- Michael Biggs
The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence
It has been a quarter of a century since Dutch clinicians proposed puberty suppression as an intervention for “juvenile transsexuals,” which became the international standard for treating gender dysphoria. This paper reviews the history of this intervention and scrutinizes the evidence adduced to support it. The intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible. The main evidence for the Dutch protocol came from a longitudinal study of 70 adolescents who had been subjected to puberty suppression followed by cross-sex hormones and surgery. Their outcomes shortly after surgery appeared positive, except for the one patient who died, but these findings rested on a small number of observations and incommensurable measures of gender dysphoria. A replication study conducted in Britain found no improvement. While some effects of puberty suppression have been carefully studied, such as on bone density, others have been ignored, like on sexual functioning.
The use of Gonadotropin-Releasing Hormone agonist (GnRHa) drugs to suppress puberty in “juvenile transsexuals” was first proposed in print in the mid-1990s (Gooren & Delemarre-van de Waal, 1996). Developed by three clinicians at Utrecht and Amsterdam, this intervention became known as the Dutch protocol. It rapidly became standard practice in the treatment of adolescents diagnosed with gender dysphoria (HBIGDA, 2001). This intervention has been described in several manifestos by its proponents (e.g. de Vries & Cohen-Kettenis, 2012; Delemarre-van de Waal, 2014; Delemarre-van de Waal & Cohen-Kettenis, 2006) and subjected to brief critical commentaries (Byng et al., 2018; Laidlaw et al., 2019; Levine et al., 2022). The aim of this paper to provide an historical account of the invention of the Dutch protocol and a critical review of the evidence that has accumulated in the quarter of a century since it was proposed.