NTVG — International criticism of the Dutch Protocol
In this article, published on 29 May 2025 in the Dutch Journal of Medicine (NTVG), medical ethicist Jilles Smids of Erasmus MC discusses international criticism of the Dutch Protocol. This is the approach developed in the Netherlands under which young people with gender dysphoria may receive puberty blockers and later hormones.
Smids argues that the Dutch guidelines for gender care for minors should be revised. In his view, the available evidence is insufficient to justify treatment with puberty blockers and sex hormones as routine care.
Key points
The author refers to the British Cass Review, which prioritizes a broad, psychosocial approach over medical intervention. He proposes that hormonal treatment for minors with gender dysphoria should become a last resort rather than a standard step.
The author and the background
Jilles Smids works in the Medical Ethics, Philosophy and History of Medicine section at Erasmus MC in Rotterdam. The article is an opinion piece, not a research report. It builds on a commentary he wrote with Patrik Vankrunkelsven in the same journal in November 2023, included in this archive as Uncertainties surrounding current gender care. That commentary calls for reform of Dutch gender care following the examples of Sweden and Finland (source).
A closer look at the proposal
Smids advocates interim guidelines based on the available evidence. He argues that the current Dutch guideline does not recommend a broad, holistic approach. He also considers it problematic that the revision of the guideline relies on version 8 of WPATH’s Standards of Care. He advocates guidelines that describe holistic care along the lines of the Cass report; psychological exploration is part of that. An overview of policy in other countries can be found under policy by country.
The responses and what followed
A discussion followed in the comments below the article. A junior hospital doctor in internal medicine (anios) called the Cass Review heavily criticised and argued that raising thresholds for transgender care is harmful; Smids replied that his recommendations in fact aim for more accessible help. Another reader cited seven publications criticising the Cass Review and warned that an article relying on it could result in patients being denied necessary care (source). More than a year later, on 30 June 2026, the Health Council wrote in its advice that the strength of the evidence is low, but saw no reason in it to organise care differently (source). The lead-up to that advice is described in the June 2024 parliamentary letter.
Why it is included in this archive
The piece appeared in the most important Dutch medical journal and prompted an extensive discussion in the comments below the article. Critics argued that the Cass Review has methodological flaws and that higher thresholds could harm vulnerable young people; the author disputed this. As a result, the page provides a good picture of the debate among Dutch doctors.