There are knowns, as the saying goes, and there are known unknowns. But most difficult of all, perhaps, are the things we can’t know for sure, but must still make definitive judgments about. The latter form the heart of the BBC journalist Hannah Barnes’s densely reported account of events inside the Tavistock Centre’s Gender Identity Development Service (Gids) in London, the country’s only specialist clinic for transgender children, where, as one clinician tells her, it was “impossible to be sure” of getting decisions 100% right, but mistakes had frightening consequences.
The book traces Gids’s evolution from its foundation in 1989 – offering a non-judgmental therapeutic approach to exploring gender identity, and serving a handful of mainly natal boys – to a modern service swamped by demand, much of it from natal girls, providing a gateway for the prescription of puberty-blocking drugs.
Barnes interviews both happily transitioned adults who found “blockers” life-saving, and others who regret taking them. The drugs, which interrupt normal pubertal development, were meant to relieve children’s distress at growing unwanted breasts or facial hair but also buy them – as the title says – time to think about what they ultimately wanted. After all, only 5% of Gids patients in the 1990s reported growing up to be trans (most identified as gay in adulthood).
But, by contrast, a 2016 study of Gids patients on blockers found virtually all medically transitioned once adults. Were the drugs unwittingly influencing outcomes? Or might a greater proportion of the 1990s children have transitioned if they had grown up in a more tolerant era? Without a contemporary control group of children denied blockers, it was impossible to be certain.
The book revolves around bigger unanswered questions about what it means to be trans. Are some people just born trans, in which case making them jump through psychiatric hoops to prove it could be cruelly pathologising? Or are some children’s identities still fluid, which might favour keeping options open and exploring any underlying issues? Barnes contacted almost 60 former Gids clinicians, and, of those willing to be interviewed, most leaned to the latter position; they tend to argue that trans children certainly exist, but probably in smaller numbers than those referred, and that the clinic became overreliant on blockers at the expense of more difficult, lengthy exploration of what exactly was going on. These doctors, too, wanted more time to think.
Some patients were very clear, from very young, about their identity. But others presented puzzles. How to approach a child professing three alter egos, two with Australian accents? Or one wanting to transition both sex and race to “become” Japanese, or survivors of trauma with compelling reasons for wishing to leave their old selves behind, or kids with complex mental health diagnoses?
Of course any child could coincidentally be both trans and have relatives suspected of sexual abuse, or trans with unrelated psychiatric disorders. And perhaps there’s some still undiscovered shared genetic or developmental factor explaining exactly why a third of Gids patients are autistic. But, even so, wouldn’t you have questions?
Yet some patients resisted deeper exploration of their feelings, Barnes writes, deeming it transphobic. Senior managers seemed scared of upsetting the patient support group Mermaids. Long waiting lists meant children were often desperately distressed by the time they were seen, creating pressure to act quickly. Meanwhile the workload was so intense some clinicians felt it unsafe. Last summer, a review commissioned by NHS England recommended Gids should close, with patients seen instead by regional units taking a holistic approach to mental and physical health.
Barnes sidesteps the broader social and political context to this, yet the two seem hard to disentangle. Some trans people saw attacks on Gids as attempts to stop children transitioning at all; some gender-critical campaigners treated its closure as vindication of wider arguments. Once being “for” or “against” the Gids treatment model was deemed synonymous with supporting or attacking trans rights generally, analysis of its clinical practices became incredibly difficult. But in any NHS specialty it should be possible to discuss problems like understaffing or differing clinical judgment without committing a hate crime. This story remains complex, defying certainty, easier perhaps for those many publishers who rejected Barnes’s book to avoid. It is one, nonetheless, that needed telling.
• Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children is published by Swift (£20). To support the Guardian and the Observer buy a copy at guardianbookshop.com. Delivery charges may apply.
