Shuttering the Tavistock

Before long, the closure of Britain’s Tavistock youth gender clinic, the world’s largest, will appear to have been inevitable, and it will be difficult to find any big names who’ll admit to once being its champion. But there was nothing inevitable about the exposure of the Tavistock’s failings. Nor is there any guarantee of success for the more mainstream approach to gender distress urged by paediatrician and service reviewer Dr. Hilary Cass, whose recommendations have been adopted in toto by England’s National Health Service (NHS). So much depends on individuals of character who seek to remedy wrongs and uphold principle, no matter how inconvenient this is for self-regarding institutions.

In truth, the seemingly overnight fall from grace for Tavistock began 17 years ago, when one of its psychiatric nurses, Susan Evans, raised concerns. Since 2009, some 20,000 children have been referred to the clinic, according to the Telegraph. In 2021–22, there were more than 5,000 new referrals, compared with a corresponding figure of 250 a decade ago.

Other whistleblowers and resignations followed Evans’s departure; internal reports were written and apparently ignored; a handful of journalists began serious investigative work despite cries of “transphobia”; critics of rushed medicalisation fought to counter the institutional influence of transgender activists who sought to quickly “affirm” the asserted trans identity of Tavistock patients; and a former patient, Keira Bell, launched test-case litigation, on the basis that her female-to-male teenage transition had been unconscionably rushed by ideologically programmed doctors who should have known better. Crucially, former health secretary Matt Hancock found time, mid-pandemic, to secure the appointment of Dr. Cass, a former President of the Royal College of Paediatrics and Child Health. She was charged with a serious independent review of NHS care of minors who’d been diagnosed with the distress of gender dysphoria that sometimes accompanies identification with the opposite sex.

And so, the stand-alone Tavistock clinic, with its main base in London, is to close next year and be replaced by regional centres more safely anchored in the mainstream mental-health system. Britain’s Conservative government has stood firm behind Dr. Cass, despite the death agonies of Boris Johnson’s leadership. The immediate past health secretary, Sajid Javid, has declared that the closure was “absolutely the right decision based on the independent evidence gathered by [Dr.] Hilary Cass.”

In plain terms, the verdict against the Tavistock is that its staff allowed gender ideology and experimental drugs to crowd out prudent medicine and exploratory psychotherapy that ought to be open to the full range of possible reasons for a troubled child’s distress. An American-style “gender affirming” treatment model zeroed in on a dysphoric child’s supposedly immutable trans soul, and gave too little weight to a patient’s more earthly issues such as psychiatric disorders, struggles with same-sex attraction, autism, or family trauma. Though nobody can prove the existence of a trans soul, gender dysphoria had a history in psychiatric diagnosis that met the bar of health insurers. But the condition is unusual because it involves what is in effect a Cartesian dualist intervention, by which hormonal drugs and surgery are used to make the body’s appearance accord with the mind’s idea of how it should be.

This regimen is known as the Dutch protocol, after the famous Amsterdam gender clinic that pioneered the use of hormone suppression drugs in the 1990s to stave off the natural but (for those afflicted with gender dysphoria) undesired development of puberty. It is still common to hear clinicians and activists describe this as a fully reversible intervention that eases the patient’s distress and allows a period of reflection. In this account, the child has a “breathing space” before the fateful decision whether to begin irreversible cross-sex hormones or to cast off a trans identity as mistaken, and to cease hormone suppression so that puberty can take its course.

But this choice appears to be illusory. On the limited data available, almost all children who begin puberty blockers will go on to lifelong cross-sex hormones. If so, this intervention is not a pause but the first step on a pathway to lifelong medicalisation. And yet children in early puberty—girls as young as nine, and boys only slightly older—are expected to have the maturity to weigh the implications of saying yes to an intervention that may render them unable to have their own children and incapable of the sexual pleasure that is necessary to sustain intimate adult relationships.

Like many other gender clinics around the world, the Tavistock has been dispensing these puberty-blocking drugs without clarifying the purpose of this interruption of the physical, psychological, and social rites of passage that turn boys into men and girls into women. In her July 19th letter to the NHS England, Dr. Cass explained that “the most significant knowledge gaps [in the evidence base for paediatric transition] are in relation to treatment with puberty blockers, and the lack of clarity about whether the rationale for prescription is as an initial part of a transition pathway, or as a ‘pause’ to allow more time for decision making.”

Some of the side-effects of these drugs are known—children may miss out on the rapid increase in bone density that is normal in puberty, for instance—but much is unknown. And it seems possible that hormone suppression interferes with the very process of decision-making that it is supposed to enable. Gender activists often dismiss concerns about puberty blockers, claiming that these drugs have been used for many decades without arousing serious medical concerns. But in this regard, they’re referring to the use of such drugs to treat a condition known as central precocious puberty—whereby secondary sexual characteristics begin to appear before age eight in girls or age nine in boys. This is something quite different, because these children are allowed to resume development in sync with their peers, and are not directed toward a lifelong drug regime.

Dr. Cass identifies a crucial uncertainty: the effects of puberty blocking, and the absence of normal sex hormones, on the still developing adolescent brain:

We do not fully understand the role of adolescent sex hormones in driving the development of both sexuality and gender identity through the early teen years, so by extension we cannot be sure about the impact of stopping these hormone surges on psychosexual and gender maturation. We therefore have no way of knowing whether, rather than buying time to make a decision, puberty blockers may disrupt that decision-making process.

A further concern is that adolescent sex hormone surges may trigger the opening of a critical period for experience-dependent rewiring of neural circuits underlying executive function (i.e. maturation of the part of the brain concerned with planning, decision making and judgment). If this is the case, brain maturation may be temporarily or permanently disrupted by puberty blockers, which could have significant impact on the ability to make complex risk-laden decisions, as well as possible longer-term neuropsychological consequences.

As such, she has urged the NHS to organise the “rapid establishment” of the research arrangements necessary to recruit patients for clinical trials of puberty blocking with follow-up into adulthood. Together with multiple systematic reviews showing the very weak evidence base for medicalised gender change among minors, this only strengthens the argument that puberty blockers should be classified as experimental.

Moreover, researchers must consider the larger question of whether experiments affecting childhood puberty could even be conducted ethically. In an expert report prepared for Florida’s Agency for Health Care Administration, advising against Medicaid subsidies for under-18s transition, paediatric endocrinologist Quentin L. Van Meter concludes that

There is evidence that bone mineral density is irreversibly decreased if puberty blockers are used during the years of adolescence. To treat puberty as a pathologic state of health that should be avoided by using puberty blockers (GnRH analogs) is to interrupt a major necessary physiologic transformation at a critical age when such changes can effectively happen. We have definite evidence of the need for estrogen in females to store calcium in their skeleton in their teen years. That physiologic event can’t be put off successfully to a later date. It is very difficult to imagine ethical controlled clinical trials that could elucidate the effects of delaying puberty until the age of consent.

Last year, the Swedish TV program Mission: Investigate, which had produced the Trans Train documentary series, related the story of a 15-year-old patient, “Leo,” who was belatedly diagnosed with osteopenia—a brittle-bone condition usually observed in the elderly—after four and a half years on puberty blockers. As for effects on the brain, a 2020 “Consensus Parameter” paper collectively produced by 24 international experts in neurodevelopment, gender development, neuroendocrinology, and related fields concluded that

The pubertal and adolescent period is associated with profound neurodevelopment, including trajectories of increasing capacities for abstraction and logical thinking, integrative thinking, and social thinking and competence … The combination of animal neurobehavioral research and human behavior studies supports the notion that puberty may be a sensitive period for brain organization: that is, a limited phase when developing neural connections are uniquely shaped by hormonal and experiential factors, with potentially lifelong consequences for cognitive and emotional health.

(The ambitious research project outlined by the paper—involving multiple gender clinics and more than one comparison group—is yet to begin.)

Paediatric transition is a complex, emotionally charged element within the wider debate over both transgender rights and the extent to which such rights should be permitted to impinge on those of women and children. Britain’s Labour Party has struggled to talk sense on this subject, and at one point last month, it seemed that the next Conservative leader would be Penny Mordaunt, who in 2021 had stood at the dispatch box in the House of Commons and intoned the mantra, “Trans men are men, trans women are women.”

How, then, did the UK manage to devise and enact a credible policy shift toward caution on the issue of medicalised gender change for minors? Are there lessons for countries such as the United States, Canada, Australia, New Zealand, Germany, and Spain, where, so far, dogmatic slogans have trumped critical thought? American trans activists denounce Britain as “TERF Island.” (“TERF” stands for “trans exclusionary radical feminist,” a term of abuse that, of late, has been adopted as a sort of ironic badge of honour by gender-critical feminists.) It seems as if some type of British exceptionalism is asserting itself in resistance to the trans zeitgeist that permeates many other Western countries.

“TERFs” outside the UK might wonder if it’s possible to clone JK Rowling, the gender-critical Harry Potter writer who’s followed the Tavistock saga closely, presciently declaring two years ago that “it feels as though we’re on the brink of a medical scandal.” Her 3,600-word open letter, written a month before that, serves as a plain English explainer for those puzzled about gender ideology, sex-based rights, the fury of trans-rights activists, and the alarming surge in teenage girls seeking a chemical and surgical escape route out of the female category. (In writing it, Rowling quoted from a January 2020 Quillette article in which former Tavistock psychoanalyst Marcus Evans explained why he’d resigned and turned whistleblower. He also picked apart the irresponsible “transition or suicide” narrative that activists—and even patients—sometimes cite as a tactic to push aside legitimate concerns.) Rowling may be a one-off, but all countries have at least some influential voices of concern that are able to reach large audiences with the message that medicalisation of children is not something to be celebrated. And those voices should be amplified.

In any event, the sobering fact is that many of the obstacles to common sense complained of elsewhere in the world also had to be negotiated in the UK, as illustrated by British politician Kemi Badenoch’s recent candid account of dealing with public-service groupthink on gender:

When I became equalities minister in early 2020, the [Tavistock] NHS clinic for young people was presented to me by government officials as a positive medical provision to support children. I was assured that there was ‘nothing to see here’; if anything, the Tavistock was getting unfair press. This was despite whistleblowers like Dr. David Bell already raising concerns about practices at the clinic.

I insisted on meeting campaigners on both sides of the debate: not just [the trans-rights lobby group] Stonewall UK but, to the horror of some officials, the LGB Alliance [which opposes gender ideology as homophobic]. I met clinicians and, most importantly, I asked to meet young people who had used the Tavistock’s services.

One such young person was Keira Bell. To my surprise, I was advised strongly and repeatedly by civil servants in the department that it would be ‘inappropriate’ to speak to her. I overruled the advice.

Badenoch also noted the threats and smears directed at sceptical journalists as well as women in the “gender critical” movement:

The reason it took this long for the Tavistock clinic to be shut down is that activists succeeded in creating an environment in which critics and journalists felt unable to interrogate the dogma that youngsters should be able to medically transition in the way overseen by Tavistock. The treatment of these women showed the heavy price to pay and many people including MPs on all sides of the house simply didn’t want to get involved.

For all its progress, Britain has a formidable task ahead in ensuring that a more mainstream therapeutic culture both displaces the influence of gender ideology, and grapples with the full complexity of distressed children and adolescents. The fall of the Tavistock clinic, if clearly explained without gender-identity jargon, will make sense to the vast majority of Brits. But there is as yet little public understanding of the broader institutional and ideological forces that put so many minors on the path to unnecessary medicalisation.

“Closing the Tavistock is a first step, but schools are frequently acting as a pipeline to the clinics,” a spokesman for a gender-critical parents’ organisation, the Bayswater Support Group, told the Times. These parents have learned that while doctors are the ones who actually prescribe puberty blockers, any strategy for avoiding unnecessary medicalization must look at the broader information environment that faces children before they show up at a clinic’s doors:

We want the [UK] Department for Education to issue clear guidance to schools, and for Ofsted [the Office for Standards in Education] to enforce rules. Many of our [trans-identifying] children came across gender identity theory in schools, which then played an active role in socially transitioning them without parental knowledge or clinical oversight. When parents question these policies, schools have denied they exist, told us we can’t view educational resources, and in some cases reported us to social services for failing to affirm our children as the opposite sex.

This is a sleeper issue in many affluent countries, where youth gender clinics have gone from novelty to claimed essential service in the space of just a few years, with scant official oversight or public awareness. Britain’s path to remedying this situation, however incomplete the process may be, offers a precedent that responsible politicians, journalists, clinicians, and parents in other nations should monitor carefully.