Hannah Barnes and Time to Think
“One has to address the treatment and whether it’s appropriate because the truth will out. The child will live that truth. It’s also cruel not to inform children what will actually happen to them.”
- Dr Anna Hutchinson (quoted in Time to Think by Hannah Barnes)
On occasion, a book that is explicitly non-feminist merits the attention of women’s rights campaigners. Time to think: The inside story of the collapse of the Tavistock’s Gender Service for Children, authored by Hannah Barnes and published by Swift Press, is one such book. FiLiA had the privilege of interviewing Hannah Barnes about Time to Think (please scroll down for that discussion). The author takes care to distance herself from any feminist position, or any other ideological stance, and instead approaches her subject with journalistic rigour.
Feminists who protect the sex-based rights of girls and women have long challenged the social and medical interventions done on children who express unhappiness with their body or strongly resist their ‘expected’ social role. Women ask: why are doctors physically intervening in children’s natural development with powerful drugs, for no defined medical pathology? How can clinicians justify this practice despite such poor scientific evidence? How does the rise in teenage girls going to gender clinics around the world relate to issues like misogyny, lesbophobia, porn-culture and the objectification of women and girls? Why are women being called ‘transphobic’ for questioning whether young girls who might otherwise grow up to be lesbians are being inappropriately medicalised for life? How is a mother trying to safeguard her child from possible medical harms acting in a ‘hateful’ way?
In the UK, there were three main clinics that were scrutinised regarding such questions. They were the Gender Identity Development Service or GIDS, based at the Tavistock and Portman NHS Foundation Trust (with premises in London and Leeds), with its psychological approach, along with endocrine clinics overseeing the prescriptions of hormone-altering medications at University College London Hospital and Leeds Children’s Hospital. In response to public pressure concerning possible medical harms, Dr Hilary Cass was tasked to lead an ongoing review of these medical practices.
Into this context entered Hannah Barnes. Barnes is an award-winning BBC journalist, with a talent for meticulously researched, balanced and neutral reporting. Time to Think: The Inside Story of the Tavistock’s Gender Service for Children is a careful portrait of a clinic afflicted by controversy. The book was developed from extensive interviews with staff, patients, and other people who had first-hand knowledge of GIDS, alongside primary documentation.
Many revelations in the book were already in the public domain, although more effective when compiled into one engaging volume. Problems at GIDS were reported to include staff complaints of homophobia being minimised, alongside instances of exceptionally vulnerable children with issues like depression, autism, sexual abuse, poverty or trauma being approved for drug treatment with little assessment and their other needs going unmet. GIDS were also reported not to have substantially changed their clinical practices despite documented shortcomings, and not to have collected long-term data on how their young patients were faring with their multiple difficulties.
Time to Think contains perhaps only a few passages that will truly shock those feminists with extensive knowledge of this topic, although certain narratives and themes will unsettle and linger. Yet this book, which does not even list feminism in its index, is a story worth reading precisely because of its dispassionate approach and very narrow focus. The tale centres solely on one clinical service. It unfolds with an admirable level of detail and care (for instance, Barnes includes footnotes explaining responses to allegations made within the main text). The narrative is cohesive and easy to read despite the niche, quite technical subject matter.
There are a few instances in Time to Think that hint at how UK feminist resistance played a role in raising public awareness of the problems at GIDS. These include mentions of Brunskell-Evans and Moore’s book, Davies-Arai’s work in the Bell vs Tavistock court case, a House of Lords meeting, and a feminist event on detransition. However, feminist analysis or critique is largely omitted as outside of the scope of the book. Arguably, a key question remains unanswered: is there something inherently wrong with the whole idea of ‘transitioning’ children?
Instead, what Time to Think offers is almost like a time capsule of what happened inside GIDS. It is a forensic piece of work that captures what clinicians, patients and staff were thinking. Barnes writes with restraint. She avoids direct commentary, highlighting instead the reflections of those she spoke with:
“When one of the leaders of a service that helps children to access powerful, life-changing drugs comments that what they are doing is “mad”, there is clearly a very big problem.”
- Dr Anna Hutchinson (in Time to Think)
Interview with Hannah Barnes
(This discussion has been transcribed and lightly edited for clarity.)
FiLiA: Your book focuses on an incredibly divisive topic, which is how to approach gender dysphoria in children. Why is this such a controversial area of medicine?
Hannah:
Well, all I can say really is what the clinicians who work in this field have told me. I'm not a clinician; I'm a journalist. But what they say is that it's a field that is not like others they've worked in. There isn't consensus on what is being ‘treated’. And I use that in the very loosest sense of the term. I don't mean it to imply that people are ill or to pathologise. But there is no agreement on that. There was a lack of consensus on what the best way to help those young people might be, and whether different people would require different treatments. There is a lack of consensus about how we measure outcomes and what a good outcome may be. So I think there are lots of difficulties in this this field of healthcare.
One of the big ones is obviously a lack of a robust evidence base underpinning the main medical treatment, so the use of puberty blockers in young people experiencing gender related distress, followed by often gender-affirming or cross-sex hormones. There really isn't a robust evidence base, when you compare that to other fields of medicine, for the use of those treatments, to treat that condition.
We have some data for the use of puberty blockers in children who start puberty very early: precocious puberty. But I think it's hard to deny that when used to treat gender-related distress they do work in a different way, in that most young people tend not to stop the blocker they just progress then on to another treatment. It’s not going through biological puberty that is very different, in this use of blockers, as compared to precocious puberty.
And why is it divisive? Well, a lack of consensus on what the best thing to do, it’s a lack of a robust evidence base. And I guess what so many of these clinicians told me was also that the standard questions that one would have as a clinician in any other field, were not treated in the same way when asked in this field. So the concerns that some clinicians had about whether this was the right treatment pathway for many of the young people, they were saying those were clinical questions. They weren't questioning the identity of those young people, or the right of people to transition more generally. Those were clinical questions and clinical concerns. And because the word gender is involved here, the waters, they say, are muddied.
So, as Dr Hilary Cass, who is undertaking a very thorough review of this whole area of healthcare for young people, has said: GIDS, the Gender Identity Development Service, has not been subjected to the level of oversight that one might expect of a service using innovative treatments on children. And the experience of some clinicians was that general concerns were not treated in the spirit that they were intended.
I think one clinician spoke about a cloak of mystery when people thought of gender, and you know, that might explain why that level of oversight wasn't there from either the wider Tavistock Trust but almost certainly from NHS England, as well.
FiLiA: On the questions of not being able to perhaps have oversight and really understand what was going on, is that part of the reason why it was so important to tell the story specifically of GIDS, and what was going on at the Tavistock in London? Because it's almost like a historical document when you read it, collecting all these things together, like an anthropological study or something. That this is what was going on at this specific time. I wondered what was it about this particular story that really drew you to the subject and why was it so important to tell it in this way?
Hannah:
Well, I've tried to tell it in a calm, evidence-based way and to create as definitive a record as I think there could be on this based on the experiences of many, many people with direct experience. I purposely took quite a narrow approach and I've only spoken with people who have direct experience of GIDS, whether that's as a clinician who's worked there, as a young person who's gone through the service or as a family member of a young person who's gone through the service, or people in the wider Tavistock Trust, that houses GIDS, who have had some interaction surrounding the service and those involved with legal battles. So it was very focused. And I think one of the things that I hope that it will do is, you know, I think up to this point, you could be forgiven, if you're the average, engaged layperson, you may think that there is no lack of consensus in the medical community about how to care for this group of young people. And that if there were concerns that they'd be motivated by transphobia, and I think nothing could be further from the truth.
Actually, there isn't agreement amongst frontline clinicians working with this group of young people about how best to care for them, and how there may be different ways to care for different people.
Those discussions are taking place in gender clinics across the world. They took place at GIDS. They're taking place in Europe, and in the United States we're hearing as well. So it was really trying to bring this out of the gender clinics and into wider society because of course, of course, this is an issue for the trans community, but it's also an issue more generally about children and young people.
That's why I wrote the book. And I got to the point where I knew more than I could ever broadcast on the BBC. Not because of being blocked – I was amazingly supported at Newsnight. You know, the work of my colleague, Deb Cohen and I, we were absolutely 100% supported by the programme, by our editor Esme Wren. But there got to a point where you can't just break things into 12-minute chunks. And so I just thought that it was a story that needed telling.
FiLiA: I wondered a bit about how it compares to other stories that you've covered in your career, because you've been working in journalism for a while. And this is something you're very experienced in, researching and telling stories so that people can understand them and it's accessible. How does it compare to perhaps other clinical stories that you've covered or aspects in other areas of society? And was there anything that was particularly surprising that you found about researching and writing this book?
Hannah:
So I'm not a health specialist journalist. I'm a generalist and I tend to do long form journalism, in depth journalism. I'm not sure which other stories I'd compare it to to make a direct comparison. You know, I'm not sure how to answer that.
FiLiA: I just wondered, for example, I think you say in the book, it's quite difficult to get psychologists to speak about something. And in this case, you had a certain cohort of people who are really quite desperate to get their story out. And then you had others who perhaps weren't so happy to have their name on the record, but would also want to be discussing things. And then others who, at least it looked like in the footnotes, there were some people who just didn't want to be participating in the book. And so I suppose from that sort of perspective, was this atypical? Is this what normally happens?
Hannah:
When things are sensitive, it is always difficult to persuade people to talk to you. And really often in journalism, there's not much in it for them to do so. To put your head above the parapet is difficult. And especially, as you will know from reading the book, there are people who have put their head above the parapet, who have been named, who are prepared to say ‘I got things wrong’ as well. And that's incredibly rare.
So it is always difficult to persuade people to go on the record, especially when there's an emotional attachment to the story as well. I can think of other stories where people have wanted to be granted anonymity because they still work in the field. Not necessarily medicine, but perhaps politics or the charity sector or what have you. It's difficult speaking out against your peers, and that was certainly an issue here. And it was more, it's not just your peers, it's people that you really like and you got on with and I think that was really striking about GIDS as I wrote the book.
It hadn't really crossed my mind before that, at a particular time at least, this was a really close-knit group of professionals, and they were encouraged to think of themselves as almost a family. And it becomes even harder then to raise concerns because you're somehow letting down the people that you cared about. And one clinician puts it this way: ‘What do you do? It's a major dilemma. Do you screw over your colleagues to help the service users, or inadvertently screw with service users to help your colleagues?’
It's really, really difficult. So I have experienced those issues before, but I think perhaps not to the scale here.
FiLiA: Yeah, that was a line that actually I wrote down because I thought it was such a striking line from one who's working within the medical sphere to even be contemplating it like that. Because obviously from an outsider's perspective, you want to just be able to say, well, of course, you're always going to put the patients first. This shouldn't even be a question. But then it comes to those sorts of human factors and the relationships. I think you at one point characterise the feeling of being within GIDS as being almost like a start-up.
Hannah:
At one point, that's how it was described to me. So I think it was very difficult for people to speak out. Lots of different competing emotions. But I don't want to suggest that others who didn't speak to me don't care about these young people, either. I think it's a story about how well intentioned people can go wrong. And an intervention that is well intentioned, can be overused for a group for whom it wasn't intended, perhaps.
FiLiA: You include lots of different perspectives and lots of different voices from people who were actually there, who were actually involved, and had direct experience. So it's not a sort of commentary from folks on the side lines. Dr Anna Hutchinson, in particular, plays quite a large role in the book. She kind of opens and closes the work with that question: ‘Are we harming children?’ You do seem to be quite careful about choosing a range of different stories with a range of different outcomes in terms of kids who've actually been through GIDS themselves and have different perspectives, and some of them seem quite positive. So do you think it's fair then to characterise what happened at GIDS as a “serious medical scandal”? And in that case, why?
Hannah:
So I don't use that phrase, for the very reason I don't think we know yet. I think we know that some people say they've been helped by GIDS, and some of those stories are in the book. And we also know that some people have been harmed by GIDS, and some of those stories are in the book as well. And I think what we don't know yet is the numbers on either side, because we don't have that data. GIDS haven't been collecting data on outcomes. Ever. They've been running since 1989. So we don't know. And hopefully, Dr Cass and her team can start to answer some of those questions. So I personally don't describe it in those terms. But I think it's very striking that a number of the clinicians who were there and were trying to help these young people fear that it may end up being a serious medical scandal because of their experiences. But I think at the moment, everybody would like some certainty, but I don't think we have it.
FiLiA: I suppose this is beyond the scope of the book and perhaps something you don't want to comment on, but there is that sort of tension. Like you said, this is a question that's being grappled with in different countries. Different places are starting to look at their own sort of services. So notably, for example, Sweden had Uppdrag Granskning that looked at, in a series of documentaries, what was going on in Sweden on the subject. And that actually ended up changing practice. In a similar way that I think the BBC and other news outlets reporting here in the UK are also now affecting practice in an English context. I don't really know necessarily what's happening up in Scotland.
And I wondered a little bit about, do you think that there's something about, like you were saying, we're not really sure if it's a disease, we're not really sure if it's a condition or if it's just a state of identity, but is there something that is almost inherently troublesome with the condition or the question of gender dysphoria and paediatrics itself? That is causing perhaps, less of a focus on child safeguarding? As in, is this a problem with the idea itself? Or is this an issue of different practices locally that seem to be going beyond the scope of what is considered to be reasonable medical practice? Given that these sorts of issues are cropping up in lots of different places?
Hannah:
I think similar issues perhaps crop up because there's no agreement on what good care looks like. I think it's striking that when systematic reviews have been undertaken of the evidence base, by National Health bodies, it has been found wanting. And that's the case in Sweden as you mentioned, it's the case here in England and it's the case in Finland. I think the fact that the evidence base isn't robust – and that, anecdotally, you have clinicians working in gender clinics who say they did see some people thrive on the medical pathway, but who also saw young people not only not improved but actually worsen in terms of their medical and physical health – I think that's why you get the similar concerns in different countries. I'm not sure I'd want to comment on the condition; that's not my place to say. I certainly wouldn't want to say everybody's ill.
I think the clinical dilemmas stem from the fact that the evidence base is weak and that the existing weak evidence base has been used on a very different group of young people from that for whom it was designed. So, GIDS have actually been open about the fact that they extended the so-called Dutch protocol, which was designed for a group of young people who were psychologically stable, who had gender incongruence from childhood, who had stable supportive living environments. They extended that medical pathway and the evidence for it, if you like, to a group of young people who didn't fit those criteria, whose gender incongruence started in adolescence, who had multiple other difficulties that they were contending with, and who sometimes had quite chaotic living arrangements. And we've seen that shift in the people presenting to gender clinics across the western world. So, I think it's the uncertainty surrounding the evidence base and the fact that the one-size-fits-all approach doesn't seem to be working. I don't know if that's answering your question. Sorry!
FiLiA: There was this kind of siege mentality, let's say, because there was pressure being put on the service from all sides. I suppose one of the questions I had also was about whether or not there was a kind of worry about feminists from that perspective, too, if that makes sense. So the sort of questions around ‘TERFs’ or ‘gender criticals’ or if there was any sort of sense of that sort of dialogue also affecting folks at GIDS, when it was happening?
Hannah:
I think certainly the service felt under attack from everyone and felt that it couldn't please anybody either. If it was too cautious, then it couldn't please the trans community and certain trans groups or trans support groups, and if it was too quick to affirm and too quick to put some people on a physical pathway or even, you know, a physical pathway at all, then it wouldn't please other groups. So I think certainly, the service felt attacked from all quarters. And, arguably, they couldn't win. I mean, what new services come out of GIDS’ closure will end up displeasing some and pleasing others. I think that that is inevitable because it is so polarised. So, I think, yeah, the answer to your question is, ‘yes’, they probably did feel attacked from the groups that you mentioned, as well as from those who wanted them to go further and faster. And as one of the clinicians said, then that became a problem in itself because GIDS said that it holds – or tried to hold – the middle ground. But what is that? And I'm not sure anybody really knows what the middle ground is. And as one clinician, Dr. Natasha Prescott, said, it actually means that you end up doing nothing. You don't end up changing practice when perhaps you should. You end up doing nothing when things probably should have changed.
FiLiA: It sounds like these clinicians were put in almost an impossible position and in certain cases, definitely the empathy that you have for the participants in your book shines through. Even though sometimes it's infuriating. Because you kind of wish that you can have a more clear-cut story, of heroes and villains, and so on and so forth. So in that sense, it can sometimes be a slightly frustrating read. But I wondered if you would mind talking to us a little bit about what your discoveries were about the child safeguarding aspects in particular. Because I think one of the other things that this book has that's really important is discussion with Sonia Appleby after she had won her case.
Hannah:
Yeah. And Sonia had not spoken before to anybody, so I was very grateful to her. Well, this was another aspect, if you like, of exceptionalism within GIDS. So you had clinicians saying what clinical concerns were not being reacted to in the same way that you'd expect in other services. And clinicians say safeguarding concerns weren't responded to in the same way that you would expect in other services dealing with children either. They say that in all other services they worked in if you were concerned, then you referred on, that's what you did. It didn't matter if that concern was true or not, because often you don't know. But you refer on. And they said that that didn't happen in GIDS, or not to the same level.
I think Sonia’s experience, as she says, was of hostility. That she was trying to get the same data from GIDS as she was from other services run by the Tavistock trust, and could never get it. And the service, because of the siege mentality that we've mentioned, felt so protective of itself that it wouldn't… I don't know, it couldn't supply data or it felt that being asked for it was in some way a hostile act, as Sonia describes. And so much so that she was seen as having an agenda, as we heard from her successful employment tribunal. And so much so that, as the judge ruled, that there had been some kind of directive from the head of GIDS to staff not to seek out Sonia Appleby’s help when it came to safeguarding.
To raise safeguarding concerns about children and young people who happen to be experiencing gender related distress should be viewed in the same way as it should be about anybody. It's not transphobic. Sonia was accused of being transphobic. But for what? For asking for data and for relaying concerns about some of the young people under GIDS’s care. It's striking. And some of those young people did seem to be in desperately difficult situations. And it seems that really anybody who raised concerns about the safeguarding of children was dismissed in some form or another.
FiLiA: I think one of the difficulties, is that it’s at every level. At the individual, when there's the two clinicians in the room, looking at the patient. Then beyond that, it's in that team meeting where you're allowed to speak but nothing seems to then happen. And then it's going to the more senior people, and having these secret meetings with, for example, Dr Bell or someone and creating this report. Then making those reports and then nothing happens from the reports. And then you have this top safeguarding lead [Sonia], who you're then not allowed to speak to because that's apparently going to be perceived as a hostile act. And so, I think is one of the questions that, I was thinking was: ‘Well, what is it about child safeguarding that provokes this idea that it’s being transphobic? Or vice versa?’
Hannah:
I think there was a complicating factor that, in some cases, safeguarding concerns… you know, there was a grey area between the safeguarding concern and the trans identification. And the service was very keen not to stigmatise these young people, not to pathologise. And so, there was a line to tread whereby a concern about a young person wasn't a questioning of their gender identity. But on balance, many clinicians felt that the bar was too high. Because of that… fear, if you like, in the service, the bar was too high for referring, for taking these concerns as seriously perhaps as they would in other services.
And I think what's striking is that those clinicians raise those concerns over and over and over again. To numerous people at numerous levels over a number of years, including with the Medical Director of the Trust in an official review, who said, ‘Our safeguarding procedures are adequate,’ and who was told by several clinicians, ‘No, they're not.’
It's also striking that it took till 2019 for GIDS to have a standard operating procedure around safeguarding. And that was one of the results of the review. But to have operated for 30 years without seemingly the feeling that there needed to be one, I think is interesting. And then not to include your safeguarding lead for children, so Sonia says, in the drafting of it is also rather striking.
FiLiA: I think that's one of the most tragic parts of the story. Not only that actual lives were, or may have been, damaged by the procedures that were going on at the time at GIDS, but also the fact that there were such difficulties in actually addressing these concerns, as they were being brought up.
I think that, really, what people need to do is to they need to go and read the book and make up their own mind. Figure out what actually happened at GIDS through this very carefully documented work.