“Are we hurting children,” a psychologist asks at the start of Hannah Barnes’ forensic and sombre telling of the story of the gender service operated by the Tavistock Trust in London.
Over a decade, the Gender Identity Development Service (GIDS) based at Tavistock has referred more than 1,000 children, some as young as nine years of age, for medication to block their puberty, despite the lack of a clear evidence base for the off-label use of these drugs and the developing concerns of many staff.
All of the children had expressed dissatisfaction (dysphoria) about their gender identity, but many were struggling with other difficulties - eating disorders, self-harm, depression, abuse and trauma. “How could such different lives and presentations lead to the same answer – puberty blockers?” Barnes asks.
The answer matters here in Ireland too, because hundreds of our children were referred to Tavistock over the years. And here too, concerned staff working with the adult gender service sounded the alarm.
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Across the world, the number of young people questioning their gender identity has exploded. The accompanying debate has been shrill and toxic, and joining it is not for the faint-hearted. Barnes found the doors of the big publishing houses closed to her, despite the scrupulously non-judgemental tone of the book and her decision to confine her research to the goings-on at Tavistock.
Demand for the GIDS clinic’s services soared; from 50 referrals a year in 2007 to more than 2,000 a decade later. At the start, boys accounted for most of the demand, but later girls predominated.
This was the first problem; most of the literature on gender non-conforming children was about boys with a lifelong sense of gender incongruence but the waiting room at GIDS was now “packed with girls whose distress around their gender had only started in adolescence”.
“Many of them were same-sex attracted – the same was true for the boys attending GIDS – and many were autistic. Their lives were complicated too,” Barnes writes.
Puberty blockers were prescribed to give young people time and space to think, but staff noticed they were not behaving as expected. “Some young people’s health appeared to deteriorate while on the medication. And yet almost no one stopped the treatment.”
Some studies have asserted the mental health benefits of these drugs, but Barnes says these have been heavily critiqued and shown to have flaws. “The science is not settled, and this field of healthcare is overpopulated with small, poor-quality studies,” she concludes. “It’s often not possible to draw definitive conclusions on the benefits or harms of these treatments.”
Senior staff at Tavistock attempted to voice concerns. A 2006 reports on GIDS warned that the long-term effect of puberty blockers was “untested and unresearched”. A 2019 report found the service was “not fit for purpose”.
And yet nothing happened. Was it the pressure exerted by patient and parent groups? Or the amount of funding flowing to Tavistock as a result of soaring patient numbers? Or that so many people were cowed by the poisonous debate playing out in wider society? All of these possibilities are explored in the book.
GIDS began seeing Irish children in 2012 under the Treatment Abroad Scheme. Three years later, as demand increased, staff started holding monthly clinics in Crumlin hospital. Between 2011 and 2021, 238 young people in Ireland were referred to GIDS. As in the UK, the Irish referrals were overwhelmingly female and had multiple other “difficulties”.
It was only when the first referrals were old enough to have their care transferred to the adult service at St Colmcille’s Hospital in Loughlinstown that concerns were raised.
Clinicians Paul Moran and Donal O’Shea have helped hundreds of people transition successfully. “For people who are ready, have a clear, stable understanding of their gender, social supports, and are physically and mentally healthy, I see it as a fantastic thing,” Moran is quoted as saying.
“We were seeing very haphazard referrals from Irish psychologists operating mainly in the private sector, where somebody was going along, saying, ‘I think I have gender dysphoria,’ and there wasn’t really an assessment being carried out,” O’Shea says. “We began to see more and more disasters,” Moran explains. There were suicides; other people barely left their homes in years.
The pair started a new service, identifying people who were ready for transition by assessing them before they started hormones. This approach, involving an assessment by a psychiatrist, was criticised as pathologising by the trans community, but they say it has resulted in dramatically better outcomes.
The head of GIDS has rejected the criticism of the service by the Irish clinicians, and has pointed out that no direct complaint has been received. The HSE claims their concerns are “not representative” of clinicians who refer to Tavistock.
The UK government is closing Tavistock shortly on foot of a critical report published last year. The HSE continues to pay for Irish children to be seen by GIDS in England but says it is developing a new model of care for the treatment of gender dysphoria.
At the end of this investigation into Tavistock, the psychologist interviewed by Barnes is certain the service has been hurting children, but has a new question - “How many?”
