MC Feature: The collapse of the Tavistock Centre
How did an NHS clinic spiral out of control?
Good morning. This week’s Morning Call Feature is by Hannah Barnes, an associate editor at the NS. Today she tells the inside story, over six pages in our spring issue, of the Gender Identity Development Service (Gids) at London’s Tavistock and Portman NHS Foundation Trust – the focal point of much of the UK’s sound and fury about trans rights – which will shut its doors at the end of this month.
Hannah is the Tavistock’s definitive chronicler. She wrote the book on it, which was shortlisted for the Orwell Prize and Baillie Gifford, and she has been interviewed in today’s Sunday Times about it. Here is the story in full. The first 1,000 words run below.
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When a tiny specialist clinic opened at St George’s hospital, south London, in 1989, with just four referrals, few would have predicted what would happen in the next 35 years. Having grown to become the world’s largest children’s gender clinic, the Tavistock’s Gender Identity Development Service (Gids) will close its doors for good on 31 March. What has unfolded there over the past decade or so is quite exceptional. The service referred around 2,000 children under 18 for puberty-blocking drugs, without robust data to support that decision. When evidence emerged indicating that this medical intervention wasn’t benefiting many of the young people receiving it, the service did not change its approach. Nor did it follow up with any of its patients to see how they were faring.
Faced with an exponential increase in referrals, and a fundamental shift in the demographics of those requesting its help, Gids ploughed on. However, it buckled under the pressure of growing demand. The leadership of the service – along with that of the NHS Trust that housed it – was inadequate and shut down the serious concerns of a growing number of their own staff.
All this happened under NHS England, which was ultimately responsible for the service. As I have written in my book, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children, this is not a story that denies transgender identities. “This is a 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.”
The Gender Identity Development Service (Gids) was the creation of the child and adolescent psychiatrist Dr Domenico Di Ceglie. Inspired by a single case he’d worked on in the early 1980s of a teenager “who was claiming that she was a boy but in a female body”, he felt children with “these rare and unusual experiences” needed a service of their own.
The focus of Gids was never on changing a young person’s gender identity, but in supporting them and their families in whatever solution they settled on to best manage it. But Di Ceglie saw that, in some cases, by addressing other difficulties experienced by the child – perhaps abuse, trauma or low mood – the gender difficulties might be resolved too. Almost all young people referred were contending with other problems.
So many people sat back, watched and did nothing.
In those early days, the offering was largely therapeutic. It provided what might be termed now a “safe space” to talk. Di Ceglie commented to the Sunday Times in 1993 that only about 5 per cent of the young people seen at his clinic would “commit themselves to a change of gender”. And 60-70 per cent of the children were gay. Medical interventions were available in the 1990s to block puberty, but only if strict criteria were met. A young person had to be 16 and have undergone extensive therapy and thorough assessment. The distress they felt around their gender had to have continued throughout puberty, too. The drugs weren’t so much used to block puberty, therefore, but to prepare bodies for the start of cross-sex hormones. Back then, as today, the service didn’t prescribe medication itself; it referred its patients to endocrinologists linked to the clinic.
When Gids moved to its current home – the Tavistock and Portman NHS Foundation Trust in north London – in 1994, it was immediately unwelcome. Colleagues at the Trust felt unease at the model used by Gids, which was based initially in a broom cupboard inside the Portman Clinic. The Tavistock was internationally renowned for its commitment to talking therapies, or psychotherapy. Medication wasn’t ruled out, per se, but it was used only sparingly and where there was a robust evidence base. That just wasn’t the case for this area of care.
Formal concerns were first raised about Gids in 2005 by Sue Evans, a nurse specialist at the service and later psychoanalyst. She thought external patient support groups – the transgender charity Mermaids and the Gender Identity Research and Education Society – had undue influence (which they deny), but her main worry was how quickly some of her colleagues were referring young people for puberty blockers. While there was thoughtful work going on, she discovered others would refer after only four sessions. The cases being seen by the service, Evans says, were all complicated. It just wasn’t possible to meet someone on so few occasions and make such a serious decision.
The concerns were investigated – and written up – by the Tavistock’s then medical director. But that report and its recommendations to improve the service remained unimplemented and hidden from Gids staff – and the wider public – until 2020. It was reluctantly released following a lengthy freedom of information battle I launched, while at the BBC’s Newsnight, with the Tavistock Trust.
It would take a decade for another group of whistleblowers to emerge. By this time, the service had changed beyond recognition.
Gids was nationally commissioned by the NHS in 2009. Children could now be referred from anywhere in England and referrals, inevitably, grew. And grew. By 50 per cent each year between 2009-10 – when there were 97 – and 2014-15, when there were 697. They doubled over the next 12 months to 1,419.
It wasn’t just the numbers. The sex ratio of those being referred reversed too, from two-thirds natal male, to two-thirds female by 2015. On top of that, most were girls whose gender-related distress had begun after the onset of puberty – not in early childhood as had been the case before. And these girls often had complex needs – depression, anxiety, eating disorders, or histories of abuse and trauma. The changes were impossible not to notice, and Gids clinicians describe how the clinic’s waiting room would be filled with self-diagnosed adolescent trans boys all with similar stories and haircuts. Many had chosen the same name too, often that of their favourite trans YouTubers.
At the same time, what Gids offered young people under its care changed significantly, too.
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