Hormones First. Research Later

The editor wanted a cut. I’d written of a hypothetical transgender woman, adding the qualifying phrase “who is biologically male.” That phrase should go, the editor insisted; “trans woman” was enough. I didn’t want to give in to pressure from activists who oppose talk of biology, but there was also a more basic reason why I stuck to my guns: I’ve met people who genuinely believe that a trans woman is a woman—in the literal biological sense—who identifies as trans. For clarity and sense, therefore, the biological reference had to stay.

The activist milieu that I think of as Transworld often seems back to front and upside down, and not just in its manic policing of language. There is an ethical inversion at the heart of youth gender medicine, one that BBC journalist Hannah Barnes describes in her new Swift Press book about the failings of England’s only youth gender clinic, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children. The Tavistock is hardly the only “gender-affirming” clinic that chose to offer medicalised gender change to children before research had delivered a verdict on its safety and side-effects. Experimental treatment on minors came first, without the ethical guardrails supplied by formal research.

The Tavistock brand once represented careful, exploratory therapy. Now it’s become synonymous with its London-based Gender Identity Development Service (GIDS), which became the world’s largest gender clinic, as well as the go-to place for troubled English children—many of them diagnosed with the bodily distress of gender dysphoria, and desperate for puberty-blocking drugs that would arrest their unwanted sexual development. The Tavistock itself did not dispense these drugs, but it was the gateway to the endocrinologists who did.

Why I Resigned from Tavistock: Trans-Identified Children Need Therapy, Not Just ‘Affirmation’ and Drugs

Sydney. London. Toronto.

QuilletteMarcus Evans

Following years of intense media scrutiny (including from Quillette authors), a judicial review arising from the case of detransitioner Keira Bell, and an official National Health Service review conducted by a former president of the Royal College of Paediatrics and Child Health, the Tavistock has been marked for closure (although the date is uncertain). Several thousand young people remain on its waiting list. This is hardly surprising given that the number of new referrals had skyrocketed from 97 in 2009–10 to 2,748 in 2019–20, an increase of more than 2,700 percent.

In her book, Barnes goes back to the first known case of puberty blockers being prescribed to a child under 16 suffering gender distress. This was reported in 1998 by the Dutch clinicians who pioneered the standardized treatment sequence that proceeded from blockers to cross-sex hormones, to surgery (at age 18). In 2011, Dutch researchers followed up with a small group of patients who’d taken blockers. And in 2014 came the post-surgery study. Barnes, an investigations producer for BBC Two’s Newsnight, notes that “the early papers from the Dutch team signalled not just a revolutionary approach to treatment, but also a rather curious trend found in this field of research: results are spoken about with great certainty, but they are based on very small sample sizes, very short-term follow-ups and high rates of participants who are ‘lost to follow-up’—that is, people who don’t respond to the researchers’ invitations to participate.”

And yet, as Barnes points out, these Dutch studies, though “based on only 57 per cent of a cohort of 70 [patients], of whom one died due to surgical complications, comprise most of the evidence base used to justify the affirmative medical approach for gender dysphoric youth—an approach which would become mainstream in the Western world.”

In London, the Tavistock clinic and its endocrinology partner had set 16 as the minimum age for puberty blocking. But in the late 2000s, GIDS clinicians came under pressure to medicate the distress of even younger patients. The same risks and uncertainties debated today were known then. Might puberty blockers affect development of the adolescent brain? Might their effect on bone density leave patients at high risk of osteoporosis? Might gender distress be caused by a range of disorders and difficulties unrelated to gender? Moreover, what did it even mean to be trans? What, exactly, was it that gender clinics were treating?

The Tavistock recognised that it was in experimental territory. In 2011, the clinic decided to introduce puberty blockers for children from the age of 12—but only under the auspices of a formal research project guided by careful patient assessment, monitoring, and informed consent. “Between 2011 and 2014, 44 patients aged 12–25 joined [GIDS’s] Early Intervention Study,” Barnes reports. “While this study began with admirable aims—to test the claims about what was seen as an experimental treatment in a safe research setting—[the clinic] did not wait for the data to emerge before rolling out early puberty suppression more widely [in 2014]. The full results would remain unpublished for almost a decade.”

The risks of early puberty blocking did not go away. But the adults who were supposed to be applying checks and balances to GIDS’s operations appear to have found it too difficult to counsel distressed children in resilience and tolerance of uncertainty. Swirling outside the clinic, in a culture driven by identity politics and lobby groups, was the alarming narrative that trans-presenting children denied swift access to puberty blockers would try to kill themselves. It didn’t seem to matter that there was never any good evidence for this reckless claim.

By 2014, the Tavistock was becoming known as a clinic that would turn no child away—where a referral for blockers seemed likely for any distressed patient who wanted them and who’d fulfilled the (easily met) diagnostic criteria for gender dysphoria. The Tavistock abandoned the stricter Dutch-style eligibility rules applied within its Early Intervention Study, and the minimum age of 12 was also relaxed. There was no data for this younger patient group, and the Tavistock knew it. Clinic director Polly Carmichael claimed that an evaluation of the research data had justified the mainstreaming of early blockers in 2014, but Barnes shows this to be unconvincing.

In a 2015 parliamentary submission, Carmichael and her Tavistock colleague Bernadette Wren, both clinical psychologists, reported:

We offer assessment and treatment not just to those young people who are identifiably resilient and for whom there is an evidence base for a likely ‘successful’ outcome. We have carefully extended our programme to offer physical intervention [such as blockers] to those who have a range of psychosocial and psychiatric difficulties, including young people with autism and psychiatric difficulties, and young people who are looked after [in care].

Their stated rationale for this approach was that “[we] have felt that these young people have a right to be considered for these potentially life-enhancing treatments.” The clinic’s leaders were admitting that they were providing physical interventions for, in Barnes’s words, “those to whom the evidence base does not apply.” And their basis for doing so was apparently the psychologists’ own feelings.

Many of the Tavistock patients were very different from those treated in the Dutch studies. In the Netherlands, the children were required to present with classic, early-onset gender dysphoria that had persisted; in other respects, they had to be psychologically stable. In this way, the Dutch experts believed, they were denying treatment in cases where mistaken trans identity would lead to post-transition regret.

“Most [young people at the Tavistock] were experiencing gender-related difficulties—no one questions that—but so much else besides,” Barnes writes. An analysis of 218 young people referred in 2012 catalogued “non-suicidal self-harm, suicidal ideation, suicide attempts, autism spectrum conditions, ADHD, symptoms of anxiety, psychosis, eating difficulties, bullying and abuse (i.e., physical, psychological/emotional, sexual abuse and neglect).”

These are the kinds of children often seen by a child and adolescent mental health service (known in the UK as Child and Adolescent Mental Health Services or CAMHS). But any passing reference to a gender issue in a child’s file was often enough to have him or her referred to the overwhelmed Tavistock clinic. As a gender clinic, GIDS was not commissioned to do the kind of complex, exploratory therapy that may be required to treat a mentally distressed child in a responsible and holistic way. In any event, its clinicians lacked the time, and were under pressure to reduce the waiting list. At the Tavistock GIDS, there was typically only one treatment path—leading to endocrinology, blockers, and hormones.

Like many public health providers, CAMHS, too, was under strain. In order to manage their own workload, its clinicians often would refuse to take on the myriad non-gender-related issues of those patients who’d been handed over to the national gender experts. How, amid this dysfunction, were the primary causes of a child’s distress to be disentangled and matched up with the right treatments? Barnes: “Self-diagnosed adolescent trans boys—natal females—started to fill up [the Tavistock] waiting room with similar stories, haircuts, even names … They’d talk about their favourite Trans YouTubers … Given how complicated these young people appeared to be, could something else be going on that explained this, something other than them all being trans?” Perhaps something such as social contagion via social media and school-organized peer groups.

One of the strengths of Barnes’s book is her inclusion of patient profiles, which span the full spectrum of possible outcomes. At one (almost) tragic extreme is the story of “Alex,” as told by his mother, “Diana” (both names being pseudonyms). A geeky gentle giant, he had come out as gay, suffered bullying, and developed a severe and debilitating form of obsessive-compulsive disorder (OCD). He was referred to CAMHS, but then suddenly declared himself trans, whereupon he was entrusted to the Tavistock. He became housebound, was showering five times a day, and used a whole roll of toilet paper on each visit (causing blocked toilets and flooded bathrooms). CAMHS dealt with him as a woman, and his OCD went untreated. A Tavistock clinician, who’d travelled from London to see Alex, held out the possibility of a referral to endocrinology. Bewildered by this suggestion, Diana turned to a private counsellor for her son. Two years later, Alex declared he was “through with gender.”

“Diana still struggles to understand how any stretched NHS service [such as the Tavistock] would send a senior clinician several hours across the country to meet someone with mental health problems so severe that they were not attending school and could not leave their home to attend appointments,” Barnes writes. “To then raise the possibility of physical transition—arguably the most invasive option—as a way forward at the very first appointment is beyond her.”

Behind the scenes, there were worried, thoughtful clinicians at the Tavistock. And in 2015, some of them took careful note of a new publication from a Finnish research project that, unlike their own, hadn’t been pre-empted by a data-blind shift in clinical practice.

The politically progressive but tougher-minded Finns had confirmed that the current patient group they were observing—chiefly teenage females—wasn’t comparable to that which had populated the Dutch evidence base. Most of these girls, the Finns reported, had first presented with gender dysphoria only after the onset of puberty, “and the vast majority suffered significant psychopathology and broader identity confusion than gender identity issues alone.” Of the many who had been bullied, the bullying began before their ruminations about gender identity. Three quarters of these patients were undergoing psychiatric treatment for non-gender reasons at the time of their referral to the gender clinic. The Finns said these severe disorders and difficulties “could seldom be considered secondary to gender dysphoria,” meaning they would need treatment in their own right. If these were patients quite unlike those studied by the Dutch, then Dutch-style medical transition might be a harmful mistake.

Having done their own research, as well as a systematic review of the evidence base common to youth gender clinics internationally, the Finns radically changed their clinical practice. In 2020, a Finnish public health agency declared that “gender reassignment of minors is an experimental practice”; that first-line treatment for gender dysphoria should be mainstream mental health care and support at school; and that if these young people showed psychiatric symptoms, one could not assume their declared opposite-sex identity to be stable.

At the Tavistock, things had proceeded in a very different way. In 2016, GIDS researchers gave an in-house presentation of preliminary findings from the Early Intervention Study of puberty blockers at younger ages. The good news came first: these children said they were happy to be on blockers. But the more objective measures—of self-harm, suicidal ideation, and body image—appeared to have either flat-lined or deteriorated.

Then, “in an astonishing aside, the researchers revealed that everyone in the early intervention group had at this point progressed from the blockers on to cross-sex hormones,” Barnes notes. “A treatment with irreversible consequences. Every single one.” This was a “holy fuck” moment for senior clinician Anna Hutchinson, a key source for Barnes:

It totally exploded the idea that when we were offering the puberty blockers, we were actually offering time to think, because what are the chances of 100 per cent of the people, offered time to think, thinking the same thing? I mean, it looked to me like it was the opposite. And that once you’re on the [medical] pathway, you stayed on the pathway, perhaps you thought less.

If the blockers were locking in the trans identities and gender distress of patients, then there would have to be young people—already suffering from trauma, abuse, and neglect, or struggles with same-sex attraction—heading for the later realisation that medicalised gender change had been the wrong choice. It also meant that children as young as age 10 were signing up to a pathway likely to sterilise them, potentially rob them of future sexual pleasure, and leave them as permanent medical patients on lifelong drug regimens. How on earth could they give informed consent to all that?

Already troubled clinicians such as Hutchinson took the initiative by warning patients and families that these supposedly “fully reversible” puberty blockers might in reality be a guarantee of never-ending medicalisation. The Tavistock leadership had been given a warning, too, but there was no formal shift to a more cautious clinical practice. Nor was there a swiftly updated information sheet for patients and families spelling out the profound ethical implications of puberty blockers.

After repeated inquiries by journalists, researchers, and judges, the full results of the Early Intervention Study were at last published in December 2020, almost a decade after it had begun. It turned out that this intervention had provided patients with no measurable benefit in psychological functioning, quality of life, or intensity of gender dysphoria. Clinical practice and research were back-to-front. (And even if the study had reported benefits, its weak design would have prevented any confidence about causation.)

The UK media has been awash with coverage of the Barnes book recently. But while the Tavistock was due to close in the (British) spring, a new system of replacement clinics networked with mainstream mental health providers isn’t ready to replace GIDS, which is still providing around 1,000 young people with treatment, including blockers.

There are links between the Tavistock and the largest gender clinic in my own country, Australia’s Royal Children’s Hospital Melbourne (RCH). In 2016, the RCH’s clinic director, Dr. Michelle Telfer, and a nurse colleague, Donna Eade, flew to London to meet paediatrician Russell Viner, the lead researcher on the Tavistock’s Early Intervention Study—and “to learn how their child and adolescent gender service works.”

Some years later, researchers from the Tavistock and RCH would publish a paper showing a correlation between the appearance of transgender-related media stories and spikes in new referrals at their clinics one to three weeks afterwards. They attributed this link to “growing awareness,” rather than social contagion.

In 2018, the medical journal the Lancet praised RCH’s new treatment guidelines in an unsigned editorial with the heading, “Gender-affirming care needed for transgender children.” This was the first dysphoria guideline “focusing solely” on children and adolescents, according to the journal. The guidelines indicate that a teenager’s depression, anxiety, or psychosis “should not necessarily prevent medical transition” (although the authors concede that these factors would make clinical decision-making more complex).

The guideline document, updated in 2020, makes no mention of the growing trend toward detransition among formerly trans-identified children. Brandishing this guideline in draft form, RCH had persuaded Australia’s Family Court in 2017 that the science of gender-affirming medicine had advanced to such a point that judges could safely wind back their supervision of hormonal and surgical treatments for minors, placing more trust in clinicians.

Like the Tavistock, RCH has been offering hormonal treatments before its clinicians had any long-term safety data. In 2012, when Dr. Telfer became director, there were just 18 new referrals. In 2019, there were 336. That year, RCH published the protocol describing its longitudinal Trans20 study, which had begun recruiting patients in 2017. The authors noted that “the Royal Children’s Hospital Human Research Ethics Committee approved this study.” But did RCH need ethical clearance, years beforehand, when it began to dispense puberty blockers and opposite-sex hormones as routine treatments in the clinical setting? The hospital did not reply when asked.

The 2019 protocol for the Trans20 project acknowledged “an urgent need for more evidence to ensure optimal medical and psychosocial interventions.” Four years later, RCH is yet to publish any data on the outcomes of its treatment. The clinic’s website still claims that puberty blockers are “reversible,” although last year it did acknowledge in a newsletter to patients and families that the effects of blockers on the developing adolescent brain are unknown.

The same year, 2019, brought us the protocol for the first longitudinal outcome study of youth gender medicine in the United States. This involved gender clinics in Boston, Chicago, San Francisco, and Los Angeles. Project leader Dr. Johanna Olson-Kennedy, a high-profile gender clinician, secured a US$5.7 million grant from the National Institutes of Health (NIH). The protocol admits that gender clinics have been operating without long-term safety data, stating that the research project will collect “critical data on the existing models of care for transgender youth that have been used in clinical settings for close to a decade, although with limited empirical research to support them.”

Much-anticipated outcome data from this NIH study were published by the New England Journal of Medicine in January 2023. The abstract reported that cross-sex hormones had “improved appearance congruence [being content with how one looks] and psychosocial functioning.” Media coverage of the study was upbeat. The NBC News headline read: “Hormone therapy improves mental health for transgender youths, a new study finds.” Except, it didn’t really. American journalist Jesse Singal, who published a detailed two-part analysis of the study on his Substack, summed it up with a tweet: “The hype is unwarranted—if you look closely, there is little here to support the idea that hormones help trans kids. Plus, there was an alarmingly high suicide rate.” Singal, the author of a famous 2018 Atlantic magazine cover story documenting early doubts about youth gender medicine, found ample reason to regard the NIH study as opaque and unreliable.

The lessons of Hannah Barnes’s book-length exposé aren’t confined to England. In country after country, clinics have made it standard practice to offer invasive medical treatments to troubled and confused young people. Barnes was told of some young trans men—biological females, that is—who wanted to know whether they would start producing sperm once they were on synthetic testosterone. Like so many others, they got the drugs they wanted, but without the evidence base to give anyone confidence about the treatment outcomes, beneficial or harmful.

And it wasn’t just patients who were misled. So was the general public: For too long, cherry-picked data, journal abstracts with fanciful claims, and Transworld activist demands have been taken as gospel by mainstream media outlets. Amid their misleading headlines, Hannah Barnes’s book appears as a beacon of truth.