Critical perspectives

Q: Why is the Cass Review important to the criticism of gender care?

The Cass Review (April 2024) is the most thorough independent evaluation of youth gender care to date, commissioned by the UK's NHS. The review concluded that the evidence base for puberty blockers and cross-sex hormones in minors is "remarkably weak" and led to a fundamental restructuring of the UK's youth gender care.

Q: Is criticism of the gender-affirmative model transphobic?

No. The criticism comes from independent paediatricians, child and adolescent psychiatrists, methodologists, ethicists and — not infrequently — detransitioners themselves. The core criticism is that weak evidence, rapid medicalization and discouraging psychological exploration harm vulnerable young people.

Q: What is wrong with the Dutch Protocol?

The original studies had small, selective samples, no control group and short follow-up. The current patient population differs substantially from the original cohort. Later replication attempts found no improvement in psychological outcome measures. The original outcomes publication included 55 participants. Yet the protocol continues to form the international basis for youth gender care.

Q: Which countries have adjusted their policies?

The United Kingdom, Sweden, Finland, Norway and Denmark have significantly tightened their youth gender care policies. All now emphasize psychotherapy as the first-line treatment and treat medical interventions for minors as experimental. Sweden has virtually discontinued puberty blockers outside research settings, and Finland has established psychotherapy as the first-line treatment.

Critical perspectives — Foto: Ali Haider via Pexels

The dominant gender-affirmative model — in which a patient's self-declared gender identity is affirmed and, upon request, medically supported — has come under intense scientific and ethical scrutiny in recent years. This page summarizes 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 underlying the care model, and the way dissenting voices within medicine have long been marginalized.

The Cass Review: a weak evidence base

The Cass Review (2024), led by paediatrician Hilary Cass and commissioned by the UK's NHS, is the most thorough independent evaluation of youth gender care to date. The review commissioned the University of York to conduct systematic reviews of all available studies on puberty blockers, cross-sex hormones and psychological outcomes. The conclusions were alarming: most studies were of low quality. There was no convincing evidence that puberty blockers improve psychological well-being, reduce suicidality or "buy time" without consequences. The NHS decided to stop prescribing puberty blockers for gender dysphoria outside clinical trials and closed the Tavistock clinic.

Recent scientific publications (2025)

New publications appeared in 2025 that confirm the conclusions drawn earlier. McDeavitt, Cohn and Kulatunga-Moruzi published an analysis in Current Sexual Health Reports (2025) entitled "Pediatric gender affirming care is not evidence-based", concluding that the gender-affirmative model for children and adolescents does not meet the basic requirements of evidence-based medicine. SEGM (Society for Evidence-Based Gender Medicine) provides ongoing overviews of new publications through its SEGM Digest — in 2025, this amounts to dozens of studies per quarter.

The Dutch Protocol: the foundation is faltering

The so-called Dutch Protocol — developed by Cohen-Kettenis, Delemarre-van de Waal and colleagues at Amsterdam's VUmc, now 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 outcomes publication), the absence of a control group, short follow-up, unfavorable selection of outcome measures, and the fact that one participant died from complications following vaginoplasty and is not included in the outcomes. Moreover, the current patient population — predominantly adolescent girls with co-morbid conditions — differs substantially from the original cohort of young children with early-onset, persistent dysphoria.

International policy shifts

The UK is not the only country to have changed course. Sweden (SBU report, 2022) has virtually discontinued the use of puberty blockers for minors outside research settings. Finland (COHERE guideline, 2020) has established psychotherapy as the first-line treatment. Norway has classified puberty blockers as an experimental treatment. Denmark is following the same path.

The WPATH Files

The WPATH Files (2024), leaked internal discussions of the World Professional Association for Transgender Health, showed that healthcare providers acknowledge among themselves that minor patients cannot fully understand the implications of their treatments — while publicly claiming that informed consent is carefully structured. This undermines confidence in WPATH as an impartial medical and 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. There are indications of lasting effects on bone density, brain development, fertility and sexual function. In 2020, the British High Court ruled in Bell v. Tavistock that children under sixteen were probably not competent to give informed consent to such treatments; the Court of Appeal overturned that ruling in 2021.

Social contagion and adolescent girls

Since around 2010, the number of referrals for gender dysphoria in the Netherlands and neighboring countries has increased ten- to twentyfold. The sex ratio has also reversed: whereas historically the vast majority of patients were biological boys, they are now predominantly 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 rates were reported as <1%, based on studies with substantial loss to follow-up and short follow-up periods. Recent cohorts and self-report studies find rates of 7 to 30% among those who have ever medically transitioned. A critical literature review (PMC, 2024) confirms that the existing data on detransition is structurally inadequate. See detransition.

Voices from the Dutch debate

In the Netherlands, too, a group of journalists, scientists and writers has emerged in recent years to critically question the gender-affirmative model. Journalist and author Sybilla Claus wrote Gender at War (2023) and Gender Rebels — both published by Uitgeverij Het Haantje. Columnist Jan Kuitenbrouwer published critical articles on gender ideology in HP/De Tijd and de Volkskrant. Media sociologist Peter Vasterman analyzed media coverage of the gender debate in the Netherlands on his blog. The NTVG published several critical medical contributions. Elsevier Weekblad wrote in 2023 about "the debate the Netherlands does not want to have".

An extensive analysis of the concept — its core claims, origins and timeline — can be found at genderideologie.nl.

Women's rights and sex-based provisions

Replacing biological sex with self-declared gender identity in laws and regulations creates tensions around sex-based provisions: sports competitions, prisons, women's shelters, changing rooms and data categories in research. The British legal case Maya Forstater vs. CGD Europe (2021, won) established that a gender-critical belief is a protected belief within the meaning of the UK's Equality Act. Philosophers such as Kathleen Stock (Material Girls, 2021) and Helen Joyce (Trans: When Ideology Meets Reality, 2021) expose the philosophical and social foundations of this tension.

Silence within the medical profession

One of the most troubling observations is how long it took for methodologically robust criticism to reach mainstream medical journals. Doctors who expressed doubts internally report intimidation, professional retaliation and public accusations of transphobia. The Cass Review explicitly documents this climate. How doubts within the Tavistock clinic were suppressed for years is described by gendersekte.nl in its case study on the culture of silence at Tavistock. A healthy medical and scientific climate requires hypotheses to be tested and dissent to be open to discussion — especially when treatments are invasive and partly irreversible.

Why is the Cass Review important to the criticism of gender care?

Is criticism of the gender-affirmative model transphobic?

What is wrong with the Dutch Protocol?

Which countries have adjusted their policies?