The Gender Identity Development Service (GIDS) was a nationally operated health clinic in the United Kingdom that specialised in working with children with gender identity issues, including gender dysphoria. The service closed on 28 March 2024 after serious concerns were repeatedly raised over a number of years by several independent NHS whistleblowers.[1]
Launched in 1989, GIDS was commissioned by NHS England and took referrals from across the UK, although it was operated at a Tavistock and Portman NHS Foundation Trust site. GIDS was the only gender identity clinic for people under 18 in England and Wales and was the subject of much controversy. In July 2022, the NHS decided to close GIDS and replace it with regional healthcare centres, following the release of an interim report by the Cass Review on the provision of gender identity services for children and adolescents conducted by paediatrician Hilary Cass.[2]
GIDS was a service provided by the Tavistock Clinic. Originally located at Tavistock Square in London, the clinic specialised in psychiatric care. The Tavistock Clinic treated both adults and children, with their first patient being a child. However, it mainly focused on military psychology, including shell-shock, now termed PTSD. In 1948, with the creation of the NHS, the Tavistock Clinic launched its children's department, which developed many works by Robertson and Bowlby on attachment theory.[3] In 1959, it opened an adolescent department and in 1967 it was absorbed into the London Child Guidance Clinic.[4]
Early years
GIDS[6] was founded in 1989 by Dr Domenico Di Ceglie, a child and adolescent psychiatrist.[2] It was one of the first child gender services in the world. After its opening, "it got two referrals over the whole year."[7] It was initially based at St George's Hospital before moving to the Tavistock and Portman NHS Trust in 1994.[8] The clinic saw 12 patients that year, increasing to 24 two years later.[8]
In its early years, the service was largely therapeutic.[9] Di Ceglie estimated in 1993 that only 5% of his patients would "commit themselves to a change of gender" and at least 60% were homosexual.[10][9]Puberty blockers were considered a usable option by the end of the 1990s but only for patients aged 16 or over who had first tried extensive therapy.[11]
In 2000, a retrospective audit led by David Freeman looked at the records of 124 patients the service had seen since opening. The audit showed it was very rare (2.5% of the sample) for young people referred to GIDS to have no associated problems. 70% had more than 5 "associated features". Common problems were associated with relationships, family, and mood. 25% had spent some time in care, compared to less than 1% of all children.[12][13]
In 2009, Dr Polly Carmichael, a consultant clinical psychologist, succeeded Di Ceglie as the clinic's director.[14][7][15][16] In that same year, GIDS became a nationally commissioned NHS service.[14]
Expansion in the 2010s
In 2009–10, 97 patients were referred to GIDS. By 2015–16, this had increased fourteen-fold to 1,419 and in 2017–18 to 2,519. The demographics of the referred patients shifted to being mostly birth-registered females. Similar developments happened around that time in other Western countries.[17] Average wait times rose to nine months in 2016[7] and two years by 2019.[18][19]
In 2010–11, the GIDS lowered the age of prescription for the puberty blocker drug from 15 to 10 years old after facing pressure from activists and from people may have otherwise travelled to America or the Netherlands to obtain the drug.[7][20]
In 2012, the service was extended to a satellite site in Leeds. Endocrine support was also extended to Leeds Children's Hospital at the Leeds General Infirmary site in 2013.[21]
In 2015 in discussion of overwhelming caseloads, the GIDS July 2015 minutes record that GIDS director Polly Carmichael acknowledged overload problems and the medical director raised "escalating risk", including "the number of safeguarding and risk concerns being brought to him for advice". An external report was commissioned and delivered by Dr Femi Nzegwu.[citation needed]
In 2016, the clinic was the subject of a Channel 4 documentary programme, told from the point of view of two satisfied trans children and their families.[7]
In February 2019, it was revealed that the National Institute for Health Research (NIHR) had announced a £1.3 million grant for a study following young people referred to GIDS, to compare mental and physical health outcomes for children referred. The study was to compare the effectiveness of different interventions, including psychological, endocrinological, pharmaceutical and alternative interventions.[22]
In July 2019, the Tavistock Centre was flooded, which temporarily affected the IT servers at the clinic.[23]
Increased scrutiny
In November 2018, the parents of patients complained in a letter to the Trust board about the alacrity at which diagnoses were rendered, leaving them unable to intervene in these "life-altering decisions".[24] This led to the commissioning of an internal report by Dr David Bell, which concluded in February 2019 that the service was "not fit for purpose", as children were being prescribed experimental drugs "after a few sessions and without proper investigation of their cases[...] under pressure from transgender rights groups". Bell urged the suspension of "all experimental hormone treatment for children who wished to change gender until there was better evidence of the outcomes."[25] Dr Marcus Evans, a member of the Tavistock and Portman NHS Foundation Trust governance board, resigned that week after a 35-year association with Tavistock and Portman. He accused its management of having an "overvalued belief in" the expertise of GIDS, "which is used to dismiss challenge and examination."[22]
Subsequent to the Bell report it was revealed that 35 psychologists had resigned since 2016, including six psychologists who claimed there was "over-diagnosis" of gender dysphoria and a push for early medical intervention,[26] because "psychologists fear being branded transphobic."[27]
In October 2019, a lawsuit was launched against GIDS by the mother of a patient at GIDS and Sue Evans, a nurse who formerly worked there.[28] Later, Evans passed their role as complainant to Keira Bell, a previous service user and detransitioner. In December 2020 following the High Court judgement, GIDS suspended all new referrals to endocrinology. The Court granted a stay on further implementation of the judgement until 22 December 2020 or until appeals are exhausted.[29] The judgment was overturned by the Court of Appeal in 2021.[30]
In December 2020 Dr Bell, a former governor of the Trust who was elected by the medical staff and who had produced in February 2019 a report on the methods of the GIDS, reported that he now faced "disciplinary action" from the Trust.[25] The threats to take disciplinary action lapsed when Dr Bell retired in 2021.[31]The Observer interviewed Bell in May 2021.[32]
In January 2021 GIDS was rated "inadequate" (the worst rating) by the Care Quality Commission.[33]
In March 2022, Hilary Cass published the interim report of the Cass Review. The report found that the existing model was "neither safe nor viable", partly as the rise in referrals had left GIDS staff overwhelmed and led to "unacceptable" waiting times, and recommended the creation of new network of regional centres.[36] It criticised the care at GIDS, saying that its clinical approach "has not been subjected to some of the usual control measures" expected of an innovative treatment and sidelined the patients' other mental health needs.[37][38]
In July 2022, the NHS decided to close GIDS and replace it with regional healthcare centres.[39][2] The regional centres are intended to provide more "holistic care", linking to other mental health services.[40][2] In response to the decision, Susie Green, then CEO of Mermaids, a campaign group for youth who question their gender, was "cautiously optimistic", but expressed concerns that priority would be given to mental health over medical care, saying that gender diversity should not be treated as a mental disorder.[41]
After a delay,[49] GIDs closed in March 2024, and was replaced with two new services at Great Ormond Street in London and Alder Hey in Liverpool, which are intended to be the first of eight regional centres.[50]
People referred to GIDS may also contribute to NIHR studies into gender dysphoria in children.[22]
Referrals
In the financial year 2018–19, 31 referrals were made for children aged 5 or under. 30 referrals were made for adults over the age of 18. In 2018–19, there was a year-on-year increase of 6%, a relative plateau compared to previous year-on-year increases.[19] Similarly, there was only a 0.1% increase in referrals between the 18–19 and 19–20 financial years.[53]
Child and Adolescent Mental Health Services (CAMHS) provides the NHS support for children with mental health issues. However, CAMHS is organised by local government area and thus coverage varies significantly. The development of CAMHS within a four-tiered framework started in 1995. In 2000 the NHS Plan Implementation Programme required health and local authorities to jointly produce a local CAMHS strategy. GIDS took referrals from all mental health care professionals, especially Tier 2 and 3 CAMHS specialists. GIDS was distinct from CAMHS as is it is nationally run, not by the local authority. It sat in Tier 4 of the CAMHS framework, as a highly specialised service.[56]
Controversy
As the only gender identity clinic for children in England and Wales, GIDS has been the subject of much controversy related to the broader topic of gender dysphoria and transitioning in childhood.[55]
High resignation rate
A 2019 Sky News report found that 35 psychologists resigned between 2016 and 2019. Six psychologists who resigned raised concerns about the over-diagnosis and medicalisation of young people experiencing gender identity difficulties. In February 2019, Tavistock trust member Marcus Evans resigned, citing similar concerns.[26][27] In July 2019, Kirsty Entwistle wrote a public letter about the GIDS service, saying professionals were often labelled "transphobic" if they raised doubts.[57] Clinicians have stated that concerns over children's welfare were "shut down".[58]
Bell Report
Following a letter to the board at Tavistock, an internal report was commissioned to look at the functioning of GIDS.[24] Dr David Bell authored the report which found that the service was "not fit for purpose". It considered that the service could result in "damaging consequences" to children's lives and failed to fully consider a child's mental health background.[22] However, it did not identify any "immediate" issues with regards to safety and in 2018 the Care Quality Commission (CQC) rated the effectiveness of the Trust as "outstanding".[59]
Conversely, there is a long wait time for a first appointment at GIDS, averaging at two years as of January 2020. GIDS blame high referral numbers and low staff numbers for this wait time.[60]
In October 2019, a legal complaint was lodged against GIDS at its satellite site in Leeds. The suit was brought by "Mrs. A", a mother of a 15-year-old patient with autism, and Sue Evans, a former nurse at the Leeds GIDS satellite site. It alleges that advice around hormone therapy was "potentially misleading" and that true informed consent could not be given under such circumstances. The suit describes hormone therapy as "experimental" and states that there is "robust evidence" to show long-lasting medical effects of hormone therapy.[28] Some time after January 2020, Evans passed on her role as complainant to Keira Bell "who was prescribed puberty blockers by GIDS when she was 16. She had a double mastectomy aged 20, and now regrets transitioning, which has left her with 'no breasts, a deep voice, body hair, a beard, affected sexual function and who knows what else that has not been discovered'. She may well be infertile as a side effect of the drugs."[61] In a judgment delivered on 1 December 2020, the judges said that it was "highly unlikely that a child aged 13 or less would be competent to give consent to the administration of puberty blockers", and that it was "doubtful that 14 or 15 year olds could understand the long-term risks and consequences" of this form of treatment. Where the young person is 16 or over, "we recognise that clinicians may well regard these as cases where the authorisation of the court should be sought prior to commencing the clinical treatment."[62] The judges also criticised GIDS for failing to publish a 2011 study relating to puberty blockers.[20] Immediately following the High Court judgement, GIDS suspended all new referrals to endocrinology. The Court granted a stay on further implementation of the judgement until 22 December 2020 or until the appeal process was complete, whichever was later.[29]Amnesty International and Liberty issued a joint statement emphasising their concern on "the wider implications this will have on the rights of children and young people of all genders, particularly on consent and bodily autonomy."[63]Consortium issued a statement stating that the ruling "could have a potentially devastating impact on young people seeking access to medical services."[64] Leave to appeal against the decision of the High Court was granted in January 2021.[65] The appeal was heard on 23 and 24 June 2021.[66][67]
In September 2021, the Court of Appeal overturned the judgment of the High Court and once again allowed people under 16 to consent to receiving puberty blockers.[30] In March 2024, NHS England announced that it would no longer prescribe puberty blockers to minors outside of use in clinical research trials, citing insufficient evidence of safety or clinical effectiveness.[68] The Sandyford clinic in Glasgow, which is the only specialist gender clinic in Scotland, announced in April 2024 that it was pausing the prescription of puberty blockers.[69]
Royal College of General Practitioners (RCGP) position
The RCGP report on transgender healthcare in the UK found several flaws in the NHS approach. It called for a "whole system" change, including addressing waiting times and the lack of research around gender dysphoria in children.[70] The report noted the expansion of gender identity services into all four UK nations and "welcomes the forthcoming postgraduate diploma in Gender Identity Healthcare Practice". The report also noted that "in England, for example, GICs have seen a 240% overall increase in referrals over five years, with referrals to the Tavistock and Portman clinic alone increasing 8.43% between March 2018-19."[70]
Sonia Appleby employment tribunal case
In July 2020, it was reported that Sonia Appleby, the "Named Professional for Safeguarding Children" at the gender identity clinic, had been in dispute with her employers since November 2019.[71]
In September 2021, it was reported that Appleby was awarded £20,000 by an employment tribunal because the NHS's Tavistock and Portman trust's treatment of her damaged her professional reputation and "prevented her from proper work on safeguarding".[72][73] The trust will not be lodging an appeal.[74]
Academics Judith Suissa and Alice Sullivan listed her alongside Allison Bailey, Maya Forstater, and J. K. Rowling as women who have experienced campaigns of harassment because they speak publicly on sex and gender identity.[75]
^The last word of the clinic's name was initially Clinic and varied over time, shifting to Unit before being standardised in the late 2000s as Service.[5]
^Barnes, Hannah (2023). Time to Think: The Inside Story of the Collapse of the Tavistock's Gender Service for Children. Swiff Press. ISBN9781800751118.
^"The service director's view". The Tavistock and Portman NHS Foundation Trust. Archived from the original on 20 February 2022. Retrieved 20 February 2022.
