Protocol › Definition · Last reviewed 2026-05-16
Definition
Summary
The Dutch Protocol is defined in the clinical literature as a phased, multidisciplinary treatment trajectory for adolescents with persistent, early-onset gender dysphoria. It comprises: (1) an extensive diagnostic psychological evaluation, (2) reversible suppression of endogenous puberty with GnRH agonists from Tanner stage 2–3, (3) cross-sex hormone therapy from around age 16, and (4) gender-affirming surgery from age 18.1
1. Clinical definition
The Dutch Protocol refers to the phased, multidisciplinary treatment pathway for adolescents with persistent, early-onset gender dysphoria as formalised at the VU University Medical Centre (VUmc) between 1987 and 2006 (see origins). The protocol comprises:
- An extensive diagnostic phase with psychological and psychiatric assessment, carried out by a specialised multidisciplinary team.
- Reversible suppression of endogenous puberty with gonadotropin-releasing hormone agonists (GnRHa, typically triptorelin or leuprorelin) from Tanner stage 2 or 3.2
- Cross-sex hormone therapy (oestrogens or testosterone) from around age 16.
- Gender-affirming surgery from age 18.
For an extensive discussion of each phase see /protocol/the-three-phases/.
2. Distinguishing features
At the time of introduction, the Dutch Protocol distinguished itself from earlier approaches by:
- The application of puberty suppression as diagnostic space: freezing pubertal development to give the patient and treatment team time for evaluation.3
- Strict age and inclusion criteria, including prior presence of gender dysphoria since childhood.
- Exclusion of patients with untreated severe psychiatric comorbidity.
- A multidisciplinary set-up with involvement of endocrinologists, child psychiatrists, clinical psychologists and — where indicated — surgeons.
3. Terminological note
In the international literature the term "Dutch Protocol" is used broadly; in the Netherlands itself, people long spoke of "the VUmc protocol" or "the Amsterdam approach". The term "Dutch Protocol" appears prominently in the cohort study by de Vries et al. (2014) and in the Endocrine Society guidelines (2009, revised 2017).4
Critical note
The wording "reversible suppression" for the GnRHa phase has been criticised by the Cass Review (2024): long-term effects on bone density, brain development and sexual maturation have not been sufficiently investigated to support the claim of full reversibility. In addition, 96–98% of treated adolescents progress to cross-sex hormones, suggesting the phase is not functionally "neutral-diagnostic".5
See also
- Historical background: Origin VUmc
- Per treatment phase: The three phases
- Clinical criteria: Inclusion, Exclusion, Age / Tanner
- Primary sources: CK 1998, Delemarre 2006
- Terms (GnRHa, CSH, Tanner): Glossary
- People register — Cohen-Kettenis, Delemarre, de Vries.
- International comparison — how other countries handle this aspect.
- Timeline — context of protocol development.
- FAQ · For parents.
Footnotes
- de Vries ALC, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. J Homosex. 2012;59(3):301–20. doi:10.1080/00918369.2012.653300
- Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol. 2006;155(suppl 1):S131–7.
- Cohen-Kettenis PT, van Goozen SHM. Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. Eur Child Adolesc Psychiatry. 1998;7(4):246–8.
- Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons. J Clin Endocrinol Metab. 2017;102(11):3869–903.
- Cass H. Independent review of gender identity services for children and young people: final report. NHS England; April 2024.