Gender Care and Untimeliness: Reflections on the Gender Identity Development Service

In the fifth post of the Waiting Times takeover, Jordan Osserman draws our attention to the ‘untimely’ nature of youth gender care.

Many people have heard many things about this place. Few ever name it in full. In the UK press and the popular imagination of the British public, it has simply become ‘The Tavistock’: a National Health Service (NHS) clinic where young people go to begin a process of medical gender transition.

The Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust.
The Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust.

For another, smaller group of people, ‘The Tavistock’ means something quite different. For those who have some relationship to the world of psychotherapy, ‘The Tavi’, as it’s affectionately called, is typically thought of as an origin point and ongoing centre of the British object relations school of psychoanalysis – a psychotherapeutic movement initially developed by the psychoanalyst Melanie Klein after the Second World War, with a particular focus on childhood development. The Tavistock is, in the minds of psychotherapeutic community, a rare example of a publicly funded clinic and educational facility oriented around a psychoanalytic approach to mental health, which prioritises sustained therapeutic work above  short-term, symptom-based treatments.

The degree to which the Gender Identity Development Service at the Tavistock, or GIDS,  functions as a psychoanalytic service is one of the things I wished to better understand as part of my ethnographic, psychosocial research at the institution. However, it soon became clear that focussing on the therapeutic modalities on offer at GIDS did not yield particularly interesting results. This was because it failed to capture something more important about the crucial and paradoxical ways that time and care intersected in this highly politicised space. What seemed important was both more basic and complex: how did the GIDS clinic carry on everyday providing a service to young trans and gender questioning people and their families whilst seemingly under never-ending siege? What kind of care happened here?

I want to begin sketching an answer to these questions through a vignette based on my observations of the clinic. I’ll end with a few reflections on what I’m calling the ‘untimely’ nature of youth gender care.

My field work at GIDS began with one crisis and ended with another: the onset of the Covid-19 lockdown in 2020 and the suddenly announced closure of the service in July 2022. In between these two events, the service face numerous additional crises, including:

  • the UK High Court ruling on Bell v Tavistock, which restricted the types of medical interventions GIDS could offer;
  • the subsequent overturning of this ruling;
  • a rating of ‘inadequate’ from the Care Quality Commission;
  • the publication of an interim independent report on gender services for young people, called the ‘Cass Report’, which led to the service’s closure.

I experienced GIDS as a site of both acute and chronic crisis.

Treatment at GIDS involves a series of ‘psychosocial assessments’ led by two clinicians and carried out with both the ‘service user’ (or person seeking treatment) and their family, over a period of months. These assessments were discussed with clinical supervisors and in weekly case discussion groups, organised by geographical region. Some assessments eventually led to a referral onto the endocrinology clinic for puberty blockers, alongside ongoing meetings at GIDS; others did not. As one clinician expressed, ‘Our party line is that we’re not providing therapy but a therapeutic extended assessment and what we think would be helpful moving forward.’

The question of whether GIDS makes patients wait too long, or not long enough, has been at the heart of public debate about the service. Whilst nearly everyone opposes extended waiting times, one position maintains that children are not waiting long enough before they are permitted to embark on medical interventions, whilst the other argues that the assessment process is excessively protracted, further delaying young people from accessing the treatment they need.[1]

All sides seem to agree that care at GIDS is never ‘on time’.

A Case Discussion Without a Case

In March of 2022, I attended one of GIDS’s weekly regional team meetings via Zoom. The meetings are structured in two parts: administrative matters, followed by a case presentation led by two clinicians and a team discussion.

In the meeting: after a long discussion regarding a new system that is meant to move people more quickly off the waiting list, someone mentions the Cass review and its uncertain implications for the service. Then, the clinicians meant to lead the case discussion, state they were happy to wait until next week to do it, since everyone is so busy. Another staff member objects: ‘I think it’s vital that we keep time for case discussions. We let this get side-lined in a previous week. I want to share, as a reflection, how difficult it is for us to keep our work – what we’re here for – central.’  The case presenters insist that they don’t think it would be helpful to present this week, which leaves  some extra time in the meeting.

Someone brings up the war in Ukraine and how it is emotionally affecting their work with young people. The team leader says: ‘Yes, I think it makes sense to speak about how we’re feeling about the war in Vietnam.’ There is a silence and then someone points out his mistake. ‘I have no idea why I said Vietnam rather than Ukraine!’ Another clinician says she tries to read the news less since the war started: ‘I feel an increasing need to be boundaried,’. Another clinician speaks for the first time: ‘I’m wondering why we’ve decided to talk about the war in Ukraine and the Cass review at the same time. The war’s been going on for a little while – why did we decide to speak about it now?’ The team leader says that the link may have something to do with hopelessness and how the young people that the team work with often feel hopeless about their gender. A clinician responds: ‘one of the things the Cass review is saying is that our service as it is, needs to end. Which is a really big thing for us all to be told. Hillary Cass said we need to go through a completely different model. Whether or not our service still has a role, or whether it’s going to disappear, is left as an open question, I think.’ Another clinician states: ‘She’s [Hilary Cass] kind of said that GIDS doesn’t need to exist – but this hasn’t actually been pointed out by the service.’ The meeting ends.

Although some might be tempted to interpret this meeting as a ‘waste’ of time, I think we can gather something more significant: a structural impossibility facing the service in relation to time. Well-meaning clinicians find themselves in a situation where making time for care is precariously balanced against shifting and intensifying administrative demands, ongoing crises, and the looming possibility of closure. An anxiety comes to fore about whether GIDS is a sufficiently caring institution – illustrated through the insistence that, whatever the workload, the case discussion should carry on. Paradoxically, time here appears both scarce (there’s too much to do, no time for discussion) and excessive (‘free’ time to talk about geopolitics). It echoes the sentiment expressed by an interviewee: ‘despite there never being enough time, at times it can feels like there’s a lot of time where nothing happens, time that we just don’t use’.

The use of therapeutic language in this meeting – speaking of the need to be ‘boundaried’, labelling criticisms as ‘reflections’, psychoanalytically interpreting the movement of their conversation to Vietnam – might appear odd, perhaps even comical. Interestingly, nobody dares interpret why the team leader said Vietnam rather than Ukraine, with the combined anti-war resonances and sense of absolute catastrophe that attend to the signifier ‘Vietnam’, but the fact of a slip is noted.

What might be at stake in this manner of speaking is the need for GIDS to see itself as caring, against all the forces that conspire to make the staff at the service feel that they fail to care. A recent open letter to NHS England, signed by 50 GIDS staff, underscores this point in its lengthy elaboration of the many forms of care – administrative, clinical, and research related – staff feel NHS England has not recognised.

The clinician’s decision to link the discussion of the Ukraine war to the Cass report was not, however, psychobabble: he correctly intuited that NHS England would employ the report to justify shutting down the service. The initial problem, which loomed over the entire meeting, was finally restated at the meeting’s conclusion: the Cass report ‘kind of said that GIDS doesn’t need to exist – but this hasn’t actually been pointed out by the service’.

Untimely care

This vignette of this meeting brings into focus what I’ve been calling the ‘untimely’ nature of everyday care at GIDS. The opportunity to grasp, in a timely way, the significance of the service’s future, as well as the care for young gender questioning people, has been missed. What remains is the disorienting sense of the persistence of chronological time – meetings and clinical sessions will begin, end, and begin again – alongside the uneven or untimely temporalities of crisis and care.

In his essay on ‘Logical Time,’ French psychoanalyst Jacques Lacan proposes three interdependent yet distinct ‘moments’ that constitute decision-making when one’s own subjectivity is at stake: the ‘instant of seeing’, the ‘time for understanding’, and the ‘moment for concluding’ (Lacan, 2006). Like all good psychoanalytic theories, Lacan’s temporality is not chronological. The ‘time for understanding’ actually concludes after the ‘moment for concluding’ has transpired. His point is that, when it comes to the self and its relation to others, there is a limit to what can be known in advance; the act itself will redefine one’s understanding of the circumstances that led to it. This is, in his words, the difficult temporality of the ‘future anterior’: ‘what I will have been, given what I am in the process of becoming’ (Lacan 2006, 247).

The uneven trajectories of gender exploration, and, from a psychoanalytic perspective, of gender itself, is intertwined with this ‘future anterior’ temporality. At what point in time has enough understanding taken place, and can enough understanding ever take place, in relation to gendered identity? Gender questioning can make care seem, in some sense, impossible. The untimeliness that GIDS is blamed for, I want to suggest, is not solely a result of NHS waiting times or service mismanagement, but also a manifestation of something untimely at the heart of gender itself, which activates cultural anxieties that are then projected onto the figure of the trans or gender questioning child. As the NHS struggles to reckon with this type of care, it seems GIDS too will need to understand itself as ‘what it will have been, given what it is in the process of becoming’.

[1] For a journalistic investigation of how GIDS has operated, see Barnes, Hannah, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children. Swift Press, 2023. The book argues that GIDS neglected to wait, or provide sufficient ‘time to think’, for both service users and their own staff.

References

Lacan, Jacques. 2006. “Logical Time and the Assertion of Anticipated Certainty.” In Écrits, translated by Bruce Fink, 161–75. London: Norton.

Lacan, Jacques. 2006. “The Function and Field of Speech and Language in Psychoanalysis.” In Écrits, translated by Bruce Fink, 197–268. London: Norton.

About the author

Dr Jordan Osserman is a Lecturer in the Department of Psychosocial and Psychoanalytic Studies at the University of Essex and is completing a clinical training with The Site for Contemporary Psychoanalysis, London. His research interests include the medical humanities, the Lacanian tradition of psychoanalysis, left wing politics, and gender/sexuality studies. Jordan’s current research involves an ethnographic study of the UK’s only publicly funded clinic for children seeking gender care. His book, Circumcision on the Couch: The Cultural, Psychological, and Gendered Dimensions of the World’s Oldest Surgery was recently published with Bloomsbury Press.

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