"I'd never thought about it that way."

Hannah Barnes’ new book, Time to Think: The Inside Story of the Collapse of the Tavistock’s Gender Service for Children, keeps spilling devastating revelations:

Less than two per cent of children in the UK are thought to have an autism spectrum disorder, but according to Gids’s own data, around 35 per cent of its referrals “present with moderate to severe autistic traits”.

In 2000, the only clinical audit of patients ever carried out by Gids found that more than 25 per cent of referrals had spent time in care, compared with 0.67 per cent of the general population. Children referred to Gids were ten times more likely than the national average to have a registered sex offender as a parent, while 42 per cent had lost a parent through death or separation, and 70 per cent had more than five “associated features” such as anxiety, depression, abuse, self-harm, bullying, eating disorders or suicide attempts.

Anna Hutchinson, a former Gids clinician who was interviewed for the book, “feared she may be contributing to a medical scandal, where an NHS service was not stopping to think what else might be going on for so many of these vulnerable children”, the author notes. Only 2.5 per cent of the children seen at the clinic had no associated problems.

I've been following this issue for a long time. It's hard to shock me. But I read this passage and my heart dropped.

These issues should have raised so many red flags for clinicians that they were dealing with something more complicated than an identity in need of affirmation.

I spend a lot of time thinking about the gender clinicians I've spoken with one-on-one. They are invariably nice—even to me, even after I express my own reservations. They all seem Midwestern to me, somehow, as though their hard edges have been sanded off by small politenesses. But I’ve been struck by their incuriosity. One doctor I met with has been working with 'trans' kids for over 10 years. As a gay man, he saw it as a moral responsibility to help kids transition. He was patient with me, despite our disagreements and his overflowing schedule. But he tensed up when he said that the pushback against gender-affirming care for kids is just like when psychiatry pathologized homosexuality. That association—deeply felt—made the cause personal for him.

I quickly pointed out several ways that the resistance to child transition is nothing like pathologizing homosexuality: that gay people wanted to be left alone, while gender-affirming care turns healthy kids into medical guinea pigs; that transgender identity often comes packaged with troubling comorbidities that can’t be explained away by the minority-stress model.

He paused. When he finally spoke, his tone was mild, without any of the passion he’d shown moments before: "Oh. I’d never thought about it that way."

I asked whether patient demographics had shifted over time and he said he never used to see ‘AFAB’’ patients and now he sees a lot of them. I asked why he thought the sex ratio would shift so dramatically. He said he'd never thought about that either.

When I look at gender-affirming care, I am struck dumb by how many things a doctor would have to not think about.

This doctor who took the time out of his busy day to speak with a critic clearly saw his work with LGBTQ patients as a calling. I could tell his heart was in it. But where on earth was his head?

And what happened after our meeting ended? I still think about our conversation, a year later. Does he? Did the questions I asked him—all those points I raised that he'd never thought about—trouble him? Or did he simply go on in the same way, as if we’d never spoken?

At the World Professional Association for Transgender Health conference—where I'd sworn I’d just observe, not interfere—I wondered what would happen if I asked the questions no one else brought up. I got the sense that the conversation would smooth over my questions without so much as a ripple. I saw how presenters packaged criticism: our critics don't understand. Parents who aren't on board don't understand. You, if you have questions, just don’t understand. If you don’t understand the imperatives, there’s nothing to say. If I'd asked my questions, I suspect they would have thought: What uninformed questions.

But who looks at such patients, who collects such life histories, and simply moves on? Who looks without seeing?