Learning from the Dutch

 The transgender sessions--and there are many of them--at the Endocrine Society meetings have been worlds better this year, mostly because they are dominated by the Dutch. They flew in from Amsterdam, and they present clear, unemotional talks, full of data, with no trace of bias, just the facts, only the facts.

What the Dutch showed was that higher doses of testosterone given to patients "transitioning" from female to male developed the complications one might expect from anyone given testosterone--cholesterol profiles shift from the happy range seen in most young females to the less happy state seen in males. Similarly, when estrogen is given in "gender affirming doses" to erstwhile males, strokes become a problem, as do clots in leg veins.

This is very different from the American doctors who run Transgender Clinics and who clearly have a financial stake for every issue.

Joshua Safer, head of the Mt. Sinai (NYC) Transgender Clinic, gave the talk about how he manages "problem cases" in his gender clinic.

His first case was a male to female patient who wanted to become for "feminine" and the question was which estrogen to use and how much. Much of what guided him, he noted, were the "Dutch data." 

To try to reduce unwanted hair on the face, a smorgasbord of drugs was presented. Some of them caused liver failure, but spironolactone got his nod, even though it is questionable how efficacious this is.

A male to female wants a new vagina constructed but the surgeons are worried about her risk for leg clots following surgery--owing to the risk imposed by the estrogen therapy. He decided to cut out the estrogen for weeks after the surgery, although there was no clear evidence this did any good. 

A female who wants testosterone but the patient wants to achieve "an androgenous experience" although wants to avoid facial hair or voice lowering. Dr. Safer never asks himself whether this patient is reasonable in demanding a more boyish body without the beard or voice changes testosterone might cause. This is the "customer is always right." He did, finally, tell the patient he could not guarantee the patient would be free of the undesirable stuff. There was a long digression about the importance of choosing the right pronouns. "Do you want to be 'disgendered' with 'she' or 'he' or 'they?'"

The next patient was a born female who is now male who wants to have a child with his cisgendered partner. The patient has ovaries and uterus and vagina but has had breasts removed. The patient has been on testosterone for years, and the recommendation was to stimulate the ovaries for egg retrieval and storage for future IVF. So now he has got the patient locked into a hundred thousand dollar plan.

The next patient is 19 and has been on testosterone to go from female to male and has attempted suicide. The suicide rate or attempted suicide rate in most transgender clinics is and has remained stubbornly at 40%. The question is what to do with the endocrinologist should do during the hospitalization on the psych ward. His conclusion was the best thing to do was to continue the "gender affirming" testosterone therapy, the argument being to withdraw from testosterone would be to risk a sort of disruption and withdrawal syndrome.

He did not present, this year, the case I liked best from last year's conference: a male to female who has not had castration but was on estrogens who has a female lesbian partner and they want to get pregnant and the question is what to do? The answer that year was to extract eggs from the lesbian partner for IVF and then to use donor sperm for the IVF procedure. The question was raised why not have the patient provide the sperm, but the objection was that this would undermine his new role as a woman. Paul McHugh, the former chief of psychiatry at Hopkins asked the obvious question, which nobody at the conference ever asked: "What sort of sex are these two folks having?"

You can see how Ron DeSantis would love talking about this case, this clinic and this whole way of thinking. 

The Dutch noted that in the Netherlands, nobody who has transitioned can get the gender on their driver's license or government forms until they have been castrated.

Presumably, the Dutch have decided you have to prove you really are completely committed to a new gender before the government will by in. This law may have been changed recently, but it is instructive about the thinking of a society with socialized medicine.