The Netherlands strengthens its gender-affirming care model for trans minors

In its official advisory report, the Health Council of the Netherlands states that puberty blockers and gender-affirming hormones achieve their intended physical effects and are associated with improvements in several mental health indicators among the young people concerned, while observed cases of regret remain rare. The report rejects the idea that withholding treatment is a neutral option: allowing an unwanted puberty to continue can produce irreversible bodily changes and intensify distress. For the Council, genuinely evidence-based medicine therefore does not mean turning uncertainty into prohibition, but combining the available evidence, clinical expertise and the individual’s preferences in an informed, individualised decision.

An official advisory report at the heart of the European debate

On 30 June 2026, the Gezondheidsraad – the Health Council of the Netherlands, an independent scientific body that advises the government and Parliament – published its advisory report on “Transgender Care for Young People”. Commissioned following two parliamentary motions, it was asked to examine the safety and effectiveness of puberty blockers and gender-affirming hormones, the evidence on regret and treatment discontinuation, and the compatibility of the Dutch model with health law.

The advisory report concerns people under the age of 18 and focuses primarily on two interventions: GnRH agonists, which pause the progression of puberty, and gender-affirming hormone treatment, which enables the development of bodily characteristics more closely aligned with the person’s experienced gender. It notes that, in the Netherlands, these treatments are offered only after an exploratory phase, a diagnostic assessment, psychological support and a clinical indication established by a multidisciplinary team.

In the Council’s view, somatic care may be offered within this specific framework, and the available evidence does not justify a general restriction on access. The remaining uncertainties must be explained during the consent process and addressed through long-term scientific follow-up.

Treatments that produce the intended physical effects

The report carefully distinguishes physical effectiveness from an overall improvement in physical health. Puberty blockers are effective in pausing changes associated with endogenous puberty: they lower sex hormone levels, slow the development of secondary sex characteristics, stop menstruation, or prevent certain changes in voice and body hair. Gender-affirming hormones – estradiol and testosterone – produce the expected hormonal and bodily changes, although their extent varies from one person to another.

The Council does not deny the possibility of adverse effects. During puberty suppression, bone mineral density declines relative to age-based reference values. It rises after gender-affirming hormones are introduced, although recovery may remain incomplete at the lumbar spine in some trans girls. The long-term clinical significance of this finding – including any future risk of osteoporosis or fractures – remains uncertain. The report also notes that lower bone density is observed in some trans girls before any treatment, cautioning against automatically attributing the entire phenomenon to puberty blockers.

Growth velocity slows under GnRH agonists and then appears to be largely regained after gender-affirming hormones are introduced. The evidence generally shows no clinically relevant adverse effect on body mass index or cardiometabolic parameters, although some findings concerning cholesterol remain inconsistent. Effects on fertility and cognition, as well as certain very long-term outcomes, remain insufficiently documented. The Council therefore calls for caution, fertility preservation where possible, information and monitoring – not for abandoning treatment.

Improvements observed across several mental health indicators

Before receiving care, the trans young people included in the Dutch studies show, on average, more emotional difficulties, depressive symptoms, suicidal thoughts and self-harm than cisgender young people of the same age. Their distress cannot be reduced to bodily processes alone: it also depends on family support, the school environment, discrimination, associated psychosocial difficulties and delays in accessing care.

After puberty blockers are started, the Dutch studies reviewed show improvements from baseline in emotional difficulties, depressive symptoms, suicidality and self-harm. Findings are less consistent for anxiety, body image and gender dysphoria – which is consistent with the role of blockers: they prevent further unwanted bodily development but do not yet produce sex characteristics aligned with the person’s experienced gender.

Dutch evidence specifically addressing mental health after the introduction of gender-affirming hormones is much more limited. Nevertheless, the report states that the available studies find significant improvements in overall functioning and well-being. The international reviews included in the supporting document also report beneficial effects of hormones on body image and gender dysphoria.

Not intervening is not a neutral option

One of the advisory report’s major contributions is to compare the risks of treatment not with a hypothetical consequence-free state, but with the real risks of waiting and withholding care. An unpaused puberty produces changes that, in some cases, can no longer be altered by hormones in adulthood – for example, voice deepening after a testosterone-driven puberty. Other changes may only be corrected surgically, such as breast development after an oestrogen-driven puberty.

The consequences are not only physical. The qualitative studies cited describe severe distress, psychological difficulties and deterioration in social life among young people facing long waits. The report also warns that a ban or excessive delay may push some people towards hormones obtained outside the healthcare system, without quality control, dose adjustment or medical monitoring.

For the Council, scientific uncertainties must be incorporated into the consent process, but they do not justify pretending that inaction is risk-free.

Discontinuation, detransition and regret: distinct realities

The report stresses the distinction between discontinuing treatment, detransitioning and experiencing regret. A person may stop puberty blockers because their dysphoria has lessened, because they now identify as non-binary, because of adverse effects, access difficulties or problems with adherence, without regretting the care they received. Conversely, someone may regret one aspect of their care pathway without wishing to discontinue all treatment.

Across the six Dutch studies analysed, the proportion of young people permanently discontinuing GnRH agonists ranges from 0 to 3.5%; for gender-affirming hormones, it ranges from 0 to 2% (Transgenderzorg voor jongeren, p. 32). In the two studies that measured regret among people who had started blockers before the age of 18, no cases of regret were observed. International reviews likewise conclude that regret rates are low, while more recent European studies report discontinuation rates ranging from 0 to 4.4%.

The Council nevertheless acknowledges that follow-up periods are sometimes short, loss to follow-up is substantial, definitions vary, and some people may not report regret or detransition to the teams that treated them.

The advisory report therefore recommends developing multicentre cohorts followed into adulthood, harmonising definitions, and organising care so that people can speak freely about discontinuation, regret or a wish to detransition. These situations should provide access to appropriate care, not be used to invalidate the needs of all trans young people.

An essential clarification about “evidence-based medicine” (EBM)

The report directly addresses an argument that has become common in public debate: because the certainty of evidence is often rated low or very low, the treatments should be considered ineffective or experimental. For the Dutch Council, this conclusion rests on an impoverished understanding of “evidence-based medicine”.

Evidence-based medicine (EBM) combines three elements: scientific evidence collected systematically and critically appraised, clinical expertise, and the individual’s values and preferences. The hierarchy of evidence places randomised trials at the top, but such trials are rare in many areas of paediatrics, particularly for ethical reasons. In trans-specific care, blinding is also impossible when the physical effects are visible, and young people eligible for treatment may refuse to be assigned to a no-treatment group. Trans-specific care should therefore not be disqualified solely because it lacks a body of randomised trials that is not systematically required in the rest of paediatrics.

The Council does not propose bypassing uncertainty: it calls for uncertainty to be stated, research to be improved, standardised data to be collected and long-term outcomes to be monitored. But it emphasises that low statistical certainty is not equivalent to an absence of effect, evidence of harm, or an obligation to prohibit treatment. After weighing these considerations, evidence-based medicine remains compatible with access to puberty blockers and hormones within personalised care.

Reducing waiting times without reproducing the GIDS shortcomings

The Dutch Council acknowledges that waiting times for care have become excessive amid a sharp rise in referrals. These prolonged waits can worsen young people’s mental health and lead some to obtain hormones outside the healthcare system, without support or medical monitoring. To reduce delays, the report notably proposes better training for general practitioners and mental health professionals, so that some questions and support can be addressed before referral to specialist centres. According to the Council, this reorganisation should also help “prevent early pathologisation and medicalisation resulting from rapid referrals to specialist gender centres” (Transgenderzorg voor jongeren, p. 45).

The Council nevertheless places this proposal within an explicit defence of the Dutch model, which it distinguishes from the operation of England’s GIDS, criticised in the Cass Review. According to the Council, GIDS did not always provide genuinely multidisciplinary care, paid insufficient attention to other factors that might contribute to psychological distress, and had not established sufficiently rigorous evaluation or data collection. It therefore considers that “the English literature and the GIDS data on which the Cass Review is based are not automatically applicable to the Dutch situation” (Transgenderzorg voor jongeren, p. 17). Within this logic, reducing delays should not mean weakening clinical assessment, but distributing responsibilities more effectively between primary care, mainstream mental health services and specialist centres.

This defence of the Dutch model does not, however, exhaust the criticisms that can be made of it. The Council recommends retaining an invariably multidisciplinary organisation, with an extensive exploratory and diagnostic phase before any somatic treatment, while also stating that “the patient, or their representative, through their preferences, wishes and expectations, plays a central role in the final treatment decision” (Transgenderzorg voor jongeren, p. 27). These two requirements are fully compatible only if multidisciplinarity remains a resource tailored to the young person’s needs, rather than a uniform sequence of steps imposed on everyone. Psychological or psychiatric expertise may be useful in assessing associated distress, capacity to consent or a need for support; it should not mean that a young patient who does not want it must undergo open-ended mental health follow-up before their request for blockers or hormones is considered. The Council does not examine this tension.

A second difficulty concerns the distinction the Council itself draws between questions about gender, which may form part of ordinary identity development and do not all require medical care, and gender dysphoria that may justify care. Despite this distinction, it recommends retaining, before any somatic treatment, an “extensive exploratory phase centred on exploration of gender identity” (Transgenderzorg voor jongeren, p. 11). This arrangement can be questioned when a young person presents with an already established identity and a specific request for somatic care. Systematic exploration of their identity may then be experienced not as support for decision-making, but as a harmful test of that identity. The Council considers that this phase supports assessment quality, informed consent and shared decision-making, but it presents no comparative evidence showing that making it systematic produces better outcomes than an assessment more closely proportionate to individual needs.

The challenge, therefore, is to reduce bottlenecks without reproducing the shortcomings attributed to GIDS, but also without turning multidisciplinarity into a uniform gatekeeping mechanism. A faster and genuinely person-centred system could preserve access to multidisciplinary expertise when circumstances require it, while adapting the intensity of assessment, psychological support and follow-up to the needs expressed by each young person.

A continental European direction, in contrast to the United Kingdom

The Dutch report forms part of a direction that is now clearly identifiable across continental Europe: acknowledging the limitations of the literature without inferring that treatment should be prohibited, retaining gender-affirming care among the available therapeutic options, and organising access around multidisciplinary assessment, shared decision-making and rigorous follow-up. This direction contrasts with the restrictive, prohibitive trajectory taken in the United Kingdom after the Cass Review.

The AWMF guideline published in 2025, developed with scientific societies from Germany, Austria and Switzerland, retains the possibility of puberty suppression and gender-affirming hormone therapy on the basis of individual clinical indications. It explicitly states that waiting without bodily intervention is not a neutral option and calls for the risks of treatment to be compared with those of withholding or delaying it. In Italy, a joint position statement by the leading societies of paediatrics, paediatric endocrinology, adolescent medicine and child neuropsychiatry likewise supports multidisciplinary care based on scientific evidence and stresses that delaying or omitting an intervention is not necessarily neutral. In France, the consensus statement issued by the French Society of Paediatric Endocrinology and Diabetology (SFEDP) has provided, since 2024, an initial national body of guidance on puberty blockers, gender-affirming hormones, multidisciplinary support and fertility preservation.

France is also preparing a specialised official framework. Following its recommendations on adult care, the Haute Autorité de santé published in February 2026 the scoping document for its forthcoming work on “support for minors and those around them, and the care offered”, which is expected to begin in the autumn. A central challenge will be to develop coherent and protective national recommendations informed by continental European experience: neither denying uncertainty nor confusing a low level of evidence with an absence of benefit; comparing the risks of acting with those of not acting; and placing the decision at the intersection of evidence, expertise and the needs of the young person concerned.