The Dutch Protocol

The Dutch Protocol is the name given to a mode of treatment for transgender ideation developed in Holland.

It is the foundation of the recent trend often called the Gender Affirmative Model of Treatment (GAMT). Here we explain why it is a very poor basis upon which to build a widely used medical approach to transgender ideation.

First, a link to a video explaining its shortcomings by Patrick Hunter MD in testimony to the Florida Board of Medicine:

In January 2023 criticism of The Dutch Protocol was published in a paper by members of SEGM (Society for Evidence-Based Gender Medicine) accompanied by a call for “urgent attention from the medical community“:

A new open-access publication, “The Myth of Reliable Research in Pediatric Gender Medicine,” focuses on the two Dutch studies that gave rise to “gender-affirmative” care for youth worldwide. The authors convincingly demonstrate that rather than “solid prospective research” or even the “gold standard” in research, as these studies are frequently described by the proponents of “gender-affirmative care,” the Dutch research suffers from profound, previously unrecognized problems. These problems range from erroneously concluding that gender dysphoria disappeared as a result of “gender-affirmative treatment,” to reporting only the best-case scenario outcomes and failing to properly examine the risks, despite the fact that a significant proportion of the treated sample experienced adverse effects.

The Dutch Studies and The Myth of Reliable Research in Pediatric Gender Medicine, SEGM

Dr Michael Biggs wrote a paper in 2022 which looked at how the protocol has been interpreted and what impact it has had on current treatment protocols, and whether it was ever appropriate. What follows is an accessible synopsis of that paper.

Biggs’ paper The Dutch Protocol for Juvenile Transsexuals (9/19/2022): Origins and Evidence takes on the claims made in the original Dutch Protocol paper and the subsequent widespread adoption of the Dutch protocol in the treatment of gender dysphoria. The Dutch Protocol, proposed by Dutch clinicians in the mid 1990s, is the practice of suppression puberty in minors experiencing gender dysphoria (defined as the persistent desire to become the opposite sex through physical interventions such as surgery and hormone therapy) and, since the mid 2010s, has been standard practice in adolescents with that diagnosis. Clinicians justified this practice with claims that it was reversible and could be used as a tool for diagnosis.

Biggs’ paper details the origins of the Dutch Protocol: the idea of ‘transgenderism’ emerged in the 1950s— after significant advances in plastic surgery and the discovery of cross-sex hormones. Special clinics for gender-identity issues sprang up in Toronto, Utrecht, Holland, and London in the mid 1970s and ‘80s; they provided counseling but did not give hormones until the patient was at least 16 years old, and did not refer for surgery until the patient was 18. A clinician at the Utrecht clinic led the way in driving down the age of treatment due to the belief that lowering the age at which a patient could receive surgery and hormones would result in better outcomes. She treated 22 younger patients with hormone therapy and surgery and claimed to achieve better outcomes than those seen in patients who had transitioned when they were older. But her conclusions are not that straightforward: the younger patients transitioned in a more tolerant era, most had no sexual partners yet and they had not yet reached the age where the might regret being unable to have children. No follow up with these 22 patients has occurred. Another Dutch researcher around this time claimed to prove there is a difference between genetic/genital sex on the one hand and “brain sex” on the other; but even he recently admits that his research has not been replicated.

Puberty suppression was rare until 2006, when a pharmaceutical-funded article was published in an influential medical journal. Patients had to meet the following criteria for this treatment: gender dysphoria should have begun early in childhood, and dysphoria should have worsened with the onset of puberty; the patient should be psychologically stable, and not suffer from other mental health problems; and the patient should have support from their family. Even as the protocol was formalized and the number of patients who received it drastically increased, clinicians did not always strictly follow it—mainly, they started treatment at earlier ages than recommended. International adoption of the Dutch Protocol happened quickly, followed even more rapidly by positive coverage in major media outlets; Oprah Winfrey broadcast a piece similar to The Wrong Body, popularizing the idea of the “trans kid” and advocating for “nipping puberty in the bud.” Positive media coverage of puberty suppression is known to increase referrals to gender clinics in the short term.

The London gender clinic began suppressing puberty in children as young as 12 and declared successful outcomes before any were officially measured; they also made misleading claims without substantiation about the puberty-suppressing drugs, saying that the body just “restarts” where it left off when you stop taking the drugs if you decide not to move forward with treatment. The London Clinic was unable to replicate the results of the original Dutch protocol, which means that results cannot be extrapolated to other countries. The Amsterdam clinic made claims of success as well, but the evidence to support it is questionable. The fatality rate from surgery exceeds 1%, a number that would stop any other experimental treatment on healthy minors. Data from long-term follow up, that of 20 years, is missing except in one case: that patient does not regret transitioning but scored high on the measure for depression because of shame about his genital appearance and his feelings of inadequacy in sexual matters. A “strong dislike of one’s sexual anatomy” is one of the diagnostic criteria for gender dysphoria in children (according to DSM-5), and so in this respect it is not clear how the dysphoria had been resolved. Another study showed that puberty suppression brought no measurable benefit or harm, but outcomes were not separated by gender in the paper—it was evident that outcomes were worse for girls than for boys.

Biggs discusses a number of problems with the original paper:

1. The cohort studied in the original paper is made up of 70 people and is the only significant evidence that puberty suppressants followed by cross-sex hormones and surgery reduced gender dysphoria and improved psychological outcomes.
2. There is no evidence that the claim of reversibility of puberty suppressants is true. In fact, The World Professional Association for Transgender Health, formerly known as HBIGDA, itself says that cross-sex hormones are not/not easily reversible; they do not explain why one hormonal treatment be reversible and another one not be.
3. Although puberty-suppressing drugs are licensed to treat conditions like endometriosis, precocious puberty in children and advanced prostate cancer, they have never been licensed as a treatment for gender dysphoria. The original paper ignored the side effects of puberty suppressants: negative effects on bone mass, cognitive and emotional development and sexual functioning.
4. The claim that puberty suppressants can be used diagnostically is dubious and does not sufficiently address the possibilities either that puberty suppression could impede the exploration of gender just as much the claim that pressures of the physical changes could and/or that puberty suppression is a self-fulfilling prophecy. Also, since 95% of people who receive puberty suppressants go on to receive cross-sex hormones, it remains unclear how the puberty suppressants could be used diagnostically since they are so rarely used apart from other interventions. The original paper downplayed the multiple studies showing that early gender dysphoria in boys is more closely related to later homosexuality than later transgenderism.

Biggs also discusses problems with the Dutch Protocol overall:

1. The main emphasis of puberty suppression was physical appearance—that is, enabling patients to more easily pass as the opposite gender. “Loss of fertility” was mentioned once in the original paper; “libido,” “orgasm,” and “sexuality”  do not appear at all in the paper. This is interesting since the drugs used to stop puberty are also used to chemically castrate men with inappropriate sexual fixations. The original 70 people in the Dutch protocol were not warned about any of these risks, including how it can increase the risk of genital surgery further down the line in treatment; about one fourth of the patients that received surgery needed further corrective procedures.
2. The original paper’s results could not be replicated; attempts to do so resulted in findings that puberty suppression and counseling was not statistically more effective than counseling alone. Findings that the protocol was not as effective as anticipated were not published.
3. Subsequent evidence that the Dutch protocol is beneficial relies on uncontrolled studies.

Overall, Biggs’ paper asserts that gender dysphoria lacks an objective diagnosis and extreme cases are rare—one per year in the Netherlands in the 1990s when the Dutch Protocol was developed. Yet the Dutch protocol has likely been used on several thousand patients, with insufficient follow-up and data collection to know if this treatment is safe or effective. It is also unclear if it is necessary; there has yet to be a sufficient explanation for the certainty that children experiencing gender dysphoria will definitely grow up to be transgender as opposed to gay or lesbian or if, with counseling, the gender dysphoria will resolve.

Finally, Dr Michael Biggs explains the Dutch Protocol and ‘puberty blockers’ in this presentation: