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Developments around bill to amend 'Trans' law in the Netherlands

The bill to amend the so-called 'Trans' act, which was submitted in May 2021, was discussed in the House standing committee for Justice and Security. Former Minister Dekker responded to this in his memorandum of 19 November 2021 and made two important further announcements. The evaluation of the Transgender Act 2014-2017 by Marjolein van den Brink remains an important point of reference. 

In 2017, UCERF researcher Marjolein van den Brink evaluated the Transgender Act (see the report ‘Recht doen aan genderidentiteit – Evaluatie drie jaar Transgenderwet in Nederland 2014-2017 '). In May 2021, based on the conclusions from the evaluation, former Minister Dekker submitted a bill to amend the Transgender Act (see the draft regulation with explanation ).

Four important amendments were proposed in this bill: the replacement of the expert statement for a two-step change procedure (a notification of the intention to change, followed by a confirmation of that intention), the introduction of the possibility to start this administrative procedure in the municipality where one lives, the introduction of the possibility of legal gender reassignment through the courts for children under the age of 16, and the declaration of the gender reassignment procedure's corresponding application to people with an intersex condition. 

Recently, new developments have taken place. The bill was much debated in the Lower House, with frequent references to the evaluation of Van den Brink and Snaathorst. Former Minister Dekker also repeatedly referred to the evaluation in his memorandum following the report of the Parliamentary Committee . He made two important further announcements. Firstly, he promised to work on a regulation for people who identify themselves as non-binary: 'I am currently charting the possibilities for and the consequences of arranging such an option'.

A second important announcement is his intention to make it possible for trans men who give birth to a child to be registered as a person other than the mother of their child: 'I do not consider it proportionate to make further amendments to the regulations on parentage law (Title 11, Book 1 of the Dutch Civil Code). The parent from whom the child is born is in almost all cases a woman. The law is in line with this. It is conceivable and understandable that many parents value the legal designation 'mother' and 'father', just as it is understandable that this will be different for some people. Unlike the legislator, I do consider it desirable and possible to regulate that the transgender man from whom the child was born is referred to in the child's birth certificate as "parent from whom the child was born". This does not require a change in parentage law, but an amendment to the Civil Status Decree 1994. I am happy to undertake this adjustment. The aim is to submit the decree for consultation at the beginning of 2022'.

Read the earlier article ' Bill to amend 'Trans' law in in the Netherlands, based on Gender Identity report by Utrecht researchers '

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Utrecht University Heidelberglaan 8 3584 CS Utrecht The Netherlands Tel. +31 (0)30 253 35 50

Dutch Cabinet ready to allow children to change gender registration

The caretaker Cabinet of the Netherlands has sent a bill to Parliament that will make it possible for people of any age to legally declare a change in their gender to the registrar of births, deaths and marriages. The proposal aims to make changing the gender on a birth certificate easier.

"In order to do justice to the emancipation of transgender people, a number of changes are proposed that simplify the procedure," the Cabinet said in a statement.

For the first time, people under 16 will be allowed to change their gender in government databases by petitioning a court. "The age limit is being dropped because interest groups and some of the parents argue that some young people go through life before the age of sixteen with a gender other than the sex designated at birth," the Cabinet said.

If the bill passes, transgender people will no longer need an expert statement from a doctor or psychologist to prove that the person is truly determined to identify as a different gender. Healthcare experts and groups representing people of diverse genders and sexualities have argued that such an assertion is difficult to demonstrate, and infringes on the rights of transgender people.

This could be replaced by someone requesting the change in registration, and confirming between four and twelve weeks later. People aged 16 and up will be able to do this procedure twice, and any subsequent change would need to be requested in court.

Further, instead of returning to their original hometown to report the change, they will only have to go the city hall where they currently reside.

The last changes to make gender registration easier happened when the Transgender Act entered into force in 2014. This allowed people to legally alter their gender on birth certificates and other official documents without undergoing sterilization or sex reassignment surgery. According to the government, some 1,630 people were able to change their legal gender thanks to the law.

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.

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.”

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.

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.

In Sweden, too, clinicians grew alarmed by the sudden increase in the number of teenagers seeking gender care. Mikael Landén, a professor of psychiatry at the University of Gothenburg, told me that this population has increased 17-fold since 2010. One explanation for that change—that more open-minded attitudes around gender have emboldened kids to seek the help they need—just doesn’t ring true to him. He’d studied those views in his early work, he said, and found that, on the whole, Swedish attitudes toward transgender people have been very positive for a long time.

When the government asked Landén and a group of other scientists to write an evidence-based review of hormone-based treatments for young people, their verdict, after two years of study, was expressed definitively: The original research findings from de Vries were outdated, and do not necessarily apply to the group of teens who have been coming forward in more recent years. The Dutch protocol had been “a valuable contribution,” he told me, and “it was reasonable to start using it” in Sweden. But times had changed, and so had the research literature. In 2021, for instance, a team based at the U.K.’s Tavistock clinic published research showing no detectable improvements in the mental health of youngsters who had been put on puberty blockers and followed for up to three years.

Read: The war on trans kids is totally unconstitutional

De Vries acknowledged some concerns about the research when we spoke in February. “Our early outcomes studies were really from another time and comprised small samples,” she told me, and they looked only at trans youth who had experienced gender dysphoria from childhood. She granted that there is some research to suggest that kids who don’t arrive at the clinic until they’re older are worse off, psychologically, than their younger peers; but she also said her team has run studies including 16-year-olds, and that their findings were “not worrisome.” She agrees that other researchers have not replicated the long-term follow-up research on kids who went through the Dutch protocol, but she pointed out that the short-term benefits of such treatment have indeed been seen in other studies. Research conducted in the U.S., and published earlier this year, found that a group of 315 trans and nonbinary youth were on average less depressed and anxious , and better-functioning, after two years of hormonal treatment.

In the meantime, de Vries and her colleagues have urged clinicians in other countries to do more of their own investigation, in part because the youngsters who receive care at gender clinics in the Netherlands seem to be in comparatively good mental health from the get-go. It’s not yet clear, she told me, that studies of this group will be applicable to youth in other countries. “Every doctor or psychologist who is involved in transgender care should feel the obligation to do a good pre- and post-test,” one of de Vries’s co-authors on the 2011 and 2014 studies said to a Dutch newspaper in 2021. “The rest of the world is blindly adopting our research.”

De Vries is now working on a research project, funded by an $864,000 grant, that will try to answer newly forming doubts about the Dutch protocol. Her proposal for the grant, filed in 2021, described its subject as a “once so welcomed but now sharp[ly] criticized approach.”

That such criticisms are becoming mainstream even in her own country is itself a startling development. After all, the Netherlands has long been at the vanguard of progressive health-care practices. When the Dutch approach to transgender care for adults first started taking shape during the 1970s (many years before the protocol for kids would be established), the country’s politics were dominated by a steadfast opposition to taboos. James Kennedy, an American-born professor of modern Dutch history at Utrecht University, has described this as the country’s “compassionate culture”: In a radical departure from its traditional Christian conservatism, long-standing policies were being spurned; and even touchy subjects such as death and sex were made the subject of broad public-policy debates. Sex work, for example, was widely tolerated , then legalized in 2000. Similarly, the Royal Dutch Medical Association offered formal guidelines for the practice of euthanasia in the 1980s, and a corresponding national law—one of the world’s first—codified the rules in 2002.

Against this backdrop of openness, in which doctors were seen as authoritative figures who were well equipped to decide what was best for their patients, one of the first dedicated clinics for transgender people was established in Amsterdam in 1972. It offered an array of services—blood tests, hormone therapy, and surgeries—to trans adults. According to a recent book by the historian Alex Bakker, Dutch surgeons, some of them inspired by their Christian beliefs, developed techniques that would reduce patients’ psychological suffering. “Helping those in need trumped ‘taboos’ about the sanctity of life or fixed gender roles,” Kennedy told me. The Dutch protocol for treating gender dysphoria in children, as established in the 1990s, reflected a further extension of this philosophy, aiming to smooth adult transitions by intervening early.

Read: Take detransitioners seriously

Nevertheless, in December, a journalist named Jan Kuitenbrouwer and a sociologist named Peter Vasterman published an opinion piece in a leading daily newspaper, NRC , that took aim at the Dutch protocol and its “shaky” scientific foundations, and alluded to the international scrutiny of the past few years. “It is remarkable that the media in our neighboring countries report extensively on this reconsideration,” the article said, “but the Dutch hardly ever do.” Like critics elsewhere, Kuitenbrouwer and Vasterman pointed to the rising numbers of children seeking care, from 60 to 1,600 in the Netherlands across a dozen years, and the unaccounted rise in those assigned female at birth; and they suggested that this new generation of people seeking treatment is not analogous to those included in the studies conducted by de Vries a decade ago. De Vries and some colleagues countered that their more recent research addresses this concern. “Scientific evaluation has always been an integral part of this challenging model of care, where young people make early decisions about medical interventions with lifelong implications,” they wrote in the same newspaper.

Also in December, a clinical psychologist at Radboud University’s gender clinic in Nijmegen named Chris Verhaak told a different Dutch outlet that puberty blockers affect children’s bones, and maybe also their brain development. “It is not nothing,” she said. Verhaak is currently running a government-funded study to understand the source and nature of the increase in the number of patients. (Results are due to be presented to the Dutch House of Representatives this year.) In another interview that month, she said that for up to half of cases, the gains in suppressing puberty are not clear. “I worry about that,” she told the newsweekly De Groene Amsterdammer . “Especially because we also experience enormous pressure to provide these puberty inhibitors as quickly as possible.”

Verhaak’s comments in particular sparked dismay among trans groups, which saw them as promoting destructive narratives about social contagion. Verhaak and her direct collaborators say that they are no longer speaking to the media until their study is released, but Hedi Claahsen, a professor and principal clinician on the Radboud center’s gender team, told me that practitioners are cautious and follow national guidelines. When I asked if her center’s approach differed from the one used in Amsterdam, she told me, “No clinic is exactly the same.” Individual providers, who are working at different institutions, may end up providing care that reflects “a different vision.”

Another, more significant round of criticism arrived at the end of February, when another widely read Dutch newspaper, de Volkskrant , published a 5,000-word article under a headline reading: “The treatment of transgender youth in the Netherlands was praised. Now the criticism of ‘the Dutch approach’ is growing.” The authors spoke with Iris, a 22-year-old woman who spent five years on testosterone and had a double mastectomy that she now regrets; they pointed to a new population of kids assigned female at birth seeking care only in their teens; and they noted reservations about the protocol in Finland and Sweden. “Is the ‘Dutch approach’ still the way to go?” the story asked.

The article prompted debate on Twitter, where Michiel Verkoulen, a health economist working with the government of the Netherlands to address the long-standing problem of ever-expanding waiting lists and their impact on young people’s mental health, accused the Dutch protocol’s critics of ignoring what he described as the elephant in the room. “What to do with the people for whom transgender care is critical?” he asked. “You can put every research aside, keep asking for more, and argue that diagnostics and treatments should be stricter … But the question remains: W hat then ?”

“In the Netherlands there are more and more people saying that gender diversity is woke and it’s nonsense and it’s bullshit,” Visser, the consultant for parents of trans teens, told me. Sam van den Berg, a spokesperson for an Utrecht-based trans-rights organization called Transvisie, argued that this debate does not need to happen. The quality of care for children with gender dysphoria is better in the Netherlands than almost anywhere else, she said. “We don’t feel it’s necessary to change anything.” Indeed, doctors in the Netherlands are still free to provide gender-affirming care as they see fit. The same is true of their colleagues in Finland, Sweden, France, Norway, and the U.K., where new official guidelines and recommendations are not binding. No legal prohibitions have been put in place in Europe, as they have been in more than a dozen U.S. states, where physicians risk losing their medical license or facing criminal sanctions for prescribing certain forms of gender-affirming care.

But the trend toward more conservative application of the Dutch protocol is likely to have real effects in European countries, in terms of which kids get treatment, and of what kind. Louise Frisén, an associate professor at Karolinska Institute and a pediatric psychiatrist at the child and adolescent mental-health clinic in Stockholm, Sweden, told me she worries that under her country’s new guidelines, many of her teenage patients will find it harder to access medical care. The benefits of treatment are clear, she said, and she further claimed that the policy change has caused anguish for some patients who are panicking at the looming prospect of puberty.

As for de Vries, when I spoke with her a few weeks before the article in de Volkskrant was published, she agreed that clinicians should be cautious, but not to the point where treatment becomes inaccessible. Outcomes for those with later-onset dysphoria do need to be investigated further, she acknowledged, but “if we are going to wait ’til the highest-standard medical evidence provides us the answers, we will have to stop altogether.” In that sense, Europe’s brewing disagreement over treatment could turn into paralysis. “That’s what worries me,” she said. “You will always have to work with uncertainties in this field.”

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Tens of thousand passed Rijksmuseum, rear, during the Pride Walk in Amsterdam, Netherlands, Saturday, July 30, 2022, calling for equal rights for members of the LGBTI community in countries where homosexuality is included in the penal code. (AP)

Gender-affirming surgery is not banned for minors in Europe, but is mostly inaccessible

If your time is short.

Europe doesn’t ban gender-affirming care in the way some American states have by enacting laws to restrict access. Rather, care in these European countries is often dictated by health policy and guidelines. 

Finland and the United Kingdom’s health policies limit gender-affirming surgeries to people older than 18. Sweden and the Netherlands allow chest surgery at age 16 and genital surgeries at 18. Norway generally does not offer surgical care to minors, but has not banned it.

Experts say that most transgender adolescents aren’t considering surgical care before they turn 18, and that such care is rare even in places where the procedures are legal. 

Twenty-two U.S. states have banned gender-affirming care for people younger than 18. An Instagram user said our friends across the pond are doing the same: 

"Norway, Finland, Sweden, Holland, and the U.K. have now banned gender transition surgery for minors," read the Aug. 23 post . 

But this post and its use of the term "ban" doesn’t accurately portray trans health care in Europe.

In two of the five countries listed, health policy reserves all gender-affirming surgeries for people 18 and older. The remaining three countries have mixed guidelines depending on circumstance and type of surgery. But none of these transgender surgical care limitations in Europe result from legal bans like those instituted in some U.S. states. Rather, they stem from agreed-upon medical guidelines, and in Sweden’s case, sterilization laws. 

"The guidelines or recommendations in these policies are simply that — they are non-binding."  said Deekshitha Ganesan, a policy officer at trans rights group Transgender Europe. "There are no sanctions for not following these policies to the best of our knowledge." 

PolitiFact found one exception to this in Sweden, where a 1975 sterilization law requires administrative approval for certain genital procedures. The law , which ended a decadeslong eugenics and forced sterilization program, doesn’t explicitly ban transgender care.

Screenshot from Instagram

This post was flagged as part of Meta’s efforts to combat false news and misinformation on its News Feed. (Read more about our  partnership with Meta , which owns Facebook and Instagram.)

Several European countries are reevaluating their approaches to gender-affirming care for minors, but these changes primarily affect access to puberty blockers and hormone therapy, not surgeries, because minors rarely get surgeries as part of gender-affirming care.

Surgery is often the last step taken in a person’s gender transition and comes after lengthy evaluation and consultation. 

"Often many young people are not even thinking about surgeries," Ganesan said.

We looked closer at each country's policies to explain how they differ. Many health systems have never recommended that people younger than 18 be eligible for genital surgery, and those policies have not recently changed. 

"Norway does not prohibit gender-affirming treatment for children," said Torunn Janbu, the department director at the Norwegian Directorate of Health, which develops health guidelines for the country.

Although there is no law prohibiting gender-affirming surgeries, the Norwegian Directorate of Health’s most recent national guideline states that surgical "gender confirmation" is generally not recommended before age 18. The guidelines make an exception for breast surgery "in special cases," based on a comprehensive interdisciplinary assessment and parental consent. A March report by the Norwegian Healthcare Investigation Board, an independent government agency, recommended greater regulations on care and a reevaluation of national guidelines. 

"Our recommendations do not involve rendering health care services for children and young people illegal, nor do we have specific recommendations concerning surgery," said Anette Bakkevig Frøyland, a senior adviser at the board. 

Meanwhile, Janbu said, the Norwegian Healthcare Investigation Board "has no authority to change guidelines or regulations." So Norway generally does not offer gender-affirming surgical care to minors, but the treatment is not "banned."

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Swedish health guidelines advise reserving chest surgeries for exceptional cases. And law states that genital surgeries that lead to sterilization are limited to people 18 and older and require government approval.

In 2022, updated national guidelines from the National Board of Health and Welfare, issued caution about hormonal and surgical treatments among adolescents and said care, including mastectomies, should be administered only in "exceptional cases."

"The guidelines are recommendations, and it's up to the physicians to interpret them and make a judgement in each specific case," said Jêran Rostam, an expert in trangender issues at the  The Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights, also known as RFSL. 

According to the federation , patients have long been required to be 18 years or older to be eligible for  certain genital surgeries. The Legal Council at the Swedish Board of Health and Welfare must approve these surgeries; people younger than 23 need "special circumstances" to get their applications approved. 

These limitations exist because, under Swedish law , it’s "illegal" to do surgeries that lead to sterilization without going through the proper bureaucratic channels, Rostam said. These restrictions result partly from a 1975 law enacted after decades of compulsory sterilizations and a large eugenics program. This law limits transgender care today, but doesn’t explicitly ban gender-affirming care. 

Additionally, transgender Swedes can apply for a legal change in gender only after they have turned 18.

The Netherlands, referred to as Holland in the Instagram post, has been a gender-affirming care pioneer since it began treating adults in 1972. When the country’s clinic started treating adolescents in 1997 , it sparked the development of the " Dutch protocol ," which became the global standard for transgender pediatric care.

Mastectomies can be done on patients older than 16, but all other surgeries are reserved for those over 18, according to a statement provided by a spokesperson for Amsterdam University Medical Center , site of the Center of Expertise on Gender Dysphoria. These policies are outlined in the Ministry of Health, Welfare and Sport’s national guidelines . 

Finland was one of the first countries to adopt the Dutch method of treating transgender patients, Forbes magazine reported. But in 2020, the Council for Choices in Health Care , which issues recommendations to the government’s Ministry of Social Affairs and Health, released guidelines prioritizing psychotherapy and stating that puberty suppression should be administered on a "case-by-case basis after careful consideration." 

Ganesan said that these are recommendations, not mandates. In the same guidelines, the Council for Choices in Health Care states that "surgical treatments are not part of the treatment methods for dysphoria caused by gender-related conflicts in minors." 

A 2017 survey by the European Union Agency for Fundamental Rights shows that the 18-year-old age requirement for gender-affirming surgical procedures is not new, but it is unclear whether official law or policy codifies this age limit. The Finnish Ministry of Social Affairs and Health did not answer our questions by publication time. 

In 2023, Finland removed its previous requirement to be sterilized to legally change gender, but this applies only to adults. 

The United Kingdom’s National Health Service website says that people 18 and older can get masculinizing or feminizing genital surgery and chest surgery if they meet certain criteria , which includes "persistent, well-documented gender dysphoria," letters of referral from doctors, and for genital surgeries, at least 12 months of hormone therapy. These policies are outlined and appear to be enforced by the National Health Service. The U.K.’s Department of Health and Social Care, which supports ministers in developing new health policy, did not respond to our questions about current or future legislation by press time.

Generally, in the U.K., people ages 16 and older are " entitled to consent to their own treatment," and can be referred to adult gender clinics at age 17.

However, because of major gender clinics shutting down and long wait times , access to care in the U.K. remains limited. 

An Instagram post said, "Norway, Finland, Sweden, Holland, and the UK have now banned gender transition surgery for minors." 

Gender-affirming surgical care in these countries is mostly regulated through guidelines and recommendations, not laws banning care. None of these countries have banned gender-affirming care for minors outright in the way that some U.S. states have. Some countries’ health systems, such as Finland’s and the U.K.’s, appear to limit all surgeries to ages 18-plus. Sweden and the Netherlands have differing guidance for chest and genital surgery, and Norway generally advises against surgeries before age 18. 

But experts note that these surgeries are rare among minors even in places where they are legal. The statement contains an element of truth but ignores critical facts that would give a different impression. We rate this claim Mostly False. 

Editor’s Note: Google Translate was used throughout the research of this story to translate websites and documents into English. We corroborated our understanding of translated documents with expert sources.

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The Principles of the Truth-O-Meter

Our Sources

Email interview with Ana Muñoz Padrós, communications and media officer at ILGA-Europe     Aug. 30, 2023

Email interview with Torunn Janbu, department director at the Norwegian Directorate of Health, Sept. 5, 2023

Email interview with Deekshitha Ganesan, policy officer at TGEU (Transgender Europe), Aug. 31, 2023

Email interview with Anette Bakkevig Frøyland, senior adviser at the Norwegian Healthcare Investigation Board, Sept. 1, 2023

Email interview with Jêran Rostam, experts on transgender issues at the The Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights or RFSL, Aug. 31, 2023

Email interview with Cullen Peele, press secretary at the Human Rights Campaign, Aug. 31, 2023

Email interview with a spokesperson from Amsterdam UMC, Aug. 30, 2023

U.S. News and World Report, " What Is Gender-Affirming Care, and Which States Have Restricted it in 2023? " Aug. 31, 2023

Instagram Post , Aug. 23, 2023

Sveriges Riksdag, " Sterilization Act (1975:580) " (translated from Swedish), June 12, 1975 (translated from Swedish)

Indiana International & Comparative Law Review, " Shared History of Shame: Sweden's Four-Decade Policy of Forced Sterilization and the Eugenics Movement in the United States, " 1998

Associated Press, " Norway didn’t ban gender-affirming care for minors, as headline falsely claims ," June 9, 2023

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Norwegian Directorate of Health, " Gender Incongruence -- Investigation, treatment and follow-up " (translated from Norwegian), June 9 , 2021

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The Journal of Sexual Medicine, " Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol ," Jan. 26, 2023

Hormone Research in Paediatrics, " The Evolution of Adolescent Gender-Affirming Care: An Historical Perspective ," Nov. 29, 2022

The Atlantic, " A Teen Gender-Care Debate Is Spreading Across Europe ," April 28, 2023

Transvisie, " Home Page " translated from Dutch, accessed Sept. 4, 2023

Transvisie, " Hormones and puberty inhibitors " translated from Dutch, accessed Sept. 4, 2023

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Transvisie, " Transition " translated from Dutch, accessed Sept. 4, 2023

Amsterdam UMC, " About ," accessed Aug 30, 2023

Netherlands Ministry of Health, Welfare and Sport, " Quality Standard Transgender Care " translated from Dutch, 2018

Forbes, " Increasing Number Of European Nations Adopt A More Cautious Approach To Gender-Affirming Care Among Minors ," June 6, 2023

Council for Choices in Health Care in Finland, " COHERE Finland ," accessed Aug. 29, 2023

Council for Choices in Health Care in Finland, " Medical Treatment Methods for Dysphoria Associated with Variations in Gender Identity in Minors – Recommendation ," June 6, 2020

Council for Choices in Health Care in Finland, " Medical treatments for gender dysphoria that reduces functional capacity in transgender people – recommendation ," June 6, 2020

European Union Agency for Fundamental Rights, " Access to sex reassignment surgery ," Oct.19, 2018

Reuters, " Finland to allow gender reassignment without sterilisation ," March 3, 2023

National Health Service, " Gender dysphoria ," May 28, 2020

National Health Service, " Gender dysphoria - Treatment ," May 28, 2020

National Health Service, " NHS Standard Contract For Gender Identity Development Service For Children and Adolescents ," April 1, 2016

National Health Service, " Consent to treatment - Children and young people ," Dec. 8, 2022

National Health Service, " Vaginoplasty Feminising Surgery ," July 27, 2021

National Health Service, " Phalloplasty Masculinising Surgery ," Oct. 20, 2021

BBC News, " NHS to close Tavistock child gender identity clinic ," July 28, 2022

BBC News, " Trans people can wait seven years for NHS initial assessment ," Aug. 2, 2023

Gender Identity Development Service, " Puberty and physical intervention ," accessed Sept. 5, 2023

Sveriges Riksdag," Act (1972:119) on determination of gender in certain cases " (translated from Swedish, 1972

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Expert Commentary

What the research says about hormones and surgery for transgender youth

Researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of gender-affirming medical treatment for transgender youth.

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This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Chloe Reichel, The Journalist's Resource August 7, 2019

This <a target="_blank" href="https://journalistsresource.org/politics-and-government/gender-confirmation-surgery-transgender-youth-research/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

In the interest of examining this important news topic through a research lens, Journalist’s Resource collaborated on this story with The Burlington Free Press,  where it first appeared .  This piece is part of the newspaper’s series of stories about transgender youth  in the state.

As Vermont regulators consider changes to Medicaid that would expand access to gender confirmation surgery for transgender youth, researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of the new proposal.

Among other changes,  the proposed rules would eliminate the requirement that transgender individuals on Medicaid must wait until the age of 21  to receive surgery. Individuals over the age of 18 and minors — with informed parental consent — would be eligible.

Such changes are in line with current thinking among academics and physicians in the field. It’s still a fledgling field, as Marci Bowers, a California-based gynecologist and surgeon who specializes in gender confirmation and serves as a professorial lecturer at the Icahn School of Medicine at Mount Sinai points out.

“Kids are coming out very young. A generation ago, they were driven into the closet,” Bowers said. “It’s only these last 20 years or so where instead of that happening, people are getting professional help.”

How common are gender confirmation surgeries in the U.S.?

Estimates suggest that in the U.S., between 2000 and 2014, 10.9% of inpatient visits for transgender people involved gender confirmation surgery. This figure comes from  an analysis of inpatient visits for a nationally representative sample that includes, but is not limited to, transgender patients, which was published in 2018 in the medical journal JAMA Surgery . Over the study period, the number of patients who sought gender confirmation surgery increased annually.

Further, the percentage of gender confirmation surgeries that are “genital surgeries” — commonly referred to as bottom surgeries — has increased over time. Between 2000 and 2005, 72% of gender confirmation surgeries were bottom surgeries; from 2006 to 2011, that number increased to 84%. And the number of patients insured by Medicare or Medicaid seeking these procedures increased threefold between 2012-2013 and 2014.

As societal acceptance of gender diversity has grown, medical thinking has changed, too, Bowers notes.

“At least in the academic circles, in the medical circles, we realize that yes, it’s valid, that yes, kids do better after treatment, yes, surgery is appropriate, and why wait till 21?” Bowers said. “That’s really completely arbitrary. In fact, it’s probably cruel.”

“Most of the research is on older patients,” Elizabeth Boskey, a social worker at the Center for Gender Surgery at Boston Children’s Hospital and co-author of several research papers on gender confirmation gender-affirming surgery in youth, notes. “But there is evidence in the literature about just overall improved health, reduced anxiety, increased ability to function, for individuals after they have these gender-affirming surgeries.”

What does research say about treatment of transgender youth?

A  review of the latest research on gender-affirming hormones and surgery in transgender youth , published in a June 2019 edition of The Lancet Diabetes & Endocrinology , supports Bowers’ assertions that gender confirmation surgery benefits adolescents, though it does not go as far as to recommend specific age guidelines.

“Several preliminary studies have shown benefits of gender-affirming surgery in adolescents, particularly regarding bilateral mastectomy in transgender adolescent males, but there is a scarcity of literature to guide clinical practice for surgical vaginoplasty in transgender adolescent females,” the authors write. “The optimal age and developmental stage for initiating [cross sex hormones] and performing gender-affirming surgeries remains to be clarified.”

The  World Professional Association for Transgender Health  (WPATH), a leading organization for transgender health worldwide whose membership consists of physicians and educators, publishes Standards of Care and Ethical Guidelines for the treatment of transgender patients.

Though WPATH’s Standards of Care was last updated in 2011 and is under revision, even the current standards suggest that individuals at the age of majority in a given country (for the United States, that’s 18) who have lived for at least 12 months in accordance with their gender identity should be eligible for genital surgery, and that chest surgeries can be done earlier.

“I think it’s important to recognize for all of these standards of care, these are flexible guidelines,” says Loren Schechter, director of the  Center for Gender Confirmation Surgery  at  Weiss Memorial Hospital , clinical professor of surgery at the University of Illinois at Chicago, and co-lead for the revision of the WPATH standards of care surgery chapter for adolescents and adults. “It is not necessarily uncommon that we will currently perform bottom surgeries under the legal age of majority now.”

Schechter also indicated that the revision of the standards will likely include lowered age guidelines.

One reason to give transgender youth access to surgery

Schechter maintains that there are many reasons why minors should be eligible to receive gender confirmation surgery.

“One of them is that post-operative care in a supportive environment is very important,” Schechter said. “So, for example, for those individuals going off to college, the ability to recuperate while at home in a supportive environment and parents during that post-operative period is quite important. Trying to have your post-operative care in a dorm room after surgery is it is not necessarily an ideal scenario.”

This reasoning was echoed in a  paper published in the Journal of Sexual Medicine in April 2017 . For the study, researchers asked 20 WPATH-affiliated surgeons practicing in the U.S. about whether and why they performed genital surgery on transgender female minors.

Respondents noted the beneficial recovery environment some minor patients may have.

“Some surgeons viewed timing the procedure before college attendance as a harm reduction measure: Younger patients who have the support of their families, support of their parents, and can have the operation while they are still at home, as opposed to being alone at school or at work, anecdotally tend to do much better than someone who is alone and doesn’t have appropriate support.”

Others suggest that receiving surgery as a minor might allow the patient to “fully socially transition” in their next phase, such as in college.

Who is ready for surgery? Considerations beyond age

Physicians involved in the study also noted that while the number of minors requesting information about genital surgery had increased, psychological maturity is their main criteria for approval.

As one interviewed surgeon put it, “Age is arbitrary. The true measures of how well a patient will do are based on maturity, discipline and support.”

Eleven of the 20 surgeons interviewed had performed such surgeries. Minors ranged in age from 15 to “a day before 18.” About two-thirds of surgeons interviewed believe that such decisions should be made on a case-by-case basis rather than in strict adherence with current WPATH guidelines, which advises to wait until 18 in the U.S.

Boskey, who works for the Center for Gender Surgery at Boston Children’s Hospital, notes: “Just setting the age guidelines in place doesn’t remove the need to appropriately assess whether the surgery is something that should be happening,” she said.

“They’re going to need to make certain that the patient is appropriate for that surgery, that they are being diagnosed with gender dysphoria, that they are taking hormones as appropriate, that they are living in their affirmed gender, that they are aware of all of the life-changing nature of these surgeries,” she said. “These are surgeries that require pretty intense assessment to make certain that they’re appropriate. But that needs to come from the clinical side, rather than the insurance side.”

Will trans youth regret surgery? What the research says

Research supports the benefits of early interventions.

A 2018 study published in JAMA Pediatrics of 136 transmasculine youth and young adults between the ages of 13 and 25 receiving care at Children’s Hospital of Los Angeles finds that, on average,  chest dysphoria, or distress caused by one’s chest, was significantly higher among participants who had not received chest reconstruction surgery as compared with those who did .

Serious complications among the surgery group were rare, and only one of the 68 patients who received surgery reported experiencing regret sometimes, with the other 67 reporting no regret over the procedure. The time that had elapsed between surgery and the survey ranged from less than 1 year to 5 years.

“Given these findings,” the authors conclude, “professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.”

Those who study the impact of early access to gender confirming surgeries often point to research from the Netherlands, home to one of the earliest comprehensive gender clinics.

“[T]hey’ve probably got the most data on transgender, gender non-conforming adolescents, who have been followed longitudinally, prospectively in the most rigorous way — that data indicates that people do well with early access and early interventions,” Schechter says. “By early, I mean late adolescence — we’re not, of course, talking about operating on children.”

Adolescents who were the first 22 people to receive gender confirming surgery at the clinic in the Netherlands  showed after surgery that they no longer experienced distress over their gender, according to a 1997 publication in the Journal of the American Academy of Child & Adolescent Psychiatry .

The study also showed that the 22 adolescents scored within the normal range for a number of psychological measures.

Further, the authors note, “Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment.”

A follow-up study, published four years later, of another group of 20 adolescents receiving surgery after the first group of 22  confirmed the initial findings .

Another, later study in the Netherlands focused on the outcomes of  55 transgender young adults  who received gender confirmation surgery between 2004 and 2011. The participants all “were generally satisfied with their physical appearance and none regretted treatment.”

Moreover, gender dysphoria was alleviated, mental health improved, and well-being among those studied was similar to or better than their peers in the general population.

About The Author

Chloe Reichel

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Access to sex reassignment surgery

Key aspects.

• In thirteen out of twenty-eight Member States, general surgery rules apply as regards the age at which children can request a sex reassignment surgery. In this context, the age requirement for access to medical treatment without the consent of the parents or of a public authority is 18 years in Bulgaria, Cyprus, Greece, France, Hungary, Romania  and Slovakia , and 15 years in Slovenia . In the United Kingdom  the age requirement ranges from 16 in Scotland to 17 in England and 18 in Wales . In Belgium, Estonia, Germany  and Luxembourg  the child’s maturity is assessed.
• In Austria , Czechia, Croatia, Denmark, Finland, Italy, Latvia, Lithuania , the Netherlands , Poland, Portugal, Spain and Sweden the minimum age requirement to request sex reassignment surgery is explicitly set at the age of 18.
• Overall, twenty Member States (and Wales ) only allow sex reassignment surgeries in individuals over the age of 18. Out of these, twelve Member States also set 18 as the age requirement for transgender hormone therapy, while in the case of sex reassignment surgery, eight countries ( Czechia, Denmark, Finland , the Netherlands, Latvia, Poland, Spain and Sweden ) ask for a higher age than for transgender hormone therapy.
• In Ireland and Malta , the age requirement for sex reassignment surgery is 16 years.
• Croatia allows children to have sex reassignment surgery before the age of 18 if they have parental consent, without laying down any specific minimum age requirement.

Language English

Netherlands adopts landmark gender identity law, bans forced sterilization

THE HAGUE, Netherlands — The Netherlands has adopted landmark legislation banning forced sterilization and allowing transgender people to change their identity on official documents with the requirement of gender reassignment surgery.

The new Dutch law applies to anyone 16 years of ago or older, and requires only a statement from an expert before registering the person’s preferred gender in official state documents.

The previous Dutch transgender law required that any change in gender registration required a gender reassignment surgery and irreversible sterilization. Both requirements have now been deleted.

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Carolien van de Lagemaat chair of the Transgender Network Netherlands group hailed the new law as “victory for transgender people in the Netherlands.”

Van de Lagemaat said the change would greatly alleviate problems transgender people face on a daily basis while applying for a new job, showing identification, obtaining health care, and using public transportation.

Article continues below

Boris Dittrich, Dutch advocacy director of the LGBT rights program at Human Rights Watch (HRW), told LGBTQ Nation: “The new law is a huge step forward for transgender people who do not wish to alter their body but would like to obtain new ID papers.”

“The old law required them to undergo gender reassignment surgery and they be irreversibly sterilized,” he said. “That these requirements have been deleted makes a big difference in the daily lives of transgender Dutch people who needed to identify themselves with IDs that did not match their preferred gender.”

Dittrich added that requirements of the age of consent for transitioning and expert approval will be up for re-examination within three years and could then be done away with.

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Privacy Overview

European Countries Restrict Trans Health Care for Minors

Citing insufficient research, European health bodies from Sweden to France are taking a more conservative approach to gender-affirming care for minors.

Europe Cools on Trans Care for Minors

Vuk Valcic | SOPA Images | Getty Images

Protesters hold 'Trans rights now' placards and a transgender pride flag during a demonstration in London on Jan. 21, 2023. The United Kingdom is among several countries in Europe that are rethinking minors' access to gender-affirming care.

Chase, a transgender teenager who identifies as non-binary, has been trying to access gender-affirming health care in the United Kingdom since the age of 13. Three years later, the wait continues.

Chase has been officially on a waitlist for care within the National Health Service system for more than a year due to high demand and, more recently, operational delays. The 16-year-old, who uses the pronoun they, says the long wait has been harmful to their mental health and, about six months ago, decided to turn to private hormone therapy treatment.

Due to an ongoing independent review of gender identity services for youth in the U.K. commissioned by its public health authority, minors like Chase might be waiting a while for clarity. Theresa, Chase’s mother, notes that because of the uncertainty around possible care-related policy changes, their situation can feel like “death by a thousand cuts.” (U.S. News is not using the real names of Chase or Theresa to protect their privacy.)

“It's infuriating really,” Chase adds.

The U.K. is not the only European country that is rethinking how to approach gender-affirming care for minors. Several countries, including traditionally more progressive nations like Sweden and Norway , are changing guidelines at least in part due to questions from some doctors about the risks of such procedures. The changes in Europe are occurring more often at the health care policy level initiated by medical professionals, rather than through new or adjusted laws pushed by legislators, and experts say they haven’t been politicized to the extent they have been in the U.S.

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“This is not a legal battle in Europe,” says Cianán Russell, a senior policy officer at ILGA-Europe, the European arm of the International Lesbian, Gay, Bisexual, Trans and Intersex Association. Rather, “governments are changing guidelines or instructions to different institutions, or the institutions are changing their policies themselves.”

The Human Rights Campaign, an LGBTQ+ advocacy group based in the U.S., defines gender-affirming care as “age-appropriate care that is medically necessary for the well-being of many transgender and non-binary people who experience symptoms of gender dysphoria, or distress that results from having one’s gender identity not match their sex assigned at birth.” Care can come in a variety of ways, from mental health support to hormone treatment like what Chase is using, to, in some cases, surgical procedures. Advocates say holistic support, or a combination of mental and medical treatments – which is recommended in the World Professional Association for Transgender Health’s standards of care – is generally the best approach.

In the U.S., conservatives often oppose the concept of youth gender-affirming due to religious beliefs and concerns about child abuse. However, in Europe the reluctance appears to be more based on science than politics, with some medical professionals questioning the health risks of administering transitional treatments on minors. One 2022 report commissioned by the Swedish government, for example, concluded that the “scientific basis is not sufficient” to continue to conduct hormone treatments on children without further research.

“Health care should not provide interventions that we do not know to be safe and beneficial,” Mikael Landén, a professor and chief physician at the University of Gothenburg in Sweden and co-author of the report, wrote in an email. “From the lack of evidence follows that a conservative approach is warranted.”

But the broader picture in Europe is not all negative from the perspective of those in favor of trans rights, Russell says, and there are plenty of examples of trends viewed positively by advocates. They say that more than 60% of the total population of the European Union – including countries such as Belgium , Germany , Italy and the Netherlands – have “clear policies in place about offering transition-related care to minors,” such as puberty blockers and hormone treatments. Additionally, the recently updated trans rights map published by Transgender Europe – a nonprofit that promotes the full equality and inclusion of all trans people on the continent – finds that 25 of the 27 E.U. member states provide legal gender recognition procedures.

A more detailed picture given by the organization brings advocates some cause for worry, however. Of the 25 E.U. members that offer those procedures, four demand sterilization, only one offers full non-binary recognition and less than half (12) offer legal gender recognition procedures for minors.

In recent years, at least a handful of European countries have gently tapped the breaks on gender-affirming care for minors.

In Finland , specialized adolescent psychiatric gender identity teams have been available for minors at two university hospitals since 2011 through the country’s adoption of the so-called “ Dutch approach ,” which in part holds that adolescents experiencing gender dysphoria “can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16.” But after years of additional research, a public health body in Finland recommended that minors experiencing gender dysphoria first be provided with psychological support and, if further medical treatment is pursued, that the patient be made “aware of the risks associated with them.”

In 2022, the Swedish government’s National Board of Health and Welfare said hormone treatments for minors “should be provided within a research context” and offered “only in exceptional cases,” while adding that the “risks of puberty suppressing treatment … and gender-affirming hormonal treatment currently outweigh the possible benefits.”

In Norway, the country’s Healthcare Investigation Board recommended in part that gender-affirming care treatments such as puberty blockers be defined as experimental. Meanwhile in France , the Académie Nationale de Médecine in February 2022 recommended the “greatest reserve” when considering puberty blockers or hormone treatments due to possible side effects such as “impact on growth, bone weakening, risk of infertility” and others, according to a translation.

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Marci Bowers, the president of the World Professional Association for Transgender Health, says the situation around youth gender-affirming care in some European countries is indeed different than in America – but she has confidence in the direction that ongoing research is headed.

“(European countries) are trying to be objective,” Bowers says. “Although they are forcing patients to become research subjects, basically, as a condition of their care, the good news is that they fund that research.”

Questions about treatment will be answered, she adds, and “they're probably going to be answered affirmatively.”

Russell, of ILGA-Europe, believes the questions around health care for transgender youth on the continent are coming from a “small minority,” but that the “vast majority of doctors who work with trans people day-in and day-out support the kind of care” promoted by the World Professional Association of Transgender Health’s standards of care. They also reference the World Health Organization’s latest International Classification of Diseases, which describes gender incongruence as a sexual – not mental – health condition.

If there is a consensus, it hasn’t been reflected in Chase’s experience.

In late 2022, Reuters reported that England’s National Health Service – as part of its review of gender-affirming care for minors – was considering calling for local authorities to be alerted about cases in which families pursue private care for their transgender children outside of the public system. Chase’s family was one of those that had pursued private options, though they were unaware of the potential consequences.

Courtesy of the family

Chase and their mom Theresa visit Whitby Abbey in England.

Theresa says they were referred to social services, but that the case was eventually resolved when Chase’s general practitioner assured a representative that Chase was “ competent to make their own decisions about their health care” and not being pressured to access private testosterone treatment by their parents.

Almost two years after the review was launched, the NHS last summer announced that it would be decommissioning the Gender Identity Development Service, or GIDS – England’s only clinic geared toward youth with gender dysphoria – and transitioning its services to two regional hubs. The latter piece of the news was largely applauded by advocates. The changes came after the independent review commissioned by the NHS found, in part, a “lack of clinical consensus and polarized opinion on what the best model of care for children and young people experiencing gender incongruence and dysphoria should be” in the country.

But activists have still expressed concern over GIDS’ already long waitlist coupled with delayed openings for the regional locations, along with the fact that no new appointments will be scheduled until one hub opens in late 2023. Bowers notes the difficulty for these children that can come with waiting, adding that the effects of puberty can be “pretty depressing” for some with the angst they are already experiencing.

In the meantime, leaked draft guidelines make the situation even more cloudy. The NHS recently announced an interim policy holding that “puberty-suppressing hormones should not be routinely commissioned for children and adolescents” outside of research settings, citing the “significant uncertainties” surrounding the use of hormone treatments.

The ongoing review’s final report – and, thus, official guidance for how youth gender-affirming care should move forward – is set to be released later this year.

“I talk to young people all the time,” says Kai O’Doherty, the head of policy and research at Mermaids, a nonprofit organization based in the U.K. that supports trans youth. “It seems like they're completely absent from, actually, the conversation of what they need and what they're gonna get.”

Deekshitha Ganesan, a policy officer focused on health at Transgender Europe, says something that’s often forgotten in the recent debate about access to gender-affirming health care is that trans people’s quality of life and, as a result, ability to participate in society, “has improved so greatly” by having that access to such care.

For now, however, transgender minors across several European countries will continue to face uncertainty.

“I'm lucky in that I have a really good support system and stuff like that, but occasionally I think, ‘Things are getting worse. I'm getting older,’” Chase says. “Honestly, the thing I think is best for me at the minute is to go somewhere else. Like I honestly don't know what would happen if I stayed here, you know what I mean? But then it's like, where would you go? Because it's the same in America. It’s the same in a whole lot of places.”

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Netherlands

The information on this page was last updated in December 2022. The information was collected in the process of EIGE’s 2021 data collection on institutional mechanisms for the promotion of gender equality and gender mainstreaming.

Legislative and policy framework

The principle of equality and non-discrimination has been set out in the Constitution for the Kingdom of the Netherlands (Grondwet) since 1983.

The first statutory laws prohibiting discrimination on the grounds of sex were the Equal Pay Act of 1975 and the Equal Treatment Act for Men and Women (wet gelijke behandeling van Mannen en Vrouwen) of 1980. The latter (amended in 1989, 1994, 1998 and 2006 to bring national law in line with EU law) establishes the right to equality for women and men in both private and public employment. In addition, the 1994 General Equal Treatment Act (Algemene Wet Gelijke Behandeling) [1] sets out the legal basis against discrimination in most forms, including labour market discrimination and discrimination on the grounds of religion, political beliefs, and race, ethnicity, gender, and sexual orientation.

The Directorate for Emancipation of the Ministry of Education, Culture, and Science introduced a national strategy for equality covering gender equality together with other equality and non-discrimination measures in 2017. The ‘National Action Plan: The Gender and LGBTI Equality Policy Plan: Putting principles into practice’ (NAP) [2] covers the period 2018-2021. [3] The current gender equality priorities include a focus on the promotion of women’s financial independence, the appointment of women to senior positions, the elimination of both the gender pay gap and harassment of, and violence against, women, fair media representation, and equal treatment. [4] The plan was introduced following recommendations from the United Nations (UN) Committee on the Elimination of Discrimination against Women in 2016. [5] There is no national action plan solely on gender equality. Progress is monitored by the Ministry of Education, Culture and Science, which is responsible for monitoring and assessing progress in all areas of women’s emancipation in the Netherlands.

National Action Plan: The Gender and LGBTI Equality Policy Plan: Putting principles into practice Priorities

• Labour market: financial independence, more women at the top, and equal pay
• Social security and acceptance: safe cities, education, vulnerable minorities, and sustainable infrastructure
• Gender diversity and equal treatment: media, youth and stronger legislation

The government has a separate policy commitment to gender mainstreaming. In 2018, the Dutch government pledged to make gender mainstreaming in the national public administration a visible part of the Integral Assessment Framework for policy and regulation (IAK). [6] Therefore, the government added a new test on the ‘effects on gender equality' [7] (effecten op gendergelijkheid) to the IAK. It requires policymakers to map the nature and extent of the consequences of proposed policies and regulations for gender equality. The quality requirement consists of two parts. First, the request must answer questions on and map the effects of, the proposal on equality between men and women. Where relevant, policymakers must indicate how those effects that exacerbate or deepen gender inequality will be minimised. Second, the request must consult (the representatives of) parties that will be affected by the proposal. The quality requirement does not necessarily mandate adjustments. Further, it is not obligatory to mention the results in the explanatory memorandum (‘memorie van toelichting’) for passing any new legislation.

Governmental equality bodies

The Ministry of Education, Culture and Science (Minister Onderwijs, Cultuur en Wetenschap, OCW) houses the gender equality body, though it also works in close cooperation with other ministries. Following a 2007 evaluation of gender mainstreaming, the Netherlands changed its approach to gender mainstreaming and adopted a ‘system responsibility’ approach. Under this revised approach, the OCW takes the lead in national gender equality policy but has cooperation agreements in place with other ministries for cases in which gender equality priorities fall within those ministries’ policy domain. These cooperation agreements specify what and how said ministries must contribute to the gender equality objectives set out in the national policy. Significantly, this ‘system-responsibility’ approach means that ministries other than the OCW are held accountable by parliament for the implementation of gender equality policy.

The Directorate for Emancipation (Directie Emancipatie), established in 1978 and brought under the OCW in 2007 is responsible for gender equality and the rights of LGBTI people.

While the Netherlands has made efforts to enhance networking and cooperation of ministries with the governmental gender equality body, there is no formal structure in place to coordinate gender mainstreaming across government.

Ministry of Education, Culture and Science (Minister Onderwijs, Cultuur en Wetenschap, OCW) Functions

• agenda-setting and establishing the general framework for gender equality and anti-discriminatory policy for the government
• support the embedding of gender equality policies across the ministries
• integrate gender equality considerations in the EU and international affairs
• support society through knowledge infrastructure and goal-oriented subsidies
• coordinate the implementation of government decisions and international agreements on gender equality
• monitor and verify progress achieved in gender equality in the country

Departments and ministries consult the OCW’s Directorate for Emancipation about some new or existing policies, laws, or programmes (in fields other than gender equality) which leads to relevant adjustments in most cases. There is no structure in place to mainstream gender across ministries and departments.

As of December 2021, the personnel resources of the Directorate consisted of 28 employees who spent approximately 50-75 % of their time on gender equality issues.

The OWE reports to parliament at least once a year via the Emancipation Progress Report (voortgangsrapportage Emancipatie). [8] In addition, an annual Legislative Consultation (Wetgevingsoverleg - WGO) on Emancipation is held in the House of Representatives. [9]

Independent equality body

The Netherlands’ Institute for Human Rights (College voor de Rechten van de Mens) is the independent equality body responsible for monitoring, protecting, promoting and raising awareness about issues related to respecting human rights (including equal treatment). [10]

The Netherlands’ Institute for Human Rights Functions [11]

• the assessment of infringements of equality law (they provide legal advice insofar as the front office can explain the Equal Treatment Act but cannot provide assistance), including deciding on complaints on discrimination on the groups of sex
• conducting research on measures to protect human rights, including gender-sensitive analysis of policies and legislation
• reporting and making recommendations on the protection of human rights, including annual reports to parliament and the government on the human rights situation in the Netherlands
• monitoring progress in achieving gender equality
• providing advice (on written request or on its own initiative) to the government, parliament or executive bodies on law and legislation with a direct or indirect impact on human rights
• publishing and disseminating information on human rights
• stimulating and coordinating education on human rights

Endowed with quasi-jurisdictional competence, [12] the Institute has legal standing to take cases on its own initiative (Article 13 of the Netherlands’ Institute for Human Rights Act), but it cannot represent victims before the courts. The Institute has no legal standing to act as amicus curiae but it can do this in practice. Regarding consultation of the independent body in policy areas other than gender equality, the Institute’s role is limited to less than 25 % of cases as it primarily consults on new laws or policies rather than existing ones. However, the Institute often provides unsolicited advice to the government on its own initiative on various issues. If the Institute is consulted, it leads to an adjustment of policies or legislative instruments in the majority of cases (50-75 %). According to the Institute’s 2020 Annual Report, [13] the personnel resources of the Netherlands’ Institute for Human Rights consisted of 62 employees who, overall, spend up to 25% of their time specifically on gender equality issues. This includes members of the ‘gender equality and human rights programme,’ a team of 10 employees focused on gender equality alongside other topics.

Parliamentary body

The relevant parliamentary body, the Standing Committee on Education, Culture and Science (Commissie Onderwijs, Cultuur en Wetenschap), includes a specific focus on gender equality. [14] Parliamentary members meet once a month to discuss related issues with a minister.

Consultation with civil society

While there is no specific legal arrangement in place for consulting NGOs or citizens in the field of gender equality, NGOs make use of online consultations to respond to legislative proposals. In addition, every five years, the Ministry of OCW enters strategic partnerships with several alliances of NGOs in the field of gender equality. These alliances receive subsidies and entail regular consultations about the subjects of collaboration.

Methods and tools

Note: the methods and tools listed under this were the focus of EIGE's 2021 assessment. If certain methods and tools are not mentioned in this section, this does not necessarily mean that they are not used at all by the Netherlands.

Gender impact assessment

Several gender mainstreaming tools are in use, including gender impact assessment and the use of gender statistics and sex-disaggregated data. However, gender budgeting is not widely used; there is no legal obligation in the Netherlands to undertake gender budgeting and it is practically an unknown concept in ministerial budgets.

Gender budgeting

There is a legal obligation to undertake an ex-ante gender impact assessment when drafting laws and policies [15] , under the IAK as discussed above. However, although policymakers are obliged to apply this gender impact assessment, they are not obliged to report on the results anywhere. This means that it is not possible to know whether this assessment has been carried out or not. In reality, policymakers most likely rarely use the gender impact assessment, especially given that the IAK contains many assessments that policymakers have to undertake, including assessments with a mandatory reporting obligation.

Training and awareness-raising

Further, there are some measures in place to raise awareness of gender equality among ministries and other government bodies, including the distribution of printed materials and workshops for the Ministry of Defence and the Ministry of Justice. More specifically, for example, the Directorate of Emancipation has developed various audio-visual resources for national government, municipalities and companies to help avoid unnecessary sex registration i.e. asking for a person’s gender when it is not necessary (onnodige sekseregistratie).

Training is offered to employees of the governmental body for gender equality and some employees of other ministries on an ad-hoc basis. However, most government employees, including those at the highest political level, do not participate in gender equality training. Gender is often considered part of diversity programmes or assertiveness training, which is sometimes specifically offered for women leaders.

Gender statistics

The Netherlands has a website dedicated to gender statistics. Since 2000, Statistics Netherlands (CBS) and the Netherlands Institute for Social Research (SCP) have published the Emancipation Monitor (Emancipatiemonitor). [16] ‘The Emancipation Monitor’ website brings together biennial research on the state of the emancipation of women. It is published every two years and the 2020 edition maps policy commitments against the most up-to-date data on the position of women and men. The website provides a link to Statline M/F , which provides direct access to relevant datasets that can be viewed online and downloaded and explored by theme. Statline M/F is the digital database of the Emancipation Monitor, developed by the Ministry of Education, Culture and Science. [17] The Emancipation Monitor is the main tool for the dissemination of sex-disaggregated data via press statements.

The Emancipation Monitor does not produce additional publications as the website itself contains extensive analysis, similar to an online report. Publications on gender equality are however available on an ad hoc basis through the SCP’s website. The SCP was established through a Royal Decree in 1973. Its official tasks are to monitor, explain and explore social and cultural issues in The Netherlands to inform policy making. The SCP uses data from Statistics Netherlands and other sources.

Monitoring progress

Indicators for monitoring progress on institutional mechanisms for the promotion of gender equality and gender mainstreaming in the eu, under area h of the beijing platform for action.

This section analyses the scores achieved by the Netherlands for data collection in 2021 for the four officially agreed-on indicators on institutional mechanisms for the promotion of gender equality and gender mainstreaming to monitor progress on Area H of the Beijing Platform for Action. It also analyses scores under an expanded measurement framework which includes the role of independent gender equality bodies and assesses the effectiveness of efforts to disseminate statistics disaggregated by sex.. Institutional mechanisms refer to national machineries that implement, monitor, evaluate, and mobilise support for policies that promote gender equality and gender mainstreaming. All indicators and sub-indicators are available on the Gender Statistics Database here , including metadata about how the scores are calculated.

For Indicator H1 on the status of commitment to the promotion of gender equality and considering only the governmental commitment in line with the officially adopted indicator, the Netherlands scored 6.0 out of a possible 12, below the EU average of 7.2. It scored particularly low on sub-indicator H1e on the accountability of the governmental gender equality body where it lost 3.5 points out of a maximum possible score of 5 because there is no national action plan in place.

Under an expanded measurement framework which includes sub-indicator H1f on the mandate and functions of the independent gender equality body, the Netherlands scored an additional 1.5 points, out of a possible 3. It lost 1.0 point because the mandate of the independent gender equality body is gender equality combined with other non-discrimination areas, rather than exclusively focused on gender equality. The overall score for the expanded H1 indicator was 7.5 out of a possible 15, below the EU average of 9.1.

Indicator H2 analyses the personnel resources of the national gender equality bodies. For sub-indicator H2a, regarding the governmental equality body, the Netherlands scored 1.0 out of 2 which was the same as the EU average, because there were 10-25 employees working on gender equality in the governmental body. For sub-indicator H2b, regarding the independent body, Netherlands’s score was also 1.0, although the EU average was slightly lower at 0.8 because there were 10-25 employees working on gender equality in the independent body. For both sub-indicators, the maximum 2 points was awarded where the number of employees was over 100 as an indication of the body being sufficiently resourced.

Indicator H3 relates to gender mainstreaming. Here, the Netherlands scored 3.3 out of a possible 12 for gender mainstreaming (governmental commitment only), which was below the EU average of 5.1. However, the Netherlands scored 3.8 points out of a maximum of 14 for gender mainstreaming overall, which again was lower than the EU average of 5.4. The Netherlands had scored 0.5 out of the maximum of 4 points on sub-indicator H3b on governmental gender mainstreaming structures and consultation processes because there is no coordination structure for gender mainstreaming across government ministries/departments.

Under an expanded measurement framework, which includes sub-indicator H3d on consultation of the independent equality body, the Netherlands scored 3.8 points out of a maximum of 14, which was below the EU average which was 5.4. Under this sub indicator, the Netherlands scored 0.5 points because the independent gender equality body is only consulted by departments or ministries on the gender impact of specific new or existing policies, law. r programmes in a few cases.

For Indicator H4 on the production and dissemination of statistics disaggregated by sex, the Netherlands scored 5.0 points, out of a possible 6, which is above the EU average of 3.4. It lost 1.0 points for sub-indicator H4c on the effectiveness of efforts to disseminate statistics disaggregated by sex, as there are only ad-hoc publications that analyse gender statistics and gender statistics are not disseminated regularly.

[1] General Equal Treatment Act (1994) https://wetten.overheid.nl/BWBR0006502/2020-01-01

[2] Ministry of Education, Culture and Science (2018). Gender & LGBTI Equality Policy Plan 2018-2021: Putting principles into practice https://www.government.nl/topics/human-rights/documents/reports/2018/06/01/gender--lgbti-equality-policy-plan-2018-2021

[3] Ministry of Education (2018). Emancipatienota 2018–2021  https://www.rijksoverheid.nl/documenten/kamerstukken/2018/03/29/emancipatienota-2018-2021

[4] Government of the Netherlands (2018). Gender & LGBTI Equality Policy Plan 2018-2021: Putting principles into practice https://www.government.nl/topics/human-rights/documents/reports/2018/06/01/gender--lgbti-equality-policy-plan-2018-2021

[5] Committee on the Elimination of Discrimination against Women (2016, 2018). Concluding observation on the 6th periodic report of the Netherlands: Committee on the Elimination of Discrimination against Women. CEDAW/C/NLD/CO/6 2016 report: https://digitallibrary.un.org/record/861850?ln=en 2018 report: https://digitallibrary.un.org/record/1654601?ln=en

[6] Ministry of Education, Culture and Science (2021). Knowledge centre for policy and regulations: Effects on gender equality https://www.kcbr.nl/beleid-en-regelgeving-ontwikkelen/integraal-afwegingskader-voor-beleid-en-regelgeving/verplichte-kwaliteitseisen/effecten-op-gendergelijkheid

[7] Ministry of Education, Culture and Science (2021). Knowledge centre for policy and regulations: Effects on gender equality https://www.kcbr.nl/beleid-en-regelgeving-ontwikkelen/integraal-afwegingskader-voor-beleid-en-regelgeving/verplichte-kwaliteitseisen/effecten-op-gendergelijkheid

[8] Emancipation Progress Report (2020) https://open.overheid.nl/repository/ronl-402f94c9-b772-4875-b991-aa165afd6bfb/1/pdf/voortgangsrapportage-emancipatie-2020.pdf

[9] Annual Legislative Consultation on Emancipation (2020) https://www.tweedekamer.nl/debat_en_vergadering/commissievergaderingen/details?id=2020A03129

[10] Standing Committee for Education, Culture and Science (n.d.) Emancipation https://www.tweedekamer.nl/kamerleden_en_commissies/commissies/ocw/eman… Please note this is the same link as endnote 16.

[11] College voor de Rechten van de Mens (2017). Jaarverslag 2017, p. 9 https://publicaties.mensenrechten.nl/file/044760d2-9295-23b6-c25d-58e1ded66cf9.pdf

[12] UN Resolution 48/134 (1993). National institutions for the promotion and protection of human rights (1993) https://www.legal-tools.org/doc/b38121/pdf/

[13]College voor de Rechten van de Mens (2021). Jaarverslag en monitor Discriminatiezaken (2020). https://mensenrechten.nl/nl/publicatie/607f92051e0fec037359cb27

[14] Standing Committee for Education, Culture and Science (n.d.) Emancipation https://www.tweedekamer.nl/kamerleden_en_commissies/commissies/ocw/emancipatie

[15] Effects on gender equality (n.d.) Effects on gender equality | Knowledge centre for policy and regulations (kcbr.nl)

[16] Emancipation Monitor (2020) https://digitaal.scp.nl/emancipatiemonitor2020/

[17] Statline M/V (n.d.) https://mvstat.cbs.nl/#/MVstat/nl/

New "20-year" Study from Amsterdam's VUmc Youth Gender Clinic: A Critical Analysis

A recent study published in The Journal of Sexual Medicine reported demographic and treatment trends among gender-dysphoric youth seeking evaluation and/or treatment at the Netherlands’ largest pediatric gender clinic in Amsterdam (VUmc) between 1997 and 2018. The study seemingly supports the emerging narrative that "gender-affirming" care for youth has been thoroughly tested over 2 decades ; that the long-term trajectories of gender-transitioned youth are both well-understood and positive , as evidenced by virtually no detransition ; and that in fact, many "transgender adolescents" do not want any medical interventions — but for those who desire them, puberty blockers, cross-sex hormones and surgery  should be widely available , as long as the adolescents are "comprehensively assessed."

However, a closer examination reveals that these assertions are not supported by the data presented. Below, we briefly explain the design of the study and highlight the study’s main findings. Next, we analyze several key assertions made by the study authors that are not supported by the data. Finally, we discuss the implications of continuing to scale “gender-affirming” medical interventions to the rapidly growing numbers of youth seeking gender reassignment absent reliable research of long-term outcomes.

Brief study description

The study reported demographic and treatment trends in 1,766 patients who were under age 18 when they first presented to Amsterdam’s VUmc pediatric gender identity clinic for evaluation or treatment with puberty blockers. This retrospective study reported the age and sex  of referrals to the youth gender clinic between 1997 and 2018 and the rate of uptake of each intervention phase of "gender-affirming" care: puberty blockers, cross-sex-hormones, and surgery. It also reported the conversion rate from puberty blockers to cross-sex hormones.

All trends were analyzed for two distinct groups of patients: those who sought their first evaluations before age 10 and those who presented to the clinic at age 10 or older (defined as "early" vs "late-presenting" groups).

The study’s key findings

Below we enumerate the most relevant points that are well-supported by the study data:

There was a sharp increase in referrals to the Amsterdam clinic, driven by late-presenting females.

The study confirms the epidemiologic trend reported throughout the Western world: a surge in late-presenting cases of gender dysphoric youth, primarily driven by adolescent females. In the Netherlands, this trend began a bit earlier than in the rest of the Western world, circa 2012.

Note : as the footnote to the graph indicates, the drop in 2018 observed in Figure 2 (above) does not represent a drop in demand, but rather, redirection of new cases to other clinics in order to keep up with growing demand for services.

The majority of late-presenting cases were female, while the majority of early-presenting cases were male.

The study reported that 67% of late-presenting cases were female (795 out of 1194), compared to only 45% of the early-presenting cases (217 out of 487). (These numbers can be found in Figure 1 in the paper.)

The majority of late-presenting cases underwent medical transition.

The study reported that 77% of the late-presenting "potentially eligible" females started puberty blockers at the Amsterdam clinic (this number was 53% for the late-presenting males). More than 90% of both late-presenting "potentially eligible" males and females started cross-sex hormones at the clinic.

A significant number of early-presenting cases of both sexes did not transition upon puberty.

The data indicate that only 36% of the "potentially eligible" early-presenting males and 53% of the "potentially eligible" early-presenting females pursued medical transition once they became eligible during puberty, while 64% and 47% respectively did not (see Table 2 in the study).

The authors also note that "a substantial proportion of children first visiting before age 10 years did not meet criteria for a GD [gender dysphoria] diagnosis." The extent to which this may be a reflection of the well-established phenomenon of high rates of desistance among those with early-onset gender dysphoria is unclear, as the authors did not specify whether these youth had ever met the criteria for a GD diagnosis.

Females were much more likely than males to initiate medical transition.

More than three-quarters (77%) of late-presenting "potentially eligible" females started puberty blockers at the Amsterdam clinic, compared to slightly more than half (53%) of the late-presenting males. Similar differences between the male and female subjects were observed for the early-presenting cases (53% of females and 36% of males pursued medical transition eventually).

The authors note this marked gap between females and males starting puberty blockers: “The difference between AMAB [males] and AFAB [females] in the relative number of people starting GnRHa [puberty blockers] is remarkable.”

There was a high rate of progression from puberty blockers to cross-sex hormones.

The study found a high rate of conversion from puberty blockers to cross-sex hormones—93%-98%. The authors concede that puberty blockers may not serve as a diagnostic tool as previously thought, but rather represent the first step in medical gender transition. The authors also hypothesize that it might be possible that “ starting GnRHa in itself makes adolescents more likely to continue medical transition .”

Surgeries continue to be a core part of the treatment path, but fewer patients are opting to remove gonads (ovaries and testes) since sterilization requirements were lifted in 2014.

Following changes in Dutch laws in 2014, which allowed for legal recognition of “sex change” without undergoing sterilization, the number of young people who sought surgery to remove gonads dropped but remained significant. Since 2014, 53% of "potentially eligible" biological males and 38% of "potentially eligible" biological females underwent gonadectomy. A significant proportion of "potentially eligible" females underwent mastectomy (79%). However, mastectomy rates were reported in the aggregate across the entire 20-year span, and the definition of "potential eligibility" for surgery may have inadvertently excluded some youth under 18 who underwent mastectomy in the later years of the study (see point 6, " The reliance on "potential" eligibility " below).

Potentially Misleading Claims

The authors make several claims which, while technically accurate, may inadvertently be misleading. Below we highlight some of these instances and demonstrate the importance and value of reading this paper carefully, rather than accepting its statements at their face value.

• The study claims to represent “the first 20 years of the Dutch Protocol,” but fails to acknowledge that the Dutch Protocol’s strict eligibility criteria were not consistently followed during the study period.

The Dutch Protocol has become internationally synonymous with the careful and cautious approach the Dutch clinicians devised and documented in 1997 , 2006 , 2008 and 2012 . It required an early childhood onset of gender dysphoria, increase of gender dysphoria after pubertal changes, absence of significant psychiatric comorbidity, and demonstrated knowledge and understanding of the consequences of medical transition. Treatment with puberty blockers could only be initiated at the minimum age of 12. Interventions with clearly irreversible effects—cross-sex hormones and surgery—were not available until ages 16 and 18, respectively. All youth were provided with psychotherapy throughout. The Dutch Protocol specified that youth with "nonbinary" presentations were ineligible for medical interventions, and instead should be treated with psychotherapy .

It is therefore surprising that the authors of the study “redefined” the Dutch Protocol as merely a “ diagnostic procedure and combined treatment of GnRHa [puberty blockers] and subsequent GAH [cross-sex hormones] ” (p.2) – without ever mentioning the Protocol’s strict eligibility requirements, which have long been juxtaposed to the much more permissive practice of "gender affirmation" which began to proliferate in the West after the publication of the Dutch Protocol's outcome data in 2014 . (The origins of the Dutch Protocol, and the outcomes of the 2014 study which launched the practice of youth gender transitions worldwide, have recently been critically evaluated).

It is even more surprising that the authors refer to the “Dutch Protocol“ and Endocrine Society guidelines by Hembree et al. interchangeably (p. 2). The Endocrine Society guidelines were only issued in 2017, while the study reports on cases assessed and treated between 2006 and 2018. In addition, there are clear differences between the Endocrine Society guidelines and the criteria outlined in the Dutch Protocol in terms of eligibility requirements. Unlike the Dutch Protocol, the Endocrine Society guidelines do not require a childhood onset of gender dysphoria, nor do they set the minimum age for puberty blockers at 12. Instead, the Endocrine Society permits the use of puberty blockers at Tanner Stage 2 of puberty, which can occur in girls as young as ages 8-9.

The authors make several contradictory claims about the fidelity of adherence to the Dutch Protocol’s requirements throughout the 20-year period. They state that the clinic “followed 1 diagnostic and treatment protocol” over 20 years, but also volunteer that "the protocol was adapted" and that “practice has evolved since the start of the Dutch Protocol.” It is unclear when the Amsterdam clinic began to deviate from the strict Dutch Protocol, which was the basis for the seminal 2014 Dutch study . It is clear, however, that as of 2018, the official Somatic (medical) t reatment guidelines from the Netherlands no longer adhered to the Dutch Protocol.

According to the 2018 Somatic (medical) treatment guidelines , eligibility for medical transition no longer requires a history of early onset of gender dysphoria—instead, adolescent-onset cases could be medically transitioned. Table 1.2 of the document (auto-translated and reproduced below) indicates that the minimum age at which puberty blockers may be initiated was lowered from age 12 to Tanner stage 2 (which can occur at ages considerably younger than 12), while the eligibility for cross-sex hormones was lowered to age 15 (and the text suggests even younger ages may be considered). The age of eligibility for mastectomy was lowered from 18 to 16. Further, it is unclear whether the DSM-5 diagnosis of "Gender Dysphoria" (with its key element of gender-related distress) is still required to initiate treatment, since the document only refers to the ICD-11 diagnosis of "Gender Incongruence" which has no distress criterion.

While it is expected that clinical practice evolves, it is not appropriate to refer to the “Dutch Protocol” when describing a practice that uses the Protocol’s highly invasive medical and surgical interventions but ignores its clearly articulated eligibility requirements.

The authors state that the goal of the study was to “review how practice has evolved since the start of the Dutch Protocol and to evaluate the treatment trajectories of people who were treated accordingly.” Evaluating the trajectories of youth treated under far less restrictive criteria is critical. However, this question is not answered by the study, since data were not evaluated separately for those treated under the Dutch Protocol and those who were treated under the newer “evolved practice” criteria.

• The “unprecedented" 20-year time span of the study, listed as the study’s key strength in the abstract, masks a much shorter 4.6-year median patient-level follow up.

While it is technically true that the study data span over 20 years, what this statement fails to address is that in terms of patient-level treatment trajectories, the median follow up is only 4.6 years from the first intake appointment. For 25% of the sample, follow up is less than 3 years from the first intake appointment.

The intake appointment was followed by "comprehensive assessments," which the authors say are critical, and which presumably took several months to complete. Further, as the study data show, puberty blockers were administered for another 1-2 years. Therefore, a substantial number of youth presenting to the clinic in the later years would have only just started cross-sex hormones around 2017-2018, just as data collection was drawing to a close. Even fewer of them would have undergone surgery by the end of data collection.

To properly evaluate outcomes, follow up consisting of months to a few years after starting medical treatment is insufficient. Prior research suggests that health problems in general, as well as psychological problems and regret often do not peak until a decade later . Recent research from the US, which has been following less restrictive “affirmative care” protocols outlined by the Endocrine Society, reveals that 30% discontinued hormones just 4 years after treatment initiation — a surprisingly high rate, considering that these treatments are intended to be used life-long in order to maintain a feminized or masculinized appearance.

Since the bulk of cases included in this “20-year" study occurred in the last few years of the study, currently available data simply do not extend out far enough to provide reliable information about eventual health outcomes.

• The study claims that among youth who initiated medical transition, “detransition was very rare” — but the authors never evaluated detransition rates.

The study conclusion states: " detransition was very rare. " This finding has also been elevated into the study abstract, which says: “the risk of retransitioning was very low . ” Aside from creating confusion regarding terminology ("detransition" and "retransition" which the authors use interchangeably), these statements may lead readers to the incorrect conclusion that most youth who had embarked on medical treatment stayed on it long term. However, the study never attempted to evaluate the rate of detransition . The only “detransition” rate assessed was detransitioning during the puberty blocker phase. The study did not evaluate detransition rates for youth on cross-sex hormones or those who had undergone surgery.

The authors did find a low rate of detransition during the puberty blocker phase: 93%-98% of youth who started puberty blockers did not discontinue them, and instead proceeded to start cross-sex hormones. This finding led the authors to appropriately conclude that puberty blockers may not serve as a diagnostic tool, but rather represent the first step in medical gender transition—and they even suggest that treatment with puberty blockers may contribute to the high incidence of subsequent treatment with cross-sex hormones.

When it comes to the question of detransition, most readers of the paper want to know: What percent of youth who start medical transition eventually detransition ? What is the average time to detransition? Do some change their mind again and retransition, and what is the timeframe for this decision? Unfortunately, this particular study cannot answer these important questions because the authors never analyzed treatment discontinuation rates for youth treated with cross-sex-hormones or surgery.

• The claim that “a substantial number of adolescents did not start medical treatment” problematically conflates "medical treatment" with "puberty blockers" and masks the fact that the vast majority of "late-presenting" females (which is now the predominant presentation) DID transition.

The statement in the abstract, “ a substantial number of adolescents did not start medical treatment ” in the abstract, while technically accurate, may lead readers to the erroneous conclusion that a substantial number of trans-identified adolescents seen at the Amsterdam clinic did not receive any medical interventions. This, in turn, may signal that the growing international concern with overmedicalizing gender-dysphoric youth is little more than a “moral panic.” Yet, closer reading of the study shows that 77% of "potentially eligible" late-presenting adolescent females (which is now the predominant presentation) DID in fact transition. And as the analysis below suggests, even this number may be a significant underestimate.

The claim in the abstract can be traced to the sentence in the body of the paper, “63% of all 1401 adolescents potentially eligible for GnRHa [puberty blockers] at the end of data collection had started GnRHa” (p. 4). This sentence does indicate that 37% of those assessed at the clinic—a substantial proportion—were not treated with puberty blockers. What it does not mean, however, is that 37% of gender-dysphoric adolescents did not undergo medical transition:

The study's definition of "did not start medical treatment" is not equivalent to "did not undergo medical gender transition ." The study problematically defines "starting medical treatment" as starting puberty blockers. However, one could start medical treatment at the cross-sex hormone treatment phase. For example, a significant number of cases listed as "not starting treatment" did so due to "medical/protocol" reasons (see Figure 6). As Table 1 below indicates, "medical/protocol" reasons subsumed youth who turned 18 during the evaluation and became eligible to bypass puberty blockers and start directly with cross-sex hormones. Thus, using "starting medical treatment" interchangeably with "starting puberty blockers" is misleading, as it results in what appears to be a relatively low number of those who "started medical treatment."

The denominator for the calculation was inflated by inclusion of "potentially eligible" subjects who were not actually eligible . The calculation of the percent "starting medical treatment" is based on the "potentially eligible" cases. However, the definition of “potential eligibility” for puberty blockers used in the study has little to do with actual eligibility. “Potential eligibility” was defined simply as "minimum age of 12 [presumably as of the end of 2018] and at least 1 year after the first visit." "Potentially eligible" cases apparently include youth not diagnosed with gender dysphoria upon assessment ("GD not diagnosed"); youth who may have desisted ("Participant related"); and the “watchful waiting” group of children whose gender dysphoria resolved ("GD in childhood"), according to Figure 6 below. The inclusion of "potentially eligible" but not actually eligible cases in the denominator led to a lower "percentage treated" number than would have been reported had the calculation been based on the actually eligible cases .

The calculation fails to account for all those treated with puberty blockers . There are several scenarios in which youth who likely received puberty blockers were not counted as such. First , youth who were "referred elsewhere" (see Figure 6 below) may have started puberty blockers at other clinics. These youth are in the denominator, but not in the numerator. Second , youth who were referred in the last few years of the study may not have yet become eligible for puberty blockade but may have pursued these interventions in the months following the end of data collection. The authors do note this possibility. Third , because of the unusual definition of "potential eligibility," some youth who were  actually treated with puberty blockers during the study period were likely excluded from the calculation entirely. For example, since the calculation required that the subject be at least 12 years of age at the end of 2018 (a key element of "potential eligibility"), a 10-year-old child treated with puberty blockers in 2017, who would not have yet turned 12 as of the end of 2018, would have been excluded. This phenomenon likely disproportionately impacts those treated in the last few years of the study – which is when the Amsterdam clinic likely began to deviate from the Dutch criteria of minimum age of 12 and began to treat youth according to Tanner stage.

A review of Figure 6 / Table 1 below makes it apparent that the 37% rate of “non-treatment” is difficult to interpret even when it comes to assessing the rate of starting puberty blockers. This number is even less reliable if one wishes to know, more generally, the percentage of initial referrals who were found eligible for medical treatment, as well as the percentage of those who subsequently medically transitioned.  

The relatively low percentage of those "medically treated" reported by the study appears to bolster the assertion that many transgender-identifying youth simply self-express their unique identities, and that many do not receive medical interventions. This assertion was recently made for the first time by the American Academy of Pediatrics , to assuage mounting concern that rapidly growing numbers of youth are being subjected to hormones and surgeries with irreversible consequences.

Therefore, it would be highly informative to know: What percentage of gender-dysphoric adolescents presenting to the Amsterdam clinic in recent years were diagnosed with gender dysphoria? How many were “cleared” to start medical transition? How many actually initiated medical transition in the months and years that followed? How have these trends changed over time? Unfortunately, the data presented in this study make it impossible to answer these important questions.

• The claim in the abstract that the results “provide ongoing support for medical interventions in comprehensively assessed gender diverse adolescents” is inaccurate.

The assertion that the study results support the continuing treatment of youth with puberty blockers, cross-sex hormones, and surgery is highly misleading. Such a conclusion is unjustified for several reasons. Besides failing to estimate the rates of desistance and/or regret after starting cross-sex hormones over a sufficient timeframe, the study also fails to examine the physical and mental health outcomes of the adolescents.

To answer these questions, all relevant outcomes must be analyzed over a sufficient timeframe. Further, treatment with puberty blockers and cross-sex hormones must be compared to alternatives (such as the choice not to treat medically, or to use noninvasive approaches such as psychotherapy) and show clear evidence that the benefits of medical and surgical interventions outweigh the risks.

• The study’s disclosure of limitations, particularly in the abstract, is inadequate.

Although the authors mention several critically important limitations in the body of the study, the only one elevated into the abstract is the study’s “retrospective design.” As many busy clinicians only read abstracts, this would lead them to believe that the study is effectively free from significant limitations. We describe some of the most important ones below.

T he “20-year sample” is heavily skewed toward recent cases, the ultimate trajectories of which are essentially unknown.

A significant number of cases came from the "explosion" in referrals in the last few years of the study, especially 2017-2018. The authors do mention that “caution needs to be taken when interpreting results from the most recent years” and that calculated proportions of youth undergoing treatment may be an underestimation. However, this key limitation is not acknowledged in the abstract, which instead states that current data “provide support for ongoing medical interventions in comprehensively assessed gender diverse adolescents.”

The reliance on "potential eligibility" rather than actual eligibility for medical interventions resulted in highly uncertain estimates that likely underestimated treatment uptake rates among those actually eligible for treatment.

As discussed earlier, reliance on "potential eligibility" when reporting on treatment trends is a double-barreled problem in this study. On the one hand, this definition includes many "false positive" cases, such as those not diagnosed with gender dysphoria. On the other hand, it may exclude some "false negatives," in which treatment deviated from the strict Dutch Protocol eligibility requirements, especially in the later years.

Based on the definition of "potential eligibility" for puberty blockers, 10-year-olds starting puberty blockade in 2017 (or 9-year-olds starting in 2016) likely would have been excluded from the trend analyses, as they would not have turned 12 by the time data collection ended in 2018 (the minimum age of 12 by the end of 2018 was a necessary condition for inclusion). Likewise, 14-year-olds treated with cross-sex hormones in 2017 would likely have been excluded as well (although the study's definition of "potential eligibility" for cross-sex-hormones is less clear). And according to the definition of "potential eligibility" for surgery, those receiving mastectomies at age 16 in 2017 or 2018 were also likely excluded, since the requirement of the minimum age of 18 was applied to the surgical trends analysis.

Using the Dutch Protocol's minimum age criteria for reporting, while lowering the minimum ages in actual practice, introduced a serious risk of bias. It likely systematically excluded those treated at younger ages than specified by the original Protocol, especially in the last 1-2 years of the study.

The utility of the statistics presented as a 20-year average is compromised by a skewed sample.

Many of the important statistics – and all the statistics in Tables 2 (treatments with puberty blockers and hormones) and 3 (treatments with surgery) are reported in the aggregate over 20 years. It is well recognized that adolescent referrals surged in recent years and the presentation of gender dysphoria markedly changed. It is also apparent that the Dutch Protocol criteria were not closely followed by the Amsterdam clinic in the last several years. Thus, these data are of little utility for readers interested in current treatment patterns and patient treatment trajectories.

One of the study's key findings is that younger gender-dysphoric children are less likely to get medical treatment once they reach adolescence. To the extent that the relatively low rates of treatment initiation in the "early-presenting group" are in part due to high rates of childhood desistance, the study unfortunately conflates the earlier time period when pre-pubertal social transition was explicitly discouraged by the Dutch Protocol , and the more recent years when the practice was much more common. Early social transition may have led to higher rates of persistence in the final years of the study, but this question cannot be answered because these data were only reported in the aggregate across 20 years.

The apparent attempt to differentiate youth with childhood vs adolescent-emergence of transgender identity relies on a crude and hard-to-interpret “presentation before vs after 10 years of age.”

The question of how to best treat youth with post-pubertal emergence of transgender identity is one of the most important questions since this has become the predominant presentation, and these youth were excluded from the Dutch Protocol eligibility in the past. A recent grant to the Amsterdam research team will be used to study the risk/benefit ratio of medically transitioning this novel patient cohort.

The lead researcher of the Dutch Protocol and a co-author of this study, Annelou de Vries, has acknowledged that youth presenting with post-pubertal emergence of transgender identity may benefit from psychological interventions rather than hormones and surgery. While this hypothesis is not addressed in the current study, the study does appear to attempt to approximate the novel cohort by presenting the data in two groups split by age of referral (younger and older than age 10 at intake). Specifically, the authors say: " To study whether there is a difference in the proportion of people starting GnRHa between those who were prepubertal and pubertal at their first visit, we compared those who had their first visit at age <10 and >=10." However, the cut-off based on the age of 10 is too blunt a measure, given the wide range of age of the onset of puberty, and the significant differences in pubertal timing in girls and boys. It is also unclear why age 10 was chosen as the cut-off when another recent paper reporting on effectively the same cohort presenting to the Amsterdam clinic defined early vs late presenters based on whether they were age 14, rather than age 10.

Using consistent age cut-offs to distinguish between the "early" vs "late-presenting" cases would help eliminate key inconsistencies between recent studies from the Amsterdam gender clinic. For example, the most recent paper in question reported that the "early-presenting" cases were predominantly male, while the "late-presenting" cases were predominantly female, and found that the "late-presenting" cases were more likely to pursue medical interventions than the "early-presenting" cases. However, another recent paper studying the same patient cohort found just the opposite: that the "late-presenting" cases were less likely to pursue medical interventions, and that both the "early" and "late-presenting" cases were predominantly female.

However, in order to differentiate pre-pubertal vs pubertal onset of gender dysphoria, one should look at the subject's stage of puberty, rather than the age. Further, instead of reporting the first encounter at the gender clinic , stage of puberty data should be analyzed based on the first documented instance of gender incongruence in the subject's medical history. These data should be collected through a comprehensive chart review.

The results of this study have very limited applicability to practice outside the Amsterdam clinic.

The study acknowledges that its results are limited by having "originated from 1 center... [and] the results may be different for centers following a different treatment approach." However, the authors do not adequately explain why this disclaimer is particularly important in this case. Prior to 2018, Amsterdam’s VUmc clinic was overseeing care for over 95% of gender dysphoria cases. However, starting about 2018 it began to redirect new patients to other clinics, and as of 2023 it is projected to serve less than 20% of youth cases. As 80% or more of Dutch gender-dysphoric youth are now treated at a dozen or more clinics, it is unclear whether the clinicians working in these other clinics will follow the same diagnostic and treatment approaches as practiced in the Amsterdam clinic.

The results of this study have very limited applicability to currently presenting cases.

The study’s data collection ended in 2018. Even for the patients that presented at the clinic in the last few years of the study, the effective follow up from treatment initiation is limited, and a number of those treated may not even be included in the analysis due to the exclusion for "ineligibility" described earlier. Since 2018, referrals of gender dysphoric youth have continued to surge in the Netherlands and worldwide, while the clinical presentations have continued to evolve, including the trend toward late-onset gender dysphoria, the preponderance of females, high rates of mental illness and neurocognitive comorbidities (e.g., ADHD, autism), and nonbinary presentations. At the same time, the Western world, and apparently the Dutch clinicians themselves, have moved away from the strict Dutch Protocol criteria that primarily reigned during much of the 20 years this study's data collection.

Thus, data gathered prior to 2018 already have limited applicability to the current clinical presentations. The significant departure from the original Dutch Protocol’s strict criteria, evident in the Dutch 2018 Somatic (medical) treatment guidelines , further limits the applicability of the findings obtained in prior years. (An upcoming update to the Dutch guidelines, expected in August 2023 , may once again “reset” the clock if the criteria for treatment eligibility are changed once again.)

The study does not address trends in 18-25-year-old gender-dysphoric youth.

As the recent UK's Cass review letter indicates, a substantial number of those presenting to adult gender clinics have just turned 18 and are under 25. The study's Figure 6 also shows that a number of 17-year-olds "aged out" of the pediatric setting while undergoing assessments. Youth aged 18-25 are a highly vulnerable group of patients subject to similar epidemiologic trends as the adolescents. This group also is showing a rapidly rising incidence of gender dysphoria, is largely female, and has high rates of co-occurring mental health difficulties. Future research should move beyond the somewhat arbitrary cut-off of age 18, analyzing the entire population of gender-dysphoric young people 25 and younger.

SEGM Thoughts

International readers asking key questions about the practice of youth gender transition are unlikely to find clear, reliable answers in this  recent study from the Amsterdam gender clinic . While the referral trends through 2018 are likely accurate, the treatment trends reported by the study are hard to interpret, and some are misleading. The treatment trend calculations appear to include those not diagnosed with gender dysphoria in adolescence. They also appear to exclude at least some youth that were treated with puberty blockers, cross-sex-hormones, and surgery in the last few years of the study, when the practice began to deviate from the Dutch Protocol's strict minimum age requirements.

Thus, this study is best understood as a time capsule of the “Dutch experience” from shortly after the inception of the practice of youth gender transition, through the first several years of the unprecedented surge in gender dysphoric youth. The study provides clear evidence of rapidly rising referrals in recent years, of the female preponderance, and of a high rate of initiation of medical transition in the older-presenting cohorts. The data also show extremely high rates of conversion from puberty blockers to cross-sex hormones.

The balance of the data presented in the study are subject to many irregularities in their definitions and calculations, which limit their utility. One of the study’s main limitations is that it appears to conflate two eras: the earlier time period when few (primarily male) pre-pubertal children presented to the Amsterdam clinic, and even fewer returned as adolescents to be treated with the original Dutch Protocol, and the later era of exploding numbers of female post-pubertal youth, who were treated using much less restrictive criteria. The fact that the study ended its data collection in 2018 poses additional challenges, as the populations of gender dysphoric youth have continued to grow and change in clinical presentations (including the rapidly growing numbers of youth who identify as nonbinary ).

While the data presented in the study are often convoluted, the study's title and abstract make a number of clear claims that can be easily misinterpreted as endorsement of current practices. However, these claims do not hold up to scrutiny when one reads beyond the abstract and has the skill to identify methodological problems. Few busy clinicians have the time or skill to engage in an in-depth critical appraisal of this and other studies, and thus, they rely on abstracts. In this sense, the study follows the unfortunate trend of many other recent studies in gender medicine, where there is a " marked asymmetry in outcomes reporting: findings of positive outcomes of medical interventions are trumpeted in abstracts, while their profound limitations remain... below the radar of busy clinicians ."

With 2 - 9 % of secondary school and college-aged youth declaring a trans identity and many seeking evaluation and treatment, the question about how to best care for the skyrocketing numbers of such youth going forward is one of the most urgent dilemmas facing clinicians today. It is vitally important to design and conduct rigorous studies in order to begin to generate data that can reliably guide clinical decision-making.

Before endorsing continued use of puberty blockers, cross-sex hormones and surgery, the field of gender medicine must interrogate and determine why the number of gender-distressed youth is exploding—and why so many more are adolescent females. While the Dutch authors note an unprecedented rise in adolescent females, they opine that this is because “in most Western cultures, it is more widely accepted for AFAB [assigned females at birth] to come out as trans men...” This is an unlikely explanation, supported by a single reference to a 2013 paper that posits a range of theories for the increasing number of females, only one of which speculates that “masculine behavior is subject to less social sanction than feminine behavior.” Many would agree that there is a greater acceptance of “tomboys” compared to feminine boys in modern societies. However, this would suggest that girls with masculine preferences should find it easier to fit in as they are, while feminine boys might choose to transition more frequently in order to make their presentation more socially acceptable.

While the authors accept that their explanation for the sharp rise in adolescent girls presenting with gender dysphoria may be inadequate, they cite a lack of competing valid hypotheses. Yet the well-documented phenomenon of “ peer contagion ” spreading through social circles, with a clear preponderance of females, for a wide range of conditions from eating disorders to self-harm , is not mentioned as a possible mechanism. In the context of gender, the theory of peer contagion has been provisionally termed “ROGD” and has been endorsed by growing numbers of clinicians and detransitioners .

A 2022 paper from the Amsterdam clinic studying the same cohort concluded that " although there may be different developmental [paths] in adolescents that lead to seeking gender-affirming medical care, our data do not allow us to conclude whether or not this suggested ‘ROGD’ subtype exists ." However, the authors appear to be discouraging the hypothesis, based on their finding that " there was gender nonconformity in childhood in older presenters, although less extreme than in the younger presenting group, which speaks against this suggested subtype ." This is not a robust explanation. Besides the questionable selection of age 14 to separate youth into "old presenting" vs "early presenting group" — both an arbitrary cutoff, and one that misses the onset of puberty for most females — this question relies on the self-report by gender-dysphoric youth. However, many teens' claims of  enduring and extreme gender non-conformity and transgender identity from early childhood on are contradicted by parental reports .

As teens learn of the requirement of long-lasting gender dysphoria to be eligible for medical treatments, there may be an increase in instances of youth amending their prior histories to more readily gain access to puberty blockers, cross-sex hormones, and surgery. The Dutch team observed this tendency as early as 2005 , reflecting on the possibility of both, “ an (unconscious) exaggeration of history if current feelings are not clear-cut, or a conscious effort to mislead the clinician. ” This phenomenon of knowing “ exactly what to say ” and importantly “ what NOT to say ” to facilitate access to “affirming” hormones has also been described by clinicians and parents . Researchers would be well-advised to scrutinize medical records for a prior diagnosis of childhood gender dysphoria or to look for other credible, objective evidence of lifelong gender distress, rather than accepting patients’ accounts at face value. Thus, the 2022 study's conclusion that "ROGD subtype likely does not exist," made largely based on the youths' self-report, is unreliable.

The scientific method requires progression from observations to hypothesis formation to hypothesis testing. Like all theories, the ROGD hypothesis must be subjected to rigorous testing, along with other competing hypotheses. However, when testing the ROGD hypothesis, it is important to test its actual key elements, rather than creating "straw-man" versions of what ROGD is in order to quickly refute it, as has been the case in many recent attempts to disparage or "disprove" it. 

Contrary to the study's assertions of having presented reliable long-term data that support ongoing medicalization, the growing voices of detransitioners (some of whom say they were treated at the Amsterdam clinic ), and preliminary patient-level outcome data from the Dutch clinicians themselves , signal problems. Even patients who transitioned under the strict version of the Dutch Protocol appear to have substantial reproductive regret, body shame, and sexual dysfunction. These preliminary findings , presented by the Dutch clinicians at the WPATH Symposium in late 2022, serve as a potent reminder that puberty blockers, cross-sex-hormones and surgery remain experimental treatments, with an unknown risk-benefit ratio.

We hope that the upcoming studies from the Amsterdam clinic will analyze all the available data and address the following key questions:

• How have the sex ratios of gender-dysphoric youth changed over the years?
• What percent of cases presenting in recent years have early-onset vs pubertal-onset of gender dysphoria (validated by medical chart reviews rather than self-report)?
• What percent of presenting cases are diagnosed as having gender dysphoria (for both types of presentations)?
• What is the rate of co-occurring mental illness and neurocognitive disorders such as autism or ADHD?
• How many of the diagnosed cases are deemed eligible to start medical treatment, and what are the eligibility criteria?
• How many of those eligible to start medical treatments do so, and how many choose alternatives such as psychotherapy or supportive watchful waiting?
• What are the rates of stopping treatment / detransitioning?
• What are the short- and long-term psychological and physical health outcomes of those who medically transitioned? Long-term outcomes of 55 participants in the seminal 2014 study  are of particular interest.
• How do the outcomes of medical transition compare to the outcomes of those who chose alternative treatments such as psychotherapy, or chose no treatments?

Until there is reliable evidence that the benefits of youth gender transition outweigh the risks, it is critical to limit medical interventions to rigorous clinical research settings, while continuing to develop noninvasive approaches to help the rapidly growing number of gender-dysphoric youth worldwide.

Note : This Spotlight has been updated since it was first posted on February 2, 2023. Among the many studies SEGM has analyzed, this has been one of the most challenging to decipher and analyze to date. We welcome dialogue and debate with the scientific community and the study authors about our interpretation of the trends reported.

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Vatican Document Casts Gender Change and Fluidity as Threat to Human Dignity

The statement is likely to be embraced by conservatives and stir consternation among L.G.B.T.Q. advocates who fear it will be used as a cudgel against transgender people.

By Jason Horowitz and Elisabetta Povoledo

Reporting from Rome

The Vatican on Monday issued a new document approved by Pope Francis stating that the church believes that gender fluidity and transition surgery, as well as surrogacy, amount to affronts to human dignity.

The sex a person is assigned at birth, the document argued, was an “irrevocable gift” from God and “any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception.” People who desire “a personal self-determination, as gender theory prescribes,” risk succumbing “to the age-old temptation to make oneself God.”

Regarding surrogacy, the document unequivocally stated the Roman Catholic Church’s opposition, whether the woman carrying a baby “is coerced into it or chooses to subject herself to it freely.” Surrogacy makes the child “a mere means subservient to the arbitrary gain or desire of others,” the Vatican said in the document, which also opposed in vitro fertilization.

The document was intended as a broad statement of the church’s view on human dignity, including the exploitation of the poor, migrants, women and vulnerable people. The Vatican acknowledged that it was touching on difficult issues, but said that in a time of great tumult, it was essential, and it hoped beneficial, for the church to restate its teachings on the centrality of human dignity.

Even if the church’s teachings on culture war issues that Francis has largely avoided are not necessarily new, their consolidation now was likely to be embraced by conservatives for their hard line against liberal ideas on gender and surrogacy.

The document, five years in the making, immediately generated deep consternation among advocates for L.G.B.T.Q. rights in the church, who fear it will be used against transgender people. That was so, they said, even as the document warned of “unjust discrimination” in countries where transgender people are imprisoned or face aggression, violence and sometimes death.

“The Vatican is again supporting and propagating ideas that lead to real physical harm to transgender, nonbinary and other L.G.B.T.Q.+ people,” said Francis DeBernardo, the executive director of New Ways Ministry, a Maryland-based group that advocates for gay Catholics, adding that the Vatican’s defense of human dignity excluded “the segment of the human population who are transgender, nonbinary or gender nonconforming.”

He said it presented an outdated theology based on physical appearance alone and was blind to “the growing reality that a person’s gender includes the psychological, social and spiritual aspects naturally present in their lives.”

The document, he said, showed a “stunning lack of awareness of the actual lives of transgender and nonbinary people.” Its authors ignored the transgender people who shared their experiences with the church, Mr. DeBernardo said, “cavalierly,” and incorrectly, dismissing them as a purely Western phenomenon.

Though the document is a clear setback for L.G.B.T.Q. people and their supporters, the Vatican took pains to strike a balance between protecting personal human dignity and clearly stating church teaching, a tightrope Francis has tried to walk in his more than 11 years as pope.

Francis has made it a hallmark of his papacy to meet with gay and transgender Catholics and has made it his mission to broadcast a message for a more open, and less judgmental, church. Just months ago, Francis upset more conservative corners of his church by explicitly allowing L.G.B.T.Q. Catholics to receive blessings from priests and by allowing transgender people to be baptized and act as godparents .

But he has refused to budge on the church rules and doctrine that many gay and transgender Catholics feel have alienated them, revealing the limits of his push for inclusivity.

“In terms of pastoral consequences,” Cardinal Víctor Manuel Fernández, who leads the Vatican’s office on doctrine, said in a news conference Monday, “the principle of welcoming all is clear in the words of Pope Francis.”

Francis, he said, has repeatedly said that “all, all, all” must be welcomed. “Even those who don’t agree with what the church teaches and who make different choices from those that the church says in its doctrine, must be welcomed,” he said, including “those who think differently on these themes of sexuality.”

But Francis’ words were one thing, and church doctrine another, Cardinal Fernández made clear, drawing a distinction between the document, which he said was of high doctrinal importance, as opposed to the recent statement allowing blessings for same-sex Catholics. The church teaches that “homosexual acts are intrinsically disordered.”

In an echo of the tension between the substance of church law and Francis’ style of a papal inclusivity, Cardinal Fernández said on Monday that perhaps the “intrinsically disordered” language should be modified to better reflect that the church’s message that homosexual acts could not produce life.

“It’s a very strong expression and it requires explanation,” he said. “Maybe we could find an expression that is even clearer to understand what we want to say.”

Though receptive to gay and transgender followers, the pope has also consistently expressed concern about what he calls “ideological colonization,” the notion that wealthy nations arrogantly impose views — whether on gender or surrogacy — on people and religious traditions that do not necessarily agree with them. The document said “gender theory plays a central role” in that vision and that its “scientific coherence is the subject of considerable debate among experts.”

Using “on the one hand” and “on the other hand,” language, the Vatican’s office on teaching and doctrine wrote that “it should be denounced as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation.”

“At the same time,” it continued, “the church highlights the definite critical issues present in gender theory.”

On Monday, Cardinal Fernández also struggled to reconcile the two seemingly dissonant views.

“I am shocked having read a text from some Catholics who said, ‘Bless this military government of our country that created these laws against homosexuals,’” Cardinal Fernández said on Monday. “I wanted to die reading that.”

But he went on to say that the Vatican document was itself not a call for decriminalization, but an affirmation of what the church believed. “We shall see the consequences,” he said, adding that the church would then see how to respond.

In his presentation, Cardinal Fernández described the long process of the drafting of a document on human dignity, “Infinite Dignity,” which began in March 2019, to take into account the “latest developments on the subject in academia and the ambivalent ways in which the concept is understood today.”

In 2023, Francis sent the document back with instructions to “highlight topics closely connected to the theme of dignity, such as poverty, the situation of migrants, violence against women, human trafficking, war, and other themes.” Francis signed off on the document on March 25.

The long road, Cardinal Fernández wrote, “reflects the gravity” of the process.

In the document, the Vatican embraced the “clear progress in understanding human dignity,” pointing to the “desire to eradicate racism, slavery, and the marginalization of women, children, the sick, and people with disabilities.”

But it said the church also sees “grave violations of that dignity,” including abortion, euthanasia, the death penalty, polygamy, torture, the exploitation of the poor and migrants, human trafficking and sex abuse, violence against women, capitalism’s inequality and terrorism.

The document expressed concern that eliminating sexual differences would undercut the family, and that a response “to what are at times understandable aspirations,” will become an absolute truth and ideology, and change how children are raised.

The document argued that changing sex put individualism before nature and that human dignity as a subject was often hijacked to “justify an arbitrary proliferation of new rights,” as if “the ability to express and realize every individual preference or subjective desire should be guaranteed.”

Cardinal Fernández on Monday said that a couple desperate to have a child should turn to adoption, rather than surrogacy or in vitro fertilization because those practices, he said, eroded human dignity writ large.

Individualistic thinking, the document argues, subjugates the universality of dignity to individual standards, concerned with “psycho-physical well-being” or “individual arbitrariness or social recognition.” By making dignity subjective, the Vatican argues, it becomes subject to “arbitrariness and power interests.”

Jason Horowitz is the Rome bureau chief for The Times, covering Italy, the Vatican, Greece and other parts of Southern Europe. More about Jason Horowitz

Elisabetta Povoledo is a reporter based in Rome, covering Italy, the Vatican and the culture of the region. She has been a journalist for 35 years. More about Elisabetta Povoledo

Treatment of adolescents with gender dysphoria in the Netherlands

Affiliation.

• 1 Department of Medical Psychology and Medical Social Work, VU University Medical Center, Amsterdam, the Netherlands. [email protected]
• PMID: 22051006
• DOI: 10.1016/j.chc.2011.08.001

In the Netherlands, gender dysphoric adolescents may be eligible for puberty suppression at age 12, subsequent cross-sex hormone treatment at age 16, and gender reassignment surgery at age 18. Initially, a thorough assessment is made of the gender dysphoria and vulnerabilities in functioning or circumstances. Psychological interventions and/or gender reassignment may be offered. Psychological interventions are offered if the adolescent needs to explore gender identity and treatment wishes, suffers from coexisting problems, or needs support and counseling during gender reassignment. Although more studies are necessary, this approach seems to contribute significantly to the well-being of gender dysphoric adolescents.

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• Homosexuality
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The Vatican says surrogacy and gender theory are 'grave threats' to human dignity

Jason DeRose

The crowd looks in direction of the window of the apostolic palace overlooking St. Peter's square during Pope Francis' prayer on April 1 in The Vatican. TizianaI Fabi/AFP via Getty Images hide caption

The crowd looks in direction of the window of the apostolic palace overlooking St. Peter's square during Pope Francis' prayer on April 1 in The Vatican.

The Vatican has released a new document calling poverty, war and the plight of migrants "threats to human dignity." But it also calls abortion, surrogacy and gender theory "grave threats" facing humanity today.

The document, titled " Infinite Dignity " says that each person's dignity comes from the love of the creator "who has imprinted the indelible features of his image on every person." This language is familiar to Christians accustomed to hearing that humans are all made in God's image.

The document goes on to say that this dignity is inalienable, beyond any circumstance or situation the person might encounter. Simply put, because a person exists, a human has intrinsic dignity.

"Infinite Dignity" details a long list of what it calls grave threats to that dignity, some of which might be expected given other Catholic teachings. It talks about the drama of poverty and how the unequal distribution of wealth denies humans their God-given dignity. It also describes war, the abuse of migrants, sexual abuse, violence against women, the marginalizing of people with disabilities, assisted suicide and abortion all as affronts to human dignity.

But then the document turns to other issues that have become more highly politicized in recent years: surrogacy, gender theory, and what it calls "sex change."

The pope wants surrogacy banned. Here's why one advocate says that's misguided

The document's framework holds that if a person is made in God's image, gender theory and gender reassignment surgery call into question why God would create a person with the wrong gender.

It says that the understanding of humanity as divided into two sexes — male and female — is biblical and deeply meaningful, especially in terms of procreation. Gender theory argues that a person's gender can be different from the sex that person was assigned at birth.

"Infinite Dignity" says the concept of human dignity can be misused to justify what it calls an "arbitrary proliferation of new rights," describing those, rather, as "individual preference" or "desire." That language is very similar to how conservatives often talk about being transgender as a choice, which is something major medical and psychological groups dispute.

The document makes a clear distinction between the issue of sexual orientation (whether a person is gay, lesbian or bisexual) and the issue of gender identity (whether a person's sex assigned at birth matches what that person understands his or her gender to be).

The document will be seen by some more conservative Catholic as a win after years of feeling embattled during Pope Francis's leadership. Just last year, the Vatican said priests could baptize transgender Catholics and allowed for priests to bless people in same-sex relationships .

Catholic Church works to explain what same-sex blessings are and are not

But many transgender Catholics and their families as well as more progressive Catholics are displeased with "Infinite Dignity."

Executive director of the LGBTQ Catholic group New Ways Ministry, Francis DeBernardo says of the document, "When it gets to the section on people who are transgender or non-binary, it doesn't apply the principles of human dignity to them."

New Ways Ministry's mission is, in part, to help pastors and religious teachers better understand gender identity and sexuality. It also fosters, "holiness and wholeness within the Catholic LGBTQ+ community."

DeBernardo argues "Infinite Dignity" does not live up to its own name. "In a sense, it's not infinite dignity," he says. "It's a very limited dignity that the church is offering."

He fears this document will be used to further persecute transgender people, and he thinks it will cause transgender Catholics and their families to leave the church.

The Vatican says priests can baptize transgender people

DeBernardo also worries the sections on gender theory and what it calls "sex change" will eclipse what he describes as the very good parts of the document on war, poverty and migrants.

The group Catholics for Choice, is also disappointed and calls into question how the document was created. "Yet again," said the group's president Jamie Manson in a written statement, "a group of all-male, celibate clergymen are telling women and gender-expansive people that their lived experiences are not real or valid."

Catholics for Choice advocates within the church on a variety of issues regarding sexual and reproductive health, including abortion rights. The group holds – and argues that Catholic teaching supports – people's individual consciences should be their guide in such decisions.

"It is clear to me that the women and trans people who continue to identify as Catholic — despite documents like this completely disregarding our experiences — only do so because of a deep love for our faith and its traditions," continues Manson in her statement. "It is devastating that our leaders do not offer the same respect and love in return."

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Thousands of children unsure of gender identity ‘let down by NHS’, report finds

Leading consultant paediatrician says unproven treatments and ‘toxicity’ of trans debate damaging outcomes

• Key findings

Thousands of vulnerable children questioning their gender identity have been let down by the NHS providing unproven treatments and by the “toxicity” of the trans debate, a landmark report has found.

The UK’s only NHS gender identity development service used puberty blockers and cross-sex hormones, which masculinise or feminise people’s appearances, despite “remarkably weak evidence” that they improve the wellbeing of young people and concern they may harm health, Dr Hilary Cass said.

Cass, a leading consultant paediatrician, stressed that her findings were not intended to undermine the validity of trans identities or challenge people’s right to transition, but rather to improve the care of the fast-growing number of children and young people with gender-related distress.

But she said this care was made even more difficult to provide by the polarised public debate, and the way in which opposing sides had “pointed to research to justify a position, regardless of the quality of the studies”.

“There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”

NHS England commissioned her inquiry in 2020 amid rising concern over the care provided by the Tavistock and Portman NHS mental health trust’s gender identity development services (Gids). It treated about 9,000 children and young people, with an average age at referral of 14, during 2009-2020.

Her inquiry has already led to NHS England shutting Gids, banning puberty blockers and switching to a new “holistic” model of care in which under-18s experiencing confusion about their gender identity will routinely receive psychological support rather than medical intervention.

“For most young people, a medical pathway will not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems,” said Cass, an ex-president of the Royal College of Paediatrics and Child Health .

The report recommends that all such young people should be screened to detect neurodevelopmental conditions, such as autism spectrum disorder or ADHD, and there should be an assessment of their mental health, because many who seek help with their gender identity also have anxiety or depression, for example.

Some transgender adults “are leading positive and successful lives, and feeling empowered by having made the decision to transition”, Cass said. However, “I have spoken to people who have detransitioned, some of whom deeply regret their earlier decisions”, she added.

“While some young people may feel an urgency to transition, young adults looking at their younger selves would often advise slowing down,” the report says.

“Some of the young adults said to us they wished they’d known when they were younger that there were more ways of being trans than just a binary medical transition,” Cass told the Guardian.

In her report, she outlines how the Tavistock trust began prescribing puberty blockers much more widely in 2014, despite a lack of evidence that they helped.

In an interview with the Guardian, Cass said that gender-questioning children have been “let down” by the NHS, health professionals and a “woeful” lack of evidence about what treatment works.

“One of the things that has let them down is that the toxicity of the debate has been so great that people have become afraid to work in this area.

“A majority of people have been so afraid, because of the lack of guidance, lack of research, and how polarised this is that they’ve passed [patients] straight on to Gids.”

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Wes Streeting, the shadow health secretary, said: “Today’s report must provide a watershed moment for the NHS’s gender identity services. Children’s healthcare should always be led by evidence and children’s welfare, free from culture wars. Clinicians and parents alike want the best for children at this crucial developmental stage. This report provides an evidence-led framework to deliver that.”

Sallie Baxendale, a professor of clinical neuropsychology at University College London, said that Cass’s report “has laid bare the worrying lack of evidence to support the treatments that were prescribed by NHS clinicians to children with gender distress for over a decade.

“These treatments inflicted significant harm on some of the most vulnerable children in our society.

“Exceptionalism often lies at the heart of medical scandals when services go rogue and start to operate outside the normal parameters of clinical practice.”

However, Dr Aidan Kelly, a clinical psychologist specialising in gender who left the Tavistock in 2021, said the NHS was struggling to recruit skilled and experienced people to run the planned eight clinics that will provide the new, broader model of care.

“Although Gids wasn’t perfect, we had a service with a history and expertise. There were things that needed to change but at least holding on to the knowledge that was accrued over time would have made sense to me,” he said.

Disputing many of Cass’s findings he said that a recent German review had found that puberty blockers were safe and effective. NHS England’s switch to a wholly different way of treating young people confused about their gender identity has left England “out of step with the rest of the world”, he added.

Cass disclosed in the report that six of the NHS’s seven specialist gender services in England for adults had “thwarted” an attempt by the University of York, at her request, to obtain and analyse the health outcomes of people who had been treated by Gids in order to improve future care.

This refusal to cooperate “was coordinated”, she told the Guardian. “It seemed to me to be ideologically-driven.”. Clinicians caring for those with gender-related distress are very divided on how best to do that, she acknowledges in the report.

It also documents how Gids experienced both an explosion in demand for its service from 2010, and also a huge increase in the number of birth-registered females, in a reversal of the pattern of referrals.

Cass said that “online influencers” had played a key role in fuelling confusion among young people about their gender identity and what they needed to do to change it.

“We haven’t done a comprehensive search but certainly when we were told about particular influencers I followed some of those up. Some of them give them very unbalanced information.

“And some of them [young people] were told that parents would not understand so that they had to actively separate from their parents or distance their parents. All the evidence shows that family support is really key to people’s well being. So there was really some dangerous influencing going on,” she said.

Rishi Sunak said: “We simply do not know the long-term impacts of medical treatment or social transitioning on them, and we should therefore exercise extreme caution.

“We acted swiftly on Dr Cass’s interim report to make changes in schools and our NHS, providing comprehensive guidance for schools and stopping the routine use of puberty blockers, and we will continue to ensure we take the right steps to protect young people.”

This article was amended on 10 April 2024 to refer to ADHD as a neurodevelopmental condition.

• Transgender

More on this story

Veteran trans campaigner: ‘Cass review has potential for positive change’

Cass review must be used as ‘watershed moment’ for NHS gender services, says Streeting

‘This isn’t how good scientific debate happens’: academics on culture of fear in gender medicine research

Five thousand children with gender-related distress awaiting NHS care in England

Ban on children’s puberty blockers to be enforced in private sector in England

What Cass review says about surge in children seeking gender services

Adult transgender clinics in England face inquiry into patient care

‘Children are being used as a football’: Hilary Cass on her review of gender identity services

Review of gender services has major implications for mental health services

What are the key findings of the NHS gender identity review?

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Vatican says sex reassignment surgery, surrogacy and gender theory threaten human 'dignity'

The Vatican has declared gender confirmation operations and surrogacy as grave threats to human "dignity", putting them on par with abortion and euthanasia as practices that violate God's plan for human life.

The Vatican's doctrine office on Monday published a 20-page declaration titled Infinite Dignity that was in the works for the past five years.

It was approved for publication by Pope Francis on March 25 after substantial revision in recent months.

In its most eagerly anticipated section, the Vatican reiterated its rejection of "gender theory" or the idea that one's gender can be "a self-determination".

It said God created man and woman as biologically different, separate beings, and said they must not tinker with that plan or try to "make oneself God".

"It follows that any sex-change intervention, as a rule, risks threatening the unique dignity the person has received from the moment of conception," the document said.

It distinguished between transitioning surgeries, which it rejected, and "genital abnormalities" that are present at birth or that develop later. Those abnormalities can be "resolved" with the help of health care professionals, it said.

The document's existence, rumoured since 2019, was confirmed in recent weeks by the new prefect of the Dicastery for the Doctrine of the Faith, Argentine Cardinal Víctor Manuel Fernández, a close confidante of Pope Francis.

He had cast it as something of a nod to conservatives after he authored a more explosive document approving blessings for same-sex couples that sparked criticism from conservative bishops around the world, especially in Africa.

While the new document rejected gender theory, it took pointed aim at countries — including many in Africa — that criminalise homosexuality.

It echoed Pope Francis's assertion in a 2023 interview that "being homosexual is not a crime", making the assertion now part of the Vatican's doctrinal teaching.

It denounced "as contrary to human dignity the fact that, in some places, not a few people are imprisoned, tortured, and even deprived of the good of life solely because of their sexual orientation".

The document restated well-known Catholic doctrine opposing abortion and euthanasia.

It also added to the list some of Pope Francis's main concerns as pope: the threats to human dignity posed by poverty, war, human trafficking and forced migration.

A child's right to 'a fully human origin'

In a newly articulated position, the declaration said surrogacy violated both the dignity of the surrogate mother and the child.

While much attention on surrogacy has focused on possible exploitation of poor women as surrogates, the Vatican document focuses more on the resulting child.

"The child has the right to have a fully human (and not artificially induced) origin and to receive the gift of a life that manifests both the dignity of the giver and that of the receiver," the document said.

"Considering this, the legitimate desire to have a child cannot be transformed into a 'right to a child' that fails to respect the dignity of that child as the recipient of the gift of life."

The Vatican published its most articulated position on gender in 2019, when the Congregation for Catholic Education rejected the idea that people can choose or change their genders.

It insisted on the complementary nature of biologically male and female sex organs to create new life.

Gender fluidity was described as a symptom of the "confused concept of freedom" and "momentary desires" that characterise post-modern culture.

The new document from the more authoritative Dicastery for the Doctrine of the Faith quoted from that 2019 education document but tempered the tone.

Significantly, it did not repurpose the 1986 language of a previous doctrinal document saying that homosexual people deserve to be treated with dignity and respect but that homosexual actions are "intrinsically disordered".

Francis has made reaching out to LGBTQ+ people a hallmark of his papacy, ministering to trans Catholics and insisting that the Catholic Church must welcome all children of God.

But he has also denounced "gender theory" as the "worst danger" facing humanity today, describing it as an "ugly ideology" that threatens to cancel out God-given differences between man and woman.

"It needs to be emphasised that biological sex and the sociocultural role of sex (gender) can be distinguished but not separated," the new document said.

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Belgium and Netherlands call for puberty blocker restrictions following Cass Review

Belgium and the Netherlands have become the latest countries to question the use of puberty blockers on children after the Cass Review warned of a lack of research on the gender treatment’s long-term effects.

Britain has become the fifth European nation to restrict the use of the drug to those under 18 after initially making them part of their gender treatments.

Their use was based on the “Dutch protocol” - the term used for the practice pioneered in the Netherlands in 1998 and copied around the world, of treating gender dysphoric youth using puberty blockers.

The NHS stopped prescribing the drug , which is meant to curb the trauma of a body maturing into a gender that the patient does not identify with this month.

In Belgium, doctors have called for gender treatment rules to be changed.

Research into impact

“In our opinion, Belgium must reform gender care in children and adolescents following the example of Sweden and Finland, where hormones are regarded as the last resort,” the report by three paediatricians and psychiatrists in Leuven said.

Figures from the Netherlands and the United Kingdom show that more than 95 per cent of individuals who initiated puberty inhibition continue with gender-affirming treatments,” the report by P Vankrunkelsven P, K Casteels K and J De Vleminck said.

“However, when young people with gender dysphoria go through their natural puberty, these feelings will only persist in about 15 per cent.”

The report was published after a 60 per cent rise in the number of Belgium teenagers taking the blockers to stop the development of their bodies. In 2022, 684 people between the ages of nine and 17 were prescribed the drug compared to 432 in 2019, the De Morgen newspaper reported in 2019.

Pressure is also building in the neighbouring Netherlands to look again at their use. The parliament has ordered research into the impact of puberty blockers on adolescent’s physical and mental health.

Dutch protocol

The Telegraph understands that the Amsterdam Center of Expertise on Gender Dysphoria, where the protocol originated, is set to make a statement on the use of puberty blockers next week.

“I too thought that the Dutch gender care was very careful and evidence-based. But now I don’t think that any more,” Jilles Smids, a postdoctoral researcher in medical ethics at Erasmus University in the Netherlands, told The Atlantic.

Attitudes in the Netherlands have hardened against trans rights, with a bill to make it easier for people to legally change their gender being held up in parliament.

The Cass Review said that the NHS had moved away from the restrictions of the original Dutch protocol, and researchers in Belgium have also demanded those restrictions be reintroduced.

Belgium is regarded as one of the most trans-friendly countries in Europe. A minister in the government is transgender and people have been able to legally change their gender without a medical certificate for the past five years.

But the hard-Right Vlaams Belang party is currently leading the polls ahead of national and European elections in June.

It has called for “hormone therapy and sex surgery to be halted for underage patients until clear and concrete research has been carried out.”

‘Greatest ethical scandals’

In March, a report in France described sex reassignment in minors as potentially “one of the greatest ethical scandals in the history of medicine”.

Conservative French senators plan to introduce a bill to ban gender transition treatments for under-18s.

On Monday, the Vatican’s doctrine office published a report that branded gender surgery a grave violation of human dignity on a par with euthanasia and abortion.

Finland was one of the first countries to adopt the Dutch protocol but realised many of its patients did not meet the Protocol’s strict eligibility requirements for the drugs.

It restricted the treatment in 2020 and recommended psychotherapy as the primary care.

Sweden restricted hormone treatments to “exceptional cases” two years later. In December, Norwegian authorities designated the medicine as “under trial”, which means they will only be prescribed to adolescents in clinical trials.

Denmark is finalising new guidelines limiting hormone treatments to teenagers who have had dysphoria since early childhood.

In 2020, Hungary passed a law banning gender changes on legal documents.

“The import and the use of these hormone products are not banned, but subject to case by case approval, however, it is certain that no authority would approve such an application for people under 18,“ a spokesperson told The Telegraph.

In August, Russia criminalised all gender reassignment surgery and hormone treatments.

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