In the dark

A major documentary in the Netherlands shakes the foundations of gender medicine

Photo by Shyam on Unsplash

The gist

Experts in research methodology in the Netherlands, the country that gave the world puberty blockers, have identified fundamental flaws in pioneering Dutch studies crucial to the evidence base for youth gender clinics internationally.

“There is no comparison group [in these 2011 and 2014 studies from the famous Amsterdam gender clinic], and all patients who received puberty blockers also received psychological counselling at the same time, so two treatments were running side by side,” Maastricht University research methodologist Gerard van Breukelen said in a new documentary, “The Transgender Protocol”, broadcast by the Dutch investigative journalism program Zembla.

Professor van Breukelen said the weak design of the foundational Dutch studies made it impossible to decide which treatment was effective. “You cannot answer that question without a control group, we are completely in the dark.”

The 2011 and 2014 Dutch papers are commonly said to still represent the best available evidence internationally for medicalised gender change with minors.

The Dutch team and their reportedly careful selection of patients thought likely to make a successful medical transition is often contrasted with risky fast-tracking under the American-influenced “gender-affirming” treatment model.

However, the Zembla documentary reflects a trend of sharper international scrutiny of the Dutch studies themselves and more scepticism about their claims of beneficial outcomes.

“There is a great deal wrong with how the [Amsterdam] gender clinic was allowed to operate with little, if any supervision by a public health authority. The Dutch protocol was exported worldwide & the Dutch government needs to be held accountable.”—tweet, Dorothy van Koolwijk, 26 October 2023

Why second best?

Swedish psychiatrist and researcher Professor Mikael Landén, who was involved in Sweden’s 2021 systematic review of the evidence base for medicalised gender change with minors, told Zembla that “the studies in this area [of youth gender dysphoria] are of low quality and would not be accepted as evidence in other areas [of medicine].”

He had worked in the gender dysphoria field since the 1990s, had prescribed hormones and knew the suffering of his patients.

“I do want the best care for each and every one,” he said.

“[But] we don’t know if [the medical treatment for dysphoria is] good or bad. Why should you require [a] lower level of evidence for this patient group than you do for all other patient groups?”, Professor Landén said.

“You do subject people to lifelong, very strong medical treatment, even surgery. You’re amputating parts of [a patient’s] body.”

Three other Dutch experts on research methodology cited by Zembla agreed with Professor van Breukelen that the lack of a control group in the Dutch studies was a serious shortcoming. There was also criticism of the small size of the patient group, the high dropout rate and the death of one adolescent following surgery.

An unnamed professor of methodology quoted by the program said the Dutch research was “not a solid basis for performing radical and non-reversible medical interventions.”

Video: The Transgender Protocol, broadcast by Dutch public media outlet BNNVARA

The detail

Starting in the late 1990s Dutch clinicians pioneered the use of puberty blockers to suppress unwanted sexual development in “juvenile transsexuals”, followed by cross-sex hormones and surgery in adulthood. It was hoped that the poor outcomes noted in adult transsexuals could be improved by earlier medical intervention.

The resulting “Dutch protocol” was adopted internationally as the number of young people identifying as transgender or non-binary underwent an unprecedented increase beginning around 2010-15. A leading Dutch clinician, Dr Thomas Steensma, has criticised gender clinics outside the Netherlands for “blindly adopting” the Dutch protocol treatments without researching their own different patient groups.

The Zembla documentary quoted Swedish child and adolescent psychiatrist Dr Angela Sämfjord—who was involved in opening the Lundstrom Gender Clinic in 2016—as saying the quality of the Dutch research was “very important” because it was “the base” for gender care worldwide.

Despite the significance of the issue, Zembla found that of the five experts it asked to assess the Dutch studies, only Professor van Breukelen of Maastricht University was willing to be identified in the documentary. A methodologist at the University Medical Centre Utrecht was warned that speaking out would be “bad for his career.”

Dutch media sociologist Dr Peter Vasterman—who co-authored a breakthrough opinion article in December 2022 calling for a “critical, independent evaluation” of gender medicine in the Netherlands before any expansion of capacity—said Zembla was seen as authoritative and “an acclaimed research program”, albeit run by a “rather woke” left-progressive public broadcaster.

“It is very important that Zembla has tackled this subject and discovered how difficult it is to get experts in front of the camera. It is now becoming easier for other media to look at this more critically. It is not an exclusive ‘right-wing’ topic anymore,” Dr Vasterman told GCN.

“It is difficult to say whether the program will gain political influence. Much depends on the new [Dutch] government after the November elections. Pieter Omtzigt’s new party New Social Contract is in the lead and therefore has a good chance of getting into government. Omtzigt is very critical of the treatment of children with puberty blockers.”

“Bias was baked into the Dutch protocol research from the start. [In the Zembla documentary] the lead researcher tells how she had already made up her mind about the efficacy of the treatment before starting the first study to determine the efficacy of the treatment.”—tweet, Louise Whelan, 27 October 2023

Transphobic science?

Dr Hanneke Kouwenberg, a Dutch radiologist and nuclear physician who has followed the gender clinic debate, told GCN it was “very telling how three of the four methodologists wouldn’t comment on screen [for Zembla] out of fear of repercussions.”

“Any critique on the medical practice in what one might call ‘gender medicine’ is framed as transphobia—even when one argues it is in fact in the very interest of the people affected by gender dysphoria to undergo treatments that are solidly proven by robust science. This fear undermines the scientific method severely, as critique and re-evaluation are paramount.”

Zembla reportedly received an eight-page trans activist complaint before the documentary went to air and posted on their website a Q&A justifying their decision to probe the weaknesses of the Dutch research.

“We are not questioning anyone’s gender identity or right to transition. We believe it is very important that young people who register for gender care receive the best possible care and are fully informed about the effectiveness and safety of any treatment,” Zembla said.

Stop the experiment

The Dutch group Genderpunt, which seeks open debate about the implications of gender ideology, told GCN that Zembla’s documentary “confirmed that the research data from Dutch gender clinics provide insufficient evidence for medical treatment of children with gender dysphoria.”

“Such unproven ineffective treatment with far-reaching long-term consequences should be stopped immediately,” a spokeswoman for the group said.

“Internationally, of course, several places [Finland, Sweden, Denmark, England and Florida] have already concluded that the evidence for gender-affirming treatment is very weak.

“The fact that this has now been [acknowledged] by Dutch [methodology] scientists is quite telling, as the Netherlands is the leading country when it comes to gender-affirming treatment of children and [it is] the founder of the Dutch protocol.”

A key figure in the Dutch research, Dr Annelou de Vries, chief psychiatrist at the Amsterdam University Medical Centre, protested in the Zembla program that the use of a control group—to enable comparison of outcomes between treated and untreated patients—would have been unethical.

However, the methodologists consulted by Zembla said there were in fact alternative methods not necessarily requiring placebo treatment that could have been used by the Amsterdam clinic to strengthen its research. The paper from Sweden’s systematic review suggests some options.

The only cure

As a physician Dr Kouwenberg offered a more fundamental critique of the Dutch protocol.

“The aim of medicine is to cure or ameliorate conditions of suffering with as little collateral damage as possible,” she told GCN.

“From that perspective, desistance [a re-embracing of birth sex before medicalisation] is a desirable outcome. It is the only actual cure that exists.

“This is not because the aim is to ‘eradicate transness’, but desistance renders medical intervention and therefore iatrogenic harm [inflicted by medicine] unnecessary.

“No treatment that undermines the outcome of desistance, therefore, is in my opinion, acceptable,” Dr Kouwenberg said.

“One should consider that no medical intervention creates a body of the opposite sex. All surgery is cosmetic, aimed at ameliorating gender dysphoria, and as such, should be classified as palliative care.”

She said she was conscious of the Dutch version of the Hippocratic oath taken by physicians, which included the precept, “I am aware of my responsibility towards society.”

“This is where gender medicine falls hopelessly short, as [Zembla’s] broadcast has proven.”

Dr Kouwenberg challenged the gender clinicians’ claim that children could comprehend the consequences of puberty blockers. Although young patients were told this intervention was reversible, the available data showed that “desistance virtually disappears under puberty suppression,” she said.

She said the false claim of no alternative to puberty blockers “locked in” not only the clinicians—who were already prone to confirmation bias—but “more dangerously” the general public and patients.

“The fundamental problem is that the [gender-affirming] narrative has been put out there and successfully spun as ‘suicide prevention’ before any solid proof was delivered,” she said.

“Only if the narrative gets replaced by a more [accurate] representation of the scientific facts, one might have a chance of performing a randomised, placebo-controlled or at least case-controlled study, without false objections that it would be ‘unethical’ to perform such studies.” 

Patient flip

Whatever the quality of the Dutch studies, it is unclear whether they apply to today’s dominant patient group of teenage females often contending with severe psychiatric disorders.

The Dutch worked mostly with the classic gender dysphoria patient—a male whose distress in his body had persisted since early childhood.

The new group of chiefly female adolescents with no apparent history of gender distress was noticed by clinicians in Finland, Sweden and England.

American health researcher has Dr Lisa Littman has hypothesised a new condition—rapid-onset gender dysphoria (ROGD)—involving distress at during or after puberty and possible social influences online or via peer groups. These patients often appeared to deteriorate after their trans or non-binary identification.

Genderpunt’s spokeswoman said: “We do think that the original approach of the Dutch protocol was more restrictive than is now international practice. Extensive counselling and psychological care were given before moving on to medication or surgical treatment.”

“It is unclear what the situation [in Dutch clinics] is now, given that the population now consists mainly of adolescents with ROGD.”

Sweden’s Dr Sämfjord told the Zembla program that she was not the only gender clinician who had doubts about treating this new patient group—doubts that led her to resign from the Landstrom clinic in 2018.

“We all had [doubts]. We started wondering because the patient group didn’t seem to be the same group as [in] the studies from the Netherlands,” she said.

“We had a lot of adolescents who had a late onset of gender incongruence in puberty. They had a lot of neuropsychiatric symptoms, like autism. That was not explained in the studies at Netherlands.

“I thought that the risk of us making harm to these kids was greater than the chance of making benefits for them, so that’s why I quit.”