When Fiction Identifies as Science
The Dutch Studies
This post is the third in a series of ‘threads I want to pull.’ Each thread is a potential clue to how we arrived here, at a place where medical ‘sex-change’ for kids is portrayed not just as healthy and normal, but something to celebrate.
The first thread was the ‘chain of trust’ as articulated by Dr. Stephen Levine: because no healthcare provider can be an expert in the whole range of possible complaints he’s expected to treat, a reliable chain of trust is essential to his ability to practice.
The second was the saga of WPATH, the World Professional Association for Transgender Health. The section of chain that concerns ‘gender medicine’ is controlled by WPATH, whose seal of approval is the hurdle all studies must clear to be relevant. While it once functioned as a medical society, today WPATH is an advocacy organization committed to a customer-service model that favors the medical ‘transition’ of children.
The logical next thread to pull is the body of research credited by WPATH as being of the right quality to determine such care.
Many, many studies have been well received by WPATH, but two — known as ‘The Dutch Studies’ — have done more than all the others combined to spread the ‘good news’ of puberty blockers, cross-sex hormones and body modification surgeries for young ‘trans’ patients the world over.
Background: adults first
The original mother ship of sex-change medicine is a research hospital near Amsterdam. A few early ‘transsexual’ patients were treated there in the mid-1900s, but the practice gained real traction after 1972, when the government of The Netherlands voted to fund gender research and cover ‘sex-reassignment’ procedures as part of their national healthcare system.
At this time, all over the developed world a culture of free expression was taking hold. Women and members of racial and sexual minorities were fighting for legal equality; American college students were protesting the war in Vietnam and demanding free speech. Young people were asserting themselves and calling for change as they’d never done before.
The Netherlands had already carved out a reputation as a world leader in progressive social change. The decriminalization of drugs and prostitution are visible statements of this bold progressivism — and also great boons to the nation’s tourism economy. A culture of openness to homosexual, bisexual and transgender people reflects a kind of forward-thinking empathy that is part of the progressive package. Most Dutch citizens appear to be proud and protective of their liberal, tolerant national identity [according the Dutch jounalists interviewed here] .
Against this backdrop, the Amsterdam Clinic was becoming a hub for ‘sex-reassignment’ medicine. Now that Dutch citizens were covered by insurance, patients — all adults and mostly men — began to arrive from all over the country seeking hormones and surgeries to allow them to present as the opposite sex.
By the late 1980s, when these adult patients had been receiving treatment for a decade or more, a preliminary study was undertaken to examine their outcomes so far. The study, published in 1989, showed a disappointing failure among these patients to thrive in the usual ways. Most didn’t regret transitioning, but they experienced very high levels of unemployment, low satisfaction with their social lives and difficulty finding romantic partners. The adult protocol could not be described as an unqualified success.
To explain these data, the researchers looked for external factors, presuming society was to blame for denying these ‘trans’ adults the seamless re-integration they’d hoped for after ‘transition.’ The team hypothesized that the best way to create happy trans adults would be to get to them before they reached adulthood — ideally before puberty made its permanent sex-specific changes to the body.
Peggy Cohen-Kettenis is a Dutch psychologist who was working in this milieu back then. She was on the verge of ‘discovering’ puberty blockade and wanted to try giving antiandrogens (androgen blockers) to boys, to prevent erections and grow breast tissue; and progestin to halt menstruation in girls. During the 1990s, Cohen-Kettenis referred some number of patients aged 16 and 17, and seven younger than 16, for this endocrine trial. They became the first cohort of otherwise healthy adolescents to have their puberty blocked.
The “Dutch Protocol” was launched in an important journal article in 2006.
These were the key steps:
Puberty blockers would be given at ‘Tanner Stage 2’ (early puberty) with twelve as the minimum age. (Interestingly, ‘social transition’ isn’t recommended before this stage)
Cross-sex hormones would begin at 16
Surgeries would follow at 18 to complete the transition
To qualify, patients must have suffered real gender dysphoria from earliest childhood; must be otherwise mentally healthy; and must have the emotional support of their parents.
The 2006 article also made these important claims:
Puberty blockers are “fully reversible… no lasting undesired effects are to be expected.”
Puberty suppression is a diagnostic tool: a ‘pause button’ to allow for therapeutic exploration before permanent steps are taken.
The Dutch Studies
Once the protocol was in place, a longitudinal study was begun on 70 young patients at the Amsterdam Clinic who began their transitions between 2000 and 2008. (The lead author, Dr. Annelou deVries, had trained under Dr. Cohen-Kettenis.)
The first study evaluated the patients as they were moving from puberty blockade to cross-sex hormones. The authors reported “Behavioral and emotional problems and depressive symptoms decreased.”
The second study examined the patients’ progress after their final surgery, which was genital alteration. Here the authors found “gender dysphoria had resolved, psychological functioning had steadily improved, and well-being was comparable to same-age peers.”
On the basis of this apparent triumph, the Dutch Protocol was embraced by WPATH and established as the ‘gold standard’ model for treating gender-dysphoric youth all over the world.
By now, the US had its own flagship youth gender clinic in Boston, with at least one psychologist who’d trained in Amsterdam under Peggy Cohen-Kettenis. (Here, the protocol was modified to allow puberty blockers for children even younger than 12.) Copycat clinics were springing up all over the country.
Meanwhile, the Affordable Care Act of 2010 now promised free or low-cost medical ‘sex-change’ (“affirmative care”) for the first time in the U.S. since 1981; for pediatric patients it was the first time ever.
Oh, and also: social media had been unleashed upon the world and was just now planting its flag inside adolescent brains all over the globe, with algorithmic precision.
What could go wrong?
Weak links in the chain of trust
The Dutch Studies lent a veneer of legitimacy to the chemical suppression of puberty in child patients everywhere. The thing is: the studies are baseless.
Some of the more glaring deficiencies of the Dutch research
The numbers: 70 patients were initially enrolled in the study. Only 55 are included in the first report, which pointed to modest improvements in psychological health — except for 15 patients who were lost to follow-up. Why would such a large proportion of kids drop out of the program and refuse to communicate further with staff at the clinic? That question remains unanswered.
The second report, where dysphoria has been vanquished and patients are seeming to thrive, is down to a pool of 32 patients. Missing are eight who refused to participate in the follow-up or were ‘ineligible for surgery’ due to becoming diabetic while taking hormones; and one patient who died from his genital surgery. The clinicians violated the most basic principles of science by selecting only the outcomes they liked for inclusion — and the ones they didn’t like included a young person they had actually killed.
It gets crazier! The 70 kids who started the protocol were given a baseline questionnaire describing their feelings of gender dysphoria. Girls were given statements like this, to be rated on a numerical scale of agreement:
“I hate my periods because they make me feel like a girl”
While boys were given statements appropriate to their sex, e.g.:
“I hate having erections”
The conclusion that the 32 patients who made it across the finish line had their dysphoria ‘cured’ comes from an astonishing bait-and-switch pulled by the clinicians: they flipped the surveys, giving every patient the sex-aligned version at the onset and the “gender” aligned survey at completion. So, a natal male on estrogen who’s had his penis and testicles removed is asked to agree or disagree with the statement, “I hate my periods because they make me feel like a girl.”
The purpose of this exit interview is basically to determine the Clinic’s final grade, because the protocol succeeds or fails according to the way the patient feels at the end of it. That is, assuming he’s still alive.
In a functional scientific universe, any one of these ‘deficiencies’ would serve to nullify the study and render it meaningless and worthy of derision. Yet the Dutch Studies didn’t just escape the lab; they were crowned the “gold standard” by WPATH. They’ve been used as evidence to recommend puberty blockers, hormones and surgeries for gender-confused children and adolescents by medical societies in every country that engages in ‘gender medicine.’
And, they’ve demonstrated how easy it is, and how profitable, to publish junk science.
More junk to follow, next week.
These are the main sources I drew upon for this article: