If you’ve followed the debate over treating gender-distressed youth, then you know that evidence-based policy changes, along with general public understanding, often lag the latest research. Such a gap might be less significant in other medical subfields, but it has incredibly high stakes in youth gender medicine. Given the nature of the treatments and their implications for the long-term physical and psychological well-being of underage patients, keeping up with the research is crucial—especially if the assumptions underpinning gender-dysphoria guidelines are proven false.

While the wheels of change move slowly, signs suggest that the Netherlands is beginning to grapple with the disconnect between its outdated gender-dysphoria guidelines from 2018 and new epidemiological data and other countries’ systematic reviews of evidence. While the Netherlands is only one country, it holds symbolic importance in the world of youth gender medicine. The country pioneered the use of medical interventions for gender-dysphoric youth (puberty blockers, cross-sex hormones, and “gender affirming” surgeries) in its original “Dutch protocol,” a document that established eligibility criteria for youth and a corresponding medical treatment pathway. Furthermore, the widespread adoption of youth gender-transition practices can be traced to the supposed success of the country’s original protocol. Dutch clinicians have also made extensive contributions to the World Professional Association for Transgender Health’s Standard of Care 8 (SOC8) as well as the Endocrine Society’s 2017 clinical-practice guidelines, which many professionals consider the definitive treatment framework for gender-distressed youth.

The Society for Evidence Based Gender Medicine (SEGM) adeptly chronicles the Netherlands’s burgeoning national conversation over youth gender medicine, tracing its rise to three recent catalysts: a medical publication in a Dutch-language medical journal; a new paper in a Dutch legal journal arguing that the 2018 Dutch protocol would not hold up as a genuine “standard of care” in civil litigation; and a (liberal) Dutch public broadcaster’s release of a two-part documentary series featuring methodological experts who highlight the weaknesses of the original protocol.

The first trigger-point in the Netherlands’s trans discourse was a medical paper by researchers Jilles Smids and Patrik Vankrunkelsven. Smids and Vankrunkelsven penned the paper in response to a clinical lesson—an overview of the treatment process for trans-identifying youth, with case studies of three youth—published in the Dutch Journal of Medicine, which concedes that a surging number of patients have been referred for gender issues, that the more complex youth cases have involved adolescent-onset (rather than childhood-onset) dysphoria, and that patients often present with other psychiatric symptoms. Despite these concessions, the young people described in the clinical lesson were all ultimately treated with, or were awaiting, “gender-affirming” medical interventions. Specifically, two of the youth had gone on to take puberty blockers, while one was awaiting the start of a more targeted menarche-blocking medication.

This concession and the doctors’ treatment decisions are relevant because critics of affirmative-care practices in the Netherlands and elsewhere contend that today’s cohort of gender-distressed youth is clinically distinct from the population in the original Dutch protocol. Critics also charge that even the findings of the original Dutch studies for trans youth, which have more narrowly defined eligibility criteria (e.g., including only patients with childhood-onset dysphoria, without other psychiatric conditions, and with family support), don’t hold up under scrutiny.

In their critical paper, Smids and Vankrunkelsven take the clinical-lesson authors to task for painting an incomplete picture of the state of scientific knowledge on youth transition, and for sidestepping the international debate over what constitutes ethical care for gender-distressed youth. Smids and Vankrunkelsven seem perplexed that the clinical lesson’s authors would endorse puberty blockers and cross-sex hormones as the default treatment approach for youth when systematic reviews, including England’s NICE review, have concluded that the evidence for these interventions’ safety and effectiveness is weak. Smids and Vankrunkelsven added that if the authors used the same GRADE system used in many evidence reviews to arrive at treatment recommendations—a methodological framework for developing summaries of evidence and assessing their reliability for making clinical-practice guidelines—they would have been highly unlikely to recommend cross-sex hormones and puberty blockers as part of routine care, especially given the known cost-benefit breakdown: guaranteed fertility complications and sexual dysfunction, reductions in bone density, and possible hindrance of brain development, compared with largely inconclusive mental-health benefits and reductions in gender dysphoria.

Smids and Vankrunkelsven also criticized the clinical lesson for failing to distinguish between clinical presentations with adolescent-onset and childhood-onset dysphoria because the first group was notably not the target of the original Dutch treatment protocol, and the developmental course of this group’s dysphoria is essentially unknown. Moreover, the adolescent-onset cohort tends to have higher rates of comorbidities, which were exclusionary criteria in “the Dutch protocol.” This is crucial because trans identity and the desire for body alteration may be a maladaptive coping mechanism for underlying mental-health problems. Any clinician who would conflate these two populations is technically running a new, uncontrolled experiment.

Smids and Vankrunkelsven also noted that the true regret rate in the emergent cohort of adolescent-onset-dysphoria sufferers is unknown because some research suggests that regret can take up to eight to ten years to manifest. Yet, the clinical lesson’s authors say that 98 percent of youth who proceed from blockers to cross-sex hormones keep taking cross-sex hormones over “the long term”—quite a claim, considering that they followed up with natal males only as far out as 3.5 years, and with natal females at 2.3 years, after first intervention.

The final two concerns that Smids and Vankrunkelsven raise involve puberty blockers. First, they challenge the lesson authors’ dubious assumption that puberty blockers provide a “pause button” and are part of the diagnostic phase, rather than the first step in transitioning. Only 1.4 percent–6 percent of Dutch youth prescribed puberty blockers for gender dysphoria stopped taking them; the overwhelming majority proceeded to take cross-sex hormones. In fact, interrupting puberty might hinder natural developmental processes that could allow kids’ dysphoria to resolve itself, while taking blockers might crystallize their cross-gender identities. Smids and Vankrunkelsven’s other concern is that the clinical lesson’s authors claimed no cognitive effects of taking puberty blockers—this despite a study of individuals with precocious puberty finding an IQ reduction of seven points after they spent two years on puberty blockers.

The second catalyst for the Netherlands’s recent reconsideration came from a Dutch legal journal, Nederlands Juristenblad, which published an article by Lodewijk Smeehuijzen, Jilles Smids, and Coen Hoekstra arguing that the country’s current national guidelines for treating gender-distressed youth—again, the 2018 Dutch protocol—fail to meet the legal definition of a standard of care. The authors note that case-law precedent has established that a standard of care must be evidence-based, follow a reproducible and properly designed methodology, and have a limited “ethical dimension.” By limited “ethical dimension,” the authors mean that a standard of care’s credibility comes from its medical expertise. If guidelines are primarily mediating questions of ethics that stand outside the bounds of their medical expertise, they are less credible.

The 2018 Dutch protocol did not follow national guidelines for developing an evidence-based standard of care, and it failed to commission a systematic review of existing evidence. Moreover, as SEGM notes in its analysis, the committee overseeing the development of the 2018 Dutch protocol failed to control for conflicts of interest; Transvisie, a Dutch patient-advocacy group, took public credit for lowering the eligibility age for a mastectomy to 16 and reducing the role of psychological assessment in patients’ ability to access gender-affirming care. The 2018 protocol is not based on an assessment of the existing research and is at odds with treatment recommendations in England, Finland, and Sweden, all of which completed their own systematic reviews.

As the article highlights, other changes made to the 2018 Dutch protocol were not based on evidence. These included removing childhood-onset gender dysphoria as a key eligibility criterion for accessing care; lowering the age of eligibility for cross-sex hormones to 15 and mastectomy to 16; allowing youth with “non-binary” gender identities (identities that fall outside of the man/woman binary) to medically transition;  and adopting the ICD-11 diagnostic terminology of “gender-incongruence” over gender dysphoria, which no longer requires psychological distress as a prerequisite for receiving medical care for gender issues. The 2018 Dutch protocol thus radically diverges from the guidelines of the original Dutch protocol, which imposed strict limitations on who was eligible for care.

Smeehuijzen, Smids, and Hoekstra contend that at the heart of the debate over the 2018 Dutch protocol is a fundamentally ethical, rather than medical, question: What is the proper societal response to a gender-incongruent child? Given the very weak research supporting affirming-care interventions and concerns that puberty blockers might sustain dysphoria, questions about whether it’s better to intervene early with irreversible medical procedures or allow dysphoria to resolve itself naturally, and concerns about prepubertal minors’ ability to consent, the debate over best practices is as much about ethics—and philosophical anthropology—as it is about science. For these reasons, the authors argue, the Dutch Handbook of Health Law does not grant medical guidelines special authority to resolve ethical dilemmas that fall outside of the scope of medical expertise.

The final turning point in the Dutch trans debate was the release of the new two-part Dutch-language documentary, the Transgender Protocol (Parts 1 & 2, with English subtitles), which has drawn activist groups’ ire for criticizing the affirmative-care model. Part 1 covers the scientific origins of the original Dutch protocol; Part 2 focuses primarily on the impact of puberty blockers on brain development.

Part 1 challenges the safety and efficacy of the foundational Dutch studies and interviews five Dutch experts (four research methodologists and one professor of child psychology) who criticize the existing evidence. This segment also highlights the hostile intellectual climate surrounding gender-transition procedures, which stifles scientific debate. It includes commentary from experts in other European countries and stories from those who have detransitioned.

Part 2 underscores the puberty-blocker controversy and the unsettled science about the drugs’ impact on the developing brain. According to the documentary, Dutch researchers as early as 2006 acknowledged the role that puberty, and associated hormonal changes, play in brain development. Despite this concession, the researchers never engaged in robust follow-up work to understand better the cognitive impact of halting these developmental processes, in part out of fear that unwanted findings would bring an end to puberty-blocking interventions.

While it’s far from guaranteed that Dutch officials will make changes to the 2018 protocol, the documentary has thrust the controversy into the Dutch public consciousness. Concurrent calls from the Dutch medical and legal establishments to reform existing practices to align more closely with those of other European countries is also a step in the right direction. 

Given the stakes, change will arrive too late for some. But late is better than never.

Photo by Romy Arroyo Fernandez/NurPhoto via Getty Images


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