So, either she was being disingenuous, or she doesn’t know what a woman is. Or perhaps she was just doing what many other indulgent parents do and was appeasing her transactivist son. Whatever the answer, it’s unforgivable. She is a public servant.

In the aftermath of the Cass Report into the state of Britain’s youth gender care services, I have little interest in condemning people for stupid things they have said in the past — but I am angry about those who only changed their stance once it becomes unavoidably obvious that they were wrong all along. One obvious candidate is Labour shadow health secretary, Wes Streeting — though, admittedly, he did reposition himself in the months before the Cass Report was published.

In the past, Streeting has resorted to what I call “the Joni Mitchell diversion tactic”, attributing the toxicity of the “debate” to “both sides”. Yet Streeting himself hasn’t always been so even-handed. In 2017, he called for “specialist GPs” to be trained to prescribe “bridging hormones” while patients waited for a referral — a practice starkly at odds with the conclusions of the Cass Report.

Yesterday, though, Streeting hailed Cass’s review as “a really important” piece of work. “[It] does raise some serious concerns that are pretty scandalous. Actually I think we’ve got to ask ourselves: why is it that we’ve seen medical interventions that have been given on the basis of very weak evidence? How is it that clinicians have been silenced for coming forward?”

Really, Wes? You don’t understand how these people — including your own colleague, Rosie Duffield — have also been silenced? Of course he does. But then yesterday, disingenuity was the order of the day. Even Stonewall — that rainbow-resplendent Garden of Eden — was forced to change tack. In its statement about the review, it said: “What is important, above all, is that trans and gender-diverse children get the quality healthcare that they need and deserve. The Cass Review can play a vital role in achieving this aim, if its recommendations are implemented properly.”

Coming from an organisation that has repeatedly extolled the benefits of making puberty blockers available for children, should we take this seriously? Probably not. But regardless, the fact they have been forced to even utter such words cannot be dismissed.

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In a similar vein, the prickly princelings at PinkNews published an uncharacteristically low-key piece — possibly the site’s most neutral article about the review since it was commissioned four years ago. In place of its usual fare — incoherent rants peppered with spelling mistakes — it set out some of the report’s recommendations, almost without comment. It even said that the World Professional Association of Transgender Healthcare (WPATH), an internationally recognised body for trans healthcare guidance, lacks “developmental rigour”.

It can’t be stressed enough how out-of-character this is. For years, PinkNews has been a key cheerleader for puberty blockers for children, repeating myths about trans kids being at major risk of suicide if denied such treatments. Yet here it simply reports: “The review also claimed that, while research suggests that hormone treatment “reduces” the elevated risk of suicide, there is ‘no clear evidence’ that social transition has any positive or negative mental health outcomes.” On a normal day, its reporters would be screeching “transphobia” and “bigotry” from the comfort of their keyboards, but then yesterday was no normal day.

And yet, for all of yesterday’s almost-mea-culpas, it would be delusional to hope that these people will ever genuinely admit their roles in the scandal, let alone their own contributions to the horrendous damage that has been done to children. I even doubt that any regret will register — other than in terms of how it might backfire on them personally. Politicians will change their tune because they want to be popular and get elected; organisations such as Stonewall know that their funding will soon dry up, their expiry dates growing ever closer.

In 2008, I was officially “no-platformed” by the National Union of Students (NUS), becoming the first individual deemed so offensive and dangerous that I was blacklisted alongside five fascist groups. At the time, Streeting was president of the NUS, and I called him and asked for his help. When he refused, I asked if he would simply denounce the allegation that I was transphobic, even if he couldn’t do anything officially to get me removed from the list. He would not. Six years later, when I was considering whether to take some kind of legal action against the NUS for reputational damage, I contacted him again. He initially agreed to an off-the-record chat, but then stopped replying to my emails about a suitable time to speak. It’s funny how things change.

If I sound bitter that’s because I am. Thousands of kids have been harmed by this ideology, along with many, many adults. Those of us who have been shunned, lost jobs, friends and reputations as a result of accusations of bigotry and transphobia are, of course, secondary victims. And as for those who have played it safe? Inevitably, they will now stay silent or pretend that the evidence of harm contained in the Cass Report is a shocking revelation. The truth, of course, is that the evidence has been there all along. To those new converts now pretending otherwise: we see you.

It was supposed to be a haven for young people experiencing gender-related distress. Instead, following a string of complaints by whistle-blowers, an “inadequate” rating by the Care Quality Commission, a high-profile judicial review and, finally, a damning independent review, it was deemed unsafe.

In its place, two new regional hubs were set to open, with several more centres to follow. For Gids’s long-standing critics, concerned about the distress its tumult was having on children, this came as a huge relief.

The story, however, does not end here.

Kathleen Stock has spent the past month speaking to a range of clinicians, NHS professionals and parents of dysphoric children — to find out whether Gids’s new service will be an improvement.

The portrait she paints is stark: her findings suggest that the NHS gender services are yet to become a clinically safe space for children and teens, with senior figures still pushing an activist ideology. Only last week, NHS bosses internally announced that they are significantly delaying the launch of one of the hubs. And as she reveals in the below investigation, it is unlikely to be the final twist in Gids’s new chapter…

Read on to learn about:

What happened to Gids?
The ideology in the new hubs
A new Wild West for patients

***

In 2014, the head of the NHS Gender Identity Development Service, Dr Polly Carmichael, appeared on a BBC children’s television programme billed as the story of “an extraordinary boy… born with a girl’s body”. Soothingly addressing the tomboyish young protagonist sitting across from her, Carmichael was filmed saying that a “puberty blocker” — or to give it its proper name, a gonadotropin-releasing hormone (GnRH) analogue — “pauses the body and stops it from carrying on to grow up into a man or a woman”.

She continued: “The idea of the blocker is that if we can take away that worry about your body doing something that you don’t want it to, then it gives you and us more time and space to be really thinking about what’s going to be best for you now, but also in the future.” As she spoke, a cartoonish pause button symbol was projected onto the child sitting opposite her, whose moving image was then frozen to a still, to reinforce the point.

Back in 2014, Carmichael’s service — known as Gids, and based at the Tavistock and Portman NHS Foundation Trust in London, with a satellite clinic in Leeds — was still riding relatively high in public opinion. The clinical psychologist was often in the media, describing the challenges of treating a highly mysterious new being — the “transgender child” — to fascinated and relatively uncritical audiences. Indeed, the children’s television programme in question, My Life: I Am Leo, went on to win a Bafta.

But times change. These days — thanks to a string of whistleblowers, a high-profile judicial review involving a former patient, a rating of “inadequate” by the Care Quality Commission (CQC), and a cumulatively devastating book by investigative journalist Hannah Barnes — the name of Carmichael’s service is now synonymous with mismanagement and medical scandal. The closure of Gids was announced by NHS England in July last year, and an independent review is now well under way, also known as “the Cass Review” after its chair, the distinguished paediatrician Dr Hilary Cass.

Following Cass’s interim recommendations, published in February last year, two new regional services are being formed to treat “gender incongruence and gender-related distress” in children under 17, with several more centres planned for launch afterwards. Slated to open next month, the “Southern hub” involves teams from Great Ormond Street Hospital, the Evelina Children’s Hospital, and the South London and Maudsley NHS Foundation Trust. The “Northern hub” partners Alder Hey Children’s NHS Foundation Trust with the Royal Manchester Children’s Hospital.

Many long-standing critics of Gids have been reassured by these developments, and by the principled and cautious approach apparently taken by Cass so far. It seems she aims to examine trans-identification in children and adolescents systemically, applying what is known about wider paediatric health rather than sacralising her patients as exotic anomalies. One parent of a Gids patient, seeking anonymity for the sake of protecting the privacy of his child, as so many parents of trans-identified children do, told me with enthusiasm: “Gender has been exceptionalised as a clinical speciality, but Cass wants to weave it back into paediatric practice.”

But the story does not end there. Over the past month, I have spoken to a range of clinicians, other NHS professionals, and parents of dysphoric young people to understand how Cass’s guidance is being enacted on the ground. I have discovered that there are deep ideological tensions and conflicts within the very institutions — clinics, hospitals, trusts, commissioning boards, adjacent adult services — whose responsibility it is to implement Cass’s new vision. Moreover, it seems NHS systems are still influenced by activist thinking; in particular, by the idea that a sex-incongruent gender identity is something to be “affirmed”, either as a matter of social justice or as personal liberation.

Considered together, my findings suggest that the NHS gender services are yet to become a clinically safe space for children and teens. Last week, NHS bosses suddenly internally announced that they are significantly delaying the launch of the Southern hub — after months of preparing training materials for clinicians recruited into the new service, and only a few days before the materials were due to be used for the first time. In line with I Am Leo’s original metaphor, it seems that senior managers too are pressing the pause button, in order to have more time and space to think. In the meantime, thousands of distressed children and their worried parents wait anxiously for a resolution.

***

What happened to Gids?

Despite the common belief that Gids closed following the announcement last year, it is still open, providing what it describes as “continuity of care” for around 1,000 existing young patients, including some on puberty blockers. (Cass recommended that in this interim period, any referrals to endocrine services by Gids staff should be reviewed by a multidisciplinary external panel).

It is unclear to outsiders exactly how patient care is now being managed at Gids, but what does seem true is that attempts have been made to improve existing processes since at least 2021. Published in February, an open letter from Gids staff concerned about Cass’s plans for the new services reveals that, after the CQC rating of “inadequate”, something called the “Gids Transformation Programme” was developed — separately from the Cass review, according to them — in order to make “wide-reaching changes to the running of the service”. The letter claims that external consultants were paid over £1.5 million to advise on the Transformation Programme, with some changes yet to be implemented.

At the heart of the controversy about the original service was its increasingly positive attitude to “gender affirmation”: roughly, the idea that a clinician should “believe” a girl who declares she is a boy (or vice versa), and so accede to her way of describing herself in clinical encounters. Though advocates deny it, critics insist that this practice precludes genuinely critical exploration of what may well be a passing phase. Without the capacity to gently challenge such a child in a therapeutic setting, an outcome involving lifelong medication is thought to become much more likely.

Even under the most scrupulous of arrangements, treating psychological distress in a physically healthy child or teen by administering experimental, powerful hormone-blockers carries risk. At Gids, that risk was increased severalfold by the organisational chaos of the service. During Keira Bell’s judicial review in 2020, High Court judges expressed surprise that clinicians did not seem to know how many young people had been referred there for blockers since 2011, nor of what age distribution. Only in 2022 — when Gids clinicians got round to publishing an analysis of outcomes for medicalised patients for the first time — was it announced that 1,151 children had been referred to the endocrine clinics in London and Leeds for puberty blockers and/or cross-sex hormones between 2008-21. According to Barnes, what proportion of them received puberty blockers still remains unknown.

There were other failures too, made clear in the course of Keira Bell’s judicial review and appeal, and in Barnes’s book. They include a startling absence of curiosity about certain recurring characteristics of patients — for instance, why so many of them were female, same-sex-attracted, and/or autistic. And there was also the close working relationship with the transactivist lobby groups Mermaids and Gendered Intelligence; inadequate preliminary assessments, both in quantity and quality; and a shocking lack of post-discharge follow ups.

In the past year or so, this impression of institutional disarray has been reinforced by Cass. In her interim report, she criticised management for having no standardised approach to patient assessment; no routine contact between psychologist and endocrinologist; no consistent safeguarding processes; poor record-keeping; and too-infrequent monitoring of medicated patients. She also seemed critical of affirmative approaches, noting with apparent disapproval: “From the point of entry to Gids there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations.”

In June, guided by Cass’s analysis, the NHS published an “Interim specialist service specification for children and young people with gender incongruence”, laying out the broad features of a new clinical pathway for this cohort — including standardised, genuinely exploratory assessment by multidisciplinary teams. Separate service specifications for puberty blockers and hormones are to follow. Cass has also insisted that, in future, puberty blockers should be administered in the NHS only as part of a properly managed clinical trial.

Despite the many criticisms of her management career to date, Carmichael remains in post as director of Gids. One of the main whistleblowers at the Tavistock, former staff governor Dr David Bell, told me: “Gids was found in the judicial review to be profoundly deficient in terms of clinical governance and record keeping. It is thus extraordinary that Polly Carmichael has been allowed to remain in position as director.” He described this as “a shocking message to parents and families who have been so damaged by this level of neglect”.

It is hard to find out which other clinicians still work at Gids, but many are assumed to be affirmative in their approach. In a second open letter from late last year — written from an affirmative perspective, in order to criticise the relatively positive response from the Association of Clinical Psychologists to the Cass Review — 13 signatories named their current workplace as Gids, including Carmichael herself.

One of the Gids-affiliated signatories was non-binary author and therapist Dr Jos Twist. Twist has edited an anthology, Non-Binary Lives: An Anthology of Intersecting Identities, which includes “stories of… how it feels to be non-binary and neurodiverse, the challenges of being a non-binary pregnant person, what it means to be non-binary within the Quaker community, the joy of reaching gender euphoria”. Another Gids signatory was clinical psychologist Dr Lorna Hobbs, who told The Guardian in January that, “for me, affirmative is starting from a stance that says gender diversity isn’t a disorder but has existed across cultures through history. It is saying ‘I believe you’ when you tell me about your experience.” Along with Twist, two other signatories who also claim to work at Gids — Dr Claudia Zitz and Dr Josh Goulding-Talbot — are now also listed as working at GenderPlus, a recently registered private provider with ambitions to prescribe hormones to teens (more on this below).

Such evidence suggests that the remaining patient cohort at Gids are not receiving the sort of care of which Hilary Cass would thoroughly approve. However, when it comes to the new services being built at the moment, it is not entirely clear that things will be much better…

***

The ideology in the new hubs:

Certainly, the presence of Professor Gary Butler in the new Southern hub does not instil great confidence that things have changed. For much of the service’s history, Butler was the endocrinology lead for Gids. In 2017, apparently with all the zeal of a true believer, he told The Daily Mail that, under his supervision, his clinic at University College London Hospitals NHS Foundation Trust “routinely” prescribed puberty blockers to children with “life-long” gender dysphoria: “When the team feels the young person is genuinely transgender they welcome [the use of] puberty-blocking drugs right from the early stages.”

Butler has also co-authored articles with Carmichael and others at the clinic. In one from 2018, he observes that “around 35% of referred young people [to the clinic] present with moderate to severe autistic traits” — apparently untroubled by the thought that he might be contributing to the premature sterilisation of autistic youth. For it is now recognised that, when combined with cross-sex hormones later, giving blockers to dysphoric young patients early on in puberty can inhibit the development of adult sexual function permanently — a fact occasionally openly mentioned by clinicians supportive of medical intervention but most of the time glossed over.

Yet Butler has now been recruited onto the team based at Great Ormond Street Hospital (GOSH) charged with developing training materials for clinicians in the new hubs. (Insiders I have spoken to believe that Polly Carmichael was initially on the recruitment panel, though the BBC reported that the decision to have her there was later “reversed”.)

Butler advertised his new role at a conference for gender medics in April, during a speech in which he also accused Cass of “nepotism” and said that the hospitals he was working with had no relevant experience with gender incongruence. He said he had “fought back” to “continue to be able to provide endocrine services for trans young people”. He has since rowed back on his comments and expressed support for Cass. But for David Bell, Butler’s presence in the new service still rings alarm bells: “Butler was responsible for being part of a service penetrated by trans ideology and neglecting the safeguarding of children; he is part of the Gids debacle and shouldn’t be involved in the new service.”

And Butler is not the only Gids clinician involved in the new hubs. I’m told that Dr Lorna Hobbs — the Gids psychologist who extolled the virtues of “believing” a trans-identified child to The Guardian in January — has advertised online that she is involved in the new service. Hobbs often reposts material from trans activist lobby groups on her public LinkedIn profile, and declares, on the website of a private therapy provider she also works for, that she applies a “social justice and equalities framework” to all the work she does.

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One person working in the Southern hub told me that some clinicians recruited into the service “only believe in an innate notion of identity rather than one developing over time”. They added that involving such different voices on a single team was causing dysfunction. “The official position is that diversity of opinion in a team is a good thing, in order to mirror the fact that people don’t all agree in real life. But it doesn’t work. You can’t say yes and no at the same time.”

In the Northern hub, meanwhile, there is also a risk of repeating old mistakes. Buried within the July 2023 meeting minutes of the Alder Hey Board of Directors is the news that Leeds Children’s Hospital has now entered into the Northern hub partnership “as the existing providers of endocrinology services for children and young people under the care of the current Gender Identity Development Service”. In other words, endocrinology appointments for patients in the new service will apparently be managed by the very same hospital department involved with Gids Leeds, the satellite clinic of the Tavistock. On the current website for the hospital team, staff all list their pronouns.

Why were affirmative clinicians who were already tarnished by an association with Gids recruited into the new hubs, even after Cass’s recommendations? According to NHS sources close to both hubs, the most common explanation is cock-up rather than conspiracy. Managers at the relevant trusts don’t know much about the area, I was told, and when recruiting and setting up new structures, were likely to be impressed by a lot of mentions of “gender” on a CV. From this uninformed perspective, having already worked at the main NHS gender identity service for children presumably looks like an unimpeachable background.

Whatever the explanation, what does seem clear is that transactivist lobby groups and networks are strongly vocal in all of the trusts involved in the new hubs. Across the NHS, activist clinicians and support staff are pushing the idea that gender identity affirmation is a minority rights issue, and a way of furthering Equality, Diversity and Inclusion (EDI) goals. With “inclusive” policies about pronouns, changing rooms, and hospital wards already in place in a trust, the job of any clinician who wishes to resist affirmative narratives for dysphoric young people becomes that much harder. For fellow staff naively unaware of the potential clinical repercussions, it can easily seem that “respecting identities” is a simple matter of courtesy.

So, for instance, GOSH’s existing “Privacy and Dignity policy” instructs clinicians that “Trans and gender variant young people should be addressed and accommodated according to their self-defined gender or presentation e.g. the way they dress, and the name and pronouns that they currently use”. Guy’s and St Thomas’ NHS Foundation Trust’s trans policy says: “Asking and correctly using someone’s pronouns is one of the most basic ways to show your respect for their gender identity.” In other words — wider hospital policy in both trusts instructs clinicians and support staff to “affirm” any non-standard gender identity automatically, wherever it is encountered. It is unclear how such policies could possibly be maintained in the sort of genuinely exploratory clinical setting Cass apparently envisages.

Over at South London and Maudsley NHS Foundation Trust, meanwhile, all job adverts have Stonewall Diversity Champion branding. Freedom of Information requests also reveal that Mermaids provided EDI training to Childhood and Adolescent Mental Health Services (CAMHS) staff at the Maudsley Hospital last year. (The training this year was cancelled after adverse press attention.) Moreover, the hospital also has a vocal LGBTQ+ Staff Network, which seems to have some influence with management. I’ve been shown a copy of an email written by their leadership team in September this year, warning members of a visit to the Women’s Staff Network from Lynn Alderson, a lesbian feminist speaker with gender-critical and sex-realist views. After complaining that the speaker’s views were “divisive and hurtful, and in contradiction of our network’s gender identity statement”, the authors continue: “We have been assured that strict protocols have been put in place to prevent the speaker stating her views on gender, and that she will be ejected from the meeting if she does so.”

South London and Maudsley Trust also participates in the NHS Rainbow Badge scheme, described as “an assessment and accreditation model for NHS Trusts” and a “partnership between the LGBT Foundation, Stonewall, LGBT Consortium, Brighton & Hove LGBT Switchboard and GLADD”. (The Rainbow Badge scheme was actually founded by a medic working at the Evelina Children’s Hospital — the third hospital involved in the Southern hub partnership.) In a recent assessment, the Trust was given a Bronze Award, with particular commendation for its trans policies and for having “awareness posters across the site that reference microaggressions relating to homophobia, biphobia and transphobia” — though it was also marked down for a maternity policy that “uses gendered language throughout”.

A similarly ideological picture emerges in the North. Manchester University NHS Foundation Trust — which includes the Royal Manchester Children’s Hospital, one of the two children’s hospitals in the hub — also advertises its membership of the NHS Rainbow Badge Scheme, and in the recent past has used another scheme from the explicitly transactivist charity LGBT Foundation for training. The other one, Alder Hey Children’s Hospital Trust, is a member of the “Navajo Charter Mark” scheme — the North West’s equivalent of the Stonewall scheme, founded in 2010 to assess organisations in terms of “LGBTIQA+ friendliness” with a remit that includes “practices and policies” and “training”. Alder Hey was reportedly accredited by Navajo this month.

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The content of Navajo training for organisations is unavailable to outsiders, but a 2019 Navajo newsletter perhaps gives us a sense of the organisation’s sympathies. It carries posts about banner-making workshops for Trans Pride, and regurgitates the persistent falsehood that “Almost half the trans kids of school age in the UK have attempted suicide”.

When it comes to implementing the recommendations of Cass, then, it is not inconceivable that local LGBT+ networks and transactivist groups within hospitals and trusts will put up resistance, whether active or passive. In April 2023, a NHS-sponsored analysis of responses to the public consultation on Cass’s interim service specification was published. Of the 411 clinicians who responded, 49% of them (the largest group) fell into “Group A”, described as “largely opposed to the proposals outlined in the interim service specification”, for reasons that included the perceived “transphobia” of some clinicians and the equation of “mental health treatments” for trans-identified youth with “conversion therapy”. Though obviously there was self-selection bias here, nonetheless the findings suggest there is a problem.

This sense is reinforced by the contents of a series of FOI requests made earlier this year to every NHS Trust in England and Wales that provides CAMHS, asking: “What if any training in gender, gender identity and equality your Clinical staff and practitioners have received in the last 4 years?” Some trusts replied that they paid explicitly trans activist organisations such as Mermaids and Gendered Intelligence to give them training; but even where trusts used less obviously partisan sources, it was clear from responses that the majority of them are employing a minority rights and inequality lens to look at gender identity, and not a psychological one.

And there is also evidence of at least partial capture in other powerful NHS bodies. NHS England was placed 68th in the Stonewall Top 100 Employers this year — an intensely fought competition with hundreds of entrants, in which a high placing indicates close policy compliance with Stonewall’s transactivist goals. The Care Quality Commission, in charge of regulation, proudly advertises on its website that it is a Stonewall Diversity Champion — as does the National Institute for Health and Care Excellence (Nice), Health Education England, and the NHS Confederation.

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Elsewhere, the British Medical Association has come out in favour of affirmation, and published a response to Cass that criticises the new service specification for failing “to recognise the highly individual nature of children and young people’s experiences or their own developing autonomy in relation to exploring their identity”. The Chair of the Sexualities Section at the British Psychological Society, Dr Rob Agnew, frequently writes or endorses transactivist content on his public LinkedIn profile, including one post claiming that “[k]ids receive cis gender ‘grooming’ from the moment they are born” and that “[s]upposedly ‘experimental’ blockers are fully approved by the medical establishment and readily prescribed to cis kids for a variety of reasons”.

But this is not so. Some analyses suggest that blockers can negatively affect the bone density levels of young patients, and perhaps their renal and cognitive functions too. ​​A 2020 Nice evidence review — later acknowledged by Agnew after pushback — has concluded that the quality of evidence for the positive impact of blockers on “gender dysphoria, mental health and quality of life” is of “very low certainty”. There is also increasing doubt about whether blockers are beneficial or even just neutral for mental health.

Indeed, one NHS research trial manager I talked to expressed strong scepticism that a properly described clinical trial for puberty blockers — as mandated by Cass — could ever meet statutory regulations for what is known as “Good Clinical Practice”. She told me: “The Tavistock’s original application for their Early Intervention Study wasn’t regulated as a Clinical Trial of an Investigative Medical Product (CTIMP) but this one would have to be.” She added: “Children get classed as a vulnerable group. They need to have very special protections, and the rationale is just not there. The possible impacts [of blockers] on a child are so high that the moment that this was recognised, the study would be shut down. If you had a healthy child, and you recognised that medication could confirm sterility issues, or fertility issues, or bone density issues, the trial would be stopped at that point.” It would be “completely insane” to run such a trial, she concluded.

Meanwhile, even within the National Programme Board for Gender Services, the body ultimately in charge of service specifications for both adults and children with gender dysphoria, there are worrying signs for those seeking a clinical approach that situates dysphoria in the realm of paediatrics and psychology.

The Chair of the Board is Dr James Palmer, Medical Director for Specialised Services, a consultant neurosurgeon who has overseen all gender services in England and Wales in the past decade, both for children and adults. In 2018, he told a conference that the NHS needed to design “a healthcare service that will allow somewhere around 1-3% of the population at some point in their lives to have a discussion about their gender”. Talking about the drop in average age of Gids patients, he added: “It’s got to be a good thing that there are people out there that want to explore their gender. The fact that it’s in the younger age group has got to be a good thing. For a young adult, to be able to come forward, to seek that expertise, earlier [rather] than much much later in life, that’s got to be a good thing.” The lack of curiosity about why so many younger people were suddenly arriving in his services is marked. And in fact, there is evidence that early social and medical transition for a child experiencing gender dysphoria — carried out, of course, by adults — tends to solidify a sex-incongruent gender identity in the child that otherwise might well have passed.

Meanwhile, on the Clinical Reference Group for Adult Gender Dysphoria Services, described as providing “independent expert advice to the National Programme Board for Gender Dysphoria Services on the various aspects of the Board’s work”, two out of five of the members are openly affirmatory of children. Dr Laura Charlton, a clinical psychologist, works at Gids Leeds and was the first author of the open letter signed by Carmichael last year, defending affirmation. At one point, the letter complains of the use of “male” and “female” for trans-identified children because it “undermines the lived experiences of the people being referenced”.

The second affirming clinician on the board, Dr Christine Mimnagh, is clinical lead at the Merseyside adult gender service CMAGIC, and also a GP and private practitioner. In an interview last year, worth quoting at length, Mimnagh said about trans-identified children: “The first thing you get taught in safeguarding for children is, if a child comes up to you and says, you know… ‘I don’t like the way they touch me’, or whatever, what you do is go ‘OK, yeah, tell me more, I’m listening’… what you don’t do, is say, ‘Oh no they didn’t, that’s Mr Jones the gamesmaster, he would never do that!’ There’s a difference between affirmation and dismissal and with everyone whose trans, affirmation is kind of the name of the game; you can’t deny people’s reality just because their reality is different from yours.”

In other words: just as we should believe a child who says she or he is being sexually abused, we should also believe a female child who says she is a boy.

***

A new Wild West:

It appears, then, that despite the apparent good sense of Cass’s interventions so far, contemporary gender medicine in England and Wales remains somewhat chaotic. Within relevant services and wider NHS institutions, there are clinicians with directly clashing views about what sex-incongruent gender identity is, what it means, and what clinical decisions should be made as a result. And it seems that the cracks are starting to show.

I have seen evidence that, only last week, clinicians in the Southern hub — getting ready to launch in a month’s time, and to trial the new training materials with clinicians that very week — received a wholly unexpected internal announcement: the November launch had been postponed. Rising clinical, legal, and communication costs were cited, as was the insufficient time for senior clinicians to sign off the training materials in line with the proposed delivery schedule. I’m told that a manager of the team in charge of producing training materials resigned. Though teams within the Southern hub continue to be employed, their work is now paused, with no revised schedule yet in place.

What will this delay mean? With Gids closed to new referrals and the hubs not yet established, waiting lists will inevitably grow longer by the day. Now taken out of Gids’s hands and managed separately by a NHS Commissioning Support Unit, as of July 2023 7,902 children and young people were on the national waiting list. It is widely acknowledged that any child who is 16 is unlikely to be seen by a children’s service before she turns 17 (the cut-off point for care under childhood and adolescent services).

In desperation, some parents with enough means are turning to private providers to buy puberty blockers and hormones for their child. GenderGP is the most well-known of these, notorious for its close links with Mermaids — even to the extent of employing former CEO Susie Green for a few months this year — and for its historical run-ins with the General Medical Council.

But there are others who also see waiting lists as a business opportunity. The “Yorkshire Gender Endocrinology Services clinic” offers blockers on its website, though it’s unclear whether its clinicians would dispense these to under-17s. And last month, a new private clinic — GenderPlus — arrived on the scene, overseen by former Gids clinician Dr Aidan Kelly, with stated ambitions to start prescribing hormones to teens in the next couple of months. Several other former and current Gids clinicians are involved in this venture, most notably Paul Carruthers — lead nurse at the NHS Gids clinic still based at Leeds Children Hospital, and described as the person who will be “leading the hormone clinic” at GenderPlus.

For some parents, this is an attractive option. One told me: “I know there are parents who want to do it by the book and feel that GenderGP is not doing it properly. They want to go to a Harley Street clinic, get a diagnosis, and feel reassured by having a clinician registered with the NHS.”

Yet while GenderPlus is presented by Kelly as a new project, focused on hormones not blockers, it seems he might already have experience in prescribing blockers to children under the auspices of another of his businesses, Kelly Psychology. As an anonymous comment on the TransgenderUK Reddit put it a year or so ago: “There is another provider to GenderGP but it’s probably more expensive. I use Kelly Psychology and have a private endocrinologist who prescribes puberty blockers to my 13-year-old child. The process is the same as Gids but private.” (Kelly Psychology did not respond to a request for comment.)

Whatever the truth here, it is clear that Kelly is aiming GenderPlus at the parents of dysphoric children and adolescents, and that he anticipates big business. The company already lists 17 staff members on its website, including a research manager.

Given the acknowledged lack of a solid evidence base, to prescribe such poorly-understood drugs privately could be seen to be incautious. Cass’s new interim service specification is very explicit, with added red lettering for extra emphasis: “Children, young people and their families are strongly discouraged from sourcing puberty suppressing or gender affirming hormones from unregulated sources or from on-line providers that are not regulated by UK regulatory bodies.” Though GenderPlus has told The Times it is seeking registration with the Care Quality Commission regulator, its website currently says that it has “clarified” with the CQC that its service “does not fall under their remit and as such is not eligible for CQC registration. If in the future we do provide services which will require CQC registration then we will seek registration.”

Another major worry for many parents of children currently on the national children’s waiting list is the increasing proximity to adult services as their child gets older. In August this year, letters were sent directly to all 17-year-olds on the list, encouraging them to opt for referral onto the adult list instead. They were told that the original date on which they were placed on the children’s list could be transferred to the adult one, so that they could be seen more quickly. The letters were signed by James Palmer.

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Since adult services tend to be uncritically affirmative, the letters have profoundly alarmed some parents desperately holding out for a non-medicalised resolution to their child’s dysphoria. In practice, it seems that a 17-year-old might self-refer to an adult clinic and be put on hormones on the day of her second appointment, without any psychological intervention; indeed, one clinic proudly advertises the possibility of prescription at this speed.

What makes this possible is the existing NHS adult service specification, written in 2019. It is a document that governs standards of care in all adult services, and is a world away from Cass’s careful formulations. Gender dysphoria, it states, is “not, in itself, a mental health condition” — making it somewhat obscure why the NHS should pay for treatment. Equally, “psychological interventions will not be offered routinely or considered mandatory”; and “the majority of individuals will have two core assessment consultations” (and no more). Individuals can also self-refer to a clinic without any intermediate referral from a GP. For breast removal, a patient will need the sign-off of one clinician within the service. For genital surgery, she will need two.

There are eight NHS gender clinics for adults in England and Wales, plus four new “pilot” services, brought in more recently to bring down adult waiting lists in local areas (one of these was mentioned earlier: C-Magic in Liverpool, run by Dr Christine Mimnagh — the clinician who made an equation between believing a child’s disclosure about sexual abuse, and affirming a child’s incongruent gender identity). The new pilot services tend to be embedded within sexual health services, are run by predominantly LGBTQ+ clinicians, and appear to be even more affirming than the already fairly ideological norm.

For instance, the website of Indigo, the pilot service in Manchester, says: “We know that trans and non-binary people are the experts of their own experience… Our services are trans and non-binary-led, with trans and non-binary people guiding and feeding into them at all levels.” An NHS commissioning document for the pilots says that Indigo is “testing the role of Care Navigators, a non-clinical role typically staffed by individuals with lived experience, to support patients before their first appointment with the specialist team”. Somewhat unusually for a primary care provider, Indigo also has a “Leave this site quickly” button on its website, taking browsers to Google if necessary.

I talked to Anna, the mother of a trans-identified daughter currently on the Gids waiting list who is nearly 17 and is seeking medical transition. Her daughter formerly identified as a lesbian. Over lockdown, she began to identify as a boy, having discovered transactivist websites. The teenager, who also has ADHD, is now living with an affirming father who supports her transition.

Anna told me: “I’m frightened that without any evidence of benefits, and with a high rate of neuroconditions and traits — bearing in mind that girls will be more undiagnosed than boys — without consideration for all of that, and with only one pathway in the adult services, our kids have no hope. I don’t want to say mutilated but that’s what is happening. There is so much regret, I don’t want our kids to have regret. They are only on one path, without any mental health considerations. I don’t understand how they can do it.” Along with another mother in a similar position, she is now seeking permission to pursue a judicial review against the NHS, “for providing unsafe treatment advice for young people from 17 years old and vulnerable adults”.

For David Bell, what is happening to dysphoric 17-year-olds is the “biggest area of concern”. He told me that, in light of their incomplete cognitive and emotional development, there is plenty of precedent already for 17-25 year olds to be treated separately from adults in mental health services; pointing me to guidelines from the Royal College of Psychiatrists and elsewhere in the NHS that have established this. He described the failure of adult gender services to recognise this as the “trans-exceptionalism” already familiar from elsewhere in the NHS. Indeed, with what another former Tavistock clinician described to me as a “beautiful irony”, the Tavistock and Portman Trust itself has an adolescent and young adult service in general mental health that covers 14-25 year olds — just not in Gids.

Cass’s interim service specification states that, when a child is moved to an adult service, “a co-ordinated transfer to appropriate local adult services will be needed where complex presentations continue”. It seems that, at the moment, such a rational arrangement is some distance away. In effect — thanks to the collapse of the old service and to delays within the new ones — a void has opened up in the systems supposed to care for gender dysphoric young people. And until it is filled, a cohort of highly distressed children and their desperate parents will continue to pay the price.

***

A spokesperson for the NHS Children’s and Young People’s Gender Service (London) said:

 “The NHS Children’s and Young People’s Gender Service for London — a partnership between Evelina London Children’s Hospital (part of Guy’s and St Thomas’ NHS Foundation Trust), Great Ormond Street Hospital and the South London and Maudsley NHS Foundation Trust — is working towards full mobilisation of the new service by the beginning of April 2024

“The set-up of this completely new service is complex. In advance of full mobilisation, we will be working with colleagues on the safe handover of current patients. We are also focused on recruitment, training and ensuring good data collection which supports the developing research, and progress made in these areas will determine how quickly it will be possible to start seeing new patients off the waiting list.”

Gids had been established in 1989, to help distressed teenagers navigate their feelings of gender dysphoria, but changes in leadership along the way led to a dramatic shift in its clinical approach. In recent years children routinely found themselves on a medical conveyor belt before the psychological effects of early adverse experiences were fully explored. Much has been written about the blanket application of an “affirmation-only” approach to a complex caseload, which too often put children on a single pathway to life-long medicalisation. By 2020, Gids had prescribed puberty blockers to more than a thousand children. 

In most academic discourse, a “no-debate” approach, such as the one described at Gids, will be stifling and unproductive — but in medicine, it will inevitably result in harm. All clinical practice should be centred around the careful consideration of competing possibilities. It is unsurprising that children were harmed at Gids when a single-minded certainty usurped clinical curiosity.

One year on, Gids remains open, although it no longer accepts new referrals. The plan is to replace the moribund service with regional hubs offering the holistic care required by young people struggling with their gender identity. The promised new services are still taking shape, but before they have even opened their doors to the ever-accumulating backlog of referrals — last rumoured to be upwards of 8,000 young people — concerns have been raised about history repeating itself. Some of the senior clinicians from Gids have seamlessly transferred into new leadership positions, despite appearing to have learned little from its terminal failings.

In April 2023, Prof Gary Butler, the lead endocrinologist at Gids and a clinician appointed to a leadership role in its replacement service, questioned any need to rethink the model. He told a conference audience that Gids was already working in “exactly” the way that Dr Hilary Cass had called for in her thorough review of services for children and young people with gender incongruence. It is difficult to see how anyone could reconcile the service described in Time to Think — BBC Newsnight reporter Hannah Barnes’s careful and balanced account of the failings reported by multiple Gids clinicians — with the holistic approach recommended by the Cass Review.

Its recommendations tear down the exceptionalism that allowed things to go so wrong at Gids; evidence-based practice will be the bedrock of the new service, just as it is in every other NHS clinic.  Those working within the new services will be contractually committed to follow Dr Cass’s recommendations, which place a new emphasis on integrated models of care and evidence-based treatments, recommendations that should be as uncontroversial as motherhood and apple pie.

But, then, motherhood and apple pie aren’t quite as uncontroversial as they used to be. And an evidence-based practice may not be quite the unifying foundation if the clinicians involved cannot agree on the evidence base.

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Earlier this month, a group of 21 eminent clinicians working across nine countries in the field of gender distress wrote an excoriating open letter in response to a bold claim from Stephen Hammes, president of the Endocrine Society. In a letter to the Wall Street Journal, Hammes had stated that more than 2,000 studies had provided a clear picture that gender-affirming care improved the well-being of gender diverse people and reduced the risk of suicide; if that were true, it would be very reassuring and closer to certainty than we often get in many medical specialities. The authors of the response, who included Dr Anna Hutchinson and Dr Anastassis Spiliadis, two of the original whistleblowers at Gids, noted that this claim had been contradicted by every single systematic review of the evidence, not least one published by the Endocrine Society itself. They noted that recommendations for clinical practice should be aligned with the best available evidence, rather than a position that exaggerated the benefits and minimised the risks.

Not all evidence is equal. There are hierarchies of evidence in science, often represented as a pyramid. The lowest level is “expert consensus”, which is barely evidence at all. Who decides who is an expert? The process of reaching a consensus can result in a compromise where lots of people agree collectively what nobody actually believes individually. Consensus may have nothing to do with empirical truth. Expert medical consensus can be very wide of the mark, sometimes disastrously so: in the early 1900s, it was expert medical consensus that smoking cured asthma and other lung diseases. It is well within living memory that the expert consensus for treating back pain was bed rest and plenty of it. We now know this is likely to increase pain and prolong recovery.

The history of medicine is littered with these examples, and there are treatments we are recommending now with the full blessing of expert consensus that will eventually prove to be ineffectual at best, fatal at worst. But perhaps the biggest problem with consensus, particularly in the area of gender medicine is the chilling effect it has on debate. As Michael Crichton, the physician and author of Jurassic Park, said: “The claim of consensus has been the first refuge of scoundrels; it is a way to avoid debate by claiming that the matter is already settled.”

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Fortunately, most branches of medicine now rely on more rigorous forms of evidence to inform their practice. Further up the “evidence pyramid” are case reports and studies that compare the outcomes in patient groups before and after treatment, with and without control groups. Close to the top of the evidence pyramid are the results from randomised controlled trials. All of these kinds of research can provide valuable information (some more than others) but no study is perfect and no study design can control for all of the biases that might have influenced the results. So sitting right at the top of the evidence pyramid are the meta-analyses and systematic reviews. These studies systematically evaluate the quality and quantity of all of the relevant evidence that has been published in peer-reviewed journals. These independent reviews summarise what we really know and how confident we can be in that knowledge. Bodies such as the National Institute for Health & Care Excellence (Nice) produce the gold standard in clinical practice guidelines based on these kinds of independent meta-analyses.

In 2020, Nice examined the evidence for puberty blockers. They concluded that “the results of the studies that reported impact on […] outcomes of gender dysphoria and mental health (depression, anger and anxiety), and […] body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria were of very low certainty”. In other words, there is no good quality evidence supporting the use of these drugs on these outcomes.

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It seems likely in the heated debates that surround gender medicine that many people are confusing “expert consensus” — the evidence right at the bottom of the pyramid — for the gold standard in clinical practice guidelines, which are based on evidence and right at the top.

This conflation appears to have been responsible for the mutual bafflement in the heated exchange between Republican Dan Crenshaw and Dr Meredithe McNamara earlier this month, in a debate in the US House Committee on Energy and Commerce on gender-affirming care. While Dr McNamara insisted trans healthcare was based on “standards of care”, the senator countered with the stark lack of evidence from any systematic reviews. Both appeared exasperated with the failure of the other to grasp the importance of their incontrovertible evidence. Just as not all evidence is equal, neither are all clinical guidelines or standards of care. They can be developed from evidence at the top of the pyramid (as in Nice guidelines), but more often come from the bottom and simply represent expert consensus with all its inherent flaws and biases. The stamp of approval from a learned society does not trump the rigours of a Nice review.

Since no high-quality evidence for the benefits of puberty blockers has been found in systematic reviews, it is unsurprising that even the doctors who work in this field have described themselves as building the plane while flying it. With mounting concerns for the possible harms associated with medical pathway of puberty blockers and cross-sex hormones (including reduced bone density, disruptions to neurodevelopment, impaired sexual function and infertility) — not to mention the growing numbers of detransitioners for whom this was never an appropriate treatment pathway, one might extend their aviation metaphor as an attempt to build a plane while flying it while someone else throws out all the parachutes and sets an engine on fire.

Who would put any children on that plane? Or volunteer to pilot it?

The only rational response in such a situation would be to ground the plane immediately. The interim recommendations of the Cass Review combined with the upcoming closure of Gids effectively do this, but the pressures on a new service to immediately take to the metaphorical skies again will be significant.

However, there is another way. Practice guidelines based on expert consensus cannot be mistaken for those based on systematic reviews. Where the systematic reviews indicate little evidence for benefit and potential for significant harm, the service should proceed with the caution that would be applied in any other branch of medicine.

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Cass has emphasised that just as there are many pathways into gender dysphoria for young people, so there could be many ways out. For some, that may still be a medical pathway, with its unevidenced outcomes and multiple inherent risks. The new teams will be tasked with explaining these uncertainties in uncompromising detail to ensure the truly informed consent of those who wish to embark on this experimental approach. Fortunately, the new service model means that other treatment pathways will now also be available.

Bringing gender distress firmly back into the fold of mainstream mental health services for children and adolescents means that these vulnerable children can finally begin to benefit from the therapeutic input and safeguards they have been denied for far too long. It can’t begin soon enough.

Given that Covid tends to affect men more than women, why would long Covid affect women more than men? And given that Covid complications are extremely rare in the young, why would teenage girls be disproportionately affected by long Covid? Finally, given that we can’t accuse a virus of transphobia, why would long Covid affect transgender people most?

The answer lies in the fact that long Covid is not a strictly physical phenomenon. A study of nearly two million people published in Nature found that people who reported three or more symptoms of long Covid included: 4.9% of people confirmed to have had Covid, and 4% of people with no evidence of having had Covid. So, reporting the symptoms of long Covid is only moderately associated with a prior Covid infection. In fact, long Covid correlates about as much with mood disorders as with Covid itself. One study found that people prone to anxiety and depression before Covid infection were 45% more likely to develop long Covid after infection, and the Nature study found that having anxiety and depression before getting Covid almost doubled the chances of reporting long Covid.

This would help explain why women and trans people are disproportionately reporting long Covid: these two demographics have particularly high rates of anxiety and depression.

But why exactly would mood disorders increase the likelihood of long Covid? Some experts have speculated that stress may affect the immune system’s response to Covid and lead to more serious infections. However, a Turkish study found no evidence that anxiety or depression alters the body’s immune response to the virus. A much likelier explanation could be that, since symptoms of mood disorders overlap with those of long Covid, people are mistaking psychological distress for the side-effects of viral infection.

This is part of a broader phenomenon. Young people are reporting despair and distress at an unprecedented rate, and this mental health crisis is a symptom of a malfunctioning society — a society that is making people sick, by teaching them to feel sick. The tendency for people to misdiagnose their despair as a medical disorder can be observed far beyond reports of long Covid. Consider the surge in cases of gender dysphoria. Between 2012 and 2022, the number of adolescents referred to the NHS’s Gender Identity Development Service (GIDS) increased by over 2000%. If the increase were simply due to decreasing stigma around being trans, it wouldn’t be mostly restricted to a single sex and age range, but it has been driven almost exclusively by young people and natal females.

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The group that’s disproportionately reporting gender dysphoria — adolescent girls — appears to be the same demographic as the group deemed in the German study to be disproportionately at risk of long Covid. This is also the group, besides trans people, deemed most at risk of mood disorders. So, again, it seems many young people, particularly girls, are confusing general distress for another illness.

And it’s not just reports of gender dysphoria that have multiplied among young people. Increases have occurred for major depressive disorder, attention-deficit disorder, obsessive-compulsive disorder, social anxiety disorder, generalised anxiety disorder, autism spectrum disorder, and various eating disorders. It seems that young people, and their doctors, are viewing personal issues as medical disorders: we are living through a pathologisation pandemic.

Why are so many people confusing sadness for sickness? It’s human nature to look for single causes to complex problems. The physician’s habit of ascribing all a patient’s symptoms to just one diagnosis led to the formulation of Hickam’s dictum, which states: “A man can have as many diseases as he damn well pleases.” Likewise, it’s tempting to look for a neat and simple reason for people blaming their troubles on a single disorder, but to do this would be to make the same mistake as them. Pathologisation can have as many causes as it damn well pleases.

One may be cyberchondria, the phenomenon whereby people anxiously google symptoms, and, due to confirmation bias, ignore those that don’t apply to them while focusing on those that do, until they become convinced they have the disorder they’re reading about. Another cause may be social contagion, whereby panic spreads through the power of suggestion. According to a UK study, adolescents who reported parents suffering from long Covid were almost twice as likely to report experiencing long Covid symptoms themselves, regardless of whether they’d actually had Covid.

It’s known that social contagions tend to affect girls more than boys, a disparity that could be exacerbated by girls tending to use social media more than boys. But the problem with social contagion as an explanation is that it’s a how, not a why; it offers a means without a motive.

Some have attempted to discern a motive. One is that girls are trying to escape unattainable ideals of femininity. As the arms race of plastic surgery and beauty filters ramps up, natural bodies seem ugly by comparison. This “selfie dysmorphia” may lead to anxiety and depression, as well as symptoms of gender dysphoria, as pubescent girls become desperate to defy the metamorphosis of their bodies into sexual objects. But this explanation doesn’t shed much light on the rise of conditions like long Covid, autism, and obsessive-compulsive disorder. However, a deeper dive into the data does.

When we include politics in the mental health data, it becomes clear that this isn’t simply about gender. A 2020 Pew survey of over 10,000 people found that self-described liberals aged 18-29 were more likely than self-described conservatives of the same age to report suffering psychological problems over the last week. They were also more than twice as likely to say they’d ever been diagnosed with a mental health disorder. Furthermore, those who were “very liberal” were more likely than those who were just “liberal” to report poor mental health. The group most likely to report poor mental health was white liberal females, an alarming 56% of whom reported having received a mental illness diagnosis.

Crucially, controlling for worldview narrowed the gender gap considerably: liberal men were more likely to report poor mental health than conservative women. It would seem, then, that the mental health epidemic among girls and young women is associated with their tendency to have a more Left-liberal mindset than boys and young men — a difference that’s becoming more pronounced over time.

But why would Leftism be associated with poorer mental health? An analysis of data from 86,138 adolescents found, in line with the Pew survey, that between 2005 and 2018 the self-reported mental health of liberals had deteriorated more than conservatives’, and that this deterioration was worst for girls. The researchers blamed this on “alienation within a growing conservative political climate”. However, the New York Times’ Michelle Goldberg debunked this explanation by pointing out that liberals’ mental health woes began while Obama was in power and as the Supreme Court voted to extend gay marriage rights — hardly a conservative political climate.

The real reasons may be deeper. One idea, more than any other, underpins the difference in outlook between liberals and conservatives. Central to Leftism is equality, backed by the idea that people’s fortunes and misfortunes are not their own doing, and therefore undeserved. As such, Leftism de-emphasises the role of human agency in social outcomes, while overemphasising the role of environmental circumstances. As the West has shifted culturally Leftward — due to most writers and artists leaning Left — the depiction of people as hapless puppets has become dominant.

Today’s Left-liberal culture teaches young people that their problems are not their own fault, but rather the product of various systems beyond their control. These systems may be sociological — late capitalism, systemic racism, the patriarchy — but increasingly, they are medical. A common example is “trauma”, a psychiatric term that has become a knee-jerk justification for everything from street crime to silencing opposing views on campus. It’s a word so overused that even clinicians fear it has lost its meaning. Most people, however, are happy to have their personal failings blamed on medical issues, because it absolves them of responsibility. It’s not your fault you violently lashed out, you have trauma. It’s not your fault you lack energy, you have long Covid. It’s not your fault you hate the way you look, you have gender dysphoria.

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Pathologisation is also an effective way to manufacture sympathy. The co-founder of Black Lives Matter, Patrisse Cullors, responded to accusations she’d used donation money to enrich friends and family by claiming that the accusations had given her post-traumatic stress disorder, a diagnosis once reserved for rape survivors and war veterans.

Claims like Cullors’s are instinctively met with sympathy and even awe on the Left, where overeager attempts to destigmatise mental illness can end up glamorising it. On social media, young liberals now engage in “sadfishing”, a kind of digital Munchausen’s Syndrome, where people fabricate ailments for pity and clout; some, such as the TikToker “TicsAndRoses”, fake Tourette’s, while others fake multiple personalities. The power of mental health disorders to attract attention online has turned them into fashion accessories, cute quirks to help kids stand out from the crowd, or “part of my dating appeal”.

Unfortunately, these designer disorders are not just harmless labels; intentional pathologisation by influencers is causing unintentional pathologisation among viewers. Reports tell of adolescent girls suddenly developing “TikTok tics” after viewing videos of alleged Tourette’s sufferers. Others tell of adolescents presenting with multiple personalities after watching videos of people claiming to have dissociative identity disorder. As atomisation makes people more desperate for sympathy, and competition makes them more desperate for attention, it’s likely that sadfishing and its consequences will only worsen.

But as disturbing as all this is, victimhood culture is not the only force behind the pathologisation pandemic. It’s been abetted by a medical industry that has its own incentives for exaggerating the prevalence of mental disorders.

Medicalisation — the tendency for clinicians to recategorise ever more things as medical issues — occurs because clinicians are just as human as their patients, and are therefore just as influenced by culture and their own personal biases. The 1973 Rosenhan experiment showed that psychiatrists who have been told that a healthy person is insane will begin to reinterpret that person’s ordinary behaviours, such as note-taking, as manifestations of their mental disorder. We saw this in the Tavistock scandal, where the staff of the infamous Gids clinic, conditioned by ideologues to look for gender dysphoria, became increasingly hasty to diagnose it.

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The ability of clinicians to see precisely the symptoms they’re looking for is facilitated by concept creep, the tendency for the definitions of disorders to gradually expand to encompass more people. The rise in autism diagnoses, for instance, can be largely attributed to a diagnostic widening of the autism spectrum. Concept creep occurs largely due to the Shirky principle, which states: “Institutions will try to preserve the problems to which they are the solution.” The motive is often financial; the number of pregnancies deemed to require caesarean sections has increased because this method of delivering babies is more profitable. Likewise, if you’re simply sad then medical companies can’t monetise you, but if your distress is reclassified as, say, gender dysphoria, those companies can sell you puberty blockers or surgical procedures. By 2021, GIDS accounted for a quarter of the Tavistock trust’s income. In the States, the sex reassignment surgery market was valued at $1.9 billion and is projected to have a lucrative annual growth rate of 11.23%.

So, we have a medical industry that is both financially and ideologically motivated to overstate the prevalence of illness, and we have a victimhood culture that encourages people to view themselves as oppressed by things they can’t control. In the middle of this we have ordinary people tempted to blame their problems on medical issues for the sake of easy answers.

These three entities together form a mutually reinforcing system. The late philosopher Ian Hacking, in his book Rewriting the Soul, details how in the 20th century, the press, the public, and the medical industry operated in tandem to create new forms of madness out of mere gossip. Prior to 1970, there were almost no cases of multiple personality disorder (now known as dissociative identity disorder), but after one case was well-publicised by the media, people began using the concept of multiple personalities to make sense of their own problems. In so doing, they began to conform, wittingly or otherwise, to the official symptoms of the disorder. When clinicians speculated that people may invent multiple personalities to deal with childhood sexual abuse, people began to do just that. Some even suddenly “remembered” being sexually abused, even though the concept of repressed memories has no basis in fact. Initially, patients reported having two or three personalities. Within a decade, the average number was 17.

Thus, patient reports influenced clinicians’ diagnoses, but clinicians’ diagnoses also influenced patient reports. Diagnostic criteria became prescriptive as well as descriptive; they told patients how they were supposed to feel and act. Hacking called this cycle of mutual reinforcement a “looping effect”, and it proved so powerful that it turned a couple of isolated cases into an epidemic. A similar looping effect, facilitated by a hyperconnected world, seems to be driving the rise in reports of mental illness today.

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By Hannah Baer

This is a problem because imagined sickness can cause real sickness. This occurs in two ways. The first is direct: in rural India, folklore tells that being bitten by a pregnant dog can make one pregnant with the dog’s puppies, and this urban myth has created a new illness: puppy pregnancy syndrome. Victims become so convinced they’re pregnant with puppies that they suffer panic attacks and even manifest symptoms of pregnancy, from persistent nausea to the sensation of puppies crawling in their bellies.

But the second way fake sickness becomes real is far more common and insidious.

Remember how Leftism de-emphasises human agency in the name of equality? Research shows conservatives tend to have an internal locus of control, which means they believe that their decisions, as opposed to external forces, control their destiny. Liberals, meanwhile, tend to have an external locus, which means they believe their lives are determined by forces beyond their control.

The American psychologists Jonathan Haidt and Jean Twenge used national survey data of adolescents to map their locus of control. Their findings were based on the proportion of respondents who agreed with statements such as: “People like me don’t have a chance at a successful life” and “Whenever I try to get ahead, something stops me”. They concluded that, since the Nineties, the locus of control for all teenagers has become more external, but the shift has been greater for liberals, and greatest for liberal girls. Further, when the self-worth of teenagers was mapped, using responses to statements such as “I feel my life is not very useful”, the data showed a universal decline in self-worth since 2012. Again, the decline was stronger for liberals, and strongest for liberal girls.

People with an internal locus of control, believing they control their destiny, tend to be happier and have healthier habits, like good diets and frequent exercise, while people with an external locus of control, believing they’re at the mercy of fate, have higher rates of anxiety and depression and are more likely to abuse drugs and neglect their health. When you believe you have no control, you don’t.

And thus, as society has liberalised, and medicalised, young people have lost both self-belief and resilience. Many have subsequently become trapped in a cycle where they feel distress, and pathologise it, causing more distress, leading to more pathologisation and more distress, which eventually becomes textbook anxiety and depression. The rise in diagnoses is therefore not simply an illusion caused by medicalisation; society is teaching kids to develop real dysfunctions.

This is the greatest danger of the pathologisation pandemic: belief in one’s sickness is self-fulfilling. It’s a disease not of any bodily organ but of hope itself, and it harms its victim by crippling their immunity to everything else.

If there’s a vaccine for the pathologisation pandemic, then the best candidate is Cognitive Behavioural Therapy (CBT). This is a form of talk-based treatment based on the Ancient Greek philosophy of Stoicism. Contrary to modernity, it teaches that our feelings are not always valid, but often deluded and self-destructive. The aim is to reframe harmful thoughts into alternatives that are more accurate, agentic, and soluble. So, instead of “The world sucks”, one could think “I feel like the world sucks right now”. Where pathologisation places problems outside your control, CBT places them within your control. Where pathologisation bundles many small issues into one giant insurmountable problem, CBT breaks down giant problems into small manageable pieces.

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No form of psychotherapy has been as rigorously tested as CBT, and its effectiveness in restoring agency and reigniting hope is documented by decades of research. Some studies suggest CBT is gradually losing effectiveness, but this is mostly because CBT, like everything else in the social sciences, has been corrupted by amateurisation and the desire to be “inclusive” and inoffensive. The newest forms of CBT, such as “Transgender-Affirmative CBT”, are the opposite of classic CBT because they seek not to cultivate strength but to validate feelings.

More than ever, a return is needed to the original, Stoicism-based form of CBT, which has helped everyone from the philosopher-emperor Marcus Aurelius, who governed Rome during a time of war and plague, to Vietnam POW James Stockdale, who used it to withstand torture at the notorious “Hanoi Hilton”. The ultimate cure to rampant pathologisation is to prepare the young to do battle against their greatest foe — their own minds — and to teach them a time-tested truth, bequeathed to us by history’s survivors: you are more than the things that happen to you. And you have as much control over your life as you believe you do.

Many of the misfortunes that befall you will not be your fault, but if you seek explanations for your suffering in things beyond your control, you risk falling prey to a culture and industry that are motivated to keep you feeling ill. Look within for the causes and, most times, you’ll find the cures. Modern society will tell you otherwise, of course, but it’s within your power to defy it, for you are not a helpless leaf in the wind but a mind that holds a world, which, depending on how you think, could be a Hell in Heaven, or a Heaven in Hell.

While some of those students may have been merely flirting with the condition, they were canaries in a very dark coal mine. All too many of their peers were undertaking life-threatening calorie restriction in great earnest. Anorexia was already known to be the very deadliest of all psychiatric ailments. (Wanting to be anorexic, then, is like pining to contract necrosis.) In the Nineties, my natural ghoulish voyeurism inspired me to read several books about obsessive self-starvation, the best of which was Jenefer Shute’s harrowing novel Life Size.

So surely this month I jumped at the chance to read Hadley Freeman’s Good Girls: A Story and Study of Anorexia? Beginning in 1992, the columnist struggled for many years with the eating disorder, for which she was repeatedly hospitalised for months on end. Yet before diving into what proved a compelling and forthright memoir, I resisted. Honestly? The topic felt dated. Because as a prestige diagnosis, anorexia has been replaced. With trans.

Although Freeman spends half a chapter on the overlap between the two afflictions — both are “rooted in the belief that if you change your body, you will no longer hate yourself” — throughout her account I began to notice other intersections.

Both neuroses are clearly communicable. Ever since a preoccupation with thinness took off in the Sixties, eating disorders have soared, making the more recent insistence that anorexia is more of a heritable genetic proclivity than a cultural contagion dubious. From the Seventies onwards, an accelerating number of young women have got the idea to express their discontent through debilitating hunger from lavish media coverage, and one another. In kind, since 2010 the number of teenage girls referred to the Tavistock Gender Identity Development Service increased by 5,000% — making claims of a purely genetic explanation equally iffy. Both these afflictions are social confections. Although tales of people who starved themselves or passed for the opposite sex exist in the historical record, eating disorders and transgenderism on a mass scale are recent inventions. Collectively, we made these dire maladies up.

Freeman identifies her “trigger” at 14 for dropping an alarming amount of weight as a single moment. Sitting beside a prominently bony classmate in gym class, Freeman asked, “Is it hard to buy clothes when you’re so small?” “Yeah,” the girl replied. “I wish I was normal like you.”

“A black tunnel yawned open inside me,” Freeman writes, “and I tumbled down it, Alice into Nowhereland. ‘Normal.’ Not ‘slim’, not ‘thin’—‘normal’. Normal was average. Normal was boring. Normal was nothing.”

Nowadays, there’s ostensibly no such thing as a norm. In Left-wing jargon, the clunky “norm” words — such as “cis-heteronormative” — are pejorative. A fifth of Americans under 30 identify as LGBT-whatever. Never mind that Eric Kaufmann has documented the large proportion of supposedly bisexual young women who don’t engage in actual same-sex coupling; today’s young people adopt the label of sexual atypicality the way earlier generations wore crocodile-logoed Lacoste shirts. As Freeman notes, normal is “nothing”. Not only heterosexuality but, increasingly, contentment with your natal sex is uncool. According to the report, 12% of millennials identify as either transgender or gender-nonconforming, compared to 6% in Generation X.

Both self-starvation and transgenderism guarantee elevation to a perceived social elite. At least in the minds of some anorexics, being immune to the temptations of crisps and biscuits that seduce mere mortals induces an emotionally nutritious sensation of superiority. Freeman portrays her fellow sufferers in hospital as competitive with one another over who eats less, as well as picky about how grimly skeletal one must become to qualify for admission to their rarefied circle; the same rivalry is readily located online. Public slow-motion suicide inevitably secures outsize attention from terrified parents, worried teachers and concerned physicians. (Freeman claims that anorexics don’t aim to look thin; they aim to look ill.) With its plethora of frenetic exercise rituals and strict internal rules surrounding food, being anorexic can readily evolve into an identity, attachment to which makes recovery still more difficult. A blandly healthy weight threatens the loss of knowing who you are anymore.

Coming out as trans likewise greatly increases attention from schoolmates, teachers and a whole industry of therapists, endocrinologists and surgeons. In a single syllable, “trans” likewise seems to offer a readymade answer to who you are. Freeman tells us that “when an anorexic says, ‘I don’t want to be fat, I want to be thin,’ they are saying, ‘I want to be other than I am, and what I am is unhappy. I want to be someone else.” Clearly, transition to the opposite sex makes the same statement: I want to be someone else. But is becoming someone else really an option?

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Especially since girls came to dominate boys in paediatric gender clinics 3:1, both forms of dysmorphia often hit the same population: suggestible, insecure adolescent girls with a fragile sense of self who are desperate to forestall all that womanhood entails: painful periods; vulnerability to rape and pregnancy; sex, often portrayed in ubiquitous internet porn as female humiliation; and fat. For some anorexics, their refusal to grow into women is implicit; when girls take puberty blockers, their refusal to become women is explicit. Having suffered the physical indignities of mature femininity for over 50 years, I don’t entirely blame them.

Both diagnoses have significant intersections with autism, anxiety and depression, making patients susceptible to a tangible-seeming solution to a generalised discontent. Both populations mistake self-annihilation for a route to enlightenment and rebirth. Both populations seek to salve psychic torment by renouncing the body, the trans child through reconfiguration, the anorexic through evaporation. Both brands of patient embrace the recognisably religious practices of self-abnegation, redemption through suffering and purification via repudiation of the flesh.

It’s in the social sphere where the disorders part ways. When self-starvation was still a hot topic last century, it might have conferred a measure of cachet, but few parents these days would boast that their child is anorexic. I’ve a niece who’s suffered for years from anorexia, and my brother and his wife have been at their wits’ ends. The experience of having a child who refuses to eat is abundantly one of helplessness and despair. Ditto many trans parents — but not all.

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For the paediatric gender clinic whistle-blower Jamie Reed testifies that in America’s liberal enclaves, having a trans kid has become a prestige diagnosis for many parents — one far preferable to the passé status of having a child who’s plain old gay. Reed identifies the root of the problem as another plain old: homophobia.

Yet two distinctions between disordered eating and transgenderism are signal: diagnosis and treatment. In its latter stages, anorexia is visually conspicuous. While anorexics are often duplicitous, starving to death isn’t subtle; it’s not a secret you can keep for long. Freeman was hospitalised because her low weight was measurably dangerous. Yet according to current medical orthodoxy, diagnosis of transgenderism is purely subjective. The condition has no observable physical symptoms, no objective correlative. If I tell you I’m really a man, you have to take my word for it. The status is therefore unfalsifiable, the population of patients prospectively limitless.

As for treatment, anorexia is universally acknowledged as an illness. Doctors regard this potentially fatal form of dysmorphia as a psychiatric ailment that must be arrested and resolved. Not so transgenderism, which is often celebrated, if not beatified as a state of higher consciousness. “Gender-affirming care” doesn’t treat the illness but indulges the patient’s delusions to the hilt. Rather than coach a child to reconcile with reality, clinicians twist reality to reconcile it with the disorder. Anyone who dares describe the bizarre and biologically baseless conviction that one was “born in the wrong body” as a mental health issue is tarred as a transphobe. Were teenage anorexics treated anything like trans kids, they wouldn’t be encouraged to finish their dinner, but rather abjured, “You’re right: you’re fat! Your true self is even thinner! You will never rise to sit at the right hand of God the Father Almighty until you completely disappear!”

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Anorexics negotiate the universal human challenges of finding identity and purpose by shrinking their internal world to a simple commandment: don’t eat. But true anorexics can never be thin enough. Freeman describes a rivalry between anorexia ward residents over who’s been “tubed” — the gold standard of really having made it as an anorexic, because the very last medical resort is force-feeding. Thus the obvious goal of severely restrictive eating is, however hazily conceived, death. Meanwhile, before this morbid conveyor belt reaches its inexorable end point, anorexics undergo hair loss, the breakdown of internal organs, osteoporosis, and mental disarray. Fellow starvelings may whisper competitive encouragement on those websites regulators are always trying to shut down, but at least no one in authority is urging that, if a cadaverous anorexic just loses another 15 pounds, her body and her deep, innate inner being will finally match up.

Conversely, we’re implicitly dangling the promise that on the other side of transitioning to the opposite sex — or feigning transition, since inborn sex is written in our every cell — all a young person’s problems will be solved. Being trans is now a misguidedly easy-seeming shortcut to knowing who you are. But I’m betting that as an identity, being surgically mangled and hormonally discombobulated rarely goes the distance. Moreover, the physical price of buying this false promise of turning into a butterfly is stupendously high: sexual dysfunction, infertility, surgical complications and infections, and the side-effects of powerful medications for life.

What these conditions have most in common is being dreadful answers to the questions that inevitably torture young people: who am I, what makes me unique, what makes me loveable, what do I want to achieve, why does just being alive seem so hard, am I the only one who feels so dejected, what does it mean to become a man or a woman, and is there any way I can get out of growing up? The responsible adult’s reply to that last one must be a gentle but firm “no”.

I wasn’t a tomboy. I liked dresses, my long red hair, my collection of Sylvanians who lived soap-opera lives in neat plastic houses carefully arranged by me and my sister. But I knew there was something contemptible about the girlish things I enjoyed from the way the boys at school talked about them. Little by little, I learned to be ashamed of being the kind of person these things belonged to.

Then there were the unmistakable signs that me and my body would not, after all, enjoy our peaceful union forever: the adult women I overheard sociably griping about their own deficiencies (too fat, too big-bummed), the girls my age whose bodies were erupting into curves. The boys leered; the girls yet to start puberty judged. We whispered that the ones wearing bras were stuffing their cups with tissue paper, and said they rustled when they walked. I dreaded becoming one of them, and I feared what it would mean if it didn’t happen to me. One day — I suppose I was 10 — I stood at the corner of the playing field (which was, as usual, taken up by boys playing football) and thought I will not be a girl.

I got no say in the matter, though. My compact, reliable body sprouted embarrassing hair, turned to gooseflesh when boys (not even boys I liked!) looked at me, and exceeded its former bounds so rapidly I was striped with stretch marks all over my hips. We were two things now.

One day, I was dozing in the back of the car as my parents drove the family home and I heard a short story on the radio — I was almost 12 — about a man who wishes to be free of his body, so first cuts off his head, then has his brain removed from his skull. I would like to do that, I thought. To be pure self, no flesh at all. I was in the wrong body. It announced my femaleness, it invited certain ways of being looked at, sometimes touched. It betrayed me. I couldn’t dispose of it, so I hated it instead.

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The metamorphosis of puberty is hard for almost everyone. For girls, though, there is a specific trauma. You don’t simply become an adult: you become a product on the sexual marketplace, regardless of your own will. This divides you: you learn to see yourself from the outside, as an object, through the imagined eyes of men. You lose your space in the world, and any part of you that goes beyond the strictly minimal can start to feel like grotesque excess.

Did I have dysphoria? There was no one to diagnose me; I only have my own memories to guide me. What I can say is that I don’t know of another word that describes my desire to discipline and punish myself into something safely un-sexed. When I read accounts from other female people describing their own dysphoria, I feel a painful recognition.

Trans man Lewis Hancox’s graphic novel Welcome to St Hell: My Trans Teen Misadventure has a diagram of Hancox’s teenage body, with the breasts marked “fatty lumps that need to be gone” and an arrow pointing to “hips from hell”. These are things I thought about myself. Not so severely as Hancox (I didn’t have an eating disorder), but I thought them.

If I had been offered a way out — a medical “pause button”, as hormone blockers are casually called — would I have taken it? I can’t think, actually, of anything I would have received more gratefully at this time in my life. Nor can I think of a more carelessly poisonous response than adults affirming what I felt about my body. It’s strange, then, that for 31 years, a specialist unit existed within the NHS which effectively took girls like me and told them: “yes, you’re right, your body is wrong, but we can fix that for you.” The unit was the Gender Identity Development Service (GIDS), contained within the Tavistock and Portman Trust in London. What happened there, and how it went so appallingly wrong, is now the subject of a remarkable book by the journalist Hannah Barnes called Time to Think.

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GIDS didn’t only treat girls, but it’s the girls who particularly interest me. That’s partly because, as Barnes outlines, GIDS itself was remarkably uninterested in them. The service was founded by child and adolescent psychiatrist Domenico Di Ceglie in 1989, and initially, the patients had a clear profile: mostly boys, and usually referred in pre-pubescent childhood. Girls with dysphoria weren’t unheard of (the initial case that got Di Ceglie interested in gender identity was female), but they were not typical.

That changed dramatically. In 2011, GIDS saw for the first time an equal number of male and female patients. In 2020-21, 68% of the patients for whom GIDS recorded sex were female. (A repeated theme of the GIDS scandal is poor record keeping: shockingly, no birth sex was recorded for 22% of patients referred in 2021-22.) And these girls were arriving at the clinic older than the boys: pubescent adolescents who, like me, had no previous history of dysphoria.

But while they were strikingly unlike GIDS’s previous patients, these girls were astonishingly similar to each other. Barnes relates the description given by Anna Hutchinson, a senior clinical psychologist formerly employed at GIDS, and one of the many whistleblowers to have gone on the record about the service’s failings:

“Self-diagnosed adolescent trans boys — natal females — started to fill up GIDS’s waiting room with similar stories, haircuts, even names – ‘one after another after another’. They’d talk about their favourite trans YouTubers, many having adopted the same name, and how they aspired to be like them in the future.”

One thing that all GIDS patients had in common, regardless of sex, was that they had far more going on than just gender trouble. A 2012 study found that associated difficulties included “non-suicidal self-harm, suicidal ideation, suicide attempts, autism spectrum conditions (ASCs), attention deficit hyperactivity disorder (ADHD), symptoms of anxiety, psychosis, eating difficulties, bullying and abuse”.

Also, a lot of the girls presenting at GIDS were bisexual or lesbian — over 90%. Or rather, they would have been lesbian, if they’d identified as female. One clinician Barnes speaks to recalls female patients saying things like, “When I hear the word lesbian, I cringe. I want to die”, and “I’m gonna vomit if I hear the word lesbian another time”. Gay and lesbian clinicians who asked whether such internalised homophobia should complicate a dysphoria diagnosis were told that they were “too close” to the subject to be objective. That this dismissal of same-sex attracted people’s experiences and insights was itself a signal instance of homophobia seemed not to occur to GIDS as an institution.

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GIDS, it seems, was no longer interested in asking questions. When the service was founded, one of its principles had been an explorative approach: “Di Ceglie could see that, in some cases, by addressing other difficulties experienced by the child — things like depression, abuse or trauma — it might ‘secondarily affect the gender identity development’. In other words, sometimes the gender identity difficulties might resolve if other difficulties being faced were dealt with as well.” But by the time the majority of GIDS’s caseload had become female adolescents, the culture of the service had decisively changed. In 2009, Polly Carmichael took over from Di Ceglie as head of the clinic. Her tenure saw the clinic adopt a high public profile — participating in a string of documentaries that boosted GIDS’s image and promoted its work — while internally adopting an “us against the world” attitude. Clinicians were encouraged to see themselves as a “family”: disagreement became a personal betrayal. One GIDS staff member recalls that anyone raising criticisms of the service was likely to be told “this has made Polly cry”.

Perhaps as important as the clinic’s leadership, though, were the external pressures: as the concept of “gender identity” took hold more widely, the idea that one’s “subconscious sex” ought to supersede the physical body began to direct treatment. Trans support groups like Mermaids and GIRES promoted an “affirmative model”, which insisted that any child who said they were trans should be treated as trans. This influenced both the expectations of patients and their families, and the practice of GIDS doctors. Hormone treatment became the default. Patients came, not because they wanted to explore their gender issues, but because they wanted puberty blockers. If doctors were unwilling to prescribe them, Barnes reports, patients would simply be referred to a different doctor. There was usually little opportunity for reflection: GIDS staff were expected to manage caseloads of up to 100 patients each, as referrals increased from 97 in 2009-10 to 2,748 in 2019-20 (a 2,800% increase overall, and an even more shocking 4,200% increase in girls). Once patients were on puberty blockers, nearly 100% would go on to take cross-sex hormones.

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A service that had once prided itself on treating its patients as individuals had become something more like an assembly line. Whatever issues a child had, the only answer the clinic had was blockers. What’s terrible about this isn’t just that many children will have been put on a path to transition that could have been avoided; it’s that they were not receiving specialised support for their other, more pressing problems. Barnes tells the story of one boy who, as well as identifying as a girl, had such severe OCD that he couldn’t leave the house. His family got no support for the OCD, but GIDS sent a psychiatrist who offered to make an endocrinology referral.

With its one-size-fits-all plan, GIDS was failing every one of its patients: one of the reasons why, in 2022, an independent review commissioned by the NHS into gender identity services for children and young people made an interim recommendation that GIDS be shut down and replaced with regional specialist centres. (This spring, that advice will be enacted.) But — without diminishing the harm done to boys, which was plentiful — girls were particularly damaged by GIDS, because girls were being put on a pathway that was the definition of male default. GIDS had developed its approach to serve the traditional paediatric sufferer of dysphoria: a pre-pubertal boy. Because the clinic’s culture militated against self-reflection, the treatment stayed the same even though the patients had drastically changed.

It’s not uncommon for women to be badly served by medicine in this way, given that women are neglected as research subjects. Historically, femaleness has been treated as an abnormality, to be ignored if it cannot be remedied. What’s exceptional about the GIDS case, though, is that the underlying philosophy of trans identity effectively made these girls doubly invisible. They were invisible, firstly, to a model that had never taken them into account. But secondly, and more profoundly, they were invisible because gender identity doctrine held that even to think of them as female was to “misgender” them. You couldn’t say how they were different to boys without conceding that they were not, in strict fact, boys.

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But to hate your body as a teenage girl is one of the most categorically female experiences possible. I didn’t hate my body because I wasn’t a girl; I hated it precisely because I was, and because of everything I feared or knew that being a woman might mean.

Trans activists tend to dismiss stories like mine: if I had truly been dysphoric, they say, I would never have grown up to be the basic bitch I am today. I would have found a way to transition. But if I’d had YouTube, Mermaids and a compliant medical service, the way would have been signposted for me in neon lights. I learned to live with my body, in time, because no one gave me an alternative.

One of the many reasons that the “pause button” claim about blockers is a lie is that going through puberty is one of the ways you become reconciled to puberty. Discovering your sexuality might help you discover that your body exists for your pleasure, not just external judgement. Gradually, the alien flesh can become familiar again. The girls who went through GIDS were denied this. Taking puberty blockers means you never reach adult sexual function. Tentative research suggests that girls who went on blockers actually felt worse about their bodies after several years. Blockers didn’t treat their dysphoria: they exacerbated it.

For some few, transition will have been the right outcome. Others are left forever learning to live with bodies that have been made strange and vulnerable — weakened bones, dropped voices, vaginal atrophy, scarred and breastless chests if they went on to have mastectomies. There is a small, but growing, community of female detransitioners. Barnes quotes one, who has undergone a double mastectomy and a hysterectomy: “I regret all of it… I wish someone would have been there to tell me not to get castrated at 21.”

The things these women did in an effort to become not-girls remind me so keenly of the girl I used to be, with her vague longing for a bodiless life. A perverse sisterhood of doomed escapologists, looking for a get-out from what biology had planned for us. The way I once felt about myself was terrible, but it was also normal: the terribly normal fact of feminine self-loathing. The tragedy of a misogynistic world is that it makes girls believe they need a cure for femaleness. The scandal of GIDS is that it pretended it could supply one.

One could hardly call that efficient. But for patients today, my experience is the stuff of dreams. Waiting lists have ballooned out of all recognition. My former GIC in London is candid: “We are currently offering first appointments to people who were referred in January 2018.” Those people have waited four and a half years, merely to get to the starting line. But dig a little deeper into the data and the forward projections look even worse. In May 2022, there were 11,407 people languishing on the waiting list; just 50 of them were offered a first appointment that same month. This figure seems typical: in April it was 56, and in March it was 33. At those rates it will take between 17 and 28 years to clear the backlog. Typically, the clinic receives around 300 referrals every month, so with each month that passes, those waiting lists get even longer.

Elsewhere, the story is much the same. A GIC in Sheffield is offering first appointments to those referred in March 2018, while one in Exeter has seen nobody referred after June 2016. Behind this data, there are people stuck on waiting lists: almost 4,000 at Exeter in a queue that has stopped moving. The message from the clinic is stark: “Please do not contact the clinic to enquire about waiting times as our staff are very busy and we cannot provide any more information than is provided here. Thank you.”

With NHS services grinding to a halt, it’s not surprising that private clinics have sprung up to provide a faster alternative. Some clinicians are moonlighting alongside their regular jobs for the NHS. Consultant psychiatrist Dr Stuart Lorimer was brutally honest about his reasons: “Doctors have mortgages too, and my partner was on the verge of retirement… I was looking for ways to generate more income.” A tidy income, it seems — Lorimer charges £300 per hour.

Meanwhile, the London Transgender Clinic, a private practice, was established by plastic surgeon Christopher Inglefield in 2015, “in response to a noticeable increase in enquires from transgender and non-binary patients. Many of these patients were unable to access quality and timely care from the overwhelmed NHS gender services.” But his fast-track pass comes at a cost. LTC’s guide price for the management of hormone therapy is £849 for the first year, and £468 per annum subsequently. And that doesn’t include the drugs: “LTC is not a licensed dispensary, therefore, we advise that you take your private prescription to your local pharmacy.” It’s a far cry from the NHS, where a prescription prepayment certificate costs just £108.10, and that covers all your medicines for the year.

While NHS surgery is free to the user, private patients pay the full cost themselves. LTC charges from £27,000 for male-to-female gender surgery, rising to at least £32,000 if a section of colon needs to be used. LTC is perhaps on the pricey side, but their fees are not off the scale. The Parkside Hospital in Wimbledon told me that, “it’s £23,000 for a vaginoplasty”. Alongside their private patients, Parkside has a contract to treat NHS patients — 132 of them in 2019. This suggests the NHS is paying north of £3 million per year to treat around a dozen patients each month.

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This model is hardly sustainable, with the London GIC alone currently receiving more than 300 referrals per month. Even if the clinic somehow increased its capacity to assess those patients in a timely fashion, what happens next? While it is perhaps feasible for the world’s pharmaceutical industry to step up production of hormone therapy and blockers, surgery is a different matter. Vaginoplasty is a skilled job that few surgeons can do. In 2016, GRS surgeon Phil Thomas pointed out that “there are simply not enough people in Britain who know how to make a vagina”. His colleague Tina Rashid said, “attracting new surgeons into the speciality was extremely difficult… GRS is a very niche area.”

As a result, the NHS system of Gender Identity Clinics is not only failing to deliver at present; it’s hard to see how it could ever deliver in the future. Even if, say, £100 million could be found every year to fund around 5,000 surgeries, it is futile if there is nobody to do them. A totally new model is needed, and we do not need to look hard for it.

Last month, the Tavistock and Portman NHS Trust announced the closure of their Gender Identity Development Service for Children and Adolescents (GIDS), the clinic for children who think that they might be trans. It was perhaps inevitable after the Cass review criticised the clinic as: “Not a safe or viable long-term option in view of concerns about lack of peer review and the ability to respond to the increasing demand.” It will be replaced by regional centres offering more “holistic care” with “strong links to mental health services”.

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Adults deserve no less. Patients who should be assessed, screened for comorbid psychological disorders, and perhaps offered counselling are instead being consigned to seemingly endless queues — and told not to bother the staff. Adult Gender Identity Clinics are another broken system in need of replacement.

There is a certain mystique surrounding NHS gender clinics, but they are NHS services like any other, where clinicians meet with their patients and discuss their treatment plans. At the GIC the options are limited, or at least they were for me. I spent less than four hours in that consulting room. After two one-hour initial assessments, the clinic wrote to my GP to recommend hormone therapy: oral estradiol valerate and an injectable GnRH agonist — a “blocker” — that desensitised my pituitary gland, which in turn shut down the production of testosterone in my testes. Whether this is safe or not, nobody really knows. The drugs are not licensed for these purposes.

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I had four further half-hour consultations. During that time, I was referred 200 metres up the road to Charing Cross Hospital for gender reassignment surgery. And that was that. No psychotherapy, and no psychiatry of note. Less than two months after surgery, I was discharged to the care of my GP. If any long-term research is going on, I am not part of it. I’ve had no contact with the clinic since 2016.

If gender dysphoria needs to be treated — and I think it does — then psychotherapy should be the first approach. It seems madness to proceed otherwise. Surely, we need to explore the issues thoroughly with a counsellor before considering hormones and surgery. Therapy can be provided locally and close to home; it certainly shouldn’t need a whole day out in London. And if surgery is what’s needed, it shouldn’t require choosing whether to pay a year’s salary or sit on seemingly endless waiting lists, with no support from the staff. A rigorous, judicious and efficient service is what’s needed. At the moment, it’s failing on every front.