Hannah Barnes has been praised for her work on BBC’s Newsnight covering the emerging crises in clinics treating children and young people experiencing gender dysphoria, reporting gender incongruence or wishing to change their gender identity – however you can put it to cover the wide variety of children and youth reporting that they are not happy in the bodies they are in.
The language is not easy. The incorrect use of the wrong words in the wrong context about the wrong person at the wrong time can lead you into trouble often followed by accusations of transphobia.
As Barnes reports, this argument-ending cliché was levelled at a number of clinicians in the Gender Identity Development Service (GIDS) under the Tavistock and Portman NHS Trust Foundation in north London (and later in its sister clinic in Leeds).
Why? For seeking to determine the best course of treatment for children and youth struggling with their gender and biological sex, that didn’t automatically involve acquiescing to approving their progression to puberty blockers as the sole response to their troubles.
Time to Think: the title refers to the rationale behind putting children, even before they have hit their teens, on puberty blockers when they are potentially questioning whether their biological sex aligns with their felt identity. The aim is/was, ostensibly, to put off the physical occurrence of puberty to give the child space to work through with their feelings with the support of therapists, social workers and others.
As Barnes uncovers, the reality is/was that this was not the case particularly in GIDS. Children were give time as appointments for support and assessment were stretched out to once every four, six or nine months once they were prescribed with puberty blockers. Limited, if any, support was provided by trained professionals to the child to think, as the child/youth was placed on an almost inevitable pathway to sex-change hormones and potential surgical transition.
This is the crux of Barnes’ book. GIDS transformed from its early days as a therapeutic model for assessing and understanding gender incongruence, helping them to work through the challenge, into a referral system where the majority of children were sent to, primarily, University College London Hospitals, to be put on puberty blockers.
As Barnes outlines, those who raised concerns were ignored, gaslit, or subtly accused of being ‘gender critical’ or ‘transphobic’. One of Barnes’s interviewees, Dr Kirsty Entwistle, was an experienced clinical psychologist. When she got a job at GIDS in Leeds, she told her new colleagues she didn’t have a gender identity. “I’m just female,” she said. This, she was informed, was transphobic.
Barnes develops a chronology of the evolution and transformation of GIDs over almost 30 years, outlining the wide array of issues that she considers having gone unaddressed by its Directors, Boards or Governors.
An essentially affirmation model was adopted where the children and youth, often their parents too, understood they were coming to GIDS to get on puberty blockers. CAMHS – the Children and Adolescent Mental Health Services – became accustomed to referring children to GIDS if they had made little more than a passing reference to gender in an assessment of their mental issues. GIDS subsequently put many, possibly most, of these children, on the path of puberty blockers.
Minimum standards of four to six sessions to assess and understand the issues affecting children and adolescents, became the maximal standard, and sometimes children before they reached their teens were referred with even fewer sessions.
Many children who were presenting with complex problems – mental health issues, self-harm, abuse (both physical and sexual), living in care, broken homes, school bullying – were treated as if gender discomfort was the sole, only issue to be addressed and the only one to be considered.
Clinicians became increasingly concerned that GIDS was receiving referrals that were unnecessary or inappropriate from CAMHS (and many other routes), which was then causing the creation of a massive waiting list (and delays for children who really needed the service).
They were even more concerned about the processing of referrals to UCLH and inappropriately placing them on a pathway that led almost certainly to cross-sex hormones without the necessary in-depth assessment of underlying problems or co-morbidities.
Puberty blockers were presented as being completely reversible with no significant side effects. The reality that this seemed to be untrue (with particular issues related to bone density development but potentially brain development as well), along with the lack of proper research into the effects of the blockers, were practically ignored.
Puberty blockers were prescribed off-label (meaning it was not what they were tested and approved for) to postpone puberty in gender-confused children (they were approved to treat precocious puberty in children).
Patients were not fully appraised of the reality of puberty-blockers in order to give informed consent. As per the initial Bell ruling (later overruled on appeal as something judges could not decide but was the proper purview of doctors), children and youth are not sufficiently capable of making informed decisions that would have potential life-long effects. And, if they are not provided with correct information then they are doubly impacted as they make decisions in their turbulent teens that may lead to infertility, a life on hormone treatment, surgery that may never fully work as designed, and potentially even fatality.
GIDS claimed that reviews showed that the majority of children viewed puberty blockers positively. However the data for this is contested – based on interpretation of the data itself but also because the data is so limited. At best, the available data appears to say as many are negative as they are positive after three years on puberty blockers. And this seemed to be the sole justification that GIDS relied on.
Barnes tells the story of a number of children who have gone down this path (and further) through very sensitive and non-judgmental conversations. Their stories are varied but provide the real-life examples of the harm that can be done when an unthinking affirmative approach and procession to puberty blockers is followed.
GIDS failed to do any rigorous follow-up of their patients to understand what happens after they go on puberty blockers. The indications that puberty blockers ‘lock children in’ to a pathway towards sex-change hormones was ignored based on the perceived positive reviews from young people.
As Harriet tells her story: “Even if you haven’t had any medical anything, once you’ve said something publicly, and, you know, you’ve asked everyone to change what they call you… That’s a lot of pressure to put on everyone around you. And if you start to have doubts about that, there is that pressure. And then there’s also the immense stigma against desisting, or detransitioning. It’s like, well, you’re just an idiot, you know? You made a mistake, let’s get on with it. Leave. And there is no compassion towards it at all.”
The understanding that gender confusion in children and youth, for the majority, would resolve itself as they developed through puberty was forgotten, as this major life-event was put on hold indefinitely, stunting physical as well as potentially mental development.
The concern for clinicians was that they were ushering children on a pathway with damaging side-effects that they need not go on. They felt that they were probably doing harm to many children at the same time as ignoring underlying social and psychological problems that needed to be treated.
GIDS directors contested and continue to contest this. However external reviews by David Bell and Hilary Cass in 2018 and 2022 respectively, all pointed towards risky practices in the Service, and the complete lack of data to back up its operating model.
When the Service commenced in 1989 there was a paucity of information and it was a relatively new area of work. But 30 years later GIDS had made minimal effort to carry out research and data management to better understand the work it was doing as well as its impacts – both positive and negative.
They are no more knowledgeable now, 30 years later, than they were in 1990’s about which children suffering from confusion about their gender will grow up to be trans adults and which will not. Ideology and hubris was driving the operating model rather than scientific fact and understanding.
GIDS was, and is still, unable to provide any data on the outcomes of its work. It can barely pull together the numbers of its referrals to the UCLH for puberty blockers, let alone tell you how many actually took up puberty blockers, how many went on to cross-sex hormones, how many went on to surgical transition, or indeed how many desisted or detransitioned (or at which stage: before blockers, before or after cross-sex hormones, or after surgery).
Nor can they provide any data on children whose gender dysphoria has resolved itself. They know almost nothing about whether their service did good, bad or was neutral. There were no control groups. It seems they were working primarily on intuition, empathy and ideology.
Many clinicians tried at length, repeatedly, to raise their concerns. They were often listened to but then nothing ever happened. It is unclear why.
The fact that GIDS made up nearly 25% of the income for the Tavistock Trust is considered to potentially be a factor. It was important for the referrals to keep coming and they would only keep coming if the children and youth though they had a good chance of being moved on to a medical pathway.
The influence of outside lobby groups such as Mermaids is regularly highlighted by the author as another factor.
The story is a sad one. Barnes acknowledges that nearly all involved were well-meaning and had good intentions. But they were blinded for whatever reason – by outside pressure, financial pressure, ideology, hubris or a bunker mentality – to the potential harm they have been doing.
The recent contentions by Irish government Ministers that transgenderism should be taught to primary school children appears to demonstrate that they are unaware of the issues that are coming to light in the UK and that have been highlighted by Barnes and others.
One of these is Irish journalist, Helen Joyce, the author of Trans: When Ideology Meets Reality. Her work has shed light on many of the issues in this area and provided a foundation for Barnes to build from. When Irish politicians say that they want to provide “people in our country with facts and with science”, one wonders if they understand the absolute lack of facts and science that exist in this area.
- Will they provide the fact that twenty years ago the majority of children experiencing gender confusion were male and the demographic rapidly changed to predominantly females between the age of 12 and 14?
- Will they provide the fact that identifying as transgender may be temporary, may be mistaken, and may be caused by other factors?
- Will they say that while less than 2% of children in the UK have an autism spectrum disorder, at GIDS, more than a third of referrals presented with autistic traits yet were treated solely for gender identity disorder?
- Will they say that socially affirming gender confusion, by putting children on puberty blockers, may be counter-productive and prevent the issues from resolving themselves with appropriate support;
- Will they listen to the voices of young teenagers themselves who explain how difficult it can be to get off the pathway once they have been socially affirmed; how difficult it is to say ‘I was wrong’ after they have asked everyone to call them by their new name and their new pronoun?
- Will they listen to the children and young people who have been marginalised because they have desisted?
Or will they chose to support the narrative that a considered approach to this complex issue is transphobic or erasing transgender people?
When President Higgins said it was his view that schools should provide “basic information regarding sexuality in the fullest sense” does this include providing the facts related to the 238 young Irish people that were referred to GIDS between 2011 and 2021?
Will he provide the facts about their treatment? Whether they got the support they needed? Whether they were pushed on a path of puberty blockers to sex-change hormones to surgical transition? Will he say how many detransitioned? For how many their gender dysphoria resolved itself? How many are now living with regrets? Living with the side-effects of puberty blockers and sex-change hormones?
It is unlikely this basic information ‘in the fullest sense’ will be provided as Barnes’ book points to the reality that no one seems to have thought to track this information and do this research. Neither in the UK nor in Ireland.
Will he listen to the words of Prof Donal O’Shea, who Hannah Barnes talked to in Ireland who said ‘Unless we get the assessment of our children with gender issues right, then inevitably the system is going to cause them harm: either by not assessing them at all and helping them to progress when they need to progress on the gender journey, or by assessing them inadequately and recommending treatments that will ultimately cause them harm’?
O’Shea said that he and Dr Paul Moran faced ‘a kind of institutional laziness’ when raising the inadequacy of the Irish response and the care provided by GIDS. It wasn’t that they weren’t listened to: ‘I think it is worse than that actually. I think that they listened, chose to ignore, and chose to push down a route that would cause them the least – I’m gonna say – hassle, distress, trouble.’
This has occurred through the period Fine Gael has been in government. Leo Varadkar was Minister for Health from 2014 to 2016. Simon Harris succeeded him in 2016 and was in the role until 2020. Ireland continued to refer children to GIDS after the NHS announced in July 2022 that it was to be closed, a year after the UK Care Quality Commissioner rated GIDS ‘inadequate’.
Hannah Barnes has done a service to children and young people who are struggling with issues related to their sex and gender. She has done a service to the dedicated clinicians who struggled to be listened to when they raised concerns about the harm being done to children. It is an important book and one that should be read by anyone before repeating ill-informed truisms or allowing ideology to displace reality.
Reviewing the book for The Guardian, Rachel Cooke says
“Such a book cannot easily be dismissed. To do so, a person would not only have to be wilfully ignorant, they would also – to use the popular language of the day – need to be appallingly unkind. This is the story of the hurt caused to potentially hundreds of children since 2011, and perhaps before that. To shrug in the face of that story – to refuse to listen to the young transgender people whose treatment caused, among other things, severe depression, sexual dysfunction, osteoporosis and stunted growth, and whose many other problems were simply ignored – requires a callousness that would be far beyond my imagination were it not for the fact that, thanks to social media, I already know such stony-heartedness to be out there.”
As such books and discussions are taking place in the UK, it seems in Ireland that the popular narrative is to choose to be appallingly unkind and wilfully ignorant.
The Irish Catholic Primary Schools Management Association (CPSMA) letter to the Ministers of Health and Education was a considered and careful letter, understanding the complexity of the issue. The response received from senior politicians and government ministers was one they assumed would cause them least distress, hassle, trouble. It was it seems, to paraphrase Helen Joyce, reality meeting ideology.
Barnes is not transphobic at all. She is concerned. Concerned for the health and well-being of troubled children and adolescents. She offers no judgement of them, only sympathy and support. Her book is not transphobic. To be worried about children is not transphobic.
Barnes ends the book returning to the question raised by clinician Anna Hutchison who worked at GIDS in 2017: are we hurting children?
‘“Yes” she says she now knows. Some. But today we are left with a new question. How many?’
- ASIN : B0BCL1T2XN
- Publisher : Swift Press (23 Feb. 2023)
- Language : English
- File size : 1405 KB
- Text-to-Speech : Enabled
- Screen Reader : Supported
- Enhanced typesetting : Enabled
- X-Ray : Enabled
- Word Wise : Enabled
- Sticky notes : On Kindle Scribe
- Print length : 557 pages