Why the Tavistock had to fall (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.

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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.

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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.

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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”?

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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.

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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.

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FAQs

Why was Tavistock shut down? ›

Tavistock and Portman NHS Foundation Trust has been told to shut the clinic by spring after it was criticised in an independent review. Instead, new regional centres will be set up to "ensure the holistic needs" of patients are fully met, the NHS said.

What happened to the Tavistock clinic? ›

The NHS trust that runs the clinic, already set to close following the February 2022 interim review by Hilary Cass, former president of the Royal College of Paediatrics and Child Health, is reportedly facing a mass action lawsuit, with a particular focus on the use of so-called puberty blocker drugs.

What are puberty blocking drugs? ›

Puberty blocker medications contain stable amounts of gonadotropin-releasing hormone (GnRH) analogs, which help suppress sex hormones like testosterone and estrogen. Once these hormones are “blocked,” the physical changes that would occur during puberty are paused. Goserelin (Zoladex®). Histrelin (Supprelin®LA).

Who is Sonia Appleby? ›

Sonia Appleby is children's safeguarding lead for Tavistock and Portman NHS Trust, which runs the Gender Identity Development Service. The tribunal ruled that the way the trust treated her had damaged her professional reputation. The trust said it was disappointed by the tribunal's decision.

What does the Tavistock Centre do? ›

The Tavistock and Portman NHS Foundation Trust is a specialist mental health trust based in Camden, London, offering high quality mental health care and training.

When was the Tavistock Clinic opened? ›

The founding

The Tavistock Clinic saw its first patient, a child, on 27 September in 1920. Its name was taken from its original location at 51 Tavistock Square. The Clinic was established by Hugh Crichton-Miller, with contributions and pledges from wealthy donors and started off with seven doctors.

What is the CASS report? ›

The Cass Review was commissioned to ensure that children and young people are able to access the best possible support from the NHS, and a high standard of care that meets their individual needs. It will gather evidence to determine how the NHS can provide sustainable models and pathways of care into the future.

Can gender dysphoria go away? ›

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

At what age can you transition? ›

The Endocrine Society recommends that they wait until age 18, but because more kids are transitioning at younger ages, some doctors are doing these surgeries earlier on a case-by-case basis.

Do puberty blockers make you taller? ›

According to medical research, doctors prescribe the puberty blocking drug to short kids to essentially give them more time to get taller, since puberty culminates with the body's long bone growth ending. Medical researchers have repeatedly warned against such off-label usage.

Who runs Tavistock? ›

Joe Lewis owns the Tavistock Group, with more than 200 assets across 13 countries. Through Tavistock, Lewis owns Premier League soccer team Tottenham and has a stake in U.K. pub operator Mitchells & Butlers.

Who owns the Tavistock Institute? ›

The Tavistock Association

How do I get referred to Tavistock? ›

Your GP can check whether your local services have an arrangement with us. If you are already seeing local services, discuss with them what you want and they should be able to refer you. You can also contact us directly via this website for advice and information on whether your local services can refer you to us.

When was Tavistock hospital built? ›

Dr Hugh Crichton-Miller founded the Tavistock Clinic in 1920, applying what he had learned treating shell shock victims during the Great War to provide treatment to civilians with nervous disorders. Though influenced by Freud and Jung, he also used his own medical experience and his faith to guide his approach.

What is CASS compliance? ›

The FCA's Client Assets Sourcebook (CASS) provides rules for firms to follow whenever the firm holds or controls client money or safe custody assets. CASS helps ensure the safety of client money and assets if a firm fails and leaves the market. CASS has many recordkeeping requirements listed throughout.

What is CASS client money? ›

CASS 7.2.1R 01/11/2007. For the purposes of this chapter and the MiFID custody chapter, client money means any money that a firm receives from or holds for, or on behalf of, a client in the course of, or in connection with, its MiFID business unless otherwise specified in this section.

When was the Tavistock Clinic opened? ›

The founding

The Tavistock Clinic saw its first patient, a child, on 27 September in 1920. Its name was taken from its original location at 51 Tavistock Square. The Clinic was established by Hugh Crichton-Miller, with contributions and pledges from wealthy donors and started off with seven doctors.

Do puberty blockers have side effects? ›

Effects of puberty blockers

growth of facial and body hair. deepening of the voice. broadening of the shoulders. growth of Adam's apple.

What is the CASS report? ›

The Cass Review was commissioned to ensure that children and young people are able to access the best possible support from the NHS, and a high standard of care that meets their individual needs. It will gather evidence to determine how the NHS can provide sustainable models and pathways of care into the future.

Are puberty blockers reversible? ›

Are they reversible? The effects of puberty blockers are physically reversible. Puberty blockers only pause the production of testosterone and estrogen hormones. Once a person stops using this medication, their body begins production once more, leading to the development of breasts and facial hair.

What does the Tavistock Centre do? ›

The Tavistock and Portman NHS Foundation Trust is a specialist mental health trust based in Camden, London, offering high quality mental health care and training.

What was Tavistock? ›

Tavistock (/ˈtævɪstɒk/ TAV-iss-tok) is an ancient stannary and market town within West Devon, England. It is situated on the River Tavy from which its name derives.

Who runs Tavistock? ›

Joe Lewis owns the Tavistock Group, with more than 200 assets across 13 countries. Through Tavistock, Lewis owns Premier League soccer team Tottenham and has a stake in U.K. pub operator Mitchells & Butlers.

Do puberty blockers make you taller? ›

According to medical research, doctors prescribe the puberty blocking drug to short kids to essentially give them more time to get taller, since puberty culminates with the body's long bone growth ending. Medical researchers have repeatedly warned against such off-label usage.

What age can you change your gender? ›

Gender reassignment surgery is widely restricted to adults over the age of 18.

Do puberty blockers affect sperm? ›

Taking puberty blockers alone should not affect your ability to have a baby in the future.

What is CASS compliance? ›

The FCA's Client Assets Sourcebook (CASS) provides rules for firms to follow whenever the firm holds or controls client money or safe custody assets. CASS helps ensure the safety of client money and assets if a firm fails and leaves the market. CASS has many recordkeeping requirements listed throughout.

What is CASS client money? ›

CASS 7.2.1R 01/11/2007. For the purposes of this chapter and the MiFID custody chapter, client money means any money that a firm receives from or holds for, or on behalf of, a client in the course of, or in connection with, its MiFID business unless otherwise specified in this section.

Can you take puberty blockers forever? ›

If your child decides that they want to develop characteristics of the sex they were assigned at birth, they can simply stop taking puberty blockers. Once the puberty blockers are out of their system, they'll go through the puberty of the sex assigned at birth.

Do puberty blockers stunt brain growth? ›

Puberty blockers delay the start of puberty, including development of secondary sex characteristics. Surprisingly, even though puberty blockers are widely used to help transgender adolescents go through gender transition, their impact on brain function during this critical stage of brain development is largely unknown.

How many genders are there in world? ›

There are many different gender identities, including male, female, transgender, gender neutral, non-binary, agender, pangender, genderqueer, two-spirit, third gender, and all, none or a combination of these.

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