The Gender Kids

Summary

Podcast Summary: The Protocol – Episode: The Gender Kids

Release Date: June 5, 2025
Host/Author: The New York Times

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Introduction

In this compelling episode of The Protocol, The New York Times delves into the intricate history and impact of medical treatments for transgender youth, focusing on the Dutch protocol's origins, its global influence, and the ensuing legal and political battles in the United States. Titled "The Gender Kids," the episode intricately weaves personal narratives with expert insights to present a nuanced exploration of transgender healthcare.

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Origins of the Dutch Protocol

The story begins in the early 2000s at an Amsterdam clinic where Peggy, a pioneering clinician, collaborates with Dr. Anelu de Frise to develop a structured approach to treating gender dysphoria in young people.

Peggy:
[00:01] "I mean, when I started working here, Peggy just moved from Utrecht."

Dr. Anelu de Frise:
[00:06] "Dr. Anelu de Frise 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 AD. And critically, the mental health assessments that were designed to help figure out which kids should get medical intervention."

The Dutch protocol introduced a phased approach:

1. Puberty Blockers: Initiated around age 12 to delay puberty.
2. Hormones: Administered around age 16.
3. Surgery: Considered in adulthood.
4. Comprehensive Mental Health Assessments: To ensure appropriate treatment pathways.

Peggy:
[00:40] "That assessment was several sessions over a longer period of time and actually really get to know the family, get to know the kids."

The team emphasized thorough evaluations, often spanning at least six months, to understand each child’s unique situation fully.

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Establishing the Protocol's Efficacy

By 2011, Dr. Anelu de Frise had embarked on a pivotal study involving 70 patients, marking the first substantial evidence supporting the Dutch protocol.

Peggy:
[02:18] "That's the 2011 study, the famous. Yeah, well, that was the first one that did some evaluation of really the medical intervention."

The study aimed to assess the psychological well-being of participants before and after receiving puberty blockers, followed by hormones and surgeries. The findings were groundbreaking, essentially launching the field of youth gender medicine.

Dr. Anelu de Frise:
[02:33] "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."

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Personal Narratives: Manon's Journey

A significant portion of the episode centers around Manon, one of the first children treated under the Dutch protocol. At 30, Manon reflects on her experiences, providing a deeply personal perspective on the protocol’s long-term effects.

Peggy:
[04:00] "This is Manon."

Manon's early life revealed a persistent discomfort with her assigned gender, leading her parents to seek medical intervention. The protocol's structured approach allowed for flexibility, ensuring that medical treatments were not rushed and that each step was carefully considered.

Austin Mitchell (Manon at age 30):
[08:23] "Always walking in my mom's clothes, wearing towels as skirts or long hair. I wanted to play with girl stuff... I always knew that it was temporary. I always knew that till the next phase were the hormones. I could stop every moment."

Manon’s narrative highlights both the benefits and complexities of the protocol:

• Benefits:

  • Emotional Stability: Improved psychological well-being post-treatment.
  • Personal Satisfaction: No regret regarding the choice to transition.

• Challenges:

  • Fertility Concerns: Making irreversible decisions about future parenthood.
  • Social Vulnerability: Increased sensitivity to societal perceptions and potential discrimination.

Manon:
[23:00] "That is such a nuanced thing that you're describing, is both saying, I don't regret it. I, I know I made the right choice, but also that there can be a part of it that, you know, is difficult for you."

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Clinical Insights and Study Outcomes

Dr. Anelu de Frise’s studies provided empirical support for the protocol, showing significant improvements in the psychological well-being of participants. After an average of two years on puberty blockers, the children exhibited decreased behavioral and emotional problems, and their general functioning improved notably.

Dr. Anelu de Frise:
[28:27] "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."

However, the study also acknowledged limitations, such as a small sample size and potential selection bias, underscoring the need for more comprehensive research.

Dr. Anelu de Frise:
[30:18] "She wrote that her study sample was small and came from one clinic. 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."

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Global Influence and Diverging Approaches

The Dutch protocol gained international attention, influencing transgender healthcare standards worldwide, notably being incorporated into the WPATH Standards of Care. However, as the protocol spread, variations emerged, particularly in the United States, leading to a divergence between the rigorous Dutch assessments and the more affirmative American approach.

Manon:
[33:04] "And to them, they were, like, very interested because there was this new thing to help."

Peggy:
[33:11] "Yeah, yeah, yeah. I don't want to pinpoint to colleagues that they are sort of the source of the things that the criticism that that's happening now. It's only quite recently that I've really been convinced that, yeah, maybe especially in the United States, there is approaches that are different from the approach that we are doing."

This divergence sparked debates over the protocol's integrity, with critics arguing that some adaptations were too lenient, potentially undermining the protocol's original efficacy.

Azine Ghreshi:
[34:31] "I would try to remind people that actually, you know, what I'm doing is so much less than what the Dutch do... So the fact that you're wanting to do, like, significantly less, less than my already pared down Dutch protocol is a little crazy."

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Conclusion and Reflections

The Gender Kids episode concludes by reflecting on the enduring impact of the Dutch protocol through personal stories like Manon's and the ongoing debates surrounding transgender healthcare. It underscores the balance between medical rigor and compassionate care, highlighting the protocol's role in shaping the lives of transgender youth while acknowledging the complexities and controversies it continues to navigate.

Manon:
[26:57] "Yeah, a nightmare I cannot even imagine... I can live my life now, how I live it. A normal job. I have a good background... I just enjoy life."

This episode of The Protocol offers a comprehensive and empathetic exploration of transgender youth medical care, illustrating both the profound benefits and the intricate challenges of the Dutch protocol as it adapts to diverse cultural and medical landscapes.

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Notable Quotes:

• Peggy (00:40): "That assessment was several sessions over a longer period of time and actually really get to know the family, get to know the kids."

• Austin Mitchell (Manon at 30) (19:22): "But I was so happy with it because I was very aware that I did not want anything to do with male puberty... it felt like a gift."

• Dr. Anelu de Frise (28:27): "Behavioral and emotional problems and depressive symptoms decreased while general functioning improved significantly."

• Manon (33:50): "There is a fear that the Dutch approach has been this rigorous... and the American affirmative approach... has somehow endangered everything."

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Final Thoughts

The Gender Kids serves as a crucial narrative in understanding the evolution and current state of transgender healthcare for youth. By intertwining personal experiences with clinical research, the episode provides a balanced perspective that informs, engages, and challenges listeners to consider the multifaceted nature of transgender medical interventions.

Transcript

[Peggy]

I mean, when I started working here, Peggy just moved from Utrecht.

[Dr. Anelu de Frise]

Dr. Anelu de Frise 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 AD. And critically, the mental health assessments that were designed to help figure out which kids should get medical intervention.

[Peggy]

That assessment was several sessions over a longer period of time and actually really get to know the family, get to know the kids.

[Dr. Anelu de Frise]

And how long typically would you say you spoke with them?

[Peggy]

So it takes at least half a year. But what we say, we take the time we need. So you cannot pinpoint me on how.

[Manon]

Much time some kids might need. More than that. Yeah, yeah.

[Dr. Anelu de Frise]

And over time, as a growing number of kids were being referred to the.

[Manon]

Clinic, it was obviously a radical new idea, a new option. What were sort of your concerns and questions you wanted to answer?

[Peggy]

Well, yeah, of course we needed proof of the effectiveness of the treatment.

[Dr. Anelu de Frise]

Anu started to study the kids they were treating.

[Manon]

What research had been published by 2003, when you started working with the group.

[Peggy]

There was the case publication.

[Manon]

Case study.

[Austin Mitchell]

Yeah.

[Dr. Anelu de Frise]

At that point, there wasn't any data to support using puberty blockers for kids with gender dysphoria.

[Peggy]

My.

[Dr. Anelu de Frise]

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. So Ana Lu 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.

[Peggy]

That's the 2011 study, the famous. Yeah, well, that was the first one that did some evaluation of really the medical intervention.

[Manon]

The Dutch protocol.

[Peggy]

The Dutch protocol.

[Dr. Anelu de Frise]

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 Ana Lu found launched the field of youth gender medicine in general.

[Peggy]

I think people were sort of convinced. Yeah. This is so clear cut if you look at this. Yeah.

[Dr. Anelu de Frise]

Ana Lu got up and led us to her nearby office and dug around her shelves.

[Austin Mitchell]

I still have one. Oh, wow.

[Manon]

It's a big buck.

[Dr. Anelu de Frise]

She pulled out an enormous coffee table book. On the COVID it said gender Kinderin. Gender kids.

[Peggy]

So these were the very first children that were treated here. They called themselves gender kids. I have gender because the whole word gender identity disorder was too complicated. So they just said, I have gender.

[Austin Mitchell]

Wow.

[Manon]

Are these patients that you saw? Yeah.

[Dr. Anelu de Frise]

She flipped through. It was filled with full page color photographs of some of the kids who took part in her research.

[Peggy]

So, for example, Manon.

[Dr. Anelu de Frise]

And she pointed to one kid in particular.

[Peggy]

Manon is the one who wants to talk.

[Dr. Anelu de Frise]

Someone who could help us understand how the Dutch protocol worked.

[Peggy]

This is Manon.

[Austin Mitchell]

Yeah.

[Peggy]

And she's now 30.

[Dr. Anelu de Frise]

I think 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.

[Manon]

Oh, no, I'll do it.

[Dr. Anelu de Frise]

From the New York Times, I'm Austin Mitchell. This is the protocol with Azine Ghreshi.

[Manon]

We're gonna meet her at her house and hear about her life with, you know, actually going to that clinic, like, probably far in the rearview mirror. So interesting.

[Dr. Anelu de Frise]

Part two.

[Manon]

All right, thank you very much.

[Dr. Anelu de Frise]

The gender kids.

[Austin Mitchell]

So we'll just sit on the table, have just like a conversation. And you will just record it.

[Manon]

Yeah. And if there's anything that you're like, you don't want to be public or.

[Dr. Anelu de Frise]

That there are not a lot of people in Manon's life who know the role she played in Ana Lu's study.

[Manon]

Have you ever talked to the media before?

[Austin Mitchell]

Yeah, when I was a kid and with the book. But later I worked with a Dutch programmer.

[Dr. Anelu de Frise]

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.

[Austin Mitchell]

It did happen that I had a new job and someone googled me. Then I hear later that, oh, your video is going through the whole company. So that was very unsafe. That was not nice.

[Dr. Anelu de Frise]

So we've agreed to use only her first name.

[Austin Mitchell]

And I thought also, I believe that if Anna Lou speaks with you, then it's for me safe to also speak with you. Yeah, I did want to ask it with that.

[Manon]

I mean, I want to hear your whole life story. Getting into everything. Meeting Anu.

[Austin Mitchell]

I can't remember. It was literally Wednesday afternoon, a few hours. And there were with a few colleagues, Peggy on the loo and the other doctor. And I think not a few. So it was all very small. And I did Realize I was a. Yeah. How do you call it? Yeah, we say pufkun, a trial.

[Manon]

Like a.

[Austin Mitchell]

A rabbit that they test, make. Yeah, yeah. Like where they test things on. So yeah, they have to test it on someone. Well, yeah, fine by me. Yeah, yeah.

[Dr. Anelu de Frise]

Manon's experience going through the Dutch protocol, along with the other kids Anilu studied was captured in a handful of papers. There was anu's seminal study. There were also a few other scientific articles that outlined in detail how the protocol worked. And what Anilu made clear in these papers was, 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. Ana Lou wrote that some of the kids who came in were gay and, 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. She explained in one study that for these kids 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. Anelu said that in all of these cases, kids should get psychological counseling, but in order to get medical intervention.

[Manon]

What was your early childhood like? Did you gravitate towards different friends?

[Dr. Anelu de Frise]

Kids had to meet a certain set of criteria.

[Austin Mitchell]

I heard from my mother that on a very, very young age, I maybe three years old, I did not understand why my cousin had long hair and I did not.

[Dr. Anelu de Frise]

The first thing that was mentioned in all the papers was an early history of what at the time was called gender identity disorder. 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.

[Austin Mitchell]

Always walking in my mom's clothes, wearing towels as skirts or long hair. I wanted to play with girl stuff. And then, yeah, she always said, yeah, but you're a boy and you have a penis. And then I said, no, I'm not a boy, I'm a girl and the penis will fall off. I always believe that. Do you remember like, yeah, yeah, absolutely, yeah. And I can also remember, I don't know if it's also in the usa, but like in Holland, if you don't close your. The zipper from Your trousers, they say, ah, then it will fly away. So I always walks with my zipper open. And I was so, yeah, convinced that, yeah, something was wrong and it will get fixed. Then I came like the realization that it will not fall off or fly away. Ah, shit, it's not going to fly off. And I am a boy, but I do not feel like one. And then I really did everything to be the best boy in the world. So I had like this sharp hair and with the gel and very boy clothes. And I climbed trees and hit people and was fighting. And yeah, so my mom said, I saw that you were so struggling being a boy, literally. So yeah, I can also remember the phase that I was very, yeah. Really, really unhappy. Yeah. And that they really said that I said, oh, I will cut it off, then they have to help me. Or. Yeah, my parents were really scared that I would maybe hurt myself. Yeah.

[Manon]

Were you? Were you? I mean, in terms of how your parents reacted, were they kind of steering you back towards boy things and trying to just.

[Austin Mitchell]

Well, I think they left me very free. I was really raised with everything is okay. And I think I always had a very strong intuitive connection with my mother.

[Dr. Anelu de Frise]

Another part of the criteria Ana Lu wrote about in her papers was that kids had to have the support of their parents or other caregivers.

[Austin Mitchell]

That moment, I think for my mother was, okay, we have to do something and help you. And. But also very, very open, also from, okay, are you sure that this is what you want? Are you sure that. That you want to go outside as a girl? Are you. Do you know that you will be bullied that people would have an opinion about you? Oh, it gives me chill when I say it, but very open with me, nearly like an adult conversation. But I was 8 years old, so if I see a child.

[Dr. Anelu de Frise]

Anulu 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.

[Austin Mitchell]

I went with my mother and we went to the H and M, bought loads of clothes and my first, like small heels and girls clothes.

[Dr. Anelu de Frise]

In Manon's case, her parents had started to let her dress as a girl when she was in elementary school.

[Austin Mitchell]

So as soon as I came out of school, curtains closed, and then I changed. And I think I change every day, 10, 15 times.

[Manon]

You mean just like put on different outfits?

[Austin Mitchell]

Yeah. And also my dad said a while ago, like you were looking in the mirror the whole day.

[Dr. Anelu de Frise]

At first just at home, and then shortly after, and then in public.

[Austin Mitchell]

I said, I want to go to my friend. Her name was Brenda. And to show the new me. That was like, really.

[Dr. Anelu de Frise]

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.

[Austin Mitchell]

Not a nice place because it was very vulnerable there. All the kids, and kids are harsh.

[Dr. Anelu de Frise]

That day, she used a back alley, so none of the other kids saw her on the way there.

[Austin Mitchell]

And then my mom said, if you want, later, I can pick you up, and then we can walk together through the playground. She said, if. Think about it, if you want it, call me. And I thought, yes, I want that. So my mom picked me up, and she hold my hand, and we walked. Yeah, I was. As a girl. Yeah. And then we walked outside and with my head up high, and everyone was outside and watching, and, yeah, everyone was like, yeah, in shock.

[Manon]

But you felt there's something.

[Austin Mitchell]

It was so. Yeah. That finally I looked. Yeah. How I felt. And also the strong hand from my mother and very protected. It was a very, very special moment, but also the moment of, okay, we're out now, and we're going for it.

[Dr. Anelu de Frise]

But when Manon first got to the gender clinic.

[Austin Mitchell]

Yeah, we went there, and in the beginning, they were very lay.

[Manon]

Hands off.

[Austin Mitchell]

Hands off. Yeah. Yeah.

[Manon]

Because you were so young.

[Austin Mitchell]

So young. They said, okay, don't stimulate, don't force anything.

[Dr. Anelu de Frise]

Her family was told to slow down, to not do anything that might influence her.

[Austin Mitchell]

We see a lot of children who say it, and later on, they, yeah, make a different decision.

[Manon]

And in the US The Dutch method was called watchful waiting. So it was like, you know, a lot of the kids by puberty might change their minds. So wait as long as you can till puberty.

[Dr. Anelu de Frise]

What Ana Lu 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. But Ana Lu 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, 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.

[Austin Mitchell]

That was uncomfortable because we had such A strong intuitive connection. She was like, very. No, I know my child. And this is not something from yesterday. And we are not these parents who, yeah, prefer a daughter or something. No, it's not the case. So later on, we came at Honolu.

[Dr. Anelu de Frise]

It was around this time that Ana Lou joined Peggy at the clinic to help lead the assessment process.

[Austin Mitchell]

In the beginning, it was only questions.

[Manon]

Questions, questions, Evaluations, assessments, assessments.

[Dr. Anelu de Frise]

She wrote that the process was designed to track how a child's gender dysphoria developed over time.

[Austin Mitchell]

How do you feel? How are you at school?

[Dr. Anelu de Frise]

And to rule out any other psychological issues or things going on in their life that might be another explanation for their distress.

[Austin Mitchell]

A lot of questions, but my dad really can remember very well what really made impact on him. A lot of children who are sexually abused, like a small girl is abused, they can also have these feelings that they prefer to be a boy with the feeling that, oh, if I were a boy, the person did not abuse me or. Yeah, so, yeah, that my dad really can remember that. They asked me a few times different ways if I was all sexual abused, if my dad touched me strange or my granddad or. Yeah, and he thought that was really heavy. And also that he had meetings on his own together with my mother or my mother on her own. So, yeah, he said sometimes it felt like an investigation on us as parents. Yeah, I thought that was very worth it, of course. But I think it was, yeah, around one year that we. Yeah, they got. We received, like, the diagnostic. Yeah, the diagnosis, gender dysphoria. And then it was more like, okay, we just keep in touch. We follow up.

[Dr. Anelu de Frise]

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. And so as she was nearing 12 years old.

[Austin Mitchell]

So then I can remember, we went, like, in the next phase of the.

[Dr. Anelu de Frise]

Treatment, Manon started having a new conversation with Anulu.

[Austin Mitchell]

We talked about puberty blockers and also, again, all the questions again, because the.

[Dr. Anelu de Frise]

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. 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.

[Austin Mitchell]

It was really, yeah, very heavy and, yeah, very big. Yeah, we felt really serious about it also.

[Dr. Anelu de Frise]

And as Manon was learning about the blockers, she was also being monitored for any signs of puberty.

[Austin Mitchell]

Tested my blood every month, if I made testosterone. And I can remember that, yeah, one day we got a telephone. Yeah, we found testosterone, so you can start the puberty blockers.

[Dr. Anelu de Frise]

And finally, when she was 12, she began getting monthly shots that paused her development.

[Austin Mitchell]

But it was always very clear to me when I started that it. If I ever thought different or changed my mind or did not feel well about it or. Yeah, you can stop whenever you want and everything will start as normal, maybe a bit later. But I always knew it was temporary. I always knew that till the next phase were the hormones. I could stop every moment.

[Dr. Anelu de Frise]

And 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.

[Austin Mitchell]

But I was so happy with it because I was very aware that I did not want anything to do with male puberty. Yeah, with wet dreams and beard and. Yeah, yeah, it felt like a gift. And I was also very aware that we were.

[Dr. Anelu de Frise]

Over the next four years, Manon kept getting her shots.

[Austin Mitchell]

My blood, I think, every two, three.

[Dr. Anelu de Frise]

Months, going into the hospital all the.

[Austin Mitchell]

Time for tests, MRI scans, bone structure scans.

[Dr. Anelu de Frise]

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 again.

[Austin Mitchell]

Ol, how are you? How are you feeling? Are you aware? Because this is the stage that, yeah, you'll get, like, breasts or your body will change.

[Dr. Anelu de Frise]

And so now the conversation was about whether to move forward to a stage where treatment would have irreversible effects.

[Austin Mitchell]

And very important. My fertility.

[Manon]

Right?

[Austin Mitchell]

Yeah, yeah. And I can remember that. Yeah, I got the question. I really had to literally sign a form that I'm aware that, yeah, as soon as I start that my fertility will go and. Yeah, do you want children? Someone asks me, could be Anna Lou or someone else. I said, yeah, I don't know. I'm 16. Yeah. Because in this phase and fertility. And I said, okay, what's the other option? Well, the option was that I then had to quit the blockers for at least six months.

[Dr. Anelu de Frise]

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.

[Austin Mitchell]

Sperm, then go back to the hospital. Go in, I saw this room in front of me with the dirty magazines and then I could do a thing, but I never did because I. It made me sick even think of it. Yeah, master. How do you call it? Yeah. Masturbate in a. Hell no. Yes. I said hell no. So I signed. And yeah, to be honest now, do I regret that choice? No. But it does have impacts on my life. I'm now 30. Everyone around me is pregnant or has children or. Yeah. And of course, I think it's a very normal age that you think, oh, shit, I would also like kids or be a mom or anything. So do I regret the choice? Absolutely not. But it was a very big decision with impacts now still on my life.

[Manon]

Right.

[Austin Mitchell]

Yeah.

[Manon]

That is such a nuanced thing that you're describing, is both saying, I don't regret it. I, I know I made the right choice, but also that there can be a part of it that, you know, is difficult for you.

[Austin Mitchell]

Yeah. And we were always like, okay, when I was 12, PBT blockers. Then the next phase was 16. Yes. Hormones, next step in. And my end point was, oh, when the operation, I'm done, Finished, buster.

[Manon]

Right.

[Austin Mitchell]

I'm a woman, I'll never tell someone again and I'll live my life and I will do everything what all my friends did when they were 12, 13, 14, I will just do it when I'm 18, like with boys and experience and sex and all the things. I literally just put my life on pause. And yeah. So in the end, when the point came when, ah, I'm now done.

[Manon]

Right?

[Austin Mitchell]

You're never done. I mean, it's not so easy then to press play and, oh, let's go and take a guy home and have the first time sex. No, that's really difficult. I'm so scared to be hurt by someone because I built as a small child such a big wall as the fence. And literally if someone stick a finger out, I took the whole arm and I broke it. Yeah, I did that literally once. So, yeah. And so it helped me the defense and made me strong. But I still have that naturally in me that the wall, the brick wall. I have to be strong, I have to be tough. I have to fight for myself, for my rights, for my yeah.

[Manon]

Hard to be vulnerable.

[Austin Mitchell]

Very. Yeah. Yeah.

[Manon]

It's so funny, you talking about boundaries and walls because, you know, I'm a reporter. I talk to people all the time, and you are so open and so evocative about. I mean, just your life experience. You feel it and you communicate it. And do you. Are you out as trans? Like, do you. Do some people just. I mean, obviously, who has to explain themselves to every single person they meet? But, like, at work.

[Austin Mitchell]

And I will not say I'm fully out, but, yeah, to be honest, I do not have to tell anyone. I mean, without being arrogant, you could not see it. You do not hear it. No one will ever, if they meet me, think, oh, she's transgender or. Yeah.

[Manon]

I mean, the. The sort of gift of the intervention that the Dutch came up with is that if you do interrupt that early block puberty, like, you never went through any of the changes that would make it more difficult, maybe down the line. I mean, do you have other friends who are trans women who didn't go through the child?

[Austin Mitchell]

Yeah, my best friends.

[Manon]

And how do your experiences differ?

[Austin Mitchell]

Yeah, very different, because. Yeah, you see it maybe or you hear it a little on her and. Yeah, she works in a. In a restaurant. A few weeks ago, a guest asked her, are you a guy or a woman, or do I need to call you miss? Or him? Yeah, she totally freaks out and cries and. Yeah, I. I never have that. Never. That's so hurting. Just because people know. Yeah, they hurt you with that.

[Manon]

Right. So when you think back on being able to go through this as a kid, like, if you imagine a life where you couldn't and had to wait till later, like, do you think that would be.

[Austin Mitchell]

Yeah, a nightmare I cannot even imagine. Yeah, I think maybe I did not even live. Yeah, I think I would maybe hurt myself or. Yeah, I think so. Because of our treatment that I luckily could get. I can live my life now, how I live it. A normal job. I have a good background. I have. Yeah. I just enjoying life, so going out for dinner, parties, festivals, traveling. I am also a person on Friday evening after, like, a work week, I love to just sit here and watch a series or a movie with my cats and close the curtains.

[Manon]

Do you guys have reality TV here?

[Austin Mitchell]

I love reality tv. I love the Real Housewives of Beverly Hills. Real houses, New Jersey. We now have Real Housewives of Amsterdam. You know what I mean? Yeah, it's amazing. They are crazy. They watch, I think too much.

[Peggy]

These kids were like, yeah, good, well functioning, nice kids doing their thing in 2011.

[Dr. Anelu de Frise]

Ana Lu published the results of her study that had followed manon and the 69 other adolescents who received puberty blockers.

[Peggy]

Using the protocol and they were doing better psychologically.

[Dr. Anelu de Frise]

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.

[Peggy]

But regarding their gender dysphoria, no improvements.

[Dr. Anelu de Frise]

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.

[Peggy]

There was no affirming treatment really.

[Dr. Anelu de Frise]

But the study had continued to follow the group as they moved on to cross sex hormones and after they were 18, surgery. And Anulu 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. 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, Ana Lu found that the 55 patients she had been following for years were generally satisfied with their physical appearance and none regretted treatment. 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 Anulu said that her study had a few limitations because that was of.

[Peggy]

Course, only a small group of adolescents that start.

[Dr. Anelu de Frise]

She wrote that her study sample was small and came from one clinic. 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. 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.

[Peggy]

It'S scientifically really, really difficult to think about what sort of control group that would be.

[Dr. Anelu de Frise]

For example, 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 and that the group who did receive the intervention would be given the enormous and lifelong advantage of not being identifiable with their assigned sex at birth. In the conclusion of her second paper in the study, Ana Lu said that the results signified the first evidence to support this new treatment protocol. She called the findings promising, 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.

[Peggy]

It's not only the medical approach, but it's the whole approach. So it's psychological assessment, but also psychological counseling if necessary, addressing really psychiatric problems, family difficulties, family challenges.

[Dr. Anelu de Frise]

It was the approach they took.

[Peggy]

I like that how we did that.

[Dr. Anelu de Frise]

But even before Ana Lu published her.

[Peggy]

Results, we both wrote reviews preparing the revision of the standards of care.

[Dr. Anelu de Frise]

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.

[Peggy]

And, yeah, other clinicians became interested, and.

[Dr. Anelu de Frise]

Providers from all over the world started visiting the Amsterdam clinic.

[Peggy]

And they sit in with our team meetings. Yeah. So.

[Manon]

And to them, they were, like, very interested because there was this new thing to help.

[Peggy]

Yeah, yeah. And they thought they could learn from us how we did that.

[Dr. Anelu de Frise]

And as they brought the care back to their countries, not everyone was following the protocol.

[Manon]

The sense I got from some people, I think even from talking to you last time we talked, was there is this fear that the Dutch approach has been this rigorous. There's a process for evaluation. Assessment is central. And the American affirmative approach and just how it has played out in our fractured health care system has somehow endangered everything. Like that it broke. Maybe something that you started. You're nodding. Is that.

[Peggy]

Yeah, yeah, yeah. I don't want to pinpoint to colleagues that they are sort of the source of the things that are the criticism that that's happening now. It's only quite recently that I've really been convinced that, yeah, maybe especially in the United States, there is approaches that are different from the approach that we are doing.

[Dr. Anelu de Frise]

Next time in part three, you know.

[Azine Ghreshi]

I would try to remind people that actually, you know, what I'm doing is so much less than what the Dutch do, which is the model that we have, the only research to support this whole thing that we're talking about. And so the fact that you're wanting to do, like, significantly less, less than my already pared down Dutch protocol is a little crazy.

[Dr. Anelu de Frise]

What happened when the Dutch protocol got to the US.