Text: Thirteen years ago, Susan Evans – then a clinical nurse with the Gender Identity Development Service at the Tavistock and Portman NHS Trust in London – walked out.

She had first raised concerns about the clinic’s “precipitous referral” of children on to the medical path to change gender several years earlier, in 2004. But it was only last week that the whistleblower felt a sense of vindication.

On Wednesday, the High Court ruled in favour of Keira Bell, a 23-year-old former GIDS patient and “detransitioner” who had started taking puberty blockers when she was 16, prior to undergoing reassignment surgery, which she later regretted; and “Mrs A”, the mother of a trans-identifying 15-year-old girl currently on the waiting list for treatment.

Evans had long supported their application for a judicial review into whether NHS guidelines on administering hormone-blocking drugs, followed by the Tavistock, Britain’s only NHS gender clinic for children, are unlawful.

Three High Court judges ruled that under-16s are highly unlikely to be able to give informed consent to take puberty-blocking medication. In practice, this puts an immediate end to the use of drugs that delay the development of sex organs by blocking the hormones testosterone and oestrogen, but which can have serious side effects and unknown longer-term consequences.

NHS England has now ordered a full clinical review of each GIDS patient offered puberty blockers under the age of 16. “I was told privately by some the case was hopeless, that the bar had been captured by transgender activists, that institutions had been captured by ideologically driven charities,” says Evans. “Certain trans groups have really cultivated an atmosphere of fear among children and their families. But I’m just very relieved and obviously pleased with the ruling.”

Evans has worked for the NHS her entire life, and met her husband, Marcus, who was also in the field of psychoanalytic practice, when training in Springfield Hospital in Tooting Bec, south-west London. “What drew me to therapeutic practice was trying to understand the internal emotional worlds of other people,” she says, “because with understanding comes an improved experience of life. I had an instinct that drugs and physical treatments were never going to provide an answer for people in emotional distress.”

When Evans started at the Tavistock in 2003, she was “proud to be working in a tiny team at a pioneering organisation”. But on hearing a colleague describe how, after only a few assessments, they had referred a distressed 16-year-old boy who thought of himself as female for hormone treatment, her “jaw dropped”. She recalls feeling “something was very, very wrong with the GIDS approach”.

In her early years as a psychiatric nurse, she had witnessed treatments, such as electroconvulsive therapy, that are now widely condemned: “I know enough of the history of psychiatry to always be cautious about intervention.”

Evans had assumed she would be able to use her psychotherapeutic skills to support the scores of children referred each year. When she raised the possibility of alternatives to medication, Evans was advised the service would not have any patients without the offer of puberty blockers. Last year, GIDS had 2,590 children referred for them, compared with 77 patients a decade ago.

Evans began to become concerned by the influence of transgender organisations on clinical practice at the Tavistock. “It was becoming increasingly difficult to discuss the needs of the patients who displayed clinical curiosity. The beginnings of the more ‘affirmative model’ of care [whereby the cross-sex identity of a child with gender dysphoria is affirmed by referring to the child as if it were the opposite sex] were taking root”.

To this day, Evans believes this practice “has not been proven to alleviate mental distress”, and that its use within the GIDS is “based on political pressures and fears of litigation, rather than what would be clinically, professionally appropriate”.

Back in January, Evans launched a crowdfunding campaign with Mrs A to cover legal costs for the judicial review. Immediately, she received letters from “distressed parents who had been told that they were at fault when their children had harmed themselves”.

Due to personal circumstance, Evans withdrew, passing on her role as claimant 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.

More than a decade after she had walked out of the Tavistock, Evans’s husband convinced her to push for a judicial review about some of the practices both had witnessed there.

In September 2018, Marcus Evans, a recently retired clinician at the Tavistock, was appointed as a governor at the trust. Susan warned him that “his time as a governor might not be easy” – and, by January 2019, he had resigned. He cited two “really serious” complaints, “which completely tied with everything Sue been talking about 14 years earlier – only this time around it was 10 times worse, because of the exponential rise in patients”.

Between 2016 and 2019, a total of 35 clinicians left the Tavistock, many reporting concerns. One psychologist, who wished to remain anonymous, feared that “young people are being over-diagnosed and then over-medicalised”. Others felt the influence of lobby groups on clinical practice.

Clinicians reported being alarmed that underlying issues, such as homophobic bullying, sexual abuse or other traumas, were systematically overlooked. New light was shed on their concerns in June, when transcripts of staff interviews from an internal review of GIDS were leaked to BBC Newsnight.

The transcripts included staff fears that some patients had been placed on to “a gender-transitioning pathway” too quickly. It also highlighted claims of homophobic attitudes among the parents of children attending the clinic, with some allegedly appearing to prefer their children to be transgender and straight, rather than gay. Staff also reported feeling discouraged from referring to social services children they believed may have been sexually abused.

“The real scandal is that the treatment pathway of children with gender dysphoria became ever more politicised, and moved away from high standards of clinical mental healthcare with good assessment and psychotherapeutic treatment.”

For Evans, the ruling was not just a vindication of her clinical concerns, it was judgment on all of those who allowed professional standards to be overlooked to suit a political ideology.

“I am relieved by the ruling, but there will be a lot of kids and their families who will be thinking, what happens now? There is a myth that the suicide rate in this group is high, particularly if children are denied medical treatment. GIDS say that the actual rate of self-harm is no higher than other comparable groups.”

The judgment will change how children with gender dysphoria are treated – but Evans believes more understanding within local children’s services is needed.

“As soon as clinicians hear the words ‘gender dysphoria’, they refer children to GIDS, as if this is something separate from all the other issues in the child’s life. I think that what these kids need is support while they grow into adulthood. They need help before they make any permanent decisions they may live to regret.”