The Beginning of Gender Care for Young People in the Netherlands

In 1987, psychologist Peggy Cohen-Kettenis founded an outpatient clinic at University Medical Center Utrecht for children and young people with gender-related difficulties. It was the first clinic of its kind in Europe. Until then, care for transsexuality had focused on adults; young people had to wait until they reached adulthood.

Why a Separate Clinic for Young People

The idea behind the clinic was that some young people might benefit from early intervention. Those who go through puberty fully in their sex assigned at birth develop physical characteristics that can later be difficult or impossible to reverse. The team wanted to investigate whether carefully selected young people could be helped at an earlier stage.

The clinic took a step-by-step approach: first, an extensive psychological assessment, followed only then by any possible medical treatment. This approach developed during the 1990s into the treatment model that became internationally known as the Dutch Protocol.

From Utrecht to Amsterdam

In 2002, Cohen-Kettenis became professor of medical psychology at VU Medical Center in Amsterdam. Care for children and young people moved with her and was brought together there with the existing gender care for adults. The Amsterdam centre, now part of Amsterdam UMC, became the best-known gender centre in the world.

What Happened Next

The first young people to have their puberty suppressed with medication were treated in the 1990s. The first scientific description of this was published in 1998; see the first publication on puberty suppression. Today, care for young people is offered in several locations in the Netherlands, including Amsterdam, Nijmegen and Groningen, and waiting times have increased to several years.

What Research in Children Showed

The Utrecht clinic saw both young children and teenagers and followed them over longer periods. This research produced a finding that had a major influence on subsequent policy. In most children who experienced gender dysphoria before puberty, these feelings disappeared during puberty; many of them later turned out to be homosexual or lesbian. In a smaller group, the dysphoria persisted or became stronger. For that reason, the team chose not to provide medical treatment to young children and instead to wait and see how their dysphoria developed around the start of puberty. The article on watchful waiting for gender dysphoria on transtijd.nl explains what this approach involved and what research on the disappearance of dysphoria has shown. Only young people whose dysphoria persisted at that point were considered eligible for treatment. The precise figures and the way in which children were selected at the time continue to be debated.

Who Is Peggy Cohen-Kettenis?

Peggy Cohen-Kettenis is a clinical psychologist who worked in Utrecht in the department of child and adolescent psychiatry. She published hundreds of scientific articles on gender dysphoria in children, young people and adults and is internationally regarded as a pioneer of care for young people. She contributed to the international guidelines of WPATH and the Endocrine Society, as well as to the description of gender dysphoria in the DSM-5. As a result, the Dutch approach found its way into the textbooks and guidelines used by doctors worldwide; see also the Endocrine Society guideline.

Significance

The Utrecht clinic began with just a few referrals per year, mainly children whose gender dysphoria had started at a young age. This was a different group from the young people who began presenting in large numbers from around 2014 onwards. Of the 1,470 young people referred to the Amsterdam clinic between 2009 and 2019, more than four in five started a medical pathway; see the news report on that study. This difference plays an important role in the current debate over whether the original approach can be applied to the group seen today.