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The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence

Michael Biggs


(...)


Conclusion


The use of GnRHa to suppress puberty has proved more popular than could have been envisaged in the mid-1990s. It has become the international standard for treating gender dysphoria and has attracted increasing numbers of patients. Down to 2015, the Amsterdam clinic administered GnRHa to a total of 333 youth aged under the age of 18 (Wiepjes et al., Citation2018). From 2012 to 2020, the London clinic administered GnRHa to 344 children under the age of 15. Both clinics were overwhelmed by referrals from the mid-2010s, and the lengthening waiting lists provided scope for unscrupulous commercial operations. GenderGP, for example, is a company registered in Singapore and owned by a Welsh doctor which will diagnose a 9-year-old with gender dysphoria over video and prescribe GnRHa on the same day (Medical Practitioners Tribunal Service, Citation2022). The total number of patients subjected to puberty suppression, worldwide, must run to several thousand. The proponents of GnRHa never reassessed the rationale for the intervention as the numbers multiplied. It is one thing to assert that very rare cases of extreme gender dysphoria—one per year in the Netherlands in the late 1990s—should be treated as juvenile transsexuals. It is another to make this claim for numerous adolescents—currently over a hundred a year in the Netherlands. Given the fact that gender dysphoria lacks an objective diagnosis, the potential for puberty suppression is expansive. When a recent survey in one American school district found 7% of students identifying as “gender diverse,” the authors urged that all receive “access to gender affirming care,” which in effect means giving GnRHa on request (Kidd et al., Citation2021, p. 3).Footnote7

Whether the availability of puberty suppression has increased demand is a question that should be raised. Taking GnRHa early in puberty promises a more passable resemblance to the opposite sex, and this is why it proved so fascinating to television audiences. It is no coincidence that media coverage of transgender youth focuses on those who suppressed puberty at a young age, most famously Jennings. Positive media coverage is known to increase referrals to gender clinics, at least over the short term (Indremo et al., Citation2022; Pang, de Graaf, et al., Citation2020). Although Dutch clinicians advise against “a complete social transition … before the very early stages of puberty” (de Vries & Cohen-Kettenis, Citation2012, pp. 308–309), the availability of GnRHa now makes it feasible for parents to treat a young child as the opposite sex, which guarantees that the child will experience the onset of puberty as catastrophic and thus demand endocrinological intervention. For boys, social transition prior to puberty is a powerful predictor of gender dysphoria persisting into adolescence, even controlling for the degree of dysphoria in childhood (Steensma et al., Citation2013). This pathway is illustrated by interviews with 30 British parents who had started raising their children as the opposite sex between the ages of 3 and 10. According to one parent, “If you don’t give a child puberty-blockers there is a consequence—it’s not that nothing happens. There’s a massive consequence” (Horton, Citation2022, p. 13). Another candidly described their child’s attitude to counseling at the gender clinic: “at the end of the day, he’s just gonna say whatever it is, that makes you shut up, so that he can get the blocker” (Horton, Citation2022, p. 14).

What has happened to the majority of children with gender dysphoria who used to grow up into gay or lesbian adults? The original articles promoting GnRHa (Cohen-Kettenis & van Goozen, Citation1998; Gooren & Delemarre-van de Waal, Citation1996) hypothesized that children whose dysphoria persisted to the age of 12 were destined to become transsexual. This arbitrary age threshold was soon forgotten. Outside the Netherlands, GnRHa was adopted with no minimum age, and has been prescribed to children as young as 8 years old.Footnote8 Delemarre-van de Waal eventually advocated for GnRHa to be administered before Tanner stage 2, “right at the onset of puberty,” followed quickly by cross-sex hormones (Delemarre-van de Waal, Citation2014, p. 202). And of course the transsexual pathway now begins long before puberty, with social transition and psychological diagnosis. As de Hingh observes, “a diagnosis says you’ve got a problem that needs to be treated … The medical process, with pills and protocols, takes over the normal process of identification formation” (de Hingh, Citation2021, pp. 182–183). Clinicians need to explain how they are sure that some of the adolescents being prescribed GnRHa would not have grown into gay or lesbian adults, with their sexuality and fertility intact.

The article that introduced puberty suppression to the medical literature was accurately titled: this endocrinological intervention is designed for juvenile transsexuals (Gooren & Delemarre-van de Waal, Citation1996). This fact should not be obscured by claiming that puberty suppression is reversible and diagnostic. It is not diagnostic because over 95% of adolescents given GnRHa will continue to cross-sex hormones, and this fraction has not declined even as the number of youths subjected to GnRHa has multiplied by two orders of magnitude. The claim for reversibility was contradicted from the outset by the unknown effect of puberty suppression on brain development. Irreversibility has now been demonstrated by randomized control trials in nonhuman animals. The central justification for puberty suppression was that it increases outward resemblance to the opposite sex and requires less surgical intervention. Paradoxically, however, early puberty suppression for males will most likely make subsequent genital surgery more risky—this is what killed one of the initial Dutch cohort—with worse results.

Evidence for the benefits of puberty suppression must be acknowledged as slender. Decisions made by clinicians have prevented the collection of robust evidence. The Dutch proponents of GnRHa chose not to conduct a randomized control trial, giving two reasons (de Vries et al., Citation2011). Firstly, adolescents would have refused to participate, which does not make sense unless they could have obtained GnRHa from another source. Secondly, it would have been unethical to withhold GnRHa from the control group, because the clinicians believed the treatment to be beneficial—this rationale is circular because discovering whether a treatment is truly beneficial requires a randomized control trial. A lesson can be drawn from the use of GnRHa to pause precocious puberty. This was supposed to mitigate short stature, as was apparently shown by small uncontrolled studies (Hayes, Citation2016), but this effect was called into question by a randomized control trial (Cassio et al., Citation1999). When the London clinic designed a study to replicate the findings from Amsterdam, the same reasons for avoiding a randomized control study were repeated, along with an argument that subjects would soon realize whether they were receiving treatment or placebo (Viner et al., Citation2010). Yet this had been no impediment to the trial for children with early puberty.

The decision to rely on uncontrolled studies was exacerbated by other decisions. The Dutch clinicians chose incommensurable scales to measure gender dysphoria, which calls into question their finding that dysphoria declined following cross-sex hormones and surgery. Worse still, American clinicians eschewed the measures of psychological functioning used by the Amsterdam and London clinics (YSR, CBCL, and CGAS), thus ensuring that their tiny samples could not contribute to cumulative knowledge. One final point to remember in evaluating published studies is that the field of transgender medicine is subject to the same publication bias as every other field: unsuccessful results will not be published. This bias is illustrated by the London clinic’s attempt to replicate the Amsterdam clinic’s findings: the lack of improvement on GnRHa appeared in print only after the clinic was taken to the High Court of Justice for England and Wales.

While the use of GnRHa to suppress puberty helped to create the juvenile transsexual, it could now be creating another “new way of being a person” (Wren, Citation2020): a sexless adult. This follows from the premise that natal puberty can be a kind of disease, and therefore failure to prevent an “irreversible development of secondary sex characteristics … may be considered unethical” (de Vries et al., Citation2011, p. 2282). Although the Dutch protocol envisages GnRHa as a preparatory phase before cross-sex hormones—imagined as undergoing puberty of the opposite sex—the logical conclusion is that hormones of either sex can be treated as vectors of disease. An Australian girl, Phoenix, was socially transitioned into a nonbinary identity at the age of 5 and took GnRHa from age 11. Reaching the age of 16, Phoenix refused to take testosterone because “remaining in an androgynous, peripubertal state is the only way their body can truly reflect their non-binary gender identity” (Notini et al., Citation2020, p. 743). The clinicians agreed to provide perpetual puberty suppression, despite the known deleterious physical effects—most obviously on bone density—and despite the unknown effects on emotional and cognitive development—which would affect Phoenix’s capacity to consent. Phoenix is not the only individual seeking indefinite puberty suppression (Pang, Notini, et al., Citation2020). Such cases are still exceptional. But cases like FG also used to be exceptional.

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