Peggy Cohen-Ketnes
Appearances
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
Because of him, we thought maybe we should do this more often, giving the blocking hormones.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
She felt the blockers would give kids time to think.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
You cannot just start and do whatever we want, particularly in the beginning, when you have no idea whether what you're doing is okay.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
Well, I think as a very careful... way to figure out who should have what kind of treatment to feel like they want to feel.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
Because we didn't want to have all kinds of disasters right from the beginning. But in much of these decisions, knowing the kids was very helpful. You just see what's happening. I mean, look at FG. Yeah. If you see how well they're doing, you know, it could not be completely wrong. It's just that exactly what you have to do with what kid, that's the challenge.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
Hello. Good to see you. Hi. Hello. I'm Austin. I'm Manalu. Hello. Hello.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
This is for adults. For adults. Yeah. Yeah. Because children were no way that anyone would do something with children.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
So when people heard that I knew something about transgender people, I got referrals for adults mainly. But occasionally there was also an older adolescent among them.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
These kids already had a lot of mental health care. They're functioning quite well.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
And I thought, that is a bit silly. For years and years, they very well know what they want. But because they don't have the right age, they have to wait.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
Couldn't we do something about that age limit? And he said, OK, we can start it a little bit earlier.
The Daily
‘The Protocol’: The Story Behind Medical Care for Transgender Kids
The first 14 or 15-year-olds and then an occasional 12-year-old.
The Protocol
The Beginning
The first case report on FG treated this note with significance. Peggy, still using female pronouns to refer to FG in the report, wrote, When she was 12, her mother found a suicidal note telling that she did not want to live any longer if she would enter puberty.
The Protocol
The Beginning
In that first report, Peggy explained the events that led up to FG showing up at her office. He had been to see a prominent endocrinologist named Henrietta Delamar van der Waal. She specialized in kids with issues relating to puberty. Some of these kids had what's called precocious puberty, where it started too early, like seven or eight years old.
The Protocol
The Beginning
And the treatment that Henrietta would give these kids was a monthly injection of a drug that would stop that from happening by blocking the release of the hormones that trigger puberty. A puberty blocker. And when she eventually stopped giving the drug to these kids, puberty would proceed as normal.
The Protocol
The Beginning
No. I don't think so. This is a story of how we got here. It's a story I've been reporting with my colleague Azeen Gureshi, a science and gender reporter, for nearly two years. And it's a story she's been reporting for much longer. And from the beginning, she's been telling me this is not just a story about politics. It's a story about medicine.
The Protocol
The Beginning
Peggy's report was matter-of-fact in talking about the significance of this moment. She simply wrote that the case is the first we know of in which a young person struggling with their gender had been given this drug. The report doesn't note the unexpected way in which it had come about, with a doctor who hadn't even been working with trans kids.
The Protocol
The Beginning
Henrietta Delamar Vandewaal died in 2014, but her husband told us that he doesn't think she saw this as some revolutionary act. This was a drug she was already using with her other patients. She understood the side effects. She saw a kid who was really hurting. And after consulting her colleagues, she decided that this might help.
The Protocol
The Beginning
He doesn't think that she had any idea, really, how transformational this would turn out to be, to use this drug in this whole new way with FG.
The Protocol
The Beginning
When he was 16, FG was referred to Peggy's office. He had been on blockers for several years, and during that time, he had remained certain about his desire to transition, to live as a boy. So the next step would be to go off the blockers and onto hormones, in his case, testosterone, a step that was only available because Peggy and Louis had lowered the age from 18 to 16.
The Protocol
The Beginning
But the report noted that his parents were, quote, not happy with the idea of sex reassignment. And that for FG, the prospect of being forced to resume female puberty was creating so much distress that ultimately his general practitioner sent his family to Peggy.
The Protocol
The Beginning
Once he started seeing Peggy, he underwent several assessments. Peggy talked in her report about the results of his IQ test, his personality tests, a Rorschach test. She mentioned he went through several therapy sessions, and so did his family, and he also attended group therapy sessions with peers.
The Protocol
The Beginning
When she concluded that there were no psychological issues that might interfere with his decision, she recommended he begin hormone treatment.
The Protocol
The Beginning
About a new kind of treatment for a small group of kids. How it came to be. Who it was meant to help. How that was codified into a protocol that spread around the world. and how, in the time since, the medicine and the politics have become impossibly entangled. From the New York Times, I'm Austin Mitchell. This is The Protocol with Azeem Qureshi. Part One. The Beginning.
The Protocol
The Beginning
Yeah. For FG, the pain he was feeling was similar to what Peggy had seen with her adult patients. It wasn't just that he felt he was in the wrong body. It was also that the world saw him as something he felt he wasn't. Peggy noted this in her report. She said that the idea that people around him would see him as someone who used to be a girl but was now a boy was, quote, "...shameful."
The Protocol
The Beginning
So rather than go through this transition in front of his classmates, FG decided to stay on the blockers an extra two years, meaning his body essentially remained frozen in his 13-year-old state until he was 18. Then, after high school, he took a year off to begin hormone treatments and go through male puberty as privately as he could.
The Protocol
The Beginning
So this is how it all started. With a kid who only ever wanted to wake up and have it be that he was born a boy, and to never have to explain himself to anyone. He wasn't the first kid to feel that way, but through some combination of his conviction, the place and time, and the doctors who took him seriously, he was the first kid to get this revolutionary medical intervention.
The Protocol
The Beginning
FG was 24 years old when Peggy published her first case report on him. It was 11 years after he'd started blockers and six years after he'd begun hormones and had his first surgery. Peggy wrote that FG, quote, reported no gender dysphoria at all. He said that he had found the adjustment to the male role to be very easy and expressed no doubts on the adequacy of his masculine behavior.
The Protocol
The Beginning
He never felt any regrets about his decision and had never contemplated to live as a girl again. In conclusion, Peggy said, for certain selected cases with a lifelong, consistent, and extreme gender identity disorder, delaying puberty may be a physical and psychological beneficial way to intervene.
The Protocol
The Beginning
Because of FG, Peggy thought that more kids could benefit from what had clearly been a transformational treatment for him. And she thought that the benefits of puberty blockers were twofold. They could prevent young bodies from growing in an undesired direction.
The Protocol
The Beginning
They also made it possible for kids to consider, without that stress, whether they wanted to go on to the next steps, which would be irreversible.
The Protocol
The Beginning
But to give this treatment to more kids, Peggy felt they needed a process.
The Protocol
The Beginning
She began to codify a protocol, what would come to be known as the Dutch Protocol.
The Protocol
The Beginning
And the critical part of that protocol was a process for assessing the kids to figure out who should receive medical intervention. which kids would benefit from it and not come to regret it.
The Protocol
The Beginning
In the early 2000s, Peggy moved her work to Amsterdam, to the biggest transgender medical program in the country. And she started to put together a team of mental health providers to assess and treat the kids coming into the clinic, including a psychiatrist named Analu De Vries. And what happened next would explain how this care that started almost by accident with this one kid
The Protocol
The Beginning
And those professionals would be trying to kind of convince these people that they... Yeah, kind of talk them out of it.
The Protocol
The Beginning
It's only been about two decades since trans and gender nonconforming kids in the U.S. have been able to get medical treatment to transition. Now, the federal government is looking to end it. And the Supreme Court is expected to rule on the issue in the coming weeks.
The Protocol
The Beginning
I don't know exactly how you will refer to him. In 1990, a 16-year-old kid showed up at Peggy's office.
The Protocol
The Beginning
And what Peggy realized when she saw him would transform the field of youth gender medicine. He's now in his early 50s, and his role in the history of this care has been closely protected. But he did agree to tell us his story.
The Protocol
The Beginning
And that's how we found ourselves on a quiet street in a European city we've agreed not to name, to meet with the first person ever given puberty blockers to treat gender dysphoria. Dodging the dog, we stepped into a bright upper floor apartment. I love these big windows.
The Protocol
The Beginning
The walls were covered in bookshelves, the floor was covered in dog toys, and there were cats, too, somewhere, we'd been told.
The Protocol
The Beginning
He brought out some coffee, some pastries, and gestured to us to sit at the dining room table.
The Protocol
The Beginning
FG is not his real name. It's what he's called in some of the medical and historical literature about him. And it's what we've agreed to call him to protect his identity.
The Protocol
The Beginning
FG asked that we protect many of the identifying details of his life today.
The Protocol
The Beginning
But he was ready to talk about his experience with Peggy, which was documented in two foundational case reports that she authored. In one of them, she wrote that he had gone on to become some kind of doctor.
The Protocol
The Beginning
In the first case report, Peggy noted that FG, who was born female, quote, wished to be a boy from early on.