Vol. 43 No. 24 · 16 December 2021

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The Black Box

It is rare for an account of the Gilbreths to give too much credit to Lillian – typically, her contributions are attributed to her husband, Frank Bunker. But Tom McCarthy’s piece on the ‘black box’ seriously overestimates Lillian’s involvement in the technical side of motion studies (LRB, 18 November). Lillian and Frank were equal partners in their industrial consultancy, Gilbreth Inc., founded in 1911, but Lillian’s contribution was more on the psychological side.

The thing that distinguished the Gilbreths’ brand of scientific management was that it tried to create non-economic incentives for workers’ co-operation. Unlike Taylorism, which focused on time and speeding up work, the Gilbreth system focused on motion studies, such as cyclegraphs or micromotion films. The supposed virtue of these techniques, mostly developed by Frank, was that workers could learn less fatiguing and more fulfilling ways to do tasks.

The Gilbreth system also gave workers and unions a say in workplace changes, introducing suggestion boxes, employer/employee boards, rest facilities and home reading programmes. It was Lillian who created these schemes. While conducting her doctoral studies in experimental psychology, she had introduced the idea of the ‘human element’ into their practice. The idea that the worker was ‘a personality’, not an economic unit, underlay her book The Psychology of Management (1914), now seen as a foundational text of industrial psychology.

After Frank’s death in 1924, Lillian carried the financial burden of putting their eleven surviving children through college. She initially tried to keep Gilbreth Inc.’s well-paid industrial consultancy work going, reassuring clients she could do anything Frank had done – except cyclegraphs, which were fiddly and expensive to produce. But clients proved unwilling to set a ‘lady engineer’ loose in their factories. Capitalising on the media interest in her large family, Lillian transformed herself into a domestic expert instead. Nothing amused her children more. As two of them chronicled in their bestselling memoir, Belles on Their Toes (1950), Lillian did not, in fact, know how to cook.

Off the back of this work, however, Lillian was able to re-establish her career and carried on in consulting and academia for another four decades. As McCarthy notes, it was during this period that she did her most consequential and lasting work, on civilian rehabilitation, which is credited with having laid the ground for inclusive design today.

Barbara Penner
University College London

At the Tavistock

As the author of the ‘damning internal report’ referred to by Bernadette Wren, I was one of several people to draw attention to concerns about the Tavistock Gender Identity Development Service (LRB, 2 December). In 2018, between a quarter and a third of the staff working in GIDS sought me out in my role as academic and clinical staff representative on the Tavistock and Portman NHS Trust’s council of governors.

Wren writes that any ‘genuine disquiet’ about failings at GIDS should have been reported ‘through the institutional channels that exist to oversee and regulate clinical work’. But it was. And there’s no question that it was ‘genuine’. Before members of GIDS staff approached me, they had already raised their concerns with their managers; with the trust’s Speak Up guardian; with Sonia Appleby, the trust’s child safeguarding lead; with the trust’s medical director and with the CEO. It was clear that they had been intimidated and sometimes threatened and were anxious about the repercussions of approaching their staff representative.

This climate of intimidation was not recorded in the Care Quality Commission report of 2016, to which Wren refers, but it is spelled out clearly in the commission’s report of 2021, of which she makes no mention. CQC 2021 also rates GIDS as ‘inadequate’, the lowest rating a healthcare provider can receive. Intimidation at GIDS was confirmed by the findings of an employment tribunal in September, which awarded Appleby £20,000 and criticised the trust for mishandling the issues she raised, including the active encouragement of young children to transition ‘without effective scrutiny of their circumstances’. For the record, the trust also tried (unsuccessfully) to prevent my report going before the governors and initiated disciplinary proceedings against me.

The escalation of referrals to GIDS – from 138 in 2011 to 2748 in 2019-20 – led to enormous pressure on the service, with children and young people (CYP) being put on a procedural pathway without the possibility of comprehensive clinical assessment; GIDS became a gateway to medical intervention. Patients and often their families felt it was their duty to give the ‘right answers’ in consultations in order to secure a prescription. As the staff representative, I heard from many members of the GIDS team that they were accused of transphobia when they raised questions about children being started on puberty blockers.

In the young patient group that GIDS took on, there is significant co-morbidity. Autism rates vary from 15 to 30 per cent, and there is strong evidence of depression, severe family problems and historical trauma: for example, sexual abuse in the maternal line, triggering dramatic conflicts around sexuality that are transmitted to the index child. Many CYP who came to GIDS were gender non-conforming gay or lesbian children. For a number of reasons, including pressure from family and peers, they could not accept their sexuality and developed an internalised homophobia, manifested as hatred or rejection of their sexual bodies – a devastating condition, including for the clinician faced with it. Yet sexuality and sexual orientation were largely under-discussed in the service, having been displaced by an overriding preoccupation with gender. I still stand by lesbian and gay GIDS staff whose concerns about under-explored medical transitioning in these children were summarily dismissed within the service.

Wren alludes to ‘subsequent feelings of regret’ on the part of patients who have transitioned. Detransitioners are a rapidly growing group, many of them young lesbians and gays, who now ‘regret’ the irreversible damage to their bodies, as in the case of Keira Bell (no relation, contrary to rumour), and the consequences of assessments which affirmed, rather than explored, the nature of their gender dysphoria. There is in any case much concern about the effects of puberty blockers on bone, brain and psychological development. In the early days of GIDS, most children desisted. Now 98 per cent move on to opposite sex hormones (with irreversible consequences, some known, others not), while an unknown proportion go to surgery.

Bell v. Tavistock, the judicial review Wren refers to, raised serious criticisms of GIDS governance: lack of follow-up, absence of data on co-morbidity or on how many patients were proceeding to surgery. But the judgment itself was confined to the issue of consent, and the judges determined that CYP were not in a position to consent. When the Court of Appeal overturned this judgment in September, it did not give an opinion on whether CYP can or cannot consent. Instead it took the view that the Divisional Court lacked the authority to reach such a judgment. By analogy, if a court finds that an official who had issued a traffic fine had no authority to do so, this would have no bearing on whether or not the offence had been committed.

The case in the Family Court that Wren discusses also turned on the question of consent, on this occasion that of the parents. As Wren explains, Justice Lieven ruled that court authorisation was not required if the parents consented – and the clinician and child agreed – to treatment with puberty blockers. In Wren’s view, this ruling ‘implicitly confirms that prescribing puberty blockers to under-16s does not constitute harm or risk of harm to the child’. I don’t agree. And neither did Justice Lieven, who was also one of the judges who heard the judicial review. She made it clear that the nature of a Family Court hearing, in which no opposing side of the argument is put forward, limited the scope of her judgment. ‘All parties agreed,’ she stated, that ‘I was in effect bound by Bell’ – i.e. Bell v. Tavistock – ‘and that they were not seeking to argue before me that any part of it was wrong … I should be entirely clear that even if I was not in effect bound by Bell, I self-evidently entirely agree with its analysis and conclusions, having been one member of the Divisional Court.’ Nothing in her judgment, she stated, ‘is intended to depart, to even the smallest extent, from anything that was said in Bell’.

David Bell
London NW3

I worked at the GIDS clinic in Leeds for twelve months in 2017 and 2018. On one occasion I watched a mother sob after I informed her that her young teenager had ‘consented’ to my colleague’s offer of puberty blockers. The child’s father, a man with a bad temper who made me feel uncomfortable, was pleased. Going along with it, and seeing that mother cry because she knew she couldn’t object, will always be a stain on my conscience. It was not a complicated philosophical question about working on ‘the edge of knowledge’, as Bernadette Wren puts it, or whether children should have ‘full freedom … to make their own mistakes’. What I did – or rather what I failed to do – at GIDS was wrong and I’m ashamed of it and wish I could go back in time and do the right thing.

Wren claims there was nothing clandestine about GIDS’s approach, but some parents were arriving with the impression that we might just as easily disconfirm their child’s trans identity as confirm it – and I knew that clinicians didn’t disconfirm. In 2019, almost a year after I left, I wrote in an open letter to parents who might be arriving at GIDS: ‘There is some unspoken rule that means GIDS clinicians do not tell families, “Your child is not transgender.”’

What’s more, in my personal experience, many of the parents arriving at the GIDS Leeds service were somewhat sceptical about their child’s transgender identity. They weren’t pushing for medical interventions, but seemed to be either ‘trusting the experts’ or anticipating that GIDS clinicians would confirm their doubts. It was clear to me that these parents were not connected with one another in the same way that the minority of parents who arrived at GIDS demanding puberty blockers at the first or second appointment were (they were usually in Mermaids). In no other psychology service I have worked in would a parent who shouted at and intimidated a clinician be ultimately rewarded for doing so, but that did happen at GIDS.

Kirsty Entwistle
Guimarães, Portugal

Bernadette Wren writes: David Bell and Kirsty Entwistle have strong, uncompromising beliefs about the wrongness of medical intervention with gender-diverse young people. They seek to persuade others of the absolute illegitimacy of the work of GIDS. I have been exposed to their critique for several years now, yet I still find their tone both wounding and dismaying. I see their accounts as a mélange of truths, half-truths and speculation, plausible as well as suspect readings of certain facts and figures, and painful emotional reports. It is quite likely that they would characterise my own narrative in similar terms.

One claim in David Bell’s letter cannot go without comment. Currently, he writes, ‘98 per cent move on to opposite sex hormones.’ It is true that in one published study of a small, highly selective group of young people with severe and long-standing gender dysphoria persisting into adolescence, 98 per cent of those who started on puberty blockers proceeded to cross-sex hormones at sixteen. The bigger picture, however, is that of the cohort of children and adolescents discharged from GIDS in 2019-20, only 16 per cent had been referred to the endocrinology team. Of those, just over half (all of them over sixteen) went on to cross-sex hormones with GIDS – less than 9 per cent. The others did not start hormone treatment, or they aged out or stopped. Some of these patients may go on to receive the treatment as adults.

Like Bell and Entwistle, I tried to be truthful in my piece, although I too omitted many details and my perspective on some events is, like theirs, limited and partial. But I did try to write in a different register. I painted a picture of the generality of GIDS staff, on all sides of the matter, as thoughtful, ethically attuned, fallible, painfully conflicted and deeply troubled by the rapid change in the profile and number of referrals and the fervid tone of a very public debate. I suggested that most GIDS staff, however much at odds they were on some issues, could agree on others, such as the impossibility of providing ample psychosocial support for many of these young people, the need for CAMHS and other agencies to get more fully engaged, and the importance of a focus on past history, family dynamics and the body in exploratory work. What I cannot bear – and this is what prompted me to write the piece in the first place – is the portrayal of the large part of GIDS staff as heedless, neglectful, unprofessional and even downright cruel.

What I hoped to convey was that single-minded, uninflected proselytising, expressed in an antagonistic idiom, lacking any demonstration of respect for one’s opponents, is getting us nowhere. It does not serve well the young people whom GIDS is still obliged, indeed still entrusted, to support. And it has no regard for the welfare of the existing GIDS team, many of whom are lesbian, gay or queer. In my piece I criticised the trust’s management, NHS England and some senior critics at the trust for their failure adequately to support the service. I called out their limited vision – limited in different ways – of the broader context of the problems with which GIDS was grappling. I also identified the unapologetic ‘capture’ of critical GIDS clinicians by obdurate senior allies, rendering impossible any kind of constructive, critical, well-supported and ethically guided examination within the institution of what the service was facing and what it was doing.

We all know, sadly, that exchanges in the letters column of a literary journal are not an adequate replacement for those lost opportunities for interpersonal processes that should have been the lifeblood of an institution like the Tavistock.

We’re Here

Neal Ascherson writes that Idi Amin expelled Uganda’s Asians ‘following the instructions he’d been given in a dream’ (LRB, 18 November). In fact, the policy had been developed and announced by his predecessor, Milton Obote, and the British had been negotiating over it for a couple of years before Amin’s coup. Amin discussed it with Home Office and Foreign Office ministers and senior civil servants during his visit to Britain shortly after seizing power, some months before the ‘dream’.

The story about the dream was initially promulgated by Amin himself, probably to give supernatural legitimation to the expulsion policy and so that it would be associated with him rather than Obote: it was very popular with most Ugandans and would probably have been carried out by any plausible Ugandan government at the time. Unsurprisingly, Edward Heath’s administration wasn’t keen to have its negotiations made public, and enthusiastically promoted the idea that the Asians were expelled because Amin was mad.

Mark Leopold
Hove, East Sussex

At Netherne Hospital

Clair Wills mentions Eric Cunningham Dax, who as medical superintendent at Netherne Hospital set up art therapy programmes alongside experiments with leucotomies, lobotomies and EC treatment (LRB, 18 November). Dax’s Australian career is a remarkable sequel to this history, beginning when he became the first chair of the Mental Hygiene Authority in Victoria in 1951. On arrival in Melbourne, Dax found that he shared an interest in art therapy with two other émigrés, the Bauhaus artist Ludwig Hirschfeld-Mack and Oscar Oeser, who held the chair in psychology at Melbourne University between 1946 and 1969. They crossed paths in 1954 at a Unesco conference on art education held in Australia. Oeser had translated Victor Lowenfeld’s book The Nature of Creativity (1939) and cited Anton Ehrenzweig’s The Psychoanalysis of Artistic Vision and Hearing. Hirschfeld-Mack had built long-standing relationships with Melbourne’s psychiatric institutions through his interest in child’s play. Neither shared Dax’s belief that mental illnesses had organic causes.

Today, Dax’s legacy is uncritically celebrated by the Cunningham Dax Centre at the University of Melbourne, whose website announces: ‘The Dax Centre was established in honour of the mental health pioneer Dr Eric Cunningham Dax, who was a psychiatrist who saw the value and potential of art programmes and art-making for people with a lived experience of a mental health issue.’ The university also houses major collections of Oeser and Hirschfeld-Mack, which reveal different, more complex legacies for the social role of the visual arts in education and the treatment of mental illness – but their work cannot be so readily tied to the current agenda of ‘wellness’.

Ann Stephen
University of Sydney

Clair Wills’s account of growing up at Netherne Hospital in the late 1960s and 1970s chimed with my experience of working at Friern Hospital as a young clinical psychologist in the early 1980s. Such institutions provided young clinicians with an education in the chronic nature of mental illness, of care rather than cure, even if the quality of care was often not what it should have been.

Friern opened its doors in 1851 as the Colney Hatch Lunatic Asylum, and in the library was the admissions book from those first years, recording diagnoses and reasons for admission. These included ‘depression from the death of a cow’ and ‘overexcitement at the Great Exhibition’.

Noel Hess
London NW3

Climate Emergency

Francis Gooding’s conflation of direct action with armed struggle will not help the movement for climate justice (Letters, 2 December). His discussion of the arguments leading to the ANC’s turn to armed struggle overlooks the fact that it wasn’t this struggle, but the unarmed direct action of mass movements, which made the largest contribution to the ANC’s eventual success. Indeed, as Erica Chenoweth and Maria Stephan show in Why Civil Resistance Works (2011), non-violent action has consistently been more effective than violent action in achieving change. There is every reason to believe that this will hold for climate activism, too.

Martin Shaw
Seaton, Devon

Mrs Gilroy

Michael Hanks points out that the Nippers series of early readers, which included a number of stories by Beryl Gilroy, was created and edited by my mother, Leila Berg (Letters, 21 October). The stories by Beryl in the series are hard to find, but there are three of them in the archive of Rosemary Stones, which is kept at Seven Stories, the National Centre for Children’s Books, in Newcastle upon Tyne. If anyone has redundant copies of any of the Nippers stories, they might consider supplementing the collection in the Leila Berg archive at Seven Stories, which presently has only about half the total of approximately 120 published titles.

Daniel Berg
Lismore, New South Wales

A Pedunculate Oak

Fergus McGhee writes about Arthur Hugh Clough (LRB, 18 November). His name is familiar to many through its association with a tree – the Arthur Clough Oak. This has long been identified (rightly or wrongly) as the tree that forms a central symbol in Matthew Arnold’s poem ‘Thyrsis’, which was written in memory of Clough.

That single elm-tree bright
Against the west – I miss it! is it gone?
We prized it dearly; while it stood, we said,
Our friend, the Scholar-Gipsy, was not dead;
While the tree lived, he in these fields live on.

Arnold refers to the tree as an elm, but it seems to be firmly associated with an oak tree on Boar’s Hill, near Oxford. It has also been known as the Umbrella Tree (reflecting its form at the beginning of the last century), and as the Signal Elm, under which name it is listed in the Ancient Tree Inventory, notwithstanding the fact that it is identified as a pedunculate oak.

The tree is familiar to arboriculturists because it has been repeatedly photographed for more than a hundred years, the series of images frequently used to illustrate the process of ‘crown retrenchment’, whereby an old tree dying back at the top can regenerate a new crown lower down, a process of not quite immortality that Arnold would no doubt have been pleased to associate with his friend Clough. The tree lives to this day.

Jerry Ross
Llangarron, Herefordshire

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