The Collapse Of The UK’s Gender Identity Clinic - Hannah Barnes

1. 0:00 – 0:33

   Intro

   1. HBHannah Barnes0:00

      Who's to blame? Lots of people are to blame. The leadership of GIDS is to blame, and they should take responsibility for the decisions they did and didn't make. The leadership of the Tavistock Trust are to blame for not taking seriously enough the concerns that were brought to them by a sizeable number of staff working in that service, who were not transphobic, who were relaying clinical concerns, safeguarding concerns, safety concerns, and potentially child protection concerns about the young people they were caring for. (wind blows)

   2. CWChris Williamson0:31

      How did you feel

2. 0:33 – 4:39

   How Hannah Thought Her Book Would Be Received

   1. CWChris Williamson0:33

      before releasing this book, and during the research, what did you think the sort of response was going to be like upon revealing your investigation, and what's it actually been like since it's come out?

   2. HBHannah Barnes0:46

      I think the weeks and months prior to publication were the worst. I was very, very nervous, and it had been years of work, and it's a bit like, it was a bit like a third baby really. I've got two kids, and, you know, you take your baby out into the world and you want people to, to love it. Um, obviously not the way that you do, and, uh, I love my children more than my work, but I was really nervous about how it would be received and, and the response that I would, would get as well. And I have to say, I've been so pleasantly surprised, in that the, the response has been overwhelmingly positive. I mean, there have been favorable reviews on the left, on the right of British politics. I've spoken with Public Service Radio in Australia, the first time the ABC have really looked at this topic, acknowledging that, you know, p- people do have concerns about the evidence base in particular. I've spoken to NPR over there in the States. Um, and I think when you get favourable reviews, um, for your British viewers, you know, from The Guardian newspaper, from The Observer, from The New Statesman, but also from The Telegraph, The Mail on Sunday, The Sunday Times, The Times, you know, it really speaks to the, what I was trying to do with this book, which is, this is a health story. It's not an ideological story. I'm not a culture warrior in any way. It's about whether the best care was always provided to each and every one of the young people being seen at, at that gender clinic.

   3. CWChris Williamson2:19

      It seems like, for the very well-meaning people who are trying to raise well-meaning concerns around the ability to consent, the effectiveness of different treatments, the, um, confusion both, on both sides of the, uh, consultant desk, around how this stuff works, that because it is so ideologically heated, it's incredibly difficult. And also, it, this decision, I would actually say that some of the people on the right have made this a more difficult conversation to have, because of how inflammatory and how reactionary some of their conversations have been, because it's very easy to lambast anyone who decides to criticize this. It's, "Oh, you must be one of those reactionary far right people. You, you just want, you know, all trans people to die." And you go, "Well..." I can see why, uh, treading carefully, as it seems like you have done, uh, has hopefully managed to, uh, even out the, uh, the balance between left and right.

   4. HBHannah Barnes3:19

      I think so. But, but also, I mean, just the way that I've approached the story and that we approached it at Newsnight, where this started, has always been, you know, we've tried to be calm. We've never questioned people's identities or the right to transition. It's not ever been about that. It's about, as I say, about the standard of care. And I think sometimes, as you mentioned, the language used when this or related issues are discussed is really unfortunate. And what I've tried to keep in mind the whole time while writing was, you know, we're talking about children and young people, and we need to, you know, be really careful in our language. And often those young people are really distressed, and i- it doesn't help to, to speak in really inflammatory terms. I think it's far more heated in the States than it is here. Obviously it's very divisive here as well, but we don't have, you know, you mentioned sort of the evangelical right and, and the hard right who want to, who deny the existence of trans people and perhaps want to take away all care. And I don't think we have that here in the UK.

   5. CWChris Williamson4:26

      No, I would agree. Um, for the people that are just in the UK and think that this is a very heated topic, turn that volume up by 10 times, and that's what you've got over here in the US. Okay, so, what is the story

3. 4:39 – 19:19

   The Story of the Gender Identity Development Service (GIDS)

   1. CWChris Williamson4:39

      of GIDS?

   2. HBHannah Barnes4:42

      Wow, where to start? Well, it started off as a, as a, uh, it was the brainchild, if you like, of a child and adolescent psychiatrist called Domenico Ticheli. And he was really moved by a single example, a young person he was seeing in the early 1980s, who was female born, but strongly identified as male and was very distressed about being in this female body. And that example, and a couple of others that he saw in his work as a psychiatrist in Croydon, sort of south London, gave him this idea that there had to be a specialist service for these young people who had this, what he called a very rare, uh, condition, where there was this mismatch potentially between biological sex and, and how they identified. And he succeeded in opening this service in 1989 at a South London hospital called St. George's. And then it moved to its current home, the Tavistock and Portman, in 1994. And, and really for quite a long time the numbers were very small, the service was about talking therapies, about trying to help those children and young people, uh......explore their gender identity, to understand it, to reduce their distress, to help them manage uncertainty. Um, there was also, they did some work in schools about sort of trying to break down stigma. And what he noticed, even in those very early days, was that often young people would obviously, they'd have their gender-related distress, but they'd also sort of have quite a few other difficulties as well. (smacks lips) And while it was never the aim of the service to try and change someone's gender identity or to sort of push them one way or the other, he noticed that sometimes by exploring someone's gender and kind of trying to help the distress being brought by the other conditions, perhaps sort of depression, anxiety, or, or what have you, then it might actually relieve that gender-related distress at the same time. So it was a very cautious, slow approach. And what we know as, colloquially as puberty blockers, they were available in the 1990s, but to 16-year-olds only. So you'd pretty much had to have, have gone through puberty, um, by the time you could have them. And the idea was that they would help to prepare the body for those who wanted to transition, um, prepare the body for the administering of, of cross-sex hormones or, or gender-affirming hormones. Um, and it was acknowledged at the time that adolescence, well, it's acknowledged by, by professionals who work with young people, adolescence is a great time of fluidity. And that gender incongruence in children was not quite the same as it is in adults, in that it, it might not be fixed. And actually, in some guidelines that Domenico Tcheli wrote in the late '90s, it actually stated that professionals working with these young people should be mindful that, um, strength of feeling might not indicate permanence, if you like. You know? That it was still, even if someone felt very, very strongly, it, it, it might not be that, that, that they would feel that way forever. Uh, and then th- the service sort of remained quite small. And in, in the 2000s, it became under increasing pressure to provide those medications to, to younger-aged people. And that was essentially because a team in the Netherlands had started doing that. Um, and JIDS was the second, is the second oldest gender clinic for, for children and young people, just after the Netherlands. Um, and-

   3. CWChris Williamson8:36

      Second oldest in the world?

   4. HBHannah Barnes8:37

      Yeah. In the, in the world. Yeah.

   5. CWChris Williamson8:38

      Wow.

   6. HBHannah Barnes8:40

      So I think that the Dutch opened in '87, I believe. And, um, yeah, JIDS opened in '89. And there weren't very many people working in this field. And, and as we went through the 2000s, pressure grew on the service. It appeared there was some very early data coming back from the Dutch team, and it appeared that there was something here that would help this very small group of young people who were very, very distressed, who had their gender incongruence from early childhood, and it had persisted and was consistent throughout, and, and had intensified with the onset of puberty. And it's, it's, it's a misnomer that pressure solely came from, from young people and families and, and perhaps sort of trans-friendly groups. It, it, it came from all quarters. It came from them certainly, but it also came from other clinicians working in this field. It came from those working in adult gender clinics, who said, "Look, we, we deal with those, those adults who have had to go through puberty, and it's really distressing, um, in some cases." Um, and it came from endocrinologists as well. And so they took a, they, they still had concerns. Like the concerns that, that, that they had at the time was what impact blocking puberty at the younger age could have on bones, because puberty is the time where our bone mineral density is increasing at its fastest rate. So if you stop that, what, what's the impact gonna be longer term? And we s- we still don't really know that. We know it's not good to stop it, but when you reintroduce hormones to the body, whether that's our naturally occurring ones or synthetic ones, it does increase again. But we don't know whether you actually would have hit the peak that you would have had you not interrupted it. We don't know that yet. Um, and they were concerned about what impact it might have on development, you know, your sexual identity, on brain, all these other things. And those, those concerns didn't go away. But, but they were, they were under pressure. And actually, there was an ethical argument that here is a treatment that might be very beneficial to this group of young people. Let's proceed on a cautious basis. We want to try and add to this evidence base because there aren't much data, so let's try and monitor a selected group of young people and s- and see what the results are. So that's what they set out to do in 2011. And they ran this research study. They recruited 44 young people from, from the age of 12, uh, over the next three years. Um, and then sort of quite strikingly, rather than wait for that data to come back, in 2014, just after they had recruited the last young person to the study, so they'd only just started the blocker, they, they rolled out early intervention as it became known a- a- as policy across the service. Um, s-

   7. CWChris Williamson11:36

      Wha- How young is early intervention?

   8. HBHannah Barnes11:39

      Well, at that point it was 12. But what they did in 2014 was not just roll it out and make it to anyone who fitted certain criteria, but, but as not part of a study. But they actually did away with that younger age limit altogether. So they moved from what was called a, an age approach to a stage approach. So providing someone had reached what they call Tanner stage two of puberty, which is pretty early puberty, um...Um, so for girls, it- it- you- you could've been- you could be in Tanner stage two, for example, but have not started your periods. Um, it's- it- it's that early. And provided you hadn't reached Tanner stage two, you could potentially go on to puberty blockers. So, for example, in- in girls in particular who tend to start puberty earlier, that could be as young as- as nine or 10. And certainly, um, data that- that GIDS have presented publicly has shown that, um, they've re- referred a nine, you know, a nine-year-old for- for puberty blockers and 10-year-olds have- have- have started on puberty blockers. Not- not many, but they have.

   9. CWChris Williamson12:41

      Okay, so that's 2014. Um-

   10. HBHannah Barnes12:44

       Yes. And then what happens is, um, at the same time that- that- that the puberty blockers have become sort of more widely available, this coincided with a really quite rapid increase in the number of young people being referred. Um, and we saw this rise in absolute numbers. So from 2009, or '09-'10, the financial year, 97 referrals to- to- to GIDS. It then in-

   11. CWChris Williamson13:11

       Had that been... Sorry, had that been relatively flat throughout the 2000s?

   12. HBHannah Barnes13:14

       Uh, well, it- it had grown, but not, you know, quite steadily, you know?

   13. CWChris Williamson13:20

       Well, when were we in 97-

   14. HBHannah Barnes13:20

       And some years it went up and some went-

   15. CWChris Williamson13:22

       Yeah.

   16. HBHannah Barnes13:22

       Yeah. So it wasn't, it wasn't huge. I mean, it- it- it'd gone up, it- it- it did double one year. Which year was it? Uh, from memory, I can't... I think it might have been about 2005, potentially. Went from 20-something to 50-odd. But- but it- it, you know, it- it was relatively small. And- and so we had this 97 in- in 2009-'10, and then it- it went up 50% per annum until 2015 where it doubled. And that was beyond anybody's expectations. And-

   17. CWChris Williamson13:57

       So what number does 2015 get us to? How many people is that?

   18. HBHannah Barnes14:00

       So, it was 1,400 and something.

   19. CWChris Williamson14:04

       Okay.

   20. HBHannah Barnes14:04

       Um, and so not only did they see this really quite rapid increase in referrals, but there had been a really dramatic shift in the demographics of the referrals at the same time. So where has- whereas previously, the majority of those referred had been boys, biological males, um, who had often had sort of lifelong gender dysphoria or gender incongruence, what happened over that five-year period or so is that the girls then equaled for the first time around 2011, and then massively overtook the boys. So by 2015, it was two-thirds female in terms of referrals, and they tended to be girls who didn't have this sense of lifelong gender incongruence, but really, their gender-related distress had started after the onset of puberty, in adolescence. And they often were contending with quite serious other problems as well, like eating disorders, suicidal ideation, depression, anxiety. Some had suffered physical or sexual abuse. Um, so they were really quite complicated young people. And this is really when clinicians working there started to worry, because the evidence base for using the puberty blockers was limited anyway. And that's why they set out to do the study in the first place, to try to add to it, because we didn't really have much data. There was a bit more by this point from the Dutch, but it- it's still, it's one- one gender clinic. But what GIDS was now doing was applying a medical treatment for... which had a low evidence base to start with, to a completely different cohort of young people, for whom there w- really was no evidence that it worked. And- and actually, the leaders of the service were quite open about that, and they spoke to the UK Parliament in 2015, and in their evidence they said, "We have extended the use of physical interventions to those for whom there isn't a robust evidence base. We're not seeing the young people that are in the Dutch study, um, but we think it will benefit them." Now, it was well-intentioned, but it wasn't evidence-based at that point. And- and- and the evidence really never came to support the widespread use of puberty blockers for- for this cohort of young people. And we haven't really s- we haven't seen that from other gender clinics either. And- and a year later, 2016, some- some... the initial data started to come back from that- that study, which showed that, at that point, every single one of the young people who'd gone on the blocker and who was eligible to go on to cross-sex hormones, the next stage of a, of a medical transition, had done so. And for some clinicians, you know, as- as one- one clinician in the book said, that was, that was their holy fuck moment, because it exploded this idea that they were telling families and that they had been led to believe themselves that the blocker was providing time and space to think, which made perfect sense. Like, the idea that someone is very distressed about their developing body, that's not the gender they identify with, so if you pause the body's development, then that made sense, that you would pause the distress and allow- allow time to think. But some people started to question, "Well, you know, what are the odds of adolescents in particular having time to think, but then all thinking t- the same way?" Like, generally, that's not something we see. And moreover, when young people were approved for the blocker-... that they were given no space to think, either by the service. Because rather than increase the amount of time they spent talking with professionals, and using that time, in fact, the frequency of appointments went down, and they saw the service less often. So, for some, it made... It just totally changed the way they practiced. They- they saw that actually, their decision to refer someone for puberty blockers ... And I say refer, because GIDS doesn't prescribe. They refer, and then some endocrinologists at- at two other hospitals do the prescribing. That decision became much, much more serious. Because if it was the case, as it appeared to be, that those young people would almost inevitably go on to cross-sex hormones, then decisions needed to be had before you started the blocker about what transition might look like, what someone should expect from physical transition, the irreversibility of cross-sex hormones, what was known, what was not known. And so this- this was a real turning point.

   21. CWChris Williamson19:16

       It seems like the puberty blockers

4. 19:19 – 30:35

   When GIDS Started Using Puberty Blockers

   1. CWChris Williamson19:19

      become much more of a- a one-way street, or a set of train tracks, that once somebody gets put on them, it's rare that they're going to deviate.

   2. HBHannah Barnes19:26

      Well, it's really difficult to know for sure. Because what we don't know is that ... We d- we don't know that going on the puberty blocker in some way causes someone to stay fixed in their identity, and therefore, um, to go on to the next stage. And we don't know that because of the way the studies are designed. We can't infer cause and effect. But that is certainly what clinicians believe, that- that it might be. And- and, you know, you can't really say any more than might, but it might be that somehow pausing development or- or- or- or blocking puberty might, in some way, lock in an identity and stop it from changing where it might have. And it- it might not have in all people. And- and I think it's really important to stress that, for any group of children and young people who have gender incongruence, from the studies that exist in the past, there have always been some that went on to transition as adults, so no one was ever questioning that. But there have always been a group that haven't as well, um, and that tended to be the larger group. But- but the- the concern actually initially about blocking puberty earlier w- w- was this: whether you would somehow lock in an identity that- that might have changed if you didn't do it. And- and that was something that was acknowledged by the Dutch team that pioneered this approach. They talked about sort of slightly unfortunate phrase, but they talked about something they called false positives, that if you blocked earlier, you might end up with these false positives, i.e., people who wouldn't have transitioned had- had they not gone on the blocker. Um, it's quite a euphemistic way of putting it. But, um ... So, it was always acknowledged that this might happen. We don't know whether that is what's happening. And GIDS would say, "Well, look, it's not surprising that all those young people went on to- to cross-sex hormones, because we really carefully screened them. And we judged ... We only, for that study, referred those for whom we thought were most likely to persist and become trans adults and transition, because they'd had this- this lifelong gender incongruence. And we assessed really carefully, and- and we're just really good at this. And- and- and that's why we got the results that we had." And I think there are a couple of problems there, in that there are named professionals who took part in some of those assessments who say, "Actually, our assessments weren't that good, and I did assessments that weren't that good." And it's not very common for human beings to admit they made mistakes. And I think when people are prepared to their name for it, I ... There- there seems to be no incentive for- for someone to do that, other than it- it being true. And I think the second difficulty is that, while that may have been the case for that small group of 44 young people, um ... Although, as I've said, clinicians who took part in those assessments have- have challenged that. But even if you accept it for those 44, it- it seems to be the case that the vast majority of young people, period, go on to take cross-sex hormones. And these were not the young people who were carefully screened and had lifelong incongruence and- and- and what have you. So, there are ... There are a couple of difficulties there.

   3. CWChris Williamson22:51

      Have you got any idea of how many patients were arriving at GIDS versus how many were being given puberty blockers?

   4. HBHannah Barnes23:01

      It's really, really difficult to put a number on it. And this is ... I have tried very, very hard, as- as have many other people, to ask GIDS and the endocrinologists at both University College London Hospitals and Leeds Teaching Hospitals where the endocrinologists are based, how many young people have been referred, uh, and then prescribed puberty blockers. The honest answer is we don't know. From what is in the public domain, it would seem about ... I'd put it about 17, 1800. Um, we know that in 2017, in response to a Freedom of Information request, GIDS said that they had referred, um, 1,261. So, that was 2017. Now, there was a period where not much happened at all because of- of- of legal disputes. Um, there was a paper published last summer which- which gave some- some more figures for 2017 to '19. And- and adding those up together with- with some data that I received back from- from- from one of the hospitals, I would say it's sort of ...... uh, yeah, min- minimum 17, 18 hundred. Which, which, might s- not sound like-

   5. CWChris Williamson24:15

      A year or across all of them?

   6. HBHannah Barnes24:16

      ... a- across a- ac- since, since 2011, or sin- since s- or, or potentially since, um, it was nationally commissioned in 2009. But, but really there was s- so few at th- in those early years anyway because they weren't available. Um, that might not sound very many, so we think they've seen, in that time, about 10,000. So it's about, about 20%. But I think it's quite misleading to look at it that way. And because it's, it's ... I think it's more fruitful, potentially, and, and this is what GIDS haven't really answered is to look at, well, how many of the people that were eligible were referred? Because there's, there's a, there's one graph in the book and this is kind of the best data we have, which is really kind of poor in itself. And this is from 2018, and it, it shows the proportion of young people who had been referred to the clinic between 2010 and 2013 who, by 2017, had been referred to endocrinology, so for puberty blockers. And what you can see very clearly is sort of a bell, a classic bell curve, that at, at both ends of the age distribution, the very young and the very old, you have quite low proportions. So, you know, the three, four, five-year-olds, um, who were referred d- during that time, um, they wouldn't have been eligible basically 'cause they hadn't started puberty. So that kind of rules them out. Sixteen and 17-year-olds, the 17-year-olds in particular, very low proportion because there's not really much point going on a puberty blocker. You can go straight on to adult services and, and, and have hormones direct. So a- and that's, clinicians say that happened quite a lot. The, the older ones would say because the rules here, not, not in the States, but the rules here were even if you were 15, 16, 17, you had to go on puberty blockers for a year before you could go on hormones. Um, you could never go straight on to hormones. So, so lots of people just waited for adult services. But what you see in the middle, these kind of adolescent years, is very high proportions of young people who were referred between the ages of 11 and 15 were then referred for blockers. Um, and those who were referred in that time period, 2010 to '13, who were 14, in fact about, about 70% of them did. So averages can be very misleading and, you know, for years GIDS put out a figure in the public domain, they gave it in loads and loads of interviews, they said about 40% of the young people are referred for puberty blockers. And of those who we see who are referred under 12, it's about 20 to 25%. Which you don't have to be a mathematical genius to work out, well if the average overall is about 40% and the under 12s is about 20, then it, it sort of implies that the over 12s is about 60. You know, just basic maths. Um, and, and those proportions have come down but really without the actual proper data in the public domain all we can surmise is ... th- these are my best estimates.

   7. CWChris Williamson27:34

      Well, isn't this place run by the NHS?

   8. HBHannah Barnes27:36

      Yeah.

   9. CWChris Williamson27:37

      Is that not owned ... But I mean, how is this not-

   10. HBHannah Barnes27:40

       (laughs)

   11. CWChris Williamson27:40

       ... freedom of information? Like, it's literally-

   12. HBHannah Barnes27:43

       Well-

   13. CWChris Williamson27:43

       ... owned by the British government.

   14. HBHannah Barnes27:46

       Well, yeah, it's not owned by the British government but I know what you're saying. I mean-

   15. CWChris Williamson27:49

       Yeah.

   16. HBHannah Barnes27:49

       ... there have been countless freedom of information requests asking for this data, and the response is, "We don't have it." Or, "We have it, but it would take far too long for us to get it because that information-"

   17. CWChris Williamson28:02

       Screams NHS. Absolutely screams NHS. (laughs)

   18. HBHannah Barnes28:07

       (laughs) Well this is, this is the individual trust. So, so they've been asked-

   19. CWChris Williamson28:10

       Oh, yeah.

   20. HBHannah Barnes28:10

       ... on, on many ... And, and you know, occasionally they've given us bits of data like that, that 1,261. That, that came from a freedom of information request. Um, and I have personally, um, FOI'd the Trust and, and the endocrinology hospitals and they haven't provided it. Um, they must have it. And, and, and it is in those patient records obviously, if a young person's been referred. But I, I think also concentrating solely on the physical interventions only tells a fraction of the story. I mean, you know, we don't know what's happened to those who weren't referred for them while at GIDS. We don't know whether their gender distress resolved, and if so, how, and what they're doing now. We don't know how many went on to adult services, we don't know how many people are happy, we don't know how many people are not happy. Um, we don't know-

   21. CWChris Williamson29:04

       G- give-

   22. HBHannah Barnes29:04

       ... much at all.

   23. CWChris Williamson29:05

       Given that this is an incredibly serious intervention that has lifelong repercussions, this is the sort of thing that tracking would have been pretty useful for. Just how effective is this sort of intervention? Just how effective is it to not intervene? Can we do talk therapy?

   24. HBHannah Barnes29:22

       Absolutely.

   25. CWChris Williamson29:22

       Can we do other things that don't lock in this set of train tracks? Down ... Okay, so am I right in saying that GIDS only ... All that they did was refer for puberty blockers? They weren't doing, um, s- they weren't referring for surgery, they weren't referring for anything else? Was the sole thing that they did refer for puberty blockers?

   26. HBHannah Barnes29:46

       Yeah, they had absolutely nothing to do with surgery. So everybody they saw was under 18, and, um, I, while I believe that you can get, uh, double mastectomies now at 17, uh, no. They, they, they have nothing to do with that, that's solely adult services. So they would refer for puberty blockers, and this is the key thing that, that from around 2014 also when they became, in their own words, an assessment service, there was no other treatment pathway that they offered.So, they didn't, they- they weren't offering extended ongoing talking therapy, like you say. They would assess for suitability for physical interventions. And that's not to imply that the majority were referred on to that, but they weren't offered anything else really either.

   27. CWChris Williamson30:32

       Are puberty blockers reversible? Because that's something that

5. 30:35 – 40:45

   Are Puberty Blockers Reversible?

   1. CWChris Williamson30:35

      I've heard claimed.

   2. HBHannah Barnes30:37

      The honest answer is, we don't know. I mean, physically, they are ... Well, the honest answer is, we don't know. The official NHS guidance is, little is known about the long-term side effects of using puberty blockers to treat this condition, because they function very differently when used, um, in gender distressed young people than they do in the treatment of precocious puberty, for which they are licensed. Because in precocious puberty, where a child starts puberty very, very early, like way before they're ready, they take the puberty blocker, it pauses the development, and then they stop, and then they go through their body's biological puberty. In ... Generally speaking, as we've already mentioned, when a young person experiencing distress about their gender takes a puberty blocker, they don't stop. They take it, and their body never goes through their biological puberty. They will then go on to cross-sex hormones, and hormones will return to their body and- and their bones will start strengthening again, but it's not- it's not their body's natural- naturally occurring hormones. So, systematic reviews of the evidence base have been undertaken here in England by NICE, the National Institute for Care and Health Excellence, in Sweden, in Finland, and I believe Norway now as well, by the respected health bodies, the official health bodies. And in all those cases where they've undertaken a systematic review, they've found the evidence base wanting on the efficacy of using both puberty blockers and cross-sex hormones, um, in- in this area of healthcare. But physically, they are reversible, in that if you stop then yes, puberty resumes. But- but what we don't know, and what's acknowledged by the NHS in its official guidance, is we don't know what long-term impact blocking puberty might have on brain development, on cognitive development, on sexuality, on the development of other identities. Uh, so we- we don't know any of that, because-

   3. CWChris Williamson32:51

      Yeah, I-

   4. HBHannah Barnes32:51

      ... the long-term data doesn't exist.

   5. CWChris Williamson32:53

      Right.

   6. HBHannah Barnes32:53

      And- and interestingly, there's a case study in the book, a young trans man called Jacob who took the blocker for four years, from 12 to 16, was not very well on them at all. And, you know, the argument is, yes, they're physically reversible and puberty resumes. Well, he didn't get his periods for two years after coming off the blocker. And even now, he's 19, they're not regular. And surprisingly, he's not being monitored at all. There's been no follow-up since he chose to leave the care of JIDS. So, the statement is made that they're physically reversible, but in fact, when used to treat this condition, we really don't know. So few people come off, and then they're not followed, that we don't know, and we don't have the long-term data.

   7. CWChris Williamson33:45

      What about the effectiveness of puberty blockers for helping with suffering and suicidality in youngsters?

   8. HBHannah Barnes33:55

      Well, again, the data are really quite poor. Um, the original Dutch studies argued that there was a psychological ... They saw psych- psychological benefit to- to going on the puberty blockers, and- and- and then they didn't actually measure the sole impact of cross-sex hormones. It was hormones and surgery. Um, and they said the whole pathway was- was- was beneficial. But- but when JIDS tried to replicate the Dutch within that study, we didn't get those data back until, well, very late 2020 in a pre-print, but officially published in 2021. And actually, when using quantitative measures, proper measurable stuff, they found no psych- psychological benefit to the young people on puberty blockers. Um, and in fact, even by the- the subjective qualitative measures, the- the self-reports from those young people, it was a really mixed bag as well. So the- the- the researchers, the team reported that, um, the majority had a positive experience, um, and obviously none wanted to come off. But actually, the data, it's not really that strong. And even in those qualitative measures, when you look at those who'd been taking them more than a year, it's about equal proportions. Some, i- in terms of about 30% reported, or just under 30% reported positive mood changes, and 30% said negative mood changes. And what's so interesting is that actually they had data that- that showed that as far back as 2016 or 2015 even. That- that for some people, well, there was no improvement, and actually for some people they appeared to get worse. So, there really isn't strong data, certainly from the UK, that supports the argument that puberty blockers, uh, improve mental health or reduce suicidality. I know that there are studies in the States, that come out of the States, that claim to show that. But actually, they're pretty methodologically flawed and- and they have been quite heavily critiqued, and- and often don't actually show what they claim to show higher up in the paper when you look at the data. So I ...Yeah. Um, it's pretty weak.

   9. CWChris Williamson36:23

      It stacks up a very serious body of evidence here. Um, you have an intervention which may not impact people in the way that it should do in the short term. It may not have the reversibility that would make it less of a big deal in the medium term. It may not fix the problems that are concerning in the long term, and it may also lock these individuals into a trajectory that they can't get out of on the life long term. That seems like an incredibly big decision to make. It should be one that's incredibly heavily scrutinised. It's one that should take a very long time to, to get to. And I understand that when this intervention or these interventions were first being rolled out, you don't know what you don't know, you don't know just how serious it is, et cetera, et cetera. Uh, I presume that the unknown unknowns and the gaps in knowledge are precisely where a lot of the holes, uh, like people fell through these holes. Both in terms of the clinicians, the, the consultants, uh, and the patients.

   10. HBHannah Barnes37:31

       Yeah. And I, I, I think it's really important to acknowledge that there are consequences to not acting as well. And, uh, you know, I've spoken to people for the book who have very happily transitioned, and they describe puberty blockers as, as lifesaving. So that is some people's experience. And there is an argument that, um, that some in the trans community and, and, and trans allies will put forward that they're not meant to be, um, you know, antidepressants or anything. They, they, they block puberty, and they prevent a young person going through changes that, that they can never reverse if they choose to transition as adults. But I think which is, which is true. Like that is one, one rationale given for the blocker is that it prevents future surgery, and it makes, particularly for, for, for biological males, it makes it easier to, to pass as adults if, if, if, if they choose to transition. I think the difficulty is that, that these various other rationales, sort of the time and space to think, and the improvements in mental health, and the reduction in distress, have been given as the rationale for using the blocker, um, by researchers and by gender clinics. And, and so it's, there's sort of shifting goal posts as to what we're measuring and, and, and, you know, uh, it, it's almost as if when, when the data doesn't support the original hypothesis, then the hypothesis changes perhaps.

   11. CWChris Williamson39:04

       Yeah.

   12. HBHannah Barnes39:04

       Um, and I think you're right with the unknown unknowns. And I think when this started, it was a perfectly ... It was trying to help a very small number of people with a very sort of specific difficulty. And they proceeded with caution, and they tried to add to data, tried to add to the evidence base. But when data came back that, that didn't, that wasn't consistent, that didn't support what they believed, they didn't, that didn't give pause for thought. And that's what's quite striking. So it, it, it wasn't an ... It may well be that, that, you know, blockers, as I say, I've spoken to people for whom they've been lifesaving. But it seems that when they're applied to a completely different cohort of young people who, um, you know, who never met the criteria of the Dutch study, you know, they weren't psychologically stable, they didn't live in supportive necessarily, um, you know, stable home environments, and they didn't have lifelong gender incongruence, it's not really that surprising that you don't get the same results. And the surprising thing is to roll out one intervention to a, a massive group of people and not think that perhaps something else might be needed in, in some of those cases. And it's not to say that, that some won't benefit from them. But I think, I think the evidence base hasn't really advanced much in 20 years.

   13. CWChris Williamson40:40

       Yeah, it doesn't seem that way.

   14. HBHannah Barnes40:42

       Um-

   15. CWChris Williamson40:42

       Given, given the fact that this, that the puberty blockers

6. 40:45 – 42:28

   Is it Ethical for Minors to Consent to Life-Altering Procedures?

   1. CWChris Williamson40:45

      aren't reversible, even if they were reversible, I don't know if this, uh, i- if it changes this concern. How can it be argued that it is ethical to allow an individual who is not old enough to buy a lottery ticket, buy a Red Bull, vote, drive a car with a teacher in the seat next to you, have sex, watch porn, how is it possible for that kind of person to be allowed to consent to any kind of procedure which could have lifelong implications?

   2. HBHannah Barnes41:30

      Well, the argument that one of the women who led GIDS for a decade, uh, she retired in 2020, Bernadette Wren, wrote was that from its outset, GIDS was not just a therapeutic project. It was a justice project, and it was about extending the rights to live one's life, personal autonomy if you like, to, to this group of children. And respecting their identity. It wasn't about challenging who they were, and, and the argument is that young people know who they are. And it would be cruel to de- deny them the, the chance to live as, as the person they, they identify and who they strongly feel themselves to be. I mean, that, that, that's the argument.

   3. CWChris Williamson42:26

      How many of these young people

7. 42:28 – 47:21

   How Many Young People in Gender Clinics Are Simply Gay?

   1. CWChris Williamson42:28

      are just gay?

   2. HBHannah Barnes42:34

      Well, I can't answer that definitively. What I can say is that from the very limited data that exist, many of the young people referred to gender clinics, well, certainly to the, to, to JIDS, are same-sex attracted or, or bisexual. Um, so what we know is that actually, so the 70 young people in the Netherlands who form, who, who were part of those, these two Dutch studies, well one Dutch study really, but two tranches, um, which forms the basis of all gender-affirming medical care for children, all of the girls in that study, all of the biological females were same-sex attracted or bisexual. None were op- opposite sex attracted, and one of the boys was, which is quite striking. The data that we have from JIDS is that of those referred in 2012, so, you know, more than a decade ago now, of the older young people that were referred, so 12 and up, uh, for whom they had data, which was about 100, just under 100, so again, not, not, not great, um, around 90% of the girls were same-sex attracted or bisexual, and about 80% of the boys, roughly. And the only more recent data we have from JIDS, but we haven't seen any sort of breakdown, it's just on their website, it's from about 2015, so we don't know what the numbers are, but this puts it at about 70% combined for the girls, either same-sex attracted or bisexual, um, and about 60% for the boys. So, so still very, very high. And this was a, a concern that many, many, many clinicians had. And I want to be clear that it is not the sole, it's not solely coming from those clinicians who are themselves gay, uh, or lesbian or bisexual. It, it was so widely seen. And I think some of those clinicians say that the, the charge was put to them, "Well, you're too close to it because you're gay, and therefore you can't be subjective about this." Now, now JIDS would d- deny that, that that happened. But, but actually, when I put that to them, when I, when I spoke to them for the book, uh, one clinician, Anna Hutchinson, she said, "Look, look at the data." (laughs) That, it's not, we weren't seeing something that wasn't there. And okay, the data aren't great. We only have a couple of years. But, but, you know, we saw this on a daily basis. Young people, mainly girls, but the boys as well, sitting in front of us, talking about how they had a relationship with someone of the same sex, been homofo- you know, experienced homophobic bullying, and then came to identify as trans. And it wasn't that they were saying that none of those people could be trans or they didn't know themselves in any way. They were saying, "We need to think about this, and we need to explore sexuality as we need to explore gender." Because it's noteworthy that in many of the cases, someone was not just, a transition wouldn't just change their gender, it would also change their sexuality. And they were just saying, "This is something we really need to think about," and that they were worried about. And it's another example, really, in this story of where knowledge seems to get forgotten as time goes on and the clinic became busier. Because the old data tended to show that when you had a group of young people who were distressed around their gender, some would grow on to be trans adults, but the majority wouldn't, and the majority of them would, would grow up to be gay. And, and that seemed to be forgotten a- a- as time went on. And clinicians said, "Look, these behaviors that many of us are taking as indicators that someone might be trans, they equally apply to kids that might grow up to be gay. Like they're really similar. So that's something we need to bear in mind." It wasn't that they would dream of telling a young person, "No, your identity is not what you think it is. You're gay." It wasn't like that. And of course no one was intending to, it's this awful, like converting gay kids, it's ... No, there was no intention, but what they were saying is, "We really need to think about this, and at the moment we're not."

   3. CWChris Williamson47:19

      How many other

8. 47:21 – 57:42

   The Mental State of Young People Referred to GIDS

   1. CWChris Williamson47:21

      mental health complications were the young people coming into this clinic suffering with?

   2. HBHannah Barnes47:31

      They were complicated young people. They were complicated young people with complicated lives. I mean, several clinicians said they didn't see a, a single young person for whom everything was fine apart from their gender identity. Um, you know, others disputed that, and they said for some you, you just knew, and there was nothing else it could be, and so therefore three sessions is fine, and you know, that's, that's fine. Um, but, but, but many said that these were the most complicated, distressed, and traumatized young people they'd ever worked with. And some of these were very, very experienced mental health professionals who'd worked in numerous other services. Um, and that's why they were so worried, because there appeared to be so much else going on. And, and even, even if some of those young people, you know, were trans and would benefit from a, from transitioning, and I'm sure some of those young people have, they were saying, "They're not in the right..."... place to do it safely. And, and some of those other issues need to be solved first. It wasn't that we're denying their identity or, or that, that it could be the right pathway for them. But it just wasn't safe to do it at that moment in time, with so much else going on. And, and equally, it could be that the, the primary difficulty was not the gender, and that if you solved something else... You know, I mean, I don't want to, wish to imply that this was the majority of cases, but there were, there were s- several cases, it's documented in the book, where, where a trans ide- identification came quite quickly after a young person had suffered a traumatic event or had potentially been, you know, sexually assaulted or sexually abused. Now, what clinicians say is that... It's quite easy to understand why someone might feel distress around their body and particular parts of their body if they've been, you know, horrifically violated, usually by people you trust, in those parts of the body. And therefore-

   3. CWChris Williamson49:43

      Occurrence.

   4. HBHannah Barnes49:43

      ... you'd want to change it.

   5. CWChris Williamson49:44

      Yeah.

   6. HBHannah Barnes49:45

      Um, you know, and, and what they were saying was, that needs to be worked through first. Again, it's not as black and white as someone's had a traumatic childhood, therefore they can't be trans and can't transition. They were saying, in those circumstances, that, that, that trauma has to be worked through so that we make sure that we get this right. And they were saying that too often, it didn't happen.

   7. CWChris Williamson50:06

      Well, fundamentally, the, the question here, I think, is, are young people distressed because they're trans and aren't fully living out their desired gender identity? Or are they trans because they're mentally distressed and haven't dealt with the underlying problem?

   8. HBHannah Barnes50:24

      Yeah, and it could well be both.

   9. CWChris Williamson50:26

      Yeah.

   10. HBHannah Barnes50:26

       Depending on, on, on, on which young, young person you're talking about. And it's interesting that it's-

   11. CWChris Williamson50:30

       But taking someone through, taking someone through CBT or, uh, uh, taking them to an, a, an anxiety counselor or a, a trauma therapist, or whatever, psychotherapy, is significantly more reversible than putting them on puberty blockers.

   12. HBHannah Barnes50:49

       Yes. I guess the counterargument would be, if you miss the relevant time window, then for someone who will identify as trans for life, then those changes to their body are very damaging and, and, and irreversible too. So that, but yes. I mean-

   13. CWChris Williamson51:10

       I wonder if the more, uh-

   14. HBHannah Barnes51:12

       (laughs) .

   15. CWChris Williamson51:12

       ... ideologically, uh, bound would even see removing some of the... Let's say that there is a, a non-zero number, uh, of people within this cohort for whom autism, OCD, trauma, et cetera, et cetera are precursors to a, a gender identity crisis. And if the precursors were removed, that the gender identity thing would fall away. Um, I can imagine the more ardent trans activists here in the US saying that that would be something which is unethical as well. That by getting rid of the precursor, this is denying somebody's trans-ness out into the world. I mean-

   16. HBHannah Barnes51:57

       Oh, yeah. And, and, and, and that's what happened at GIDS in, in, in that clinicians say that they were discouraged from providing what you might call a diff- differential diagnosis. So that i- to even suggest that someone's distress might be as a result of something else other than being trans was discouraged and seen as transphobic. So, so yes. I mean, that, that is the view of some people. Um...

   17. CWChris Williamson52:25

       Didn't you... You had a story about a, a boy who was showering five times a day and wouldn't, wouldn't leave his room. What was that story?

   18. HBHannah Barnes52:34

       Oh, it was a absolutely heartbreaking story. So this is a young sort of teenage boy, was openly gay. Um... And yeah, was coming home, showering as soon as he got home from school. And his mum didn't really think that much of it. She just thought, "Oh, wow, I'm blessed with a really hygienic teenage boy." Um, rare. And it became very, very serious. And she quickly realized that he, he had quite, he had very severe obsessive-compulsive disorder. And sought help from local what we call CAMHS here in the UK, so Child and Adolescent Mental Health Services. And not long after he was seen at CAMHS, he blurted out to his mother, "You don't understand. I'm trans. You've been misgendering me my entire life." And put it into perspective, he was six feet. You know, big, big, big, uh, very tall, you know, size 13 feet, what have you. As I say, openly gay and, and, and happy to be. And hi- his mum was just like, "Wh- what?" You know, and it was 2014. It wasn't... She didn't even know what it meant really. And from the moment that he'd said that, CAMHS would affirm him as female. And, um, and set about referring him to gender specialists, to, to GIDS. And his mum was like, "Hang on. He's really unwell. Like, even if this is true, he's in no state whatsoever." And, and his mental health deteriorated very, very rapidly. He, he got to the point where he, he couldn't leave the house. He couldn't go to school. He... The floor of his bedroom had to have plastic sheets on it. He, his bathroom would be flooded because he was going to the toilet so much he couldn't keep clean and then the toilet would flood. And it w- it was absolutely... I mean, talking to his mum, you know, eight years after the event, it was-She was in tears, and it was very, very distressing. And he was so ill that he couldn't actually attend his appointments at GIDS. And rather than take that as a sign that perhaps he wasn't well enough to transition, or to consider transitioning, a very senior GIDS clinician traveled to his home instead. Uh, well, to, to, to nearby his home, um, several hours. Um, and his mum claims that at that very first appointment, not, he wasn't offered blockers, but, but the subject was, was brought up, and, and she just couldn't believe it. And ultimately, she took him out and he had private therapy. She lost all faith in NHS clinicians, and said, "This is, this is just mad, basically. My son is really, really ill and no one's helping him." And, and, and then after several years, he, he, he didn't identify as trans anymore, and he's happily gay and has a partner, and their relationship isn't very good. He still has mental health problems, but... Um, but it was just extraordinary that someone who cannot leave their own home, who, who wanted to cut off their own penis, and saw things crawling up the walls, th- that, to even consider that they would be in a, a state ready to transition.

   19. CWChris Williamson56:15

       You said that less than 2% of children in the UK have a autism spectrum disorder-

   20. HBHannah Barnes56:21

       Mm-hmm.

   21. CWChris Williamson56:22

       ... and at GIDS, more than a third of the referrals had autistic traits.

   22. HBHannah Barnes56:27

       Yeah. Yeah. And that's something that, that worried clinicians too, because they're like, "Well, that seems to be very high." I mean, the 2% thing, I mean, that may well be an underrepresentation. I mean, this, this debate's had all the time. The d- the, the data on, on, on autism, autistic spectrum disorder is not fantastic. But, but yeah, I mean, that's the best we've got. Um, and again, it wasn't them saying that no one who's autistic could be trans. It's just with this really high proportion exhibiting moderate to severe traits, might we be medicating unnecessarily autistic kids? And they were really worried about that. Because what we know about autism is that, not just on gender, but on, on, on other things as well, you know, autistic people can think very, you know, in very black and white terms. And it seemed to those clinicians who were sitting in the room with those kids and, and, and their families, that it, it was a way of, it was potentially a way of making sense of their world rather than a true, you know, a true identity. Um, and they just wanted to be as careful as they could be.

   23. CWChris Williamson57:38

       What have you come to believe about

9. 57:42 – 1:05:47

   What Caused the Influx of Admissions to GIDS in 2015/16?

   1. CWChris Williamson57:42

      why this 2015, '16 period just saw an insane increase in the number of admissions? What, wh- what do you think is going on there? And also, what were the downstream implications for what happened inside of GIDS?

   2. HBHannah Barnes58:00

      Okay, so the first part of the question, I think there are lots of things that explain it. I don't think I can give a definitive answer, but I would, I'd say there's, there's a load of factors. So GIDS themselves would, would put this rise down to increased acceptance of trans people, increased visibility, and it being easier to, to come out and put a name to something. I think that might be true for some people. So for example, there's a young trans guy in the book called Jack, and for him, that kind of fits him, really. He, for his entire life since childhood didn't feel like a girl, and really when he came across the idea of, of trans around sort of 2010, um, he said, "Yeah, that's me." So I, I... That, that might be the case for some people. But it, it really, it doesn't explain the full picture. And all I can really say is what clinicians have told me, and what, what, what young, um, both trans and detransition people have told me, which is, you know, a variety of things. So, for some people, and, and actually WPATH, the World Professional Association of Transgender Health, which is based out there in the States, um, and is very affirmative, even they accept that for some young people, there will be a social influence to this, to their trans identity, and, and that we have to bear that in mind. Um, and for one of the young people in the book, Harriet, that was certainly a factor for her, the fact that many of her friends were also identifying as trans or non-binary and it was quite trendy, um, at that time. For her, she also was having some quite severe mental health problems, and she had had a same-sex relationship and been made to feel quite ashamed about that, and she didn't want to be a lesbian. And the combination of these things, and she was a really heavy social media user, and in her own words, she, she saw trans identity as a, as a way of understanding of, of jumping ship, but also of making sense of who she was. And for a while, she was much, much happier. She was. Um, she went through this honeymoon period for several years. It wasn't a fleeting identity. And in that time, you know, she, she took testosterone and had a double mastectomy. And, and now regrets that. But... So I think... So I think that's a, a host of other factors, and I think particularly for girls, it's, it's, it's quite hard being a teenage girl. I mean, puberty's quite difficult anyway. I mean... (laughs) But I think now, we have, you know, qu- hardcore porn is quite ubiquitous, and-... I think it's probably difficult being a teenage girl when there are certain expectations of you sexually, and perhaps having your first sexual experience with boys who have consumed that kind of material. And I think it's hard, uh, for- for some girls who don't perhaps feel that, you know, they don't live up to the... They don't feel uber feminine, perhaps they don't... th- they don't fit what they see as girls should be, you know, that they're not doing girlhood properly. I think it can be a really difficult time, and I think all these things perhaps explain why, uh, a different identity might- might be the answer.

   3. CWChris Williamson1:01:37

      That would also, uh, coincide, you know, we were talking about this flip almost, that it was mostly biological men, uh, males, uh, and then you get this whoosh, this big sort of liftoff. So you go, "Okay, well, what's happening to just the girls?"

   4. HBHannah Barnes1:01:52

      Hmm.

   5. CWChris Williamson1:01:52

      Uh, advent of social media, ubiquity of online porn, um, expectations, or I guess a- a- a backend of a sexual liberation movement that perhaps makes sex at younger ages more common, you know. British TV series like Skins and stuff like that, you know-

   6. HBHannah Barnes1:02:13

      (laughs) .

   7. CWChris Williamson1:02:14

      I- I- uh, it really does put relationships at the forefront of a 14, 15, 16-year-old's life. So it doesn't surprise me.

   8. HBHannah Barnes1:02:24

      Yeah. No, and- and clinicians, you know, w- these are not my sort of ideas. These come fr- fr- from professionals, but, you know, clinicians would also say that- that girls in particular, um, and- and they've noticed this in their professional careers, I mean, girls have a tendency to express distress through their bodies. So whether that's eating disorders, cutting, um, that tends to, you know, it tends to affect girls in greater proportions than- than- than boys for some reason. Um...

   9. CWChris Williamson1:02:51

      I remember, um-

   10. HBHannah Barnes1:02:52

       But also, you know, I- I do want to say that, sorry to, just very, very briefly, that-

   11. CWChris Williamson1:02:56

       Yeah.

   12. HBHannah Barnes1:02:56

       ... I talked about Jack, and I, you know, some of the number may well be that, you know, some of these people, some of these will- will, they'll identify that because they'll grow up to be trans. So I- I want to sort of acknowledge that as well.

   13. CWChris Williamson1:03:08

       Yeah, I- I remember, um, hearing a story, two really interesting stories recently, actually. The first one was a girl who overate, uh, well, well into adulthood. Uh, and after a ton of, uh, therapy, it turned out that she'd been sexually, uh, abused when she was younger, and what it seems was happening was this woman was making herself into as, um, unsexual of an object as possible by gaining weight. So she was using weight not only physically to create a barrier around her that made her feel safer, uh, but also, um, like, figuratively, symbolically, so that she wasn't seen in that same kind of sexual light. And I was like, "Okay, well that's interesting." And then this other one, um, it was a YouTube channel called Kidology. She's a British YouTuber, 100 and something thousand, uh, subs, so it's- it's an interesting channel. Um, and there is a common subculture on the internet at the moment that there's no such thing as a female incel.

   14. HBHannah Barnes1:04:12

       (laughs) .

   15. CWChris Williamson1:04:13

       That basically any woman would be able to get sex. It might not be the sex that they want, but it's sex. And for men, there are men who want sex and can't get it, therefore there is no such thing as a female incel. Uh, and she really changed my opinion on this, because she spoke about the fact that she had gone through some trauma, not in terms of a sexual assault, but just in terms of, like, an unpleasant, unenjoyable experience, uh, that had left her feeling, um, like incredibly averse to sex. So even if she likes a guy, even if she wants to get intimate with a guy, she can't bring herself to do it. And I thought, "Holy fuck. Like that- that, uh, type of dynamic that could cause someone to want to be intimate but be unable to bring themselves psychologically to do it, like, that ticks all of the boxes of incel, as far as I can see." Uh, and both of those just very interesting, uh, obviously, uh, as- as much as I can try to understand the female psyche, much smarter people than me have done it and failed.

   16. HBHannah Barnes1:05:21

       (laughs) .

   17. CWChris Williamson1:05:21

       Um, but both of those were, I- I found it- it really interesting and insightful around, you know, some of the- the challenges that I think are unique to the way that females' minds work.

   18. HBHannah Barnes1:05:35

       Hmm. Yeah, I mean, I- I don't know if I can add anything really (laughs) .

   19. CWChris Williamson1:05:41

       Nice. It's such a fantastic story. So okay, one of the elephants in the room, I suppose,

10. 1:05:47 – 1:14:00

    The Role Ideology Played in Gender-Affirming Policy

    1. CWChris Williamson1:05:47

       especially for the people that are listening from America, especially for the people that are listening to this coming out of the culture war, raging left versus right thing, is how much of a role did ideology play when it came to the behavior of, uh, and- and policies at GIDS?

    2. HBHannah Barnes1:06:07

       I think it's really complicated. I think it absolutely did play a role, but it's not as blatant as some would want to believe and- and- and- and talk about. So there are certain groups, um, you know, trans groups, trans support groups, who were very active and their presence was certainly felt, um, by clinicians at GIDS. And I mean, pretty much everyone I spoke to, I mean, it depends what period of time you're talking about, but the period of time where the referrals were going up through the roof and the pressure was absolutely, uh, uh, uh, immense to get through the numbers, um-The- there was a- a particular group called Mermaids, but- but there have also been others in- in more recent years. Gendered Intelligence is probably the most influential group. But their presence was felt, and clinicians say that even- even though they weren't in the room, they were in the room. They were in out- they were in our minds. We had this pressure from Mermaids all the time. And Mermaids were, or are, a charity which supports, uh, gender diverse, as they put it, um, and trans children and their families. And they're very much in favor of a medical model. Um, and they lobbied GIDS for years, um, both to introduce the blocker at a younger age, um, so th- in- in the 2000s, and- and then to reduce the age at which hormones could be given, and to relax, um, the criteria whereby a young person had to go on the blocker before going on hormones. Now, it's not ... The reason I say it's complicated is because they didn't get everything that they wanted. So those- those two later things didn't really happen, so there wasn't a big reduction in the age at which hormones could be given. It came down a little bit to around 16 as opposed to a hard 16, and so you could be, you know, 15 and eight months, nine months, or what have you. But it didn't really shift significantly. Um, but they were influential. We know that the head of that charity would make requests on behalf of families for a young person's clinicians to be switched if they weren't getting a referral for- for blockers as quickly as they wanted. And- and on occasion, I don't know how often this happened, I'm not suggesting it happened often, but it did happen, and those- those requests were granted. We know that senior people in the wider trust which- which housed GIDS asked- wanted to coordinate the content of GIDS's website with that of Mermaids and make sure that they were consistent and get approval for that from- from Mermaids. Um, and I think there's probably a more subtle influence that they had, which is, it appears that when new information came to light during the course of the work, whether that's information on the blocker and how it was working, you know, there's everybody going on to cross-sex hormones, or the vast majority, um, or- or other things that came known, for example, the risks to biological males who had their puberty blocked too early who then went on to transition. Actually, if you block too early, it can make it very, very difficult to perform certain surgeries. Um, when information came to light, it wasn't routinely passed on and it wasn't written down. And the suggestion from- from clinicians I've spoken to is that that was because there was some kind of fear of a backlash from these groups if that information was codified, because it was, you know, it was scary to tell a- a young male who identifies as female that, you know, "Surgery could be very difficult for you, uh, if we block too early." It's probably not something they want to hear, and- and- and it- it also makes it much more real, doesn't it? You're talking about many, many years in the future. So I think it's they were influential. They weren't running the show, but they ... clinicians were definitely aware of them and potentially changed their practice because of them, because they were in their heads. Um, and I think it prevented GIDS from changing direction when perhaps it could and should have over- ov- over the years, because they were ... the- the relationship was too close. And- and what clinicians have said is that, who've worked in other places where, you know, you have patient groups. And sometimes patient groups come into conflict- conflict with- with medical professionals, because they might want something that actually is not clinically indicated. Um, and- and what professionals said was that, "In other places, we saw the service be able to hold a proper boundary," and they didn't see that happening at GIDS. Um, again, the service dispute it, but- but it came up with pretty much everyone I spoke to. E- even those who spoke favorably about the service, they said that- that Mermaids were very influential. But what I- what I didn't find, and why I say it's- it's more complicated when you ask about ideology, I didn't find that the vast majority of people working there were ideologues in any way. I mean, there were some, but it was the minority. Most were just caring, thoughtful professionals who wanted to do the very best for the young people sitting in front of them. And so I don't think it was staffed by a load of ideologues, but it's quite telling that- that one of the people in charge of leading that service said, you know, described it as a justice project as- as well as a therapeutic project.

    3. CWChris Williamson1:12:01

       Yes. The- (sniffing) the, uh, energy, the vibe, the, um, culture trickles down from top to bottom, right?

    4. HBHannah Barnes1:12:11

       Yeah.

    5. CWChris Williamson1:12:11

       And if you have somebody leading at the top that essentially everyone else is responsible to, culpable to, answer to. So I mean, you can say it- it- it's not a bunch of card-carrying, flag-waving ideologues with foam fingers saying that we want to trans the kids and all the rest of it. But it does seem like there is a pretty big laundry list of errors that occurred.

    6. HBHannah Barnes1:12:36

       Yeah.

    7. CWChris Williamson1:12:36

       Uh, it seems like ... I have no idea how malpractice-y, how calling into dispute someone's medical ethics and whatnot this is. But we can definitely say that it was a suboptimal, like, clinical environment, I think. Um-Who... Who's to blame? Wh- And why... Why did... Why did this be allowed to happen? Why, given the, uh, especially in the UK as well, just for the people that don't-

    8. HBHannah Barnes1:13:13

       Hm.

    9. CWChris Williamson1:13:13

       ... that are maybe from the US, um, you know, to get interventions, you know, to get prescribed... You can't get prescribed melatonin in the UK, right? You can buy 10 milligram tabs on Amazon over here in the US. The- The- The general patient-doctor relationship in the UK is starkly different to the way that it is in the US, and they're not incentivized to typically intervene. You'll... A number of times I've gone into the doctor, I'm sure it's been the same for you as well, you- They'll print off a single sheet of paper, give it to you and say, like, "Well, you know, give this a read and- and try not using your phone before you go to bed," or- or-

    10. HBHannah Barnes1:13:52

        (laughs) .

    11. CWChris Williamson1:13:52

        ... you know, "Stop eating so much kale," or whatever the, like, whatever the thing is, and then they'll say, "Right, on your way you go." Um, my point being that they seem to be, uh-

11. 1:14:00 – 1:26:13

    Why Are There So Many Problems & Who is to Blame?

    1. CWChris Williamson1:14:00

       uh, reticent when it comes to interventions, and, um, most people enter this... I have tons of friends that are doctors, uh- uh- and- and work in the medical industry. I- I don't think that they would want to go in to do anything to damage people, and yet it seems like there's been massive litany of problems. Why did they occur? Is there someone that's having the finger pointed at them? Wh- Why are there so many holes in the system?

    2. HBHannah Barnes1:14:31

       Big questions. I think... I think it starts in a way from- from the previous answer, in that I think where ideology... That ideology did trump medical evidence here. So... It may have been, and I- I'd like to believe it was well-intentioned, that- that there was a desire to help distressed young people. But by expanding the group for which you refer, young, uh, for- for puberty blockers, that was a decision that may have been well-intentioned and... But it stemmed from a belief that you were helping someone, um... fulfill, meet their true identity. It- It wasn't evidence-based. There was no evidence to support that. And actually, data came back that- that actually challenged that. And- And they didn't change practice. And that's what's so, sort of difficult to understand. So I think, you know, that- that is where you can certainly say that ideology influenced, because it... This was a belief system, really. Um, it wasn't based on evidence. Um, it was a belief that they were helping. Um, and as one clinician put it, you know, things can be well-intentioned but, um, ill-informed. Who's to blame? Lots of people are to blame. Th- The leadership of GIDS is to blame, and they should take responsibility for the decisions they did and didn't make. The leadership of the Tavistock Trust are to blame for not taking seriously enough the concerns that were brought to them by a sizeable number of staff working in that service who were not transphobic, who were relaying clinical concerns, safeguarding concerns, safety concerns, and potentially child protection concerns about the young people they were caring for. And really to have taken those concerns seriously would have needed huge change. And, for whatever reason, the leadership of the trust didn't do that. NHS England is to blame. They did not provide adequate oversight. Why did they allow the rolling out of the early blocking of puberty without seeing any robust data at all? Why did they not step in earlier? Why, when the referrals were going through the roof and that they saw that these were very complicated young people, did they think it was sensible to staff the service with predominantly junior, inexperienced members of staff, which is what happened? And why, when it was clear that wasn't working, did they not change direction? Why did they not act until 2021 in, um, asking someone to undertake a thorough review, an independent review of this service, uh- uh, or this area of care, when they'd heard concerns for many years, and- and, you know, at least as back as 2018, if not before? Um, all those people are to blame. So are the media, who for many years did not, um, scrutinize this in- in the way they probably should have. So are the politicians who have heard about these concerns for many years and nothing has changed, and so are the healthcare regulators who, until our work at BBC Newsnight showed them some of these very, very serious concerns that were relayed to the trust during an official review, uh, hadn't inspected it for... Since 2016, and then did go in and- and rate it inadequate. So, so many people are to blame. Um, it- it's systemic failure on quite a large scale. Um, why did this happen? Well, again, I don't think it's something that I can answer definitively. I think... It's something I me- mentioned before that, you know, why didn't they change direction? We've talked about this when it was quite clear that it probably wouldn't be the right pathway for all of the young people. Well, it's very hard, isn't it, to admit we've made mistakes. It's not something that-... is in our nature, really, as human beings. And I think Anna Hutchinson puts it this way, when she was talking to the medical director of the trust, she said, "For someone to have been recommending or referring for a potentially life-changing medical intervention for a decade or so, what are the implications of admitting that you may have got that wrong?" It's quite intolerable, actually, potentially. So it may well be that some of it is explained to the fact that it's, it's, it's too hard to, for some people to, to admit that this might not have been the right thing to do in each and every one of those young people's cases. I think what clinicians told me on many occasions was, this was just not a service that operated according to the normal rules that you'd expect in the NHS. And they said that the word gender, because it was there in this, it, it muddied the waters. Um, it meant that it wasn't subject to the normal oversight that you'd expect. And this is something that Dr. Hilary Cass has pointed out in her interim findings, that it hasn't been subject to the normal oversight that, that one would expect of a service that, that refers for innovative treatments for children. Um, and the usual checks and balances, the usual data collection, it's just not been there. Um, you know, one very senior clinician said to me, "It's almost like, for NHS England, there was this cloak of mystery created by our gender service, and it was assumed that, that we were the experts, and it was so special that... and we knew what we were doing." So, and, and so the oversight wasn't there. And, and I think there are practical reasons that explain it as well. You know, GIDS was part of what's known as specialist commissioning in the NHS. Um, you know, it's a, it's a specialist service. And, and there are hundreds of them. And I think, for a while, it was, it was really small. It didn't come across their radar. And I think some health insiders that I've spoken to admit they were far too slow to act. But I think, for many years, it just didn't figure. And, you know, that's not, that's not good enough. That's not an excuse, and it doesn't... But, but, but maybe, yeah. It's, it, you know, there's no grand conspiracy, but maybe it just fell through the cracks.

    3. CWChris Williamson1:21:51

       That, the fact that there are so many different parties who, through fear, habit, negligence, busyness, uh, distraction, whatever, um, for a whole host of reasons, um, and the fact that there is no single hooded figure with a long hook nose and a staff, you know, that's coordinating all of this, is so much more banal and, um, less conspiratorially impressive...

    4. HBHannah Barnes1:22:30

       (laughs)

    5. CWChris Williamson1:22:30

       ... than I think a lot of people might have considered.

    6. HBHannah Barnes1:22:32

       Yeah.

    7. CWChris Williamson1:22:32

       But it's the, the problem, the problem with it, and it's the same way that intelligence services work, right? By compartmentalizing information, you, uh, limit any one person from being able to work out what's going on. But by compartmentalizing inefficiency, what you do is you stop any one person from being able to fix it, because there are numbers-

    8. HBHannah Barnes1:22:52

       Mm-hmm.

    9. CWChris Williamson1:22:52

       ... of different vectors, all of these different angles. Well, this person's shit, and this person's shit, and this person's shit.

    10. HBHannah Barnes1:22:57

        (laughs)

    11. CWChris Williamson1:22:57

        And, you know, you know, when you pile it all together, it's not one big mound of shit. It's multiple spokes of shit all pointing at the same thing. Um, and yeah. I, uh, I -

    12. HBHannah Barnes1:23:09

        I think that busyness point you make is really important, actually. I think sometimes there just, there just was no time to think, to think through what they were doing.

    13. CWChris Williamson1:23:20

        What's happened to GIDS now?

    14. HBHannah Barnes1:23:23

        So, so GIDS is still open. It's, it's, it has lost a lot of staff recently. And I was talking to, um, a parent of someone being seen there at the moment, who has said this has been quite difficult, because it's made continuity of care really quite tricky, being, having lots of different clinicians. So they've lost a lot of staff. They're still open. The NHS has announced last summer its plan to, to close it. And it's going to be replaced by, um, regional services in the, in England. Um, two to start with, but then the idea is that there'll, there'll be maybe s- seven or eight. Um, and that will hopefully address sort of the, the busyness issue which is, you can't have one clinic attending to all the children of one country. It, it's crazy. But also, there is a very different approach that's been signaled that these new services will take. So, so gone is any mention of, you know, a time-limited assessment. Whereas the, the current, um, document that guides GIDS talks about three to six sessions, that an assessment will be carried out. There's, there's just no mention of that. The primary focus is gonna be psychosocial and, and psychological, so talking. It's going to be the primary aim is reducing distress. It's gonna be far more holistic, much more mental health support for young people, um, expertise in all these other factors that we've talked about, in autism, in other neurodiverse, um, conditions, safeguarding expertise. And now, what they have said is that these gaps in the evidence base, which have been identified-... by the systematic evidence review. They've got to be plugged. We can't just continue with no long term data or, um, a really clear view on who benefits from this treatment and who, who might not benefit, and what the long term impact might be. So what they've said is that, uh, physical transition and access to puberty blockers probably will still be available, but young people will be expected to enroll onto a research program, um, so that some of that data can start to be, to be collected. And, and, and actually, on the point of data, as we, as we've discussed, uh, pfff, these new services are going to have routine and consistent data collection, which doesn't appear to have been the case over the last 30-plus years. But, but in the meantime, there are at least 7,500 young people waiting on a waiting list for help, some of them waiting for years, o- in distress and with nothing. And that's awful.

    15. CWChris Williamson1:26:08

        One of the reframes that I'm gonna take away from your work

12. 1:26:13 – 1:30:38

    The Lesson Chris Has Learned from Hannah’s Book

    1. CWChris Williamson1:26:13

       is that when we talk about that, when we talk about 7,500, uh, young people that are struggling with what they are saying is gender identity, uh, and, and for s- some of them very well may be, they require trained counseling f- a- a- and interventions, uh, to help them work out what's going on. That this could be from all manner of different places. And the reason that I think it's, that's such an important takeaway is that that's politically neutral. Ideologically, it should be relatively neutral. Look, there are lots of contraindicators and, and precursors to what can manifest and present as a gender identity problem. That should be treated regardless of what i- Like, okay, so you're not gonna treat... You know, even the most card-carrying, evangelical, like, hard righty. What, you don't wanna treat a kid that's got ADHD or OCD or autism?

    2. HBHannah Barnes1:27:11

       Mm-hmm.

    3. CWChris Williamson1:27:11

       Like, of course not. Like, you'd have to be an idiot. Um, so I think that that's, that's very important to think about it that way, as in, look, there are a suite of things going on here. It is important that we give people, um... Even if, you know... And I'm sure teenagers, belligerent, coming in, saying that they know what the problem is, and they've read it on TikTok or on, on Reddit or whatever, and blah, blah, blah. Even if what ends up happening is that, uh, OCD, autism spectrum disorder, et cetera, counseling is couched within a gender, uh, care, uh, world, gender care treatment, which will perhaps encourage teenagers who wouldn't have gone for this kind of treatment because they're, uh, adamant that it's one issue when it may be something else-

    4. HBHannah Barnes1:28:00

       Mm-hmm.

    5. CWChris Williamson1:28:00

       ... even if you do frame it within that, that very well make, may make them more open to it and go, "Okay." And then perhaps, over time, if some of these, uh, like, issues, mental health issues, which are perhaps upstream, uh, from this problem, if they do get relieved and you go, "That's another way, perhaps, o- of dealing with this." And, you know, again, the massive influx that we've seen, and you mentioned it earlier on, that there are, uh, uh, pockets of, uh, sort of gender issues that occur. It's, you know, f- five girls in one class in one school. Well, I mean, what's going on here? Like, uh, it, that, that seems to push against the it's simply the fact that people are seeing that they can live their true selves because they're less... You know, there are role models out there in the world. And you go, well, if that was the case, it would be completely evenly distributed. If there was no sense of a, a psychological influence, a psychological contagion effect, like some sort of memetic thing that's going on, it would be exclusively distributed randomly and evenly. But it's not.

    6. HBHannah Barnes1:29:02

       Mm-hmm.

    7. CWChris Williamson1:29:02

       It happens in, in particular towns, in particular cities, in particular schools, in particular classrooms. I'm sure that if you mapped the place that these kids sit at, at the lunch table, where they sit in class, you're also going to see that it happens within friend groups. So given that you have this massive increase, I actually think, you know, if the UK is able to enact what it is that you're talking about, I actually think that that's quite reassuring. I think that, you know, all of the different, uh, propositions, care, security, safety, uh, holistic model, focusing on talk therapy, et cetera, et cetera, that, that to me seems like a pretty unobjectionable, good approach to this issue.

    8. HBHannah Barnes1:29:46

       Yeah, I mean, the mood music is very positive. I think the problem is we're quite a long way from that actually being realized. But I think it's interesting that of the countries that have looked at the evidence base, they've all started to proceed slightly more cautiously when it comes to medical transition. They haven't ruled it out. But, you know, Sweden, Finland, Norway, potentially here in England as well, that, that, there's a, there's a, there's a sort of rowing back from, from affirmation only and, and, and medical approach only. And it's, it's talking therapies first and not ruling it out to those for whom it will still be the right answer. But, but it, but not the only answer for all of the young people coming forward. Um... yeah.

    9. CWChris Williamson1:30:34

       I really appreciate how, uh, gentle

13. 1:30:38 – 1:31:59

    Where to Find Hannah

    1. CWChris Williamson1:30:38

       you are with this discussion. That's the best, that's the best word that I-

    2. HBHannah Barnes1:30:41

       (laughs)

    3. CWChris Williamson1:30:41

       ... the best proxy I can come up with for it. I think you're incredibly measured, um, which I think is very important, you know? If you want to try and change people's opinions, if you want to try and slice through a very divisive and sort of ideologically fueled topic, I think that you're going about it the right way. I'm very, very impressed with the way that you present your stuff. So if the people that are listening want to find out more about you and the work that you do, where should they go?

    4. HBHannah Barnes1:31:06

       Well, I, I work at the BBC, so I don't have a, uh, my own website or anything. But, um, yeah, c- f- find me on Twitter. I'm @HannahSBee. So Hannah and then S-B-E-E. Um, the book's called Time to Think. It's on ... In the States, you can get it on Amazon. I don't have a US publisher, so if there's anyone listening and wants to publish it, then please do get in touch. Um, but you can buy it on Amazon on Kindle or hard copy. It will be sent from the UK. Um, yeah. That's me really. (laughs)

    5. CWChris Williamson1:31:35

       Hannah, I appreciate you. Thank you for today.

    6. HBHannah Barnes1:31:37

       Thanks so much for your time. Thanks for having me.

    7. CWChris Williamson1:31:39

       (upbeat music) What's happening, people? Thank you very much for tuning in. If you enjoyed that episode, then press here for a selection of the best clips from the podcast over the last few weeks. And don't forget to subscribe. Peace.

Episode duration: 1:31:59