Taking estrogen would "trigger female puberty"

NY Times podcast "The Protocol" episode 2

The second episode of the NY Times podcast “The Protocol” presents a trans-identifying male called Manon who received “gender affirming care” in accordance with the Dutch Protocol. The episode sells the idea – enthusiastically promoted by the Dutch – that the Dutch Protocol was well-founded and life-saving but has sadly been diluted by others. Although Patient Zero (FG, interviewed in episode 1) is a trans-identifying female, the Dutch Protocol was written for young boys, who were the vast majority of the Dutch clinic’s patient population in the 1990s. In short, the rules for diagnosis of gender dysphoria and admission for treatment were that the child’s distress with his sexed body had to be experienced from an early age, it had to have intensified with the onset of puberty, there should be no accompanying psychiatric problems, and there had to be good parental support. The Dutch Protocol has been criticized at length by others, so I will not do so here.[1] Suffice it to say that it has little or no application to today’s cohort, consisting largely of teenage girls.

The Dutch clinician Annelou de Vries says that the evidence of her initial research on the first 70 patients that they were doing so much better after treatment was “so clear-cut” that it led to the Dutch Protocol. She selects one person to interview: Manon. Surprise, surprise -- like FG, this is someone who is happy that he [Manon is referred to by female pronouns by everyone in the podcast] was treated with “gender affirming care.” Manon, now aged 30, says he understood from an early age that he was a guinea pig in an experiment.

Manon reports his desire to be a girl from an early age: to have long hair, wanting to play with “girl things” and wear girls’ clothes. He disliked his penis so much he hoped it would fall off. He used to leave his pants zippers open since he heard folklore that if you did this, your penis might “fly away.” He was just eight years old. We don’t hear anyone question why he disliked his penis so much; although the team did ask at length about any possible sexual abuse.

Anyway, his mother allowed him to wear girls’ clothes and he changed outfits 10 to 15 times a day and looked at himself in the mirror all day long. We don’t hear anyone question why he was so obsessed with his appearance at the age of eight. Then he started to wear girls’ clothes in public. At age 9, he was diagnosed with gender dysphoria. As he approached 12 years of age, discussions started on puberty blockers. The aim was to make sure he understood the implications. Austin Elliot says he “did not have any other psychological issues that needed to be addressed first” [the basis for this assertion is unclear] and suggests that the possible impact on bone density and cognitive development was fully explained to this eleven-year-old boy so that he could give informed consent. When he started getting injections of puberty blockers at age 12 he was told that blockers were fully reversible. (Not true, of course). He “always understood that it was temporary, I always knew that … I could stop at any moment.” He was very pleased he would not get wet dreams or a beard [“ew!”]

It is clearly absurd to suggest that an eleven-year-old can fully appreciate factors such as bone density and cognitive development and how the impact on them may affect his life as an adult. The UK disabilities charity recently observed that around 50% of trans people are disabled – and young people using wheelchair users and walking sticks are remarkably common sights in demonstrations for “trans rights.” We also know that puberty is the period during which young people gradually learn to manage their emotions. Just putting that out there.

At age 16, Manon was asked if he wanted to start cross-sex hormones, which in his case would mean estrogen. Here Austin Elliott reveals one of the weirdest misunderstandings about gender “treatment.” He says starting on estrogen would “trigger female puberty.”

What??

Female puberty involves diverse things: notably (for girls) breast development and – most significantly -- the start of menstruation, marking the onset of fertility.

Boys who take estrogen do grow “breasts” and acquire a certain redistribution of fat but they certainly don’t menstruate and they will certainly never be able to conceive a child. This idea – that a child can go through the “right” or “wrong” puberty -- is only one of the bizarre stories that are told about cross-sex hormones – which its devotees often refer to wrongly as “HRT” – “hormone-replacement therapy.” They are nothing of the kind, of course. HRT is given to women to make up for diminishing natural hormones, usually around the menopause.

Manon was also warned about the loss of fertility. He had no idea about this, as he says “pfff I was 16. … It would mean having to …. it made me sick even to think of it …. What’s it called …. mast..” [he cannot say it although the Dutch word is almost identical to the English word]. His disgust about masturbation was apparently never questioned. “Do I really regret the choice [not to preserve fertility]? Absolutely not, but it … has a big impact now still on my life.”

He had assumed that at the final stage – surgery – he would become a woman and would never tell anyone and never have to refer to his “transition” again. After surgery he became quite disillusioned and had difficulty “taking a guy home and having sex for the first time.” [like FG, he was homosexual – a point that is scarcely touched on]. He was so scared of getting hurt.

Then comes the most revealing moment of the podcast: revealing about Manon and about Azeen. He is trying to explain the wall, the strong defenses he had built as a child. There is a Dutch expression that translates roughly as: “give him a finger and he will take the whole hand.” (obviously similar to the English “give him an inch and he will take a mile.”) Manon reminisces and misquotes the Dutch expression: “if someone stuck a finger out I took the whole arm, and I broke it. Yeah, I did that literally once.” At this admission – that he once broke someone’s arm because of his “strong defenses” – Azeen breaks into peals of laughter. This inappropriate laughter of Azeen’s is starting to become a bit of a thing. “And I still have that in me, the wall, I have to be strong, I have to fight for my rights.”

Azeen says it’s so funny that Manon is “so open, so evocative” about his boundaries, his rights, his life experience.

There is a discussion about the contrast between Manon’s experience – as a boy whose puberty was blocked at an early age -- and the sad case of a friend, a “transwoman” who still looks male. Manon muses that he might not have survived if he had been forced to wait.

So the episode leaves us with the impression that the Dutch Protocol was evidence-based and designed to weed out people with diverse comorbidities – it wasn’t. And that early “treatment” could stop suicide. It doesn’t. When we hear that only 55 out of 70 were followed up (loss to follow-up of 21%), we don’t hear after how many years. There is a minor admission that there may have been selective bias. Marlou de Vries suggests that there was a need for an experiment with a randomized control group. (Given that it would be immediately obvious who has been prescribed hormones and who has not, this seems a fanciful notion.) We hear that one patient died “as a result of surgical complications.” We are not told why. This patient died at age 18 because he had received blockers so early that there was not enough penile tissue from which to create what is known as a “neo-vagina.” The surgeons had to use part of the colon (quite a common procedure these days), leading to a fatal infection.

As in the case of FG, we don’t hear about Manon’s relationships of intimacy or any matters of physical health. Aside from the brief glimpse into his anger management issues – the evidently hilarious moment at which he broke someone’s arm – we do not see behind the surface.

It should be emphasized that the whole notion that early “treatment” will help the child “pass” better as an adult only relates to boys – who develop features such as broad shoulders and coarser facial features in puberty that are impossible to disguise or reverse. So I would like to repeat: the Dutch Protocol was designed for boys. It has little or no relevance for girls presenting as teenagers – who now constitute the majority of those demanding gender “treatment.”

One of the most misleading statements from De Vries is that the Dutch are so careful to evaluate patients’ diverse psychological or psychiatric problems. She has “only recently” started to think that others have taken the oh-so-careful Dutch Protocol and applied it with far less care. Oh really, Annelou? I know from personal conversations with people very close to the Dutch team that they have been thinking this way for many years. And I also know that the Dutch gender teams do not practice differential diagnosis. No specialists in depression, anorexia, anxiety, self-harm, ASD are involved in the process. It is simply: “Has this child got gender dysphoria or not?” Moreover – just like the Tavistock GIDS at London, since closed -- teenagers are often not even asked about their sexual orientation.

Let’s listen to Jet:

And here is a different section:

I wonder when they will get around to the girls.

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[1] https://www.boomportaal.nl/tijdschrift/FenR/FENR-D-24-00001; https://x.com/twisterfilm/status/1573125582619086848?s=46;