A Teen Gender-Care Debate Is Spreading Across Europe
Doubts have now come to the Netherlands, where the most-contested interventions for children and adolescents were developed.
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As Republicans across the U.S. intensify their efforts to legislate against transgender rights, they are finding aid and comfort in an unlikely place: Western Europe, where governments and medical authorities in at least five countries that once led the way on gender-affirming treatments for children and adolescents are now reversing course, arguing that the science undergirding these treatments is unproven, and their benefits unclear.
The about-face by these countries concerns the so-called Dutch protocol, which has for at least a decade been viewed by many clinicians as the gold-standard approach to care for children and teenagers with gender dysphoria. Kids on the protocol are given medical and mental-health assessments; some go on to take medicines that block their natural puberty and, when they’re older, receive cross-sex hormones and eventually surgery. But in Finland, Sweden, France, Norway, and the U.K., scientists and public-health officials are warning that, for some young people, these interventions may do more harm than good.
European health authorities are not reversing themselves on broader issues of trans rights, particularly for adults. But this turn against the Dutch protocol has inflamed activists and politicians in the United States. Republicans who have worked to ban its recommended treatments claim that the shifts in Europe prove they’re right. Their opponents argue that any doubts at all about the protocol, raised in any country whatsoever, are simply out of step with settled science: They point to broad endorsements by the American Medical Association, the American Psychiatric Association, and the American Academy of Pediatrics, among other groups; and they assert that when it comes to the lifesaving nature of gender-affirming care, “doctors agree.”
But doctors do not agree, particularly in Europe, where no treatments have been banned but a genuine debate is unfurling in this field. In Finland, for example, new treatment guidelines put out in 2020 advised against the use of puberty-blocking drugs and other medical interventions as a first line of care for teens with adolescent-onset dysphoria. Sweden’s National Board of Health and Welfare followed suit in 2022, announcing that such treatments should be given only under exceptional circumstances or in a research context. Shortly after that, the National Academy of Medicine in France recommended la plus grande réserve in the use of puberty blockers. Just last month, a national investigatory board in Norway expressed concerns about the treatment. And the U.K.’s only national gender clinic for children, the Tavistock, has been ordered to close its doors after a government-commissioned report found, among other problems, that its Dutch-protocol-based approach to treatment lacked sufficient evidence.
These changes in Europe have so far been fairly localized: Health authorities in many countries on the continent—among them Austria, Denmark, Germany, Italy, and Spain—have neither subjected the Dutch approach to formal scrutiny nor advised against its use. Yet questions about the protocol seem to be spreading. At the end of March, for example, a Belgian TV report described a 42-fold increase in patients at a leading gender clinic in Ghent and raised questions about the right approach to care. Doubts about the protocol have even come to the country that invented it, at the Center of Expertise on Gender Dysphoria in Amsterdam. “Until I began noticing the developments in other EU countries and started reading the scientific literature myself, I too thought that the Dutch gender care was very careful and evidence-based,” Jilles Smids, a postdoctoral researcher in medical ethics at Erasmus University in the Netherlands, told me via email. “But now I don’t think that any more.”
But in the years after her two studies were released, research done in other European countries led to concerns about their relevance. In 2015, for example, Finnish researchers described a phenomenon that “called for clinical attention,” as they put it: More children were reporting gender dysphoria, and a greater proportion of them had been assigned female at birth. The fact that three-quarters of those Finnish teens had been diagnosed with separate and severe psychiatric conditions appeared to be at odds with the data from the Netherlands, the paper argued. The Dutch studies had found that just one-third of adolescents with gender dysphoria experienced other psychiatric issues, suggesting they were in far better mental health.
Kirsten Visser, a Netherlands-based advocate and consultant for parents of trans teens, says her own son, Sietse, started receiving “definitely lifesaving” care at the Amsterdam center in 2012, at the age of 11. Around the time that Sietse showed up at the clinic, the Dutch protocol was becoming established internationally, largely through the work of a child and adolescent psychiatrist there named Annelou de Vries.
After completing a Ph.D. on gender dysphoria in Dutch adolescents, de Vries published two seminal papers with the clinical psychologist Peggy Cohen-Kettenis and other colleagues, in 2011 and 2014. The former looked at the psychological effects of puberty suppression on 70 young people over a period of two years, on average; the latter tracked outcomes for 55 of those people who had gone on to receive gender-reassignment surgery, over an average of six years. Taken together, the studies found that the teens showed fewer symptoms of depression after having their puberty suppressed, as well as a decrease in behavioral and emotional problems; and that the ones who went on to take gender-affirming hormones and have surgery grew into “well-functioning young adults.” De Vries’s expertise has since been widely recognized within the field: She served as a co-lead on the revision of the adolescent section of care guidelines recently published by the World Professional Association for Transgender Health, and is now president-elect of the European equivalent, EPATH.