Published January 30, 2024
Nearly 300 pages into BBC journalist Hannah Barnes’s bold account of the collapse of the Tavistock Clinic—the UK’s premier “gender service” for minors—she describes the case of “Harriet,” a teen girl who abruptly decided to identify as a boy and who later “detransitioned.” Barnes careens between the pronouns “he” and “she” to reflect different points in Harriet’s story. A quick example of the resultant muddle:
He knew he wasn’t a man. What’s more he knew he was a woman attracted to other women. He stopped taking testosterone in November 2020 and identified once more as female.
Ollie is now Harriet again.
For the remainder of the chapter, Barnes refers to Harriet as “she.” In the series of anonymous case studies that appear throughout the book, Barnes engages in similarly confusing pronoun-switching. In addition to making the stories difficult to follow, this peculiar style choice underscores a central problem with Barnes’s Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children. The attempt at journalistic objectivity makes the book far more opaque than necessary; it leaves the reader wondering what she is actually trying to say.
Time to Think certainly serves an important function: it chronicles the shoddy services, supported by shoddy science, that upended the lives of thousands of UK children over decades. Barnes first broke this story on BBC Newsnight in 2019, during which she described troubled young people who had suffered lasting physical or psychological harm after being swiftly placed on puberty blockers or cross-sex hormones. She focuses on the famous Tavistock Clinic, the UK’s only dedicated gender-identity service for children and young people, which was shuttered in the summer of 2022. Barnes’s casual references to the UK’s labyrinthine National Health System make the story of Tavistock a bit difficult to follow too, at least for this American reader.
Before examining the details of Tavistock’s downfall, it is worth noting that Barnes repeatedly emphasizes the many parents or clinic employees who had tried to sound the alarm but whose warnings were ignored by clinic authorities. But Barnes is loath to draw any firm conclusions from these stories. Her cautious wording and frequent qualifiers undermine some of the book’s most important points and questions.
One such question concerns the nature of transgenderism. Barnes admits that there is something confounding about the condition, which has been folded into a broad social movement that includes anti-racism, but simultaneously has been pathologized. It’s difficult to conceive of any other immutable identity being “treated” through an established medical pathway. Barnes gestures toward this difficulty but never properly addresses it. By contrast, Abigail Shrier’s 2020 blockbuster book Irreversible Damage, which takes a similar journalistic approach to evaluating gender treatments for minors, more forcefully counters the idea that doctors should ever treat spiritual or emotional challenges through permanent damage to sound, developing bodies. And it should be clear that sterilization, an inevitable consequence of mainstream “gender-affirming care,” constitutes damage.
Barnes’s project is not to point this out, however. As the book’s title, Time to Think, suggests, she hopes to encourage the medical community to spend more time considering what it is they’re doing. Time to Think is also a double-entendre: the overworked staff at the Tavistock clinic weren’t granted sufficient “time to think” before being pressured to refer distressed young people to endocrinologists. And many of these young people were rushed down a road they might not have chosen had they had more time. All this despite the fact that puberty blockers are marketed as allowing young people more “time to think.”
Barnes also never makes it clear what exactly clinic leaders should have done vis-à-vis complaints from parents; the NHS is notoriously impervious to parental challenges to its medical authority.
To turn to the Tavistock story: The very short version is that the original iteration of Tavistock was founded in September 1989, under the leadership of child and adolescent psychiatrist Dr. Domenico Di Ceglie. In Barnes’s telling, Di Ceglie’s interest in transgenderism was piqued “by a solitary case he’d worked with in the early 1980s,” a teenage girl who kept claiming she was a boy. As Di Ceglie put it, “There was something very profound about her sense of identity of being a boy which could not be easily explained and that was fundamental to her being.”
Di Ceglie was prompted to focus his therapeutic practice and research on gender identity problems in youth, but for a long time, he had trouble finding more than a handful of cases. This did not stop him from setting up the Gender Identity Development Service (GIDS) in St. George’s Hospital in south London. In 2017, Di Ceglie recalled someone asking him if, in creating the service back in 1989, he had created the problem. Di Ceglie laughed and admitted he did not know.
Di Ceglie’s work in the 1990s was largely limited to talk therapy; he reported that approximately 60–70 percent of his early clients turned out to be homosexual, and only around five percent committed to switching genders. During that time, his clinical team also visited schools “to help them understand how best to help young people struggling with their gender identity, and tried to educate other health professionals.”
Barnes paints this period in a rosy light, as the “good old days” of GIDS during which talk therapy and social transition were normative treatments for gender-dysphoric youth. Physical intervention was rare, a choice Barnes seems to approve. But there’s something nefarious about Di Ceglie’s open attempts to recruit patients, in part by seeking relationships with local schools. And it wasn’t long before puberty blockers, cross-sex hormones, and, often, surgeries became the order of the day for patients who started out at GIDS.
In 1998, Di Ceglie co-authored guidelines issued by the UK’s Royal College of Psychiatrists. These emphasized the importance of extensive talk therapy for gender-dysphoric youth before embarking on medical treatment. He urged clinicians to take full family histories and to focus primarily on improving comorbidities in patients, such as general depression and social anxiety, which often existed alongside gender dysphoria. Di Ceglie emphasized that physical interventions should “be delayed as long as it is clinically appropriate.”
Importantly, the document also recommended that adolescents experience “the post-pubertal state of their biological sex” before starting on puberty blockers. This was a necessary step, Di Ceglie argued, the only way minors would be able to provide properly informed consent to the gender transition process.
This is important because, when gender-dysphoric children are prescribed puberty-suppressing drugs, they are told that this will allow them an assessment period, time to consider whether “transitioning” to the opposite sex is the right choice. But as Oxford sociologist Michael Biggs has pointed out, it may seem plausible that “therapeutic exploration of gender identity, without the pressure of the physical changes accompanying puberty” would be helpful, but it is “also plausible that stopping normal cognitive, emotional, and sexual development would impede such exploration.” Biggs points to a 2007 study that measured an average drop of seven IQ points in children after two years on puberty blockers; another study found a gap of eight points between fifteen children on blockers and a matched control group.
Further, without experiencing natal puberty, as a lawyer friend put it, gender dysphoric children and teens must “decide the case based on only one side’s briefs.” For children who have not yet undergone puberty—natural or artificial—the notion that they could understand that experience well enough to reject it and embrace an alternative seems risible.
By the 2020s, however, much of the caution urged by Di Ceglie had fallen by the wayside. In 2009, the NHS commissioned GIDS as a national service, and Dr. Polly Carmichael took over from Di Ceglie as leader. The number of referrals to GIDS soon began to skyrocket. In the 2009–2010 fiscal year, only seventy-seven referrals were made to GIDS. By 2018–2019, that number jumped to 2,590. Children were placed on puberty blockers at much younger ages and much more quickly than Di Ceglie recommended. Barnes cites many GIDS employees who found the new workload and approach exhausting, draining, and alarming.
The title of Barnes’s first chapter is “Are We Hurting Children?” This question had been posed in 2017 by psychologist Dr. Anna Hutchinson to her supervisor Dr. Sarah Davidson, one of three psychologists leading the service. Davidson was unable to reassure her. During their meeting, Hutchinson detailed two especially troubling cases of young people who seemed likely to have been sexually abused at home before seeking gender-related resources from GIDS. According to Hutchinson, Davidson replied by asking her why she was raising “such complex cases.”
Hutchinson did not believe many of the young people given puberty blockers met clinical criteria for those drugs. As she put it, the service had become accustomed to “offering an extreme medical intervention as the first-line treatment to hundreds of distressed young people who may or may not turn out to be ‘trans.’” Hutchinson feared that many were victims of abuse; others seemed to develop severe health problems as a direct result of taking puberty-blocking or cross-sex drugs. Some of these problems are spotlighted in horrifying and revealing case studies from Time to Think. For instance, a severely obsessive-compulsive gay teenage boy was given hormone treatments and no other help; his mother was shamed for seeking other options as her son’s mental state broke down. A young woman had long-standing, terrible physical reactions to hormone treatment and eventually collapsed at school. She suspended treatment on her own accord.
Most damning in Barnes’s view, though, is not the idea of referring minors to be sterilized, but that the Tavistock had been transformed from a therapeutic service to a rapid-assessment facility. Children were swiftly rerouted to NHS endocrinologists for hormone treatments. The Tavistock caved to pressure from patient-advocacy groups like Mermaids, which embraces the full scope of gender-affirming care. Clinicians were subject to undue institutional pressure; the Tavistock leaders were intransigent and unwilling to reflect on available evidence and their own employees’ concerns. There was no NHS service where young people with gender dysphoria could turn for the sort of extensive therapy Di Ceglie had once prized. The wrong patients were receiving treatment.
As Barnes explains in the conclusion of her opening chapter,
This is not a story which denies trans identities; nor that argues trans people deserve to lead anything other than happy lives, free of harassment, with access to good healthcare. This is the story about the underlying safety of an NHS service, the adequacy of the care it provides and its use of poorly evidenced treatments on some of the most vulnerable young people in society. And how so many people sat back, watched, and did nothing.
Barnes has done invaluable work. In the years following her 2019 BBC report, the Tavistock gender clinic came under additional scrutiny, and in July 2022, the NHS announced its closure. This does not mean that gender-affirming care will no longer be available in the UK, but rather that there will be a shift in favor of regional and more “holistic” services. Barnes has helped curb some of its worst excesses, however.
Still, one senses the book could have been taken to its proper conclusion: that there is something viscerally objectionable about sterilizing children, about blocking their progression to natural puberty, with all its inevitable discomfort and strangeness. Puberty is of course a bridge between childhood and all that follows; among other things it seems designed to provide time to think.
Devorah Goldman is EPPC’s Tikvah Visiting Fellow. Her work focuses primarily on medical policy, culture, and public bioethics.