WeeklyWorker

11.08.2022

Happily flying blind

Closure of the Tavistock GIDS clinic highlights the conflict between culture war politics and science, argues Isaac McCabe

After a tumultuous few years, the national health service has decided to close the Gender and Identity Development Service (GIDS) based in the Tavistock Centre in London’s Swiss Cottage. This would seem to bring to a close one phase of the ‘gender wars’, in this country at least; what comes next is not clear.

The NHS is clear what it wants to come next, at least: in line with the interim report from Hillary Cass,1 a prominent paediatrician assigned to review the Tavistock clinic’s work, the aim is to move from one single central institution to a series of regional hubs with the relevant expertise to treat children and adolescents presenting with gender dysphoria. Some of the problems, at least, are broadly agreed: the waiting lists at the GIDS were beyond unmanageable; a service staffed to handle a few hundred cases a year found more than 2,000 knocking at its door annually by the end of the last decade. That must be at least a contributing factor to a decline in its clinical standards - rated inadequate by the Care Quality Commission (CQC). Under increasing scrutiny from the media, it turned out that the clinic kept poor records and frequently lost touch with its former patients - given its enthusiasm for off-label usage of powerful drugs, this rather looked like indifference to long-term outcomes. But how could it be otherwise, with such a never-ending caseload of distressed youngsters to treat?

The recent silence of the pro-trans organisations2 contrasts with the pleased statements of their opponents, divided between social conservatives on the one hand and liberals and lefts influenced by second-wave feminism on the other (‘gender-critical’ or GC feminists - or ‘trans-exclusionary radical feminists’, or terfs, to their enemies). The latter seem rather more relaxed about the future prospects for trans healthcare in this country. The less culture war-poisoned among the GC feminists hope that all this comes true: that fully staffed services are created in more places around the country, that the GIDS continues to operate in the interim, as promised, and that more use will be made of talking therapy and other treatments short of puberty blockers and hormones. The social conservatives (and the more poisoned GC feminists) will feel that, with the two contenders to be the next prime minister currently squabbling over who is the most contemptuous of ‘gender ideology’, and her majesty’s opposition completely paralysed on the question, far more extensive victories may be obtained.

The fear must be that the conservatives get their wish, and the failure of the left to produce a meaningful policy on this will produce a severe backlash against all gender-non-conforming people, from gay men to lesbians to trans people. Indeed, this is already happening in the US; and American political cancers have a habit of metastasising globally.

Understanding why this should be the case requires a closer look at how the Tavistock GIDS clinic came to be so overloaded, and also the political divisions that have amplified its difficulties.

But before doing so, some housekeeping. Despite phenomena like the aforementioned conservative backlash, I do not consider the treatment of gender-dysphoric youth, access to single-sex facilities, access to single-sex sporting competitions, use of nominated pronouns, and elaborate theories about sex and gender to constitute one vast mega-question called ‘trans rights’ (or ‘gender ideology’, if you are way out on the other side) that one must either accept or reject in toto. This is an article specifically about the treatment of gender dysphoria in young people, and the recent history of that in the UK. It is perfectly consistent (for example) to support access to women’s toilets on the basis of gender self-identification and simultaneously to oppose the use of puberty blockers on gender-dysphoric teenagers, or vice versa. The fact that people do not reflects the high temper of political feeling on these issues, which have been polarised in a way that unhelpfully obscures their subtleties.

Lastly, defining terms: I use ‘male’ and ‘female’ to refer to members of the male and female biological sexes. Gender dysphoria is a psychiatric diagnosis given when one’s feeling about one’s sex generates debilitating distress; it is the diagnosis that typically brings people to the attention of services like the GIDS. In many patients, dysphoria desists over time without treatment; in others, it may be treated by psychotherapy, social transition (living as another gender, either as the opposite sex, as non-binary or something else) or medical transition (basically puberty blockers, hormones and/or surgery). One who transitions and then reverses the process is called a detransitioner, and they are relevant to this tale.

Changing times

For most of its existence, the GIDS clinic enjoyed a mostly quiet life. It filled a much needed niche, handling a few dozen referrals for gender dysphoria a year.

That began to change around 10 to 15 years ago. A study cited in the Cass interim report notes that, between 2009 and 2016, annual referrals increased from 51 to 1,766 (by the end of the decade the number was over 2,000). That is not the only thing that changed in this time. The referrals got older - 75% were adolescents rather than children in 2009, and 85% in 2016. They shifted even more dramatically on the sex axis. Two-thirds of the youngsters in 2009 were male. In 2016, slightly over two thirds were female.

As noted, the sheer numbers caused quite enough havoc on their own. Whistleblower complaints focused on an overzealous drive to get people on blockers and hormones - the assumption on the right is that this represents ideological capture, but the need to get people through the door seems to be a major contributor. With (by 2020) over 4,000 dysphoric kids and teens on the waiting list, follow-up appointments with those already put on a course of hormones or blockers atrophied. Staff increasingly disagreed over the core approach - whether it should be primarily ‘gender-affirming’ (that is, proceeding on the assumption that the overwhelming likelihood was of an underlying stable transgender identity) or whether careful assessment was needed to establish that this was the case, and that the dysphoria was not merely an emergent result of comorbidities and environmental factors. In the former view, getting patients on the path to transition - or at least not unduly closing it off - was of the essence; in the latter, psychotherapy and other interventions are more obviously a first resort.

Into this increasingly unmanageable situation walked Keira Bell, a 16-year-old girl suffering acute dysphoria. After a few sessions of therapy, she was prescribed puberty blockers, later going on to male hormones and a double mastectomy. By her early 20s, she regretted her decision, and detransitioned. She ended up as the plaintiff in Bell vs Tavistock, a civil case brought against the GIDS clinic. Bell’s victory in the initial high court hearing, though it was later overturned on appeal, truly set us on the way to NHS England’s decision. The CQC found the service inadequate, and the Cass review was set in train; the NHS had already mooted regionalising this care, and with Cass’s endorsement in her interim report of January of this year, the process is now beginning.

The interim report is worth reading, since it usefully and sensitively summarises the controversies on this issue. It also highlights the matter of most serious concern, clinically speaking, which is the poor state of evidence on the effectiveness of medical transition as a treatment for youth gender dysphoria. The best evidence comes from a pioneering clinic in the Netherlands, which prescribes puberty blockers for far younger people than Tavistock ever did; but it did so on the basis that the patients they treated were largely of the ‘old’ sort: that is, predominantly males who had suffered dysphoria from a very young age, and who had undergone careful psychological assessment. The doctors and researchers at the Dutch clinic noticed that such patients, if their dysphoria persisted into puberty, typically never desisted, and so the off-label use of blockers seemed a promising treatment, and found promising initial results, though they were careful not to oversell their findings.3 Is the same true of the newer cohort of largely female pubescents? The uncomfortable fact is, nobody knows.

And the same is true of other crucial questions, concerning the long-term health effects of blockers and cross-sex hormones on young patients, and their impact - positive or negative - on mental health. On the latter question especially, the literature consists almost entirely either of honest, but inconclusive, studies by clinics or tendentious advocacy research, typically crippled by unrepresentative samples and forms of ‘P-hacking’ (hunting around in basically meaningless data to find something - anything - that breaches the threshold of statistical significance)4. This low-grade, irreproducible research is routinely presented by trans rights NGOs and the like as irrefutable evidence that any caution in prescribing puberty blockers is directly causative of suicides.

The Cass report’s recommendations - further to those already mentioned, that blockers and hormones should be available more or less on the Dutch model and subject to clear explanations of the potential risks to patients, that her commission should conduct a detailed review of the extant literature and try to plug some gaps, and that research should be built into the work of the new centres - seems reasonable, given this situation. But does the political will exist to implement it, in a period of sharpening political reaction on the subject?

Clear heads

Note that none of the above implies that gender identity is not innate and immutable (or, indeed, that it is); or that trans women’s access to women’s sports, changing rooms or prisons presents a problem for biological women’s safety (or that it does not); or that sex is a binary (or a spectrum). These are extrinsically related questions, but have been glued together as a single source of political polarisation. Gender dysphoria is a clinical matter; but there are political decisions to be made as to whether treatment should be available, and which treatments to which patients.

This is hardly a purely technical matter - baseline access to healthcare of any kind, after all, is involved, as is the unconscionable underinvestment over decades, particularly in mental health services. The NHS as a whole found out the limits of ‘just in time’ provisioning when Covid-19 hit and overwhelmed shoestring-operation hospitals; something similar happened to the GIDS in 2010-20, albeit on a much smaller scale, when slowly and then all at once its patient base increased in size by 4,000% and radically changed in its composition. This Tory government does not seem terribly likely to fund truly transformative levels of care for these distressed youth, but, even if it does, it is best not to start with a two-year waiting list!

That said, there is irreducibly a lack of scientific consensus about what, in the end, the course of treatment for these patients ought to be. Where there is a lack of consensus, there is a lack of evidence; and perhaps the most depressing aspect of the whole controversy is how utterly inimical the present climate is to serious efforts at plugging the gap. If you find evidence in favour of transition as a treatment for gender dysphoria, an army of bigoted rightist trolls and an ever-larger number of nihilistic ex-rad fems will brand you a ‘groomer’. If you find reasons for caution, liberal NGOs and their Twitterati enablers will blame you for teenage suicides. This is hardly an environment conducive to robust scientific discussion.

The right’s contribution to this toxic climate barely needs explanation - rightism works by demagogic exploitation of narrow differences between the exploited and oppressed, and always has. The extraordinary hostility between the two factions of feminism - GC and trans-inclusive, along with the socialist allies of each camp - is the more serious problem. There is a basic refusal to acknowledge that this is a division within the left, rather than between feminism and violent misogyny, or alternatively between trans people and ‘fascist terfs’; but this in the end reflects the fact that feminism cannot provide a sufficiently cohesive and comprehensive political programme, so that disagreement on details may be settled. It cannot build the political organisation that could back such a programme, for that would have to be a party. Instead, it devolves into an endless series of NGOs, whose existence depends on forcing each of their successive single issues to the apex of contemporary moral concern. Where those goals appear to conflict, no resolution - grudging or otherwise - is possible, except the extermination of one side by the other.

For all that rightists like to complain about professional liberal activists, the NGO-ification of the left is perhaps the greatest favour we have ever paid our enemies. There is no clearer evidence of this than the destructiveness of the ‘terf wars’, and the paralysis of the left in the face of rampant social conservative reaction.

  1. cass.independent-review.uk/wp-content/uploads/2022/03/Cass-Review-Interim-Report-Final-Web-Accessible.pdf.↩︎

  2. Neither Stonewall nor Mermaids UK, the youth transgender charity, have commented on NHS England’s decision, though both cautiously welcomed Cass’s interim report back in March.↩︎

  3. A de Vries et al, ‘Young adult psychological outcome after puberty suppression and gender reassignment’: Pediatrics October 2014: pubmed.ncbi.nlm.nih.gov/25201798.↩︎

  4. Apart from the summary material in the interim report, a long article by the US science writer Jesse Singal addresses the flaws in several commonly-cited studies and the way they are typically cited by advocates of gender-affirming methods: jessesingal.substack.com/p/science-vs-cited-seven-studies-to.↩︎