Gender-affirming care for minors — the global policy map

The original Dutch protocol, developed at the Amsterdam clinic in the 1990s and 2000s by Peggy Cohen-Kettenis and colleagues, was designed for a specific population: children with intense, persistent, long-standing gender dysphoria, typically presenting in early childhood, with comprehensive psychological assessment. The protocol used puberty suppression as a "diagnostic time" to allow further assessment without the distress of pubertal development, followed by cross-sex hormones around sixteen and surgery in adulthood. The published outcome data on this original cohort was generally positive but came from a relatively small group with strict inclusion criteria.

Beginning around 2012, gender clinics in multiple Western countries saw a dramatic rise in referrals, with the demographics shifting substantially: more adolescent presentations rather than early-childhood ones, more natal females than males (reversing the historical ratio), more co-occurring conditions (autism, anxiety, depression, eating disorders), and more cases where the dysphoria appeared rapidly in adolescence rather than persistently from childhood. Whether the original Dutch protocol's evidence base applied to this new population was an open question that clinical practice in many places did not pause to ask.

Hilary Cass, a pediatrician and former president of the Royal College of Paediatrics and Child Health, was commissioned by NHS England to conduct an independent review of gender services for children and young people. The final report, published April 2024, ran several hundred pages and commissioned multiple systematic reviews of the evidence. Its central conclusions: the evidence for puberty blockers and cross-sex hormones in adolescents is weak and based largely on low-quality studies; the assessment processes at GIDS were inadequate; co-occurring conditions were under-addressed; and the field had become characterized by an unusual degree of polarization that impeded normal scientific debate.

Hannah Barnes, a BBC journalist, published Time to Think in 2023, a detailed account of internal concerns at GIDS over the preceding decade. The book documented clinicians who raised concerns about assessment quality, about the rapid increase in referrals, about the lack of long-term follow-up, and about the institutional culture that made it difficult to voice concerns. The reporting was meticulous and largely uncontested on facts, and provided context for the Cass Review's institutional findings.

The Karolinska Institute in Sweden announced in 2021 that it would restrict hormonal interventions for minors to research contexts, citing the absence of robust evidence and the rising case numbers. The Swedish National Board of Health and Welfare followed in 2022 with national guidance taking a similar cautious position. Sweden's reversal was significant because of its medical reputation and because it came from institutions not associated with conservative politics.

Finland's Council for Choices in Health Care issued guidance in 2020 that prioritized psychotherapy and treatment of co-occurring conditions before medical intervention, restricted puberty blockers and hormones to a small subset of cases meeting strict criteria, and explicitly cautioned against social transition as a first-line intervention for children. Finnish researchers, including psychiatrist Riittakerttu Kaltiala, have published critically on the evidence base. The Finnish position predated the Cass Review and influenced subsequent European deliberations.

The country that originated the protocol has moved more cautiously than is sometimes reported, while not abandoning the protocol. Dutch researchers have published acknowledgments that the contemporary referral population differs from the original cohort, that long-term outcomes are less well-characterized than once claimed, and that more research is needed. The Netherlands has not banned interventions but has tightened assessment processes and engaged more publicly with the evidentiary critiques.

The World Professional Association for Transgender Health published Standards of Care version 8 in 2022. The document generally moved toward broader access, removed specific minimum age recommendations from earlier drafts after public consultation, and affirmed gender-affirming care for minors with appropriate assessment. WPATH SOC 8 has been criticized by some researchers and by the Cass Review's commissioned systematic reviews for methodological choices, including the use of expert consensus where systematic evidence review was thin, and for involvement of advocacy positions in clinical guidance. Eli Coleman, the lead author, has defended the standards as the best available synthesis given the evidence and clinical realities.

Diane Ehrensaft, a developmental psychologist at the University of California San Francisco, has been a prominent advocate of the gender-affirmative model, which holds that children's expressed gender identity should be taken seriously and supported, including medically when appropriate. Her work, including The Gender Creative Child, has shaped American practice. The model has substantial clinical support and substantial critique, and represents one pole in a real disagreement about how to weigh affirmation against assessment.

Jack Turban, a psychiatrist at UC San Francisco, has published research arguing that gender-affirming care including puberty blockers is associated with better mental health outcomes for transgender youth. His research has been cited in support of broader access. Methodological critiques of some of his studies — including questions about causal inference from cross-sectional data, sample selection, and confounding — have come from researchers including Stephen Levine and others. The disagreement is real and continues in the peer-reviewed literature.

The detransitioner literature — accounts of people who medically or socially transitioned and later detransitioned, often reporting iatrogenic harm — has grown substantially since 2018. Studies vary widely in their estimates of detransition rates, partly because the question is methodologically hard (loss to follow-up, definitional issues, reluctance to return to original clinics). The Cass Review concluded that detransition rates are not reliably known and that better long-term follow-up is essential. Persistence of childhood gender dysphoria into adulthood, similarly, varies dramatically across studies and across the population being studied (the older "desistance" literature found high non-persistence rates that the affirmative model disputes).

US state-level bans on gender-affirming care for minors had been passed in more than 20 states by 2024, with legal challenges proceeding in multiple federal circuits. The Supreme Court took up United States v. Skrmetti, a challenge to Tennessee's law, with arguments in December 2024 and a ruling expected in 2025. The legal questions concern equal protection, due process, and parental rights. Whatever the ruling, the political polarization will continue, and the US will remain an outlier in having the question fought in courts and legislatures rather than primarily in medical bodies.

A parent facing this question with their own child is doing so inside a system that does not have settled answers. The honest things a parent can ask for, regardless of jurisdiction or politics, are: thorough psychological assessment that takes months, not weeks; identification and treatment of co-occurring conditions before or alongside any gender-related intervention; honest discussion of what the evidence does and does not show; conservative pacing that begins with reversible interventions and reassesses; long-term follow-up. These are not radical positions. They are roughly what the most careful European reviews have concluded should be the standard. They are also what serious clinicians on multiple sides of the affirmative-cautious debate have endorsed when speaking outside the polarized public arena. The collective work, the Law 4 work, is to build clinical systems that can deliver this kind of care — careful, honest, slow, accountable — regardless of which way the political winds are blowing in any given month.

Cass, Hilary. Independent Review of Gender Identity Services for Children and Young People: Final Report. London: NHS England, April 2024.

Barnes, Hannah. Time to Think: The Inside Story of the Collapse of the Tavistock's Gender Service for Children. London: Swift Press, 2023.

Coleman, Eli, A. E. Radix, W. P. Bouman, G. R. Brown, A. L. C. de Vries, M. B. Deutsch, R. Ettner, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8." International Journal of Transgender Health 23, sup1 (2022): S1–S259.

Ehrensaft, Diane. The Gender Creative Child: Pathways for Nurturing and Supporting Children Who Live Outside Gender Boxes. New York: The Experiment, 2016.

Turban, Jack L., Dana King, Jeremi M. Carswell, and Alex S. Keuroghlian. "Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation." Pediatrics 145, no. 2 (February 2020): e20191725.

Levine, Stephen B., E. Abbruzzese, and Julia W. Mason. "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults." Journal of Sex & Marital Therapy 48, no. 7 (2022): 706–27.

Kaltiala, Riittakerttu, Elias Heino, Marja Työläjärvi, and Laura Suomalainen. "Adolescent Development and Psychosocial Functioning after Starting Cross-Sex Hormones for Gender Dysphoria." Nordic Journal of Psychiatry 74, no. 3 (2020): 213–19.

Socialstyrelsen (Swedish National Board of Health and Welfare). Care of Children and Adolescents with Gender Dysphoria: National Knowledge Support. Stockholm: Socialstyrelsen, 2022.

Council for Choices in Health Care in Finland (COHERE). Medical Treatment Methods for Dysphoria Associated with Variations in Gender Identity in Minors — Recommendation. Helsinki: COHERE, 2020.

de Vries, Annelou L. C., Jenifer K. McGuire, Thomas D. Steensma, Eva C. F. Wagenaar, Theo A. H. Doreleijers, and Peggy T. Cohen-Kettenis. "Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment." Pediatrics 134, no. 4 (October 2014): 696–704.

Block, Jennifer. "Gender Dysphoria in Young People Is Rising — and So Is Professional Disagreement." BMJ 380 (February 2023): 382.

NHS England. Clinical Policy: Puberty Suppressing Hormones for Children and Adolescents with Gender Incongruence/Dysphoria. London: NHS England, March 2024.