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 was 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 failed to take place.

More on this site: NTVG — International criticism of the Dutch Protocol, House of Representatives — Parliamentary questions on the Dutch Approach (2023) and McDeavitt, Cohn & Kulatunga-Moruzi.

Subtopics can be found in Amsterdam UMC and the Dutch Protocol.

Origins and content

The protocol was developed by the gender team at VU University Medical Center (now Amsterdam UMC), particularly Peggy Cohen-Kettenis, Henriette Delemarre-van de Waal and later Annelou de Vries and Thomas Steensma. It consists of a phased model: psychological screening, followed by puberty blockers around Tanner stages 2–3, then sex hormones from approximately age 16, and finally surgery from age 18.

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

The original studies

The evidence base rests primarily on several studies by the Dutch group — particularly De Vries et al. (2011) and De Vries et al. (2014) — based on a cohort of just 55 young people. Important methodological limitations include:

• Small, highly selected group: not representative of current referrals.
• No control group: there has never been a comparison with young people who did not receive medical treatment, so causality cannot be established.
• High attrition and missing data: one participant died during surgery; data on dropouts are largely missing from the analysis.
• Short follow-up: 1–2 years after surgery, at an average age in the early twenties.
• Outcome measures: psychometric scales that were not administered consistently over time; outcomes relating to well-being were less unequivocal than is often suggested.

Michael Biggs (University of Oxford) also analyzed the UK replication of the Dutch Protocol at the Tavistock clinic: among 44 young people, no improvements in psychological outcome measures were found during the same period. Those results went unpublished for years. The Cass Review and SEGM documented this “failed replication” as a reason for caution.

International spread

The protocol was adopted in the guidelines of the Endocrine Society (2009) and WPATH (SOC7, 2011) and rolled out worldwide. In practice, however, it was applied much more broadly than originally intended: the strict selection criteria were abandoned, comorbidity was no longer considered a contraindication, and the population shifted from young children with early-onset dysphoria to adolescents — especially girls — with later-onset dysphoria, psychological comorbidity and intensive social media use. The original protocol was not designed for this group.

International criticism and policy shift

Scientific criticism of the protocol has increased sharply since 2018, including from Stephen Levine, Michael Biggs, William Malone, Susan Bradley, James Cantor and Sallie Baxendale. An overview of three decades of research can be found in Dutch Protocol research lacks reliable evidence after 30 years.

• Cass Review (2024, UK): a systematic review concluded that the evidence base is “remarkably weak” and recommended extreme caution for minors. See Cass Review.
• SBU (Sweden, 2022): insufficient evidence; Socialstyrelsen then restricted treatment of minors to exceptional cases.
• COHERE (Finland, 2020): psychotherapy as the first option, with hormones only in strict exceptions.
• Sundhedsstyrelsen (Denmark, 2023): significant restriction.
• Ukom (Norway, 2023): Norway’s healthcare investigation board advised that puberty blockers and hormones for minors be considered experimental treatment; the Norwegian guideline has not been withdrawn.
• WPATH Files (2024): leaked internal documents showed that even within WPATH it was acknowledged that informed consent is difficult for minors and that harmful outcomes were known.

Situation in the Netherlands

Amsterdam UMC and Radboudumc still work with variants of the Dutch Protocol. Of the young people referred to Amsterdam UMC, more than four in five began a medical pathway. In 2024, the House of Representatives called for research into the Dutch Protocol. The Health Council concluded on June 30, 2026, that transgender care for young people in the Netherlands is carefully organized; a policy shift such as those seen in the United Kingdom or Scandinavia has not taken place. Critical voices from the medical community are growing, however (see the Dutch Journal of Medicine), and there is increasing attention to the fact that the Netherlands is now out of step with neighboring countries.