Medical Care for Transgender Youth: ‘The Protocol’ Podcast

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

archived recording (donald trump)

With the stroke of my pen, on day one, we are going to stop the transgender lunacy.

[CROWD CHEERING]

archived recording 1

I am so hated for just existing and being who I am.

archived recording (donald trump)

It will henceforth be the official policy of the United States government that there are only two genders, male and female.

archived recording 2

How has this impacted us? Well, it was already not a safe place, but now we feel like asylum seekers in our own country.

archived recording (donald trump)

And now, I want Congress to pass a bill permanently banning and criminalizing sex changes on children and forever ending the lie that any child is trapped in the wrong body. This is a big lie.

[APPLAUSE]

archived recording 3

Being able to transition absolutely saved my life.

austin mitchell

It’s only been about two decades since trans and gender-nonconforming kids in the US 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.

archived recording (brett kavanaugh)

If the treatment’s barred, some kids will suffer because they can’t access the treatment. If the treatment is allowed, some kids will suffer and get the treatment and later wish they hadn’t. And then the question becomes, how does the court choose which group?

[MUSIC PLAYING]

archived recording 4

Trans rights! Human rights!

archived recording (ron desantis)

You do not have the right to abuse your kids. This is cutting off their genitals!

archived recording 5

I’m scared for myself, for my own health care.

archived recording (jim olsen)

There’s not enough evidence to put our children out on a huge experiment.

archived recording 6

If they cannot get treatment, children will die.

archived recording (ralph massullo)

These treatments do much more harm than good.

archived recording 7

Trans kids are under attack! What do we do? Stand up, fight back!

archived recording (matt walsh)

We are not going to rest until every child is protected, until trans ideology is entirely erased from the Earth.

archived recording 8

We are trans people! We are trans human! And we will never be eradicated!

azeen ghorayshi

Um, so are you going to be able to bring that inside? No.

austin mitchell

I don’t think so. No. We’re going to leave it out here.

austin mitchell

This is a story of how we got here.

azeen ghorayshi

That’s why I wonder if they’re going to even let our phones in.

austin mitchell

It’s a story I’ve been reporting with my colleague, Azeen Ghorayshi, a science and gender reporter, for nearly two years.

azeen ghorayshi

Let’s see what they say.

austin mitchell

OK.

azeen ghorayshi

For now.

austin mitchell

And it’s a story she’s been reporting for much longer.

azeen ghorayshi

We have so much ground to cover with her.

austin mitchell

And from the beginning, she’s been telling me this is not just a story about politics.

azeen ghorayshi

Just getting into the history and —

austin mitchell

It’s a story about medicine, about a new kind of treatment for a small group of kids.

azeen ghorayshi

We are going to the outpatient —

austin mitchell

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 —

azeen ghorayshi

It’s such a sensitive topic and —

austin mitchell

— the medicine and the politics have become impossibly entangled.

From “The New York Times,” I’m Austin Mitchell. This is “The Protocol” with Azeen Ghorayshi. Part one, “The Beginning.”

OK, so where does this story start then, in your mind?

azeen ghorayshi

Yeah, so there have always been a small number of young people who have felt this deep disconnect between their inner sense of themselves, as boys or girls, and their bodies — you know, how they’re seen by society. But when it comes to the medical story, and when these kids are actually beginning to interact with the medical community, there’s actually a really clear beginning. And it’s one that pretty much everyone in the field knows about and points to, and it starts in the Netherlands.

The Netherlands is this small, very socially liberal country. And back in the 1950s, they were among the few countries in the world that were actually treating trans patients, so at this point, just adults, medically.

So at the time, the mainstream medical establishment really viewed trans people with a lot of suspicion. And so if a trans person came into a doctor’s office, saying that they felt like they were in the wrong body, often those doctors would assess those patients as being mentally disturbed or sexually deviant, or even psychotic. And so if they got any health care at all, it would usually be from an analyst or a psychiatrist.

austin mitchell

And those professionals would be trying to convince these people that they —

azeen ghorayshi

They would talk them out of it. I mean, it was sort of corrective, trying to convince them to let go of the idea that they could ever live as the opposite sex.

But there were a small number of doctors around this time who felt like that approach was actually failing these patients, that it was completely ineffective in addressing the pain that they were feeling. There’s a foundational medical book from around this time on trans medicine that talks about this. One second.

It says that these patients that were treated with psychotherapy languished and that, quote, “The majority were miserable, unhappy members of the community, unless they committed suicide.” So you know, what some of these doctors were doing at around this time was actually listening to what these patients were saying and believing them that what they needed was to change their bodies. And so these doctors were treating these patients with hormones, giving trans women estrogen so that they developed female characteristics, giving trans men testosterone so they developed male characteristics. And they also performed surgeries.

peggy cohen-ketness

Yeah, well, it started — started long ago.

azeen ghorayshi

And so by the 1980s, as these treatments were becoming a little less fringe —

peggy cohen-ketness

I just had my PhD, and I became —

azeen ghorayshi

— a clinical psychologist named Peggy Cohen-Ketness started to research how these patients were actually doing.

peggy cohen-ketness

— first follow-up study in the Netherlands.

azeen ghorayshi

This is for adults?

peggy cohen-ketness

For adults, yeah, yeah. Because the children were — no way that anyone would do something with children.

azeen ghorayshi

And she found that while they were still struggling — there was still a pretty high risk of suicide in the group — the vast majority of the patients reported feeling happy about their medical transitions.

peggy cohen-ketness

And so I became —

azeen ghorayshi

And at the same time that Peggy was doing this research —

peggy cohen-ketness

But I was also a psychotherapist.

azeen ghorayshi

— she also had a clinical practice.

peggy cohen-ketness

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.

azeen ghorayshi

And she started getting a few referrals for younger patients who are 16, 17, and who are saying really similar things as the adult patients — that they had felt they were in the wrong body for as long as they could remember.

peggy cohen-ketness

These kids already had a lot of mental health care. They’re functioning quite well.

azeen ghorayshi

But because they weren’t 18, they couldn’t get treatment.

austin mitchell

Right.

peggy cohen-ketness

I thought, that’s a bit silly.

azeen ghorayshi

Mm-hmm.

peggy cohen-ketness

For years and years, they very well know what they want. But because they don’t have the right age, they have to wait.

azeen ghorayshi

And, you know, Peggy knew that there was already all this skepticism about treating trans patients at all, and she knew it was going to be way more controversial if she tried to treat these kids who were under 18.

austin mitchell

Right.

azeen ghorayshi

Adolescence was known to be this period of great flux and identity exploration, and she knew there would be a lot of skepticism about whether they could make a decision like this. But she also saw that not every teenager could handle their distress for a prolonged period of time, that having to wait to get medical treatment could lead to the same dire outcomes that she saw in the adults that she’d been working with. So in her mind, if a 16 - or a 17-year-old was expressing as much clarity about who they are as an 18-year-old, they should be able to get help. So she went to the lead endocrinologists overseeing hormone treatments for trans adults in the Netherlands.

peggy cohen-ketness

— and said, can we do something about that age limit? And they said, OK, we can start it a little bit earlier.

azeen ghorayshi

And together, they decide they’re going to lower the age that patients can receive hormones from 18 to 16 and actually study it to see if it helps. And what they found was really interesting because —

peggy cohen-ketness

This looked promising, and —

azeen ghorayshi

The kids who got hormones were doing better psychologically than the adults they’d been treating.

austin mitchell

Hmm.

azeen ghorayshi

And she thought that part of the reason why was because they had what she called — and she wrote this in the paper — a convincing appearance. She wrote that they could more easily pass in society, because intervening earlier had managed to block some of the effects of their natal puberty before it had fully set in. And so what Peggy was realizing was that puberty was this incredibly critical period in these patients’ lives.

austin mitchell

Mm-hmm. Right. A turning point.

azeen ghorayshi

Yeah, in their development, I mean, they’re going through these irreversible changes that will be much harder to undo further down the line. And this was becoming even more clear to her as she started to see younger kids —

peggy cohen-ketness

— 14 - and 15-year-olds, and then, an occasional 12-year-old —

azeen ghorayshi

— kids who were in extreme distress, kids who hadn’t yet gone through puberty or were just starting to, and their distress was actually being exacerbated by that, or even by the prospect of going through puberty. So there’s a scientific paper from around this time that talks about how in the years before puberty, these kids would engage with a kind of magical thinking. And it was this belief that one day, they would just wake up and their bodies would finally match the way they felt inside.

And what Peggy was seeing was that puberty just shattered this magical thinking. And it made these kids feel like their bodies were basically betraying them, that they were actually becoming less and less the way they felt inside. And there was nothing they could do about it.

peggy cohen-ketness

But we said, we don’t — don’t give up.

azeen ghorayshi

And just as Peggy was starting to recognize the significance of this moment for her patients —

peggy cohen-ketness

And then I came across FG.

azeen ghorayshi

That’s when a kid walked into her office and offered an unexpected solution.

austin mitchell

I don’t know exactly how we’ll refer to him.

austin mitchell

In 1990, a 16-year-old kid showed up at Peggy’s office.

azeen ghorayshi

In, like, our early emails, we had talked about what his comfort level was with his voice even appearing in this.

austin mitchell

His voice? He knows I’m recording, right?

azeen ghorayshi

He knows you’re recording.

austin mitchell

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.

azeen ghorayshi

So we’re coming up on his number.

austin mitchell

And that’s how we found ourselves on a quiet street in a European city we’ve agreed not to name —

austin mitchell

Hi.

azeen ghorayshi

Hello!

fg

Hi. Perfect.

azeen ghorayshi

Hi.

fg

Hi, nice to meet you.

austin mitchell

— to meet with the first person ever given puberty blockers to treat gender dysphoria.

[DOG BARKING]

azeen ghorayshi

Do you mind if keep my shoes on?

fg

Yeah, yeah, yeah.

azeen ghorayshi

Yeah?

austin mitchell

Dodging the dog, we stepped into a bright upper-floor apartment.

austin mitchell

I love these big windows.

azeen ghorayshi

I know. It’s beautiful. The light is so nice.

austin mitchell

The walls were covered in bookshelves. The floor was covered in dog toys. And there were cats, too — somewhere, we’d been told.

fg

Can I get you a coffee or tea or something?

azeen ghorayshi

Can I have coffee?

austin mitchell

If you’re going to have something —

austin mitchell

He brought out some coffee, some pastries, and gestured to us to sit at the dining room table.

azeen ghorayshi

And what is your comfort level with your name? FG is what we’re sticking with? Yeah. OK.

austin mitchell

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.

fg

And I’ve spent my whole life being covert and —

azeen ghorayshi

Right.

fg

So.

azeen ghorayshi

Yeah. What is your — do you share with people in your professional space and your —

fg

No, I don’t — I —

azeen ghorayshi

You’re just a man in the world.

fg

I try to get away with a murder. I literally don’t tell people that knew me when I was — before my transition. No.

azeen ghorayshi

So they don’t know that you played this, like — do you feel like you played a seminal role?

fg

I did.

azeen ghorayshi

Yeah, you did.

fg

Yeah, that’s one of my bragging rights, right?

azeen ghorayshi

Yeah.

fg

I was the first person, so I was like the Guinea pig.

azeen ghorayshi

So some people do know that — like, people close to you know —

fg

No, the people that — no, the people that are close to me and the people that need to know or I’ve told —

azeen ghorayshi

Mm-hmm.

fg

Oh, then I love to share, because it’s something that — there’s so much that’s happened, and it explains so much of your personality, your character, your decision-making.

azeen ghorayshi

Yeah.

fg

It’s nice to be able to have somebody to talk to about that. But it doesn’t need to be common knowledge.

azeen ghorayshi

Right.

fg

Because —

austin mitchell

FG asked that we protect many of the identifying details of his life today.

fg

And if you do mention my profession, then kind make it a medical profession rather than —

azeen ghorayshi

Very vague.

austin mitchell

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.

fg

I think that was just to show that I’d managed to achieve some kind of level of profession, which is not completely stupid.

azeen ghorayshi

No, but there is this coded, like, well, did he turn out OK? Did he succeed in life?

fg

Yeah. If I was some loser, then that would be another thing they could hitch to the bandwagon.

azeen ghorayshi

Right.

fg

I mean, I could be a loser anyway, regardless.

azeen ghorayshi

[LAUGHS]:

fg

I know many normal, like, cis people that are complete losers.

azeen ghorayshi

Yeah.

fg

So — actually, more than —

Well, but I think — no, no, sorry.

[MUSIC PLAYING]

azeen ghorayshi

Maybe to start, tell me a little bit about just your life growing up, like early childhood.

fg

My mother is — well, was English, because she died. My father’s Italian, and they’re quite, um — well, I think my mother was more liberal than my father, because he came from a small village, and he’s Italian. You probably read that in the case report as well.

But you know, I had more or less — I had a pretty happy childhood. But I was very — I was very aware of my, um, frustrations, which at the time I didn’t see as frustrations. I just didn’t understand. And I just assumed that would itself out.

azeen ghorayshi

When you say “frustrations” and “sort itself out,” you mean, sort of, the things that you were drawn to or the people you were drawn to? Like, what?

fg

Well, in the sense that — being a boy or a girl. [CHUCKLES]

azeen ghorayshi

Right.

austin mitchell

In the first case report, Peggy noted that FG, who was born female, quote, “wished to be a boy from early on.”

fg

And I was — I remember being five and coming down, and I had to wear, like, a dress thing. And I put a safety pin in between, because I wanted to — I wanted to be like Knickerbockers. And —

azeen ghorayshi

Oh, so you put, like —

fg

Yeah.

azeen ghorayshi

— two, to connect to the front and back.

fg

Yeah, yeah, exactly. Because I was like, why am I wearing — why am I wearing a dress?

azeen ghorayshi

That’s very innovative.

fg

Yeah, it’s quite smart. Then, I was. Now, I’m not. But —

azeen ghorayshi

[LAUGHS]:

fg

And, um, when I had a choice in the matter, I had my hair cut short.

azeen ghorayshi

Mm-hmm.

fg

I’ve never had it long again.

azeen ghorayshi

Wow.

fg

And so I think my parents just thought I was a tomboy. I was pretty rough and ready and rambunctious, and I tussled. I fought. All my friends were boys — you know, the usual cliche. I did — I played football, blah, blah. I did judo, all these things. But I was quite aggressive.

azeen ghorayshi

Mm-hmm.

fg

Because I was very, uh — I guess, in retrospect, very, um, geared at proving myself as, you know — so that we didn’t have to go into the formalities and say, this is who I am, and I was so overwhelming that people just had to deal with me. And half of them didn’t even know if I was a boy or a girl. And that was my protection. But I was not unhappy — when I was little.

azeen ghorayshi

You weren’t unhappy, but it was — was it an expression of frustration? Or was it more just an assertion of —

fg

Up until about 9 or 10, it was an assertion — 11. Up until then, I thought, oh, it’ll still work out. It’ll still work. One day, I’ll wake up, it’ll be fine. And then as I hit 12, 13, and puberty started to set in, I started to get really worried. Because then I was also aware of that, hmm, this is probably not going to work out how I want it to be.

azeen ghorayshi

It’s not going to just disappear.

fg

No. And my parents, up until then, had been pretty good, especially my mum. I was very close to my mum, and which put a little strain on the relationship with my dad, because he was also quite jealous, and I think he didn’t really understand. So then we would often sit around the table and have massive arguments, which is also quite Italian, so it’s very emotional.

And it wasn’t until I was 11 or 12, and then I started to become really anxious, which just, I think, translated to being even more aggressive, like, even more difficult and demanding and opinionated and axes to grind. And then —

azeen ghorayshi

Were you angry?

fg

Yeah, I was angry. But like I said, that made me — at school, I talked with my fists. I also talked with my mouth, because I was also very argumentative. But I wouldn’t tolerate anything. And if anyone said anything to me that I didn’t like, I’d smack them. But I would always smack people that were bigger than me —

[laughs]

which wasn’t —

azeen ghorayshi

Never punched down.

fg

No, exactly, which wasn’t very difficult, because I was small anyway. But, um, no, I was quite explosive, which —

azeen ghorayshi

And your friends — were they — you said they were mostly boys?

fg

Yeah.

azeen ghorayshi

And was — do you have any memory of it — of anything about your gender coming up with them, or did they just accept you as you were and —

fg

It did — well, it came up, but probably — and I don’t know what happened behind my back. I don’t care.

azeen ghorayshi

Right.

fg

I certainly didn’t care. But there was — I met — when I was 12, I met a girl. She was in my class, and she was also a bit of a tomboy. And we became very close very quickly. And it was at that time that the gym lessons were separated to boys and girls.

So the very first gym lesson where we had to do it, I was there with this person. And I felt such resistance. It felt wrong. I said, I’m not doing this. I’m not doing it. She said, no, I don’t want to do it either.

And then I — and so I went to the — I said, I want gym on the other side. And they went, OK. And ever since then, I always did gym with the boys, but so did she. And at the time, we both decided that we were boys.

And I was convinced that she was the same. And she just turned out to be quite a butch lesbian.

[laughs]

But we didn’t think anything of it. We didn’t feel foolish about doing that. And so it became — I think half of the people were just confused at that point.

azeen ghorayshi

Right.

fg

They’re like, what is this? You know? What are they?

azeen ghorayshi

Yeah.

fg

Yeah.

azeen ghorayshi

But it is interesting, thinking about that time and what you were saying about your anxiety increasing — that that is when the splitting starts to happen, right? Both with puberty and with school and with —

fg

Yeah, exactly.

azeen ghorayshi

— when sexuality and everything is — so was that all weighing on you at that time?

fg

I was really worried about what was happening, what was going to happen, because I could see it around me. And I was —

azeen ghorayshi

You mean puberty?

fg

Puberty, yeah. And that was something that I voiced to my parents in the usual prepubescent, adolescent, ridiculous, soppy way of writing poems and leaving notes, hoping that they read them. And then so my mum found one of these really pathetic poems and — which, clearly, I’d left there. And then she addressed it, and she —

azeen ghorayshi

Do you remember, kind of, what the poem said?

fg

It was along the lines of, uh, you know, if I can just — ugh, if I can just lay down my sword and blah, blah, blah. It was about battling this life and not being able to see a way out. And I think it was like with the undertone of suicide, but it wasn’t at all. It wasn’t at all. I can’t remember the exact, but it was — I think I blocked it from my memory.

azeen ghorayshi

Yeah.

fg

So that was the general sense of it — that I was feeling hopeless and desperate and blah, blah, blah, blah.

austin mitchell

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.”

azeen ghorayshi

Did your mom react in the way that you wanted, which was to —

fg

Yeah, yeah. Because she took it very seriously. And also my aunt, bless her, who did nothing but lie in bed and read — but read a lot — she happened to have just read a book on transsexuality. And she sent this to my mum and a couple of others. She goes, don’t you think that this might be what is the case? And I guess my mum thought, yes. So, made an appointment with a psychologist, and I started talking to her.

azeen ghorayshi

And so you were 12, so that would have been ‘86?

fg

Yeah.

azeen ghorayshi

Was your body changing? Were you —

fg

It was changing, but it was just, like it was prepubescent. And I can’t remember how long I was in conversation with this psychologist, but she put me on to Delemarre —

azeen ghorayshi

Mm-hmm.

fg

— who sadly has passed away.

austin mitchell

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 Henriette Delemarre-van de 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. And the treatment that Henriette 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.

fg

So I went to see her, didn’t have a clue who she was. And she, um, listened to my case. I think Louis Gooren came into it as well, who’s also just died. And —

azeen ghorayshi

Who was also —

fg

Yeah, yeah, he was the father of the whole gender team.

azeen ghorayshi

For adults, right?

fg

Yeah, yeah.

azeen ghorayshi

Yeah, came up with, like, basically — was a pioneer worldwide for adult care.

fg

Exactly, exactly. So they evaluated me, and then they decided that I would be a good candidate. No, they — well, I was the first to put on blockers.

azeen ghorayshi

Had they — did they come up with the idea in response to meeting you? Is that your sense?

fg

Yes, that is my sense. Only because I was the first, and because I was so convincing.

azeen ghorayshi

Yeah.

fg

And I’m not sure if the conversation had come up that, well, normally, what we do is, when you’re 16 or 17 — because I think that was when they started putting — the youngest age you could put your hormones in. And I was like, no, I’m not doing it. Why can’t we just — I think probably said, why can’t we just pause it now and just let me be?

So yeah, I just wanted to wake up and — that’s what I said — I just want to wake up, and I want to have been that I was born a boy, full stop, so that my history was congruent with that narrative. And I didn’t want to have to explain myself, because that made me feel weak, in hindsight, and it made me vulnerable. And my whole life, I was not about being vulnerable. So yeah, in a nutshell, that was probably — I just analyzed it. That’s probably what it was.

azeen ghorayshi

Yeah.

fg

And so they — so they took me seriously, and I think they said, well, this is such a bloody convincing case. Great idea to experiment on this child.

[chuckles]

My parents were behind it.

azeen ghorayshi

They were?

fg

Yeah.

azeen ghorayshi

So, I mean, you used the word “Guinea pig” earlier. Were they —

fg

Aware?

azeen ghorayshi

— aware?

fg

Don’t think so.

azeen ghorayshi

You don’t think they were aware it was the first — you were the first?

fg

Yeah, no, I don’t think I was aware I was the first.

azeen ghorayshi

Really? Oh, wow. OK.

fg

But, I mean, it wasn’t completely new, because these hormone blockers were being given to kids that were entering precocious puberty — and in the East Bloc countries, for gymnasts, but we don’t talk about that.

azeen ghorayshi

[LAUGHS]:

fg

So there is some kind of data there, right?

azeen ghorayshi

Or at least clinical experience.

fg

Clinical — yeah, exactly.

austin mitchell

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.

Henriette Delemarre-van de Waal 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. 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.

azeen ghorayshi

Do you think that would have scared you out of it?

fg

No, because there was an alternative.

azeen ghorayshi

It was sort of irrelevant?

fg

Yeah. It was like, otherwise, I’m leaving. I’m leaving this world — which I wasn’t, but it was that kind of, that — that was like —

azeen ghorayshi

The feeling was there.

fg

It was like, there’s no choice. We have to do something. This is not OK. I’m not doing this.

azeen ghorayshi

Yeah.

fg

I was putting my foot down.

azeen ghorayshi

Yeah.

fg

No, I could be very pigheaded. [CHUCKLES]

azeen ghorayshi

Yeah.

fg

So no, I’m not doing it. Nope, nope, nope, nope, nope. So, puberty, that was.

I mean, it literally saved my life. So I feel indebted.

[MUSIC PLAYING]

azeen ghorayshi

So, sorry — so you — so you started the blockers at 12.

fg

Yeah. 12 or 13.

azeen ghorayshi

Uh-huh. Do you remember the first time getting it and —

fg

I just — yeah, I do, and it hurt. Because there’s — you injected it into a muscle. And because I was also so, so body-critical, I didn’t want them to inject it into my bum, which is the much better option. So I had it done in my leg the first time, and that hurt like a motherfucker.

azeen ghorayshi

And had you met Peggy?

fg

No. Yeah, no. No, I met her — I think I got into conversations with her when I was about 16.

austin mitchell

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. 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.

fg

Yeah, I had to do a lot of psychometric and psychological testing anyway at various points in time. And I remember doing it with Peggy. I filled in a lot of paperwork. [CHUCKLES]

azeen ghorayshi

Yeah, yeah.

fg

A lot of questionnaires and —

austin mitchell

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. When she concluded that there were no psychological issues that might interfere with his decision, she recommended he begin hormone treatment.

fg

And then I decided I didn’t want to go onto them until I finished school.

azeen ghorayshi

OK.

fg

Because —

azeen ghorayshi

Why —

fg

Because I didn’t want to have to explain myself. Now, I just — I had frozen time. And if I went onto hormones — which is very paradoxical, because on the one hand, all I wanted to do was go on male hormones. I just didn’t want to have to explain it to people.

azeen ghorayshi

Right.

fg

Because, again, it would make me vulnerable. And why do I have to explain myself to you? You mean nothing to me. Well, they did, but you know what I mean. It just puts you in a very vulnerable position.

azeen ghorayshi

Right.

fg

I’ll never know how it would have been if I — If I’d said, hello, well, this is what’s going to happen — stand up in class, like, out yourself. I don’t want to do that. I never wanted to do that.

azeen ghorayshi

Yeah.

fg

So I chose not to.

azeen ghorayshi

Yeah.

fg

And maybe that’s my own little hang-up. But that’s just pretty much how I went through life.

azeen ghorayshi

[INAUDIBLE]

fg

Yeah.

azeen ghorayshi

And when you —

austin mitchell

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.” 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.

fg

I think that year was a bit stressful, to be fair, because you have this kind of underlying stress, a stress with phones. Because you’d answer, and you didn’t want to be considered a woman because you had a high voice, but at the same time — so that’s always a — that always stressed me out, especially when I — as your voice started to change, it just became difficult. Because, well, how are they addressing you now? So it was — you’re always thinking about those things — plus toilets. But —

austin mitchell

Even going to the clinic to get his hormone treatments was a stressful experience.

fg

I spent my whole time just sneaking in, I felt. I didn’t want people to point me out as, oh, that’s somebody that’s going to — ‘cause I just didn’t want to be seen.

azeen ghorayshi

Right, right.

austin mitchell

After a year on testosterone, he was ready to start university as a man.

fg

But there is still that transition of old life, new life. Who am I going to run into? What do I have to say? I’ve — even at university, I ran into people that were from my school.

azeen ghorayshi

Yeah.

fg

And I remember the one thing I said — I met this guy, and he was a year below me. And of course, he knew who I was. And he goes, oh, blah, blah, blah, and my voice is lower. And I went, oh, by — one thing — don’t say “she” to me. And that was the only thing I said to him, and that was it. We never talked about it again.

azeen ghorayshi

Wow.

fg

But there were a few dicey situations with somebody else that was — it’s amazing how small the world is, that some things got back to other people, and they confronted me with it, and I just laughed it off and pretended that I even — I made it ridiculous, because I said, oh, what, you think I want to be a girl? I just turned around, and these people were so confused that they dropped it. But that was pretty — you’re always — in the back of your mind, you’re always worried about these things, especially then. Because why do I want people to view me differently? That’s my whole thing. Then people start to look at you differently. I’m like, no, that’s exactly what I don’t want people to do, or feel that they have a special bond with me because they know something about me, which, at the same time — it’s OK, but at the same time, by saying that, you’re saying it’s a weakness. That’s what you’re saying. And they can use it against you whenever they like, even though it’s like faulting me for being small, which people still do. It’s still used as a weakness.

Like, it’s not my fault I’m small. What do you want me to do about it? It’s not something that I’m responsible for. I’m responsible for how smart I am, what I’ve done with my life. So you’re the loser.

[chuckles]

But not about how I was born into a body that didn’t belong to my mindset. And the only thing I can do is deal with it and be successful at it.

[THUD] Oh.

azeen ghorayshi

That was — [CHUCKLES]

austin mitchell

Right then, one of FG’s cats fell off a window ledge.

azeen ghorayshi

I saw it, yeah. [CHUCKLES]

fg

No, so anyway, so I have a lot to say about — but at the time, fuck off, I don’t feel like — why do I even have to have these thought processes? I’ve already got my defense ready if it ever came up. Because, no, I will not be treated in a different way or have the idea that you feel superior because, oh, poor you, you know. Fuck off. That hasn’t actually happened. But I’m — just to give you an idea of how my mind works.

azeen ghorayshi

Well, that’s valid. What you went through as an adolescent is still with you.

fg

Oh, absolutely. And that’s what’s formed me, and that’s how — that’s why I said, I’d never seen myself as a victim. But I do feel that I should get some credit for something, which — but obviously, I can’t, because then I’d have to put myself out as a victim.

azeen ghorayshi

Right.

fg

But you know, it is a big deal. No, it’s like, oh, be the martyr. You know, in my first year at university, I had three operations. Nobody knew about it.

azeen ghorayshi

Wow.

fg

And I completed my first year with flying colors.

azeen ghorayshi

Wow.

fg

And I didn’t think anything of it. And then, all the years to come, I was in and out of hospital with operations, and even a complication, where I had to rush myself off to hospital because I couldn’t pee anymore.

azeen ghorayshi

Oh, my god.

fg

And — but nobody had a clue. And then I had to make a story around that. And I thought, god damn it, I did all that.

azeen ghorayshi

Yeah.

fg

But I can’t say that. Do you know what I mean?

azeen ghorayshi

Yeah. I guess just this idea of wanting, your whole life, to blend in and blending in — and there’s been such a sea change in views and attitudes towards gender since the ‘80s. So many of the young people now want to visibly challenge the binary and — I don’t know, what do you make of that? And what do you make of what that means for getting the medical treatment that you pioneered? I mean, you know?

fg

Yeah, I think it’s a difficult question, because I do know I have a very strong opinion on that, but that’s my opinion, because it’s also fed by my own story. And I try to make the distinction between being — coming from that particular narrative and being narrow-minded.

azeen ghorayshi

Right.

fg

My conclusion now is that I find that it’s gone — it’s gone a bit extreme to the other side, so it makes a laughing stock of what it’s really about. Or at least, it seems to be a fashion statement nowadays. And it’s like when you were — in the ‘70s, you were a punker. In the ‘80s, you were a punker, too.

We always to — we have to fight against something. We need to — we’re forging our identities as young people, so we need to stand out. We need to have an opinion against the given society, because that’s our rite of passage. And it feels like this has become another forum for that, that it’s just taken over that role.

And for the group that is pure, like proper transsexuals, this flirting with pronouns and gender identity — it’s insulting. Because like I said, we spend all our time trying to just fit in or be able to live the life that we feel we should have had. And it’s not a great help when you’ve got people shouting from the barricades and trying to give you a different position, a third sex or whatever, and then talk about things that we don’t want you to talk about, so that they can identify you.

But maybe that’s my own — I’m still stuck in my own paradigm. And maybe that shouldn’t be a taboo. Maybe we should break it open. And I don’t know. That’s not how I feel, but I can intellectually — I have to think about that.

azeen ghorayshi

Right.

fg

But I don’t take a lot of these people that seriously, because it does seem to be a bit of a fashion statement.

azeen ghorayshi

It’s just interesting to me, because you were once an adolescent who adults chose to take seriously.

fg

Yeah.

[MUSIC PLAYING]

austin mitchell

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.

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.

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.”

peggy cohen-ketness

Because of him, we thought maybe we should do this more often — giving the blocking hormones.

austin mitchell

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. 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.

peggy cohen-ketness

— give them more space and time to think about the decisions.

austin mitchell

She felt the blockers would give kids time to think. But to give this treatment to more kids, Peggy felt they needed a process.

peggy cohen-ketness

You cannot just start and do whatever we want, particularly at the beginning, when you have no idea whether what you’re doing is OK.

austin mitchell

She began to codify a protocol — what would come to be known as “the Dutch protocol.”

azeen ghorayshi

How would you define the Dutch protocol?

peggy cohen-ketness

Well, I think it’s a very careful way to figure out who should have what kind of treatment to feel like they want to feel.

austin mitchell

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.

peggy cohen-ketness

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. [CHUCKLES]

If you see how well they are 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.

[MUSIC PLAYING]

austin mitchell

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 Annelou de Vries.

woman

And what’s your name?

azeen ghorayshi

My name is Azeen Ghorayshi.

austin mitchell

And what happened next would explain how this care that started almost by accident with this one kid would quickly spread around the world.

azeen ghorayshi

Hello.

annelou de vries

Hi, good to see you. Hi. Hello.

austin mitchell

I’m Austin.

annelou de vries

I’m Annelou. Hello. Hello.

austin mitchell

That’s next time, in part two.

[MUSIC PLAYING]

Special thanks, for this episode, to Emily Bazelon and Alex Bakker.