Barnes Time to Think

The Inside Story of the Collapse of the Tavistock's Gender Service for Children
1. Auflage 2023
ISBN: 978-1-80075-112-5
Verlag: Swift Press
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 464 Seiten

SHORTLISTED FOR THE BAILLIE GIFFORD PRIZE FOR NON-FICTION ?SHORTLISTED FOR THE ORWELL PRIZE FOR POLITICAL WRITING ?'This is what journalism is for' - Observer ?Time to Think goes behind the headlines to reveal the truth about the NHS's flagship gender service for children. The Tavistock's Gender Identity Development Service (GIDS) was set up initially to provide talking therapies to young people who were questioning their gender identity. But in the last decade GIDS referred around two thousand children, some as young as nine years old, for medication to block their puberty. In the same period, the number of referrals exploded and the profile of the patients changed: from largely pre-pubescent boys to mostly adolescent girls, who were often contending with other difficulties. Was there enough clinical evidence to justify such profound medical interventions? This urgent, scrupulous and dramatic book explains how GIDS has been the site of a serious medical scandal, in which ideological concerns took priority over clinical practice.It is a disturbing and gripping parable for our times.

Hannah Barnes spent fifteen years at the BBC specialising in analytical and investigative journalism, most recently as Investigations Producer for BBC Newsnight. Hannah is now an Associate Editor and Writer at the New Statesman.

Autoren/Hrsg.

Barnes, Hannah

Leseproben

2

The Vision

The Gender Identity Development Service was the creation of child and adolescent psychiatrist Domenico Di Ceglie. Described by his long-term colleague Dr Polly Carmichael as ‘Italian, obviously, and a bit of a terrier, and also a very curious man’, he wanted to, in his own words, create a service ‘for children with these rare and unusual experiences’ of having a gender identity that didn’t seem to match the biological body they were born with.1

Di Ceglie was spurred on by a solitary case he’d worked with in the early 1980s, a teenager ‘who was claiming that she was a boy but in a female body’. Although she spoke very little during their psychotherapy sessions, Di Ceglie felt ‘there was something very profound about her sense of identity of being a boy which could not be easily explained and that was fundamental to her being.’2

Working as a consultant child psychiatrist in Croydon, south London, shortly afterwards, he and a couple of colleagues attempted to see all the patients who presented with gender identity problems in the area. In a borough whose population stood at around 300,000, they ‘ended up with 3 or 4 cases’.3 Despite the small numbers involved, the complexity of the cases he saw convinced Di Ceglie of the need for a specialist service.

The term ‘gender identity’ was coined by American psychiatrist Robert Stoller in 1964, and is generally understood to mean someone’s personal sense of their own gender.4 (For some that may not be the same as their physical sex – a trans woman, for example, is born with the physical body of a man but has a gender identity of a woman. But the concept is not without its problems; many people feel they don’t have a gender identity at all.) Di Ceglie read Stoller’s work, along with ‘other literature on trans-sexualism’, when he encountered his first case.5 The two met in person at a 1987 conference, with Stoller apparently being ‘very encouraging’ of Di Ceglie’s plans to start a service for children and adolescents. ‘He thought that there was a real need for such a service and predicted that there would be many referrals and a lot of interesting work.’6

In September 1989, Di Ceglie succeeded in setting up the Gender Identity Development Clinic for children and adolescents within the Department of Child Psychiatry at St George’s Hospital in south London. The name was relevant: the emphasis would be in promoting the of the young person’s gender identity, not changing it. Staff were to maintain an open mind as to what solution the young person might settle on in terms of managing their gender identity and to support families in reaching that solution – whether it be to transition medically, or to become reconciled with their own sex without changing their body. But Di Ceglie could see that, in some cases, by addressing other difficulties experienced by the child – things like depression, abuse or trauma – it might ‘secondarily affect the gender identity development’.7 In other words, sometimes the gender identity difficulties might resolve if other difficulties being faced were dealt with as well.

Not attempting to alter the young person’s gender identity, but instead fostering ‘recognition and non-judgemental acceptance of the gender identity problem’ would become one of the core guiding principles of the service.8 Others included trying to ‘ameliorate associated emotional, behavioural, and relationship difficulties’, encouraging ‘exploration of mind–body relationship’ by working with professionals with other specialities, and helping the young person and their family ‘tolerate uncertainty’ with their gender identity development.9 Although they were written in the 1990s, those leading the service in later years say that these principles endured throughout: ‘Those therapeutic aims still represent the core values of the service – they’re Domenico’s lasting legacy,’ said Bernadette Wren, a member of the GIDS Executive team from 2011 to 2020. ‘He grasped that if you want to have a genuine engagement with young people you have to take very seriously what they feel and what they say.’10

Di Ceglie’s peers were baffled. ‘Originally people were saying to me, you know, what do you want to do? Who are these children?’ Di Ceglie recalled, speaking in 2017. ‘And then somebody said to me, “But is it that you, [by] creating a service, you are creating the problem?”’ Di Ceglie reflected. ‘I don’t know the answer to that question, but still!’ he laughed.11 This question would grow ever more pertinent decades later.

The service in these early days was largely therapeutic: providing individual therapy, family work and group sessions. Some young people would remain in the service for years, others could be helped relatively quickly. In terms of outcomes, Di Ceglie said that only about 5 per cent of the young people seen at his clinic would ‘commit themselves to a change of gender’ and that ‘60% to 70% of all the children he sees will become homosexual’.12 At this point in time, the small number of studies that existed supported this general picture.13 These early findings would later appear to be forgotten as demand for GIDS grew and the clinic became busier. Alongside its therapeutic work, the clinical team also visited schools to help them understand how best to help young people struggling with their gender identity, and tried to educate other health professionals. There had been little need to ‘radically change’ this model over the clinic’s early years, but it had been refined ‘particularly with reference to physical interventions’ so that some adolescents could access medication that would block their puberty.14

If, after extensive therapy and thorough assessment, a young person’s distress in relation to their gender remained throughout puberty, they met a series of strict criteria and were around 16 years old, they could be offered medication to halt the process of their natural sex hormones being released – puberty blockers. In the 1990s little was known about how these drugs might help in the treatment for gender-related distress, and the service was cautious about recommending them. The blockers were not prescribed or administered by Di Ceglie and his colleagues themselves, but rather by paediatric endocrinologists, working alongside the gender identity team.

As the 1990s progressed, however, the Royal College of Psychiatrists established a working party to establish best practice on when, whether and how to treat young people with gender-related distress with medication. It followed a conference Di Ceglie had hosted in 1996, bringing together colleagues from around the world. There were very few professionals working with this group of children and adolescents, and it was an important moment to share ideas and experiences. A team in the Netherlands were already reporting early data that beginning the process of transitioning to another gender in late adolescence could lead to favourable outcomes in adulthood.15 Should the UK follow suit?

A pioneer in this field, Di Ceglie co-authored the Royal College’s resulting official guidelines, published in January 1998.16 The guidelines explained that gender identity ‘disorders’ were ‘rare and complex’ in children and adolescents, more common in boys, and often associated with other difficulties. The document stressed that, when compared with adults, there was ‘greater fluidity and variability in the outcome’, and only a ‘small proportion’ of young people would go on to transition in adulthood. The majority, it said, would be gay. The first stage of any treatment, therefore, should be extensive therapy and include taking a full family history. It should focus on improving ‘comorbid problems and difficulties’ in the young person’s life and reducing their distress caused by both these and their gender identity. The guidance advised that, if used at all, physical interventions should be staged: first puberty blockers, which are described as ‘wholly reversible’; then ‘partially reversible’ cross-sex hormones (oestrogen and testosterone) to either feminise or masculinise the body; and, finally, ‘irreversible’ surgical procedures. This staged approach remains the same today.

While surgery was strictly ruled out before the age of 18, the document didn’t make any age stipulations when it came to the use of puberty blockers. However, it recommended that adolescents have experience of themselves ‘in the post-pubertal state of their biological sex’ before starting any medications. This was considered vital to being able to provide ‘properly’ informed consent. The authors urged a ‘cautious’ approach and argued that physical interventions ‘be delayed as long as it is clinically appropriate’. They also stressed the need to ‘take into account adverse affects on physical growth’ that might result from blocking hormones.

The guidance explained that adolescents could present with ‘firmly held and strongly expressed’ views on their gender identity, and that the pressure to prescribe or refer young people for these drugs could be great. However, this distress and certainty had to be understood in the context of adolescent development – a time of great fluidity. Strength of feeling ‘may give a false impression of irreversibility’, it explained. ‘A large element of management [of the gender-related distress],’ the guidance said, ‘is promoting the young person’s tolerance of uncertainty and resisting pressures for quick solutions.’

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