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Journalist Hannah Barnes on the inside story of the collapse of Tavistock’s gender identity clinic

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• Jonathan Chang
• Meghna Chakrabarti

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The United Kingdom’s only dedicated gender identity clinic opened nearly 35 years ago.

In recent years, those inside the clinic began to raise concerns.

After a scathing independent review, the National Health Service decided to close the clinic.

Today, On Point: Journalist Hannah Barnes tells us what happened.

Hannah Barnes , investigations producer at BBC Newsnight. Author of Time to Think: The Inside Story of the Collapse of the Tavistock's Gender Service for Children . ( @hannahsbee )

Also Featured

Dr. Anna Hutchinson , clinical psychologist based in London who was part of the Gender Identity Development Service (GIDS) senior team from 2013 to 2017.

Dr. Marci Bowers , OB/GYN who specializes in gender affirming surgical care. President of the World Professional Association for Transgender Health (WPATH)

Jamie Reed , clinical research manager and former case manager at The Washington University Transgender Center at St. Louis Children’s Hospital.

Read: Jamie Reed's affidavit to Missouri's attorney general. Her allegations have been denied by some families whose youth received care at the St. Louis transgender center.

MEGHNA CHAKRABARTI: Until this past year, the Tavistock Gender Identity Development Service was the U.K.'s only center for treating children suffering from gender dysphoria. In March 2022, an independent report commissioned by Britain's National Health Service found that the type of care provided at Tavistock was, quote, 'Not safe or viable as a long-term option for the care of young people with gender related distress.' It also found that the center had not used customary control measures that are typically in place when new treatments are introduced. Nor had the center collected consistent data on its patients and treatments.

Following the report, the National Health Service decided to close the Tavistock Center and find a new model of care for gender questioning young people. Hannah Barnes is an investigations producer at Newsnight, one of the BBC's flagship television news programs, and she writes about what happened at Tavistock in her new book, Time to Think: The Inside Story of the Collapse of the Tavistock's Gender Service for Children. And she joins us today from London. Hannah Barnes, welcome to On Point.

HANNAH BARNES: Thank you so much for having me.

CHAKRABARTI: So when the Gender Identity Development Clinic was first opened in London in 1989, what was its original mission?

BARNES: Its original mission was to provide a space for a very small group of very distressed children and young people to talk about the difficulties they might be having with their gender. So originally, [it] opened at another London hospital, but really in those early years we were talking a couple of handfuls of young people each year. I think actually there were only two in the first year. And it provided a space for young people in their families to go and talk about what they were going through.

The idea was always that it wouldn't aim to change a young person's gender identity but would help them tolerate the distress they were experiencing. Tell them that they weren't alone, that there was nothing wrong with them. Sort of break down stigmas, really provide a safe space, if you like, and predominately provide talking therapies for this very small number, but albeit some of them very distressed children.

CHAKRABARTI: That's why in the book you emphasize that its original mission was to support gender identity development versus change.

BARNES: Exactly. Exactly. And that that aim continued through to the present day.

CHAKRABARTI: Okay. But so then how what how small of a percentage of young people are we talking about that were seen at the service in the early days?

BARNES: It's difficult to know in terms of percentage of the population, but we're talking, you know, a handful of children per annum that were referred out of millions of young people here in the U.K. And at that time, the founder of the clinic, a psychiatrist called Domenico Di Ceglie, he would often talk to the press as we went into the 1990s, saying that the vast majority of these young people would come through their period of gender related distress and a small minority would indeed transition and live their lives as trans adults.

CHAKRABARTI: So then at around approximately 2005, if I remember correctly from your book, there was an internal audit done by the gender service center there. What did that internal audit find?

BARNES: So there are two things here. There was a report into the service in 2005. There was also an audit carried out in about 2000. So I can talk briefly about both of them, if that's helpful. So in 2000, by this point, the service had moved to its current home, the Tavistock and Portman NHS Foundation Trust. And really there was a request made that the trust wanted to learn a bit more about these young people that the trust was seeing.

What other difficulties might they be experiencing? How did they arrive at the clinic? What was happening to them? Basically. So a group, including Domenico Di Ceglie, they audited the first 124 young people that had gone through. So from 1989 to 2000, and they excluded the very current patients. And that showed that the vast majority of these young people absolutely were experiencing distress around the agenda. But actually, so much else besides. A large, very large proportion had been in care.

So not living with their parents or their immediate family, that was up to a quarter. A large proportion had experienced abuse, either physical or sexual. They experience depression, anxiety, all sorts of things. And what they found was that only a very small proportion didn't have any other difficulties alongside their gender distress. But I think what you were talking about in 2005 was that some concerns were being raised at that point within the service about how it was functioning.

And although puberty blockers, as we know them colloquially were available at that point, a young person had to be 16 here at that point. But there was still concern that some people were going forward for these interventions quite quickly. And in some people's eyes, without adequate assessment or talking beforehand. And the then medical director of the entire Tavistock Trust conducted a review, if you like. He spoke to endocrinologists; he spoke to people in the service in the wider trust. It was really thorough, and he called for lots of things.

He called for better data collection. He said, We don't really know any of the outcomes of the young people we've seen so far, even though we've been going at that point, what, 15, 16 years. He said, We need to collect outcomes on those who go forward for the physical interventions. We need to collect data on those who don't. We need to collect data on how the young people who do go forward for physical interventions are using that time on the blocker. Is it that they're using it as time to sink and explore their gender identity or is something else happening?

And he identified this core, not disagreement, but sort of conflict, if you like, in the service surrounding the use of physical interventions, I suppose, and how quickly they should be provided. Who was responsible for it? Was it the mental health practitioners working in the service, assessing the young people, or was it ultimately the endocrinologists? All kinds of things. And Dr. David Taylor was the man who did the report. He made a number of recommendations, and frankly, none of them were really taken forward.

CHAKRABARTI: Well, in your book, you talk about how in this report by Dr. David Taylor, again, this is the 2005 review. That the pressure, he talks about the pressure to provide puberty blockers became much more intense around that time. Where was the pressure coming from?

BARNES: It was coming from all quarters, really. It was coming from trans support groups. Absolutely. But I think there's a danger that especially here in the U.K., that it's felt that all the pressure was coming from them alone, and that isn't the case. It was also coming from clinicians working with gender diverse young people in other countries, particularly in the Netherlands at that time. Some conditions in the United States as well.

And it was also, I'm told, coming from endocrinologists who obviously work with hormones in the body. And the pressure was saying, look, it appears at this moment in time the Dutch are doing this thing where they're using puberty blockers in very highly screened young people who have this distress around the gender. And it appears that it could be a good intervention. So why aren't you doing it? That was the message, really.

CHAKRABARTI: Well, and also around this time, there begin to be quite a significant rise in the number of referrals right to the Tavistock Gender Service in the U.K. We spoke with Dr. Anna Hutchinson, who Hannah, you spoke to extensively for your book, and she was part of the senior team at Tavistock between 2013 to 2017. She went on maternity leave shortly joining after joining the team. And then when she came back at the end of 2014, she had noticed that in that time the number of referrals for hormone blockers had rapidly increased.

ANNA HUTCHINSON: I'd have the referrals from the week on my desk and it was very visceral. The numbers are going up, you know, week to week. That pile of referrals would be getting more remarkably larger. So there was a sense of everybody was really busy trying to keep on top of the deadlines. At that time, we were aiming to see all young people within 18 weeks and the team was just really running around trying to meet young people on time.

CHAKRABARTI: So that's Dr. Anna Hutchinson. Hannah Barnes, If you could sort of summarize, there was also a growing chorus of concern coming from practitioners within the clinic at this time. What were those concerns?

BARNES: So what had happened at this point is because of the pressure that we spoke about before coming from all quarters, GIDS, the Gender Identity Development Service ... had started a research study to say, well, look, let's test this out for ourselves. Are the puberty blockers beneficial to a selective group of young people?

And in 2014 they rolled out the early blocking of puberty as policy anyway, without waiting for that data. So that's the context. So you've got the wider availability of puberty blockers at younger ages. And that point there was no actual lower age limit. It moved to a stage of puberty rather than age. And you had these referrals that Dr. Hutchinson speaks about really increasing at a very, very rapid rate.

And in 2014, in fact, they were sticking to that 18-week target. But as we went into 2015, that was the year that referrals actually doubled. And so, they'd been increasing at 50% per year from 2009. They absolutely rocketed in 2015, they doubled. And at the same time, more and more young people were wanting this medical intervention. There was pressure on them to provide it. They were trying to get through the numbers. Caseloads were absolutely exploding. And a single clinician might have 100 families on their individual caseload. And to put that into some context, that would compare to, I'm told, around 20 to 30 in any other regular National health service setting.

CHAKRABARTI: Hannah, as you well realize, you're speaking to a largely U.S. audience in this program here. And as I'm sure you know, the political situation around the issue of care for gender questioning youth, the political situation in this country is extreme, to the point where the trans community legitimately has fears, existential fears. So I wanted to ask you briefly for all that you spoke with many, many clinicians who worked at the Tavistock Center. Were any of them, you know, even questioning the existence of trans identities, or did they have some kind of, you know, political concern? What was their approach to the whole issue of gender questioning youth?

BARNES: No, absolutely not. And thanks for giving me the opportunity to say that, because really the motivation for these clinicians speaking out and raising concerns over many, many years, both within the service and then outside of it, was really the care of these young people who were often very vulnerable and very distressed. And what they were saying was just as there appeared to them to be different ways, perhaps into a young person's gender related distress, then perhaps there needed to be different ways out of it.

And they were seeing with that increase in referrals, a sort of increase in the complexity of the young people coming forward too, and often they were contending with so much more besides the gender identity difficulties. And that's what was really worrying these clinicians. And at no point will they ever questioning these young people's identity or that trans people exist. Of course they do. And that's absolutely not anything that is questioned in the book. And I've spoken to trans people, their stories, their successful transition stories are in the book, too.

It's just that it was felt that the way the Gender Identity development service was practicing was risky and that perhaps a one size fits all approach, a referral for puberty blocking medication, wasn't the safest route, nor the best one for each and every one of those young people, both for whom you know it will benefit. And we have to provide the best care for them. And we also have to provide care for those for whom it won't.

CHAKRABARTI: Okay. So we spoke with Dr. Hutchinson, who we heard from earlier. We'll hear a little bit more from her in a moment. But we also spoke with Dr. Marci Bowers. She's a leading OB-GYN in gender affirming surgical care. And Dr. Bowers is also the president of the World Professional Association for Transgender Health. And she told us that what happened at the Tavistock Clinic, in a sense, shouldn't have been a surprise because of that really big spike, that increasing demand for this kind of service.

MARCI BOWERS: Like anything that expands rapidly, sometimes we see health systems overrun and this is the case as it is in Tavistock. They saw referrals rise. I think they were like 250, in I believe it was 2012. And then in the last two years, they were over 5,000 referrals for gender related care.

CHAKRABARTI: We'll hear more from Dr. Bowers a little later in the show. But on that point of trying to manage that massive rise of referrals, here's Dr. Anna Hutchinson again, who worked at the Tavistock Center. And she told us, she told you as well, Hannah, that for some young people in their families, once they were on hormone blockers, they would actually disengage from the service, no longer come to Tavistock. But for others who wanted to explore potential consequences of continuing to cross-sex hormones:

HUTCHINSON: We as a service weren't providing any therapeutic space to explore identity once the young people were on the blockers. So I was beginning to really worry. The blockers themselves were possibly and inadvertently shutting down options rather than opening them up.

CHAKRABARTI: Dr. Hutchinson also talked about concerns over the lack of data being collected on the patients, and the services and their effectiveness that were being provided to young people. And she said that one piece of early data, in fact, did find that most people who were on puberty blockers had proceeded on to cross-sex hormones. And Dr. Hutchinson told us that concerned her.

HUTCHINSON: I was being asked to sign off on something and I wasn't sure it was in their long-term best interests. Because there wasn't the data there. But I was beginning to think, okay, so if a young person blocks their puberty early in adolescence and then proceeds to cross sex hormones and maybe or maybe not surgery later on in life, and then it doesn't work out for them because, you know, some of these kids were telling us their identity was fluid. You know, we know that. My concern was, what would that be like for them? You know, it suddenly felt like we had to make a huge sort of cost benefit analysis.

CHAKRABARTI: So Hannah, help us understand how this happened, because as you said earlier, the the Tavistock Center's own internal studies and audits from 200, 2005 found that, you know, perhaps a very small percentage of young people would go on at that time to take puberty blockers and then cross cross-sex hormones. And then most of the other children coming to the center would have hopefully been able to access treatments to assist whatever their other core needs were. But it sounds like later on there was this rush to puberty blockers and then, as Dr. Hutchinson said, to cry onto cross-sex hormones. I mean, I don't quite understand how the Tavistock Center got caught up in all that.

BARNES: I think that's a really difficult question to answer definitively. But I think, you know, it depends who you ask. I mean, I've spoken to dozens of clinicians and they'll give you slightly different reasons. But I think there are a number of factors that explain how things went wrong. And I think it's difficult to deny that things have gone wrong. Partly it's about numbers, as Dr. Bowers said, but it really can't explain it all. And I don't think anyone I spoke to would say it was just that we had too many young people coming forward. Of course, those huge pressure as the numbers really increased very, very dramatically. But it can't just be put down to the numbers.

What happened was, as one would expect in sort of areas of medicine, when new data comes to light that questions the way you think and intervention is working, that should provide pause for thought. And I think what Dr. Hutchinson, what she told me certainly is when that data came back, that early data that showed that at that point, every single one of the young people who started on puberty blockers had chosen to go into cross-sex hormones, that kind of exploded this idea that the puberty blockers were providing time and space to think. Because, as she puts it in the book, what are the chances of every single young person with their very different needs and backgrounds given time to think, and all thinking in the same way?

And GIDS would counter that and say, well, these people that we chose were the ones that we thought were most likely to transition. So it's not surprising. And we picked those who were the most distressed and whose gender related distress was very lasting and had, you know, been going on for years. And we do very thorough assessments. But the difficulty with that is that I have clinicians who have spoken to me bravely, on the record, who say actually our assessments weren't always very good, they weren't always very thorough. They could be two, three sessions. And I've taken part in those. So it's just not the case that each and every one of those young people going forward for the blocker was subject to a very detailed assessment and had lifelong gender dysphoria.

And I think what you saw, what they did was they started to apply an albeit quite limited evidence base from these two early Dutch studies, which only allowed young people who had lifelong gender dysphoria, a very stable, supportive environment in which they lived and who was psychologically stable. They applied that to a completely different cohort of young people. And they didn't pause to reflect on what was happening. I think at the same time, not all of this was their fault. There was very limited oversight, if any, from the Central National Health Service that was commissioning them.

It's something that the independent review, which you referred to right at the beginning has commenting on, that this clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are offered. That just didn't happen here. And a further aspect was the GIDS would say that they were only there. Their job, if you like, was to tackle and addressed a young person's gender difficulties. All the other things that they might be struggling with at the same time should have been dealt with by local mental health services and that didn't happen. And that's because those services themselves were completely overwhelmed. They had their budgets cut.

So there was a whole host of reasons why the model wasn't working. And as Dr. Hutchinson said in one of those clips, not only was the rationale for the blocker exploding in terms of everyone was thinking the same way. But actually GIDS didn't provide any opportunity for those young people to use that time to actually explore their gender identity. Rather than increase the number of appointments. They became very few and far between. And as she said, people would skip them, so they might only check in twice a year.

CHAKRABARTI: Now I want to just clarify something for people who aren't familiar with it, because you mentioned this Dutch study, which it comes up rather frequently in discussions about care for gender questioning youth. The Dutch study was one that was done, I believe the cohort was mostly people who were born male. And then as you specified, they had long term gender dysphoria or gender questioning, mental status, and no other concurrent mental health issues. And it's that group of young people then who were put on puberty blockers and later on, I believe, cross-sex hormones as well, and had largely positive outcomes, correct?

BARNES: Correct. I mean, there were girls as well. I think the majority were male, but not the overwhelming majority. And you're right, these Dutch studies, these formed the basis really of all gender, affirmative medicine, pediatric medicine taking place across the world today in gender clinics, both in the United States, here in the U.K. and in the rest of Europe. And those young people had to be screened in the way that I've suggested, but also, they received ongoing talking therapies at the same time.

And those studies themselves ... they're not the be all and end all. They're the best that we have in terms of longitudinal data. We're awaiting actually an update on those very first group of young people who receive puberty blockers, then cross-sex hormones and then surgery. And those are the criteria. So actually, there were two studies of the same group of people, but we lost 15 out of 70 by the time we got to the second one, one of whom actually died tragically during gender reassignment surgery.

And a close look of those studies really calls into question how robust they are. But, yes, so this arguably limited evidence base has been used as the basis for gender affirmative care in young people. But it did apply to quite a different group of young people than the ones we see today.

CHAKRABARTI: Right. And one of the key differences is all of the concurrent other mental health issues.

BARNES: But also sorry to interrupt, but also the fact that we have this, it's been witnessed in every single gender clinic across the world, this preponderance of females now. But not just females, but females whose gender related distress only started in adolescence or after the onset of puberty. And that absolutely was not the presentation of those young people in the Dutch study. And we're also applying this evidence base, if you like, to young people who identify as non-binary, as other gender identities. And again, there was no evidence for that whatsoever.

CHAKRABARTI: Hannah, I appreciate that clarification because it's an important part of the overall story and especially regarding what later on happened at the Tavistock Center. I want to hear a little bit more from Dr. Hutchinson, because, again, this lack of data, it comes up as a as a regular concern. And Dr. Hutchinson says that, in fact, there wasn't even clear evidence about ... the long-term outcomes of some of the procedures and medications that the young people were taking, about whether or not they were successful.

HUTCHINSON: Once they were referred to adult services or they left the service, or whether they left because they decided not to get on the medical pathway or any other reason, we didn't have data on any of those young people. We didn't have any outcome data. When I was there, we had only had the data of those who were within the service. And you know, what was striking about the early intervention study was that the patient satisfaction was high, but the clinical outcome measures were not particularly positive in terms of reduced distress or reduced dysphoria.

CHAKRABARTI: People like Dr. Hutchinson and others that you interviewed extensively for the book had been raising concerns internally for some time. But what finally triggered that independent commission that the NHS called for a couple of years ago?

BARNES: A number of things, I think. Dr. Hutchinson was one of ten members of staff who took their concerns to a then very senior psychiatrist at the Trust. He's now retired, called Dr. David Bell, and he wrote a report in 2018. And it was really when that was leaked to the media. And in 2019, and we heard some of these concerns that were very, very serious, that clinicians had, really things started to sort of gain momentum. And we started looking at this for BBC Newsnight in 2019.

And our reporting certainly prompted a inspection of the service by the health care regulator in England, which then rated the service inadequate. ... Some court proceedings were instigated against the Tavistock by a young woman who transitioned, then de-transitioned called Keira Bell. And that really brought the world's attention on onto GIDS, if you like, in a way that never had been before. And it really highlighted this absence of data. And I think it got to the point where NHS England just couldn't avoid tackling it head on. They had to do something. And that's what led to the independently commissioned report.

CHAKRABARTI: Hannah Barnes, I had mentioned at the top of the show the independent report that was commissioned by the NHS, and I believe that an interim report was published in March of 2022 that found that the type of care provided at Tavistock was not a safe or viable long-term option for young people with gender related distress. This is the Cass report. So can you tell us a little bit more about what it found?

BARNES: Well, interestingly, it vindicated, I don't know if that's the right word, but it vindicated what so many clinicians had been saying for four years and who hadn't been listened to. So Dr. Cass acknowledged that there was an issue of what she called diagnostic overshadowing. So this was where a young person who may have multiple coexisting difficulties but who had gender related difficulties as well, once the word gender was mentioned, everything else got parked, if you like, it wasn't dealt with.

So she would call this diagnostic overshadowing. And she said this is just not good enough, that young people with gender related distress aren't being given the same amount of care and attention that any other young person would. She said this has got to change. She talked about a real lack of consensus amongst clinicians working in the service. She said there were completely different views within the staff group, some more strongly affirmative and some much more cautious when it came to the use of physical interventions. Again, this is something that clinicians have been talking about for four years and that might be problematic.

I mean, it's quite striking that in the leads that the site that GIDS had in the north of England, there were clinicians whose approaches, if you like, were deemed to be so incompatible that they couldn't work together with any given family, which is quite striking. Dr. Cass found that the service was providing a predominantly affirmative, non-exploratory approach, often driven by a family's expectations and how far or not, the young person had gone in a social transition prior to starting the service.

She found, as you've mentioned several times, that there had not been routine and consistent data collection in the service. And actually it was still difficult writing in 2022 for staff to raise concerns about the service. Now, she absolutely acknowledged, and I do throughout the book, and even the regulator who rated the service inadequate, acknowledged that the staff at the service care about these young people greatly. That has never been called into question. But one clinic dealing with the nation's distressed children could not work.

And there's been a temptation among some in the trans community in particular here to say that all that Dr. Cass said is that we need more services and we can't have one clinic. But I think really any reading of that report highlights a certain number of difficulties that the service is explaining. And she talks about the lack of evidence base as well, particularly for this cohort of young people that we're seeing in gender clinics across the world who are predominately female, whose gender related distress started in adolescence and who have multiple other mental health problems. And she said that's the group which are greatest in number, but actually for whom we hold the least data and the data we have is not persuasive.

CHAKRABARTI: And so as a result of the Cass report, the NHS decided to close down. I don't know if that's the right word, but --

BARNES: It's still open.

CHAKRABARTI: It's open.

BARNES: So that's why they decided to call it. Well, they decided that, you know, when one of the country's most respected and senior pediatricians says we need a fundamentally different service model, then the NHS has listened to Dr. Cass, and that's what they're trying to do now. So it made the announcement in summer 2022 that GIDS would close and be replaced initially by two. But the plan is to have more regional services, which would be far more holistic, if you like, in their approach, taking in all aspects of a young person.

And it's acknowledging the work that has been done as part of Dr. Cass's review, looking at the evidence base for both puberty blockers and cross-sex hormones. And what those systematic reviews have shown is that really the evidence base is wanting and it's not clear really the benefits and harms of those treatments and whether one outweighs the other. So going forward, and these new services are not ready yet. And the plan was to close GIDS in the spring and that isn't going to happen.

But the plan is that no one plans to take away, it seems, obviously the option of transitioning for young people. We talked about this really early on. It's not about denying health care, it's about making it better for each and every one person. But Dr. Cass has said, look, we have to plug these gaps in the evidence base, because they're big. And so the plan, it seems that we haven't heard the final details yet, is that puberty blockers will still be available to young people after a decent assessment, but they will have to be enrolled on a research program to try and get some better data.

It's long term data. And crucially, what Dr. Cass said and what these new services going forward will offer is different treatment pathways, because she has said that not one approach is going to benefit each and every young person experiencing gender related distress or gender dysphoria. And, you know, physical interventions for some. Yes, but that won't benefit everybody. And we need to care for those people, too.

CHAKRABARTI: Well, in fact, Dr. Marci Bowers, again, currently the president of the World Professional Association for Transgender Health and a leading surgeon, OB-GYN, in gender affirming care, she told us that she sees it very similarly. This is a moment sort of accelerated by the Cass report that we should encourage and allow an improvement in care for gender questioning young people. And here's what Dr. Bowers told us.

BOWERS: It's a supportive environment where ongoing evaluation continues. And if they meet certain criteria entering adolescence, at that point, a decision would be made as to whether or not they would be candidates to have puberty blocking. And we have to be mindful that ultimately it has to be informed consent and it has to be a volitional decision on the part of the child.

CHAKRABARTI: So that's Dr. Marci Bowers talking about what improved care for gender questioning young people ought to look like. Now, Hannah, if you could just listen along with me for a minute. We have to acknowledge that obviously, the question about what should care for young people entail is very, very, very urgent here in the United States.

And we recently spoke with Jamie Reed. She's a former case manager at the Washington University Transgender Center at Saint Louis Children's Hospital. And earlier this year, she used Missouri's whistle blower statute to raise public concerns about the care she saw children receive at the Washington University Center. And she closely tracked the cases of at least 600 children.

And some of her concerns mirror what we've been hearing about what was happening at the Tavistock Center, both reported by Hannah Barnes and in that independent review as well. Reed talked about a lack of consensus amongst care providers at the St. Louis Center about the best standards of practice for treating gender questioning youth.

JAMIE REED: The documents that I believe the doctors were working under were routinely cast aside and considered on some level suggestions. Which from a medical perspective felt like it was whatever the doctor decides at that day in time goes. And there was no operating framework or guideline to provide this care.

CHAKRABARTI: Reed also says the Washington University Center lacked appropriate resources to provide comprehensive mental health care for its patients.

REED: The center provides some basic mental health medications ... for some patients, for depression and anxiety. But that's if you get scheduled with that certain provider. The system as a whole did not actually put in place the necessary care availability for patients.

CHAKRABARTI: And Reed says that while some patients may have received longer term mental health support for others, that was not the case.

REED: I do not believe that the quality standard of care to medicalize a child with interventions that are lifelong, that can impact their fertility for life, that the quality of care is two visits with a kid.

CHAKRABARTI: Now, Jamie Reed herself identifies as a queer woman. She is married to a trans man and says that she firmly supports trans rights and has previous experience working with trans youth in clinical environments. She says her concerns, though, were not taken seriously by leadership at the Washington University Center.

REED: Part of the problem with this kind of care right now is it's become ... this huge extreme thing where you can't say anything questioning this care without. I mean, I've basically been told that I'm going to be, like, responsible for children's deaths. You cannot question a care model, and that is not how medicine is supposed to work. Medical staff are supposed to be the people in the room with the doctors who see things going on and have the backup of the medical institution to be able to say, Hey, pause, timeout. Something's not going right here. Without being absolutely vilified. From every angle.

CHAKRABARTI: That's part of our conversation with Jamie Reed, and a longer version will be available in our podcast feed later this week. Now, following Reed's accusations, Missouri's Republican Attorney General Andrew Bailey launched an investigation into the facility at Washington University. And as a result, Washington University is not commenting. The St Louis Post-Dispatch and Missouri Independent have spoken with families who report positive experiences at the center.

... Now, Hannah Barnes, again, just to put a fine point on it, here in the United States right now, we're in a political environment where, you know, in some places like Florida there even, you know, the legislature there is considering violating people's First Amendment rights by banning preferred pronouns. We have other states in the United States, Tennessee, Texas, more who are contemplating making seeking care for gender questioning youth equivalent to child abuse.

So we have parents who are concerned about their children being taken away from them. So it does very much feel like an existential threat, as I said earlier, to members of the trans community. I'm wondering what the political environment around this issue of quote-unquote, gender affirming care is like in the United Kingdom.

CHAKRABARTI: Well, fortunately, not like that. No, I mean that's appalling, isn't it? And as Jamie Reed said, there so many things. You have so many parallels with what clinicians have said and have told me about their time at the Tavistock. And I think I hope that books like mine, that testimony like Jamie Reed's and like Anna Hutchinson and others, and of course, leading trans doctors themselves, like Marci Bowers in the position she has ... everybody working in this field really wants the same thing, which is the best care possible for each and every one of those young people.

Making transition as safe and positive as possible for those for whom it will be the right option, and preventing those for whom it won't be going down that path and making their lives better as well. And it's about having a calm conversation where you can question the standard of care being provided to a group of young people without questioning them themselves, without questioning their identity or their rights, and doing that without being vilified.

And for those concerns to be taken in the spirit in which they're intended, which is from concerned mental health practitioners or clinicians who have dedicated their entire working lives to helping young people, it's just not credible to write them off as transphobic. But we are fortunate here in the U.K., it's obviously very heated as well. But we don't have laws going through our Parliament or even proposed that pronouns shouldn't be respected, or that care be taken away.

CHAKRABARTI: ... I understand that you had trouble finding a publisher or even someone to do the cover art for your book, is that right?

BARNES: The cover art thing is a bit of a misnomer, but yes, it's been widely reported here in the U.K. that the proposal, which was very detailed in itself, and we'd been looking at this together my colleague Deborah Cohen and I for Newsnight for well close to two years. I wrote a 17,000-word book proposal and it was rejected by 22 publishers. And interestingly, the responses didn't they weren't negative. They didn't say, No, this is this is something we don't want to do. Just really this is an important story. But not for us.

And actually, almost half didn't reply at all, which I've been told by my very experienced agent is almost unheard of to get a rate of, you know, almost a half of norm responses. I mean, you'd expect 90% to reply. So it was, it was pretty demoralizing for a while. But fortunately, Swift Press ... did want to take it on and I'm delighted that they have. And it's a Sunday Times bestseller, so I'm really grateful to everyone that's read it and bought it.

CHAKRABARTI: And for the people who spoke with you both.

BARNES: Oh, absolutely. Yeah. There'll be no book without any of those people, and particularly the young people who went through. It's both those who had a great experience and are happily transitioned and those who didn't and frankly have been harmed and those clinicians as well. And I'm so grateful to each and every one of them.

Book Excerpt

Excerpt from Time To Think by Hannah Barnes. All rights reserved. Not to be republished without permission.

Related Reading

BBC : " Tavistock children's gender clinic closure leaves uncertain future " — "There are more than 7,500 children and young people with gender incongruence or gender-related distress waiting for help from the NHS."

This program aired on March 9, 2023.

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Jonathan Chang Producer/Director, On Point Jonathan is a producer/director at On Point.

Meghna Chakrabarti Host, On Point Meghna Chakrabarti is the host of On Point.

More from On Point

Tavistock: the UK clinic with a history of overhasty gender transitions

A new book delves into a sex change center that the british government is shutting down.

Hanna Barnes thinks long and hard about her answers. Some questions she rejects outright because she is not an opinionated journalist, politician or activist. For over 10 years, Barnes has worked as an investigative journalist only comfortable with confirmed facts. Her most recent story is about a well-intentioned health initiative that produced unforeseen impacts and forced healthcare professionals to stop and think. Now that it is winding down, there is much concern for the vulnerable people it served – individuals questioning their gender identity who need urgent professional help. Barnes recently spoke to a group of foreign correspondents in the United Kingdom about her new book, Time To Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children , available in British bookstores on February 23. The book expands on the author’s extensive investigation for the BBC’s Newsnight program, which won her the prestigious Royal Television Society award for television journalism. The Financial Times has already named it one of the books that will frame the public debate in 2023.

In mid-2022, after a rigorous internal investigation, the UK’s National Health Service (NHS) decided it would temporarily close (in the spring of 2023) the only center treating minors who question their gender identity . For over 30 years, Tavistock operated the Gender Identity Development Service (GIDS). The NHS report by Dr. Hilary Cass recommended that GIDS be moved to local health centers to mitigate “the lack of peer review” at Tavistock due to its limited “capacity to cope with increasing demand.” While the report stopped short of complete condemnation, it described a treatment center that skipped over any “open discussion” about the nature and causes of the “gender incongruence” of its patients before opting for the gender transition process.

“This is not a story which denies trans identities; nor that argues trans people deserve to lead anything other than happy lives, free of harassment, with access to good healthcare,” writes Barnes. “This is a story about the underlying safety of an NHS service, the adequacy of the care it provides and its use of poorly evidenced treatments on some of the most vulnerable young people in society. And how so many people sat back, watched, and did nothing”.

In 2007, a small group of psychologists, psychotherapists, family therapy specialists, social workers and nurses went from treating 50 children a year to becoming the entire country’s referral center for thousands of patients. The most striking thing about this expanding mission was not the numbers (which are vague because of poor record-keeping) but the diversity of the people who came for help. Most of the existing scientific literature is about children assigned male at birth who have suffered gender incongruence virtually all their lives. However, Tavistock’s GIDS office slowly filled up with unmanageable numbers of girls whose anxiety about their true gender identity had begun to emerge during adolescence. Barnes shies away from simplistic explanations that blame this trend on the influence of social media, although she does not deny that it is a factor. She interviewed dozens of patients, all of them different, and found multiple factors.

“Take someone like Harriet. She says, for her, for sure, there was a social influence element,” said Barnes. “She was struggling with her sexuality. She didn’t like the fact that she was a lesbian. She’s had a relationship with another girl and was made to feel ashamed about it. The idea [of transtioning] was becoming a quiet trend in her friendship group, and actually gave her a sense of social kudos to be non-binary and then trans.”

The mere mention of gender dysphoria is sure to cause controversy. Many people in the field refuse to label it a mental health problem because of the stigma it carries for people who want to self-determine their gender. The NHS has accepted the diagnosis for decades: the incongruence between a person’s biological sex and the gender with which he or she identifies. The World Health Organization (WHO) does not consider it a pathology and prefers to use the term “gender incongruence.” In practice, a professional will conclude that a patient suffers from gender dysphoria if experienced for more than six months.

In the book, Harriet tells Barnes, “I would have liked to be challenged on why I thought certain things were signs of gender dysphoria, such as not liking skirts or not liking my voice. They could have questioned why I changed identities so rapidly from non-binary to a trans boy to whatever else.”

Puberty blockers: time to think?

Patients who decide they want to undergo a medical gender transition process take their first steps at GIDS and then are referred to pediatric endocrinologists (specialists in medical diagnoses with hormonal causes) at NHS public hospitals. The first step is treatment with gonadotropin-releasing hormone analogs, known as puberty blockers. These are drugs commonly used for children with precocious puberty (before eight in girls and nine in boys). They directly affect the pituitary gland and prevent the release of sex hormones such as testosterone or estrogen. They have also been used for treating prostate cancer in men and even for the chemical castration of sex offenders. Still, their use in gender dysphoria does not align with the original purpose of these drugs. In simple terms, they slow the development of physical traits such as breasts in girls and body hair or Adam’s apples in boys.

GIDS was created to help young people and their families “develop their gender identity” through extended psychotherapy sessions. Puberty blockers were only prescribed when the adolescent was at least 16, and everyone involved was convinced that a gender change was the answer. Professionals believed waiting until the age of 16 was needed so adolescents could have time to form ideas about their developing sexuality. The concept was to give minors “time to think,” hence the book’s title. Another meaning of the title is that society should stop and reflect before designing responses to actual, urgent situations. Instead, puberty blocker treatment became a prelude to an irreversible process because the drugs became a sort of self-fulfilling prophecy – their effects confirmed the conviction to change gender.

“Evidence shows that this isn’t really how they work in practice,” said Barnes. “There was always this hypothesis, and it was no more than a hypothesis, that they provided time to think, time and space to think and to take away the distress caused by this developing body in a way that that young person didn’t want, and therefore allow them exploration. In theory, it makes sense. In practice, it doesn’t. Almost all – more than 95% – progress to the next stage…. The specialists began to suspect that, rather than helping them to think, what they were doing was cutting short this period of reflection, which had become the first phase of the transition process.” The NHS report prepared by Dr. Cass also called for “the need to better understand the reasons” why almost all the young people who began puberty-blocking treatments chose to proceed to the next phase of hormone replacement.

Many adolescents coming to GIDS had complicated family lives, financial difficulties and even sexually abusive situations. Many had eating disorders, self-harmed, suffered from depression or had symptoms of autism. Barnes questions how such diverse people were all given the same answer – puberty blockers.

When children with precocious puberty are treated with blockers, their bodies usually revert to natural biological development after treatment is stopped. But for children undergoing a gender transition, the treatment doesn’t stop until they go to the hormone replacement phase. The few medical studies on the subject are contradictory. Many of these children clearly gain some peace of mind and experience less anxiety due to the blockers. But some studies found changes in sexual functions, bone weakening and mood swings. People who switch to synthetic hormone replacement therapy have an increased risk of coronary heart disease. The third phase – surgical intervention – is virtually irreversible, and any hypothetical gender reversal procedure would undoubtedly be painful.

However, the potential side effects were not the main reason for the Tavistock shutdown. As the Cass report notes, the fundamental cause is that the institution never clearly established whether the gender incongruence detected in many young people “was an inherent and immutable phenomenon, for which the best response was a transitional treatment, or whether in some more fluid cases, temporary responses to a series of psychological, social or developmental factors were possible.”

The Tavistock story produces a flood of doubts and questions that Barnes’s book discusses with nuance and care. Why did a process with such enormous consequences proliferate so quickly and broadly? Why did it proceed based on such poor evidence and test results? Why was there no proper follow-up of all the people who went through Tavistock? Were there external pressures on the decisions of the center’s professional staff?

“They [GIDS staff] were not ideologues,” said Barnes. “They were mental health professionals who cared about young people. But the fear of being criticized was much stronger. We’ve had this shift in society, and rightfully so, of concern for the rights and just treatment of minority groups. I think there was a real fear of being branded transphobic…. It’s difficult to say how much influence groups like Mermaids [an organization that supports trans youth] had over clinical practices [at Tavistock]. I think there was undoubtedly a fear of how they would react if the clinic did certain things.”

The impending publication of Time to think has spurred conservative politicians and pundits to reinvigorate their culture war on the trans movement. On the other side are those who welcome the book, like university professor Kathleen Stock, who resigned from the University of Sussex (UK) after a campus smear campaign against her for questioning some of the trans movement’s approaches. Stock applauds Barnes for spotlighting the most urgent issue of the Tavistock shutdown: more than 7,000 young people in the UK have been left in limbo, awaiting help, diagnosis and care.

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I worked at the Tavistock gender clinic. This is why closing it was the right move

Good clinical care is about ensuring we can question practices, to exercise caution with new ideas, and to ensure we develop a sound evidence base for any treatments..

By Sue Evans

12:01 PM on Apr 22, 2023 CDT

Last summer, Britain’s National Health Service issued an order to close the U.K.’s only dedicated gender identity clinic for children and young people. That clinic, the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust in London, had been criticized in an independent review that said it left young people “at considerable risk” for poor mental health and distress.

I worked at Tavistock for years. Closing it was the right decision.

The closure made headlines the world over and was quickly followed by an opening up of the conversation around the validity of the current World Professional Association for Transgender Health recommendations for standards of care. Those standards were predicated on what has become known as the Dutch Protocol, which was developed for the treatment of a very different group of gender dysphoric patients, mostly natal boys who had experienced and expressed feelings of gender dysphoria from an early age, in contrast with many of the children who are now developing gender dysphoria at the onset of puberty.

I have been working in this clinical area since 2003, and it is my experience that each child is unique, and people who experience gender dysphoria often have complex psychological needs and should not be treated in a formulaic affirmation-only way. This can lead to their other needs being overlooked or ignored in the hope that a solution will result from social and medical transition. While in some cases it can, in many other cases it does not.

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Children and consent

I am a psychoanalytic psychotherapist working in private practice. I am retired from the National Health Service, which has allowed me some freedom to speak regarding my clinical experiences and the contentious issues regarding the treatment and care of children who experience gender dysphoria. Before I retired, I was a senior clinical lecturer at Tavistock and senior fellow in education at the University of East London.

Between 2004 and 2007, I became very concerned that hormone treatments prescribed at the Tavistock Gender Identity Development Service did not adequately consider the complexity of the children presenting there. Their cases were, in most cases, psychologically complex, and many had comorbidities.

An article in the medical journal Archives of Disease in Childhood , a six-page review on the Tavistock Gender Identity Development Service, contained these two sentences: “A range of psychometric measures are used to assess behavioral and emotional functioning, including features of autistic spectrum disorder and self-harm. Around 35% of referred young people present with moderate to severe autistic traits.”

I witnessed some children being medicalized after as few as four assessment meetings, during which time very little psychological support or treatment could possibly have occurred. In my clinical experience, it takes much longer to make a full assessment of children and adolescents, and a therapeutic alliance can take months to build. I was shocked by this superficial psychological approach, as it led to irreversible changes, both physical and mental, some of which are as yet unknown, due to the paucity of follow-up data on the children receiving these treatments.

Bell vs. Tavistock Judicial Review

By 2019, Tavistock’s caseload had grown from approximately 80 referrals per year to more than 3,000. There were several child safeguarding issues being raised by staff that were not being adequately addressed by the senior management.

Meanwhile, there was a growing awareness in the U.K. that all was not well with the political influence on medical and psychological approaches to treatment of gender dysphoria in children. One central issue of concern is whether a child or adolescent is able to give informed consent to the medicalized treatment.

That issue came to a head in legal proceedings involving a woman named Mrs. A. who had a teenage daughter with autism who was on a waiting list for treatment. Following an event in the House of Lords where many professionals and parents spoke of their growing concerns in this clinical area, Mrs. A. and I became claimants in the judicial review. I helped the legal team assemble witness statements from professionals throughout the world on the issue regarding standards of care, child development, neuroscience, endocrinology and autism. We built an application to challenge the issue of children being psychologically mature enough to understand the complexities of the consequence of medical treatment in order to give informed consent to the use of puberty blockers and cross sex hormones. As part of the application, I invited Keira Bell, a female who started gender transition following just a few appointments at GIDS. She became a joint claimant in the case and has become an international symbol of the ethical concerns of gender-affirming care.

Bell had been treated at Tavistock beginning at age 16. She started on puberty blockers, advanced to testosterone shots, and eventually had a double mastectomy. But at 21, Bell came to regret the treatment and became one of a rapidly increasing number of patients who have either regretted their transition or decided to reverse it, something called “detransitioning.”

At 23, Bell realized she had not had the maturity and understanding to give informed consent to the medicalized procedures before adulthood. She had also been psychologically vulnerable and felt what she had needed was psychological care.

Like Bell, Mrs. A. did not consider her daughter capable of fully understanding the attendant risks of undertaking gender reassignment treatment due to her autism diagnosis and other psychological conditions.

Our team submitted a huge amount of evidence, which three high court judges reviewed, along with evidence submitted by Tavistock. In December 2020, the judges ruled in our favor. The court wrote, “There will be enormous difficulties in a child under 16 understanding and weighing up this information and deciding whether to consent to the use of puberty blocking medication.” Further, the court said it was “doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences” of this treatment. It ruled that it was “highly unlikely that a child aged 13 or under would be competent to give consent to the administration of puberty blockers.”

During the period of the judicial review and appeal process, Tavistock board member Marcus Evans and I co-authored a book on gender dysphoria that offers a psychological understanding of some of the factors involved. We hope it offers a therapeutic model to support children with gender dysphoria in their time of distress.

Adolescence and anxiety

In my clinical experience, I have learned that many of these children are managing their anxieties through a system of rigid psychological defenses. They often struggle to be able to think about their internal emotional world, with its attendant conflicts and confusions. For professionals, it may feel anxiety-provoking to explore this with the child, but our and others’ clinical experience strongly suggests that a holistic, empathetic approach can help the child begin to be self-curious and this may help to relieve the distress they are experiencing.

If, however, they are not supported or able to do so, psychic discomfort is often channeled into the idea of making concrete changes to the body as if this will get rid of the difficult issues. It sometimes works in the short term, hence the much quoted “satisfaction surveys” taken shortly after commencement of medical treatment but with little or no long-term follow up to back this claim.

The idea of puberty blockers may be very appealing to put a stop to adolescent development, with its often unwelcome and sometimes terrifying rush of hormones, leading to bodily changes, the emotional demands of becoming more grown up and integrating somehow into the world. This relief at finding the “answer” to the maelstrom of adolescence can appeal to kids, parents and clinicians because it appears to be an easier route out of the chaos and disturbance.

However, the task for us all in life, is to develop from a child into an independent adult. Adolescence, and the accompanying chaos it brings, is a very normal human experience, though not easy. The anxieties some children are hoping to avoid are often around their adolescent physical development and maturation, associated with a difficulty in negotiating sexuality and relationships and also separation from parents. Affirmation and puberty blocking interferes with ordinary human development in all areas.

There has been a push to say that gender dysphoria has nothing to do with mental health. But it is curious to imagine that ideas which develop in the mind in relation to otherwise healthy physical bodies are not of some psychological origin. Good clinical care is about ensuring we can question practices, to exercise caution with new ideas and to ensure we develop a sound evidence base for any treatments, whether psychological, medical or surgical. At the moment we just don’t know enough about any of this.

Desistance and detransition

Current gender-affirming models ignore a growing body of data from detransitioners like Bell and “desisters” — those who simply stop pursuing gender transition.

According to multiple studies, there is a very high level of desistance in children with gender dysphoria if they are offered time and psychological support or alternatives to affirmation such as “watchful waiting.”

A 2021 report from the University of Toronto followed up with a group of people who experienced gender dysphoria in childhood. Thirteen years after their initial diagnoses, 87.8% of them were classified as desisters.

In addition, there is early evidence, such as that published in the Journal of the American Academy of Child and Adolescent Psychiatry , to suggest that this rate lowers, but still remains fairly high , even when children are socially and/or medically transitioned.

We have no true idea of the growing number of children who have given so-called informed consent to this medicalized route, received hormones and/or surgeries, but have lived to regret their transition and will suffer lifelong consequences of this experimental treatment.

The independent review that led to the closure of the Tavistock clinic, called the Cass review after its chair, Hilary Cass, revealed that there is very little gold standard research and follow-up data in this area of medicine. Many desisters and detransitioners speak of the wish that a professional had stopped them in their headlong run toward medical transition. Sadly, however, few go back to tell their medical providers that they have, together, made an irrevocable mistake and caused perhaps irreversible harm. This is probably also true in America.

The medical profession has an opportunity to look more closely at the potential harms being done and also to improve its practices in the care of gender dysphoric patients. Society, too, has its part to play in developing some tolerance for uncertainty and some curiosity to learn more about what is really going on with our kids.

But in order to improve care for all trans-identifying children, we need much more in-depth research with longer follow-up studies before we really know what is best in gender care.

Parents and physicians

In my consultation work with parents, it has become clear to me that many feel tyrannized by gender identity issues, sometimes by their child’s state of mind and subsequent demands of them to accept and conform with the child’s ideas and wishes, but also often by teachers, professionals and wider society.

It is important that parents, who usually know their children very well, have some support to explore their own feelings without judgment, and be helped to understand and process what might be going on between them and their child.

Certainly, my experience to date is that most parents are not transphobes or bigots, but deeply care about their child and hope to avoid irreversible harm. Many are concerned or fearful. Parents often know far more about their child’s complexities, background and emotional intricacies than anyone else, including the child. It is very rarely in the best interest of the child to have parents pushed out or rejected.

There are things that need to be understood from many angles and this requires nonjudgmental professionals to try to keep all ideas open, and allow for differences of opinion.

There is often inadequate or misleading information given to parents and professionals. Asking for better research and improving the evidence base is not transphobia. It’s medicine. It’s about safeguarding children. Until we know more, doctors should remember to “first, do no harm.”

Sue Evans is a psychoanalytic psychotherapist in the United Kingdom. She wrote this column for The Dallas Morning News.

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Perspective: The tide has turned in the UK on gender-affirming treatment for children

Legal action over puberty blockers prescribed to minors will likely reverberate across the atlantic.

By Valerie Hudson

Over the past few weeks, an amazing turn of the tide has occurred in the United Kingdom, one which has profound ramifications for the United States. It involves The Tavistock Clinic in England, the hub of gender-affirming treatment under the country’s National Health Service.

The term “gender-affirming treatment” refers to the steps of treating gender dysphoria first with puberty blockers, then with cross-sex hormones and finally, for a sizable number of patients, with sex reassignment surgery. 

“Affirming” means that any questioning of whether this stepladder of treatment is appropriate for a particular person expressing gender dysphoria was considered inappropriate, practically akin to “ conversion therapy ,” which has been outlawed in most Western countries.

The first clues that all was not going to end well for the Tavistock model were cases of Keira Bell and Sonia Appleby , both decided several months ago. In the Appleby case, Sonia Appleby was employed in the clinic as the “safeguarding lead” for gender dysphoric children being treated at Tavistock. She raised concerns that medics were not keeping careful records, not screening children for mental health comorbidities, and were being inconsistent in their treatment of children. She was then officially reprimanded — for trying to do her job. The court awarded her damages.

In the more famous Bell case, Keira Bell is the young woman treated at Tavistock who brought suit because she felt she was fast-tracked for gender affirmation treatment by the clinic, even though as a minor she had little understanding of the long-term consequences of what she was supposedly consenting to undergo. Now detransitioned, Bell accused Tavistock of shunting children along a treatment path to irreversible changes they could not possibly understand, such as sterility, bone loss, altered brain development and even inability to ever experience sexual climax.

From Bell’s standpoint, she and other children had been experimented upon in the most cruel fashion. The verdict was unanimously in her favor. The high court found much of the treatment is not based on solid evidence at all, and that children under 16 simply could not consent to a treatment with such major and irreversible consequences.

These two cases presaged the next development, which is known in the U.K. as the Cass Report . Dr. Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, was tasked by the Boris Johnson government with reviewing practices at Tavistock. Cass undertook a comprehensive literature review, a qualitative study of patients and clinicians at Tavistock, and a quantitative study of 9,000 patient outcomes. What she and her team found was disturbing . The evidence base for the treatment Tavistock was providing was found to be shaky and had already been repudiated by several other Western European countries, including Finland , Sweden and France .

Cass also found there was almost no follow-up of patients, and thus very little understanding of whether Tavistock’s treatment helped patients or not. In interviews, a number of patients and staff expressed concerns over the one-size-fits-all approach.  Cass recommended, and the government agreed, that Tavistock be shuttered, that regional centers to treat gender dysphoria in a more whole-of-care fashion be established, and that a firm evidence base be established before puberty blockers, in particular, were used on children.

This week, the big news hit. A law firm in the U.K. is launching a class-action suit against Tavistock, and it anticipates that more than 1,000 clients will be joining the suit. The suit will accuse Tavistock of “multiple failures of duty of care” with regard to its pediatric patients suffering from gender dysphoria. The clinic will also be charged with having “recklessly prescribed puberty blockers with harmful side effects and (having) adopted an ‘unquestioning, affirmative approach’ to children identifying as transgender.”

The days of the “affirmation-only-no-debate” approach to pediatric gender dysphoric patients is over, at least in the U.K. This great turning of the tide in Britain has taken place in the space of approximately 11 months.

Will the same happen in the United States?  I believe it will for pediatric cases. While most Americans take a live-and-let-live attitude toward adult transition, the increasing evidence that puberty blockers do not simply “press pause” on puberty and may have seriously damaging and irreversible effects on children who cannot meaningfully consent, is becoming too great to ignore. The American Association of Pediatrics is already embroiled in a civil war over the issue. In addition to states such as Florida and Texas pursuing investigations of clinicians and pharmaceutical companies, the law firm Girard Sharp appears poised to launch a similar class-action suit; the firm is soliciting reports of adverse effects of puberty blockers from the guardians and parents of children who have been treated with them.

What is currently termed “gender-affirming treatment” for pediatric patients is likely to one day be seen as one of the greatest medical scandals of the 21st century. The light that will be shone on the practice in U.S. courtrooms will see to that, as happened in the U.K.

Valerie M. Hudson is a university distinguished professor at The Bush School of Government and Public Service at Texas A&M University and a Deseret News contributor. Her views are her own.  

Sex reassignment in minors may be medical history’s ‘greatest ethical scandal’, French report says

F rench Senators want to ban gender transition treatments for under-18s, after a report described sex reassignment in minors as potentially “one of the greatest ethical scandals in the history of medicine”.

The report, commissioned by the opposition centre-Right Les Republicains (LR) party, documents various practices by health professionals, which it claims are indoctrinated by a “trans-affirmative” ideology under the sway of experienced trans-activist associations.

The report, which cites a “ tense scientific and medical debate ”, accuses such associations of encouraging gender transition in minors via intense propaganda campaigns on social media.

Jacqueline Eustache-Brinio, an LR senator who led the working group behind the report, concluded that “fashion plays a big role” in the rise of gender reassignment treatments.

If this factor and the risks involved are underestimated, she added, “the sexual transition of young people will be considered as one of the greatest ethical scandals in the history of medicine”.

LR senators now want to table a Bill by the summer that would effectively ban the medical transition of minors in France by halting the prescription or administration of puberty blockers and hormones to people under the age of 18.

Sex reassignment surgery could also be banned for minors.

Reacting to the report, Ypomoni, a French parents’ group, said: “We welcome this return to reason.”

Maud Vasselle, a mother whose daughter underwent gender transition treatment, told Le Figaro: “A child is not old enough to ask to have her body altered.

“My daughter just needed the certificate of a psychiatrist, which she obtained after a one-hour consultation. But doctors don’t explain the consequences of puberty blockers,” she added.

“My daughter didn’t realise that life wasn’t going to be so easy with all these treatments... She was a brilliant little girl but now she’s failing at school. And she is far from having found the solution to her problems.”

Shocking and ideological

Transgender activists and certain health professionals expressed alarm at the report.

Clément Moreau, the clinical psychologist and coordinator of the mental health unit of the association Espace Santé Trans (Trans Health Space), said the report was “shocking” and called the move “ideological”.

“Using blockers if necessary or hormones before coming of age reduces the rate of suicidality, depression and anxiety,” he added.

The French report comes after the NHS banned children from receiving puberty blockers on prescription earlier this month.

France’s health regulation body, the Haute Autorité de Santé, was already examining a similar move.

The LR senators want to accelerate the process following the report.

Citing British, Swedish and American studies, the report said that the number of children identifying themselves as trans has exploded over the past decade.

One hospital in Paris receives around 40 new requests from minors every year, with 16 per cent of those under the age of 12 and the report points out that many suffer from other issues.

A quarter of the children seen at the Pitié-Salpêtrière Hospital for gender dysphoria have dropped out of school, 42 per cent have been victims of harassment, and 61 per cent have experienced an episode of depression. One in five has attempted suicide.

Their conclusions are in line with those of British experts called in to investigate London’s Tavistock clinic over its use of mass gender reassignment surgery on minors.

David Bell. a British psychiatrist and psychoanalyst, found that a third of the children consulted at the Tavistock suffered from autistic disorders, and many were victims of family violence or had difficulty in accepting or expressing homosexuality, yet they were rushed into gender transition regardless.

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How to find an NHS gender dysphoria clinic

Trans and non-binary people's general health needs are the same as anyone else's. But trans people may have specific health needs in relation to gender dysphoria.

Your particular needs may be best addressed by transgender health services offered by NHS gender dysphoria clinics (GDCs).

All NHS GDCs are commissioned by NHS England, who set the service specifications for how they work.

A GP or another health professional can refer you directly to one of the GDCs. You do not need an assessment by a mental health service first. Neither does the GP need prior approval from their integrated care board (ICB). 

The websites of the clinics listed on this page also have useful information for you to think about before you see a GP. 

Children and young people's gender services

Children and young people should be referred to the National Referral Support Service for the NHS Children and Young People's Gender Service .

These NHS services specialise in helping young people with gender identity issues. They take referrals from anywhere in England.

Gender dysphoria clinics in London and the southeast

The Tavistock and Portman NHS Foundation Trust: Gender Dysphoria Clinic for Adults

Lief House 3 Sumpter House Finchley Road London NW3 5HR

Phone: 020 8938 7590

Email: [email protected]

The GDC website has an overview of information useful for anyone with gender identity needs, not just those in the area.

Gender dysphoria clinics in the north

Sheffield Health and Social Care NHS Foundation Trust Gender Dysphoria Service

Porterbrook Clinic Michael Carlisle Centre 75 Osborne Road Sheffield S11 9BF

Phone: 0114 271 6671

Email: [email protected]

The  Sheffield clinic's website includes information about referrals, clinic opening hours and links to eligibility criteria.

Leeds and York Partnership NHS Foundation Trust Gender Dysphoria Service

Management Suite 1st Floor The Newsam Centre Seacroft Hospital York Road Leeds LS14 6WB

Phone: 0113 855 6346

Email: [email protected]

The Leeds clinic's website covers referrals, commonly used medicines and information on the clinic's Gender Outreach workers.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northern Region Gender Dysphoria Service

Benfield House Walkergate Park Benfield Road Newcastle NE6 4PF

Phone: 0191 287 6130

Email: [email protected]

The Northern Region Gender Dysphoria Service website has a range of leaflets, including information about referral, hormones and support groups.

Gender dysphoria clinics in the Midlands

Northamptonshire Healthcare NHS Foundation Trust Gender Dysphoria Clinic

Danetre Hospital H Block London Road Daventry Northamptonshire NN11 4DY

Phone: 03000 272858

Email:  [email protected]

Visit the  Northampton clinic's website for more information about how to get a referral and the role of the GP.

Nottinghamshire Healthcare NHS Foundation Trust The Nottingham Centre for Transgender Health

12 Broad Street Nottingham NG1 3AL

Phone: 0115 876 0160

Email: [email protected]

Visit The Nottingham Centre for Transgender Health website  for more information about how to get a referral.

Gender dysphoria clinics in the southwest

Devon Partnership NHS Trust West of England Specialist Gender Dysphoria Clinic

The Laurels 11-15 Dix's Field Exeter EX1 1QA

Phone: 01392 677 077

Email: [email protected]

The Laurels' website has information about the types of services on offer and the help available during transition.

New gender dysphoria services in 2020

In 2020 new NHS gender dysphoria services for adults will open in Greater Manchester, London and Merseyside.

These services will be delivered by healthcare professionals with specialist skills and based in local NHS areas, such as sexual health services. Full details will be available once each service is opened.

Initially, access to these services will be available to people who are already on a waiting list to be seen at one of the established gender dysphoria clinics.

NHS England will assess how useful these new pilot services are.

Page last reviewed: 13 May 2020 Next review due: 13 May 2023

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How a Small Gender Clinic Landed in a Political Storm

Washington University’s youth gender clinic in St. Louis, like others around the world, was overwhelmed by new patients and struggled to provide them with mental health care.

Jamie Reed, a former case manager at a youth gender clinic affiliated with Washington University in St. Louis. Credit... Bryan Birks for The New York Times

Supported by

By Azeen Ghorayshi

Reporting from St. Louis

• Published Aug. 23, 2023 Updated Aug. 29, 2023

The small Midwestern gender clinic was buckling under an unrelenting surge in demand.

Last year, dozens of young patients were seeking appointments every month, far too many for the clinic’s two psychologists to screen. Doctors in the emergency room downstairs raised alarms about transgender teenagers arriving every day in crisis, taking hormones but not getting therapy.

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Opened in 2017 inside a children’s hospital affiliated with Washington University in St. Louis, the prestigious clinic was welcomed by many families as a godsend. It was the only place for hundreds of miles where distressed adolescents could see a team of experts to help them transition to a different gender.

But as the number of these patients soared, the clinic became overwhelmed — and soon found itself at the center of a political storm. In February, Jamie Reed, a former case manager, went public with explosive allegations, claiming in a whistle-blower complaint that doctors at the clinic had hastily prescribed hormones with lasting effects to adolescents with pressing psychiatric problems.

Ms. Reed’s claims thrust the clinic between warring factions. Missouri’s attorney general, a Republican, opened an investigation, and lawmakers in Missouri and other states trumpeted her allegations when they passed a slew of bans on gender treatments for minors. L.G.B.T.Q. advocates have pointed to parents who disputed her account in local news reports and to a Washington University investigation that determined her claims were “unsubstantiated.”

The reality was more complex than what was portrayed by either side of the political battle, according to interviews with dozens of patients, parents, former employees and local health providers, as well as more than 300 pages of documents shared by Ms. Reed.

Some of Ms. Reed’s claims could not be confirmed, and at least one included factual inaccuracies. But others were corroborated, offering a rare glimpse into one of the 100 or so clinics in the United States that have been at the center of an intensifying fight over transgender rights.

The turmoil in St. Louis underscores one of the most challenging questions in gender care for young people today: How much psychological screening should adolescents receive before they begin gender treatments?

Shaped by ideas pioneered in Europe, these clinics have opened over the past decade to serve the growing number of young people seeking hormonal medications to transition. Many patients and parents told The New York Times that the St. Louis team provided essential care, helping adolescents feel comfortable in their bodies for the first time. Some patients said they were lifted out of grave depression.

But as demand rose, more patients arrived with complex mental health issues. The clinic’s staff often grappled with how best to help, documents show, bringing into sharp relief a tension in the field over whether some children’s gender distress is the root cause of their mental health problems, or possibly a transient consequence of them.

With its psychologists overbooked, the clinic relied on external therapists, some with little experience in gender issues, to evaluate the young patients’ readiness for hormonal medications. Doctors prescribed hormones to patients who had obtained such approvals, even adolescents whose medical histories raised red flags. Some of these patients later stopped identifying as transgender, and received little to no support from the clinic after doing so.

Unwanted outcomes and regrets happen in every branch of medicine, but several clinics around the world have reported challenges similar to those in St. Louis. Pediatric gender medicine is a nascent specialty, and few studies have tracked how patients fare in the long term, making it difficult for doctors to judge who is likely to benefit.

In several European countries, health officials have limited — but not banned — the treatments for young patients and have expanded mental health care while more data is collected. In the United States, health groups have endorsed what’s known as affirming care even as their peers in Europe have grown more cautious. And conservative lawmakers in more than 20 states have taken the draconian step of banning or severely restricting gender treatments for minors.

Civil rights groups are challenging the Missouri ban in a hearing this week, and Ms. Reed testified on Tuesday in favor of it, describing her allegations in detail.

Washington University created an oversight committee to carry out weekly reviews of the gender clinic’s operations. The school’s investigation claimed that none of the clinic’s 598 patients on hormonal medications reported “adverse physical reactions.” In a statement to The Times, the university said that it would not address specific allegations because of patient privacy, and that “physicians and staff have treated patients according to the existing standard of care.”

But doctors in St. Louis and elsewhere are wrestling with evolving standards and uncertain scientific evidence — all while facing intense political pressure and an adolescent mental health crisis.

An Affirming Approach

America’s first youth gender center opened in Boston, in 2007, after two clinicians — Dr. Norman Spack, an endocrinologist, and Laura Edwards-Leeper, a child psychologist — traveled to the Netherlands to observe a promising treatment for children with gender distress, known as dysphoria.

The Dutch doctors were prescribing drugs that stalled puberty in order to prevent the physical changes that often exacerbate dysphoria. The approach, they reasoned, would give the adolescents time to consider whether to proceed with estrogen or testosterone treatments later on.

Transgender children have high rates of anxiety, depression and suicide attempts. The Dutch found that for a specific group — adolescents with no severe psychiatric disorders who had experienced gender dysphoria since early childhood — their depression lessened after taking puberty blockers.

When Dr. Spack and Dr. Edwards-Leeper opened the Boston clinic, they hewed closely to the Dutch approach. In its first five years, the clinic treated just 70 patients .

Similar clinics opened around the country, diverging over time from the strict Dutch protocols into an affirming approach that prioritized a child’s inner sense of gender. It was unethical, some argued, to deny care to children with psychiatric problems when gender treatments could help resolve those issues.

In 2012, parents in St. Louis began lobbying leaders of the children’s hospital to set up an affirming clinic. The parents invited Dr. Spack to town to talk about his experience in Boston.

“In Missouri there were no knowledgeable doctors on this subject,” said Kim Hutton, a founder of the group, called TransParent. “It was left to the parents to try to figure it out.”

The clinic opened in 2017, led by Dr. Christopher Lewis, a pediatric endocrinologist, and Dr. Sarah Garwood, an adolescent medicine specialist, who had each attended TransParent meetings. They saw patients once a week on the second floor of the St. Louis Children’s Hospital, spending most days elsewhere in the sprawling complex.

When Ms. Reed arrived, in 2018, she was the clinic’s only full-time employee. Eventually, the clinic would have about nine staff members, most part-time.

Their patients were part of a striking generational change: Between 2017 and 2020, about 1.4 percent of 13- to 17-year-olds in the United States identified as transgender, nearly double the rate from a few years earlier.

It’s clear the St. Louis clinic benefited many adolescents: Eighteen patients and parents said that their experiences there were overwhelmingly positive, and they refuted Ms. Reed’s depiction of it. For example, her affidavit claimed that the clinic’s doctors did not inform parents or children of the serious side effects of puberty blockers and hormones. But emails show that Ms. Reed herself provided parents with fliers outlining possible risks.

Ms. Hutton’s son, who requested anonymity because of privacy concerns, is now in college, and said he was grateful he transitioned years earlier. “I have normal-people problems, which is all that I ever wanted,” he said.

Another patient, Chris, now 19, who also requested anonymity to protect his privacy, recalled Dr. Lewis patiently drawing diagrams on the paper sheet of his exam chair, explaining how testosterone would redistribute his body fat and permanently deepen his voice. Chris felt “drastically improved” after taking the hormone, he said, but was still distressed by his breasts. At 17, he went to a surgeon in Ohio for a mastectomy.

And Becky Hormuth, a teacher in St. Charles, Mo., praised the center’s doctors for their approach to her son’s mental health. The doctors diagnosed her 15-year-old with autism, she said, and connected him with a dietitian to help treat his eating disorder — before prescribing testosterone. Now, at 16, her son is “better than he’s ever been,” Ms. Hormuth said.

A family therapist in St. Louis, Katie Heiden-Rootes, said she had worked with or supervised the counseling of roughly 30 of the clinic’s patients and had never seen problems with their care.

“The biggest complaint I heard about the clinic was, ‘We can’t get in,’” Dr. Heiden-Rootes said.

The Red Flag List

When Ms. Reed, 43, began working at the clinic, she considered herself a fierce champion of the gender-affirming model. In her previous jobs — at Planned Parenthood, at an H.I.V. clinic and in the foster care system — she had also supported L.G.B.T.Q. young people. And her husband, a transgender man, had shown her how essential gender-affirming care could be.

Ms. Reed’s job at the clinic was akin to that of a social worker — collecting medical histories, triaging appointments and supporting patients in the hospital, at school and in court.

Her doubts about the affirming model arose in 2019, she said, after hearing from an upset patient who regretted their medical transition. She grew more concerned in 2020 as more new patients sought the clinic’s help, many with psychological problems exacerbated by the pandemic. She saw parallels with England’s youth gender clinic, known as the Tavistock, which was under investigation after employees complained about feeling pressure to approve children for puberty blockers as their wait-list swelled.

The St. Louis center relied heavily on outside therapists to vet patients, emails show. Doctors there prescribed hormones to patients who had identified as transgender for at least six months, had received a letter of support from a therapist and had parental consent.

Frustrated that the clinic had no system to keep track of patient outcomes, Ms. Reed and the clinic’s nurse, Karen Hamon, kept a private spreadsheet, which they called the “red flag list.” (Ms. Reed gave The Times a version of the spreadsheet without identifying information. Ms. Hamon and other clinic employees declined to comment for this article.)

The list eventually included 60 adolescents with complex psychiatric diagnoses, a shifting sense of gender or complicated family situations. One patient on testosterone stopped taking schizophrenia medication without consulting a doctor. Another patient had visual and olfactory hallucinations. Another had been in an inpatient psychiatric unit for five months.

On a different tab, they tallied 16 patients who they knew had detransitioned, meaning they had changed their gender identity or stopped hormone treatments.

One patient emailed the clinic, in January 2020, to say they had detransitioned and were seeking a voice coach for their masculinized voice. They also requested a referral for an autism screening, noting, “I have mentioned this before at appointments and over email, but it did not seem to go anywhere.”

In another email thread, the center’s staff discussed a patient who regretted a recent mastectomy. The patient had messaged their surgeon at Washington University twice about wanting a breast reconstruction, but had not received a reply.

The Times independently found another St. Louis patient who detransitioned, Alex, who posted on Reddit last year to “give a warning” about the clinic. (Alex shared medical records with The Times to corroborate her account.)

Alex arrived at the center in late 2017 at age 15, she said, after identifying as transgender for three years. She had been referred by a therapist who was treating her for bipolar disorder and anxiety.

Alex was prescribed testosterone, she said, after one appointment with Dr. Lewis. “There was no actual speaking to a psychiatrist or another therapist or even a case worker,” she wrote on Reddit.

After three years on the hormone, she realized she was nonbinary and told the clinic she was stopping her testosterone injections. The nurse was dismissive, she recalled, and said there was no need for any follow-ups.

Alex, now 21, does not exactly regret taking testosterone, she told The Times, because it helped her sort out her identity. But “overall, there was a major lack of care and consideration for me,” she said.

The number of people who detransition or discontinue gender treatments is not precisely known. Small studies with differing definitions and methodologies have found rates ranging from 2 to 30 percent . In a new, unpublished survey of more than 700 young people who had medically transitioned, Canadian researchers found that 16 percent stopped taking hormones or tried to reverse their effects after five years. Survey responders reported a variety of reasons, including health concerns, a lack of social support and changes in gender identity.

‘Disastrously Overwhelmed’

Nearly 15 years after bringing the Dutch approach to America, Dr. Edwards-Leeper, the Boston psychologist, had grown alarmed by the rise in adolescents seeking gender treatments.

In a November 2021 Washington Post opinion piece , Dr. Edwards-Leeper warned that American gender clinics were prescribing hormones to some children who needed mental health support first.

“We may be harming some of the young people we strive to support — people who may not be prepared for the gender transitions they are being rushed into,” she wrote with Erica Anderson, the former president of the U.S. Professional Association for Transgender Health and a transgender woman.

In St. Louis, Dr. Andrea Giedinghagen, the clinic’s psychiatrist, emailed the essay to her colleagues. “This basically encapsulates the (very complex, nuanced) views that the child and adolescent psychiatrists I know at various gender centers hold,” Dr. Giedinghagen wrote.

The head of the clinic, Dr. Lewis, responded, adding a university administrator to the thread. “I DO think our clinic, and transgender care at large, exhibits some of the concerns mentioned,” he wrote, including being “disastrously overwhelmed.”

But, he added, “No matter the approach there will be a percentage of patients that should have been started that weren’t and vice versa.”

By the end of 2021, emails show, the clinic was getting calls from four or five new patients every day — a sharp rise from 2018, when it saw that many over the course of a month. And, according to an internal presentation from 2021, 73 percent of new patients were identified as girls at birth. Gender clinics in Western Europe , Canada and the United States have reported a similarly disproportionate sex skew that has bewildered clinicians.

Other parts of the St. Louis hospital were also seeing more transgender patients. In August and September of 2022, Ms. Reed and Ms. Hamon, the clinic’s nurse, conducted a half-dozen training sessions with the emergency department to explain their work at the gender clinic. At the trainings, E.R. staff shared concerns about their own experiences with their young transgender patients, which Ms. Hamon later relayed to her team and university administrators.

The E.R. staff, she wrote in an email, had been seeing more transgender adolescents experiencing mental health crises, “to the point where they said they at least have one TG patient per shift.”

“They aren’t sure why patients aren’t required to continue in counseling if they are continuing hormones,” Ms. Hamon added. And they were concerned that “no one is ever told no.”

As similar mental health issues bubbled up at clinics worldwide, the international professional association for transgender medicine tried to address them by publishing specific guidelines for adolescents for the first time. The new “standards of care,” released in September, said that adolescents should question their gender for “several years” and undergo rigorous mental health evaluations before starting hormonal drugs.

Dr. Lewis worried that his clinic would not be able to adjust to the new standards, known as the S.O.C.

“Right now I have no idea how to meet what would be the most intensive interpretations of the SOC,” Dr. Lewis texted Ms. Hamon. (She took a screenshot of the message and sent it to Ms. Reed.) He suggested meeting with staff members to discuss how they could abide by the new guidelines.

In its statement, the university said that the clinic prioritized mental health care and that licensed external therapists “make a vital contribution to that effort.” It also said that “patients have ongoing relationships with mental health providers.”

Some former staff members said the clinic was doing the best it could for patients with complex psychiatric histories. Cate Hensley, a social worker who interned at the clinic from 2020 to 2021, said that the team had a weekly meeting to discuss such cases.

She also said that U.S. hospitals and health insurers invested far too little in mental health, putting extra pressure on doctors and hurting patients.

“This center is providing ethical care in an unethical system,” Mx. Hensley said.

Political Agendas

By the end of last year, Republican lawmakers in Missouri had turned gender care for minors into a rallying cry. And Ms. Reed, formerly a staunch defender of the affirming model, had become openly skeptical of it, raising concerns in internal emails and in meetings despite warnings from higher-ups.

Her performance review in 2022 stated that she “responds poorly to direction from management with defensiveness and hostility.” In November, she left the gender clinic and started a new role at the university coordinating pediatric cancer research.

Ms. Hamon raised doubts as well, according to text messages and emails provided by Ms. Reed. In January of this year, she emailed an administrator to explain why she did not want a management role at the center.

“You know I have struggled with ethical dilemmas about how we do things for quite some time,” Ms. Hamon wrote.

That month, Ms. Reed obtained a prominent parental rights lawyer, Vernadette Broyles. Shortly thereafter, she filed her complaint with the state and publicized her allegations in an essay in The Free Press . Ms. Broyles is a vocal proponent of gender treatment bans for minors and has said the “transgender movement” poses an “existential threat to our culture.”

Ms. Reed said that she supported the rights of transgender adults like her husband, and that Ms. Broyles was the only lawyer who would take her case pro bono. Still, Ms. Reed does not deny that her views have hardened and become political: “I support a national moratorium on the medicalization of kids,” she said.

One parent said that, perhaps in pursuit of this political aim, Ms. Reed had misrepresented her child’s experience.

Ms. Reed’s affidavit describes a patient whose liver was damaged after taking bicalutamide, a drug that blocks testosterone. It makes a specific claim about what a parent had written to the child’s doctors: “The parent said they were not the type to sue, but ‘this could be a huge P.R. problem for you.’”

The parent, Heidi, a data scientist in the St. Louis area who requested anonymity because of privacy concerns, said she was stunned to read this “twisted” description of her teenage daughter’s case.

Heidi’s daughter indeed had liver damage, a rare side effect of bicalutamide. But she had been taking the drug for a year, records show, and had a complicated medical history. She was immunocompromised, and experienced liver problems only after getting Covid and taking another drug with possible liver side effects.

In a message to doctors that was shared with The Times, Heidi actually wrote, “In our world, it’s like a P.R. nightmare” — referring to tensions in her family about the gender treatments. The message did not mention anything about suing the clinic. To the contrary, it said: “We don’t regret any decision.”

Ms. Reed said that she learned about the case from Ms. Hamon, who helped compile examples for the affidavit, and that she regretted citing the case when she had not seen the medical record herself.

“My daughter’s situation was exploited,” Heidi said, noting that the hospital told her that her records would be shared with the state.

Missouri’s ban of gender care for minors will begin on Aug. 28 unless the hearing this week results in a preliminary injunction. If the law goes into effect, the clinic will not be allowed to enroll new patients.

Some families are not waiting for the legal proceedings to play out. Jennifer Harris Dault, a Mennonite pastor, moved her family from St. Louis to New York in July to ensure that her 8-year-old transgender daughter could get gender treatments when she nears puberty.

“The more I see coming out of Missouri the more I know we made the decision that was right for us,” she said.

The attorney general’s investigation into the clinic’s practices is ongoing, as is an inquiry by Senator Josh Hawley, a Republican. While several families said they blamed Ms. Reed for the political fallout, others said the university bears responsibility, too.

For decades, Dr. John Daniels was the sole endocrinologist in St. Louis prescribing hormones to transgender adults. He did so, he said, because he saw profound benefits in his patients and because, as a gay man, he appreciated the diversity of the human experience.

When Ms. Reed’s allegations came out, he was shocked, and emailed her to ask if she had ever reported concerns to Washington University. She replied that she had, but was ignored.

“I hate that the politicians have gotten involved with this, but I do have great concerns about how adolescents and preadolescents are being treated,” Dr. Daniels wrote. “That the higher-ups at W.U. didn’t take you seriously is now on them.”

Kirsten Noyes contributed research.

An earlier version of this article referred incorrectly to Dr. Katie Heiden-Rootes’s work with patients at the clinic. After reviewing her records after publication, Dr. Heiden-Rootes said she had worked with or supervised the counseling of roughly 30 patients; she did not counsel 50.

How we handle corrections

Azeen Ghorayshi covers the intersection of sex, gender and science for The Times. More about Azeen Ghorayshi

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New NHS children’s gender clinic hit by disagreements and resignations

At least four experts quit Great Ormond Street team after disputes over text of training module for recruits, sources say

A string of resignations from a team preparing for the launch of the new NHS children’s gender clinic has further complicated plans to open the services in April.

Disagreements over the text of a training module for medical recruits to the new gender service have prompted NHS England to remove the training materials project from a team at Great Ormond Street hospital and outsource it to the Academy of Medical Royal Colleges.

Great Ormond Street last year recruited a small team, including paediatricians and child psychologists, to write training guidance for new medical staff who will work in NHS England’s reshaped gender services for children and young people.

But at least four members of the team resigned late last year after disagreements over how children with gender dysphoria should be treated, according to sources close to the process.

The new NHS Children’s and Young People’s Gender Service for London is scheduled to open its doors to patients in early April, a year later than first scheduled and almost two years after NHS England announced the closure of the gender identity development service (Gids) for children at the Tavistock clinic in north London.

Gids was set up at the Tavistock three decades ago to help children and other young people struggling with their gender identity. But after a series of concerns and complaints from inspectors, whistleblowers, patients and families, the clinic is to close and be replaced by a number of hubs, including at Great Ormond Street.

Great Ormond Street is working with the Evelina children’s hospital and the South London and Maudsley NHS trust to pilot the first of several regional hubs that will take on the work previously conducted by the Tavistock clinic.

The team of experts recruited to write the training material included former Tavistock employees who left because they were uneasy about that service’s treatment of young people, plus other clinicians said to be opposed to the NHS’s new approach to handling children and young people with gender dysphoria.

Sources close to the discussions said there was “no consensus” within the team and that their work was incomplete when members resigned.

In 2022, Dr Hilary Cass, the paediatrician charged with reviewing the NHS’s care of children with gender dysphoria, said a “fundamentally different” approach was needed because of rising referrals and a significant change in the case mix, with a sharp rise in adolescent girls presenting with gender incongruence in their early teen years.

She also noted that many children displayed a wide range of other complexities, including mental health needs. Her independent review highlighted uncertainties surrounding the use of hormone treatments. Interim NHS service specifications say the new clinics will take a multidisciplinary approach, offering psychological support.

Some clinicians working on the new training materials are understood to have felt it important to affirm a patient’s gender identity and believed patients could benefit from medication. Others, some of whom resigned their posts, stressed the need to adhere to Cass’s recommendations and take a holistic, “exploratory” approach.

A spokesperson for the Academy of Medical Royal Colleges said the body had agreed to step in to write an interim training module, and was working to meet a six-week deadline, “because our members are keen to help ensure this service can go live as planned” [in April].

He added that because “time is tight”, the body would deliver induction training to let clinicians begin seeing patients, and a more in-depth programme would be commissioned at a later stage.

Great Ormond Street said the team recruited to develop the training and education programme had “now wrapped up its part of the process, having produced a range of high-quality materials. The programme has now been passed on to the Academy of Medical Royal Colleges, who will complete and deliver the induction programme.”

Some parents are turning to private healthcare, frustrated by the continuing turmoil and NHS waiting lists that can stretch to several years.

This week a private hormone clinic for transgender young people said it had become the first UK-based private provider to be registered by the health regulator, the Care Quality Commission, to prescribe cross-sex hormones for patients over 16.

The service is part of the Gender Plus group, run by several ex-NHS former Tavistock clinicians, which also offers psychological consultations, and for those over 18, referrals for gender-affirming surgery.

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