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What is gender identity? Why do some people feel an inconsistency between their natal sex and the gender they consider themselves to be, and when and why does that “dysphoria” begin? A few very young children, mostly boys, prefer the clothes, names, and activities of girls before they even have a concept of “boy” and “girl.” But do the reasons for their gender incongruence apply to the adolescents, mostly girls, who show no interest in transitioning until puberty or later? How shall we determine which procedures are safest and most effective for treating children and young teenagers with gender dysphoria, without assuming they all are the same as the countless others who are nonbinary, “questioning,” and experimenting?

Many Republican politicians and pundits are focusing on the groundzero battlefield: gender-affirming clinics. In these clinics, children and young teenagers who come in presenting with gender dysphoria are often given puberty-blocking medication; later they may move on to cross-sex hormones and eventually to breast and genital surgery. Scores of Republican-led bills across the country aim to limit or prohibit these procedures for anyone under the age of 18 or 19. And while they are at it, Republicans in states such as Tennessee, Arkansas, Oklahoma, and Kentucky hope to ban or restrict drag queen performances and any discussion of LGBTQ issues in schools.

It’s no wonder that anyone who opposes these hate-fueled attitudes and political measures is uncomfortable raising concerns about the gender clinics. Who wants to give ammunition to bigots? Don’t I have an obligation to defend the clinics if states are passing laws to close them? Besides, what’s wrong with helping children transition? Who wants to prohibit medical interventions for these children and youths if, as parents are assured, puberty blockers will keep their anxious 12-year-old from committing suicide? What parent, when asked “Would you rather have a live son, or a dead daughter?” (yes, this is a common question), would not approve any intervention proposed? An increasing number of professionals, detransitioners, and transgender adults themselves, that’s who,¹ arguing for complexity and evidence, nuance and patience. But, inevitably in our nation’s current hyper-polarized political climate, it’s getting harder for “gender critics” to make themselves heard over the din of hate-mongers on one side and righteous “gender-affirming” warriors on the other.

That is why Hannah Barnes’s Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children is particularly relevant today. Barnes, an investigative journalist for BBC’s Newsnight, delineates each step in the rise and fall of the Tavistock’s Gender Identity Development Service (GIDS). Her book deserves widespread attention, when so many liberal media outlets are censoring dissenting voices and when very few books that question gender-affirming assumptions can even be published. (Barnes has yet to find an American publisher.) Readers may wonder what a book about a London clinic, albeit a prestigious one, in a country with a National Health Service that is as different from the American health care as possible, can have to say about the situation here, but it can, and it does. To be sure, the story Barnes tells is measured, contained; the life and death of one clinic is an important chapter, but only one, in a larger book that remains to be written.

Barnes interviewed dozens of clinicians who worked at GIDS—some with years of experience in cases of gender dysphoria and others practically drafted right out of school to keep up with the tidal wave of referrals; staff and directors; staunch defenders of the GIDS program and their doubting colleagues. She also interviewed several patients, some who transitioned and others who did not, to give a flavor of their experiences, satisfactions, anger, and regrets.

At the start, Barnes reports her conversation with Anna Hutchinson, a senior clinical psychologist who, in 2017, wondered aloud: “Are we hurting children?” In the four years she had been there, the number of children referred to GIDS had jumped from 324 to 2,016. (In 2022, there were more than 7,500 children on the waiting list.) Hutchinson dared wonder, says Barnes, whether medical interventions were “the best and only approach for all the young children in her care.” A large number of the children had psychological problems; many had been in foster care or endured parental divorce, death, abuse, or trauma. The elephant in the waiting room was that many were gay or bisexual, yet all were thrown into the same transgender hopper. The gay patients told of their self-hatred and being bullied in school, resulting in their wish to be transgender rather than gay—a wish shared by more than a few of their parents. “Better a straight son than a gay daughter” would be an accurate mantra for them.

“How could such different lives and presentations lead to the same answer—puberty blockers?” Hutchinson mused to Barnes. Precisely the central question, and Barnes gives us the answer in a timeline of GIDS’s history. Timelines can help us go forward by looking backward. How did we get from then to now? Who are the players? Who got the money? Where did it come from? Who set the policies? How and why did the central issue ignite, how did it become a wildfire, and who got burned? Barnes provides a timeline to highlight a central narrative in a cacophony of voices and events.

1989: The Gender Identity Development Service opened at a small hospital in south London.

1994: GIDS moved to the prestigious Tavistock and Portman Trust in north London. The Tavistock was psychoanalytically oriented, and its treatments for gender dysphoria were standard at the time: psychotherapy, exploration of the child’s gender distress or confusion, and a philosophy of “watchful waiting” to see whether these issues continued through the changes of adolescence or abated. The service saw 12 patients that year; 24 two years later.

2000: The “Dutch protocol,” developed by a gender clinic in the Netherlands, was gaining attention in medical circles. Its developers maintained that youths who had shown gender dysphoria since early childhood and who were psychologically stable should be offered puberty blockers as early as age 12, followed, if they wished, by crosssex hormones at 16 and breast and genital surgery at 18. (The protocol claimed—incorrectly, it would later turn out—that puberty blockers’ effects on bones, muscles, and brains were completely reversible if the child later wanted to detransition.) Such early intervention with puberty blockers would allegedly aid diagnosis and treatment by giving transgender children time to explore their gender identity without the potentially distressing physical changes of puberty. In practice, none of the 54 children initially selected stopped taking blockers; all went on to cross-sex hormones.²

The Dutch were so…Dutch. So sane, so committed to gender equality; what could go wrong with their protocol? Pressures were therefore mounting on GIDS to make its gender treatment less conservative—that is, less psychotherapeutic and “talky”—and replace it with the Dutch protocol, shifting from its early “watchful waiting” approach to intervention with puberty blockers. One GIDS clinician told Barnes that “the political pressure from activist groups was astonishing.”

What will it take for the United States to learn from GIDS’s fall and from the ability of Sweden, Finland, Norway, and now England to change their guidelines?

By 2000, GIDS, having treated 150 children and adolescents, decided it would be a good idea to assess how they were doing with a “retrospective audit.” Two-thirds were boys. Fully 97.5 percent had one or more of the associated problems that would concern Hutchinson 17 years later: many had been in foster care, had lost a parent through death or divorce, and reported sexual or physical abuse. Many were depressed or anxious, and 25 percent had histories of self-harm. Some were autistic. Fully 70 percent had five or more of these difficulties. Of course, this unscientific study could not determine the causal relation, if any, between a child’s emotional problems and gender dysphoria; the goal was simply to identify the patients’ needs and plan future research. This was GIDS’s “first clinical audit,” Barnes writes. “It was also its last.”

2000–2005: The tension among the staff at GIDS was mounting: on one side, those who wanted to conduct therapy with the children and help them explore gender issues; on the other, a younger cohort of newly-minted activist clinicians who accepted children’s self-identification more readily and were less inclined to value extensive therapy. As Barnes shows, this fundamental schism revealed itself in arguments about how many assessment sessions a new patient needed before being prescribed puberty blockers or hormones: from six to four to three to…

2005: A report by the medical director, psychiatrist David Taylor, triggered by staff concerns that some children were being referred for puberty blockers after only two or three assessment sessions, 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.’” The central problem, he noted, was that the clinicians “fundamentally disagreed” about what they were treating and thus how to treat it: children distressed because they were trans, or children who identified as trans because they were distressed? Or both? Taylor advised the board that GIDS be turned into “an assessment and treatment service of the highest standard,” with research being “an essential component.” His report was suppressed and remained unavailable to the GIDS staff and the public for 15 years.

2011: GIDS and University College London Hospitals began an Early Intervention observational study to test the Dutch protocol. The impact of suppressing puberty in 44 children ages 12 to 15 would be assessed. An interim report would be produced in three years, a final report in six. Another lost opportunity: nothing was published for ten years.

2014–2015: GIDS rolled out its Early Intervention plan, removing the lower age limit of 12 for puberty blockers. By now, GIDS was largely a medical referral service, with little if any psychotherapy provided. As the volume of patients increased, the number of therapeutic assessments declined. And just as with the Dutch protocol, most of the children put on blockers went on to cross-sex hormones, with little time and space for reflective “exploration.”

2015: The number of teenage girls with gender dysphoria had risen by 5,000 percent (!) in seven years, now making up 70 percent of new referrals.³ Pressed once again by concerned staff, the GIDS leadership commissioned an external consultant to advise on working practices. The consultant recommended that GIDS “take the courageous and realistic action of capping the number of referrals immediately.” They did not.

2018: Another opportunity to change course arose when psychiatrist David Bell presented the concerns of ten experienced GIDS clinicians to the Tavistock board. His staff was worried that children were being harmed with irreversible procedures and lack of follow-up evidence to assure their safety. His own conclusion was that GIDS was “not fit for purpose.” The Trust overruled his report, finding no evidence of “any immediate issues in relation to patient safety or failings in the overall approach taken by the Service.” Nothing changed.

2020: About 25 percent of the Tavistock’s income was now coming from referrals to GIDS, up from six percent in only five years. Money from GIDS was “propping us up,” one senior Tavistock clinician told Barnes.

2021: The results of the Early Intervention Study, begun in 2011, were finally published. The researchers “identified no changes in psychological function, quality of life or degree of gender dysphoria” in the youngest patients put on puberty blockers. No changes meant no improvement. An assessment of GIDS by the Care Quality Commission, which regulates all health and social care services in England, gave GIDS its lowest rating, “inadequate.”

2022: England’s National Health Service announced that GIDS would be closed in 2023, replaced by smaller regional centers that will offer a greater focus on mental health.

* * *

Why did GIDS persist so long, in the face of repeated objections from its own staff and in the absence of research and clinical follow-up on the thousands of young patients in its care? A perfect combustion of money and institutional rigidity. No one in authority wanted to jeopardize the budget that came from the enormous number of referrals. Ultimately, GIDS succumbed to the rigidity of institutions that, once certain practices are in place, cannot readily turn themselves around. A truly adequate response to the problems at GIDS, as David Bell told Barnes, would have required “a complete structural rethink.” The Tavistock had become so committed to GIDS, he said, that it could not allow itself to see the evidence that threw the whole enterprise into question. GIDS had such power “that no doubt could be allowed in.”

Rethinking? Doubting? Not abilities that most institutions welcome or reward.

Still, GIDS would likely have stumbled along if it were not for the major “rethink” of the risks of the Dutch protocol. The NHS commissioned Dr. Hilary Cass, a highly respected pediatrician and former president of the Royal College of Pediatrics and Child Health, to review GIDS’s service for patients under the age of 18, and in 2022 she issued an interim report. There was simply insufficient evidence, the report concluded, to advise about the value of hormone treatments. Because GIDS evolved so rapidly in response to demand, it was not subjected to “the normal quality controls that are typically applied when new or innovative treatments are introduced.”⁴ Accordingly, the Cass report recommended significant changes in treating children and young teenagers with gender dysphoria: clinicians should begin with psychosocial therapy and psychological support, not medical treatments. They should keep in mind that gender incongruence can be “a transient phase” for prepubescent children and adolescents, so caution is warranted before beginning transition procedures. To avoid the dominance of any one clinical or medical perspective, young people would henceforth be treated by a team of experts in pediatric medicine, autism, neurodisability, and mental health; puberty blockers would be permitted only as part of a formal research program.

The Cass report is not an outlier. Sweden, Norway, and Finland have all revised their guidelines for transgender treatment. They too have severely curtailed the use of puberty blockers for youths under 18, concluding that the evidence to support puberty blockers and cross-sex hormones is weak and that the risks currently outweigh the benefits.⁵ Even the Dutch are rethinking the Dutch protocol.⁶

Barnes’ chronology is deeply informative as a case study of how an organization lives, thrives, and dies. That is its strength and its limitation. She does not place the GIDS story in the larger context of what has been happening in the worlds of sexology and gender medicine over the last twenty years, let alone of the politically and ideologically motivated groups fighting for trans rights. We learn only obliquely how powerful lobbies came to shape and control the conversation, ostracizing dissenters and doubters as being “transphobic” and ignoring the role of homophobia seething under the surface.⁷ Although Barnes’s interviewees spoke often of the “pressures” they were under from activist groups, and although we hear from the GIDS whistleblowers and dissenters who were shunned and ignored, Barnes offers no examples of the human costs of those pressures elsewhere, in lives uprooted, careers destroyed, and, to this day, eminent professionals in the field silenced and disrespected. Stephen Levine, a noted psychiatrist who won the Society for Sex Research and Therapy’s highest award in 2005 and had been its president, was rejected in 2022 and 2023 from presenting his critical analysis of the Dutch protocol.⁸

* * *

What will it take for the United States to learn from GIDS’s fall and from the ability of Sweden, Finland, Norway, and now England to change their guidelines? It’s hard to imagine our ever having a single, highly respected scientist, such as Dr. Hilary Cass, whose conclusions would be accepted by both sides on this politically bifurcated issue. Here, “following the money” in the transgender marketplace leads not to one leading institution but to a vast web of clinic locations, state politics, and vested interests: hospitals, which offer menus of hormonal and surgical options; plastic surgeons, ever on the lookout for a new market; the pharmaceutical company that manufactures puberty blockers, once a niche market that exploded; “cowboy surgeons” (a term popularized by the non-cowboy surgeon Atul Gawande) who blur boundaries, ignore guidelines, and are at the ready to provide operations for the growing market; and of course the independent clinics, including Planned Parenthood, that have expanded their health services to include (and to be compensated for) transgender medication.

How do you assure a young person of a procedure’s safety and longterm effectiveness when there are no randomized controlled studies that demonstrate the superiority of one intervention over another?

To be sure, there are signs of change. Genspect, an international group of professionals, trans people, detransitioners, and parents who are gender critical, hosts webinars and provides services for detransitioning individuals. Whistleblowers are coming forward: Jamie Reed, a former case manager at the Transgender Center at Washington University’s Children’s Hospital, finally felt compelled to file a report with the Missouri Attorney General’s office complaining—just as the GIDS dissenters did—of inadequate evaluations, lack of a consensus protocol, and the numbers of young patients inappropriately rushed to treatment.⁹ Dissenting members of the American Academy of Pediatrics have publicly accused their own professional body of pushing a harmful drugs-first approach on teenagers based on “scant and shoddy” evidence, bowing to pressure from young activist doctors, and suppressing dissenting voices.¹⁰ The May 2023 issue of The Economist made its cover story: “The evidence to support medicalised gender transitions in adolescents is worryingly weak.”¹¹

And a growing number of gender-critical physicians, including midwives and OB-GYNs, are reporting their own cases of unanticipated harms suffered by the detransitioners they treat. A February 2023 paper in Frontiers of Global Women’s Health contains the first published account of a young woman who had transitioned early; had her breasts removed, leaving her with extensive, painful scarring that required more surgery; detransitioned; and later, after having a baby, “grieved her inability to breastfeed.” The authors observe that breastfeeding is “undervalued” in transgender medicine; the common attitude is that removing breasts is no big deal, breast milk is nothing special, and a detransitioned woman can always have a “reversal.” To read this article is to feel heartsick at this woman’s original reasons for transitioning—she developed breasts at 10 that made her uncomfortable with her changing body; the other kids teased her and boys and men sexually harassed her—and after hearing about gender identity she “became persuaded that her bodily discomfort was because she was transgender.”¹²

But what it will take—what it almost always takes—are lawsuits. Chloe and Layla are suing Kaiser Permanente and the medical providers who facilitated their hormonal and surgical transitions as young teenagers, including a double mastectomy for Chloe at age 15 and for Layla at 13. These lawsuits will bring the issue of “informed consent” front and center, because all clinics say they take no action without it. Unfortunately, as Stephen Levine has shown, the statements that pass for informed consent today are inconsistent and unsatisfactory.¹³ How do you assure a young person of a procedure’s safety and long-term effectiveness when there are no randomized controlled studies that demonstrate the superiority of one intervention over another? What outcomes are even considered ideal? Will you inform your patient, Levine writes, about “rates of later desistance, increased mental suffering, increased incidence of physical illness, educational failure, vocational inconstancy, and social isolation”? Parents give consent because they believe they are saving their children’s lives and guaranteeing their children’s future satisfaction with their bodies, but are they told of the higher risk of severe lifelong medical complications, depression, and, yes, suicide among transgender adults?

This article appeared in Skeptic magazine 28.2
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Moreover, what does having “informed consent” from a 12-year-old or a 14-year-old mean? Teenagers, by definition, want what they want now, consequences be damned—especially if they are autistic, depressed, and/or anxious. How many of them can imagine how they will feel in five years, let alone 10 or 30? Does a 13-year-old understand the physical complications of having her breasts removed, or that he will lose his fertility, or that they may never be able to have an orgasm? Barnes quotes one therapist who spoke of the “worrying lack of understanding” among patients, such as a young trans man, a natal female, who asked if he would start producing sperm once on testosterone.

The final footnote to Barnes’s story: This year, prompted by the Cass report, an English law firm is expected to file a class-action criminal-negligence suit against the Tavistock and Portman Trust. More than 1,000 clients are expected to join the suit. I suspect that clinics in the United States will be paying close attention. The lawyers certainly are.

Suggested Resources

• Lisa Selin Davis’s Substack
• Society for Evidence-Based Gender Medicine
• Genspect