Tavistock: A Microcosm of the Debate on How Best to Care for Trans* Kids

By Dr. Paul R. Eddy and Dr. Preston Sprinkle. 

The cultural tensions surrounding transgender experience are evident. But no aspect of the transgender discussion has ignited more controversy than how best to care for children who experience gender dysphoria. This issue has become, as one scholar puts it, the “Transgender Battle Line.”[1]

 

Perhaps the best glimpse of this “Battle Line” can be found at the Gender Identity Development Service (the GIDS) housed within the London-based Tavistock and Portman NHS Foundation Trust. The GIDS is the sole gender clinic serving children in Britain. Over the last few years, the tensions and conflicts among the GIDS personnel concerning how best to treat gender dysphoric children has become an international spectacle. From heated words splashed across tabloid covers and social media to mass resignations, open letters, book banning, and legal interventions, the controversy at the GIDS serves as something of a microcosm of the wider cultural debate on transgender children.

 

The Tavistock Gender Identity Development Service

 

The GIDS was founded in 1989 by its original director, Domenico Di Ceglie, in connection with London’s St. George’s Hospital. In 1996, the GIDS was transferred to the Tavistock and Portman NHS Foundation Trust, a non-profit corporation that offers mental health services as part of the UK’s National Health Service. While the GIDS is based in London, it also has a northern location in Leeds, as well as a number of satellite clinics around the UK. Polly Carmichael succeeded Di Ceglie in 2009, and currently serves as the GIDS’s Director and Consultant Clinical Psychologist.

 

From its inception, the GIDS has tried to steer away from one particular—and often polarizing—approach to treating kids with gender dysphoria. While many clinics (in the U.S. especially) take a “gender affirmative” approach, where one’s expressed identity is never questioned and various possible causes of dysphoria are not explored, GIDS has viewed gender dysphoria as a “multi-factorial” phenomenon that calls for treatment that integrates “psychodynamic, biological, and psychosocial aspects, and sensitivity to cultural attitudes within the UK.”[2] Di Ceglie reports that he initially “felt under extreme pressure” to side with one of two polarized perspectives. On one hand, there was the view of certain mental health professionals who held that gender dysphoric young people should be offered psychological treatment but “not the possibility of any physical intervention.”[3] On the other hand, “a number of service users and self-help organizations” held that early physical intervention (e.g., puberty blockers or cross-sex hormones) was crucial for alleviating the distress of gender dysphoric youth, and an important key to preventing self-harm and suicide.[4] For Di Ceglie, it was important that the GIDS be “positioned between these polarities” as a via media, a balanced middle way; one that charted a course between the extreme and polarizing views of transgender experience so commonly found in Western culture.[5] As Di Ceglie himself puts it:

In our attempts to understand the nature of atypical gender identity development the danger is that we are seized by the ‘Scylla’ of focusing on the workings of the mind and neglecting the reality of the body, or alternatively we are sucked into the ‘Charybdis’ of a focus on the reality of the body which neglects the contribution of the mind . . . . The challenge is to find the middle ground avoiding the risk of falling afoul of either of these two polarities.[6]

 

On can find leading voices at the GIDS today continuing to offer clear expressions of this commitment to a balanced middle ground.[7] However, as one might expect, maintaining this middle path can be challenging, especially for a sizable mental health institution composed of a diverse group of co-workers with various clinical backgrounds and therapeutic intuitions. For all of its diversity, however, under Di Ceglie’s – and now Carmichael’s – leadership, attempting to therapeutically change a gender dysphoric young person’s own sense of gender identity has never been an option on the table. Again, Di Ceglie:

Young people are very sensitive and feel intruded upon by anyone attempting to change who they feel they are, in other words: their identity. From the very beginning of the Gender Identity Development Service we have developed a model of management in which altering the perceived gender identity is not a therapeutic objective.[8]

 

And so, while the GIDS has sought to present itself as a balanced middle path, the fact remains that, from Di Ceglie’s tenure through to Carmichael’s directorship today, when it comes to the fraught question of physical interventions for gender dysphoric young people, its chief clinical leadership has effectively sided with the gender affirmative model over against more traditional psychologically-oriented treatment approaches.[9] It is this fact that lies at the heart of the current controversy.

 

The Rise of Referral Rates at the GIDS

 

Adding fuel to the controversy is one fact that everyone agrees on. Recent years have brought a stunning rise in the number of gender dysphoric children and adolescents being referred to GIDS.  The United Kingdom, for instance, has witnessed a 1,460 percent increase among males and a 5,337 percent increase among females identifying as trans* compared to the number of referrals ten years prior.[10] A steep spike in referral rates are reported in many other western countries as well, with researchers describing the rapid increase as “substantial,” “unprecedented,” and “simply staggering.”[11] And the sex ratio should not be missed.[12] In the past, gender dysphoria was a condition largely found in males. But now—at least among (mostly) white teenagers living in the West—natal females far outnumber natal males in the referral rates. Regarding the exploding referral rate, James Barrett, lead clinician at the London NHS Gender Identity Clinic for adults, has remarked: “It obviously can’t continue like that forever because we’d be treating everyone in the country, but there isn’t any sign of that levelling off.”[13] The much debated cause of the sky-rocketing rate of referrals lies at the heart of the controversy itself. A controversy which has witnessed 35 psychologists resigning from the Tavistock clinic since 2016.[14] 

 

Controversy at Tavistock: The Backstory

 

The controversy came to public light in 2019, but there is an important backstory. Over a decade before that, Susan Evans, a psychotherapist, raised concerns about “the thoroughness of the assessment process by some staff.”[15] The core concern of the dozens who have resigned is captured by the words of one psychologist (who chose to remain anonymous):

Our fears are that young people are being over-diagnosed and then over-medicalised. We are extremely concerned about the consequences for young people . . . . For those of us who previously worked in the service, we fear that we have had front row seats to a medical scandal.[16]

 

In 2017, two clinicians formerly associated with the GIDS wrote a letter expressing their concerns to The Guardian, a British daily newspaper. The letter, titled: “Do you REALLY want to know ‘WHAT I AM REALLY THINKING’?,” expresses several areas of concern about the GIDS’s treatment approach for young people experiencing gender dysphoria. It ends with these words: “What I am really thinking is that we have truly wandered through the looking glass with our eyes closed and opened them only to see the Emperor’s new clothes.”[17] According to its authors, the newspaper chose to ignore this letter.

 

A key moment came in 2018 in response to various concerns, including a letter sent by a group of parents expressing the fear that, in light of the growing number of children being referred and the consequent over-burdening of the system, “the GIDS team is being asked to engage with and assess complex and difficult cases within a highly constrained time frame,” resulting in “‘fast-tracking’ young people into life-altering decisions.”[18] Ironically, the GIDS was also receiving complaints from the other direction: that things were moving too slow – i.e., “lengthy waiting times for access to its services and drawn-out assessment periods.”[19]

 

A tipping-point came when ten clinicians associated with the GIDS – roughly 1/5 of the staff at the time – contacted the Tavistock’s staff governor, David Bell, with

grave ethical concerns similar to those expressed in the parents’ letter—including inadequate clinical assessments, patients being pushed through for early medical interventions, and GIDS’ failure to stand up to pressure from trans activists.[20]

 

Growing concerns from both parents and clinical staff prodded David Bell to commence an internal investigation—one which yielded a rather disturbing report. Bell’s assessment, among other things, expressed concerns that

the service was failing to fully consider psychological and social factors in a young person’s background – such as whether they had been abused, suffered a bereavement or had autism – which might influence their decision to transition. Such views are dismissed by many transgender rights activists who believe they play little, if any, part in a person’s desire to transition.[21]

 

In the end, Bell concluded that “the GIDS service as it now functions [is] not fit for purpose and children’s ends are being met in a woeful, inadequate manner and some will live on with the damaging consequences.”[22] Bell’s report was submitted to the Tavistock’s board in the later part of 2018.

 

But it doesn’t appear that Bell’s report produced the kinds of changes one would expect. The Tavistock’s medical director, Dinesh Sinha, reviewed Bell’s report, and concluded (in the summary words of Paul Jenkins, board member and Chief Executive of the Tavistock) that, while “improvements could be made,” there were no “immediate issues in relation to patient safety or failings in the overall approach taken by the Service in responding to the needs of the young people and families who access its support.[23] A subsequent public statement by the GIDS was released, saying:

The Trust has thoroughly investigated the concerns raised in Dr Bell's report. None of the concerns around safety or safeguarding were upheld by our Medical Director . . . . We are disappointed this unsubstantiated report authored by individuals with no expertise in this field made its way to the Sunday Times and would urge caution about reproducing its content.[24]

 

The claim that Bell’s concerns were “unsubstantiated” contributed to its suppression. But “Bell’s report was not ‘unsubstantiated’,” write two critics of GIDS, “since it recorded the evidence of clinicians, nor did it convey the views of ‘individuals with no expertise in the field’ since all those involved with the report came from the GID.[25]

 

Eventually, the Tavistock’s board of governors issued a statement that distanced itself from Bell’s critical review and supported Sinha’s assessment. In reference to Bell’s accusations, the statement reads: “The trust is concerned by the tone and manner in which these allegations have been made. They reveal a negative attitude to gender dysphoria and gender identity which does not reflect the views or the approach of the trust.”[26]

 

Although he is still associated with the Tavistock as a Consulting Psychiatrist, Bell no longer serves as Staff Governor. He went on to write the Forward to a 2019 book of essays that are highly critical of the GIDS approach to the treatment of gender dysphoric children.[27]

 

2019—The Controversy Comes to Public Light

 

The controversy blew up when, in early 2019, Marcus Evans resigned. Evans served as one of the governors of the Tavistock and had a 35-year association with the Trust. He also served as Consultant Psychotherapist and Associate Clinical Director of Adult and Adolescent Service. In his own words: “I resigned from the Tavistock board of governors, in protest over the Trust’s failure to address the serious concerns that Dr. Bell and parents had raised.”[28] In a Letter to The Times, Evans expressed his deep concerns about how the Tavistock had treated both Bell and his troubling report:

the [Tavistock] tried to bury these important concerns about an experimental treatment of vulnerable children. It also displayed its prejudice by trying to discredit Dr Bell, a respected clinician, and the staff he spoke to. The treatment of gender-dysphoric children has become highly politicised and, in many ways, operates outside good medical practice.[29]

 

The Guardian reported that, in his resignation email, Evans wrote:

In my 40 years of experience in psychiatry, I have learned that dismissing serious concerns about a service or approach is often driven by a defensive wish to prevent painful examination of an ‘overvalued system’ . . . . I do not believe we understand what is going on in this complex area and the need to adopt an attitude which examines things from different points of view is essential. This is difficult in the current environment as the debate and discussion required is continually being closed down or effectively described as ‘transphobic’ or in some way prejudicial.[30]

 

Evans eventually wrote an essay explaining all that was behind his decision to resign from the Tavistock. Among the observations he makes is that

 many clinicians at GIDS [appear] to be driven more by political ideology than the clinical needs of presenting children. In part, this trend is rooted in the faddish idea that everyone—including children—has an innate gender identity, akin to a religious soul, that one discovers and nurtures.[31]

 

Evans goes on to say:

Many mental-health professionals share these concerns. But saying so publicly is difficult. Journalists who have researched this area report that while interviewees are willing to speak in confidence about their concerns, they shy away from being named, for fear of being accused of bigotry or taken up on human-rights claims.[32]

 

Others share Evans’ concern, that critical voices are being muzzled. One psychologist reflects: “The alarm started ringing for me . . . I didn't feel able to voice my concerns, or when I did I was often shut down by other affirmative clinicians.”[33] Across contexts, anonymity is reportedly an increasingly common choice made by those who decide to publicly question the gender affirmative approach. Fear of retribution and the public maligning of one’s reputation are commonly expressed concerns.[34]

 

Following his resignation, Evans went on to make a presentation before the House of Lords in May 2019. Among the points he argued was the contention that

[w]e do not fully understand what is going on in this complex area, and it is essential to examine the phenomenon systematically and objectively. But this has become difficult in the current environment, as debate is continually being closed down amidst accusations of transphobia . . . .[T]his de facto censorship regime is harming children.[35]

 

Other Voices Speak Out

 

In the wake of Marcus Evans’ resignation in early 2019, more critical voices found their way into the public sphere. A number of GIDS-related professionals have published academic papers that – either directly or indirectly – raise critical questions about, or advocate alternative approaches to, the GIDS’s model of thinking about and treating gender dysphoric youth.[36] And in April 2019, another five GIDS clinicians resigned due to “ethics and safety fears,” including their concern that the GIDS’s approach to gender dysphoric young people is functioning as a form of “conversion therapy for gay children.”[37] As most researches know, if a gender dysphoric child grows out of their dysphoria, they almost also end up being gay or bisexual adults. And according to all the available studies, anywhere from 61-88% of children with dysphoria do end up growing out of it after adolescence. This is where the claim of “conversion therapy for gay children” comes in. By converting their biological sex, a gay adult ends up becoming straight—in as much they no longer identify as the sex they’re attracted to. 

 

One could argue that this is harming the children, as most opponents of gay conversion therapy would say. And yet the accusation of “harm” comes from all sides. Trans activist groups often say that anyone who questions the gender affirming approach is “transphobic” and is endangering children.[38] This accusation is based on the ideological assumption that one’s gender identity is the most true aspect of a person’s humanity, and therefore helping them accept and live into their biological sex is harmful. But the accusation of “harm” can easily come from the other side. That encouraging undertested, irreversible physical treatment to a teenager who psychologically believes they are the opposite sex could usher in its own harm.

 

In July of 2019, Kirsty Entwistle, a former psychologist at the GIDS in Leeds wrote an open letter to the GIDS Director, Polly Carmichael,[39] which warns that the GIDS are “making decisions that will have a major impact on children and young people’s bodies and lives . . . without a robust evidence base.”[40] She goes on to challenge the long-standing claim made by GIDS leaders that it represents a balanced, middle-ground approach to gender dysphoric children. Entwistle writes:

Polly, one of the things that I have realised since leaving GIDS is that you used to say in the service meetings that at GIDS it was our job to hold the middle ground in this polarised field but after having read the criticisms of the ‘affirmative model’ and the medical pathway for children I don’t think GIDS holds the middle ground at all and is more closely aligned with the affirmative model, informed consent stance and is a very long way away from with [sic] the critical stance.[41]

 

As alluded to in Entwistle’s comments, one of the central flash-points of the controversy involves the prescription of puberty blockers for children who experience gender dysphoria. According to the GIDS, the use of puberty blockers allows additional time for the child to decide whether they will eventually physically transition by suppressing the secondary sex characteristics that naturally come with puberty.[42] According to critics, there are no robust longitudinal studies of significant length that are needed to determine the potentially negative long-term effects of puberty blockers (e.g., infertility regret statistics, bone density and neurodevelopmental problems, etc.).[43]

 

Critics also point out that the gender dysphoria of children who are prescribed puberty blockers tends to persist on into adolescence and adulthood at far greater rates than those who choose not to make use of them.[44] The UK’s puberty blocker controversy reached a new intensity in June 2019 when the Royal College of General Practitioners (RCGP) issued “an unprecedented warning over NHS treatments for children” suffering from gender dysphoria.[45] In their statement, the RCGP voiced concerns about the “lack of ‘robust evidence’ about the long-term effects of ‘puberty blockers’ that stop the body maturing, and cross-sex hormones.”[46]

  

The Lawsuit

 

In October 2019, a legal suit was filed in the British court against the GIDS’s satellite site in Leeds. The suit was brought jointly by a woman identified as “Mrs. A,” the mother of a 15-year-old patient with autism who desired to remain anonymous to protect her daughter’s identity, and Sue Evans, a former psychiatric nurse who worked at the Leeds GIDS from 2003-07.[47] The lawsuit focuses on the use of puberty blockers and cross-sex hormones in treating minor-aged young people at the GIDS. The plaintiffs accuse the GIDS of presenting an “inaccurate and potentially misleading” picture about the risks of hormone blockers, and that true informed consent cannot be given under such circumstances. In the suit, “Mrs. A.” describes the hormone therapy as “experimental treatment,” writing “There are many parents, like me, who are anxiously trying to support their children … We want the best for our children, but we need this to be from a position of evidence-based, not  experimental, medicine.”[48]The suit is asking that the GIDS be legally banned from giving these treatments to children unless a court decides that it is in their best interests.

 

In January 2020, it was announced that a 23-year-old woman, Keira Bell, was joining the High Court lawsuit as the lead claimant.[49] Bell, a former patient at the GIDS, originally planned to be a witness for the case. But given her first-hand experience, it was decided that she should join the suit as a plaintiff. In a statement following the hearing, Bell explained her decision:

I have become a claimant in this case because I do not believe that children and young people can consent to the use of powerful and experimental hormone drugs like I did. I believe that the current affirmative system put in place by Tavistock is inadequate as it does not allow for exploration of these gender dysphoric feelings, nor does it seek to find the underlying causes of this condition. Hormone-changing drugs and surgery does not work for everyone and it certainly should not be offered to someone under the age of 18 when they are emotionally and mentally vulnerable. The treatment urgently needs to change so that it does not put young people, like me, on a torturous and unnecessary path that is permanent and life-changing.[50]

 

Bell was referred to the GIDS when she was 16. According to her account, after three one-hour appointments, she was prescribed puberty blockers. Now, as an adult, Bell says the GIDS didn’t provide her with enough assessment or therapy prior to placing her on the hormone blockers. In her words, “I should have been challenged on the proposals or the claims that I was making for myself. And I think that would have made a big difference as well. If I was just challenged on the things I was saying.”[51] In response to the filing of this suit, a High Court judge has been given the go-ahead to begin a judicial review against the Tavistock. its staff” and renewed concerns that, once again, the GIDS is “silencing debate.”[52]

 

The Truss Announcement

 

In April 2020, it was reported that Liz Truss, the British Trade Secretary and Minister for Women and Equalities, had announced to MPs that the wellbeing of minor-aged young people would be a key principle guiding her assessment of a review of governmental policy on transgender-related matters.[53] In Truss’ words, a central concern for her is “making sure that the under 18s are protected from decisions that they could make, that are irreversible in the future.” She continues:

I believe strongly that adults should have the freedom to lead their lives as they see fit, but I think it’s very important that while people are still developing their decision-making capabilities that we protect them from making those irreversible decisions.[54]

 

Truss explained that an assessment of the feedback related to a consultation on the future of the Gender Recognition Act had been completed, and that she anticipated that new legal restrictions regarding the treatment of transgender children would be announced before the summer’s end.[55] At the time of this writing (mid-summer 2020), nothing yet has been announced.

 

What Now?   

 

Controversy at Tavistock has become a sort of microcosm for the debate about how best to care for kids who experience gender dysphoria. Why the sudden spike in females identifying as trans*? Is medical transitioning the best thing for a teenager’s well-being? Is helping a teenager accept and live into their body “conversion therapy?” Are puberty blockers and cross-sex hormones safe? Is the “gender affirmative” model of care better for trans* identified kids, or is the “watchful waiting” model best?

 

Scholars and medical professionals will continue wrestle with these questions. We do hope that science and ethics, rather than ideology, will drive the discussion.