Dossier · Legal analysis · 2026-05-24
Those who operate today may answer in court tomorrow
Why Dutch physicians who continue gender-affirming medical treatment on minors stand on increasingly thin legal ice — a warning and an analysis.
Core
Since 2020 the international evidence base for puberty blockers and cross-sex hormones in minors has been formally downgraded in four Western countries (Finland, Sweden, Denmark, the United Kingdom). The Cass Review (April 2024) confirmed this. In December 2024 a research group from Amsterdam UMC around Vrouenraets acknowledged in BMC Medical Ethics that the empirical underpinning for effectiveness falls short, and proposed shifting the justification framework toward autonomy. For Dutch physicians, this changes the legal reality: "I followed the guideline" holds up less and less as a defense.
A turning point physicians cannot ignore
In April 2024 the British pediatrician Hilary Cass published her final report on medical care for children and young people with gender dysphoria.1 The conclusion: the scientific basis for puberty blockers and cross-sex hormones in minors is weak. Earlier, Sweden, Finland and Denmark had already tightened policy. NHS England stopped routinely prescribing puberty blockers. In the United States dozens of civil cases and class actions against clinics and clinicians are pending.
The Netherlands — the country where the Dutch Protocol was developed — is moving slowly. In December 2024 a research group at Amsterdam UMC, including the head clinician of the Dutch gender clinic, published an article in BMC Medical Ethics in which they acknowledged that the empirical underpinning for the effectiveness of these treatments falls short.2 Their proposal: release the requirement of demonstrated effectiveness and justify the treatments going forward through autonomy and personal preference, analogous to abortion and contraception.
From a legal standpoint, that is a far-reaching proposal. It amounts to clinicians themselves acknowledging that they can no longer defend their care along the usual medico-scientific yardstick. For physicians who continue these treatments, this opens a legal perspective that has barely been thought through in the Netherlands — but that is coming.
The timeline of the turning point
The Dutch Supreme Court (Hoge Raad) has repeatedly held that a clinical guideline does not provide automatic exoneration.3 When the science moves forward and there are substantial international signals that a guideline is contested, an independent duty arises for the individual practitioner to take note of that development. The decisive question becomes: from when on should a reasonably competent colleague have known that the evidence base was wavering?
- 2020 — Finland is the first Western country to revise its minor-care guideline via COHERE: psychotherapy becomes first line, medical treatment exceptional.4
- 2020 — NICE (UK) publishes systematic reviews rating the evidence quality for puberty blockers and cross-sex hormones as very low.5
- 2020 — The British High Court rules in Bell v Tavistock that it is "highly unlikely" that children under sixteen are competent to consent to puberty blockers (overturned in 2021 on procedural grounds, not on the substance).6
- 2022 — Sweden (SBU/Socialstyrelsen) restricts puberty blockers and cross-sex hormones in minors to research settings.7
- 2023 — Denmark imposes restrictions.
- 2024 — The Cass Review appears: 388 pages of research, commissioned by NHS England.1
- 2024 — Vrouenraets et al. (Amsterdam UMC) acknowledge in BMC Medical Ethics that empirical underpinning falls short.2
- 2024 — NHS England removes puberty blockers from routine care outside clinical trials.
A Dutch physician who in 2026 prescribes puberty blockers without reservation, or refers a 16-year-old for mastectomy, cannot in a later proceeding maintain that they were unaware of these developments. The cumulative evidentiary weight is too large, too international, and — since December 2024 — confirmed explicitly from within the Dutch center itself.
Continue in this dossier
Three legal tracks
Civil law (Wgbo), disciplinary law (BIG Act) and criminal law — what each track can and cannot do.
Informed consent as the strongest route
Five elements on which the duty of disclosure in gender care structurally falls short.
Defenses parried — and what to do today
How the standard defenses (guideline, signature, WPATH, suicide risk, ex tunc) are countered — and the action agenda for the physician.
Notes
- Cass H. The Cass Review: Independent Review of Gender Identity Services for Children and Young People — Final Report. NHS England, April 2024.
- Vrouenraets LJJJ, et al. The Dutch approach to gender-affirming care for adolescents — a rejoinder. BMC Medical Ethics. 2024.
- Hoge Raad 2 March 2001 (Trombose) and subsequent case law: a guideline is an aid, not a safe harbor; the individual physician remains bound by the reasonably competent practitioner standard.
- COHERE Finland. Recommendation of the Council for Choices in Health Care on medical treatment methods for variations of gender identity in minors. June 2020.
- NICE. Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria and Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria. March 2020.
- Bell v Tavistock [2020] EWHC 3274 (Admin); reversed on procedural grounds in [2021] EWCA Civ 1363.
- SBU/Socialstyrelsen. Care of children and adolescents with gender dysphoria — National guidelines. 2022.
This piece is a legal analysis for a general audience and does not constitute individual legal advice. For concrete matters, specialized medico-legal counsel is advised.