The “Dutch Protocol” and impact on ROGD adolescents

[rogdmum]

This is a bit niche but for those of us directly impacted by treatment for gender distressed/gender dysphoric young people, it’s great news.

Put simply, the Dutch protocol is how we ended up with the Tavi not differentiating between the old cohort of male adolescents who had identified as the opposite sex from a young age and persisted into adolescence. This group was the target group for the introduction of puberty blockers. They were seen to be mentally stable with little evidence of underlying issues (am generalising here, but you’ll get the point). As the cohort started to change over recent years to more adolescent girls who had not shown any signs of gender distress as children and who were presenting with a number of underlying issues, the protocol was equally applied to them as well- no questioning was made if the protocol was suitable for them as well.

This is now being questioned by the author of the original study and it is suggested that differing paths including where mental heath support might be more appropriate.

twitter.com/zaneemma/status/1309517727598481409?s=21

Link to paper: pediatrics.aappublications.org/content/early/2020/09/17/peds.2020-010611

“ This raises the question whether the positive outcomes of early medical interventions also apply to adolescents who more recently present in overwhelming large numbers for transgender care, including those that come at an older age, possibly without a childhood history of GI. It also asks for caution because some case histories illustrate the complexities that may be associated with later-presenting transgender adolescents and describe that some eventually detransition”

Thank you for posting this. I’m sorry to say it but I feel a bit cynical about this. Could it be that these Dutch medics are thinking mainly about their reputation, along the lines of “what a disaster - and we will forever be associated with this?” A reverse ferret, trying to save their bacon? The Netherlands are an odd country in many ways, individualism reigns supreme and they also allow child euthanasia.

Personally, I think the idea of paediatric transitioning is always questionable, even with male children who exhibit ‘gender issues’ early on. Does non-conformity to stereotypes ever require serious medical intervention? Can they categorically say that even in this older cohort, there were never any issues such as loss of IQ, bone density or regret? Even one detransitioner is one too many and I suspect what is happening here is medics trying to protect their original ‘invention’ when the entire practice is flawed and should be outlawed. Children cannot consent to this kind of radical treatment, no matter how much they might want it. There is also too much scope for parental interference (‘gay eugenics’), IMO.

”One year ago, the Radboud UMC Amalia children’s hospital in Nijmegen responded to a call from the ministry to help get rid of the enormous waiting list in Amsterdam. About 175 children have been seen in Nijmegen since the start. 30 percent of them received puberty blockers after a series of interviews.”

Given that it is well documented that 80% of children traditionally presented at gender clinics will desist if allowed to go through puberty, then if 30% of this new cohort are put on puberty blockers, either they ought to be very certain that the new cohort are significantly less likely to desist, or they are knowingly putting a percentage of children on a medical pathway that they are fully aware will cause significant harm.

Thanks for the update.

I fear how much time it's going to take to unpick all this globally.

Worth remembering also that the entire idea of childhood transition has been justified by better ‘passing’ in adulthood. Who actually benefits from this? Certainly not those who support more non-conformity. It protects the sensitivities of those who are disturbed by an obviously male person acting in feminine ways, and it relieves those who want to pass from having to be honest about their history. I find that problematic.

There's a video on youtube with an American endocrinologist saying that this all went badly wrong when medical practitioners decided to combine the Dutch Protocol with the affirmation approach. In his view the Dutch Protocol was only supposed to be applied with a significant psychiatric intervention.

I believe it's this video but am not sure:

That must be a worrying position for Steensma - if his research is being misused to justify treatment.

Tbh if his research wasn’t there I’m not sure it would make much difference - they would just rely on the WPATH standard which as I understand are fairly loosely based on research or reality.

It is good that he is adding his voice to the concerned professionals, especially as he is an expert in this area.

I think we can return to the question of ‘where were all these girls 20 years ago?’ It can’t be a lack of knowledge because a) it is supposed to be innate and they ‘just know’ and b) the boys (and some girls) were doing it - but now we have significantly more girls

The girls in my school had various fads that came and went (becoming avid Christians after a visit from a Christian rock band, girls with dark hair bleaching their fringe blond etc.). None of it stuck, all of it was a social ‘activity’ to ensure fitting in and I imagine looked back at now wondering what they were thinking.

How is your dc getting on Rogdmum?

Steensma is a WPATH member is on the committee rewriting standards of care for children.

I should think, here in the UK, a lot more research will take place now. The poor Dutch sound desperate for more help. I wonder if, in the US, this will be ignored because the situation is different both in terms of medical and pharma which benefit greatly. Anyone on the transition route now has to sign a declaration which basically prohibits them from pursing any claim.

Thank you for posting this. I’m sorry to say it but I feel a bit cynical about this. Could it be that these Dutch medics are thinking mainly about their reputation, along the lines of “what a disaster - and we will forever be associated with this?”

Spot on Daca. I recently read some of the papers they published about ten, 15 years ago, where they prided themselves in having picked the right patients to puberty block because they all went onto cross-sex hormones.

But the research at the time suggested that it was puberty itself that helped most of these patients to desist. And empirical studies showed that it was impossible to accurately predict which child would desist and which wouldn't. The literature itself showed some of the most dysphoric and persistent eventually reconciled body and mind while some of the least persistent and dysphoric would not. The inability to predict which child would do what was openly discussed at the time.

However, these doctors believed that unlike anyone else in the world they were uniquely qualified to tell the difference.

They also went ahead ignoring the fact that while there was no evidence that someone could be born with a cross-sex identity, there was evidence that gender dysphoria in early childhood was a reliable predictor of the child growing up to be homosexual. (A much more reliable predictor of homosexuality than transsexualism in fact.)

The best practice approach at the time - Watchful Waiting - did not ignore those facts, and so protected the majority who would desist, leaving the few who persisted to "go through the wrong puberty". That wasn't good enough for the Dutch specialists, who (in good faith) believed they could much better support the persisters by blocking their puberty.

So they devised a protocol extremely heavy on psychological assessment and treatment in order to avoid medicalising those who would desist, and at the same time they also embraced the doctrine of gender identity.

From their own clinical practice they knew that trauma of various kinds was present in very many of the children diagnosed with gender dysphoria in early childhood. But their knowledge that the identity issues these children experienced have an underlying cause directly contradicts the doctrine, which holds that gender identity is something we are born with and the only difficulties these children have in relation to their cross-sex identity are caused by society not accepting them.

So they decided that there are really two cohorts of child patients with gender dysphoria in early childhood - those who were born that way, and those who reacted to trauma. Hence they devised that protocol with a heavy emphasis on psychological assessment and treatment in order to separate out the two cohorts.

Some of these doctors started rumbling quietly about five years ago or so, because the affirmative approach adopted elsewhere by proponents of the doctrine of gender identity assumed there was only one cohort of children presenting with gender dysphoria, those who were born this way. So there was no need to carefully explore whether trauma might be the reason underlying their dysphoria, because the doctrine of gender identity doesn't allow for that.

The Affirmative Approach in use worldwide now utilises the puberty blocking part of the Dutch treatment protocol and leaves out its intense psychological assessment and treatment part and is applied to all children presenting with gender dysphoria, regardless of the age they first present with it.

But everyone still calls this the Dutch Approach. And they don't like it. It's not that they know they were wrong about having only puberty blocked the right kids - this is dawning on them only now - it's that they actually very carefully even back then only developed this approach for children who presented with gender dysphoria in early childhood.

So, the teenage girls now being treated under this protocol were never even considered as a cohort when it was devised. And they are the ones now swelling the ranks of detransitioners, going public, attacking the Dutch treatment protocol.

So this is the tip of the iceberg of damage control, and one they can justify. They can point to the many papers that detailed how important an intense, ongoing psychological assessment and treatment was to their approach. And that it isn't their responsibility when others don't properly follow their methods and apply it to the wrong patient cohort to boot.

But when the shit hits the fan about the fact that blocking puberty prevents desistance, they will be in serious trouble.

Thank you, Charlie, for this very informative post.

If you have citations for the papers, that would be great. So the Dutch protocol always had issues (ignoring that puberty can resolved GD) but these were compounded by getting rid of the gate keeping and going for affirmation only. I wonder what convinced the Dutch to block puberty in their patients in the first place. Was it all about ‘passing’? Or relieving adolescent distress?

If you do a Google scholar search for de Vries or Steensma, who are lead authors from the Dutch clinic, you'll find loads of papers. I then look up any co-authors, and then search for their papers.

Here's one that carefully detailed their approach, including the use of puberty blockers and cross-sex hormones.

Annelou L. C. de Vries MD PhD & Peggy T. Cohen-Kettenis PhD (2012) Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach, Journal of Homosexuality, 59:3, 301-320

Interesting to note that their assessment of medical interventions reflected the thinking of the time, which framed puberty blockers as fully reversible, cross-sex hormones as partially reversible and genital surgeries as irreversible. As we now know, the evidence base to make those assessments was either inadequate, misapplied, misinterpreted or all of the above.