A new academic paper says decades of Dutch Protocol research have not produced reliable evidence for medicalized gender-transition procedures in minors, while separate Biden administration emails showed internal objections to a foster care rule’s “family rejection” rationale.
By yourNEWS Media Newsroom
A new academic critique is challenging the research foundation behind the Dutch Protocol, the model developed in the Netherlands in the 1990s for treating minors with gender dysphoria, as separate records show Biden administration officials relied on a disputed “family rejection” theory while advancing a foster care regulation tied to gender identity.
The controversy centers on whether decades of studies from the Amsterdam University Medical Center’s Center of Expertise on Gender Dysphoria provide reliable evidence for the use of puberty blockers, cross-sex hormones and surgeries in minors. The debate comes after critics of the U.S. approach to pediatric gender medicine argued that American providers departed from the more restrictive Dutch model, which discouraged any transition before puberty and limited adolescent interventions to cases involving long-term gender dysphoria.
That split between the Dutch approach and the U.S. model was discussed in a podcast episode, explored in The New York Times’ “The Protocol” and cited by critics who argue that social transition may contribute to persistence in children whose distress otherwise may not continue.
The new challenge to the Dutch research was outlined in a May 30 paper in the Taylor & Francis publication European Journal of Developmental Psychology. The paper responded to a Feb. 23 review in the same journal that said the evidence base now provides “far more confidence” in medicalized gender transitions for minors than existed when the protocol began.
The May 30 paper was written by Baylor Medicine psychiatrist Kathleen McDeavitt, who also authored a Department of Health and Human Services-commissioned systematic review of so-called gender-affirming care for minors, and Jay Cohn of the Society for Evidence-Based Gender Medicine. Cohn’s research was cited in the HHS review, which included several authors associated with SEGM.
The paper said “Three decades of ‘Dutch Protocol’ research has not produced reliable evidence,” according to the authors.
Manhattan Institute senior fellow Leor Sapir, another author of the HHS review, said the paper “chronicles failure of Dutch clinicians to respond scientifically and appropriately to problems of evidence from their own clinic” and “documents how the Dutch (and others) responded by shifting the rationales for treatment,” according to his X post. Sapir’s commentary was also displayed in an embedded X post.
The paper has already drawn political attention in the Netherlands. Dutch Member of Parliament Diederik van Dijk submitted 17 written questions to Health, Welfare and Sport Minister Sophie Hermans in response to the journal article.
According to a Google translation, van Dijk asked whether Hermans agreed that the “methodological basis” for giving children puberty blockers and cross-sex hormones is “highly questionable.” He also asked why the Netherlands has not followed Finland, Sweden and the United Kingdom in scaling back such treatments for children, and whether the new paper will be included in the Health Council’s related review.
“Is it true that in the scientific study underlying the Dutch Protocol, a male patient died as a direct result of complications following colovaginoplasty [making an artificial vagina from a segment of colon], which had to be performed because of underdevelopment of the penis and scrotum due to the administered puberty blockers?” van Dijk asked.
Van Dijk also raised questions about informed consent for minors and parents, including the “uncertainty surrounding the expected mental health benefits,” risks such as infertility and the lack of evidence that “puberty blockers and hormone treatments reduce suicidality or depression.” The issue of suicide-related evidence was also raised in a separate report about a U.S. researcher accused of withholding findings for years, and was referenced in another embedded X post.
McDeavitt and Cohn argued that the Amsterdam center relied on three decades of studies that lacked “methodologically robust” designs while presenting the youth regimen of blockers, hormones and surgery as successful. The authors said most of the studies cited in the February narrative review, which they said “comprise a large part of the evidence in this field,” have already been assessed by high-quality systematic reviews.
Those reviews, according to the rebuttal, identified major limitations, including “lack of long-term follow-up” to evaluate outcomes such as cardiovascular disease risk and “treatment regret,” lack of proper comparison groups, “use of surrogate outcome measures,” low follow-up rates and inadequate methods for addressing confounding variables.
The paper also said none of the studies used randomized controlled trials, widely considered the strongest form of clinical research. Two studies on mental health outcomes, described in the paper as the foundation of the field’s evidence, involved the first 70 patients who received puberty blockers, were later approved for hormones after psychological evaluation and were then assessed after surgeries.
McDeavitt and Cohn said those studies were mislabeled as “prospective” and were vulnerable to selection bias from the beginning. They said the early analysis excluded patients who needed extended psychological evaluation or did not continue from blockers to hormones. The final analysis, the authors said, excluded five additional patients who stopped treatment, developed “uncontrolled diabetes,” became severely obese or died.
The authors said the center’s conclusions about improved “psychological functioning” after “endocrine and surgical interventions” did not account for important factors. Patients had to be psychologically stable before treatment began, data were missing for nearly half of patients on some measures, and all patients received “regular, frequent psychotherapy and psychosocial support” from the center, creating a major confounding variable.
“Improvements were not seen in all mental health outcome measures, and in those that did improve, the improvements were small and of unclear clinical significance,” McDeavitt and Cohn wrote.
The paper also said researchers switched “measurement scales” between time points in the post-hormone and surgery study, weakening claims that body image improved and gender dysphoria resolved. McDeavitt and Cohn said the switch was not caught by systematic reviews, meaning reviewers likely “underestimated the methodological problems.”
The rebuttal’s central criticism was that the February narrative review made claims that the research methods could not support. McDeavitt and Cohn wrote that the review “fundamentally misrepresents” the center’s work “as having historically employed a methodical, stepwise approach.” The concerns were also highlighted in additional embedded X posts.
The research dispute emerged alongside a separate controversy over Biden administration handling of gender-identity policy in foster care. Two years after then-Assistant Secretary for Health Rachel Levine was reported to have demanded removal of age minimums from an update to international transgender medical standards, The Daily Wire reported that administration emails showed officials moved ahead with a foster care rule despite scientific objections to the claim that “family rejection” explains why LGBTQ children are overrepresented in foster care.
According to the reported emails, Administration for Children and Families senior adviser for LGBTQI+ initiatives Julie Kruse asked transgender activists in 2024 for “data on why LGBTQI+ children and youth are overrepresented in child welfare.” The information was sought as the administration worked to justify a proposed regulation that threatened federal funding for states that did not agree to affirm a child’s “LGBTQI+” identity in foster placements.
UCLA social welfare professor Bianca Wilson responded that no known data supported “the go-to explanation of ‘family rejection’ that is often adopted by queer organizations.” Wilson said her research on LGBT youth in foster care found most “entered care before they were teens,” making it unlikely that their sexual and gender minority identities were “especially salient” at the time they entered the system.
Wilson also warned Kruse that a federally funded study finding that nearly one-third of foster youth ages 12 to 21 identified as “LGBTQ+” did not support the family-rejection theory. A month later, the proposed rulemaking cited the study as evidence for that theory. Wilson told The Daily Wire she stood by her objection.
The final foster care regulation was later blocked by a federal judge, who found that it exceeded HHS authority under the Administrative Procedure Act. The Trump administration later accepted a final judgment to rescind the regulation.
Together, the Dutch Protocol critique and the foster care emails have renewed scrutiny of how medical research and federal policy have been used in disputes over gender identity, minors and state authority. The new journal paper argues that the evidence behind medical interventions for minors is weaker than Dutch protocol defenders have claimed, while the foster care documents show federal officials relied on a contested explanation even after a researcher warned that the data did not support it.
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