Protocol › Inclusion criteria · Last reviewed 2026-05-16

Inclusion criteria

Summary

Original inclusion criteria of the Dutch Protocol required a DSM-IV-TR diagnosis of Gender Identity Disorder, lifelong gender dysphoria intensifying at puberty, psychological stability, an adequate social environment and the capacity for informed assent. Each criterion is documented in Delemarre & Cohen-Kettenis (2006) and the dissertation of de Vries (2010).

1. Diagnostic criteria

DSM-IV-TR diagnosis of Gender Identity Disorder (later DSM-5: Gender Dysphoria) made by at least two independent clinicians.¹
Persistent cross-gender identification since early childhood — supported by Steensma 2013 (desistance research).
Intensification of dysphoria at the onset of puberty.
Presence of Tanner stage 2 or 3.

2. Psychological criteria

Sufficient psychological stability to tolerate a long diagnostic trajectory.
Capacity for informed assent (in minors) and — from majority age — informed consent.
Understanding of the nature, scope and limitations of the intervention.

3. Social criteria

A supportive family environment and involved parents / carers.
No current untreated serious psychosocial problems — see exclusion criteria.

4. Shift under DSM-5

The transition from DSM-IV-TR to DSM-5 (2013) replaced "Gender Identity Disorder" with "Gender Dysphoria" and relaxed some criteria, including the requirement of a lifelong onset.² In practice the Amsterdam UMC team used a stricter reading than DSM-5 allows.

Critical note

The requirement of "lifelong" or "early-onset" gender dysphoria has been largely abandoned in international implementation. Contemporary referral populations consist largely of late-onset cases, often biologically female and with high psychiatric comorbidity — a profile that does not meet the original Dutch inclusion criteria. Abbruzzese, Levine and Mason (2023) conclude that the Dutch Protocol is thereby applied outside its empirical range of validity.³