Luke was a teenager, but sometimes he suffered from hot flashes so intense he felt faint.

His bones ached. Sitting on the edge of his bed, he twisted repeatedly to relieve the pain in his back, which “feels like it could snap in two.” The discomfort was like having an illness, he says, except he was not sick. Instead, he was suffering from the side effects of puberty blockers—a drug that suppresses the estrogen his body would otherwise naturally produce. Luke was supposed to be on the blockers for a year, part of a mandatory thinking period for minors before they can be prescribed genderaffirming hormones through the United Kingdom’s National Health Service. That deadline, like others before it, had passed. When I first met him, he was 17, and he had been waiting six years for care.

Luke is one of thousands of young people in the U.K. living in limbo, casualties of a battle being waged in the media and the court system over the Gender Identity Development Service, a division of the NHS that performs psychological assessments for gender-diverse youth. The fight has divided British mental-health professionals: On one side are clinicians who believe if a child says they’re trans, they’re trans—and they have the right to puberty blockers and hormones.

A small group, however, has sued to force gids to adopt a more conservative approach and withhold medical interventions. Their aim, they say, is to prevent young people from making decisions they might regret. The case they brought, Bell v. Tavistock, continues to play out in the British courts, but the repercussions are already being felt. For almost a year, gids was brought to a near standstill. After an early court decision, no gids patients were referred for gender-affirming hormones, and today, roughly 5,300 young people are on the waiting list for a first appointment, with an expected wait time of 23 months.

“I was in an absolutely terrible place because I couldn’t cope with waking up and things being the same every single day,” Luke says. He socially transitioned at age 12, the same year he was diagnosed with gender dysphoria. He has been binding his chest for so long that he barely thinks about it anymore. To boost his five-foot-four frame, he often walks in black lace-up boots with a chunky heel. (They also look cool.)

He is now in his final months of secondary school. When the academic year started, his hope was that he could go on testosterone before university. “To see the treatment there and be running toward it, and it moves at the same pace as you away from you—coming to terms with that is the hardest thing,” he says.

In places with a more progressive approach, such as the Netherlands or some parts of the U.S., Luke could have gone on blockers as early as age 12, preventing breast growth and menstruation. If he had continued on to hormones, he would have experienced a male puberty alongside his peers. But in the U.K., that path was closed to him.

There are signs that the debate in the British courts has found an audience in the U.S. Last month, Texas governor Greg Abbott ordered state agencies to investigate parents of children who medically transition for child abuse. In his written opinion supporting the order, Texas’s attorney general cited arguments from Bell v. Tavistock. Nationwide, right-leaning lawmakers proposed 43 bills last year aimed at preventing minors from accessing gender-affirming care.

As the lawyers and legislators fight, countless gender-diverse young people are caught in the middle. Without access to blockers, some of them are forced to go forward with a puberty that doesn’t align with their gender, producing irreversible changes that can only be corrected with painful and expensive surgeries later on. In the meantime, governments and health authorities seem further than ever from reaching a consensus on the best kind of care for trans kids. So Luke and his peers wait, month after anguishing month.

UNTIL HE TURNED 10, Luke (who asked to be identified by first name only) never thought much about his gender. He was, by his own telling, “a very, very girlie girl.” His mother, a caretaker in a residentialcare home, and his father, an engineer, never suspected that he might be grappling with his gender identity—and for the first decade of his life, he wasn’t. “I had quite a balanced upbringing,” says Luke, who now lives about two hours outside London with his mother and 14-year-old brother. (His parents separated when he was 7.)

With the onset of puberty, however, Luke began to feel disoriented in his body. He was particularly bothered by his hips. When he looked in the mirror, it was almost like staring at someone who’d had botched plastic surgery, he says. Instead of seeing minor curves, the reflection was like looking at “a badly done caricature, like Betty Boop.” Luke discovered that dressing in masculine clothes made him feel a little bit better, so he started wearing tracksuits.

At age 11, he discovered videos about gender dysphoria on YouTube, made by people whose experiences matched his own. After watching videos by Jamie Raines, a British man assigned female at birth who documented his medical transition online, “I eventually settled on what I was,” says Luke. He had his long brown hair cut off and told his mother that he was, in fact, a boy. A few weeks later, he told his father, too.

He eventually decided he wanted to be called Luke and use male pronouns. His father covered up a tattoo on his hand of the name they’d given Luke at birth, which Luke saw as an act of love. “He’s not superemotional, but that was his physical action, like, showing a lot of acceptance,” he says.

Luke’s mother took him to see a general practitioner to discuss starting a medical transition; that doctor referred Luke to a specialist who, over the course of several appointments, diagnosed him with gender dysphoria, which meant he was feeling dis

tress over his gender identity and body not aligning. (To be transgender is not necessarily to have gender dysphoria: the latter is a medical diagnosis; the former is not.)

In the early aughts, a protocol developed at the Amsterdam Center of Expertise on Gender Dysphoria to help dysphoric children began to gain traction. Researchers found that they could alleviate their depression by halting puberty at a relatively early stage (often around age 12, but earlier in some kids) using drugs that had, for decades, been prescribed to children with precocious puberty (when puberty starts too early, sometimes as soon as age 8). These puberty blockers prevented sex changes driven by adolescent hormones: Transfeminine kids could avoid developing an Adam’s apple and a deep voice, for instance; transmasculine kids could stunt breast growth. At age 16 (though sometimes younger), according to the protocol, those patients could choose to start on estrogen or testosterone. At 18, they could consider surgery.

Shortly after his appointment with the specialist, Luke learned that in order to access blockers and perhaps eventually hormones, he would still need to be separately evaluated by gids clinicians. In September 2016, two months before his 13th birthday, Luke received his referral. He was told it would be roughly ten months until his first appointment. Then the letters began arriving. “I’d probably get a letter every four months telling me that the waiting list has been extended. Basically, you move forward a month and then you move back a month,” he says. During this time, “there were no checkups, nothing like that” to help Luke with his gender dysphoria.

To cope, Luke tried to alter his body on his own. He began binding his chest, first using “really rubbish” binders he’d ordered on Amazon before finding one that didn’t hurt quite as bad. He Googled ways to deepen his voice, none of which worked, and lifted weights in the hopes of broadening his shoulders. He began menstruating, and his depression worsened. “I was getting really desperate,” he says.

As his male peers began to physically mature around him, Luke felt stuck in place. “I was basically paused sounding like a teen girl,” he says. “Mentally, it created a conflict because my personality got forced to develop in order to cope with the circumstance, but I still had to inhabit a body that made me feel really immature and disconnected from myself.” Even though he’d once loved performing, he gave up theater when his classmates’ voices changed and his didn’t; he stopped doing gymnastics when he became hyperaware of the differences between his body and those around him.

Luke considered using GenderGP, a telehealth service registered in Hong Kong that could potentially prescribe him blockers and hormones. The service has become popular with transgender people in the U.K. frustrated with the slow pace of the NHS. “It’s what everyone goes on,” says Luke. But the fees were expensive, and his family couldn’t afford it.

Meanwhile, his first appointment with

gids kept getting pushed back. The initial ten-month period became 18 months, then 22 months. Finally, he received a letter with a firm date. By then, he was almost 16 years old—the age at which young people in the U.K. are eligible for gender-affirming hormones. “I thought, Okay, I’ll go and get interviewed. They’ll see that I’ve been living as male for about four years, and they will put me on hormones because I’ve wanted it for a long time,” says Luke. At first, the letter felt like a winning lottery ticket.

WHILE LUKE WAITED YEARS

to be seen by gids, a rift was developing within the organization. In 2014, the service’s leadership adopted the protocol developed in Amsterdam, but some clinicians objected that

gids was pushing patients toward blockers and hormones too quickly. They began voicing their concerns internally, arguing for a greater commitment to therapy for patients with gender dysphoria.

They were calling, in a sense, for a return to the organization’s roots. gids was founded in 1989 by Domenico Di Ceglie, a psychiatrist at St. George’s Hospital in London who wanted to create a place for young patients to explore their gender identities. It was one of the first clinics in the world dedicated to helping children with gender dysphoria. In 1994,

gids was moved under the umbrella of the Tavistock, the talk-therapy arm of the NHS. It had “three or four staff in a tiny office” and saw as few as 50 patients a year, says Bernadette Wren, a retired consultant clinical psychologist and family therapist who started at gids around that time.

Almost 20 years later, gids was still seeing only 300 or so patients a year. But then, in 2016, the organization made it easier for doctors to refer patients to them, and by 2018—the year Luke received notice of his first appointment— that number had jumped to 2,500. (Most patients are seen at the Tavistock clinic in London, although gids operates a smaller clinic in Leeds and has outreach sites in Bristol and Birmingham.)

As the numbers grew, patients and their parents began arriving at gids already aware of blockers and hormone therapy, says Wren. gids director Polly Carmichael and some of the senior members of her team supported the gender-affirming model, but other clinicians were startled by the number of patients demanding medical interventions right away. They had trained as psychoanalysts and family therapists and came to the service expecting to do long-term therapeutic work.

(gids’ most recent data shows that patients averaged ten appointments before moving on to hormone therapy. Carmichael did not respond to interview requests.)

Anastassis Spiliadis, a psychotherapist and psychoanalyst who worked at gids from 2015 to 2019, says that at times, he felt like “the only thing that the service was offering was a medical approach.” Spiliadis was alarmed when, he says, Carmichael told clinicians not to bring their concerns to the service’s child-safeguarding lead. (A spokesperson for gids denied this, but evidence presented before a tribunal investigating the matter backs up Spiliadis’s account.)

When the gids clinicians in favor of a less medicine-focused approach felt their objections weren’t addressed by management, ten of them (from a staff of around 70) shared their worries with David Bell, a high-ranking psychiatrist and former president of the British Psychoanalytic Society who had been at the Tavistock for more than 25 years. Bell worked with adults and was not affiliated with gids, but he was a staff representative on the Tavistock Council of Governors, which meant he was elected by employees to make sure they have a voice in how things are run.

He was also not a neutral sounding board. He says that gids always made him “uncomfortable,” and that while he supports an adult’s right to medically transition, in his view, minors “can’t make that kind of decision.” He was skeptical of the idea that someone could be born trans. “Over time, you develop a gender identity, which is probably quite early on in life, but it’s not assigned at birth,” he says. “There isn’t a gendered soul.”

Bell, who is 71, suspects clinicians came to him because “I had a reputation, I think, of being the kind of person who wasn’t scared to say what he thought.” In his conversations with clinicians, “the most important thing was that they felt, or they

“Seeing girls my age starting to look very curvy and like women, and knowing I was technically on the same playing field as them, that was really frightening.”

believed, that the children referred to the service were not adequately cared for and were in danger of being motored on an inappropriate pathway, which would have irreversible consequences, without sufficient thought,” he says.

In the summer of 2018, Bell wrote a report on the clinicians’ concerns and submitted it to the Tavistock Council of Governors. “Dr. Bell kind of ran away with it and wrote a report that was full of his own criticisms,” says Wren. He used “very, very extreme language, implying senior staff were harming children.”

The 55-page report, which includes lengthy, anonymous testimonies from

gids clinicians, was damning for gids management, going so far as to assert that the service is “not fit for purpose” and that “children’s needs are being met in a woeful inadequate manner.” Bell pointed to unmanageable caseloads, “an excessively affirmative attitude” that he attributed to external political pressures, ethical questions around consent, systemic homophobia among staff and parents (one clinician said some parents would rather their child be trans than gay), and inexperienced clinicians tasked with complex cases.

Bell called for an overhaul of gids. If the concerns he raised weren’t acted upon, he warned, there could be long-term, damaging consequences for the service’s patients, and the reputation of the Tavistock would be “very seriously at risk.”

IN THE FALL OF 2018, just a few months after Bell submitted his report, Luke got ready for his first gids appointment. It had been four years since he socially transitioned. He had partially gone through puberty by then: His hips and breasts were developing, his body taking a shape that made him uncomfortable in his own skin. But he was no longer menstruating, after his general practitioner put him on what he believes were birthcontrol pills. Luke says that intervention, at least, had been helpful; it ended what had become a monthly crisis. “I’d just have a nagging feeling in my head, like, You’re actually an idiot. Look, you’re clearly a woman. You’re clearly going through this. You’re not what you think you are,” he says. “It’s a very oppressive feeling because it’s your own body against you.”

Still, the pills “didn’t make everything okay,” he says. Luke got upset looking at photos of himself before puberty, when his body was “genderless,” what he describes as a blank canvas—when “it could have gone another way, but it didn’t.” He stopped going to gym class. He avoided parties. As his classmates started to look more like adults, Luke oscillated between two states of panic. Sometimes, it was like he was on a train he couldn’t jump off, barreling toward womanhood while knowing he was male. (“Seeing girls my age starting to look very curvy and like women, and knowing I was technically on the same playing field as them, that was really frightening,” he says.) Other times, he felt trapped, unable to move forward without the testosterone he needed.

His experience stands in contrast to that of transgender minors with easier access to hormones. In December, I sat down with Jason (who asked that his name be changed to protect his privacy), a 16-year-old in the U.S. who came out as transgender in the eighth grade. He started on testosterone shortly before his 14th birthday, and at 15, he underwent transmasculine top surgery. He’s now having the high-school experience he imagined. He plays on the boys’ lacrosse team and doesn’t have to worry about taking off his shirt in the locker room; in fact, most of his teammates don’t know he is transgender. Sometimes, “I’ll be at a party talking to a girl, and I’m like, Oh, this is so normal,” he says.

For Luke, the moments of normality arrived rarely, but he did his best to find his comfort zone. Over time, he grew his hair into a proper male shag and replaced the tracksuits with thrift-store finds, silk scarves, and patterned shirts (very ’70s Mick Jagger, though Luke was particularly inspired by Queen). He tried to focus on the positives of his body—that he was lean and not particularly curvy and didn’t have a high voice. It was much harder for transfeminine people stuck in the same waiting process, he suspected. His friend, who was assigned male at birth, couldn’t access blockers or hormones either. Over the span of several months, her voice broke, she shot up to five-foot-ten, and her shoulders broadened. “That is, like, a real dire thing because those few months determine the rest of your life if you are male to female,” says Luke. When he looked at himself, he simply saw a boy who was a late bloomer.

For his gids appointment, Luke drove with his mother to the service’s satellite office in Birmingham. It didn’t look like much, just some chairs in an otherwise empty waiting room, but Luke was elated that he was about to see the specialists who could change his life. “We were really excited to be moving forward and talked a lot about how far we had come,” says Luke.

When two gids clinicians came in to talk with Luke and his mother, he expected that they’d quickly go through his history and start discussing medical options. Instead, “it was a very kind of vague check,” says Luke. “They were just like, ‘How old are you? How do you feel? When do you feel it?’” Most of the questions focused on the past year—if he’d felt more like a girl or a boy, if people treated him like a girl or a boy, if he felt his life would be better as a boy. They ended the meeting by handing him forms to fill out and said he’d need to come in for a total of four to six appointments. Luke soon found himself back in the car, somewhat bewildered, thinking, That’s it?

Unlike the fast-paced care outlined in the Bell report, Luke’s experience with gids was maddeningly slow. He wasn’t yet caught up in the consequences of the court fight to come—the delays came instead from an overburdened service and the very thing the Bell report wanted more of: a staff invested in talk therapy, with no rush to prescribe blockers or hormones.

Luke tried to stay positive, telling himself it was a start. Now, there was a clinician on his case and he was moving forward, at least incrementally. “First appointments are often introductory,” he figured. “I’ll come back next week, and we’ll start talking about my treatment.”

It was a couple of months until he was seen again. During the next appointment, Luke and his mother kept saying the same things over and over—that he’d been living as a boy for years and that he’d been interested in gender-affirming hormones for years as well. He already had a genderdysphoria diagnosis and had been seen by a general practitioner and a mental-health

professional. Luke had assumed that because gids clinicians were gender specialists, they would read his file, get consent from both Luke and his parents, and move him on to an endocrinologist who could administer the hormones.

By the third appointment, emotions were running high. One of the forms he was told to fill out asked if Luke thought of himself as a hermaphrodite, which he found offensive and outdated. He was similarly upset when a clinician challenged him on why he had never had a romantic relationship. Luke explained that he was too uncomfortable in his body to connect with another person on that level. “I can barely hug my family because it makes me so hyperaware of my body—that’s why I’m here,” Luke, who is bisexual, told her. He says that the clinician pushed back, stating that plenty of transgender teens are in relationships. In the same conversation, the clinician mentioned that Luke had said he sometimes wore eyeliner, and wasn’t that kind of experimental for someone who wanted to be perceived as male? Luke’s frustration grew. “It’s a bit of eyeliner. It’s not that deep.”

“She really had a complete lack of understanding that transgender people are different, not everyone’s the same,” Luke says. “I was saying to her, ‘For me, it’s a very biological thing. For me personally, I could dress in feminine clothes and I would be fine as long as my chest was flat and my hips were narrow.’ And she was like, ‘What? What? You can’t do that.’”

The appointment became a turning point for Luke and his mother. Until then, they’d been confident that they were on the path to starting his medical transition. But time was slipping away—by then, Luke had turned 16, the age he’d hoped to start his male puberty. A student in the grade above him at school, who had come out as transgender years after Luke, had paid for private care and was already on hormones. Luke’s younger brother was starting to go through puberty as well. It was as though everyone was passing him.

The real bombshell came in a later appointment, when (Continued on page 87)