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The Dutch Protocol

The Dutch Protocol is the medical treatment model for gender dysphoria in minors that was developed in Amsterdam in the 1990s. It has been rolled out worldwide as 'the gold standard', but its scientific foundations are narrower than has long been presented. Since 2020 the protocol has increasingly been abandoned or restricted internationally; in the Netherlands itself a comparable reorientation has so far not taken place.

Origin and content

The protocol was developed by the gender team of the VU medical centre (now Amsterdam UMC), in particular Peggy Cohen-Kettenis, Henriette Delemarre-van de Waal and later Annelou de Vries and Thomas Steensma. It involves a phased model: psychological screening, followed by puberty blockers around Tanner stage 2-3, then cross-sex hormones from around the age of 16, and finally surgery from the age of 18.

The original selection criteria were strict: early, lifelong, persistent dysphoria, no serious comorbidity, stable family context, and good psychological functioning. Only a minority of referrals originally met these criteria.

The original studies

The evidence base rests mainly on a few studies by the Dutch group — in particular De Vries et al. (2011) and De Vries et al. (2014) — based on a cohort of just 55 adolescents. Important methodological limitations:

• Small, heavily selected group: not representative of current referrals.
• No control group: there was never any comparison with adolescents who received no medical treatment, so causality cannot be established.
• High dropout and missing data: one participant died during surgery; data on dropouts are largely absent from the analysis.
• Short follow-up: 1-2 years after surgery, at an average age of the early twenties.
• Outcome measures: psychometric scales that were not administered consistently over time; outcomes on well-being were less unambiguous than often suggested.

Michael Biggs (University of Oxford) has additionally analysed the UK replication of the Dutch Protocol at the Tavistock clinic: among 44 adolescents no improvements on psychological outcome measures were found in the same period. Those results went unpublished for years. The Cass Review and SEGM have documented this 'failed replication' as grounds for caution.

International spread

From 2007 onwards the protocol was adopted by WPATH and the major endocrinological associations and rolled out worldwide. In practice, however, it was applied much more broadly than originally intended: the strict selection criteria were dropped, comorbidity was no longer a contraindication, and the population shifted from young children with early-onset dysphoria to adolescents — mainly girls — with later onset, psychiatric comorbidity and intensive social-media use. The original protocol was not designed for this group.

International criticism and policy reversal

Scientific criticism of the protocol has grown sharply since 2018, from clinicians and researchers including Stephen Levine, Michael Biggs, William Malone, Susan Bradley, James Cantor and Sallie Baxendale.

• Cass Review (2024, UK): systematic review concluded that the evidence base is 'remarkably weak' and advised extreme caution in minors. See Cass Review.
• SBU (Sweden, 2022): evidence insufficient; routine treatment of minors was ended.
• COHERE (Finland, 2020): psychotherapy as first choice, hormones only in strict exceptions.
• Sundhedsstyrelsen (Denmark, 2023): sharp restriction.
• Helsedirektoratet (Norway, 2023): classified puberty blockers and hormones for minors as experimental.
• WPATH Files (2024): leaked internal documents showed that within WPATH itself it was acknowledged that informed consent in minors is difficult and that harmful outcomes were known.

The situation in the Netherlands

Amsterdam UMC and Radboudumc still work with variants of the Dutch Protocol. A formal reassessment comparable to the British or Scandinavian evaluations has not been published in the Netherlands. Critical voices from the medical world are growing (see the Nederlands Tijdschrift voor Geneeskunde) and there is attention to the fact that the Netherlands is now out of step with its neighbours.