Probe the protocol

Calls for a rethink in the country that launched puberty blockers on the world

Photo by Noralí Nayla on Unsplash

The gist

The parliament of the Netherlands—the country whose experiments with “juvenile transsexuals” inspired the global adoption of puberty blockers—has called for independent scrutiny of the “gender-affirming” treatment approach.

On January 25, the Dutch House of Representatives passed a motion asking the government to seek advice from the independent Health Council on the medico-legal implications of medicalised gender change for minors.

“I hope this will cause a breakthrough in the gender debate [in the Netherlands] and that we will change course regarding gender treatments in children,” said Diederik van Dijk, of the conservative Calvinist Reformed Political Party (SGP), who sponsored the motion.

He told GCN that, “From an international perspective, it is interesting that now also the Dutch parliament seems to want a more critical course, following other countries such as Finland, Sweden and the UK.”

“At the same time, I want to stress that the necessary steps still need to be taken to really turn the policy around.”

The Netherlands has an outgoing caretaker government. Coalition talks are continuing after last November’s elections delivered strong support to centre-right and populist right parties.

Following the sudden resignation of Health Minister Dr Ernst Kuipers, acting ministers have held the portfolio. As yet, there has been no government response to the passage of Mr Dijk’s motion.

Media sociologist Dr Peter Vasterman told GCN that the success of the motion was “a clear signal that the right-wing parties who now have a majority in the House of Representatives wish to put the issue of gender-affirming treatments on the political agenda.”

Dr Hanneke Kouwenberg, a Dutch radiologist and nuclear physician who has followed the gender clinic debate, welcomed the successful motion as a sign that “the political arena seems to be becoming aware that gender-affirming care does not deserve the uncritical stance propagated by the so-called progressive parties.”

“A treatment lacking scientific foundation can never be indicated in a medical-legal sense, and informed consent cannot exist if the objective medical-scientific findings [about treatment] are not discussed with those seeking help,” Dr Kouwenberg told GCN.

“I was scared for this patient. She had so many overlapping problems that needed addressing, it seemed like malpractice to abruptly begin her on a medical gender transition that could quickly produce permanent changes. I emailed a program manager in my department at [an American children’s hospital] and outlined my concerns. She wrote back that my client’s trauma history has no bearing on whether or not she should receive hormone treatment.

“ ‘There is not valid, evidenced-based, peer-reviewed research that would indicate that gender dysphoria arises from anything other than gender (including trauma, autism, other mental health conditions, etc.),’ she wrote. She also warned that ‘there is the potential in causing harm to a client’s mental health when restricting access to gender-affirming care’ and suggested I ‘examine [my] personal beliefs and biases about trans kids’. She then reported me to [the] risk management team, who removed my client from my care and placed her with a new therapist.

“A risk manager’s job is to minimise the hospital’s liability, but in my case, they deemed that my concerns posed a greater risk to my client than giving her a life-altering procedure with no proven long-term benefit.”—Social work whistleblower Tamara Pietzke, article, The Free Press, 5 February 2024

The detail

The van Dijk motion in the Lower House invokes the “sharp rise” in demand for transgender treatment and international debate “about (the lack of) evidence for the safety and effectiveness of gender-affirming treatments in minors”.

It requests the government “to seek advice from the Health Council on the extent to which the current approach to gender-affirming treatments in minors does justice to the applicable health law framework.”

The council, which has a committee on ethics and law, would be asked to consider how a diagnosis is made, the thoroughness with which treatment efficacy has been investigated and the completeness of information for patients, including unwanted side effects, according to a news report in the Dutch Protestant newspaper Reformed Daily. (It appears the motion’s success has been ignored by mainstream media outlets.)

The SGP has a small presence in the 150-seat House of Representatives, but the motion also had support from the right-wing populist Party For Freedom (PVV) of potential prime minister Geert Wilders (37 members), the centre-right New Social Contract (NSC) party of Peter Omtzigt (20) and various minority parties.

The major groups opposed to the motion were GreenLeft-Labor (GL-PvdA) with 25 members and the centre-right People’s Party for Freedom and Democracy (VVD) with 24.

The passage of the motion—against the advice of acting Health Minister Conny Helder of the VVD—reflects the anti-progressive results of last November’s elections as well as more intense scrutiny of the puberty blocker-driven “Dutch protocol” of medicalised gender change, both within the Netherlands and internationally.

This scrutiny includes investigative journalism, scientific analysis and questions in parliament tarnishing the reputation of the Dutch protocol as the “gold standard” for international gender medicine.

The three stages of the protocol—designed for patients then described as “juvenile transsexuals”—are puberty blockers to stop natural development, cross-sex hormone drugs to masculinise or feminise the body, followed by surgery from age 18.

Stop and think

A 38-year-old Dutch woman, who experienced the distress of gender dysphoria as a child but did not go down the medical path, told GCN she believed it was “very important” to scrutinise the Dutch protocol for paediatric transition. (She spoke on condition of anonymity to protect her livelihood from activist attack.)

“We need to ask as many questions as we possibly can, turn it upside down, and inside out,” she said. “I am not against any care, I’m against giving it to the wrong people.”

From around age 4-5, she felt “distinctly different” from other girls, avoided traditionally female toys and activities, insisted on keeping her hair cut short and was often mistaken for a boy.

“As I entered the ages of 6 to 11, my dreams often depicted me in a male body, deepening my confusion,” she said.

“When puberty struck at 11, my gender dysphoria was neither acknowledged nor addressed. The medical professionals my parents consulted were at a loss, and I was prescribed various medications primarily for depression.

“The onset of puberty and my first romantic feelings for a boy at 12 brought an added layer of complexity. Media and societal expectations on femininity made me feel like an outcast, failing to fit the desired mould. This internal battle caused deep depression and a struggle to reconcile my emotions, hormones and self-perception.

“In my teenage years, I managed to survive the darkness and trauma. Slowly, I began to make peace with my body, learning to appreciate my feminine features through healthy relationships and genuine compliments. The realisation that I didn’t have to conform to a specific stereotype to be accepted was liberating.

“A turning point came with the understanding that changing my biological sex was not a viable path for me. Had puberty blockers and surgical options been accessible, I would have pursued them without hesitation.

“By my mid-20s, my life began to significantly improve and, at 30, I was diagnosed with autism spectrum disorder, offering further clarity on my life experiences.

“I am grateful for my birth year: 1985. Had I been born later, say in 2010 [around the time when puberty blockers were becoming more available], my life might have been irreversibly altered by contemporary medical protocols for gender dysphoria.

“Today, I advocate for a critical reassessment of these protocols.

“I believe there’s a lack of understanding among medical professionals about who truly benefits from medical interventions for gender dysphoria. The urgent need for the medical community to pause and re-evaluate these protocols stems from my conviction that the current Dutch approach, influenced by prevailing gender ideology, is causing unintended harm.”

Uncertainty ahead

Dr Vasterman noted the groundwork laid last year by parliamentary questions about puberty blockers and paediatric transition from the NSC’s Mr Omtzigt and Dr Nicki Pouw-Verweij, a physician and formerly a politician with the Farmer-Citizen Movement (BBB).

Mr van Dijk said the SGP party had been raising concerns about youth gender medicine since 2019 when two of its MPs visited the VU Medical Centre in Amsterdam, where the Dutch protocol for medicalised gender change was developed.

Despite the recent critical focus on the protocol, medicalised gender change is well established in the health sector and still enjoys strong support from parties of the progressive left.

Earlier this month, Ms Pouw-Verweij told GCN she hoped the Health Council would call for “a (temporary) stop to treatment until more investigation has been done into at least the rise of young women seeking treatment, but I am afraid chances are big they will just embrace the current mainstream narrative.

“I think it will be difficult for the Health Council to really investigate. I assume most experts in the Netherlands will blindly state the current treatment is the best one, making it very hard for [the council] to suggest otherwise.”

One Dutch detransitioner, who spoke to GCN on condition of anonymity to avoid activist harassment, was sceptical about the chances of a Health Council-driven correction to the Dutch protocol.

“I doubt [the council investigation] will actually happen, and if the results are bad, I doubt anything would actually change,” she said.

“Gender care in the Netherlands is a stronghold, and I believe the clinicians will only be taken down by a societal shift.

“[The motion] is another tiny seed that might sow doubt among MPs [but] the entire left will dismiss it, as this guy is with a Christian party.”

Mr van Dijk conceded that his motion had the support of “some more right-wing political parties”.

“However, I notice that in the public debate a very diverse coalition of progressives, conservatives, feminists, Christians and secular thinkers are speaking out critically about hormone treatments for minors,” he said.

“My hope is that those critical voices will now gain a greater foothold in the [House of Representatives]. After all, it is about the welfare of young people and doing justice to medical-scientific standards.”

While the outcome of talks to form a new Coalition government remains uncertain, Mr van Dijk said he believed the new political reality would create a cabinet willing to “pay more attention to the existing and justified concerns regarding the drastic treatment of underage transgender people.”

“[W]e believe the situation is critical: an exponentially growing number of children want to go into medical transition, without the cause of that growth being known and without it being possible to say on good grounds that transition will make their lives better. In our view, therefore, the Netherlands should immediately radically reform gender care, following the example of Sweden and Finland.

“This would mean that hormones could only be prescribed as a [last resort], in strict research settings and only to the original target group of the Dutch protocol, namely: children with severe gender dysphoria from early childhood onwards. For the large group of adolescents who do not experience gender dysphoria until early adolescence or even later, less invasive interventions, such as psychosocial support and treatment of additional psychological problems, should become the first-line intervention. After all, the starting point should be [to ‘Do no harm’].”—Philosopher Dr Jilles Smids and physician Patrik Vankrunkelsven, opinion article, Dutch medical journal Nederlands Tijdschrift voor Geneeskunde, 7 November 2023

Beware of ideology

Back in late-January, Acting Health Minister Helder had resisted the van Dijk motion on the grounds that it would offer “no added value” to current work updating quality standards for trans treatment under the Federation of Medical Specialists.

A response to the Lower House motion now falls to the newly sworn-in acting Health Minister, Pia Dijkstra, of the social liberal party D66, which voted against the motion in the Lower House.

“The minister is not obliged to implement an adopted motion,” Mr van Dijk told GCN.

“However, if the minister disregards a motion of the House of Representatives, it usually means that the minister is in conflict with a majority of the House.

“So, I assume that the minister will simply go ahead and implement the motion, as is proper in our state system. In any case, she should let us know within a few weeks how she is going to implement the motion.

“The Health Council usually presents a report with recommendations. The council cannot enforce these recommendations, but usually we see that the council’s advice is taken very seriously as an authoritative advisor to the government.

“The Health Council could theoretically recommend that treatment with hormone inhibitors be stopped but cannot enforce it. I am obviously curious to see what the council comes up with. Hopefully it will also take the findings from other countries seriously.”

With an update to the 2018 quality standard for “somatic” trans treatment due to be finalised in 2025, it was “quite a clever move” for Mr van Dijk and his party to target his motion at the ethical and legal dimensions of the Dutch protocol for paediatric transition, according to the group Genderpunt, which advocates for more open debate about gender medicalisation.

“The health law perspective hasn’t had much attention so far,” a group spokesperson told GCN.

“The discussion is often dominated by emotional arguments and heavily influenced by trans lobby groups. This request [for referral to the Health Council] displaces the discussion to the domain of health lawyers and ethicists, hopefully a less influenceable and more thoughtful environment.

“Also, there have recently been some critical publications on the medical and legal aspects of gender-affirming care of minors in the medico-legal literature in the Netherlands, which hopefully will be taken into account.”

The council’s ethics and law committee includes medical ethics professor Martine de Vries, who is a research collaborator with the Amsterdam clinic responsible for the Dutch protocol. She is one of 10 committee members, but it is possible others may defer to her as the “gender expert”, observers told GCN.

The working group updating the 2018 quality standard includes representation from trans advocacy organisations as well as clinicians committed to the current treatment model. Outlining their objectives, the group stated one of their aims to be “to link up” with international guidelines, including those from the gender-affirming World Professional Association for Transgender Health and the Endocrine Society (WPATH).

Dr Kouwenberg, the physician sceptical of current practice, saw a danger that the Health Council’s proper focus on the scientific literature might be blurred by appeals to gender ideology.

“It is essential that policymakers do not let themselves be led astray but insist on a critical review of the literature, explicitly examining the goals of gender-affirming care on one hand and the quality of the evidence for those goals on the other,” she said.

“The ideological takeover by activists at the Tavistock clinic is what led to the serious derailment of care; it is crucial that such a situation is prevented in an evaluation [of the Dutch protocol] by external parties.”

She said the Dutch political sphere had adopted gender activist jargon and used terms such as “transgender,” “gender identity” and “gender incongruence” as if they were self-explanatory.

“I find this highly problematic because, in the actual scientific state of affairs, the construct ‘gender incongruence’ lacks a convincingly established aetiological explanation and the associated ‘gender identity’ is not necessarily a personal characteristic but rather a result of behaviour.”

She said policymakers had to be alert to the possibility that the distress attributed to gender dysphoria might have compelling, non-gender explanations—arising, for example, from distorted self-perception, distorted interpretation of the self or from confrontation with reality in daily life.

She said the “argument from authority” justification of gender jargon—invoking the influence of organisations such as WPATH—was “not only a fallacy but one that, through politics, can threaten both scientific and conscientious freedom.”

Note: GCN sought comment from two leading clinicians associated with the Dutch protocol, Dr Annelou de Vries and Dr Thomas Steensma