Dr. Annelu de Vries
Appearances
The Protocol
The Gender Kids
At that point, there wasn't any data to support using puberty blockers for kids with gender dysphoria. There was Peggy's case report on FG, but that was just an account of a single kid who had been given the blockers before the Dutch protocol even existed. There was no way to know how well they would work for other kids or what risks there might be.
The Protocol
The Gender Kids
At this point, Manon was a strong candidate for puberty blockers. She had felt gender dysphoria from a very early age. She had a supportive family. She didn't have any other psychological issues that needed to be addressed first. And crucially, as she approached puberty, her dysphoria was not going away.
The Protocol
The Gender Kids
Because the last part of the criteria kids needed to meet to start medical intervention was making sure that they understood the impact the treatment would have on their lives. The papers talked about blockers as a reversible treatment. So if a kid were to stop taking them, they would eventually resume their natal puberty.
The Protocol
The Gender Kids
But the papers also noted there may be risks to pausing what's usually a time of rapid growth, like the impact on bone density and possibly brain development.
The Protocol
The Gender Kids
And as Manon was learning about the blockers, she was also being monitored for any signs of puberty.
The Protocol
The Gender Kids
This is what the Dutch thought of as one of the radical innovations of the blockers, that it was just a pause that could be undone. And meanwhile, Manon could think about what came next.
The Protocol
The Gender Kids
At some point, she remembered there were some concerns about her bone health. She said she was told to eat more cheese and exercise. And then she turned 16, the age when doctors at the clinic said she could decide if she wanted to move on to cross-sex hormones. For Manon, this would mean taking estrogen, which would trigger female puberty.
The Protocol
The Gender Kids
And so now the conversation was about whether to move forward to a stage where treatment would have irreversible effects.
The Protocol
The Gender Kids
So Analu set out to look at a group of patients who were getting the treatment at the clinic. What ended up being 70 patients over the course of the study.
The Protocol
The Gender Kids
If Manon wanted to keep the option of having biological kids down the line, she would have had to go off the blockers, delay the estrogen treatment, and let her body go through enough male puberty for her to develop and bank sperm.
The Protocol
The Gender Kids
The idea was to see how the kids were doing psychologically before they started puberty blockers and follow up with them over time to see how the blockers and then hormones and surgeries impacted their well-being and whether the kids they thought would benefit from the treatment actually were doing better. And what Analu found launched the field of youth gender medicine.
The Protocol
The Gender Kids
In 2011, Analu published the results of her study that had followed Manon and the 69 other adolescents who received puberty blockers using the protocol.
The Protocol
The Gender Kids
She found that after an average of two years on the blockers, the psychological well-being of the participants was improved, writing that their, quote, behavioral and emotional problems and depressive symptoms decreased while general functioning improved significantly.
The Protocol
The Gender Kids
Despite the improvements in general functioning, she found no change in their feelings of gender dysphoria, which she said made sense because the blockers hadn't actually changed their bodies.
The Protocol
The Gender Kids
But the study had continued to follow the group as they moved on to cross-sex hormones and, after they were 18, surgery. And Analu published another paper about how they were doing after these interventions. By this point, the group had narrowed to 55 of the original 70. Some patients weren't included because they didn't respond to questionnaires.
The Protocol
The Gender Kids
Some weren't far enough out from their surgery to be included, or couldn't get surgery because of other medical issues. One patient died as a result of surgical complications. And in the follow-up paper, Analu found that the 55 patients she had been following for years, quote, were generally satisfied with their physical appearance and none regretted treatment.
The Protocol
The Gender Kids
She found that their gender dysphoria had resolved. She also wrote that their psychological functioning had continued to improve over time, that their rates of clinical problems were now, quote, indistinguishable from general population samples. But Analu said that her study had a few limitations.
The Protocol
The Gender Kids
And she noted that because of the number of participants who had fallen out between the blockers paper and the follow-up paper, there was the possibility of selection bias. The kids who had remained could possibly have been the ones more likely to improve.
The Protocol
The Gender Kids
She wrote that ideally there should have been a randomized controlled trial, a study that would have included a group of gender dysphoric kids who didn't receive treatment for her to compare her results to.
The Protocol
The Gender Kids
She said to deny treatment to kids who met all the criteria was not a, quote, neutral option. That without medical treatment, these kids would further develop characteristics that might bring them more distress, which could fuel depression and suicidality.
The Protocol
The Gender Kids
And that the group who did receive the intervention would be given the, quote, enormous and lifelong advantage of not being identifiable with their assigned sex at birth. In the conclusion of her second paper in the study, Analu said that the results signified the first evidence to support this new treatment protocol. She called the findings promising.
The Protocol
The Gender Kids
Analu got up and led us to her nearby office and dug around her shelves.
The Protocol
The Gender Kids
But her final words sound now like a bit of a warning. Clinicians should realize, she wrote, that it was not just the early medical intervention that led to the success of this study.
The Protocol
The Gender Kids
But even before Analu published her results, the protocol had been adopted into the industry's leading guidelines, the WPATH Standards of Care, essentially the go-to manual for doctors and other providers working in transgender healthcare.
The Protocol
The Gender Kids
And providers from all over the world started visiting the Amsterdam clinic.
The Protocol
The Gender Kids
And as they brought the care back to their countries, not everyone was following the protocol.
The Protocol
The Gender Kids
She flipped through. It was filled with full-page color photographs of some of the kids who took part in her research.
The Protocol
The Gender Kids
What it was about this process and the kids who went through it that was so convincing to the rest of the world. So I guess we should find a car to go after.
The Protocol
The Gender Kids
From the New York Times, I'm Austin Mitchell. This is The Protocol with Azeen Qureshi.
The Protocol
The Gender Kids
Yeah, and if there's anything that you're like, you don't want to be public or that... There are not a lot of people in Manon's life who know the role she played in Analu's study.
The Protocol
The Gender Kids
But as one of the first kids to go through the Dutch protocol, she's had some experience with the media, including one where she said her full name was published without permission.
The Protocol
The Gender Kids
And critically, the mental health assessments that were designed to help figure out which kids should get medical intervention.
The Protocol
The Gender Kids
Manon's experience going through the Dutch protocol, along with the other kids Anneloo studied, was captured in a handful of papers. There was Anneloo's seminal study. There were also a few other scientific articles that outlined in detail how the protocol worked.
The Protocol
The Gender Kids
And what Analu made clear in these papers was that clinicians who worked with gender dysphoric kids shouldn't push for any particular treatment outcome. The primary goal was to help them function better, so that they could go to school, get along with their friends and family. And for some kids, that might not mean medical intervention. That was about 30% of the kids they saw.
The Protocol
The Gender Kids
Honolulu wrote that some of the kids who came in were gay and thought that transitioning might help them feel more accepted. Others had psychological issues that needed to be dealt with first. She also talked about kids with autism spectrum disorder, which was about 10% of the kids referred to the clinic.
The Protocol
The Gender Kids
She explained in one study that for these kids, quote, it can be complicated to disentangle whether the gender dysphoria evolves from a general feeling of being just different or whether a true core cross-gender identity exists. Analu said that in all of these cases, kids should get psychological counseling. But in order to get medical intervention... What was your early childhood like?
The Protocol
The Gender Kids
So from a very young age, kids had to have a strong identification with the opposite sex, as well as a persistent discomfort with their sex at birth.
The Protocol
The Gender Kids
Dr. Annelu de Vries was one of the first people to join Peggy's new team at the Amsterdam Clinic. At the time, Peggy was still developing her set of rules for providing this new medical intervention to young people, what came to be known as the Dutch Protocol. Puberty blockers when puberty started, usually around 12, hormones as early as 16, and surgeries in adulthood.
The Protocol
The Gender Kids
Another part of the criteria Analu wrote about in her papers was that kids had to have the support of their parents or other caregivers.
The Protocol
The Gender Kids
Analu wrote that family support mattered because, quote, parents can play a significant role in creating an environment in which their child can grow up safely and develop optimally.
The Protocol
The Gender Kids
That was like really my... Manon remembers going to her friend's house nearby. It was just on the other side of a playground where the neighborhood kids hung out.
The Protocol
The Gender Kids
That day, she used a back alley, so none of the other kids saw her on the way there.
The Protocol
The Gender Kids
Her family was told to slow down, to not do anything that might influence her.
The Protocol
The Gender Kids
What Analu explained in her papers was that when gender dysphoria started in early childhood, it could change, and some kids would grow out of it. The important milestone, according to the Dutch protocol, was puberty. To be eligible for medical intervention, the distress needed to be intensifying as puberty neared.
The Protocol
The Gender Kids
But Analu said that for most kids, their distress would dissipate around that time. And because of that, they should keep options open for as long as possible. So while it was okay to try out wearing different clothes at home or on vacation, kids shouldn't fully socially transition until the early stages of puberty.
The Protocol
The Gender Kids
In part because if they changed their mind, they could avoid having to make the transition back. And so that's the guidance that Manon and her parents were getting from Peggy and her team.
The Protocol
The Gender Kids
It was around this time that Honolulu joined Peggy at the clinic to help lead the assessment process. Yeah.
The Protocol
The Gender Kids
She wrote that the process was designed to track how a child's gender dysphoria developed over time.
The Protocol
The Gender Kids
And to rule out any other psychological issues or things going on in their life that might be another explanation for their distress.