I was threatened with disciplinary action. The CEO stated that the review did not identify any “failings in the overall approach taken by the service in responding to the needs of the young people and families who access its support”. The trust then conducted a “review” of Gids, based only on interviewing staff. This formed the basis of the report submitted to the board in 2018. I was a senior consultant psychiatrist, and it was in my role as staff representative on the trust council of governors that a large number of the Gids clinicians approached me with their grave concerns. The then medical director heard concerns but did not act ditto the Speak up Guardian and the Tavistock and Portman NHS foundation trust management. The attempts of Gids clinicians to raise concerns about safeguarding and the medical approach were ignored or worse. The lack of long-term evidence underlies the decision of the NHS to put an end to their routine prescription for children as a treatment for gender dysphoria – that is, for those whose bodies were physically healthy. But they had not been prescribed by Gids to children experiencing gender dysphoria before 2011. They had been used in precocious puberty (for example where a child, sometimes because of a pituitary abnormality, develops secondary sexual characteristics before the age of eight) and in the treatment of prostate cancer. It is often claimed that puberty blockers were not experimental, as there is a long history of their use. However, having come under considerable pressure, they have now relented. Six adult gender clinics refused to cooperate and provide data to Cass. This is one of the most serious governance problems of Gids – also specifically addressed by the judges in Keira Bell v Tavistock. But these numbers are likely to be an underestimate, as 70% of children were transferred to adult services once they were 17, and their data lost, as very regrettably they were not followed up. Cass quotes figures showing around 30% of Gids patients in England discharged between April 2018 and 31 December 2022 were referred to the endocrinology service, of whom around 80% were prescribed puberty blockers the proportion was higher for older children. Some claim that low numbers of puberty blockers were prescribed. Children struggle to even imagine themselves in an adult sexual body. It is, I think, not possible for a child in acute states of torment to be able to think through consequences of a future medical transition. Thus children suffered thrice over: through not having all their problems properly addressed by being put on a pathway for which there is not adequate evidence and for which there is considerable risk of harm and lastly because children not unreasonably believed that all their problems would disappear once they transitioned. Cass helpfully calls this “diagnostic overshadowing”. The many complex problems that affect these young people were left unaddressed once they were viewed simplistically through the prism of gender. Studies indicate that a majority of children in the absence of medical intervention will desist – that is, change their minds.

The policy of “affirmation” – that is, speedily agreeing with a child that they are of the wrong gender – was an inappropriate clinical stance brought about by influential activist groups and some senior gender identity development service (Gids) staff, resulting in a distortion of the clinical domain.

To precipitate definition