August 1, 2022

For years, the seeds of the Tavistock’s downfall have been hiding in plain sight, as a picture has slowly emerged of its clinicians doling out harmful drugs to gender-confused youth as if they were sweets. At the same time, though, a more subtle clue to the clinic’s endemic dysfunction has been contained in the generic communications that followed each new crisis.

“Thoughtful” is a self-description that crops up repeatedly. In response to critical reporting from Newsnight in 2019, the clinic’s Gender Identity Development Service insisted that it was “a thoughtful and safe service”. When Keira Bell and others took their case to the High Court a year later, arguing that under-16s could not give informed consent to puberty blockers, a GIDS spokesperson replied obstinately that theirs was “a safe and thoughtful service”. And when the Care Quality Commission rated the service as “inadequate”, the Tavistock’s ensuing statement defensively began: “The first thing to say is that GIDS has a long track record of thoughtful and high quality care.”

Alongside this manic insistence on thoughtfulness, there has also been a marked tendency to engage in special pleading about the especially difficult and highly contested cultural position the service occupies. For instance, in response to the damning CQC report, CEO Paul Jenkins replied that GIDS “has found itself in the middle of a cultural and political battleground”. And to the news of the closure last week, a spokesperson commented, with the air of someone sighing heavily: “Over the last couple of years, our staff… have worked tirelessly and under intense scrutiny in a difficult climate.”

Presumably what they really mean by this is that, as is now known, for several years GIDS has been caught between the emotionally blackmailing demands of transactivist organisations such as Mermaids and GIRES, talking constantly about suicide risk and lobbying hard for yet more relaxed attitudes to medicalising children, and the criticisms of those who profoundly object to the notion of a “trans child” in the first place. Former employees such as Susan Evans have reported the historical influence of Mermaids and GIRES on managers at the service, despite their lack of formal medical expertise and the possession of clearly vested interests.

Now, you might think that it is the job of a healthcare provider — and especially one who dispenses medication to children — to try to remove itself from current furores, social trends, and pressure from political activists, and to just get on with providing evidence-based medicine according to whatever gold-standard methodology is available at the time. And you might also think that while being thoughtful is all very well in a medical provider, you don’t exactly want them to emulate Hamlet. But to apply these earthbound medical standards to GIDS is to fail to recognise some of the distinctive and converging influences on the service that have led to the unholy mess we now see.

A crucial yet underappreciated part of the story is the clinic’s strong emphasis on psychoanalysis and psychodynamic approaches to mental health. The founder of the Tavistock, Hugh Crichton-Miller, was explicitly influenced by Freud and Jung. And when Domenico Di Ceglie founded the Gender Identity Service for children in 1989, later commissioned nationally as the only English NHS provider, he too was heavily influenced by psychoanalytic methods.

In a 2018 article describing his process, Di Ceglie quotes a Jungian perspective approvingly: “the psyche speaks in metaphors, in analogies, in images, that’s its primary language, so why talk differently? We must write in a way that evokes the poetic basis of mind… it’s a sensitivity to language.” He goes on to describe some of the metaphors and images he has found useful in trying help young dysphoric patients understand their own experience: the metaphor of being “a stranger in one’s own body”, for instance, or the image of navigating between the binary of sea monsters Scylla and Charybdis from The Odyssey. Throughout Di Ceglie’s published writing, there is an emphasis on the co-creation of meaning with young patients in the absence of access to any empirical certainty about who the patient “really” is.

This intellectual focus upon the fluidity and construction of meaning, and upon the power of narrative to create more stable personalities, is also heavily present in the published work of Bernadette Wren, Head of Psychology for 25 years at what insiders tweely call the “Tavi”. By her own description, she was “deeply involved” with the GIDS team for much of that time. Alongside psychoanalysis, she adds post-structuralist philosophy to her formative influences, citing figures such as Richard Rorty and Michel Foucault as important in her thinking.

True to the relativism of these philosophers, in Wren’s intellectual vision there are no objective truths but only a series of subjective narratives. She writes: “If the idea of living in the postmodern era means anything, it is that in all our activity together we are in the business of making meaning.” She continues: “In our time, it is hard to see any knowledge or understanding as ‘mirroring’ nature, or ‘mirroring’ reality.” She concludes: “There is an implication here for our work in gender identity clinics: that we are in the business of helping actively to construct the idea and the understanding of transgender, and for this we should accept responsibility.” In other words, ordinary binary notions of truth and falsity, or of discovering what is right and wrong, are inapplicable when it comes to the treatment of gender-dysphoric youth — because there are no prior fixed facts about identity, or truth, or morality here to discover. All meaning is up for grabs.

Against this intellectual background, the Tavistock’s flannel about being a thoughtful service sheltering from the storm of our present culture wars starts to make more sense. At least historically, senior clinicians at the Tavistock have never believed there is anything but certain context-bound forms of thought, floating about in a post-modern void. They have assumed meaning is constructed, not found. They have denied that there is any certain or timeless knowledge, but only specific cultural dynamics to navigate in the here and now. Under such an approach, what else could you do but be “thoughtful”?

A recognition of ambiguity within the life of the psyche would be perfectly fine — indeed, I assume, therapeutically helpful — if all that had ever happened at GIDS was that people sat around talking to one other. But the general relativist stance of senior clinicians was made incredibly dangerous for patients by the presence of an additional factor in the therapeutic mix, nestling somewhat anomalously among Di Ceglie’s stated foundational aims for his service. Alongside commonplace psychodynamic goals such as “to ameliorate associated behavioural, emotional and relationship difficulties”, “to allow mourning processes to occur”, “to enable symbol formation and symbolic thinking” and “to sustain hope”, we also find: “to encourage exploration of the mind-body relationship by promoting close collaboration among professionals in different specialities, including paediatric endocrinology.”

I don’t know about you, but when I read this, the birds — or rather the mermaids, perhaps — stop singing. For it’s at this point that it becomes clear to the percipient reader that these people think it a reasonable goal to alter a child’s healthy bodily tissue in order to accommodate a mind which is, by their own admission, constantly developing. It’s true they don’t think medicalisation is inevitable for every particular child, and it’s also true that they admit lots of uncertainty and liminality. But still, this option is on the table at GIDS, courtesy of friendly endocrinologist colleagues and their injections. (Even more shockingly, academic Heather Brunskell-Evans has documented how Mermaids and GIRES helped put this option on the table at GIDS in the first place.)

Worse, with the availability of a medicalised option, there seems to have been little real recognition among managers that its presence put the remit of the service on an entirely new footing — one that absolutely required stringent standards of truth and falsity, and a thoroughly old-fashioned belief in the existence of prior standards of right and wrong. Talking to children about their identity issues and co-creating meaning with them may be an art, but giving them gonadotropin-releasing hormone analogues (GnRHa) is still very much a science — or at least it should be.

During GIDS’s experiment in administering these unlicensed drugs, doubts were already emerging about the poor quality of the evidence base, and about the potentially negative effects of GnRHa on brain maturation, bone density, kidneys, height, sexual function, and mature genitalia formation. Yet the Patient Information Sheet offered to patients and their parents by clinicians minimised the then-suspected risks. And though the process was widely advertised as a harmless “pause” on puberty, of the initial 44 children in their initial cohort for the treatment, almost all went on to cross-sex hormones, raising the question of what made this treatment a meaningful pause for reflection in any real sense. By 2017, the Mail on Sunday was reporting that GnRHa had been prescribed to 800 adolescents under 18, including 230 children under 14 and some as young as 10.

As with Di Ceglie’s method, there is a lot of euphemism generally around discussing what happens to gender-questioning children and adolescents once they are started by adults on a medicalised route like this. Whether it is metaphors of strangers in their own bodies, heroes steering between sea monsters, mermaids, or butterflies, the effect remains pleasingly distanced and somewhat etiolated. So it’s perhaps worth spelling some things out.

Consider the following: for over a decade, and for highly uncertain gains, an NHS service appears to have been been potentially “sterilising” a cohort of minors dominated by homosexual and autistic children, leaving some unable ever to experience orgasm at all. It has exposed them all to increased risk of other irrevocable physical effects (only this month, for instance, the US Food and Drug Administration added “loss of vision” to potential side effects of GnRHa). And it has apparently made it highly likely that each will eventually end up taking cross-sex hormones in young adulthood, so moving towards a permanent change in their sexual characteristics and the surgical loss of body parts.

When looking for a suitable Homeric metaphor for GIDS clinicians and their endocrinologist associates, we should probably think about sirens, luring passing young sailors with enticing songs to their ruin on the rocks. Perhaps the sirens are somewhat quietened now, thanks to Dr Hillary Cass and her review. Unfortunately, though, there are Mermaids still out there. With a bit of luck and a following wind, the closure of GIDS will eventually spell the end of them too.