The Enduring Deceptions of the Dutch Protocol

Published September 8, 2023

Side Effects

On March 16, 18-year-old Layla Jane announced that she is suing Kaiser Permante for “intentional fraud and concealment” involving her attempted medical transition from female to male. Jane underwent a double mastectomy at the age of 13 on the advice of her doctors, after having identified as a boy since the age of 11. She now identifies as a woman, and is part of a growing group of young “detransitioners” claiming to have been pressured at a vulnerable stage of life into making irreversible and harmful medical decisions. She is not alone; Chloe Cole, who is 19, is suing the doctors who performed a double mastectomy on her at the age of 15. 

These women not only regret having undergone “gender-affirming surgical care,” but are seeking to end such procedures for all minors. Gender-affirming care typically involves a course of puberty-suppressant drugs followed by cross-sex hormones and, in some cases, surgical procedures. All this is an attempt to, first, help young people avoid developing secondary sex characteristics via natal puberty and, second, to help them look and sound more like members of the opposite sex. Eight states have passed laws restricting such practices, while at least 23 others are considering similar measures. 

Stories like those of Cole and Jane have been vital in drawing attention to the inherent risks of gender-affirming care. But its origins and early, unfulfilled promises are less widely understood. In a September 2022 article in the Journal of Sex and Marital Therapy, Oxford sociologist Michael Biggs offers a comprehensive examination of the “Dutch protocol,” the combination of puberty suppression and cross-sex hormones that has become the international standard for treating gender dysphoria in youth. In tracing the scientific, financial and political history of the protocol, Biggs demonstrates that the original 2006 Dutch study, which appeared to demonstrate the effectiveness of this course of treatment for minors, was deeply flawed and has never been replicated.

He also shows, among other things, that researchers who tried and failed to replicate it were suppressed, and that the 2006 study was funded by a major manufacturer of “puberty-blocking” drugs. Through all this, Biggs makes several crucial observations.

I. The Dutch Protocol’s Eligibility Criteria Are Routinely Ignored by Clinicians

First, Biggs notes the cavernous gap between the Dutch protocol as it is presented in formal settings, and the ways in which it is actually implemented in clinical practice. Without going too deeply into the details of the original 2006 study, suffice it to say that it appeared successful. But in that study, eligibility criteria appeared strict.

Only patients who had suffered from gender dysphoria since early childhood were to be admitted for the experimental treatment, and only if the dysphoria had worsened with the onset of puberty. (Layla Jane, remember, only began identifying as male at age 11.) Puberty suppression was not to be administered before the age of 12, with cross-sex hormones permitted starting at age 16 and surgeries at the age of 18.

Importantly, eligible patients were required to be psychologically stable apart from the challenge of gender dysphoria; they were not to be admitted if they suffered from other serious mental-health problems. Finally, patients were not to be admitted without support from family. The serious intervention of puberty suppression—which disrupts normal human development in a variety of ways, most obviously in regard to sexual function and bone density—was not to be prescribed if any of these criteria were not met. 

This protocol, as evident in the cases of Chloe Cole, Layla Jane and many others, has been  widely disregarded—even by the Dutch researchers who promoted it. Cole and Jane’s doctors dismissed the protocol’s recommendations regarding a minimum age for medical intervention. They also appear to have ignored its warnings about mental-health comorbidities; both young women report long histories of mental-health challenges apart from gender dysphoria. And other cases have shown that clinicians frequently do not account for family support, as the protocol demands. In short, the research that is widely considered authoritative does not support gender-affirming care as it is actually practiced. 

II. Puberty Blockers Were Wrongfully Presented as a “Diagnostic Tool”

Biggs also scrutinizes the rationale for the particular interventions in the Dutch protocol. So-called puberty suppression was first put forth to help manage gender dysphoria in the 1990s, primarily by Dutch psychologist Peggy Cohen-Kettenis. As Biggs writes, gonadotropic-hormone blockers, which had previously been used to treat prostate cancer and occasionally as a means of castrating male sex offenders, were championed as a way “to provide space for therapeutic exploration of gender identity, without the pressure of the physical changes accompanying puberty.” In other words, puberty blockers would function not as a cure for gender dysphoria, but as a sort of diagnostic aid during “therapeutic exploration.” 

As Biggs notes, “This claim was plausible, though it was also plausible that stopping normal cognitive, emotional, and sexual development would impede such exploration.” Young people given puberty-suppressant drugs are unable to explore what natal puberty is actually like; their understanding of their options is limited by default. They literally do not know what they are missing. For these and other reasons—the buy-in to the treatment protocol by doctors and patients not least among them—it makes sense that many would move on to the next stage of the gender-affirming sequence. 

This has turned out to be the case. As Biggs points out, “the Dutch clinicians found that the diagnostic test invariably yielded the same result.” Virtually every young person given puberty blockers goes on to take cross-sex hormones. 

Biggs again: “This might be explained by a rigorous selection process. An alternative explanation is that puberty suppression becomes a self-fulfilling prophecy.” In short, puberty suppression was sold as a diagnostic tool, but it has not served as one. 

III. The Effects of Puberty Blockers on Cognitive Capacity and Sexual Function

Further, as Biggs points out in some detail, the decision-making capacity of children and teenagers may actually be damaged by puberty-suppressant drugs.

A 2017 case study found that, after 28 months on puberty blockers, a child who had commenced puberty suppression just before the age of 12 scored 10 points lower on an IQ test. A 2007 study of 25 children measured an average drop of seven points after two years on puberty blockers; another study found a gap of eight points between 15 treated children and a matched control group. A 2015 study found that eight adolescent males undergoing puberty suppression performed worse in a test of executive functioning than three control groups; the samples are small, but the differences are statistically significant. Randomized controlled trials on non-human mammals provide more evidence of the substantial, damaging cognitive effects of puberty suppression. These effects remain even after the treatment is stopped, undermining the idea that it is reversible. 

The effects of puberty suppression on sexual function are also alarming. Surgeon Marci Bowers, president of the World Professional Association for Transgender Health (WPATH), recently acknowledged that every male child “who was truly blocked at Tanner stage 2 has never experienced orgasm.” 

IV. Conclusion

Biggs’s report is worth reading in full; among many other things, he provides detailed, well-documented examples of medical misconduct. For example, GenderGP, a company registered in Singapore and owned by a Welsh doctor, diagnosed a 9-year-old with gender dysphoria over video and prescribed puberty blockers that same day. Among his core conclusions, Biggs notes that the extremely rare cases of juvenile dysphoria of a few decades ago–one per year in the Netherlands in the late 1990s–were documented in a way that bolstered a remunerative new specialty. As he writes, “When a recent survey in one American school district found 7% of students identifying as ‘gender diverse,’ the authors urged that all receive ‘access to gender affirming care,’ which in effect means giving [puberty blockers] on request.” The original 2006 study, remember, was sponsored by a company that produces puberty-suppressant drugs. 

Biggs also points out attempts to suppress inconvenient research. The pioneers behind the Dutch protocol have repeatedly chosen not to conduct a randomized controlled trial to verify their findings. Other major studies, which indicated the lack of effectiveness of gender-affirming treatments for minors, including one performed at a major London clinic, were either stopped, never published, or simply quashed, prevented from being presented at conferences. 

Biggs’s report ends on a haunting note, with a description of a new sort of person: the “sexless adult.” Puberty as outlined in the Dutch protocol is viewed as a kind of disease, something to be avoided. An Australian girl, Phoenix, was socially transitioned into a nonbinary identity at the age of five, and began taking puberty suppressants at the age of 11. Upon reaching the age of 16, Phoenix refused cross-sex hormones, opting instead to remain in an androgynous, pre-pubertal state; she explained that this would be the only way for her to express her “non-binary gender identity.” The clinicians in her case agreed to provide perpetual puberty suppression, despite the health risks, and the unknown effects on her cognitive capacity and ongoing development. This case is exceptional; but until recently, the cases of Cole, Jane, and countless other young people would have been considered so as well.

Devorah Goldman is EPPC’s Tikvah Visiting Fellow. Her work focuses primarily on medical policy, culture, and public bioethics.

Devorah Goldman is EPPC’s Tikvah Visiting Fellow. Her work focuses primarily on medical policy, culture, and public bioethics.

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