The Trouble with a One-Size-Fits-All Approach to Gender Care

Time To Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children draws on thousands of pages of internal documents and over 100 hours of interviews with clinicians and service users. One service user, Jacob’s, story is told here.

Jacob has never really seen himself as a girl.

“Even when I was like a toddler, I would go by names from male characters I saw on TV,” he says. “I would say, ‘My name’s Jack-Jack,’ or Indiana from Indiana Jones or Harry from Harry Potter.”

Jacob’s mum, Michelle, agrees.* From the age of three Jacob would take his younger brother’s clothes and wear them. “And Jacob’s favorite thing was the backwards hat and an Indiana Jones T-shirt.” Even at preschool, he hadn’t liked answering to the female name he’d been given at birth, Michelle remembers.

Jacob started presenting as a boy at school from Year 1, he says, aged five or six. “I wore a hat, because I didn’t want to show my long hair, and when we went swimming, I’d wear trunks.”

When Jacob was seven, Michelle went to her GP for advice. Jacob’s desire to be a boy was increasing, not going away. She’d read about something called gender dysphoria online, but didn’t know much about it. She thought that Jacob’s behavior seemed “a little bit more than just tomboy behavior,” she says. Jacob wanted to be a boy, Michelle explains, and “used to describe thinking as a boy.” The GP listened and sent Michelle away. “She said, ‘Look, go away for two years. Come back when Jacob’s nine and then we’ll talk about it again.’”

That’s exactly what Michelle did. At nine years old, Jacob still wanted to be a boy. He used the boys’ toilets at his junior school and continued to choose boys’ names to be referred to. This time the GP agreed that what Jacob was experiencing seemed more than just being a tomboy. The GP was aware that there was a specialist gender clinic for children at the Tavistock in London, but referred Jacob to his local CAMHS first so that they could explore if there was anything that might be influencing Jacob’s behavior.

Michelle thought CAMHS did a good job. The psychotherapist Jacob saw talked about all sorts of things—not just gender. “They talked about relationships at home, relationships with friends at school,” Michelle says. And they talked about an “incident” that occurred, which, Michelle explains, “could have exacerbated the issue with being a bit more anti-female.” She doesn’t go into any more detail because Jacob doesn’t want her to. But the implication is that something happened to Jacob that might make him feel uncomfortable towards his female body.

CAMHS also discussed Jacob’s parents’ divorce and how that had made him feel. He’d been about five when the split happened, but Michelle describes her ex as “very sexist.” He’d get their sons doing what he saw as ‘very masculine jobs’, Michelle explains, but get the girls— Jacob and his sister—to “tidy up and clean things.” CAMHS explored both this family background and the “incident” with Jacob but felt when it came to his continuing desire to be a boy, he needed to be seen by experts. CAMHS referred him to GIDS, noting in their referral letter that Jacob had “persistent ideas about wishing to be seen and treated as a ‘boy.’”

Jacob and Michelle had their first appointment at GIDS in 2014. Jacob was 11 years old. That same month, GIDS’s Early Intervention Study recruited its final participant, having reached the end of its first three years.

By now, all Jacob’s school friends knew him “as a guy.” But it was a confusing time. “Being trans,” he explains to me, “is like you have moments where you feel like yourself, you feel like the person you should have been,” but his feelings changed a lot. “There were moments where I felt very, very low” about being trans. “I wanted to create a new person to go with how I actually feel,” he says. But there were other moments when “it wasn’t really something that mattered as much” as things going on in everyday life: starting a new school or other life events. “But it was always there. It wasn’t something that went away.”

When Jacob arrived for his first GIDS appointment, he says he was at the beginning of his “lowest point.” Puberty had started, and while Jacob hadn’t had a period yet, he was frightened. “It feels wrong,” he explains to me. “That’s not what should be happening; that isn’t the right type of puberty; that’s not the one you should be experiencing. And then it’s the fear. You start overthinking about what it’s like to have periods, what it’s like to have breast tissue, and it becomes more scary than anything else.”

Jacob had a good group of friends at school, who accepted him for who he was. They saw him as a boy, called him by the name he’d chosen and thought little of it. These were the people he relied on and with whom he felt most himself. “But then you have moments where that kind of is pushed aside by the fact that you weren’t born properly, if that makes sense?” he says. “Boys thought I was weird,” he says. “They didn’t like hanging around with someone who wasn’t a real boy.” But girls were more accepting. “So you end up living your entire life in a no man’s land, where you’re not really a girl but you’re not a boy. You don’t fit in with either side… If I hang around with the boys, I have this, like, envious jealousy towards them. Because for me, I want that so badly… But it’s not a reality. And… when you hang around with the girls, you feel like you’re in the wrong place.”

Neither Jacob nor Michelle knew anything about puberty blockers when they arrived at GIDS. They’d never heard of them and weren’t asking for them.

“I think it was my first, maybe second appointment with Tavistock, and they were the ones who brought up hormone blockers,” Jacob recalls.

A lot of the things that had been discussed at CAMHS—the distressing “incident,” Jacob’s parents’ divorce—weren’t really spoken about at GIDS, Michelle says. There was next to no exploration of Jacob’s broader life. The sole focus was on gender identity. How Jacob saw himself, where he saw himself in the future, and what he wanted from GIDS. It felt strange to Michelle to ask this of an 11-year-old child. Both she and Jacob say that the clinicians were keen to promise an outcome that would make Jacob “happy.” But Jacob describes himself repeatedly, even at the age of 11 or 12, as “a realist.” “Jacob’s very much, ‘Well, this is the gender I was born and no surgery or drugs or anything is ever going to change the biology. It’s very much putting a cloak over it,’” Michelle says. “I admire Jacob for that because by being a realist—although it does make Jacob very unhappy—it does mean that Jacob has a kind of very logical understanding about being gender-dysphoric or transgender. And the Tavistock actually got frustrated with Jacob about that.”

Jacob did not even speak in some of the GIDS appointments. He felt unable. ‘”I had pretty bad anxiety,” he explains, “so I couldn’t, like, talk to them properly. To me, they were strangers.” When the conversation turned to puberty blockers, he didn’t feel able to talk to his two clinicians about “more personal stuff.” Michelle would do most of the talking. Not in an overly pushy-parent way, but because Jacob couldn’t. He would tell Michelle what he wanted to say on the train ride from home to the Tavistock, so that she could then pass this on to the GIDS workers. “And so she would say, ‘Well, Jacob’s feeling really bad about herself** at the moment,’” experiencing body-image problems “because of all of the anxiety about having to go through girl puberty,” Jacob says. Michelle asked the GIDS team if there was any kind of therapy or therapeutic intervention that could help ease Jacob’s distress, that would mean that puberty wouldn’t be as bad as he feared. Jacob and Michelle say they were told no. There wasn’t. But Jacob says the GIDS clinicians explained that “there’s this thing called hormone blockers. And they’re basically like a full stop at the end of the sentence. They’ll stop your puberty for as long as you need it to be stopped. And then as soon as you get old enough, you can go on testosterone.” Jacob relays the words as if he can remember the conversation as though it were yesterday.

Jacob was pleased when he heard about puberty blockers. He was a realist, but these sounded great. “I was relying on the so-called experts to give me information,” he says, and they had given him this option. “A cure is how they sold it to me.” He was told not to worry. Puberty blockers were “completely reversible” and wouldn’t harm his body. “It basically stops your female hormones,” the GIDS clinicians had said, adding ‘it doesn’t make you gain weight.”

“After the conversation we had with them, I was like, I want to do it,” Jacob explains. “I am scared. I don’t want to go through puberty, I can’t go through puberty. I really don’t want to. And then my mum’s like, ‘Okay, well, I really want to do some more research about [the blockers].’” Jacob couldn’t wait for Michelle to do the research. He wanted the blockers immediately. “I actually ended up pushing my mum to just sign the consent forms,” he says. “I was the one pushing my mum to push my dad to sign the consent forms, because the way it was sold to me was like an answer to all my worries.”

To Michelle it seemed that the message coming from GIDS was less of a sales pitch, but more “Why else are you here?” “I know that’s awful to say,” she says, “but that is how I felt. Unless you’re there for them to be a vehicle to send you to the UCLH to get the drugs, I felt that their view was, well, what’s the point?” She understood why young people were so keen on a “miracle cure,” as she puts it. “I think from their perspective, they’re living in a body that they don’t feel comfortable in and obviously they’d want to do anything to fix that situation. And I really did feel that GIDS did play upon that.”

Michelle was surprised too. When she’d first sought help years earlier from her GP, she’d been told that GIDS were the experts. They’d be the ones to talk through what all the options were for Jacob. “But that fundamental word, ‘options’—I really didn’t feel that that was really covered. They offered one solution. One. There is an option—which [is] you go on blockers, and then you go on testosterone, and then you have an operation,” Michelle claims. Less invasive options, like Jacob continuing to dress in the gender he preferred, weren’t discussed.

Although she was concerned, Michelle says she felt she was in an almost impossible situation. “As a parent, you feel like you have to be so careful what you say because one of them is a social worker,” she says, referring to the people assessing her child at GIDS. It would never have been GIDS’s intention to make parents feel uncomfortable—GIDS clinicians simply have a variety of professional backgrounds. But it did impact on Michelle. Michelle says she felt like she didn’t have much of a choice, “that that was the route that they were taking with Jacob.” She didn’t feel she could say she wasn’t sure.

Ultimately, Michelle trusted the experts. “I’m quite an enquiring mind,” she says, “but you think that they’re doctors and psychologists, and they kind of know what they’re talking about… we felt like they knew what they were talking about. And we thought that we were doing the right thing to help Jacob, really.”

It wasn’t just the medical pathway that Michelle felt was being pushed. She says the family were asked whether they’d thought about changing Jacob’s name by deed poll. “And then the next minute, we’ve just done it,” she says.

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Time To Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children by Hannah Barnes has been shortlisted for the 2023 Baillie Gifford Prize for Non-Fiction.

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After four appointments spread over just four months, Jacob was referred to UCLH to commence treatment with the blocker. He had just turned 12. The assessment report written by his two GIDS clinicians stated that “hormone blockers can provide young people with the opportunity to explore and experiment with their identities without the anxiety and challenges associated with ongoing pubertal development.” It added, “It is considered to be a fully reversible treatment.” Jacob arguably did not meet the criteria of the Early Intervention Study, or early intervention more generally, which had now been rolled out as standard practice at GIDS. Jacob had not actively been requesting blockers. Technically, by the time his assessment report and referral were written, he had been at GIDS for six months—as stipulated by the study—but his four appointments had taken place over just four months. He had no contact with the service outside of those.

Like all GIDS patients on the medical pathway, Jacob continued to be seen by the service, albeit infrequently. Appointments would be every four months, then every six months. He would have liked to have been seen more often. Meetings were spaced so far apart that an issue he might have raised at the previous meeting could have changed or resolved itself by the next, he explains, but it would then be brought up again. “You never get a chance to actually move on,” Jacob says.

Jacob’s mum Michelle says that the trans-led support group Gendered Intelligence was talked about ‘all the time’ throughout Jacob’s time at GIDS. The group listed GIDS Executive member Sarah Davidson as part of its team for a time and also, according to Anastassis Spiliadis, once worked alongside GIDS clinicians to deliver official training on gender diversity to other health professionals. Bernadette Wren has also spoken publicly of GIDS’s relationship with Gendered Intelligence.

Jacob was encouraged to look at the group’s website and do some research. But this baffled Michelle. “To me, if you’ve got someone that’s working for the NHS, why are they pushing a charity?” she asks. Jacob was given a leaflet for Mermaids too, but it was Gendered Intelligence that was talked about more. Michelle felt that to point young people towards certain resources and “like-minded people” was “pushing an agenda.” At the time of writing in 2022, young people are still directed towards Gendered Intelligence and their resources on several pages of the GIDS website.

The influence of these outside groups—Mermaids and Gendered Intelligence—was also felt at GIDS “Family Days.” Neither Jacob nor Michelle speaks favorably of the events, Michelle branding them “chaos” and lacking any kind of structure or boundaries. Jacob did not like the fact that the sessions for young people attending GIDS were invariably led by trans adults from either Gendered Intelligence or Mermaids. These adults had often not been through GIDS themselves, Jacobs says, and they were only interested in hearing about positive stories. “I couldn’t discuss my way of thinking,” he says, because those facilitating the discussion only chose people who were like them—fully sold on medical transition and its merits, Jacob recalls. It’s understandable that GIDS would want to try to show that many who transition are happy. But to Jacob there was no diversity of opinion allowed or presented. No other ways of seeing what “being trans” could mean.

The GIDS appointments and Family Days were a sideshow, however. Life for Jacob was immensely difficult. Being on the blockers was not living up to what he had been promised.

The puberty blockers prescribed to Jacob by UCLH slowed down his puberty, he says, but they didn’t stop it. “I still got showings,” Jacob says, referring to spots of blood. “And I still got breast-tissue development.” The response from the endocrinology team at UCLH was to adjust the dose of medication Jacob was on. It didn’t work. Each time a higher dose of triptorelin—the drug predominantly given to the young people attending GIDS—was tried, Jacob still “broke through.”

“I was on the highest-level dose of a completely experimental drug they’d only used twice,” he says. When upping the dose or changing the drug didn’t work, they say, endocrinologists at UCLH gave Jacob beta blockers—medication that slows the heart down—alongside the puberty blockers in the hope that this would help. Michelle says she was told that this was to see whether they could get the hormone blocker to move more slowly around Jacob’s body, something that—combined with the higher dose of the blocker—might “stop the breakthrough.” “To be honest,” she says, “that’s an experiment.”

And one that seemed dangerous.

Jacob collapsed at school. Just 14 years old, he was left lying on the floor behind a locked toilet door for 40 minutes before someone found him. “I rang up UCLH and I was not happy,” Michelle recalls. “And I said to them, ‘I’m not doing this—the beta blockers—any more. If you want to carry on with the blockers with Jacob, you need to find a way of doing it without putting Jacob at risk’… I said there’s no way you should be messing around experimenting with these things with my child.”

The puberty blockers affected Jacob in other ways he wasn’t anticipating, and which he says he hadn’t been told about before starting treatment. He experienced a range of intense and unpleasant side effects, as he tried different doses. “On one of them I had really bad insomnia. And another one, I had really bad anger problems.” The anger didn’t feel normal. “I actually broke my knuckle while I was on the blocker,” from punching something, he says.

Then there was the depression. “Your mood goes like it’s a roller coaster,” he explains. “There are moments when you’re euphorically happy. And the next day, you crash really bad and you are exhausted. And then you’re really, really depressed, like, suicidal depressed.” Jacob says he had felt depressed before starting on puberty blockers and had experienced anxiety. These had made him “feel low” but nothing compared to his temperament on the blocker. Jacob’s physical health suffered too. He gained “tons of weight,” so much so that he got stretch marks.

Then there was the problem with Jacob’s bones. They kept breaking. “I’d never ever broken a bone before I started the blockers,” Jacob tells me. “On the blockers I broke my wrist twice, my knuckles, my toe. It really ruins your bone density.” Four broken bones in just a few years. Jacob was advised to take vitamin D. His blood work showed that he was “incredibly deficient.”

As Jacob’s health deteriorated and his puberty continued to “break through,” he grew increasingly distressed. Like any other person experiencing medical problems he wanted to be able to talk to his doctors in privacy, but he didn’t feel he was given that basic right. Every time Jacob and Michelle would attend appointments at UCLH, someone from GIDS would sit in. They wouldn’t have minded so much if it were Jacob’s own clinicians, but that’s not how the arrangement works. GIDS clinicians are rota’d to attend the endocrine clinic at UCLH. It means that on any given day there’s a chance the young people attending might be their own patients, but the likelihood is that they won’t be. But the agreement between GIDS and UCLH is that someone from GIDS must attend all endocrine-clinic appointments at UCLH. For Jacob, it meant that every time he and Michelle made the trip to London to talk about the medical problems he was encountering while on the blocker, a different member of GIDS staff would sit in each time. “It’s awful,” Jacob says. “These were private medical discussions about things that I was already self-conscious about. And I had to talk about them in front of a stranger.”

After more than four years on the blocker, Jacob felt worse than he ever had before the medication. While his friends were getting their first boyfriends and girlfriends, experiencing their first kisses and sexual experiences, he felt nothing. “You have no desire, no drive whatsoever,” he says. “You don’t even feel attracted to people.” While sitting his GCSE exams he felt he was “being left behind.” Emotionally, he felt years younger than his peers. Michelle noticed it too. And physically, Jacob had stopped growing. Her child was not developing in the way he should.

“I was desperate for it to work,” Jacob says. But the puberty blockers weren’t working. And he’d been told by his doctors that even when he went on to testosterone, he would have to continue taking blockers. “They told me that I would have to be on the blocker for the rest of my life if I decided to take testosterone, and I was like—excuse my language—I was like, screw that.”

At the beginning of 2019, Jacob had had enough. He told his mum, Michelle, “I’m not doing this any more.”

Jacob took his last injection of puberty blockers in January 2019. He had started on them aged 12, and had been receiving regular injections for more than four years. They hadn’t been the “magic bullet” he and his family had been promised.

His decision to walk away from UCLH and GIDS wasn’t planned really, but he’d had enough. A number of factors combined. There was the news that even when Jacob went on to testosterone, as GIDS had talked about from his initial assessment at the age of 11, he would still have to take blockers to suppress his naturally occurring estrogen. He could not face the prospect of his health problems—both physical and mental—continuing indefinitely.

Then there was the challenge from Jacob’s siblings. “You’ve been on the blocker for so long,” they said. “How do you even know that you’re trans? How do you even know that you have these feelings?” Jacob knew these questions were coming from a place of love. His brothers and sister thought he should come off the blockers because they were ‘ruining’ his body. Michelle remembers Jacob’s response. “I don’t know. I just know that’s how I feel,” he said, “and I dream as a boy.”

And finally, there was what happened at UCLH. Jacob was 16 and feeling “very body-conscious,” Michelle explains. He wanted to have a private conversation with his doctors, without a GIDS member of staff present. On one occasion, the request was agreed to, but Michelle and Jacob say they were told, “If this happens again, you won’t be allowed to be seen without a representative from GIDS in there.” Those were the rules, and they had to adhere to them.

Jacob claims they were told that there were many others who could take his place if he was unhappy.

Jacob never went back to GIDS. A year later, in March 2020, Jacob’s GP received a letter informing them that he had been discharged.

The improvement to Jacob’s health was immediate when he stopped the blockers. “I felt so much better in terms of mood. I could sleep better. I grew quite soon after I stopped them.”

His identity didn’t change.

In 2022, more than three years after stopping puberty blockers, Jacob is 19 and still trans. He uses a male name and male pronouns, and dresses in a way that he says is typically male. His passport and driving license say male. But he’s not on any medication. He hasn’t chosen to take testosterone and has no plans to. “I’m quite content with just being me at the moment,” he says. “To be honest, I think I’m gonna be like that for the rest of my life. I’m just all right with what I’m doing at the moment, which is nothing. I’m happy dressing as a boy, I’m happy saying that I’m a ‘he.’ And even if people don’t really believe it… it doesn’t really bother me.” As he gets ready to start university, Jacob tells me he wants to leave the experience at GIDS behind, and “live my life.”

But he’s angry about the five years he was at GIDS. He says he was “sold a lie.” Jacob uses the word “sold” dozens of times over the several hours that we speak. He says it’s the only accurate way he can describe how he feels.

GIDS clinicians “raced at 100 miles an hour,” Jacob says. “There had only been four appointments, and they had already been discussing hormone-replacement therapy, already discussing the operations you could have. Always talking about hormone blockers. For me they were complete strangers, and they were selling me false hope.”

Michelle is angry too. Watching Jacob go through so much pain was “shocking.” All she wanted was for her child to be safe, healthy and happy, but she didn’t know how to help him. “It felt like they were abusing my child, and I felt helpless to stop it,” Michelle says, explaining that she hates to put it this way, but it’s how she feels. “And I actually felt like if I did speak up and say anything, that I was the one that was being judged. Because why would I think like that? Surely, I should be doing everything I can for Jacob to follow his pathway?”

Michelle is left with unanswered questions. “They’re happy to dish out drugs without knowing those answers,” she says. GIDS had talked about the blocker providing young people “with the opportunity to explore and experiment with their identities without the anxiety and challenges associated with ongoing pubertal development,” Michelle says, so why weren’t the ongoing meetings with Jacob about doing that “exploring”? They weren’t. Instead, it felt more like “you get on the train, and you continue to testosterone,” Michelle says. She is understanding about the fact that GIDS clinicians might not have known everything there was to know about the blocker and its impact at that time, but says that should have been reflected. She questions why the blocker was talked about with such certainty. “It shocked me that they’re pushing for the kids to go on [them],” Michelle says. “It did feel like that.”

Michelle would have liked it if they had been better supported as a family, too. It would have been useful, she says, to have someone to talk to and “not feel judged.” Someone independent, perhaps, who she could honestly air her worries with. It would have helped Jacob’s brothers and sister too, who also struggled to deal with what their sibling was going through.

What Jacob wanted was for someone to be more truthful with him. Someone to explain what going through puberty might be like. Someone to prepare him for what challenges might lie ahead if he continued to identify as male. And someone to acknowledge that the medical pathway might not be the only way to live a happy trans life. The Tavistock does not have the capability “of offering anything other than giving you the drugs,” Jacob claims. “I honestly don’t think that they have the slightest clue about what it actually means to be trans.”

Jacob absolutely believes that puberty blockers should be available to young people. For some people, he says, that will be the “only option.” And for those people the blocker must be fully explained, he says, complete with all the side effects and unknowns. “But I think that there is a spectrum,” he says. Not everyone has to “go the full nine yards to be trans like the Tavistock suggests. I honestly do not think that’s how it works.” Plenty of people, just like him, are “going to the Tavistock as children not really knowing where they stand and being offered permanent solutions,” Jacob believes. “And I think that that is wrong.” “All I wanted was guidance,” Jacob continues. “How to use bathrooms when you’re comfortable enough to use the boys’ toilets, how to explain yourself when you have relationships (if that’s what you want),” explaining being trans to family. “I was needing that. But that’s not what I was given. I was given miracle cures and false hope and then I was told to put up with it, and if you’re not willing to, then leave. And that is what happened.”

It’s difficult talking to Jacob and Michelle. The experience of more than four years on puberty blockers and frequent visits to both the Tavistock and UCLH have clearly taken their toll. They both regret, and possibly resent, all the time spent focusing on Jacob’s gender identity. Michelle says the more Jacob’s gender identity was concentrated on—”and it was talked about all the time”—the more it became the only focal point in life.

“I would have preferred Jacob to spend all of that time at school,” Michelle says. “Every day that we had to go the Tavistock, or the UCLH or to CAMHS or to the doctor, was school time.” “When I left [GIDS] and I actually got a chance to do proper work and proper revision… my grades got increasingly better,” Jacob says.

How is Jacob now?

He still feels left behind when he compares himself to his friends and his siblings. It’s like “playing catch-up,” he says, “but it’s that you can’t really catch up because you’re so far behind.” It’s “weird,” he says. “I still haven’t had my first kiss and I’m almost 19.” But he does not have any sexual feelings at all. “I still don’t feel attracted to people,” Jacob says, and he doesn’t know if that is something that will ever come back.

The claim always made about puberty blockers is that they are physically reversible at least, and as soon as you stop, normal puberty resumes. This is based on their use in the treatment of precocious puberty, where treatment is generally discontinued as soon as a child reaches ten or 11. When used in the treatment of gender dysphoria, so few young people come off puberty blockers that we really don’t know what happens.

With Jacob, his growth resumed quickly, he and Michelle agree. But resumption of puberty was much slower. It took more than two years for Jacob to start having periods. They didn’t begin until a few weeks before his eighteenth birthday. Even now, more than three years after coming off the blocker, Jacob’s periods are sporadic and there are many months between them.

These “data” are not being recorded anywhere, however. Since deciding to come off puberty blockers in February 2019, no one from GIDS or UCLH has been in touch to see how Jacob is, or to offer monitoring of any kind. Michelle finds this astonishing. She cannot understand how Jacob could have been on a drug for more than four years, experienced known adverse side effects, and been offered no follow-up. Both GIDS and UCLH have “absolutely no idea how Jacob is and more importantly how both having blockers and subsequently coming off them has affected him,” Michelle says. And Jacob does not know either. “It is one of the biggest regrets in my life is that I went on blockers,” Jacob tells me. “I went on the blockers because I was petrified of the possibility of puberty.” He says GIDS should have prepared him better for that and “not just given me this drug.”

“I was a child,” Jacob says. “And I still don’t know how it’s affected me properly. I still don’t know the full damage that it could have done to my body. And that is just a scary fact.”

*Names have been changed.

**This is a verbatim quote.

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