Fall of the Tavistock
Fall of the Tavistock
A once influential gender clinic goes from scandal to closure
The gist
The world’s largest youth gender clinic, the stand-alone U.K. Tavistock Gender Identity Development Service (GIDS), is to be shut down and replaced by regional centres more safely anchored in the mainstream mental health system.
The aim is to cope with skyrocketing demand from children and teenagers while making sure that “gender-affirming” groupthink does not lead clinicians to ignore non-gender causes of distress such as psychiatric problems, same-sex attraction, autism or family trauma.
The list of concerns about the Tavistock clinic includes inadequate assessment, rushed medicalisation, failures in child safeguarding, being oblivious to the special vulnerability of autistic children and those struggling with same-sex attraction, poor data collection, insufficient research, undue influence of gender ideology and trans activist groups, and intimidation of whistleblower staff.
The Tavistock, once famous for talk therapy, is known internationally because of the 2019-22 litigation brought by a former patient, detransitioner Keira Bell, who argued that she was incapable of giving informed consent to the puberty blocker drugs she began at age 16 after a deeply troubled childhood.
The dramatic shut-down of the clinic follows advice from paediatrician Dr Hilary Cass, who is heading an independent review of gender dysphoria care in England’s National Health Service (NHS).
“I just hope that what this [closure] means is the end of medicalisation of children,” Bell told Daily Mail.
The Society for Evidence-based Gender Medicine welcomed this “move away from the simplistic ‘gender-affirming’ model embraced by gender clinics, and toward whole-person care by traditional children's hospitals and professionals trained in standard, developmentally-informed approaches to helping distressed youth”.
Under the Cass advice, puberty blockers are to be relegated to experimental status, with the NHS being urged to swiftly organise clinical trials to begin to clarify the risks and benefits of suppressing normal sex hormones in children.
As the only NHS specialist youth gender clinic for England and Wales, the Tavistock received more than 5,000 referrals last year, compared with 138 a decade ago. Some 20,000 children had been referred to the clinic since former psychiatric nurse Sue Evans became the first Tavistock whistleblower 17 years ago, according to The Daily Telegraph.
“No matter that a significant proportion of [its increasing] new referrals were on the autism spectrum, or already suffering eating disorders, or were in care, or had complex histories of trauma or abuse — the [Tavistock] GIDS leadership pursued an ‘affirmative’ approach which critics said effectively treated a child’s declaration that they were born in the wrong body as sacrosanct and treated all their other complex problems through the prism of gender,” journalist Lucy Bannerman wrote in The Times.
The move to caution in the United Kingdom is the most significant since Finland in 2020 shifted to treatment of mental health issues as the first-line response to young people with gender issues, and Sweden earlier this year confined puberty blockers and cross-sex hormone treatment to strictly controlled research.
In the U.S., Florida’s Republican government has mounted a comprehensive scientific challenge to the gender-affirming treatment model, while Texas has launched an investigation into drug companies Endo Pharmaceuticals and AbbVie over allegedly deceptive promotion of hormone suppression drugs for “off-label” use as puberty blockers. (The drugs are approved for various medical conditions including central precocious puberty and prostate cancer.)
Pioneered by Dutch researchers in the 1990s, puberty blockers have been central to the exponential growth of gender clinics internationally, offering distressed children an escape from an unwanted puberty and the promise of more successfully “passing” as the opposite sex in adulthood — all this, while supposedly being a safe and reversible “pause” in development, should there be mistaken choice.
But in her July 19 letter to the NHS, Dr Cass punctures the superficial marketing of puberty blockers.
“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,” she wrote.
“We therefore have no way of knowing whether, rather than buying time to make a decision, puberty blockers may disrupt that decision-making process.”
Last year, in Persuasion, Keira Bell recounted the effect of puberty blockers on her.
“The idea was that this would give me a ‘pause’ to think about whether I wanted to continue to a further gender transition,” she wrote.
“This so-called ‘pause’ put me into what felt like menopause, with hot flushes, night sweats, and brain fog. All this made it more difficult to think clearly about what I should do.” (She went on to testosterone and a double mastectomy before detransitioning.)
Several systematic reviews of the medical literature on paediatric transition have confirmed its very weak evidence base, and Dr Cass says “the most significant knowledge gaps 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”.
Gender clinicians and trans-friendly ethicists talk up the autonomy of “young people” to refashion their bodies, but Dr Cass says the difficult task is to work out “when a point of certainty about gender identity is reached in an adolescent who is in a state of developmental maturation, identity development and flux.
“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 judgement).
“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.”
Video: Helen Joyce, author of Trans: When Ideology Meets Reality, talks about Tavistock clinic
The detail
Affirm the mainstream
In conflict with mainstream understanding of adolescent development and informed consent, the gender-affirming approach at its most extreme regards even very young children as “experts” in the discovery of their immutable trans identity.
Standard exploratory psychotherapy — why does this child feel “born in the wrong body?” — is then easily discouraged as a transphobic assault on a core identity shielded by human rights.
In her March interim report Dr Cass said: “From the point of entry to [the Tavistock clinic] there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition [living as the opposite sex] that has developed due to the delay in service provision”.
“[After the Tavistock’s stand-alone specialist clinic, a] fundamentally different service model is needed which is more in line with other paediatric provision, to provide timely and appropriate care for children and young people needing support around their gender identity. This must include support for any other clinical presentations that they may have.”
Dr Cass picked up concerns of “diagnostic overshadowing” at the Tavistock, whereby clinicians were so focussed on the gender lens that they were oblivious to other possible reasons for a child’s distress.
“… many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be overlooked,” she said.
Hence her advice to anchor the new regional gender centres in mainstream health, enabling a “more holistic” approach to the patient with access not only to paediatric endocrinology for hormonal treatment but also to mental health services, autism support, and expertise in trauma and child safeguarding.
Tavistock staff are likely to be involved in training for the new centres but the Cass review, which has an ambitious research program, is to develop protocols for assessment and treatment. Consistent data collection will be subject to independent oversight.
Carry on
In April, Dr Cass’s devastating account of the weak or missing evidence for paediatric transition was challenged by Australia’s biggest youth gender clinic at the Royal Children’s Hospital in Melbourne and trans activist lobby Transcend.
In her interim report Dr Cass had said the state of the evidence base meant it was simply not possible to give “definitive advice” on the safe use of puberty blockers and cross-sex hormones.
This was “problematic [and] a disappointment”, according to the Australian authors of an opinion article in the journal BMJ.
They protested it would “take many years to obtain these [undoubtedly needed] long-term data” and claimed there was enough evidence and international consensus to carry on medicalised gender change with minors.
They made no mention of the shift to caution in Sweden and Finland, nor did they acknowledge any of the systematic reviews of the medical literature confirming the poverty of the evidence base.
A tale of two clinics
The RCH gender clinic, which sees itself as an international leader, has multiple links with the Tavistock.
In 2016, the RCH clinic director Dr Michelle Telfer and nurse Donna Eade flew to London to meet paediatrician Professor Russell Viner — lead researcher on the Tavistock’s controversial 2011-14 study on the early use of puberty blockers — and “to learn how their child and adolescent gender service works”.
Professor Viner, a paediatrician who studied medicine in Australia, was working at UCL Hospitals, which handled the hormonal treatment for Tavistock patients.
As for Eade, she has a crucial role at the RCH clinic in Melbourne, running a “Single-Session Nurse Assessment Clinic” designed to cut waiting time. She conducts a 90-minute triage interview with each new patient and parents. Part of her job is to identify urgent cases for “rapid review”.
“This system enables those patients who will benefit most from puberty-blocking treatment to be fast tracked into the multidisciplinary assessment pathway to access treatment as required,” Eade wrote in a 2018 paper.
The Tavistock and RCH clinics — both gender-affirming, both offering puberty blockers and cross-sex hormones — have some key points of difference.
The Tavistock never campaigned for trans mastectomy so that female patients under 18 could look more like boys.
In 2019, the RCH clinic director Dr Telfer told a royal commission into mental health that “many” of her new, “post-pubertal trans male” patients wanted “chest reconstructive surgery”, and the hospital had the expertise but not the funds.
This surgery, she said, “is an integral part of the transition process for trans males”.
Dr Telfer said there were “no private surgical services available for (trans) adolescents under the age of 18 years in [the clinic’s home state of] Victoria, leaving them with no option but to seek chest reconstructive surgery interstate or overseas should they be unable to manage their distress until they turn 18 years of age”.
“There is a significant gap in Victoria’s current health care system with the absence of public funding for chest reconstruction surgery despite the high demand for this evidenced-based intervention.” (The claim that trans mastectomy is evidence-based has been challenged.)
Last year, RCH said it had “no plans to introduce ‘top surgery’ [trans mastectomy]”.
Video: Trailer for a new documentary by Jennifer Lahl
Transition or suicide?
Another difference between the two clinics is that the Tavistock did not use disturbing (but low-quality) statistics on suicide risk for emotive promotion of medicalised gender change.
Trans activists in the U.K. certainly did, but the Tavistock clinic’s former lead psychologist Dr Bernadette Wren had warned that “inaccurate [suicide] data and alarmist opinion” could adversely affect young people who identify as trans.
The Tavistock’s “Evidence base” webpage states that “suicide is extremely rare”, a truth confirmed in a recent study by University of Oxford sociologist Dr Michael Biggs.
As for the RCH clinic, it has made repeated use of a claim that 48 per cent of young trans people attempt suicide before the age of 24.
The source for this figure is an online, anonymous survey of a non-representative “convenience sample”, meaning there is no firm basis for claiming that the results apply to young trans people generally.
Earlier this year, RCH recycled the 48 per cent claim when appealing for donations. It appeared in an article about the gender clinic posted on the hospital foundation’s Where your money goes webpage.
While seeking donations from the public with the message that RCH is “leading the way in transgender health care”, the patients and parents were recently told by gender clinic newsletter that “we do not know whether using puberty blockers affects development of the brain”.
Puberty on hold
The story of the Tavistock is that it was pressured by trans activist groups and parents to give puberty blockers — and to give them to children as young as 10.
By contrast, RCH has championed nationwide adoption of puberty blockers through its 2018 Australian Standards of Care and Treatment Guidelines document.
The Melbourne clinic also ran a successful campaign to persuade Australia’s Family Court that it should radically cut back its supervisory role over paediatric gender medicine — and trust clinicians, patients with immature brains, and parents to decide when to go ahead with puberty blockers, cross-sex hormones and surgery.
In the 2013 puberty blocker test case, known as re Jamie, the judges summed up the evidence before the court — “Dr G [the endocrinologist] saw no problems in carrying out [hormone suppression]. It is fully reversible. It has no side-effects”.
“Jamie” was the pseudonym of a 10-year-old male child who identified as a girl.
Australia’s human rights commission, which took part in the case, told the court: “it seems that the risk of making a wrong decision is low and that the consequences of making a wrong decision are not grave (particularly because the treatment is reversible).
“The much more significant risk appears to be that young people in Jamie’s position are not able to access treatment in a timely way.”
The commission’s intervention testifies to the unusual nature of gender medicine in which identity politics and medical technology are enmeshed. The court heard no evidence contrary to the superficial presentation of puberty blockers.
Some years later, the extraordinary secrecy that surrounds these cases was partially waived so that Jamie could take part in promotion of the RCH clinic and its treatments.
But that veil of enforced confidentiality still frustrates any attempt to ask “Dr G” about the evidence for his confident assertions. (Side-effects of early puberty blockers followed by cross-sex hormones include sterility and impaired sexual function.)
After the Family Court in 2017 made it easier to access cross-sex hormones, researchers associated with the Children’s Hospital at Westmead, Sydney, noticed some troubling trends.
“With the change in law, some families began to put increased pressure on clinicians from our gender service (and clinicians in New South Wales, more generally) to provide cross-sex hormones before the children turned 16 and sometimes as young as 12,” they said in an April 2021 paper.
In commentary prefiguring the Cass review, these NSW clinicians said they also felt pressure to “abandon ethical, reflective practice in mental health” and to allow what they called “conveyor belt” treatment.
They attributed this to the gender-affirming approach being equated with a simple medical solution in the minds of patient families with complex histories including abuse, neglect, traumatic loss, parental mental illness, and exposure to domestic violence.
Network effects
Both the Tavistock and the RCH clinic — and their trans activist allies — resist the suggestion that social contagion online and via peer groups may have something to do with the international surge in atypical cases of gender dysphoria among teenage girls. Both institutions cry “transphobia” when confronted with awkward scrutiny.
In a 2020 paper in the journal JAMA Network Open, researchers from these two clinics were among the authors of a study of the links between media coverage and patient numbers.
They showed a correlation between 2,614 media items on trans and spikes in new referrals at the RCH & GIDS clinics 1-3 weeks afterwards.
In Australia, for example, the media coverage linked to new referrals included —
“Referrals soar at Australia’s clinic for transgender youth as support programs get fresh funding” — a 2014 report from the country’s public broadcaster, the ABC
“Ollie’s brave journey: Gender clinic helps growing number of young transgender people” — a 2015 article in The Age newspaper in Melbourne
“About a girl” — a 2016 ABC Australian Story program
Both the ABC and The Age have a history of uncritically showcasing the RCH gender clinic and its medical treatment.
But this kind of media coverage merely encourages trans youth to declare their pre-existing identity and to seek the treatment they had not been aware of before, according to the authors of the 2020 JAMA paper.
“Anecdotally, many of our patients have reported that their clandestine feelings of gender diversity were brought to the surface by media stories that prominently featured [trans] individuals and helped them to appreciate that others share similar feelings,” they wrote.
When Dr Telfer took over as RCH clinic director in 2012, there were 18 new referrals. Last year, there were 821.
Regrets, too few to mention
In the JAMA paper, the researchers did note the argument that media, especially social media, may drive social contagion, with young people “erroneously” attributing their distress to gender dysphoria, undergoing medical interventions and coming to regret them.
On this point, the authors acknowledge in their reference list the work of psychotherapist Lisa Marchiano, who framed the surge in adolescent trans identification as a “psychic epidemic”, and of public health researcher Dr Lisa Littman, who coined the term “rapid onset gender dysphoria” for the seemingly overnight gender distress of teenagers spread by networks.
But the Tavistock-RCH researchers claimed there was no evidence of an increase in treatment regret, citing an often-quoted Dutch long-term study that reported a regret rate of “approximately 0.5 per cent”.
The researchers did not state that this regret rate is narrowly defined and arguably inapplicable to today’s gender clinic caseload.
It applies only to patients who had gone all the way to gonadectomy (genital surgery) as adults, following a minimum of 1.5 years on cross-sex hormones.
They also had to return to the clinic after their change of mind, and switch to hormone treatment aligned with their birth sex. (In a 2021 survey of 100 detransitioners, only 24 per cent told their former clinic that they had ceased hormone treatment and re-identified with their birth sex.)
Under the strict Dutch definition, Keira Bell would not have qualified as a case of treatment regret, according to a November 2021 letter from Australian psychiatrist Dr Alison Clayton published in the journal Archives of Sexual Behavior.
“The adolescent subgroup [in the Dutch regret study, known as Wiepjes et al 2018] was carefully selected, being meticulously assessed and managed via the rigorous ‘Dutch protocol’ and the vast majority had a relatively short follow-up period,” she wrote.
The Dutch protocol discouraged early social transition, and restricted medical transition to patients with confirmed long-standing gender dysphoria and no severe psychiatric issues.
“Most contemporary youth gender clinics do not follow the [more cautious elements of the] Dutch protocol, which further limits the applicability of [the Wiepjes] study’s regret rate findings,” Dr Clayton wrote.
Of the 14 patients recorded by the Dutch as cases of treatment regret from 1972-2015, almost all were biological males who underwent surgery before the year 2000, starkly different from the post-2010s surge in adolescent-onset gender patients seeking puberty blockers or cross-sex hormones.
Moreover, the authors of the JAMA paper failed to include the crucial fact that the Dutch researchers had no data for 36 per cent of the former patient group, meaning a significant number of patients were “lost to follow up” and potentially more likely to have regretted treatment.
Note: GCN does not dispute that gender-affirming clinicians believe their interventions are of benefit to vulnerable patients in distress. RCH has said its gender clinic treatment is based on the “best available medical evidence”, in line with “international best practice”, and follows “strict clinical governance standards”. After news of the closure, Tavistock chief executive Paul Jenkins emailed staff to say he was proud of the service for its “hard work in caring for patients”.
These developments are excellent news and Bernard is due great credit for his mighty battle to ensure public attention for this important issue.
And the Dutch long term study dropped the 36% of people receiving this lifetime treatment who simply stopped coming to the clinic for their lifetime treatment. This clinic treats 95% of those in the Netherlands. Did those 36% restart anywhere? No one knows! The study simply dropped them! The authors point this out but not in their abstract.