Medical, legal, and cultural debate over the practice of youth gender transitions has come to the birthplace of the Dutch Protocol
The following is an extract from an article on the Society for Evidence Based Gender Medicine’s website about the beginnings of discussion and debate in the Netherlands about the practice of gender transition in minors. This is particularly significant as the practice in the Netherlands has been extremely influential on gender clinics around the world, including the UK’s Gender Identity Development Service.
https://segm.org/Dutch-protocol-debate-Netherlands
The Netherlands, like the rest of the Western world, has experienced an unprecedented increase in the number of youth seeking to undergo gender transition. Like the rest of the West, this sharp increase has been driven largely by adolescent females. Unlike the rest of the Western world, where this dramatic epidemiological shift has led to scientific debate about the practice of youth transition, the Netherlands practice has been insulated from scrutiny—until now.
However, three recent events in 2023 — a medical publication in a prominent Dutch-language medical journal, a legal publication in the Dutch legal weekly journal, and a two-part documentary by BNNVARA, a liberal Dutch public broadcaster — suggest that the debate about the practice of gender transition of minors has finally reached the Netherlands. Below, we detail the key points raised in the debate, discuss the factors that contributed to the debate, and reflect on the significance of this debate in the Netherlands and its implications for the greater international reckoning about the practice of youth gender transition.
The Debate in the Netherlands – key takeaways
- The highly medicalized approach for youth presenting with gender dysphoria has come under scrutiny in the Netherlands. The Netherlands is both the birthplace and the international center of expertise for the practice of youth gender transitions. As of 2023, there is growing Dutch debate in the medical, legal, and cultural contexts regarding the practice of youth gender transitions. The current practice of youth gender transitions in the Netherlands is guided by the 2018 Dutch Protocol.
- The debate in the Netherlands is important for the rest of the Western world. The 2018 Dutch Protocol is based on the 2017 Endocrine Society and the 2012 WPATH “Standard of Care 7” guidelines. These same guidelines shaped the practice of youth gender transitions in the rest of the Western world. Further, the Netherlands continues to shape the state of care for gender-dysphoric youth worldwide, as evidenced by the Dutch clinicians’ active participation in WPATH “Standards of Care 8” published in 2022. As such, Dutch debates about “gender-affirming” treatments for youth have direct relevance to the practice of youth gender transitions in the rest of the West.
- A growing number of Dutch and international experts are concerned that the potential adverse effects of puberty blockers — a treatment that is central to the Dutch Protocol — have not been adequately researched. There has been insufficient focus on adverse effects, particularly the effects of puberty blockers on brain development, cognition, and the possibility of a “lock-in” effect of what might otherwise be transient gender dysphoria. There is growing recognition that the impact of puberty blockers on the brain is largely unknown. Due to the sensitivity of the subject and the the possibility that findings may be negative, it appears uncertain that proper research into the effects of puberty blockers on the brain will be funded.
- The Dutch critics have noted that the 2018 Dutch Protocol deviated from the original protocol in a number of important ways without providing any scientific justification for the changes. The 2018 Dutch Protocol did away with many of the eligibility restrictions in the original Dutch protocol. In the original version of the protocol, only adolescents with early-childhood onset of gender dysphoria were allowed to medically transition. However, the 2018 Dutch Protocol relaxed this and a number of other prior restrictions, while failing to provide an appropriate scientific justification for the changes. This is highly consequential, as the majority of youth transitioned under the 2018 Dutch Protocol today likely have post-pubertal emergence of gender dysphoria, and would not have qualified for gender transition based on the original criteria.
- Several Dutch legal and ethics experts have opined that the current Dutch treatment guidelines are not “standard of care” in medical-legal context. To be considered standard of care, first and foremost guidelines should be evidence-based. In contrast, the 2018 Dutch Protocol was not based on a systematic review of evidence. There were other limitations, including a biased stakeholder team composition. The legal and ethics experts call for a proper guideline update, but note that ultimately, no medical guideline, no matter how well-written, may prove to be authoritative in this heavily ethically laden context. This is because the quesiton of whether gender transition is an appropriate societal response to a gender-incongruent child or adolescent (whose identity development is not yet complete) is largely an ethical, rather than medical, matter.
- The Dutch critics of the current practice are calling for re-evaluation of the practice of youth gender transitions. A growing number of voices note that providing highly invasive medical and surgical interventions as the first and primary response to gender incongruence in youth ignores the findings of recent systematic reviews of evidence. These reviews have failed to find credible evidence of psychological benefits. Given the known harms (including, but not limited to, infertility and sterility), and the many more unknowns, the critics are questioning whether the Netherlands should consider aligning its policies and practices with Sweden, England, and Finland. This would entail reserving medical interventions to childhood-onset gender dysphoria and administering them in strictly research settings, while treating adolescent-onset gender dysphoria with psychological support.