When the American tide started turning against social and medical affirmation of gender confusion in children, some observers blamed the backlash on U.S. providers’ failure to follow clinical standards developed in the Netherlands in the 1990s, which discouraged any form of transition before puberty or in adolescents without long-term confusion.

The divergence between the so-called Dutch protocol and its American knockoff, which affirmed confusion early and often regardless of concurrent mental health problems and social dynamics, was the throughline of the New York Times podcast The Protocol and cited by critics of social transitioning, which may bias children to persist in otherwise fleeting confusion.

The scientific underpinnings of the Dutch protocol are now facing serious academic scrutiny, with political ramifications in the Netherlands, while stateside the Biden administration’s politicization of gender-identity research has been exposed again.

“Three decades of ‘Dutch Protocol’ research has not produced reliable evidence,” says the May 30 paper in the Taylor & Francis publication European Journal of Developmental Psychology, rebutting a Feb. 23 review in the same journal that claimed research has supplied “far more confidence” in medicalized transitions for minors than when the protocol started.

It was written by Baylor Medicine psychiatrist Kathleen McDeavitt, an author of the 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, whose research was cited in the review, several of whose authors are associated with SEGM.

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,” Manhattan Institute senior fellow Leor Sapir summarized. He’s another author of the HHS review.

Dutch Member of Parliament Diederik van Dijk submitted 17 written questions to Health, Welfare and Sport Minister Sophie Hermans, in response to the journal paper.

As translated by Google, van Dijk asked whether Hermans agrees that the “methodological basis” for giving children puberty blockers and cross-sex hormones is “highly questionable,” why the country hasn’t followed Finland, Sweden and the U.K. in pulling back on such care for kids and whether the paper will be included in the Health Council’s related study.

“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.

He posed several questions related to informed consent for children seeking care and their parents, including “uncertainty surrounding the expected mental health benefits,” known risks such as infertility and the lack of evidence that “puberty blockers and hormone treatments reduce suicidality or depression,” which a U.S. researcher buried for years.

McDeavitt and Cohn’s European Journal of Developmental Psychology paper says Amsterdam University Medical Center’s Center of Expertise on Gender Dysphoria, which developed the Dutch protocol, judged the blocker, hormone and surgery regimen for youth a success based on three decades of studies that lacked “methodologically robust” designs.

Most of the studies the center authors reviewed for their February “narrative review,” which “comprise a large part of the evidence in this field,” have been “formally assessed by one or more high-quality” systematic reviews, the rebuttal says.

Those reviews identified multiple methodological problems: “lack of long-term follow-up” to appraise outcomes such as cardiovascular disease risk and “treatment regret,” no suitable comparison groups, “use of surrogate outcome measures,” low follow-up rates and “lack of analytic methods that adequately adjusted for confounding variables.”

No studies used randomized controlled trials, the gold standard for research, the paper says. Two of them on mental health outcomes, “considered to be the evidentiary foundation of the field,” reported data on the first 70 patients given blockers, approved for hormones after psychological assessment, then assessed again after surgeries.

Mislabeled as “prospective,” the studies were “susceptible to selection bias from their inception” because the initial analysis excluded patients who “needed extended psychological evaluation” or didn’t continue from blockers to hormones, while the final analysis excluded another five who quit treatment, developed “uncontrolled diabetes,” became severely obese or died.

While the center authors concluded that “endocrine and surgical interventions” had improved the “psychological functioning” of youth who sought gender transitions “from early puberty on,” they stacked the deck to reach that result, the critical review says.

Their patients “were required to be psychologically stable at baseline in order to commence treatment,” they had incomplete data for nearly half the patients on some measures, and the confounders were massive: “regular, frequent psychotherapy and psychosocial support” through the center for all patients.

“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 “measurement scales were switched between different time points” in the post-hormones and surgery study, casting doubt on the center authors’ claim that body image improved and gender dysphoria had resolved, the new paper says. This switch wasn’t noticed in systematic reviews, making it likely the “reviewers actually underestimated the methodological problems.”

The primary error in the narrative review is that the center authors “make definitive statements that cannot be supported by the methodologies of the included studies” and that it “fundamentally misrepresents” the center’s research “as having historically employed a methodical, stepwise approach,” McDeavitt and Cohn wrote.

Two years after then-Assistant Secretary for Health Rachel Levine got caught demanding the removal of age minimums from an update to international transgender medical standards, The Daily Wire “unearthed” Biden administration emails showing it ignored scientific objections to its claim that “family rejection” explains the abundance of LGBTQ kids in foster care.

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,” to justify its proposed regulation threatening funding for states that don’t 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.” Her research on LGBT youth in foster care found most “entered care before they were teens,” so it’s unlikely their sexual and gender minority identities were “especially salient.”

Despite Wilson warning Kruse that a federally funded study on the number of 12-21 year-olds in foster care who identify as “LGBTQ+” – nearly a third – didn’t support the “family rejection” explanation, the proposed rulemaking a month later prominently cited the study as evidence for the family-rejection theory. Wilson told The Daily Wire she stood by her objection.

A federal judge blocked the final regulation a year ago on the basis that it exceeded HHS authority under the Administrative Procedure Act, soon followed by the Trump administration accepting a final judgment to rescind the regulation.

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