What if the "Gold Standard" of Youth Gender Medicine is More Like Tarnished Brass?

Dismantling the claims of the "Dutch protocol."

When gender-affirming practitioner Dr. Aron Janssen testified before the Florida Boards of Medicine and Osteopathic Medicine last October, he asserted that “the best longitudinal data we have on transgender youth comes primarily out of the Dutch clinic… That’s the prevailing model that most of the American clinics have based their care upon.” His point was that gender-affirming care was “proven” safe and effective because of the research out of the Netherlands—and that Americans were abiding by it.

That model is based on two studies of the same cohort, from what is now The Center of Expertise on Gender Dysphoria at the VU University Medical Center Amsterdam. The first, “Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study,” by Annelou L. C. de Vries et al, was published in 2011. It chronicled 70 patients after puberty blockers, when they were approved for cross-sex hormones but not yet on them. The second, in 2014, “Young adult psychological outcome after puberty suppression and gender reassignment,” reports the results of 55 of those initial 70 patients after hormones and surgery, concluding that gender dysphoria “was alleviated and psychological functioning had steadily improved.”

The studies seemed to show a miraculous turnaround for adolescents with consistent, persistent and insistent gender dysphoria since childhood, who had undergone long-term, careful evaluation, lacked other serious co-morbidities and lived in supportive families. The research may have excited a generation of doctors, eager to help these poorly understood youths, and perhaps make up for past transgressions in psychology and psychiatry. These fields had pathologized normal variations in gender and sexuality, including homosexuals, feminine boys and masculine girls, for decades. Maybe clinicians also thrilled at the thought of some kind of miracle cure in a arena where improvements tend to be slow and hard-won.

These studies became the basis for youth gender care around the world. Indeed, institutions from the Endocrine Society to the World Professional Association for Transgender Health extol the research’s virtues. Psychologists and endocrinologists imported the Dutch protocol to the US in 2007, via Boston Children’s Hospital.

Here, it eventually morphed into something we call “gender-affirming care,” which begins with affirming a child’s subjective identity, and often leads to socially transitioning that child—two actions which were not part of the original protocol (for reasons outlined below). Plenty of people have testified that much of what happens now in American clinics doesn’t line up with the Dutch protocol. Almost every person I’ve talked to who has partaken of gender-affirmative care said that they, or their children, were offered puberty blockers, regardless of the length the dysphoria had lasted—often without any psychological evaluation. Pediatric endocrinologist Dr. Jeremi Carswell, director of Boston Children’s Hospital’s pediatric gender clinic, herself admitted that puberty blockers were being given out “like candy.”

For a long time, the shift from Dutch caution to American affirmation concerned many who chronicled the rapid rise of gender dysphoric youth—even those, like Dr. Laura Edwards-Leeper, who helped import it here. In 2021, she and Dr. Erica Anderson blew the whistle on the rush and pressure to medicalize in American clinics, the abandoning of perceived Dutch caution. Even some Dutch pioneers of youth gender medicine complained that “the rest of the world is blindly adopting our research.”

But two recent papers, published in the Journal of Sex & Marital Therapy, scrutinize the science and the history of the Dutch protocol itself. They ask a deeper, and perhaps more concerning, question: What if the findings from the original Dutch studies don’t hold up—even for the cohort they were purported to work for?

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A paper published earlier this year called “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed,” by E. Abbruzzese, Stephen B. Levine & Julia W. Mason, aims to show that the original studies are “methodologically flawed and should have never been used in medical settings as justification to scale this ‘innovative clinical practice.’”

Switched scales

The authors look critically at the Utrecht Gender Dysphoria Scale, which researchers used to evaluate gender dysphoria before and after treatments in the Dutch studies—or at least, that’s what they aimed to do.

Most supporters of the Dutch protocol don’t realize that the scales were switched before and after treatment. A girl would get the female-to-male version before, which would indicate a high amount of gender dysphoria when strongly agreeing with, for instance, “I prefer to behave like a boy.”

Then she’d get the male-to-female version after. The female-to-male patient would then strongly disagree with “My life would be meaningless if would have to live as a boy.” Thus, it would look as if, on that point, her gender dysphoria had dissipated. But had they given her the female scale again, she would have had the same answer: I prefer to behave like a boy. (Meanwhile, there’s no interrogation into what it means to “behave like a boy,” or why one would need drugs and surgery in order to do so.) [Later researchers developed a more gender-neutral gender dysphoria scale, to measure “binary transgender and nonbinary/genderqueer” people as well.]

The problem with the scale-switching is that it’s not tethered to the treatments; these kids might have answered the same way regardless of whether or not they’d undergone surgical or medical interventions. It’s not saying, “Now that people call me a boy, I’m happy.” Thus, there is no way to discern what effect the treatments themselves had, if any, on gender dysphoria, or even whether the gender dysphoria had actually improved. The kids just answered different questions, the old apples-to-oranges issue.

Nor is there any way to know how much effect the accompanying therapy had, versus the meds. As Abbruzzese et al write, it is “impossible to determine whether gender reassignment, therapy, or the psychological maturation that occurs with the passage of time led to these few modest ‘improvements.’”

Sampling bias

The 2011 study evaluates outcomes of 70 patients, and the Dutch authors called that study prospective—a term that means following people over time, as opposed to less reliable retrospective studies, which can be prone to faulty memory. In theory, the participants were first-come, first-served, their outcomes traced for several years.

But in practice, researchers evaluated the first 70 who were eligible for cross-sex hormones, not just who went on blockers. These clients were doing well enough on puberty blockers, mentally and physically, that they could move on to the next phase. The ones who weren’t wouldn’t have made it through, which would have weeded out many young people with complicated mental health or physical problems, skewing the results toward only the successful cases. Thus, they were selected retrospectively, and not randomly from a larger group of 111. What results might they have had if they’d followed all 111 from the time they administered puberty blockers, rather than just those chosen because they’d done well?

“In our view,” Abbruzzese et al write, “such case selection methodology invalidates the 2011 study conclusions of psychological benefits of puberty suppression—or, as research methodologists would say, puts this finding at a ‘critical risk of bias.’”

Then, for the second study, 15 of the original patients, already predisposed to positive outcomes, didn’t make it in. Some weren’t there, de Vries said, because they weren’t yet one year post-surgery, thus weren’t eligible. But there were others not included: The one patient who died from postsurgical necrotizing fasciitis after vaginoplasty. The three patients who developed obesity and diabetes and couldn’t progress. Five who didn’t return the questionnaire or dropped. Did those folks detransition? Regret? Desist? Get hurt? Thrive so much they didn’t need to participate?

We don’t know. And we don’t know if the 15 weren’t all passed on to the next phase because of bad outcomes, which then didn’t get included in the results of the second paper, or why researchers didn’t wait for the others not yet at a year past surgery to catch up.

Meanwhile, those admitted to the study were already mentally healthy; there’s no reason to believe blockers or hormones increased their mental health, which was already quite good. This may be why, beyond the dramatic shift in gender dysphoria, other measures of improvement were modest. There were no changes in anger, anxiety and depression.

The one study that attempted to replicate the Dutch findings failed to do so. Those researchers found “no changes in psychological function,” likely because they conducted true prospective and chronological research, “and as a result, ended with a diverse range of outcomes, including worsening of problems among female subjects during puberty blockade,” Abbruzzese et al write. If this study were the one touted by proponents of gender-affirmation, it wouldn’t hold up.

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Nearly all gender-dysphoric youth transitioned by the Dutch were lesbian, gay, or bisexual.

And what of the actual participants in the Dutch study? “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence,” by Michael Biggs, spotlights some important information that’s often in the shadows, perhaps deliberately: namely, the connection between childhood-onset gender dysphoria and same-sex attraction. “Of the first 70 adolescents referred to the Amsterdam clinic from 2000 to 2008 and given [puberty blockers], 62 were homosexual while only 1 was heterosexual,” Biggs notes.

Indeed, the original researchers knew that for most, dysphoria was temporary. “Not all children with [gender dysphoria] will turn out to be transsexuals after puberty,” Dutch researchers Peggy Cohen-Kettenis and Louis Gooren noted. “…this phenomenon is more closely related to later homosexuality than to later transsexualism.” They admitted that most gender dysphoric children under 12 don’t grow up to be trans.

Yet as Biggs notes, “These findings were downplayed in subsequent publications; the key manifestos for the Dutch protocol did not mention homosexuality.”

More concern for passing than health

Knowing that most such children will grow out of gender dysphoria and eventually reconcile with their bodies as they develop, why the pressure to intervene so young? “The crucial advantage of puberty suppression was creating ‘individuals who more easily pass in to the opposite gender role,’” Biggs writes, noting an emphasis on external appearance—that is, the goal was about gender conformity, with little thought to long-term health effects.

There is one mention of “loss of fertility,” and “the words orgasm, libido, and sexuality do not appear,” writes Biggs. Though doctors and journalists often present puberty blockers as harmless and fully reversible, they were developed for prostate cancer with the unfortunate side effect of “complete loss of erotic interest” and are “licensed to chemically castrate men with sexual obsessions,” Biggs reminds us. Why wouldn’t they affect sexual function?

When I attended a conference for families of trans and gender-diverse youth, I asked a panel of doctors what they wished they had more research on. Four of them refused to answer my question. The fifth said, “Sexual function,” and nothing further. Marci Bowers, a trans woman, surgeon, gynecologist and president of WPATH, who specializes in procedures like vaginoplasty, said in a video that every child whose puberty was blocked at Tanner stage 2 “never experienced orgasm.” (She later recanted slightly in a Reuters article.)

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Europeans walk it back

The Dutch studies were conducted before the large-scale adoption of evidence-based medicine—now the standard—had occurred. It makes sense that they’d have accepted rather anemic evidence for a novel, small and poorly understood population—evidence that seemed to show some improvement.

Alas, the medical field conflated this unproven medical innovation with proven practice, and it became absorbed by the larger industry. Thus, the situation we have before us today: a relentless battle over how to treat what is now a much bigger population of kids with little-before seen presentations of gender dysphoria, and a refusal to consider the limits and blind spots of the research.

De Vries herself admits that her studies do have limitations, but that more recent research makes up for them. Alas, as Jesse Singal pointed out, both a well-publicized study in JAMA Network Open last year and another one this year in The New England Journal of Medicine are subject to “statistical cherry-picking that tends to generate wobbly findings.” The new research isn’t much better, despite how often it’s hyped.

Multiple European countries have commissioned systematic evidence reviews, which revealed that the evidence base for youth gender medicine, including the Dutch studies, is of low or very-low quality, which means “that the benefits reported by the existing studies are unlikely to be true due to profound problems in the study designs.” (It’s true, also, that many medical interventions proceed despite low-quality evidence, but not usually life-altering identity-based interventions on children and teens.) Those countries have instituted strict protocols for continuing treatment, but here in the US, medical organizations and non-profits promote the false narrative that the “science is settled,” which “stifles scientific debate, threatens the integrity and validity of the informed consent process—and ultimately, hurts the very patients it aims to protect,” Abbruzzese et al write.

Even if the research were high-quality, we would have no way to know if the original Dutch findings apply to today’s ballooning cohort of adolescents with late-onset gender dysphoria and psychiatric comorbidities, because the research wasn’t conducted on that population. With the number of young people identifying as trans doubling, and the number of those seeking medical interventions increasing exponentially, it’s no longer a small cohort, and we don’t know how effective other treatments are.

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20 years later

In January of this year, the Dutch themselves released a highly anticipated new paper: “Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol.” This retrospective study of 1,766 children and adolescents seen at the Amsterdam gender clinic shows that the Netherlands experienced the same demographic shift as many other Western countries: a sharp rise in females with late-onset gender dysphoria, beginning around 2014.

Perhaps we’d expect the paper to answer to some of the concerns raised by these other researchers, like how much was gender dysphoria related to sexual orientation, or do we know how satisfied and safe patients are after transition? But those issues aren’t addressed. Rather, the paper shows that those who visit the gender clinic before age 10 are less likely to go on puberty blockers than those who visit after age 10—that could be taken as confirmation that childhood-onset GD is likely to desist. But it’s not taken that way.

As to why teen girls suddenly flooded the clinic, the suggestion is, “in most Western cultures, it is more widely accepted for [assigned females at birth] to come out as trans men, as opposed to [assigned males at birth] longing for a more feminine appearance.” They do admit that “a conclusive explanation has yet to be found.” I’ve always suspected that the reason young boys were once the majority of patients was because tomboyism was far more acceptable in Western culture than, well, sissyism—we don’t even have a neutral name for it, which is one clue to its unacceptability. But if that’s true, we’d see fewer girls than boys transitioning, and the opposite is now the case.

This paper concludes that the “risk for retransitioning was very low.” Retransition is code for detransition—reversing to one’s natal sex, as much as one can after medical sex changes, usually due to regret. But there’s really nothing in the paper to suggest this, beyond those who don’t go onto cross-sex hormones after puberty blockers. Of all those eligible who sought treatment before age 10, 36% of males and 53% of females started puberty blockers; 3.4 % of males ceased blockers after starting, and just .8% of females. Of those eligible who sought treatment after age 10, 53% of males and 77% of females started blockers. Few of those ceased blockers after, too, some because they were sub-threshold for the gender dysphoria diagnosis, others because their dysphoria passed.

Still, the researchers claim that “detransition was very rare” and that these findings provide “ongoing support for medical interventions in gender-diverse adolescents.”

Listening to all voices

It’s odd to see that recommendation, considering all we know now about the limits and complications of these studies. How do we parse this complexity, these conundrums, when one side of the culture war insists the science is settled and safe, and the other heavily restricts it (which some people call bans), as is happening in Idaho or Tennessee. Good research, good policy—they’re hard to create in our politically polarized climate. Some schools expose children to the notion that they may have been born in the wrong body and require medical interventions to alleviate their distress. Some objectors to those lessons take to censorship laws and arrive at Pride parades with guns.

How do we depolarize? We listen to and consider multiple sides, as the Journal of Sex & Marital Therapy has done by publishing all of these different viewpoints within articles, along with rebuttals to them. We allow people to have all the information—the basis of informed consent. We don’t vilify our opponents. And we don’t accept the press or the medical industry politicizing research.

Some of the people we really need to listen to are the emerging Dutch detransitioners, like someone called Teiresias, who shared his harrowing tale on Gender: A Wider Lens. He and his mother had been told that Teiresias would be carefully evaluated over a long period of time, that they’d explore the trauma and internalized homophobia in his past. But, he said, “They barely question and they barely explore anything.”

After a few appointments, he explained, “I went on hormones. I had facial feminization surgery. So I fixed these things that I hated about myself. But especially after facial feminization surgery, I realized it didn't fix anything, it just moved it.”

In the end, it doesn’t seem that the Dutch are following their own standards, whether or not they are gold, or just tarnished bronze.

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