"The transgender protocol" by Zembla - looking into the Dutch Protocol

[Helleofabore]

The Blurb says:

There are currently almost 3,000 young people on the waiting list for gender care in the Netherlands. They are vulnerable adolescents who are frequently subjected to discrimination. Many of them suffer severe mental distress. Doctors at the gender clinic in Amsterdam are pioneers in care for transgender young people. The treatment developed here years ago is now used worldwide. Now, criticism is growing. International experts are questioning the scientific evidence put forward by the clinicians in Amsterdam. Zembla investigates the Dutch transgender protocol.

A bit of a recap of this video for those who haven't got the time to watch. What this covers is that no gender clinic has been able to replicate the results of the Dutch paper. One patient of the group died due to the surgery complications of gender surgery and even de Vries questioned why no one seemed interested in that patient while accepting the study. Dr Riittakerttu Kaltiala (Professor of Pschyiatry, Tampere and who set up gender clinics) and Mikael Landen (Professor of Pscyhiatry, Gotenberg) and Dr Angela Samfjord (Head of Child and Adolescent Psychiatry at the University of Gotenberg ) all are interviewed about the quality of the study behind the protocol and its flaws that became apparent later. Ie. The 55 patients is so small and de Vries acknowledges that they are not really similar to todays cohort of adolescent transitioners. That only 32 filled in the survey with positive results. The others were not chased up and one died.

Gerard van Breukelen, a professor of Methodology at Maastricht university goes on record to say that the methodology of that initial study was weak. There was no control group so the conclusions should not have been considered as strong as the gender clinicians claimed. Other academics declined to be interviewed due to fear for their employment as it is such a contentious issue. When talking to de Vries, she mentions that many more studies have been done by other countries now. And the doco makers mention that all those studies de Vries refer to have stated that the evidence is low quality. A Swedish team led by Landen was asked to do a full review by the Swedish government and he confirms that the evidence was just not there. Hence the Swedish government withdrew treatment.

The mention the Cass review and discuss ‘lock in’ and contradicts the ‘time to think’ narrative. They interview two transitioners. One detransitionered before surgery and one is happy with transition but not with the process the team followed. The one who detransitioned was put on hormones despite not even socially transitioning as he felt wearing a dress was ‘a man wearing a dress’. But was put on hormones but didn’t go through surgery after all. It also wraps up with Lucy who was stuck on the waiting list and who believes that if she was given PBs, she would not have ended up transitioning. She has obviously detransitioned now after double mastectomy and testosterone, then ovaries and uterus removal.

It is a good recap of where the world is at the moment with the Dutch Protocol. The ethical issues and the review findings. It is about 42 minutes long and strives for balance. Yet, obviously there are the glaring inconsistencies being covered, so really, it shows that the Nederlands Gender clinics are adhering to the protocol despite knowing that it might not be relevant to current cohort and while acknowledging that there is no control group but doubling down that they must continue anyway. Because to not continue might mean that some patients are harmed by not receiving treatment for their distress. It shows what a vicious cycle this really has become.

This is brilliant to have thanks very much

Thanks Helle. Placemarking to watch later

It is good to hear from other countries what is happening. It helps to understand that we are not the alone in the UK.

That was an excellent watch. What really stood out was the medical practitioners in the Netherlands who were certain of their own brilliance contrasted with the Finnish doctor who, rather than being dazzled by the gloss, looked past it and thought critically about what was actually in front of her own eyes. The Finns and the Swedes, even though they'd been applying the treatments, were willing to think "what if what I'm doing is wrong?" and to change course. I'm not sure that anything would persuade the Dutch doctor de Vries that what she's been doing for all these years might actually be wrong.

Hannah Barnes was as measured and excellent as always.

I also thought the discussion on the methodology was interesting. It mirrored the discussions we have here about ethics and control groups.

It was heartbreaking again to think of the two detransitioners that they interviewed and how similar the stories are to others. How one showed very clear reluctance to even socially transition and yet still received estrogen and one was clear about body dismorphia and had hormones AND surgery. Yet, supposedly they should have had extensive psychotherapy.

Something was just not adding up.

Mikael Landen wrote the following about that Bränström and Pachankis study that was discredited.

The Effect of Gender-Affirming Treatment on Psychiatric Morbidity Is Still Undecided

Mikael Landen M.D., Ph.D.

Published Online:1 Aug 2020

TO THE EDITOR: In this issue of the Journal, Bränström and Pachankis study mental health treatment and suicide attempts in persons diagnosed with gender dysphoria in Sweden. Their claim that the study shows that gender-affirming treatment reduces the risk of mental health treatment and suicide attempts is misleading because the study design is flawed.

The authors first found what was already known: the rate of psychiatric morbidity is much higher in persons with gender dysphoria compared with the general population. The authors then explored if the risk for mental health treatment changes as a function of years since starting hormonal treatment. They find no effect (odds ratio=1.0), but they do find a trend toward increased risk of suicide attempts as a function of years since starting hormonal treatment. In their key analysis, allegedly showing that gender-affirming surgery decreases risk for psychiatric treatment and suicide attempts, they relate these negative outcomes to the number of years since surgery. Contrary to what the authors repeatedly claim, they do not employ a longitudinal design but conduct a retrospective analysis unfit for their research question.

First, the authors include only persons who were alive in 2014. That means that those who died by suicide before 2014—and hence were at highest risk for suicide attempt—are excluded and confound the results. Second, any analysis starting with a negative event is bound to find a decreased risk for related negative outcomes with increasing time after the event. To exemplify this point, the rate of antidepressant treatment would decrease with time after a suicide attempt. This does not mean that suicide attempts cause a decrease in risk of antidepressant treatment; it is merely a case of regression toward the mean.

Third, persons undergoing gender transition have, by definition, contact with mental health services in Sweden. After the transition, persons are followed up by endocrinologists and sometimes general practitioners; only those with persistent mental health issues are followed in psychiatric care. The authors’ finding of lower rates of mental health treatment with increasing time after surgery is therefore not only a case of regression toward the mean, but it also follows from the standards of care and is not a proxy for improved mental health.

Because the authors do not present data prior to gender-affirming surgery, the study is uninformative with regard to the effects on psychiatric morbidity. Moreover, the authors miss the one conclusion that can be drawn: that the perioperative transition period seems to be associated with high risk for suicide attempt. Future research should use properly designed observational studies to answer the important question as to whether gender-affirming treatment affects psychiatric outcomes.

Here is the link to the study he is critiquing .

Richard Branstrom (The Karolinska Institute) and John E. Pachankis from YALE.

ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.1778correction

And adding this here which is about Hannah Barnes’ report on the re-analysis of the GIDS data recently.

And a final note on the segment by Hannah that I posted above but was included in the Dutch documentary.

The reanalysis of the original study by the Tavistock resulted in finding the following changes (or not) to mental health following treatment:

34% deteriorated
29% improved
37% no change

David Freedman did the reanalysis (and was on the original team that did the analysis to start with) and this new paper is awaiting peer review. It will be one to watch for, I think.

In the meantime, it is being reviewed also be the Cass team as well.

Oh. And speaking of which, here is the freshly published peer reviewed paper!

https://www.tandfonline.com/doi/full/10.1080/0092623X.2023.2281986

Psychological Outcomes of 12–15-Year-Olds with Gender Dysphoria Receiving Pubertal Suppression in the UK: Assessing Reliable and Clinically Significant Change

Susan McPherson & David E. P. Freedman

Published online: 29 Nov 2023

Abstract

The evidence base for psychological benefits of GnRHA for adolescents with gender dysphoria (GD) was deemed “low quality” by the UK National Institute of Health and Care Excellence. Limitations identified include inattention to clinical importance of findings. This secondary analysis of UK clinical study data uses Reliable and Clinically Significant Change approaches to address this gap. The original uncontrolled study collected data within a specialist GD service. Participants were 44 12–15-year-olds with GD. Puberty was suppressed using “triptorelin”; participants were followed-up for 36 months. Secondary analysis used data from parent-report Child Behavior Checklists and Youth Self-Report forms. Reliable change results: 15–34% of participants reliably deteriorated depending on the subscale, time point and parent versus child report. Clinically significant change results: 27–58% were in the borderline (subclinical) or clinical range at baseline (depending on subscale and parent or child report). Rates of clinically significant change ranged from 0 to 35%, decreasing over time toward zero on both self-report and parent-report. The approach offers an established complementary method to analyze individual level change and to examine who might benefit or otherwise from treatment in a field where research designs have been challenged by lack of control groups and low sample sizes.

I am looking forward to reading the rest

Something just came to my mind about the programme. It was when the Dutch doctor de Vries, who cheerleads medical transition for children, was asked about alternatives and she made clear that any treatment that meant that some children wouldn't undergo medical transition was unthinkable. That was chilling.

Yes. Exactly my thoughts.

Agreed. That really struck me too.

It's a fundamental belief that children can BE trans, rather than, that they are still developing beings exploring or struggling with identity.

If you hold that belief (child being trans), and see the approach to dysphoric children through those eyes- you are going to support medical treatment, and a trans conversion therapy ban.

Whatever I think about this, however much evidence I have for my opposing view; people and professionals with the other view will hold theirs just as sacred as I hold mine, and will fight just as strongly for it.

Whenever the reality of this impossibility really strikes me, I feel hopeless about it all.

And when trying to discuss/debate, it's like talking two completely different languages.

I can't see how we can ever resolve the polarity of worldview between those who believe in this, and those who don't. Especially when those with both views are working in the field (as we can see in Time to Think, and in the concerns around the new clinics in the UK).

The more time has gone on and the narrative of the Trans Child has become even more entrenched in the culture, this fundamental difference of view feels like an enormous ravine to bridge.

Cass is aiming to to do this (to find a workable solution) I think- but I don't know how she will manage it. The opposing understandings just don't lend themselves to compromise. How can they?

It was clear to me that she would hold this belief, in a sort of pseudo-religious, way, to the bitter end because she's bet her whole reputation on the righteousness of what she's done. That's a terrible stance for a medical professional to take. Especially when she could be smack bang in the middle of a massive medical malpractice scandal.

This kind of thinking is going to result in a significant part of the medical establishment obstructing the scandal being fully revealed to the public.

Is it that the belief was there first (from the earliest of the Dutch studies which referred to 'juvenile transexuals'- that says something) and that then was the lens through which they viewed the research- selectively, with blind-spots. And even now, in the face of mounting evidence, are unable to make a shift in perception to even question the fundamental belief? I don't know- as I can't relate to it at all!
My very different belief about it feels instinctive- but probably comes from being more aware of and interested in psychology than medicine/'fixing the body' to match the mind.

So much of the issue seems to be around believing in addressing the external (body/society) Vs the internal (self/mind)
These stances can be so fundamental for people!

I was really struck in the De Vries interview on Gender a Wider Lens, by how utterly incurious about/confident in her worldview and consequent approach De Vrie was. She didn't even consider that Stella and Sasha might have a different perspective.

I'm not sure if she is doubling down with cognitive dissonance, or is still just totally convinced of that view and unable to see it from any other angle.

I suppose both possibilities still have the same outcome re obstructing revealing the medical scandal you outline, Nauticant.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0293868#sec018

Parking this here too. It is a qualitative paper from Canada exploring the experiences of detransitioners there. It is a small sample, but an important read.

Well that was all rather frustrating! Thanks @Helleofabore !

The original study woman is a bloody zealot, she is never going to address the problems with her results whilst she thinks not giving them drugs is unacceptable. she can't or rather won't see the problems.

All these kids if they ever get around to reading the research that their lives are decided on will not be impressed that they were used to shore up some adults crazy ideas and it's all based on crap research.

To understand the motivation of de Vries and fellow travellers you need to understand that not only did they stake their reputations on these treatments but they see themselves as pioneers who have created a whole new area of medical practice that they're looking to have a quasi-ownership over as first (and most important) movers. Since they'll be highly motivated to defend this territory and their "founder" status don't expect them to shift their position in any way that doesn't support that.

So, about them and their egos, more than about belief in the concept then.

So many poor motivations driving all this; from ego, money, and reputation protection, to basic closed mindedness and lack of courage or critical thinking. And tribalism too.

Have just started watching 'Bad Surgeon' on netflix. About a Surgeon at the Karalinska Institute with a god complex who believed he had pioneered a groundbreaking technique using stem cells and plastic to replace/create windpipes... who doubled down despite immediate and tragic failures.

I guess this situation with the Dutch "pioneers' is in that kind of territory.

The Karolinska Institutet surgeon story was recently reported on Woman's Hour:

https://www.bbc.co.uk/sounds/play/m001sv4s (from 23.20)

Obviously that might contain spoilers.

Thanks Nauticant. Will check that out too

Thinking this might be the best/most relvant thread to post this on.
SEGM founder (scientist-Zehnya Abbruzzese) goes through the history leading up to and including the Dutch Protocol.
Starting with the Christine Jorgenson case, and how Jorgenson's Christian surgeon persuaded a Christian hospital medical ethics committee on the ethics of the treatment, as the 'soul is more important than the body'- links with my post comment above about belief, interestingly to me.

Anyway, very thorough overview of how we came to be where we are.
I really would like this to be widely viewed. All presented in a simply factual way and easily referenced:

That is fascinating. Here's a segment from the video:

So now I will switch to how Christine Jorgensen's, Danish doctor, Dr. Christian Hamburger, described the situation in his own words.

Even before our patient had been discharged from the surgical clinic. The news of the change of sex had spread all over the world in record time. The news had reached the remotest corners of the earth, and since my name was quoted in the reports, letters began pouring in. Between 1952, between December 1952 and October 1953, I received 1117 letters from patients.

So Dr. Hamburger loved taking care of his patients, but he also loved data. So what he did with the letters after he read them is he analyzed them, synthesize them and published them in a peer reviewed or scientific article. I'm not sure if it was peer reviewed. So the the study and you can read it, it's available revealed some interesting findings at the time. Now, they're not very surprising. They were three times as many men as there were women who contacted him.

The motivations for changing the desire to change sex varied widely among the men. Some genuinely were convinced they were women. Some expressed that they had an extreme desire to cross-dress that they couldn't control, and some had some form of body dysmorphia.

However, for women who contacted Dr. Hamburger, the reason was always the same. The women were all same sex attracted. They did not have any significant distress with their body. And instead they wanted, and I quote, to be able to marry their female friend.

Yep. The whole talk is very illuminating- such clear context; to understand the present look at the start and all that.

That's a great section to pull out.

So Dr. Hamburger loved taking care of his patients, but he also loved data. So what he did with the letters after he read them is he analyzed them, synthesize them and published them in a peer reviewed or scientific article. I'm not sure if it was peer reviewed. So the the study and you can read it, it's available revealed some interesting findings at the time.

There's a pdf link to the study on this page. I can't post a direct link.

https://scholar.google.co.uk/scholar?as_q=sex+change&as_epq=&as_oq=&as_eq=&as_occt=any&as_sauthors=%22c+hamburger%22&as_publication=&as_ylo=1953&as_yhi=1953&hl=en&as_sdt=0%2C5