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Critical perspectives
The dominant gender-affirmative model — in which the patient's self-declared gender identity is affirmed and, on request, medically supported — has come under heavy scientific and ethical criticism in recent years. This page summarises the main objections. The criticism is not directed at the existence of gender dysphoria or at trans people as such, but at the quality of the evidence, the assumptions behind the care model and the way dissenting voices within medicine have long been marginalised.
The Cass Review: weak evidence base
The Cass Review (2024), led by paediatrician Hilary Cass and commissioned by the British NHS, is the most thorough independent evaluation of youth gender care to date. The review had the University of York carry out systematic reviews of all available studies on puberty blockers, cross-sex hormones and psychological outcomes. The conclusions were striking: the quality of evidence was predominantly "very low" according to GRADE criteria. There was no convincing evidence that puberty blockers improve psychological well-being, lower suicidality or "buy time" without consequences. The NHS decided no longer to prescribe puberty blockers for gender dysphoria outside clinical research and closed the Tavistock clinic.
The Dutch Protocol: the foundation is wobbly
The so-called Dutch Protocol — developed by De Vries, Steensma and Cohen-Kettenis at Amsterdam UMC — forms the international basis for youth gender care. Levine, Abbruzzese and Mason (2022) and others point to fundamental problems: a small, highly selected sample (n=55 for the original outcome publication), the absence of a control group, short follow-up, unfavourable selection of outcome measures, and the fact that one participant died during surgery without this being mentioned in the main publication. Moreover, the current patient population — a majority of adolescent girls with co-morbid problems — differs greatly from the original cohort of young children with early, persistent dysphoria. Generalisation of the protocol to this new group is not scientifically justified.
International changes of course
Not only the UK has turned. Sweden (SBU report, 2022) has largely abolished puberty blockers in minors outside research settings. Finland (COHERE guideline, 2020) has established psychotherapy as first-line treatment. Norway has labelled puberty blockers as experimental treatment. Denmark follows the same line. The convergence of these conclusions in countries with full social health care and without political polarisation around the topic is telling.
The WPATH Files
The WPATH Files (2024), leaked internal discussions of the World Professional Association for Transgender Health, showed that care providers among themselves acknowledge that minor patients cannot oversee the implications of their treatments — such as loss of fertility, anorgasmia or lifelong dependence on hormones — while outwardly it is stated that informed consent is carefully arranged. Standards of Care version 8 (SOC-8) removed minimum age limits for various interventions, which happened under pressure from the US Department of Health. This undermines confidence in WPATH as an impartial medical-scientific authority.
Puberty blockers are not a pause
The claim that puberty blockers are "reversible" and "buy time to think" is not supported by the available evidence. Between 96 and 98% of children who start blockers go on to cross-sex hormones — a ratio that contradicts the idea of neutral exploration. There are indications of lasting effects on bone density, brain development, fertility and sexual function. The British High Court ruled in Bell v. Tavistock that minors are likely not competent to give informed consent for such treatments.
Social contagion and the adolescent girls
Since around 2010 the number of referrals for gender dysphoria in the Netherlands and surrounding countries has multiplied tenfold to twentyfold. The sex ratio has flipped: where historically the overwhelming majority of patients were biological boys, the majority now are adolescent girls, often with co-morbid autism, anxiety, depression or trauma. Littman (2018) described this pattern as "rapid-onset gender dysphoria" and pointed to the possible role of social networks and online communities. See also ROGD and desistance.
Detransition is underestimated
For a long time detransition percentages were given as <1%, based on studies with high loss to follow-up and short follow-up. Recent cohorts and self-report studies find rates of 7 to 30% among those who ever medically transitioned. Many detransitioners report that they were insufficiently informed by their care providers about alternatives and risks. See detransition.
Women's rights and sex-based provisions
Replacing biological sex with self-declared gender identity in law and regulation causes tensions around sex-based provisions: sports competitions, prisons, shelters for women, changing rooms and data categories in research. Critics — including gender-critical feminists — point out that these trade-offs deserve serious social discussion and that labelling every criticism as "transphobia" blocks an open debate.
The silence within the medical world
One of the most worrying observations is how long it took before methodologically strong criticism reached mainstream journals. Doctors who expressed internal doubts report intimidation, professional retaliation and public accusations of transphobia. The Cass Review documents this climate explicitly. A healthy medical-scientific climate requires that hypotheses be tested and that dissent is open to discussion — precisely with treatments that are far-reaching and partly irreversible.