Matt Bristow, a trainee psychologist in his late 20s, was excited in 2013 when he joined the Gender Identity Development Service, part of a renowned mental health care provider in London known as the Tavistock and Portman NHS Foundation Trust. A gay man, he considered himself an ally to the transgender community, and the U.K.’s only national pediatric gender clinic had an atmosphere that made employees feel special. “I felt excited when I joined the service,” he told reporter Hannah Barnes.“And I was really looking forward to it.”
Nearly five years later, he left after being required to shoulder 140 complex cases, distraught about the well-being of the young people in his care, some of whom he felt had been pushed toward medical intervention even though they were gay rather than trans. He described himself as “broken.”
Bristow’s experience is one of dozens that underpin “Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children,” a deeply reported account of what went wrong at one of the world’s largest clinics for children with gender dysphoria. The narrative explores both the uncertainties in the evolving field of gender medicine and what can happen when organizations become dysfunctional.
Barnes, a journalist at the BBC, first reported on problems at the clinic for “Newsnight,” a leading British current affairs program. In her book, she interviews former patients, parents, clinicians, and leaders at the service, and deftly weaves their stories into a troubling but intensely readable account, propelled by a core question: Did the right young people receive the right care?
The title of the book is double-edged. Prescribing medication to block puberty was viewed as giving young patients time — time to think about their gender identity — but it also refers to the fact that rocketing demand and a buckling system left clinicians with little time to think.
The Gender Identity Development Service was established in 1989 by Domenico Di Ceglie, a psychiatrist inspired by a teenager he’d worked with who, in his words, “was claiming that she was a boy but in a female body.” Di Ceglie subsequently encountered three or four similar cases, and set up a small gender identity clinic in south London.
By 1996, he was in touch with Dutch practitioners who had developed a protocol for transitioning patients in late adolescence, reporting positive outcomes. According to the original Dutch guidelines published in 2006, youngsters suffering from “lifelong extreme gender dysphoria” and who met certain diagnostic criteria — including having good mental health and supportive families — would be prescribed drugs to stall pubertal development when they reached age 12, followed by cross-sex hormones, if they wished, at age 16.
Back then, the service was small. Initially housed at St. George’s Hospital, it later moved to the Portman Clinic where it operated in what some referred to as “a broom cupboard.” The clinic later became a national service under the aegis of the Tavistock and Portman Trust (often shortened to “the Tavistock”). Initially, the providers precribed puberty suppressants only to teenagers who were already 16; but from the start there were questions about the practice of medical intervention in young patients.
An early review of the clinic — whose findings were suppressed for 15 years — described a service mired in confusion. As Barnes puts it, clinicians did not even agree about what they were treating: “Were they treating children distressed because they were trans, or children who identified as trans because they were distressed? Or a combination of both?”
Di Ceglie found himself torn between the concerns of colleagues who favored talk therapy over medical intervention, and patient advocate groups arguing that the medications were life-saving. Even as its leaders sought to please different stakeholders, “the pressure to provide puberty blockers” from patients, parents, advocacy groups, and international medical bodies became “more intense,” Barnes writes. In 2011, the clinic began offering puberty blockers from age 12.
The narrative explores both the uncertainties in the evolving field of gender medicine and what can happen when organizations become dysfunctional.
The number of patients began to rise steeply, from a couple of hundred in 2012 to 3,585 a decade later. At the same time, many more birth-assigned girls began coming forward, a shift that was (and remains) poorly understood. By 2013, Barnes recounts, the service was receiving more than twice the predicted upper limit of referrals. By then, Di Ceglie had retired and the clinic was being led by Polly Carmichael, a clinical psychologist.
To cope with soaring caseloads, the clinic tried to streamline its processes. Each patient would receive between four and six assessments, rather than the more numerous therapeutic appointments De Ceglie had envisaged. Some clinicians began to depart from the original Dutch protocol, recommending blockers for patients who had psychological problems or came from backgrounds that made them vulnerable.
As the service became stretched, some young patients were given medications after just two sessions, even when they had “a history of trauma,” one clinician told Barnes, or seemed to be depressed and struggling. Not only that, but the full implications of medical intervention were not always communicated to children and their families. For example, suppressing puberty can result in a trans adult having insufficient penile skin for a vaginoplasty, requiring surgeons to do a complex and risky procedure using segments of bowel. “Despite knowing that this was a risk for the natal boys at the start of puberty, it would take another decade before this information was routinely passed on to families,” Barnes writes.
The scientific research on which the Dutch protocol was founded was also evolving, and, to critics, its effectiveness was inconclusive. Carmichael had promised to use the Tavistock gender service’s data to contribute to the field, but information-gathering was patchy. Barnes reveals that of the thousands of children to go through the clinic’s doors after 2015, few if any were followed up with to see whether the treatment had improved their lives: “No one knows what happened to them.”
Barnes’ interviews with former patients are a central part of this story, varying the pace and giving readers insight into the human consequences of both the clinic’s more effective practices and its organizational disarray. She highlights the perspectives of seven young people treated at the clinic. The range of their experiences, and the choices they made, illustrate how diverse the patient cohort was. At age 11, for example, Ellie had a few sessions with Di Ceglie and found the process “really helpful,” but decided not to pursue medical treatment. She is now approaching 40, bisexual, and in a long-term relationship with a woman. Phoebe was 15 when she became a patient in 2009. She went on blockers, hormones, and later transitioned, and said the clinicians were kind and supportive.
Jacob, meanwhile, had just turned 12 when he was first prescribed puberty blockers, around 2014. At first, puberty suppression didn’t work so Jacob’s dose was increased and then coupled with beta blockers. He gained weight, felt depressed, and his bones “kept breaking.” One day he collapsed at school. Jacob still identifies as trans but has discontinued treatment. He told Barnes that he believes the protocol should be available, but adds that not everyone has to “go the full nine yards to be trans like the Tavistock suggests.”
Barnes excels at tracing the well-intentioned but flawed culture that developed at the clinic. Staff were highly trained, wanted to do their best, and everyone apparently listened when worries and complaints were voiced. But those who spoke up to raise criticisms were slowly pushed out. Critical reports were quashed and whistleblowers ignored.
Among the latter was Anna Hutchinson, who ended up giving media interviews and speaking on panels about her concerns. “But she also didn’t want to be right,” Barnes points out. “‘Let’s pray that I am wrong,’ she had said, ‘because if I am not wrong very many vulnerable children have been very poorly treated and will be left with, potentially, a lifetime of damage here.’”
In recent years, complaints about the service multiplied. In October 2020, Keira Bell, a woman who had received treatment at the Tavistock, brought a court case arguing that she was put on a path to blockers without adequate exploration of her other psychological issues. In July 2022, following a critical independent review led by pediatrician Hilary Cass, it was announced that the clinic would close in 2023. Today, British policymakers have promised to create a new regional system that better serves its youth, following Cass’s recommendations.
In the end, Barnes concludes that while some children treated at the clinic benefitted, many others — who may have been wrongly guided towards the medical path — did not. “This is a story that is yet to end,” she writes, adding that for the thousands of patients who visited the clinic over its three decades, “it is a story that may never end.”
Frieda Klotz is a journalist based in Brussels covering culture, health, and reproductive medicine. Her writing has appeared in the Guardian, Irish Times, Al Jazeera America, Mosaic Science and other outlets.