University in St. Louis, reflect many of the concerns raised by Tavistock clinicians. As in the United Kingdom, there is a confluence of patients, parents, providers, and activists pushing to further medicalize the treatment of gender dysphoria in children.

Children with gender dysphoria want solutions. Parents want to see their children happy. Physicians want to help. But amid this wave, who is going to take responsibility for objectively deciding what is in the child’s best interests?

Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children

by Hannah Barnes

Swift Press, 466 pp., $25 (paper)

Tom Rawlings is an Atlanta-based attorney and principal of Child Welfare & Justice Transformation, International.

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