It was a report in this newspaper that sparked my real interest in Gids – that made me ask “what’s going on?”. It was November 2018 and the article, by Jamie Doward, revealed that the Gender Identity Development Service, to use its full title, was undertaking a review. The details were scarce, but a senior member of staff had claimed that the service was “failing to examine fully the psychological and social reasons behind young people’s desire to change gender”.
In the week that Gids’s 35-year history has finally ended, I’ve been thinking about that time. How it set the scene of what would unfold over the next few years, and how things could have been so different. What if NHS England had acted when it saw a report of those concerns? It didn’t, and the service remained open for another six years. A service which referred children for puberty-blocking drugs, without robust data to support that this was beneficial, and that shut down the concerns of a growing number of its own staff.
Those professionals never questioned the identity of the young people they saw, nor the intensity of their distress. What they questioned was whether the NHS service they worked in was providing safe, evidence-based care for thousands of vulnerable children, or whether they might, in fact, be witnessing a medical scandal unfold.
In February 2019, just a few months later, more details emerged – in the Sunday Times, and then in the Observer. The senior staff member mentioned was Dr David Bell, a highly respected psychiatrist and psychoanalyst. These weren’t his claims and concerns per se – though he clearly shared them – but, rather, 10 members of clinical staff from Gids had gone to him with their worries about how the service was operating.
NHS whistleblowers are uncommon. To have 10, from one small clinic, is unheard of. I didn’t know if what they were saying was true, but the claims were extremely serious. I wanted to find out more.
And that started a process resulting in a series of films for BBC Newsnight, together with my then colleague Deborah Cohen, and later a book chronicling this extraordinary episode in NHS history.
The clinicians had sought out Bell after repeatedly raising concerns within Gids and the wider Tavistock itself to no avail. They told him how the service was unable to cope – the number seeking its help had increased tenfold in just five years. There was enormous pressure to “process referrals rapidly”, or, more bluntly, refer children on to endocrinologists who would prescribe puberty-blocking drugs.
Sometimes – though not often – this would happen after just an hour or two, staff said. Procedures for gaining consent to these potentially life-altering treatments were inadequate, and many of these children, staff explained, were vulnerable. Many were autistic. Many had been bullied, in some instances after coming out as gay. Most were unhappy. These children had complicated lives, and sometimes had suffered horrendous abuse or trauma. But this wasn’t always explored properly before referring for medication.
In a small minority of cases, it’s difficult to properly convey just how troubled these children were. Some were non-verbal. Some could not read or write. Others even identified as another race.
The official review that followed Bell’s report didn’t give Gids a clean bill of health, but the Tavistock trust told the press that the service had been found to be “safe and operating in line with the best practice in this field internationally”. The trust’s chief executive insisted that “none of the concerns around safety or safeguarding [highlighted by Dr Bell] were upheld by our medical director”. This wasn’t true. And the message underpinning these public statements was symptomatic of how the trust was responding to the difficulties Gids was facing.
The Tavistock told this newspaper in November 2018 that it was “concerned by the tone and manner in which these allegations have been made”, and that they revealed “a negative attitude to gender dysphoria and gender identity”.
For some who had contributed to Bell’s report, this confirmed what they had been saying all along: that if you raised concerns, you would face accusations of transphobia. That word wasn’t used in the statement, but it’s how staff interpreted it. When Bell’s report was leaked, the trust claimed that it “presented hypothetical vignettes, rather than actual case studies”. This was also untrue. Some were so appalled by the statement that they resigned. Others who stayed at the trust say it sent a message: if you spoke out, you would be vilified.
When, in June 2020, Newsnight broadcast parts of transcripts of official interviews clinicians had held with the Tavistock’s medical director as part of that review, the trust’s claims didn’t stand up. A sizeable minority of staff had, in fact, told him that Gids’s model of care was unsafe, and that some children were being harmed.
At about the same time, legal proceedings against the Tavistock trust questioned whether children could properly consent to treatment with puberty blockers. Keira Bell, the lead claimant, was referred for the drugs after just three or four appointments. She was also prescribed testosterone while under Gids’s care. A double mastectomy followed via adult services and, aged 22, she regretted it all. No alternatives had been explored by the service at the time, she said.
The case was ultimately lost on appeal, but it showed how, over 30 years, Gids appeared to have collected no meaningful data on its patients or its core treatment pathway. It could not tell the court how many children had been referred for puberty blockers, how old they had been, what sex they were, or if they had gone on to take hormones.
Change quickly followed Newsnight’s broadcast and the start of litigation. In September 2020, NHS England announced that paediatrician Dr Hilary Cass would undertake an independent review of gender identity services for children and young people. The Care Quality Commission (CQC) inspected Gids a month later. It rated the service inadequate and, in a damning report, upheld most of the concerns clinicians had been raising for years.
Contrary to denials from the Tavistock, the CQC found examples of two-session assessments (the trust would later concede that one-session assessments had occurred too). The watchdog noted that Gids did not always adequately manage risk; that consent was not recorded routinely; and that some staff “felt unable to raise concerns without fear of retribution”. In some cases, it said, “there was no clear rationale for clinical decision making”.
Cass’s interim review, published in February 2022, marked the beginning of the end for Gids. The “single specialist provider model is not a safe or viable long-term option”, she wrote; a “fundamentally different service model” was needed.
Once children with complex needs were identified as having gender-related distress, those other important healthcare issues were sometimes overlooked, she said. There were “significant gaps in the research and evidence base”, and Gids’s “clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced”, the report explained. Cass was referring, diplomatically, to NHS England allowing Gids to routinely refer children as young as nine for puberty blockers from 2014 onwards, without insisting on any robust data to support the policy.
On 28 July 2022, NHS England announced its intention to close Gids. It would be replaced, initially, by two new regional services – one in London, the other in north-west England. They would follow a very different model of care, offering more “holistic treatment”, “a range of pathways”, and with the primary intervention being “psychological support” – not medication. NHS England confirmed on 12 March that puberty blockers would not be available going forward because there was not enough evidence to support their safety or clinical effectiveness. Blockers will not be prescribed on the NHS unless and until a research trial has been established.
NHS England has updated its policy around hormones accordingly. Previously, someone could start hormones at “around their 16th birthday” (interpreted by Gids staff as 15 years and nine months) only if they had been on blockers for 12 months beforehand. Otherwise, they would have to wait to access adult services. NHS England’s new policy – largely copy-and-pasted from the previous one, complete with out-of-date document references – confirms hormones will now be available without the need for prior treatment with puberty blockers. A new safeguarding measure has been introduced whereby a national clinical team will have to agree the young person meets all relevant criteria for the drugs. The policy will be reviewed following Cass’s final recommendations, so may well be short-lived.
The opening of the new youth gender service has been beset by delays; the aim was to have the first two clinics running by spring 2023. They will finally open on Monday, while a third is being set up in the Bristol area. Over time, there may be up to eight operating across England.
But it won’t be easy. Great Ormond Street hospital, one of the trusts involved in the London services, has found it so difficult to recruit staff that it took to offering a £500 “refer a friend” bonus as part of its most recent recruitment drive. “Our two new providers on their own are not going to be able to make a significant dent immediately in that waiting list,” John Stewart, NHS England’s national director for specialised services, has confirmed. There is little to smile about for the 6,000 or so children on the waiting list for help. Some have already waited five years, and no one will be coming off that list soon – if ever.
Initially, the only children who will be seen by the new services will be those whose care is being transferred from Gids. But only 250 of them. According to Tavistock board minutes, 58 patients will require a face-to-face handover because of “complexity and/or risk”. Anyone already receiving puberty blockers or cross-sex hormones, or who has been referred to endocrinology but not begun treatment, will not have their care overseen by the new services. This is about 400 children and young people, NHS England told me. Some are eligible to be transferred to adult clinics; the others will receive a “wraparound service” from Nottinghamshire Healthcare NHS foundation trust.
There are few details about the arrangement, which I first revealed in the New Statesman. The BBC has reported that job adverts for senior roles in this new service only closed to applicants the week before last. The choice of Nottinghamshire is also somewhat surprising: its CQC ratings are currently suspended because of a series of problems.
Others have stepped into the void created by a stagnant Gids (about half the clinical and administrative teams have left since its closure was announced) and the absence of new services, recognising that there are high levels of distress and huge demand for interventions.
It seems that some GP practices are sidestepping NHS guidance in their approach to young people aged between 16 and 18. One prescribes hormones to 16-year-olds at their first appointment, and says it follows an informed-consent model of care. As a rationale, the practice cites “Gillick competence” – the legal principle that a child may be sufficiently informed to consent to treatment on their own – and rules over interim “bridging prescriptions”, saying it is a harm-reduction measure while patients wait to be seen at a specialist gender clinic. It is not at all clear that this is correct: GMC guidance states bridging prescriptions only apply to “doctors treating adults”, and they are not generally used to start treatment.
The private sector has seized the opportunity, too. Gender Plus, a private service, currently lists 10 Gids workers, or those who have worked in endocrinology services connected to Gids, on its team. Predominantly aimed at the 16-25 age group, Gender Plus will prescribe hormones to those 16 and older. Under-18s will need to have about six appointments, spanning six months, before being eligible for hormones, with each hour-long appointment costing £275.
The Gender Plus team have stated their opposition to NHS England’s plans to end the routine prescription of puberty blockers. And while its own hormone clinic won’t prescribe puberty blockers to under-16s, it will inform them of those that will. Gender Plus argues that its approach to care is in line with best practice, as demonstrated by NHS England’s recent policy update on hormones.
Cass’s long-awaited final report and recommendations on youth gender identity services will be published in the next fortnight. There is an opportunity to change the way gender-questioning young people are cared for – with compassion and underpinned by research and evidence, just like other areas of healthcare. This approach will no doubt be challenged, while private providers and NHS GPs alike continue to do their own thing.
NHS England will have to do far better than it has in the past at providing oversight to ensure Cass’s recommendations are followed. It knew of serious concerns about Gids from at least 2018. Thousands of distressed young people have been badly let down and are now lingering on a waiting list, wanting help. Many will believe what “experts” have told them – that puberty blockers are the only thing that can take away their pain – and be distraught that these are now unavailable. There will be no quick fixes.
Hannah Barnes is associate editor at the New Statesman. The updated paperback edition of her book, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children (Swift Press), was published on 28 March
