Protocol › Exclusion criteria · Last reviewed 2026-05-16
Exclusion criteria
Summary
The original Dutch Protocol excluded adolescents with untreated severe psychiatric comorbidity, an acute psychosocial crisis or insufficient parental support. The clinical literature explicitly mentions high rates of comorbid autism-spectrum features in referred adolescents — recorded at around 7–8% of the VUmc cohort, multiple times the population average (de Vries 2010). See also /protocol/inclusion-criteria/.
1. Clinical exclusion criteria
- Untreated severe psychiatric disorder (psychotic disorder, severe depression, suicidality).1
- Recent, unprocessed traumatic event.
- Active eating disorder.
- Insufficient parental involvement or unstable social environment.
- Inability to give informed assent.
2. Autism-spectrum disorders
In the original VUmc cohort an autism-spectrum disorder was diagnosed in about 7.8% of referred adolescents — substantially higher than the estimated 1% in the general Dutch population.2 Autism was not an automatic exclusion, but led to a more extensive diagnostic phase. Later international clinics (including Tavistock GIDS) have reported even higher ASD percentages, up to 35%.3 See also /international/united-kingdom/.
3. Points of attention in practice
Various publications (including the Cass Review 2024) point out that the strict exclusion criteria originally applied at VUmc have been relaxed or not consistently applied in the international spread of the protocol. This point is discussed in more detail at /international/spread/.
Critical note
The fact that autism-spectrum disorders occur several times more often in referred populations than in the general population is by various authors (Cass 2024, Levine et al. 2022) not seen as incidental but as a signal that the nature of dysphoria in this group may differ — which undermines the assumption that the same treatment pathway fits. The Cass Review recommends that ASD comorbidity be assessed as standard before any form of medical intervention, and that psychosocial interventions take priority.4
See also
- Inclusion criteria — who did qualify according to the original protocol.
- Steensma et al. (2013) — desistance — childhood dysphoria that spontaneously decreases without treatment.
- Cass Review (2024) — recommendations on comorbidity and ASD screening.
- Levine — critiques — reassessment of eligibility criteria.
- International spread — how inclusion and exclusion criteria were relaxed upon adoption.
- People register — Cohen-Kettenis, Delemarre, de Vries.
- International comparison — comorbidity policy per country.
- Timeline — protocol development chronologically.
- FAQ · Glossary · For parents.
Footnotes
- Delemarre-van de Waal HA, Cohen-Kettenis PT. Clinical management of gender identity disorder in adolescents. Eur J Endocrinol. 2006;155(S1):S131–7.
- de Vries ALC, Noens ILJ, Cohen-Kettenis PT, et al. Autism spectrum disorders in gender dysphoric children and adolescents. J Autism Dev Disord. 2010;40(8):930–6.
- Cass H. Independent review of gender identity services for children and young people: final report. NHS England; April 2024.
- Cass H. Final report. NHS England; 2024. Chapter 9.