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Pediatric rollout from 2000

From 2000 onwards, the Dutch approach to puberty suppression for young people with gender dysphoria spread internationally. The VUmc protocol rested mainly on one study of 70 adolescents without a control group. The Cass Review calls this "an area of remarkably weak evidence" (source).

The "Dutch Protocol": an experiment on children

The Dutch protocol was developed by Peggy Cohen-Kettenis, founder of the Utrecht gender clinic, and colleagues; an article from 2006 elaborated it. In the original protocol puberty suppression started from age 12 in early puberty, and cross-sex hormones followed from around age 16 (source). The best-known study, by de Vries et al. (2011), describes the first 70 adolescents who received puberty suppression between 2000 and 2008, compared before and after treatment and without a control group (source). According to the Cass Review these 70 were a subset of 111 consecutive referrals, selected because they were the first ready for the next stage of treatment (source). See also the Dutch Protocol and the criticism of the VUmc protocol.

One participant in the follow-up study died after a vaginoplasty, from necrotising fasciitis; the study of de Vries et al. (2014) reports this, and its final measurement included 55 of the first 70 adolescents (source). Of 50 studies on puberty blockers, the York systematic review for the Cass Review rated 1 as high, 25 as moderate and 24 as low quality (source); NICE (2020) judged the certainty of the evidence on the critical outcomes (gender dysphoria, mental health, quality of life) as very low (source).

International rollout: from VUmc to the world

The UK's Gender Identity Development Service (GIDS) at the Tavistock offered puberty blockers from 2011 in an uncontrolled "early intervention study" with inclusion criteria in line with the original Dutch protocol (source). In 2007 Norman Spack established a clinic in Boston modelled on the Dutch protocol and began prescribing puberty blockers from early puberty (Tanner stage 2) (source). The interim report of the Cass Review noted that little is known about the medium- and longer-term outcomes of these treatments (source).

The WPATH Standards of Care 8 (2022) also cover care for adolescents. The Cass Review concluded that the WPATH guidelines "lack developmental rigour" and that WPATH 8 overstates the strength of the evidence (source). According to The BMJ (31 October 2024), Johns Hopkins researchers who carried out evidence reviews for WPATH wrote that they had problems with the client, which tried to limit their ability to publish; WPATH denied that it prohibited publication (source). See also the WPATH Files, the US rollout and the European rollout.

The target group shifted — the protocol did not.

The Dutch protocol was developed for a different group than the adolescents who started presenting in growing numbers from 2014 (source). In the original Dutch study 89% of the 70 patients were same-sex attracted to their birth-registered sex, and only one was exclusively heterosexual (source). The Cass Review describes a change in the UK from mostly prepubertal birth-registered males to mostly birth-registered females in or after puberty, without clear explanation (source). Older studies found that a minority of prepubertal children with gender incongruence persisted (approximately 15%, and 10–33% in later studies), and that most became same-sex attracted cisgender adults (see desistance research) (source). Lisa Littman (2018) proposed the term rapid-onset gender dysphoria (ROGD) as a hypothesis; it is not a formal diagnosis (source).

The Cass Review concluded that the evidence on puberty blockers and hormones for minors is weak (source). The Swedish systematic review by researchers including SBU staff (Ludvigsson et al., 2023) found the evidence insufficient to assess the effects of hormone treatment in children with gender dysphoria (source). In December 2022 Sweden's Socialstyrelsen gave a weak negative recommendation: treatment only in exceptional cases (source). In the Netherlands, the Gezondheidsraad advised on 30 June 2026 that the care for young people is carefully organised and fits the legal framework, while rating the strength of the evidence for the effects found as low to very low (source). See SBU, NICE, the Dutch rollout and the spread from 2010.

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