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International comparison
Over the past five years a striking change of course in youth gender care has been taking place in north-western Europe. Countries that previously embraced the Dutch model have, after independent evaluation, substantially tightened or reversed their policy. The convergence of conclusions is telling: it is precisely the health systems with public funding and without sharp party-political polarisation around the topic that have significantly restricted medical pathways in minors.
The Netherlands: pioneer and blind spot
The Netherlands is internationally known as the inventor of the Dutch Protocol. The original outcome studies are, however, small, uncontrolled and methodologically weak; the current patient population (predominantly adolescent girls with co-morbid problems) differs greatly from the original cohort. Nevertheless Amsterdam UMC and the University Medical Centre Groningen largely continue to apply the protocol. Independent evaluation and transparent publication of outcome data are barely available in the Netherlands — a striking lag compared with the countries around us.
United Kingdom: the Cass Review
The Cass Review (2024) is the most thorough independent evaluation of youth gender care in the world. Conclusion: the quality of evidence for puberty blockers and cross-sex hormones in minors is "remarkably weak". The NHS no longer makes puberty blockers available outside clinical research and has closed the Tavistock clinic. Care has been restructured into regional, multidisciplinary centres with an emphasis on psychological evaluation and attention to co-morbid problems.
Sweden: SBU report
The SBU report (2022) from the Swedish Agency for Health Technology Assessment concluded that the risk-benefit ratio of puberty blockers and cross-sex hormones in minors is unfavourable. The Karolinska Institute had already in 2021 unilaterally decided no longer to prescribe blockers outside research settings. SEGM describes the Swedish policy change as the de facto abandonment of the Dutch Protocol.
Finland: COHERE
Finland was in 2020 the first country to fundamentally revise its national guideline. The COHERE guideline establishes psychotherapy as first-line treatment, requires extensive investigation of co-morbidity and reserves medical interventions in minors for "exceptional cases". The Finnish approach was emphatically based on systematic review of the evidence, not on political considerations.
Norway and Denmark
The Norwegian independent health authority Ukom has labelled puberty blockers as experimental treatment. Denmark (2023) has substantially restricted access and explicitly chooses psychotherapy as the main treatment for adolescents. The Danish approach stresses that about 90% of young patients should not undergo medical transition.
United States: political paralysis
The US is strongly polarised. On one side are WPATH, the American Academy of Pediatrics and the Endocrine Society, which defend affirmative care — institutions whose independence has been compromised by the WPATH Files and internal documents. On the other side are states that restrict or ban youth gender care through legislation, and scientific organisations such as the Society for Evidence-Based Gender Medicine (SEGM), which contest the evidence base. The 2025 HHS report (commissioned by the federal government) concluded, in line with Cass, that the evidence base is weak.
Belgium
Belgium offers youth gender care through a few specialised centres. After a critical report by VRT NWS (2024) and public questions surrounding the Ghent University Hospital, a national debate has arisen about the use of puberty blockers in minors. A formal guideline revision is under way.
Common tendency: away from the affirmative model
The common thread in north-western Europe: psychotherapy as first-line treatment, restraint with medical interventions in minors, longer observation periods, attention to co-morbid problems, and transparent treatment as experimental care. This reflects the findings of independent systematic reviews. The Netherlands, given its role as the inventor of the original protocol, has remarkably lagged behind in this change of course.