Carry on regardless

A Dutch committee recites the reasons to rethink the gender medicalisation of minors, then sees no reason to act

Photo by Sabina Fratila on Unsplash

The gist

The Health Council of the Netherlands has acknowledged the weak evidence for paediatric medical transition, the side-effects and uncertainty of hormonal interventions, as well as the unknown rate of patient regret, but concludes that treatment should continue.

In advice issued earlier this week, the council said the puberty blocker-driven Dutch protocol fell within the country’s health law framework, although it based this view on the content of treatment guidelines and had “not evaluated the delivery of care in daily practice”.

The council said the Dutch gender clinics were also seeing the troubling shift in patient profile which in Finland, Sweden and the UK has led to restrictions on puberty blockers and hormones for minors.

Dutch referrals had more than doubled between 2020 and 2022, reaching a total of 2,772, with long waiting lists, the council said, and classic early-onset dysphoric boys had given way to teenage-onset females, often with non-binary identities and conditions such as autism, depression, anxiety and ADHD.

This was the flip in patient profile that made Finland’s health authorities think again—and become the first to adopt a more cautious, less medicalised approach than the Dutch protocol in 2020.

Still, the Health Council of the Netherlands insists that “exploration is central to the Dutch model”.

“Treatment with GnRH agonists [puberty blockers] does not primarily serve as a stepping stone to further treatment [with cross-sex hormones], but as an intervention which—albeit within specialist care—creates time for further exploration,” the council says.

“Not all young people who present for [blockers] ultimately commence this [potentially lifelong hormone] treatment, but the majority do.” More than 90 per cent, according to international data, the Netherlands included.

Dutch radiologist and nuclear physician Dr Hanneke Kouwenberg, statement to GCN: “All in all, it is puzzling that the [Health Council] committee maintains that the care for young people meets the legal health care framework.

“For that to be the case, a treatment must be safe and effective, it must be proportionate, and patients must be properly informed about treatment options and alternatives—in short, there must be a proper medical indication. The [council’s] report does not establish that any of these conditions have been met.”

Thumbs on the scale

The request for the Health Council’s independent advice arose from two 2024 resolutions passed by the Dutch House of Representatives seeking medico-legal scrutiny of paediatric gender transition and research comparing the Dutch protocol patient outcomes with those of European countries, such as Sweden, which have shifted to caution.

Half the members of the 12-strong council committee were directly involved in Dutch protocol treatment, and the impartiality of its advice has been questioned. Declarations of potential conflicts of interest for committee members have been published. The main advice document shows internal contradictions, with vague positive claims for continued treatment undercut by acknowledgement of poor data and uncertain outcomes.

In that main document, the council notes that minors had to have “the emotional and cognitive maturity required to give informed consent” but concedes that the cognitive effects of hormonal treatment during the crucial brain-development phase of adolescence are not known.

“The greatest uncertainty surrounds mental health outcomes, namely the extent to which hormone treatments—particularly GnRH agonists (puberty blockers)—have a lasting impact on the psychosocial and cognitive development of young people,” said the council, calling for more research.

Microbiologist Dr Rosanne Hertzberger, the MP behind one of the 2024 parliamentary resolutions, NRC article: “Even after a dozen consultations, the final medical decision is still based on the feelings of troubled young teenagers.

“Even after a dozen consultations and months of evaluation, the final medical decision is still based on the feelings of troubled young teenagers. They arrive at their choice in the midst of a society where, in recent years, nothing less than a complete gender frenzy has erupted.

“Why are the Dutch not concerned about the Dutch protocol, whilst Finland, Sweden and England are taking a step back? There is no reassuring answer to that. In the university medical centres (with their gender clinics), people seem genuinely convinced that only we in the Netherlands work in such a multidisciplinary, exploratory and careful manner.

“The [Health Council] report offers few new insights. It is an almost exact copy of what doctors in gender clinics were already saying before. The patient group and society may have changed completely in a short space of time, but we are simply expected to carry on treating patients stoically. As long as it is done with care. Disturbing.”

Director’s cut: Dr Jay Bhattacharya, director of the US National Institutes of Health, talks with authors of the Gender Dysphoria Report commissioned by the US Department of Health and Human Services

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Brain freeze

As long ago as 2006, clinicians from the famous Amsterdam gender clinic admitted it was “not clear yet how pubertal suppression will influence brain development”. British neuropsychologist Professor Sallie Baxendale has argued that puberty blockers may interfere with critical windows of cognitive development in adolescents, whose brains are not fully matured until age 25.

In 2024, another prominent Dutch clinician, psychiatrist Dr Annelou de Vries, said the Amsterdam clinic had intended in the past to carry out magnetic resonance imaging (MRI) studies of patients’ brains.

“We were planning to do such MRI studies, but we were not given the grants,” Dr de Vries told GCN?

Clinical and educational psychologist Roelien den Ouden, statement to GCN: “It’s as if everyone has forgotten that there is such a thing as developmental stages, and children should just be able to experience those, without being medicalised for the rest of their lives.

“Children can’t make these far-reaching decisions and, in fact, shouldn’t be asked. They [lack] the cognitive skills and the social-emotional development to decide whether they would like to retain the possibility to have an orgasm, or to have children one day. They are focused on finding a short-term solution for their negative feelings about their lives, or themselves.”

Gaps abound

In its June 30 advice, the Health Council says: “Another significant knowledge gap is the lack of data on long-term outcomes, both physical and mental. There is also much uncertainty regarding the possibilities and outcomes of fertility preservation and how young people will view this in adulthood. Another knowledge gap concerns the lack of information on the clinical relevance of most of the observed effects.

“The [hormonal] treatments may also have undesirable effects, but the Health Council sees no reason, based on the limited data available on this, not to offer the treatments, particularly as doing nothing can also have harmful consequences for mental health.”

The suggestion that alternatives to the medicalised Dutch protocol represent “doing nothing” also implies that the benefits of blockers and hormones are well attested.

In some passages, the council appears to claim exactly that: “Research into the physical and mental outcomes of hormone treatments for young people with gender dysphoria generally shows consistent results. Physically, the treatments have the intended effects (they do what they are supposed to do), and mentally there are indications of some improvement.”

Elsewhere, the council is more candid: “The systematic reviews that summarise and assess the research into physical and mental outcomes agree that the strength of evidence for the observed effects is low to very low.

“There are several reasons for this. The available research consists solely of observational studies, most of which lack an (adequate) control group. Studies that do include such a control group often provide little or no information about possible differences between the groups and do not (sufficiently) adjust for these in their analyses (so-called confounding).

“As a general rule, it is not really possible to demonstrate a causal link between treatment and outcome on the basis of observational research. Furthermore, the study population in most studies was small in size, and it was not always clear how the study population compared in size and composition to the population that would be eligible for study participation (possibility of selective inclusion).

“Another important methodological limitation is that the follow-up period was short in many studies. Those studies that did have a long(er) follow-up period experienced substantial participant dropout during the study period. This can lead to selective bias, meaning that the results are no longer representative of the entire study group. Due to the generally short follow-up period and the substantial participant dropout, it is difficult to draw conclusions about long-term effects.”

Dutch journalist Jan Kuitenbrouwer, statement to GCN: “The essence is that [the council’s committee members] don’t address the essence of the problem, as clearly laid out now in several systematic reviews: there is no solid scientific basis for this treatment, and therefore is it a potential long-term debacle.

“It’s an embarrassing cop-out by a formerly well-respected, astute and independent council. They’ve clearly drunk the Kool-Aid, even adopted the ‘assigned at birth’ formula, which clearly indicates ideological capture.

“No surprise really, the gender medical community in the Netherlands is a small tightly knit coterie. All somehow invested in, or intimidated by, the prestige of the pioneering Amsterdam clinic. They’re virtually untouchable.”

Knowing, unknowing

In confident mode, the health council at one point contrives to see “indications … that the number of cases of regret is low”.

And, then, more candour: “[B]ased on the available literature, it is difficult to determine the number of people who regret their decision due to the generally short follow-up periods and substantial dropout rates in studies.”

Next, this: “These uncertainties do not give the committee cause to recommend any changes to the way care is organised.”

Regret rates below one per cent from the Amsterdam Cohort of Gender Dysphoria Study (1972-2015, with a median follow-up time of 6.4 years) are often cited internationally, but not the fact that 36 per cent of former patients were “lost to follow-up” in this study, meaning the clinic had no data for them and their regret rate might be significantly higher.

Dr Hanneke Kouwenberg: “The Dutch protocol has now been applied for more than twenty years in Dutch gender clinics, and yet the [Health Council] committee concludes that much of the evidence for the presumed positive effects is weak, while framing the actually iatrogenic harm [of hormonal treatment] as ‘it does what it is supposed to do’.

“Insights from elsewhere—for example, that [puberty blockers] likely prevent desistance [of dysphoria] and thereby pre-sort children onto a path of medical intervention—are ignored.

“This is very serious, because desistance currently offers the only chance of actual recovery from gender dysphoria.”

Over there, not here

Despite the missing data and unknowns, the new advice from the Health Council protests that gender clinics in the Netherlands have been immune to slipshod use of the Dutch protocol internationally.

“In the Netherlands, any somatic treatment is only considered following extensive assessment, diagnosis, psychological support and a determination of eligibility by a multidisciplinary team,” the council says.

The council appears to compare the careful ideal of the Dutch quality standard for physical interventions with actual delivery overseas, such as at the London-based Tavistock clinic, where treatment did not live up to the promise of cautious, multidisciplinary care.

“The starting point [in the Dutch standard] is not the affirmation of a pre-determined identity, but the careful assessment of the individual child’s needs from various perspectives,” the council says.

“This distinguishes the model from care practice elsewhere, as described in the [UK] Cass review and the Tavistock ruling, where treatment was based on a strongly affirmative approach with insufficient attention to alternative explanations for suffering.”

However, the new, revised Dutch guideline for hormonal treatments is to be aligned with the 2022 standards of care from the World Professional Association of Transgender Health (WPATH).

Those current WPATH standards were rated 35/100 for the rigour of their development in a peer-reviewed, University of York evaluation of international guidelines commissioned by the Cass review. The current Dutch guidelines are based on WPATH’s 2012 standards, which scored 26/100. Neither WPATH guideline was recommended for use by the York University researchers.

The perception of the Dutch as more rigorous and prudent has come under new challenge. In 2024, two detransitioners launched litigation against the Amsterdam clinic, claiming they were misdiagnosed. The Dutch protocol’s foundational studies from 2011 and 2014 have had their methodology re-examined critically. In any event, that earlier research data may not apply to today’s troubled teenage female patients.

Dr Hanneke Kouwenberg, a Dutch radiologist and nuclear physician who has followed the gender clinic debate, said: “While the term ‘careful’ may apply to the guidance prior to medical intervention, the accounts of both some persisters (such as Thiuri in the Zembla documentary) and especially desisters, detransitioners and/or their parents paint a very different picture.

“Diagnostics were not ‘extensive’ or exploratory; no questions were raised about the stated ‘gender identity’, no investigation was made into possible underlying causes, and the focus was simply on confirmation and steering towards intervention,” Dr Kouwenberg told GCN.

“Alternatives such as watchful waiting were not presented as serious options, as is also clear from Lieke Vrouenraets’ studies and from tweets by parents responding to the report. The gender clinics in the Netherlands therefore seem to illustrate the old saying: when your only tool is a hammer, everything looks like a nail.”

Dutch philosopher Jilles Smids, 2025 paper: “[B]etween 2000 and 2018, 84 per cent of the 1,487 adolescents referred to the Amsterdam clinic were diagnosed with [gender dysphoria] and 78 per cent began a medical transition …

“Such a high percentage might be explained if all these young people had first undergone a comprehensive diagnostic process elsewhere. However, this seems unlikely, given that GPs can refer patients directly to academic gender clinics and it has often been observed that there is a ‘reluctance to intervene’ amongst youth mental health care professionals when it comes to gender-related issues.”

Unjustified treatment

On the eve of the release of the Health Council’s advice, a group including clinicians and ex-politicians put their names to an opinion article in the newspaper Trouw calling for deep inquiry into the Dutch protocol’s rationale. What follows is their initial assessment of the council’s June 30 report; the subject-matter experts of the group are still considering their individual “detailed and carefully weighed responses”—

“The [Health Council] advice contains some important acknowledgements of uncertainty and calls for better long-term research and monitoring. We welcome that. But those acknowledgements make the central problem more urgent, not less: the council has not answered the core question of whether the Dutch protocol itself is scientifically and ethically justified.

“Instead, the council has largely assessed the implementation of the protocol. It looks at whether the Dutch procedure is carefully organised, but it does not seriously return to the underlying question: is this medical pathway for minors justified in the first place? A careful procedure is not the same as a sound medical indication.

“This matters because one of the parliamentary motions that led to the advice explicitly asked for research into the physical and mental health outcomes after treatment with the Dutch protocol methodology, compared with cohorts in other European countries with different standards of care. In our view, that question has not been answered. The council has not provided such an outcomes-based comparison, nor has it made a serious attempt to establish whether the Dutch protocol produces better long-term health outcomes than alternative approaches.

“That omission is especially serious because these are far-reaching and partly irreversible interventions: puberty blockers, cross-sex hormones and, in some cases, surgery. They may have consequences for fertility, sexual function, bone development and lifelong medical dependency. For interventions of this kind, the evidentiary threshold should be high. Yet the strength of the evidence, the balance between benefits and harms, and the question whether these interventions produce real long-term health gains remain seriously contested.

“A further problem is that the council appears to adopt much of the conceptual framework behind the Dutch protocol at the outset: the existence of ‘gender identity’, the idea that everyone has one, and the idea that gender dysphoria may require medical alteration of the body because ‘doing nothing’ is not an option. But these are precisely the assumptions that should have been examined.

“The international comparison is also problematic. The council presents countries such as England, Sweden and Finland as if their concerns mainly relate to poor implementation elsewhere, while the Netherlands supposedly applies the protocol more carefully and is therefore largely vindicated.

“But the criticism from Dr Cass, Professor Kaltiala in Finland, Sweden and other recent literature goes deeper. It concerns the weak evidence base, the changed patient population, psychiatric comorbidity, the lack of robust causal evidence for long-term health benefit, and the question whether medical transition in minors is the right treatment pathway at all. This is particularly striking in the case of Finland, whose registry-based long-term follow-up studies should have been central to any serious international comparison.

“Finally, if the council recognises that robust long-term evidence is still lacking, it should also explain why available long-term data have not been analysed.

“The Netherlands has decades of clinical experience with this pathway, and relevant data sources exist in clinical databases, insurance records and national registries. The council cannot simply point to a lack of long-term evidence without asking why these data have not been linked and studied to examine outcomes such as psychiatric morbidity, physical health conditions, treatment discontinuation, detransition and mortality.”

And while the term ‘careful’ may apply to the guidance prior to medical intervention, the accounts of both some persisters (such as Thiuri in the Zembla documentary) and especially desisters, detransitioners and/or their parents paint a very different picture. Diagnostics were not ‘extensive’ or exploratory; no questions were raised about the stated ‘gender identity’, no investigation was made into possible underlying causes, and the focus was simply on confirmation and steering towards intervention. Alternatives such as watchful waiting were not presented as serious options, as is also clear from Lieke Vrouenraets’ studies and from tweets by parents responding to the report.

The gender clinics in the Netherlands therefore seem to illustrate the old saying: when your only tool is a hammer, everything looks like a nail.