Time to Think

1. Founding Vision: Therapy-Led Exploration, Not Quick Fixes.

The name was relevant: the emphasis would be in promoting the development of the young person’s gender identity, not changing it.

Initial therapeutic focus. The Gender Identity Development Service (GIDS), founded by Dr. Domenico Di Ceglie in 1989, was initially conceived as a small, therapeutic service for children with rare gender-related distress. The goal was to explore the young person's identity and support families, maintaining an open mind about the outcome, whether social transition, medical transition, or reconciliation with their birth sex. Early principles included non-judgemental acceptance, ameliorating associated difficulties, and tolerating uncertainty.

Psychological over physical. Di Ceglie and colleagues believed in a mental-health-led service, prioritizing psychological exploration over physical interventions. Medication, specifically puberty blockers, was considered cautiously and only for older adolescents (around 16) after extensive therapy, with the aim of providing "time to think" before irreversible steps. This approach was rooted in the understanding that gender identity could be fluid in childhood and adolescence, and that many gender non-conforming children would grow up to be gay adults.

Early resistance from within. The service's move to the Tavistock and Portman Trust in 1994 brought tension, as its approach to physical interventions clashed with the Trust's psychoanalytic tradition, which typically avoided body-altering medications for mental distress. Some colleagues viewed gender identity issues through the lens of other complex presentations seen at the Portman Clinic, where patients expressed psychological distress through their bodies, leading to skepticism about medical pathways. Despite this, the service persisted, albeit initially marginalized within the Trust.

2. Early Warnings Unheeded: Concerns About Pressure and Lack of Data.

It is the consistent impression of a number of GIDU staff that the service was coming under pressure to recommend the prescription of drugs more often and more quickly, and that the independence of professional judgment was also coming under increasing pressure.

First internal review. Concerns about GIDS practices emerged early, leading the Trust's medical director, Dr. David Taylor, to conduct a review in 2005. Staff reported feeling pressured to recommend medication more frequently and quickly, sometimes against their clinical judgment, influenced by patient and parent expectations and external groups. Taylor noted fundamental disagreements among clinicians about what they were treating and the best approach.

Lack of evidence and follow-up. Taylor's report highlighted the experimental nature of puberty blockers for gender dysphoria, noting they were "relatively untested and un-researched." He questioned if they truly provided "time to think" and found GIDS was not collecting data to answer this or track long-term outcomes. An earlier internal audit (around 2000) had shown high rates of associated difficulties like trauma, abuse, and family problems among patients, but this was the service's last comprehensive audit.

Recommendations ignored. Taylor recommended maintaining puberty blockers but prioritizing long-term therapy, supporting clinicians who declined referrals, seriously considering informed consent issues, and conducting thorough, long-term follow-ups of all patients. He also suggested integrating GIDS with other adolescent services. These recommendations were largely ignored, setting a precedent for future concerns to be raised but not acted upon, and allowing the service to continue without robust data collection or outcome monitoring.

3. The Shift to Medicalization: Puberty Blockers as the Primary Path.

If GIDS did not offer blockers, the service would simply not exist.

Increasing external pressure. From the mid-2000s, pressure intensified from patients, parents, and advocacy groups like Mermaids and GIRES to lower the age for puberty blockers. They pointed to practices in other countries, particularly the Netherlands, and argued that delaying treatment caused distress and increased suicide risk, sometimes labeling cautious clinicians as "transphobic." This pressure created a difficult environment for GIDS staff.

Blockers as the draw. Some GIDS staff believed the service's existence became dependent on offering physical interventions. As one clinician recalled Domenico Di Ceglie saying, "It's because we have this treatment here that people come." While other support work was valuable, the offer of a medical pathway was seen as the primary driver for referrals, creating a dynamic where the service felt compelled to provide access to medication to maintain its relevance and funding.

The "established pathway". By the early 2010s, particularly after becoming a nationally commissioned service in 2009, GIDS increasingly operated with a focus on assessing eligibility for puberty blockers. Clinicians felt pressure to process referrals quickly, and for many young people, especially teenagers, the expectation was clear: assessment leads to a referral for blockers. This became the default "established pathway," sometimes overshadowing the therapeutic exploration that was the service's original foundation.

4. Uncritical Adoption of the "Dutch Protocol": Limited Evidence, Unforeseen Consequences.

Providing a young person met the eligibility criteria, they could receive puberty blockers at 12, followed by cross-sex hormones at 16, and surgery at 18.

Pioneering Dutch approach. The "Dutch protocol," developed in the Netherlands, became influential, offering puberty blockers from age 12 for carefully selected adolescents with lifelong, severe gender dysphoria who were psychologically stable and in supportive environments. Early Dutch papers, though based on small samples and limited follow-up, reported positive outcomes, including improved psychological well-being and better surgical results, which helped spread the model internationally.

UK study and rollout. In 2011, GIDS and UCLH began an "Early Intervention Study" to evaluate early puberty suppression in the UK, recruiting 12-15 year olds. Despite initial ethical concerns about the lack of a control group and limited data, the study proceeded. Crucially, GIDS rolled out early puberty suppression as standard practice across the service in 2014, allowing children younger than 12 (based on pubertal stage) to be referred, before the study's results were published or evaluated, based on perceived positive early findings and international practice.

Unacknowledged risks and limitations. The Dutch protocol's early data hinted at risks, such as potentially increasing "false positives" (young people transitioning who might not have otherwise) and unknown long-term effects on bone density and fertility. The GIDS study protocol also listed significant risks, including the possibility that blockers might "fix transgender beliefs" and impact brain development. However, these risks, along with potential surgical complications for natal males blocked early, were not always explicitly or consistently communicated to young people and families, and the high rate of progression to cross-sex hormones seen in the Dutch data (and later GIDS's own) was not fully disclosed or explored.

5. Explosive Growth & Complex Patients: Overwhelmed Service, Changing Demographics.

In the four years she had been there alone, the number of children referred had risen from 314 to 2,016.

Referrals skyrocket. Following national commissioning in 2009 and the rollout of early intervention, GIDS experienced exponential growth in referrals, far exceeding initial predictions. Numbers rose from under 100 in 2009/10 to over 2,000 by 2016/17, overwhelming the service's capacity and leading to lengthy waiting lists that never recovered. This rapid increase meant less time per patient and immense pressure on staff.

Changing patient profile. The demographic of young people referred shifted dramatically. Historically, the majority were natal males with childhood-onset gender dysphoria. By 2015, natal females, often with gender distress beginning in adolescence, became the majority, eventually outnumbering males significantly in some age groups. Many of these young people presented with complex co-occurring difficulties:

• High rates of autism spectrum conditions (around 35%)
• Significant mental health issues (depression, anxiety, self-harm, eating disorders)
• Histories of trauma, abuse, and chaotic family backgrounds
• High proportion of young people in care

Mismatch with service model. This new, complex cohort did not fit the profile of the "carefully selected" young people in the Dutch studies. GIDS, however, largely maintained its assessment-focused model, which was ill-equipped to provide the in-depth therapeutic support needed for these complex cases. The reliance on local CAMHS for mental health support often failed due to austerity cuts and CAMHS reluctance to engage with gender-related cases, leaving many young people's other significant needs unaddressed.

6. Mounting Internal Alarm: Safety, Ethics, and Lack of Exploration Ignored.

‘Are we hurting children?’ she asked, keen to be reassured. It’s the question that underpins everything she’s feeling. She was not told ‘no’.

Growing clinician unease. As referrals surged and the patient profile changed, many GIDS clinicians, particularly those with experience in complex child mental health, felt increasing unease about the service's practices. They worried about the speed of assessments, the pressure to refer for medication, and whether the single medical pathway was appropriate for all the diverse and complex young people they were seeing. Questions arose about medicating children with trauma, autism, or internalised homophobia.

Lack of space for thinking. Despite the complexity, clinicians felt there was insufficient time or space for in-depth psychological exploration. Team meetings became managerial, leaving little room for clinical discussion or reflection on difficult cases. The focus shifted to processing numbers and managing the waiting list, rather than nuanced assessment and therapeutic work. This created a sense of working in the "unknown" and feeling like "gatekeepers" to medication rather than therapists.

Concerns dismissed or minimized. When clinicians voiced their worries about safety, ethics, and the lack of exploration, they often felt their concerns were not adequately addressed by the GIDS leadership. Discussions would occur, but they rarely led to meaningful changes in practice. The complexity of the work was acknowledged, but this was sometimes used to justify inaction, leaving concerned staff feeling frustrated and unheard, believing the service was not learning or adapting to the challenges it faced.

7. Culture of Silence and Retribution: Clinicians Punished for Raising Concerns.

‘There were always scapegoats,’ explains Anna Hutchinson. ‘There were always people who represented the concerns of the group, and they were always driven out one way or another.’

Speaking up discouraged. Despite formal channels for raising concerns, many GIDS staff felt there was an unwritten rule against speaking out, particularly if it questioned the service's core approach or leadership. Clinicians who voiced worries about safety, ethics, or the speed of referrals sometimes faced subtle or overt pressure to conform. This created a climate of fear, where staff felt unable to speak freely without risking being labeled negatively.

Labeling and marginalization. Clinicians who persisted in raising difficult questions were sometimes labeled as "troublemakers" or accused of being "transphobic." This marginalization could manifest in various ways, from being excluded from interesting projects to facing hostility in meetings. Some staff felt that their concerns were framed as personal failings or an inability to cope with the work, rather than legitimate professional observations about systemic issues.

Staff departures. The difficult working environment and the feeling that concerns were ignored or punished led many experienced clinicians to leave GIDS, often after only a year or two. Some felt they could no longer work in a way that felt clinically safe or ethical, while others were exhausted by the pressure and the lack of support. This high staff turnover meant that institutional knowledge and lessons learned were lost, perpetuating inconsistencies in practice and hindering the service's ability to improve.

8. Absence of Crucial Data: Outcomes, Detransition, and Co-morbidities Untracked.

GIDS could not say how many people had been referred for puberty-blocking medication between 2011 and 2020, nor the age distribution for those referred.

Lack of basic statistics. Despite operating for over 30 years and referring thousands of young people for medical interventions, GIDS collected remarkably little systematic data on its patients and their outcomes. When asked by the High Court in 2020, GIDS could not provide basic statistics on:

• The number of young people referred for puberty blockers over the years.
• The age distribution of those referred for blockers.
• The number of patients with an autism diagnosis.
• The proportion of those on puberty blockers who progressed to cross-sex hormones (outside the small Early Intervention Study).

Failure to track outcomes. GIDS did not conduct routine, long-term follow-up studies to understand what happened to its patients after they left the service, whether they transitioned successfully, detransitioned, or experienced regret or adverse outcomes. Despite acknowledging the importance of this data and even planning a database for detransition information, these efforts were abandoned, citing "disproportionate effort." This meant the service lacked crucial evidence about the long-term impact of its interventions.

Implications for practice and consent. The absence of data meant GIDS clinicians were making decisions about potentially life-altering treatments without a clear understanding of the outcomes for their specific patient population. It also made it difficult to provide truly informed consent, as the long-term effects and likelihood of progression to further medical steps were not fully known or consistently communicated. This lack of evidence base and outcome monitoring was a significant failing highlighted by external reviews.

9. Damning External Scrutiny: Reports Expose Systemic Failings.

He branded GIDS ‘not fit for purpose’.

Bell Report's stark findings. Dr. David Bell, a staff governor, compiled a report in 2018 based on concerns from ten GIDS clinicians. His report was highly critical, describing a lack of a coherent clinical model, an "excessively affirmative attitude," inability to resist external pressure, rapid processing of referrals, and inadequate care for vulnerable, complex children. Bell concluded GIDS was "not fit for purpose" and warned of risks to children and the Trust's reputation if concerns were not addressed.

Trust's internal review. Following the Bell Report, the Trust's medical director, Dr. Dinesh Sinha, conducted a review in 2019. While the Trust publicly stated the review found no safety failings, Sinha's report acknowledged many of Bell's points, including excessive caseloads, pressure to process referrals quickly, variance in practice, lack of uniform consent processes, and senior staff being aware of concerns but failing to act. However, the report's conclusions and the Trust's public response were seen by many concerned staff as downplaying the severity of the issues.

CQC rates GIDS 'Inadequate'. In a major blow, the healthcare regulator, the Care Quality Commission (CQC), rated GIDS "Inadequate" in January 2021. The CQC found assessments were inconsistent, poorly recorded, and lacked clear rationale. It noted inadequate risk management, insufficient exploration of complex needs (like autism), and inconsistent consent processes. The CQC also found staff felt unable to raise concerns without fear and that leadership was inadequate, validating many long-standing internal criticisms.

10. Legal Challenges Force Change: Consent, Oversight, and Accountability.

The three High Court judges agreed with Keira Bell: children under 16 with gender dysphoria are unlikely to be able to give informed consent to treatment with puberty-blocking drugs.

Keira Bell's judicial review. A landmark legal challenge led by former GIDS patient Keira Bell argued that children under 16 cannot give informed consent to puberty blockers due to the unknown risks and the experimental nature of the treatment in this context. Bell's case highlighted her own experience of rapid referral and subsequent regret. The High Court initially sided with Bell in December 2020, ruling that under-16s were unlikely to be able to consent and that blockers were experimental and part of a single pathway to cross-sex hormones.

Impact and appeal. The High Court ruling halted new puberty blocker referrals for under-16s unless court authorization was obtained, causing significant disruption. The Tavistock appealed, and the Court of Appeal overturned the ruling in September 2021, stating it was for doctors, not courts, to assess capacity and that Gillick competency applied. While the legal challenge on consent ultimately failed, it brought intense public and professional scrutiny onto GIDS.

Increased external oversight. The legal challenges and CQC findings prompted NHS England to implement significant changes. From August 2021, an independent Multi-Professional Review Group (MPRG) was established to review all proposed puberty blocker referrals for under-16s, adding an extra layer of scrutiny to GIDS's decisions. This oversight revealed that even with internal review, a significant proportion of GIDS's submissions to the MPRG initially lacked sufficient information or raised safeguarding concerns, indicating ongoing issues with assessment quality.

11. Varied Patient Journeys: From Success to Regret and Unmet Needs.

‘I do feel, like, that really, those doctors gave me my life.’

Positive outcomes. For some young people, like Phoebe and Jack (who transitioned as adults after GIDS referral), the pathway through GIDS and subsequent medical transition has been overwhelmingly positive. They express gratitude for the support received and feel that transition allowed them to live authentically and happily. These stories represent the intended positive impact of gender-affirming care for those for whom it is the right path.

Unmet needs and regret. However, other patient stories reveal significant challenges and negative outcomes. Jacob's experience highlights the potential for puberty blockers to be ineffective, cause adverse side effects, and lead to years of distress without clear benefit, leaving him with lasting physical effects and unanswered questions. Harriet's story illustrates how rapid assessment and progression to medical and surgical steps can occur despite complex underlying issues (sexuality, mental health, trauma), leading to regret and the difficult process of detransitioning. These cases underscore the risks of inadequate assessment and the potential for harm when the medical pathway is pursued without fully addressing co-occurring difficulties.

Lack of follow-up. A critical gap highlighted by patient experiences and external reviews is GIDS's failure to systematically follow up with patients after they leave the service, regardless of their pathway. This means the service lacks comprehensive data on long-term outcomes, including how many detransition or experience regret. Patients like Jacob and Harriet, who detransitioned after leaving GIDS, received no follow-up care or monitoring from the service, leaving them to navigate the consequences of their medical interventions largely alone.

12. Closure and a New Beginning: Acknowledging Failure, Seeking Better Care.

‘A fundamentally different service model is needed,’ for this group of young people, she insisted.

Cass Review's final recommendation. Dr. Hilary Cass's interim report concluded that GIDS's single-provider model was "not a safe or viable long-term option." Her final recommendation, accepted by
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Last updated: May 24, 2025