Debate › Ethics · Last reviewed 2026-05-16
Ethical criticism
Summary
Ethical criticism of the Dutch Protocol focuses on (i) the capacity of minors to consent to interventions whose long-term effects are partly unknown, (ii) the framing of GnRHa as "fully reversible" diagnostic time, (iii) loss of fertility and sexual function, and (iv) the balance between autonomy and protection in paediatric medicine. See also /protocol/informed-consent/.
1. Capacity
The core question — can adolescents aged 12–16 competently consent to treatment with partly unknown long-term effects — is central in both ethical and legal literature. Levine et al. (2022) argue that informed consent is in practice not possible when essential outcome information is missing.1 See also /debate/legal-cases/.
2. "Diagnostic space" as a concept
The original argument that GnRHa creates "diagnostic time" has been criticised by various authors: GnRHa treatment functionally already starts gender transition, and the continuation rates to cross-sex hormones (≥ 96% in most studies) suggest that the "diagnostic" phase is in practice not very optional.2 See /protocol/the-three-phases/ for the phase structure, and /studies/follow-up-studies-overview/ for continuation data.
3. Fertility and sexual function
GnRHa directly followed by CSH without prior pubertal maturation leads almost certainly to infertility and may lead to limited development of sexual function. Whether an adolescent of 13–16 years can sufficiently grasp the implications of this is a recurring ethical concern — see also /evaluations/wpath-files-2024/ where internal discussions between clinicians on this point are documented.
See also
- People register — Levine, Hughes, Anderson.
- International comparison.
- Timeline.
- Informed consent and assent — WGBO framework and information duty.
- The three phases — the phase structure to which "diagnostic space" is linked.
- Age criteria — the original age thresholds (12, 16, 18).
- Levine — critiques — arguments on validity of consent.
- WPATH Files (2024) — internal doubts among clinicians.
- Legal cases — legal context (Bell, Skrmetti).
- Scientific criticism — methodological objections.
- FAQ · Glossary · For journalists.
Footnotes
- Levine SB, Abbruzzese E, Mason JW. J Sex Marital Ther. 2022;48(7):706–27.
- van der Loos MATC, et al. Continuation of gender-affirming hormones in adolescents and young adults. Lancet Child Adolesc Health. 2022;6(12):869–75.