201. Hannah Barnes

0:01This is a Global Player original podcast.

0:11Well behaved women rarely make history. Bloody difficult women do. Hi, folks, just a quick note to say that we recorded this interview with Hannah Barnes a few weeks ago back at the end of November. there's been a bit of movement on the puberty blockers trial very controversial trial since then so we did re-record her answer on when I asked her about that question

1:04I love doing journalists, especially the stormtroopers of our inky trade, investigative journalists. And Hannah Barnes is a particularly fine and effective one, now the investigations editor at the New Statesman. Formerly at the BBC's Newsnight, her book Time to Think, the inside story of the collapse of the Tavistock's gender service for children, was a Sunday Times bestseller and shortlisted for both the Bailey Gifford and the Orwell Prizes. Hannah, I see you, I think of you as the journalist who closed the JIDS clinic. That was them, but it's not over, is it? It's not, but that's very kind and it was a lovely introduction.

1:45I don't think any one person was responsible for that and certainly not even one journalist. So that's very kind. I think I played a part, but journalists are only as good as the people that are willing to talk to them. and there were lots of concerned clinicians over you know a 20 year period and also other journalists obviously my news night colleagues and other journalists in print as well but but thank you but no it's not over it's not over we will come to that but let's get back to jids because that's i think what you are most well known for your investigation of jids at the and it's you know it was founded I think opened in 2009 it closed in 2023 so RIP JIDS.

2:29Rachel Cook the late Rachel Cook the Observer journalist said this is what journalism is for yet your acclaimed investigative book was turned down by every major publisher. Can you set out why you think that was? the kind interpretation is that i'd never written a book before i was just a senior producer at the bbc uh and you know they didn't see any commercial viability in it but i think the more realistic explanation is that there was institutional cowardice really across the publishing sector. I think what was most surprising or most eye-opening about the responses that my agent got back was that, well, only actually about half replied, which is rare, I'm told.

3:23So you'd at least get out of being polite a no. But actually lots didn't reply. But of those that did, no one said, no, there's no story here or this isn't well written. and it was a really detailed, I think it was like 17 ,000 words, the proposal. And it was really clear what the tone would be and how evidence-based it would be. Explain just before we get more into it what the JIDS clinic did. So JIDS actually happened in 1989. Okay, sorry. Not 2009, but it underwent a sort of a huge metamorphosis really in the time that it was open. So it opened originally at St George's Hospital in South London And then it moved across to the Tavistock and Portman in the 90s.

4:09To begin with, it was a tiny, tiny service that would see probably a handful of children each year that were distressed around their gender. They felt that they weren't the typical boy or the typical girl and they had bits of their bodies they didn't like. And it was sort of accepted at the time that this group was really small and they could be really distressed about that. But it was small and it was rare. And then over time, and generally what happened, because I spoke to people who went through the service as children in the 90s, in fact, who said actually it was amazing because no one that I spoke to could understand at all how I felt.

4:56And yet this did give me an opportunity to talk about it. and it was sort of what you'd call in modern parlance really a sort of a safe space to talk and it was mainly that talking therapies and then you'd either go away or you'd stay talking for a long time and that was sort of generally it sort of therapy I guess and then around 2000 so quite a long time ago actually what we now call is puberty blockers so drugs that that stop the the release of the sex hormones in boys and girls, became available, but for a completely different purpose, really. They would only be available at 16 years old for a start, by which point most people would have pretty much, certainly girls, would have gone through puberty.

5:42But they were there really as a sort of a precursor to properly medically transitioning, so to get the body in a state where you could introduce cross-sex hormones. So either testosterone for females or estrogen for males. And again, they weren't used very often at all. You had to have had significant amounts of therapy beforehand. So it was really quite rare. then what happened was a team in the netherlands uh introduced what has now been dubbed the dutch protocol which hypothesized that when you look they looked at the trans adult population mostly trans women so biological males and they found that some were really unhappy because effectively they didn't pass.

6:30They didn't pass as women. And so they felt, well, if we could have helped those adults in childhood, they'd be much happier now. It'd be a more successful outcome. And so this idea sprung up that you could introduce these drugs, which are not licensed for this purpose. They're licensed to treat prostate cancer, to actually chemically castrate adults. and in children they're only licensed to stop what we call precocious puberty which is when you start puberty abnormally early which would be extremely distressing for the child and you take them for as short a time as possible and then you go through puberty.

7:08So they introduced this protocol whereby relatively strict criteria whereby if a child had had this kind of distress and he had to be distressed about it, about their gender They didn't identify with their biological sex. And this had gone on for many years and then had got worse as puberty had started. They could, and they had no other major difficulties in their life. Their mental health was stable. They had a stable home life. Then they could take this blocker. And the idea was kind of twofold, really. One was this, for those who are going to continue in their trans identity, it will make life easier in adulthood.

7:52and the other was a sort of a more, it was strictly theoretical, but the idea was if you pause the development of the body in a way that's causing distress, then you pause the distress, which does make sense. If it's your sexed body. I know, I understand. I was just thinking to myself, hmm, I'm not sure. Well, as a theory, as a theory. Yes, if the, yeah, carry on, carry on. And so they did that and then that was the first stage of the protocol. The second was if by 16, I think it was at the time, your trans identity endured, you would take hormones to either masculinize or feminize the body. And then in the original protocol, you had to have surgery as well, which would happen after 18.

8:39And lo and behold, every single child in the study went on to the next stage and what have you. That's in the Dutch study. But really, so this one study was the basis of what we see now as the gender affirming model of care for children. One study. How many children? It was 70 originally. But what happened was when they followed, they published in two stages. And when they published the next stage, which is after they'd all had hormones and surgery. In fact, the group had reduced. So they only had data at this time now for 55. One of them had died out of 70, which by any stretch of the imagination is a terrible outcome.

9:31And yet this was just mentioned in methodology. It's not discussed. and others had become really too unwell to be approved for surgery. Now we don't know whether that's as a result of the hormones they were taking or changes in their lives. The Dutch team don't tell us. But you have a really quite significant drop in participants by this point. And then even of the 55, which is what, 20 % down on the original back of a fag packet, we only actually have data for about like full data sets for about half of the original group so it's a really weak observational study and yet this was the basis for this model being rolled out and it showed purportedly that these children that had been carefully selected were all much happier after than they had been and their gender dysphoria this distress had ceased.

10:34But the survey didn't show that at all. And yet these were the premises upon which JIDS was founded. Exactly. I mean, retrospectively, there's been some amazing analysis of those Dutch papers, which one of the main critiques showing that actually what the, sorry if this is too technical and boring, the revelation that the gender dysphoria had ceased, which I guess is the outcome that you want, that distress is gone, could be based simply on the fact that the way they asked the children. So what they did was they used this scale. And what they did is there's a boy version and a girl version, effectively.

11:16And so before they started the interventions, they gave the boys the boy version and the girls the girl version, obviously. And it says things like, if you're a boy, I hate having erections. I don't like my penis. I don't want an Adam's apple, etc. Now, when they were given the scale again to kind of measure the impact of the intervention, they switched them. So they gave the biological females who are now trans men the male version. So these females were asked to answer those same questions. Well, they don't have a penis, so they can't answer that question, and they don't have erections. So this is irrelevant.

11:56And things like, I hate being perceived as a boy. Well, no, that's what they absolutely desire. so it's argued that in fact that the the overcoming of the gender dysphoria can be purely down to the fact that they switched the scales so the methodology was flawed as well as the data outcomes okay

12:35Your investigation into JIDS, which was based on interviews with people who'd been through JIDS and clinicians, led partly to the closure of the Tavistock JIDS Clinic. And you said sometimes the truth is awful. Just summarise that experience. Well, I think professionally, writing the book is the hardest thing I've ever done.

13:02I felt this enormous responsibility to get it right for everyone actually I didn't want to write a polemic because at the back of my mind the whole time was there are very divided opinions about this but actually at the heart of it is children so I just I was very conscious of that fact I had an enormous amount of data enormous and just going through that not not just I mean I did hundreds, probably just shy of 200 hours worth of interviews. But then I had thousands of pages of documents. I'd gone through every freedom of information request that Tavistock had ever been asked and answered. Did some of my own.

13:44And so it was exceptionally difficult. It was very lonely. I'd never written a book. I don't know if you have. It's so different to anything that I had done before. because in broadcast journalism, which up to that point is all I had done, you're always with somebody else. And I was very fortunate that most of my career up to that point had been with the BBC, and I knew that, thankfully, this had never happened. But if I made a mistake, I'd always have the backing of an enormous organisation, and I felt completely on my own. Not that my publisher, Swift, weren't supportive, it wasn't that, but that's just the facts of the matter.

14:20I had a newborn baby, I was on paternity leave, and my oldest child as well. And I just felt completely overwhelmed by it all. Many of the people I spoke to had never spoken about the experience before. They were exceptionally upset. They told me things that were objectively extremely upsetting. And it was just sort of intellectually, emotionally, just completely overwhelming. and also we should we should remind people because although it's come back into the news because there is now a trial of the puberty blockers that were banned as a result of the cast report into gender reaffirming treatments at the time you wrote the book it was all you know trans activists versus turfs wasn't it and presumably you got a lot of flack from people who said you're just a tough?

15:21Well, it was a bit like that. I mean, one of the difficulties was that the story hadn't ended. It was ongoing the whole time. So, in fact, when I submitted the manuscript, I think it was about literally a week later that they made the decision to close Chips. So I think it's worth remembering that all of the people that spoke to me, it was much riskier than it maybe would be now because there wasn't that consensus and Cass hadn't reported. so it was much riskier for people to speak. It was divisive. But also the other thing was the numbers of children being seen at JIDS had leapt from, as you said, like 100 to 1000s and a lot of girls as well.

16:04So there was a kind of social contagion around gender affirming treatments and children declaring gender incongruence as we now call it. Did you ever get to an explanation of what led to that spike? I think it was down to many things. I think there's this temptation to see this weird binary as either it's completely social contagion or from the other side of the argument, oh, it's greater societal acceptance. I mean, neither explain it. I think there might be an element of both. But my experience was, talking to the young people who'd been through the service, that it was kind of different for different people.

16:50There certainly was an element of social contagion, because why wouldn't there be? There is for everything. You know, if you talk to psychiatrists, psychologists, doctors, there is. The hysteria aspect of it, yeah. And certainly some of the young people I spoke to readily acknowledged that, that their peer group, there's one young woman in the book who I call Harriet who detransitioned so she went through a medical and surgical transition only to regret it and now lives again as a woman but she was saying she was at an all girls school and her entire group I think six out of the eight of them I can't remember the exact figures now identified as either non-binary or trans and the way they were treated was different because of that.

17:40They were now cool and people were like, oh, you're so brave. So social contagion was an aspect. And fashion. Yeah, but I don't think it explains the remarkable shift in the demographics and the rise in the overall numbers. I think particularly for the girls, some of it was just wanting to escape femininity and sort of the pornification that we've seen of society. like it's really hard being a teenage girl now and what's expected of you and the exposure you have to really sort of violent sex that was certainly part of it there were some both boys and girls who were absolutely same sex attracted and were repulsed by that particularly in the girls didn't want to be a lesbian and I think back to my school days I mean this really upset me actually I mean I couldn't believe it either to start with And I think this is one of the things that when I spoke with friends and colleagues, they're like, oh, it can't be true.

18:38Because, you know, we live in London and it's very accepting and different and we've all got gay friends. They're like, don't be silly. But actually, I think when you go out of London and even in London, the level of homophobia going on in schools is really quite shocking. Some of the stories that the clinicians told me were awful, like these horrendous homophobic slurs that I thought had died in the 80s. yeah so in order to escape homophobia these these children enter the world of transphobia which is a separate composite can i just ask you um some of the clinicians you interviewed in the book time to think compared the treatment of children with gender dysphoria either puberty blockers and surgery and and so on and all the physical consequences of those treatments to the East German doping scandals in the 70s or the failings of Midstas Hospital in the 2000s.

19:33In your experience since that book came out and the Cass Review, has there been any acknowledgement on the part of the trans community, the trans activists who still stand by these treatments, that the treatments are quite inhumane because of the consequences on terms of sexual pleasure, in terms of reproduction, in terms of physical presentation. They're not ideal. And so is there a recognition that the CAS report was actually a force for good by the trans community? That's a really interesting question. I think it's really difficult for trans people. I mean, I've had conversations privately with some trans adults who are really concerned about what's happened.

20:21And it's exceptionally difficult for them to voice those without receiving huge criticism themselves and sort of face being ostracized by the... Yeah, they're tally against their tribe. Yes, because you can... It's perfectly consistent for a trans person to believe that transition is beneficial at a certain stage, and it has been for them. You often get this with people who have transitioned sort of in early adulthood, but that actually you do need to live your teenage years to know that because we all change our minds. But so I think it's quite difficult. I mean, interestingly, there has been this sort of strange thing where the risks of early medical transition are well acknowledged by gender clinicians, including transgender clinicians.

21:07But then when they're asked about them, they're very sheepish about them. So, for example, in the US, trans woman Dr. Marcy Bowers, she was actually president of this organization called WPATH, which is the World Professional Association for Transgender Health. It sounds very official and medical, but it's not particularly. But she had been very open in the past about the dangers, particularly in boys, of blocking puberty too early. So if you do it too early, you don't have enough genital growth in order to make surgery as successful as it could be later on. So actually, it's counterproductive.

21:45Moving things on a bit, post-Tavistock and post-CAS report, the use of puberty blockers for gender distress is decisively back on the agenda again with this PATHWAYS trial, which is a randomized controlled trial into puberty blockers. it has been sanctioned and it is I think beginning this month. Is this a gold standard trial that most people should or would welcome? I think it's they would say it's gone through all the ethical approvals and legal requirements that these things need but I think actually when you look at the detail of the study it kind of raises more questions than it answers. You know reason they're doing this trial is because Dr.

22:33Cass, now Baroness Cass, recommended that more evidence was needed, particularly on the long-term impact of puberty blockers. And when you do a deep dive into what this trial does, it doesn't fill those gaps in the long-term evidence. It's only looking relatively short-term. And I asked the researchers, you know, what's going to happen and long term. And they obviously intend to do that and to get more money, but that isn't there at the moment. And then you kind of look at the design of it. And there are loads of questions here as well. So, for example, the children that are selected to go on, they'll be accepted if a clinician believes that there's a reasonable prospect that that individual child will benefit.

23:24Well, what does that mean? How are they going to judge it? Because one of the things I found from talking to so many of the staff at the Tavistock was that they had seen, some of them, hundreds of children. And they said, do you know what? There is no way. I can't tell with any given child before me, even the most distressed, who will benefit and who will not and whose trans identity will last and those for whom it won't and it will resolve. So you've got a problem there about selection. And then you kind of look a bit further. And I've had the opportunity to ask the team, you know, what is the primary purpose of it?

24:01And they said to me, well, it's about pausing the puberty so that these young people can explore their identity without the distress of irreversible changes. Now, for those who follow this, that sounds an awful lot like the argument. Well, that's time to think, basically. And you go back to Cass, who all of this is being pinned on, if you like, whether that's the health secretary, West Street is saying, I'm doing it because Cass recommended it. And you go back to the Cass review and she pretty flatly rejects that. She says, this is a quote now, she says, there is no evidence that puberty blockers buy time to think.

24:40So, again, I'm just thinking, does the trial actually sort of square with CAS? And there's so many sort of issues with the design of the trial. And in fact, because there's no group in the trial who don't get the puberty blocker, you've got one group that get it immediately and then you get another who get it a year later. So, there's no placebo group? There's no placebo group. what they're going to do is they're going to try to match as best they can a group of children who don't go on the trial. But, you know, this, again, I mean, this prompts loads of questions. So, what they're actually studying with the drug is not the drug itself, but the impact of the timing of it, whether you get it immediately or whether you get it a year later.

25:29And then to say that the children that aren't on the trial are a meaningful comparison, well, I think that's questionable because they either aren't eligible for one reason or another, or they simply don't want the puberty blocker. So, to compare that group of children with those that desperately do want it, obviously, is problematic. And there are all these issues and you look at what they're actually measuring and the primary outcome, they're looking at basically happiness, well-being of these kids and they're using a questionnaire with 10 questions um and to to ascertain whether the the puberty blockers are successful or not right yes because we know that they block puberty but you can see why this has been called the most controversial um trial in modern medical history but i mean but it was something that cass suggested in her report wasn't it so and it's been signed off by Westreating and it is happening.

26:30Well she did recommend it Rachel but I think it's really important to point out she recommended a load of other stuff too and not all of that has happened. Okay so listen. I asked her whether you do this one first and she said in an ideal world no you wouldn't you there are some other things that you look at you'd look at the impact of kind of you know non-medical interventions but we're not in an ideal world so. Just lastly before we move on to your other work and maybe a tiny bit on the BBC and what you're doing now Hannah Barnes Just the fact that so high a percentage of children who say they have gender dysphoria also have other complex needs.

27:11In your view, and this is a very binary question, is it appropriate to treat children with gender dysphoria, which is a mental illness, with physical treatments?

27:30I think what should happen before... You know, I'm not a clinician. I think what Dr Cass highlighted in her review was that what had happened at JIDS was that these children with an array of conditions, some with very traumatic childhoods, and actually that relates to your previous question about what was upsetting, I think that was upsetting hearing some of the cases. Truly extreme. But that was never explored prior to any kind of physical intervention. And so you had this situation where you could have a young person sitting in front of the team with a year's worth of history of anxiety, eating disorders, depression, and potentially this distress around their gender and all the other stuff was ignored.

28:23Or sexuality. Yeah, and all the other stuff was ignored. and seen through this prism of gender. So that, I think, is the fundamental difficulty. And until you can have... Yeah. I know it's a very hard question, and I can see why you didn't want to answer it. But it seems to me that there used to be distinct cases of extreme body dysmorphia. But then this spike of children rushing to be gender affirmed in a different gender from their biological sex speaks of a confusion around what it is to be a boy and what it is to be a girl and a kind of horror of adulthood in that particular biological sex.

29:18And speaking as a gender-critical feminist, my problem with the whole thing is there is no one way to be a boy or to be a girl you are you know the idea that you are assigned a sex at birth is is just a nonsense these are this is your sex and you can obviously be boyish or you can be feminine but you don't have to change your physical presentation um in order to feel boyish or feminine i mean speaking as a former tomboy who made people call me richard you know the moment passed and everyone just ignored me for a year. And here I am having had three children and talking to you about why we should probably not treat children who think they should be a boy or want to be a boy and turn them into a boy physically.