Time to Think
For many years, cracks have been appearing in the (metaphorical) walls of the Gender Identity Development Service (GIDS), the only NHS gender-specialist service for under-18s. Those cracks – in the form of concerns from staff members, employment tribunals, court cases, and deeply discontented ex-patients – were warning signs that the foundations of GIDS are unsafe and unfit for purpose. The Cass Review has now given official confirmation of this, and a demolition order (still metaphorical!) has been issued. GIDS will soon close and will be replaced by new NHS services that will follow a very different approach to that which has been the norm at GIDS.
Time to Think by Hannah Barnes tells, as the subtitle states, ‘the inside story of the collapse of the Tavistock’s gender service for children.’ It is not a comfortable read. Barnes offers a thorough account of the progress and subsequent demise of what’s hard not to conclude has been a significant medical and safeguarding scandal.
The scope of the book is primarily to tell the story of GIDS: ‘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’ (p.22).
In the process, however, through interviews with staff, patients and parents, and through examination of the available data and research, Barnes also gives us a lot of helpful insight into the phenomenon of trans-identification among teens. For those of us who have been engaging with this phenomenon for a while, there’s nothing particularly new, but there’s a lot to confirm what we already know or have suspected. Here a few points I think are particularly helpful for us to be aware of, especially those of us working with young people.
It so often isn’t about gender
For many – perhaps most – young people identifying as trans today, there is very good reason to think that gender isn’t the main issue. So often, gender is a symptom of something else, not the root cause. This means the best way of helping young people, is to support them holistically, not letting gender trump everything else, and helping the young person to put gender in perspective.
‘Why were more teenage girls being referred to the clinic than ever before, many of them with no previous problem with their gender identity in childhood – girls who often had complex mental health problems such as depression, anxiety, eating disorders and self-harm? Could the past traumas of some of these children explain why they wanted to identify as a different gender to escape from their bodies? Did the increasing number of patients who appeared to experience homophobic bullying before identifying as transgender need to be explored in greater detail? Was GIDS actually medicating some gay children, and some on the autistic spectrum?’ (p.20).
‘An audit of patients in the early 2000s ‘showed that it was very rare for young people referred to GIDS to have no associated problems. This was true of only 2.5 per cent of the sample. On the other hand, about 70 per cent of the sample had more than five “associated features” – a long list that includes those already mentioned [e.g. family difficulties, depression, time in care, self-harming] as well as physical abuse, anxiety, school attendance issues and many more. Those who were older (over 12) tended to have more of these problems’ (p.31).
‘What was really going on was that I was a girl insecure in my body who had experienced parental abandonment, felt alienated from my peers, suffered from anxiety and depression, and struggled with my sexual orientation … I was an unhappy girl who needed help. Instead, I was treated like an experiment’ (p.332).
‘Harriet says her trans identity provided “an easy answer” to her poor self-esteem and mental health problems. “I think sexuality was my big trigger for it at the time, where I started freaking out. I was a repressed lesbian at a girls’ school. And then I was quite a heavy Tumblr user. And it was like, you can jump ship and be this other thing … I’m very into computers, and always have been,” she explains, and this was portrayed as being interested in “male” pursuits. Reflecting on those conversations now, Harriet says many were symptoms of autism. Or just being a teenage girl’ (pp.382-383).
It’s usually about distress
To say that gender isn’t usually the main issue, isn’t to say that there isn’t something real going on for these young people. For many, it seems that trans-identification is embraced as an explanation for very real distress and transition is then seen as the solution. In many ways, the trans narrative is a gospel – good news of salvation from distress. The problem is, it’s a false gospel.
‘Clinicians did not agree on what exactly they were treating in young people: were they treating children distressed because they were trans, or children who identified as trans because they were distressed? Or a combination of both? It was unsurprising then that they couldn’t agree on the best way to treat it’ (p.43).
‘I kind of wonder if in these moments of distress in people’s lives – it’s not that I’m saying being trans or [poor] mental health causes you to say you’re trans, but that that might be the thing you think it is because you’re so unwell … you might think that your life might be better if … you’ve got a label for the struggle you’re feeling that isn’t mental health, and it’s part of your identity’, Jack, a trans man (p.94).
‘[H]ere was a potential solution to that distress. The problem with that was that part of what GIDS was trying to do as a service was to “support families to support young people with distress”. “Part of life and development is learning how to manage and tolerate distress, not thinking it’s supposed to be taken away,” [Dr Natasha] Prescott explains. The decision may have been well meaning, but “lots of things can be well meaning, and ill-informed”’ (pp.122-123).
Sexuality is very often a factor
The thing that most surprised me in reading Time to Think was the prominence of sexuality. I knew that many of the young people identifying as trans experience same-sex attraction. I knew that past studies have shown many children who express discomfort with their gender prior to puberty turn out to be gay in adulthood. I knew that being gay at school often isn’t deemed cool, but being trans is. I think I just hadn’t realised how big a factor this is and how hard it is to be a same-sex attracted teenager today, especially if you’re a girl.
‘Homophobic comments from young people themselves, or their families, would be an almost daily occurrence … Some young people themselves would be repulsed by the fact that they were same-sex attracted’ (pp.203-204).
‘He [the patient] had “experienced horrific homophobic bullying” after telling another boy he had feelings for him. This had then spread around the school. “In talking to this young person, I could hear lots of things which pointed towards same-sex attraction, and very little which pointed towards gender dysphoria, discomfort with a body, nothing more indicative of a trans experience”’ (p.204).
‘When GIDS asked older adolescents about who they were attracted to, over 90 per cent of natal females reported that they were same-sex attracted or bisexual. Just 8.5 per cent were opposite-sex attracted – attracted to males. For the natal males, 80.8 per cent reported being same-sex attracted or bisexual’ (p.206).
‘[T]here were families who could not “tolerate” their sons being gay: “the child then sees trans as a way out of this dilemma and the family pressure the child to go along with this”’ (p.211).
‘Young people appeared to be experiencing internalised homophobia and […] some families would make openly homophobic comments … Some parents appeared to prefer the idea that their child was transgender and straight than that they were gay, and were pushing them towards transition’ (pp.309-310).
There are still many unknowns about the impact of transition
While transitioning is often trumpeted as the solution to gender-related distress, there is much we still don’t know about the impact it has on a young person. We need to be honest with young people about this.
‘While there are studies that describe the self-reported high satisfaction of young people and their families of being on puberty blockers, and some improvement in mental health, others suggest there is evidence that puberty-blocker use can lead to changes in sexuality and sexual function, poor bone health, stunted height, low mood, tumour-like masses in the brain and, for those treated early enough who continue on to cross-sex hormones, almost certain infertility’ (p.18).
‘There is a lack of evidence on the impact of social transition, and what limited data there are can be interpreted in different ways. A study showing that only a small proportion of children who socially transitioned later reidentified with their birth gender has been argued to show both how gender identity is stable and unlikely to change through time, and that social transition shuts down options for a child, cementing a gender identity that may change. While there are opposing views on the benefits versus the harms of early social transition, it has been argued that “it is not a neutral act, and better information is needed about outcomes”’ (p.130).
‘Transitioning was a very temporary, superficial fix for a very complex identity issue’, Keira Bell, a detransitioned woman (p.341).
Young people need adults to focus on their long-term good
While things are changing at the level of official NHS policy and this should have an impact in other areas (such as schools when new guidance is released shortly), this will not quickly change things in youth culture. If anything, the changes in official policy may cause a further solidifying of the dominance of the trans narrative among young people.
This is a generation who are suspicious of traditional authorities. They often prize personal experience over professional expertise. And many are more likely to turn to the internet for answers to their questions than to the adults in their lives. The task of rescuing young people from the unhelpful narratives to which they have been exposed will be a bigger and slower one than the task of changing official policy.
So, it’s likely that for a while we will continue to be in a context where adults will sometimes have to act in the long-term interests of young people, even if doing so will be unpopular with those young people. This will be particularly important for parents (and probably won’t be a new situation for most parents!).
‘I wish someone would have been there to tell me not to get castrated at 21’, a detransitioned woman (p.330).
‘When I was 16 … I never considered that I could be interested in my [long-term] health’, a destransitioned woman (p.330).
‘Harriet believes that with more discussion of her sexuality, and the fact that she was a heavy social-media user, she may well have decided not to go through with medical and surgical transition … “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 through non-binary to trans boy to whatever else’’’ (p.383).
Reading a book like Time to Think it’s hard not to conclude that as a society we have failed a huge number of young people. I imagine we can expect various attempts to hold certain people accountable for that in the coming months and years. Looking forward, this recognition gives us a chance to make a difference. We can do better at protecting and helping teenagers who are finding the challenges of life too much. We can love them well, not by denying their distress or offering false quick fixes, but by coming alongside them in their distress and helping them learn how to navigate it well. For Christian parents, youth leaders and church leaders, this is a moment of opportunity. Time to Think shows us it’s time to love.