Dutch Protocol's Defender Says The Quiet Part Out Loud
De Vries Proposes a New Metric for Success That Prioritizes Ideology Over Ethics
Annelou L.C. de Vries, child psychiatrist, co-architect of the influential Dutch Protocol and a co-author of the WPATH guidelines for adolescent transgender care seems to be “saying the quiet part out loud” about gender-affirming medical treatment in a new article she penned with several colleagues from the Center of Expertise on Gender Dysphoria in Amsterdam. Titled “Gender-affirming medical treatment for adolescents: a critical reflection on 'effective' treatment outcomes,” the article was published in BMC Medical Ethics. It acknowledges the evidential shortcomings of the protocol de Vries helped pioneer amidst growing public and professional scrutiny over gender-affirming medical treatment (GAMT) for minors.
In a novel move to address the lack of evidence of effectiveness, de Vries and company propose a radical shift: They advocate abandoning traditional medical metrics of effectiveness in favor of assessing these treatments through a lens of gender theory. While the article was technically written by two Phd. candidates, de Vries signs off on and takes responsibility for all aspects of the paper.
Episode 5 of the Informed Dissent Podcast—a weekly news podcast offering dispatches from the gender culture war with Ben Appel, Cori Cohn, Lisa Selin Davis, Eliza Montegreen and Jamie Reed—breaks down the article’s implications with precision.
The Dutch Protocol, once heralded as a breakthrough in transgender healthcare, was designed for a select group of youth exhibiting persistent early-onset gender dysphoria. However, it has long been under fire for its methodological flaws including: lack of control groups, short follow-up periods, and an absence of long-term outcome data. Critics like the Society for Evidence-based Gender Medicine and academic Michael Biggs have questioned the scientific basis and ethical implications of the protocol, with Biggs notably criticizing the work’s omission of the connection between homosexuality and gender dysphoria.
De Vries has attempted to stand up for the work such as when she appeared on the Gender a Wider Lens podcast. Despite many critiques and this article’s admission of the lack of evidence, this isn't a retraction of her support for GAMT but an attempt to redefine what “effectiveness” means in the context of transgender health care for minors.
In order to redefine treatment success, de Vries et al. introduce concepts such as “gender congruence satisfaction,” meant to capture the subjective experience of feeling ‘right’ in one's gender, and “identity validation metrics,” which might include measures of self-esteem, social acceptance, or the degree to which one feels recognized or validated by others in their affirmed gender. These terms emphasize the subjective experience of gender identity affirmation over traditional health outcomes. They propose, in essence, that the true measure of success in GAMT should not be how well these treatments align with medical metrics but how effectively they validate and affirm an individual’s gender identity. This is a departure from evidence-based medical practice, where treatments are traditionally evaluated based on their impact on health, function, and quality of life.
The article is rife with paradoxes. The authors refer to the historical pathologization of transgender experiences, where identities were medicalized and stigmatized. Yet, in advocating for de-pathologization, they overlook that adolescents need medical diagnoses like gender dysphoria to access insurance and treatment. Furthermore, although many trans-self-identifying adolescents don’t understand this: By going through gender-affirming medical treatment they will become lifelong patients. This contradiction underscores the inherent medicalization of transgender identity, even as the article promotes destigmatization, resulting in a complex narrative where destigmatization is paradoxically achieved through further medicalization.
In addition, the article argues strongly against using “avoiding regret” as a consideration in deciding whether to proceed with transitioning. Although autonomy is a strong theme in any argument for GAMT in minors, the paradox here lies in the fact that denying adolescents the opportunity to consider regret undermines their autonomy and decision-making capacity. Autonomy, particularly in medical ethics, involves making choices with full awareness of the potential outcomes, including negative ones. By shielding them from these considerations, the approach paradoxically restricts their ability to make a truly autonomous decision.
While the authors acknowledge the dearth of traditional evidence supporting the effectiveness of GAMT, they conspicuously omit or downplay the critical discussion on the substantial health risks these treatments pose to minors. Puberty blockers, while reversible in theory, have potential long-term effects on bone density, brain development, and fertility. Cross-sex hormones introduce risks of cardiovascular issues, metabolic changes, and significant mental health implications, including the potential for increased depression or anxiety if underlying conditions are not addressed. Surgical interventions, especially when performed on minors, carry the risk of surgical complications, loss of sexual function, and the psychological weight of regret or dissatisfaction with outcomes. Their superficial treatment of risks is particularly jarring in an article published in an ethics journal, where one would expect a rigorous examination of the ethical implications of any medical practice.
De Vries’ dual role as both a researcher and practitioner of GAMT introduces a clear conflict of interest. Her advocacy for treatments she admits have insufficient evidence raises ethical questions about the objectivity of her recommendations. Plus, this most recent move toward embracing gender theory as a basis for judging the effectiveness of GAMT raises the question of whether these procedures were ever about improving health in the first place. Indeed, a central component of the Dutch Protocol was the early introduction of puberty suppression using gonadotropin-releasing hormone agonists (GnRHa) in order for patients to better pass as the opposite sex as adults. These drugs, as we now know, carry significant risks.
This article by de Vries et al. appears to signal a future where medical diagnoses for transgender treatments in minors might become obsolete, suggesting to both advocates and the medical community a shift toward a model where identity affirmation, rather than medical necessity, dictates care. This could significantly reshape policy, insurance frameworks, and cultural perceptions of GAMT.
While de Vries and company acknowledge the evidential gaps for these procedures, their proposal to redefine success through a gender theory lens rather than through traditional medical outcomes marks a significant departure from conventional medical ethics. Ironically published in a medical ethics journal, this approach not only raises critical questions about the ethical foundation of GAMT for minors but also risks prioritizing ideological objectives over health outcomes. The threat of such a shift demands an urgent and critical return to evidence-based, ethical medical practices, where the health and well-being of minors is given paramount consideration, ensuring that the care they receive is based on solid scientific evidence rather than ideological narratives.
Just like cosmetic surgeries that are not medically necessary, body modification procedures should not be covered by medical insurance.
i wonder if the whole thing eventually will be excised from medicine to instead create a new culture of body modification focused on personal freedom. If that happens, i don’t look forward to the gaslighting that i predict. it’s already begun actually with more and more narratives of people claiming trans surgeries were never supposed to make them feel better, they just need them anyway.