messages not sent

But in the early 2000s the work of a gender clinic in the Netherlands was gaining notice and influence among both medical and trans advocacy communities. Clinicians there were developing the “Dutch protocol”, whereby children who had experienced lifelong gender dysphoria, and were psychologically stable, were offered puberty blockers at twelve, followed, if desired, by cross-sex hormones at sixteen and surgery at eighteen. Advocates of the protocol argued that early intervention with puberty blockers gave children time to explore their gender identity without the potentially highly distressing, even “traumatic”, progression of physical changes that, in the event of transition, would have to be arduously and imperfectly medically reversed.

As Barnes explains, initially promising results from the Dutch clinic led to mounting pressure for GIDS to make its own treatment less conservative. As one clinician working there in the early 2000s put it to Barnes, “the political pressure from activist groups was astonishing”. In 2005 a report by the psychiatrist Dr David Taylor, triggered by staff concerns that some children were being referred for puberty blockers too quickly, described “a pressure [from patient and parent groups] that was ‘quite onerous’ and one that ‘made it very difficult for people to have freedom of thought’.”

There was also pressure from medical communities, including guidance shifting towards the Dutch approach. In 2011 GIDS set out to test the Dutch protocol for itself, with forty-four carefully screened children of twelve to fifteen recruited to an “early intervention” observational study. (There was no control group.) In early 2016 junior staff presented preliminary results at an internal event. Although the children reported high satisfaction with their treatment, clinical measures of self-harm, suicidal ideation and body image showed no improvement; some even worsened. In other words GIDS had not seen the same positive results as the Dutch – a reduction in distress that would better allow “time to think”.

The biggest bombshell, however, came in “an astonishing aside”: every single child had progressed to cross-sex hormones, a treatment with irreversible consequences. A former senior GIDS clinician, Anna Hutchinson, described this revelation as her “holy f*ck” moment. “It totally exploded the idea that when we were offering the puberty blockers, we were actually offering time to think”, Hutchinson told Barnes, “because what are the chances of 100 per cent of people, offered time to think, thinking the same thing?”

Yet these findings were never formally discussed. Indeed, early intervention with puberty blockers had already been rolled out more widely within the service, and age limits removed. With characteristic understatement, Barnes observes that it is “difficult to understand why this decision was permitted by GIDS’s commissioners at NHS England”. At a 2016 conference Polly Carmichael, the director of GIDS, reported that just two of this larger, more clinically diverse group of 162 children had stepped off the medical treatment pathway. In theory this could be explained by referral accuracy: that GIDS clinicians were all but infallible at picking out who would benefit from medical transition. But, according to Barnes, “[a]lmost every GIDS clinician I have spoken with is honest and open about the fact that they simply could not predict which young people would grow up to be happy trans adults, and which would not; who would always identify as trans, and who would not”. Rather than providing “time to think”, the blockers appeared to be reliably setting young people onto a path to medical transition that some would come to regret. Yet, Barnes writes, “GIDS as a service did not adapt its practice in any meaningful way”. Nor was there any process for providing this information to new clinicians, or ensuring that it was passed on to young people and their families. “They couldn’t pass on what they didn’t know.”

By 2016 referrals had doubled to 1,419. Clinicians had enormous caseloads, pressured by a long waiting list of distressed children, some eagerly passed on by underfunded mental health services at the slightest mention of “gender”. “It was abundantly clear to some staff that things at GIDS were far more complicated than the assessment process allowed for”, Barnes writes. Some clinicians worked around the constraints of the service model as best they could, and Barnes includes the voices of young people happy with the care they received. But a disproportionate number of cases were complex, involving autism, severe mental health issues, sexual abuse, external and internalized homophobia, and even identification as another ethnicity, as well as suspected “fabricated or induced illness”. There was also an unexplained rise in referrals of female adolescents whose sense of gender incongruence had appeared post-puberty.

All of this was quite different clinical phenomenology to the young people among whom the Dutch clinic, albeit not GIDS, had had positive preliminary results with the use of puberty blockers. It didn’t matter: “the answer was always the same”, one clinician told Barnes. “That the young people eventually get put on the blocker unless they themselves say they don’t want it.”

Piece by piece Barnes reveals GIDS’s indivertible path. Inconvenient information was forgotten, not formally distributed, unshared or never sought. Taylor’s report from 2005 was hidden (unearthed in 2020 following an extensive Freedom of Information Act battle). His recommendations – including long-term follow-up of children treated with puberty blockers, described in his report as “relatively untested and un-researched” – went unheeded. A legal challenge brought against GIDS in 2020 by a former patient, Keira Bell, although ultimately overturned by the Court of Appeal, made the absence of basic information glaring and public. This left some GIDS clinicians “stunned” and “furious”. “It wasn’t obvious that no meaningful data was being collected”, one told Barnes.

A governor on the Tavistock’s council, Dr Juliet Singer, had been pressing the top leaders at the time, CEO Paul Jenkins and chair Paul Burstow, on the lack of data since her election in November 2018. GIDS claimed to be experts, but: “How can you be experts when we don’t know the impact of the treatment, the side effects and the long-term effects?”, Singer observed to Barnes. “And we don’t know any of the outcomes. Without all of that, what are you expert in?” In response, Jenkins acknowledged the significance of the data issue, but described the task of retrospectively creating a data set as requiring “disproportionate effort”. A recurring theme of Barnes’s account is how many, how often, and in how many ways, GIDS staff and others acting on their behalf raised concerns, but were soothed, shamed, sidelined, silenced or scapegoated. In 2021, an employment tribunal ruled that the trust had vilified its own children’s safeguarding lead, Sonia Appleby, for raising staff concerns.

How did an initially tiny, cautious and reflective gender service end up negligently medicalizing an unknown number of vulnerable young people? Barnes’s exhaustively researched account presents readers with a complex confluence of factors – from the “family” ethos within the GIDS team to the curtailed youth mental health services of austerity Britain – while rightly avoiding stressing any single one. In many ways this is a textbook organizational scandal, a perfect storm of multilevel pressures, weak oversight and readily accessible and well-meaning rationalizations.

But there is also a less generic moral to this story: the importance of the distinction between values and facts in social justice movements, particularly for institutions in the business of producing objective information. Medical science can and should fully embrace the values of trans equality. To that end, it should produce reliable knowledge and safe and effective interventions that help those with gender identity incongruence or distress to flourish. This entails attending to hidden biases and other distortions of knowledge production. Instead trans rights activism demands the endorsement of a set of contestable “facts”: that gender identity is innate and objectively known even by children, while sex is a social construction; that trans identification never arises from psychological distress; that the sudden rise in trans identification, including marked changes in sex and age demographics, is satisfactorily explained by greater trans visibility and acceptance; that regret over medical transition is rare; that blockers are safe and reversible, promote mental health and avert suicide risks. It’s a take-it-or-leave-it package deal, and to question any part of it is to be “anti-trans”.

Examples abound in Time to Think of the permeation of this activist logic within GIDS. A clinician who declared that she didn’t herself have a gender identity was branded transphobic. Natal sex was no longer referred to as a fact observed at birth, but as “assigned”. Or consider events following the publication in 2018 of a controversial book, Transgender Children and Young People: Born in your own body. Its editors proposed that the “‘transgender child’ is a relatively new historical figure, brought into being by a coalition of pressure groups, political activists and knowledge makers”. Following complaints, a copy of the book was removed from the Tavistock library. A clinic director who sent an email letting staff know where the book could be purchased more cheaply ended up with a note on his HR file, and the prospect of disciplinary action, for abusing the Trust’s email policy.

In a review of the book for an academic journal, a GIDS psychotherapist observed that, in her clinical experience, body dysphoria may not always be caused by an “inborn ‘trans’ nature”, as she put it. While readily acknowledging the reality of flourishing trans adults, she concurred with the book’s authors that “the current socio-cultural situation is one which has permitted an inflation of the idea, and”, her review continued, “that we are indeed co-creating the very notion of the ‘trans kid’”. In response the head of the trans charity Gendered Intelligence wrote to Polly Carmichael suggesting that steps be taken, including a public statement of apology. The charity Mermaids, meanwhile, in a written submission to parliament, referenced the review as evidence of GIDS staff being “openly unsupportive” of young trans people, suggesting that “a thorough audit” be made of the staff’s views. That Carmichael supported her employee to Gendered Intelligence, and did not comply with Mermaid’s request, is reassuring only to a point. “[W]here ideology impacted GIDS so strongly”, Barnes concludes, “was in the service’s failure to keep an appropriate distance” from these charities, opening the door for ideology to push the service beyond the medical evidence.

It is hardly surprising, then, that even to suggest what had once been known, that not every young person with gender dysphoria would identify as trans for life, seemed forbidden, Anna Hutchinson told Barnes. That “the service seemed to ‘forget’ what had gone before” was a point “made repeatedly by former GIDS staff”, says Barnes. Nor did GIDS gather evidence that might revive institutional memory of such off-limits ideas. And this is where the perverse effects of trans rights activism kick in. Fears of attacks on the rights to healthcare of young people with gender dysphoria and distress are understandable. Barnes’s book, which repeatedly relays clinicians’ support for young people’s access to a medical pathway, offers no grist for prejudice-fuelled mills. On the contrary. Socially just medical science interrogates what counts as sufficient evidence and recognizes the importance of empirically adequate science. It carefully considers, from the perspective of marginalized groups, what measures of harms and benefits are included and excluded. It seeks to identify and respond to the heterogeneous experiences and needs of those groups, including those who are missed by established frameworks. Barnes’s book is replete with examples of how far short the gender service fell from this ideal.

Despite claims that the science is settled, the clinical field remains suffused with uncertainty. “National health bodies in Sweden, France and Finland have all called for far greater caution in the use of puberty blockers following reviews of the evidence”, observes Barnes. Bell’s witness statement – “I am a twenty-two-year-old woman left with no breasts, a deep voice, body hair, a beard, affected sexual function and who knows what else that has not yet been discovered” – highlights the fact that there are also high stakes for the unknown number of young people for whom blockers are not the right approach. Hannah Barnes’s scrupulous research is a painful, important reminder that clinical care that promotes the wellbeing of young people experiencing gender incongruence and distress, and that protects their autonomy, cannot be built on ideological sands of ignorance, forgetting and silencing.