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Clinical Management of Gender Dysphoria in Children and

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Clinical Management of Gender

Dysphoria in Children and Adolescents:
The Dutch Approach
a a
Annelou L. C. de Vries MDPhD & Peggy T. Cohen-Kettenis PhD
a
VU University Medical Center, Amsterdam, the Netherlands

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DOI: 10.1080/00918369.2012.653300

Clinical Management of Gender

Dysphoria in Children and Adolescents:
The Dutch Approach
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ANNELOU L. C. DE VRIES, MD, PhD and

PEGGY T. COHEN-KETTENIS, PhD
VU University Medical Center, Amsterdam, the Netherlands

The Dutch approach on clinical management of both prepubertal

children under the age of 12 and adolescents starting at age
12 with gender dysphoria, starts with a thorough assessment of
any vulnerable aspects of the youth’s functioning or circumstances
and, when necessary, appropriate intervention. In children with
gender dysphoria only, the general recommendation is watchful
waiting and carefully observing how gender dysphoria develops
in the first stages of puberty. Gender dysphoric adolescents can be
considered eligible for puberty suppression and subsequent cross-
sex hormones when they reach the age of 16 years. Currently,
withholding physical medical interventions in these cases seems
more harmful to wellbeing in both adolescence and adulthood
when compared to cases where physical medical interventions
were provided.

KEYWORDS gender, gender identity, gender identity disorder,

gender identity disorder of childhood, gender identity disorder of
adolescence, gender variance, pubertal suspension, transgender,
transsexual, treatment

The first specialized gender identity clinic for children and adolescents in
the Netherlands opened its doors at the Utrecht University Medical Center
in 1987. The number of applicants was initially low: No more than a few
children and adolescents were referred to the clinic annually. In 2002, the
clinic moved to the VU University Medical Center in Amsterdam and is now

Address correspondence to Annelou L. C. de Vries, VU University Medical Center, PO

Box 7057, Amsterdam, 1007 MB, the Netherlands. E-mail: alc.devries@vumc.nl

301
 302 A. L. C. de Vries and P. T. Cohen-Kettenis

50
45
40
35
30
25
20
15
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10
5
0
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
FIGURE 1 Referred children, Dutch Gender Identity Clinic, 1987–2011.

50
45
40
35
30
25
20
15
10
5
0
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011

FIGURE 2 Referred adolescents, Dutch Gender Identity Clinic, 1987–2011.

part of the Center of Expertise on Gender Dysphoria. Compared to the early

years, the number of referrals increased considerably. To date, more than
400 children and an almost equal number of adolescents have attended the
gender identity clinic (see Figures 1 and 2).
Between 2004 and 2009, an average of 40 children and 40 adolescents
registered per year for the first time at the clinic with a mean age of 8.0 and
14.3 years, respectively. In the past decade, 12- to 18-year-old adolescents
have been attending the clinic in ever greater numbers and at ever younger
ages (see Figures 2 and 3).
When the gender identity clinic for children and adolescents first
opened, there were no diagnostic guidelines, no Dutch language screen-
ing instruments, and no guideline or protocol for dealing with gender
 Dutch Approach to Gender Dysphoria in Children and Adolescents 303

19

18

17

16

15 Age

14
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13

12
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
FIGURE 3 Mean age of referred adolescents, 1987–2011.

dysphoria at an early age. A great deal has been accomplished in this field
in the past three decades. In addition to the increasing numbers of refer-
rals, the care for these gender dysphoric children and adolescents has also
experienced growth. Over the course of years, diagnostic protocols for chil-
dren under 12 years, as well as adolescents from 12 to 18 years, of age
have been constructed (Cohen-Kettenis & Pfäfflin, 2003; Delemarre-van de
Waal & Cohen-Kettenis, 2006), screening and diagnostic instruments have
been developed, and there are now specific approaches for both age groups.
These are not isolated developments: Outside of the Netherlands, even
more experience has been gained and knowledge has expanded in the field
of juvenile gender dysphoria. Various international treatment guidelines have
been developed (de Vries, Cohen-Kettenis, & Delemarre-van de Waal, 2007;
Di Ceglie, Sturge, & Sutton, 1998; Hembree et al., 2009; World Professional
Association of Transgender Health, WPATH, 2011).
Especially with regard to the clinical management of gender dysphoria
in adolescents, the Netherlands has pioneered and played a leading role
internationally. The “Dutch protocol” has become proverbial in this field.
Various publications have demonstrated the efficacy of parts of this approach
(Cohen-Kettenis & van Goozen, 1997; de Vries, 2010; de Vries, Steensma,
Doreleijers, & Cohen-Kettenis, 2010; Smith, van Goozen, & Cohen-Kettenis,
2001), although the protocol has also been subject to criticism (Korte et al.,
2008).
As a likely result of the professional and media attention to the Dutch
approach, there is an increasing clinical interest in the rationale and descrip-
tion of the ways gender dysphoria in children and adolescents is managed
in the Netherlands (Kreukels & Cohen-Kettenis, 2011). However, to date
such a description did not exist. In this article, we will, therefore, give an
account of our diagnostic and treatment protocols, which differ for children
 304 A. L. C. de Vries and P. T. Cohen-Kettenis

and adolescents. Before proceeding, we will dwell shortly on the context of

views on etiology and gender development that have contributed to devel-
oping the Dutch approach. This discussion of the context is by no means
complete.

CONTEXT
Etiology
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No unequivocal etiological factor determining atypical gender development

has been found to date. The most extreme form of gender dysphoria, Gender
Identity Disorder (GID) in the current Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association, 2000) is most likely a
multifactorial condition in which psychosocial as well as biological aspects
play some role. In recent years, a great deal of attention has been paid to
biological theories (for an overview, see Meyer-Bahlburg, 2010), whereas
psychosocial factors used to be considered of primary importance in the
past. For instance, it was once theorized that GID was a symptom of certain
psychiatric disorders such as borderline personality (Lothstein, 1984) or psy-
chosis (a Campo, Nijman, Merckelbach, & Evers, 2003). Current studies on
psychopathology among adults with GID do not support either of these con-
clusions (e.g., Gomez-Gil, Vidal-Hagemeijer, & Salamero, 2008; Haraldsen &
Dahl, 2000; Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005).
However, the relationship between certain forms of psychopathology
and GID is still not entirely clear (Meyer-Bahlburg, 2010). In adults, elevated
psychopathology has been found in some studies (e.g., Bodlund, Kullgren,
Sundbom, & Hojerback, 1993; De Cuypere, Janes, & Rubens, 1995; Hepp,
Kraemer, Schnyder, Miller, & Delsignore, 2005). Research among children
and adolescents referred to gender identity clinics has demonstrated more
frequent (internalizing) psychopathology than observed in their peers from
the general population (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker,
2003; de Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011; Di Ceglie,
Freedman, McPherson, & Richardson, 2002; Wallien, Swaab, & Cohen-
Kettenis, 2007; Zucker & Bradley, 1995; Zucker, Bradley, Owen-Anderson,
et al., 2010; Zucker, Owen, Bradley, & Ameeriar, 2002). One theory about
this relationship is that a predisposition to anxiety combined with parental
psychopathology in gender variant children can lead to full-blown GID
(Zucker & Bradley, 1995). Zucker and colleagues (Zucker, Bradley, Ben-Dat,
et al., 2003; Zucker, Bradley, & Lowry Sullivan, 1996) have found among chil-
dren referred to the Toronto gender identity clinic more separation anxiety
in the boys and more psychopathology in their mothers than in the gen-
eral population. At the Dutch gender identity clinic, some indications were
found for a predisposition to anxiety among the referred children (Wallien,
Swaab, et al., 2007; Wallien, van Goozen, & Cohen-Kettenis, 2007). However,
parental psychopathology was not demonstrated (Wallien, 2008).
 Dutch Approach to Gender Dysphoria in Children and Adolescents 305

The increasing quantity of research on typical gender development

demonstrates that a number of psychological and social factors play a role
(for a review, see Ruble, Martin, & Berenbaum, 2006), in addition to biolog-
ical factors. It remains to be seen whether and to what degree these same
influences also influence gender dysphoric development. Biological factors
do seem to be involved in the etiology of GID. For example, brain anatomy
and brain activation patterns are reported to be different in adult transsexuals
in comparison to non-gender dysphoric controls (Carrillo et al., 2010; Garcia-
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Falgueras & Swaab, 2008; Kruijver et al., 2000; Luders et al., 2009; Zhou,
Hofman, Gooren, & Swaab, 1995; Berglund, Lindstrom, Dhejne-Helmy, &
Savic, 2008; Gizewski et al., 2009; Schoning et al., 2010). Genetic factors are
also likely to be important in the development of gender dysphoria (e.g.,
Coolidge, Thede, & Young, 2002; van Beijsterveldt, Hudziak, & Boomsma,
2006). However, this research is still very limited and the findings are some-
times inconsistent. It is unclear whether these findings are also applicable to
less extreme forms of gender dysphoria.
With the current state of knowledge, it remains most plausible that
a complex interaction between a biological predisposition in combina-
tion with intra- and interpersonal factors (Crouter, Whiteman, McHale, &
Osgood, 2007; Maccoby, 1998; Zucker & Bradley, 1995) contribute to a
development of gender dysphoria, which may come in different forms and
intensities. Assuming, therefore, that gender dysphoria is most likely deter-
mined multifactorially, in clinical practice an extensive work-up weighing
various symptoms and evaluating all kinds of potentially relevant factors
seems indicated.

Perspective of Developmental Trajectories

In the diagnosis and treatment of gender dysphoric children and adoles-
cents, one must take the perspective of development into account. Gender
variant behavior and even the wish to be of the other gender can be either a
phase or a normal developmental variant without any adverse consequences
for a child’s current functioning (e.g., Bartlett, Vasey, & Bukowski, 2000).
Follow-up studies have demonstrated that only a small proportion of gender
dysphoric children become transsexual at a later age, that a much larger pro-
portion have a homosexual sexual orientation without any gender dysphoria,
and that a small proportion of these children develop into heterosexual
adults. The proportions of persistence found in the initial studies were below
10% (for a review of the literature, see Zucker & Bradley, 1995). More recent
studies show a variation from 12 to 27% (Cohen-Kettenis, 2001; Drummond,
Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).
It is important to note that these figures are for children attending a gender
identity clinic; in a study on children from the general population, these
numbers were different. Adults, whose parents had indicated that their
children either showed gender variant behavior or expressed the wish to
 306 A. L. C. de Vries and P. T. Cohen-Kettenis

be of the other gender during childhood, more frequently indicated that

they were either homosexual or bisexual, but none of them was transsexual
(Steensma, van der Ende, Verhulst, & Cohen-Kettenis, in press). This implies
that gender variant children, even those who meet the criteria for GID prior
to puberty, for the most part are not gender dysphoric at a later age. To date,
we do not yet know exactly when and how gender dysphoria disappears or
desists. Clinical experience has shown that this most often takes place right
before or right after the onset of puberty. This is also confirmed by youths in
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a qualitative study in whom the gender dysphoria disappeared after puberty

(Steensma, Biemond, de Boer, & Cohen-Kettenis, 2011).
In contrast to what happens in children, gender dysphoria rarely
changes or desists in adolescents who had been gender dysphoric since
childhood and remained so after puberty (Cohen-Kettenis & Pfäfflin, 2003;
Zucker, 2006). Youths who began the reversible treatment with puberty sup-
pression at an average age of 14.75 years, to enable them to explore their
gender dysphoria and treatment wish, were still gender dysphoric nearly
two years later. All started with the first steps of their actual gender reassign-
ment trajectory, the cross-sex hormones (de Vries, Steensma, Doreleijers, &
Cohen-Kettenis, 2011).

CHILDREN
Diagnosis
In the Amsterdam gender identity clinic, several sessions spread out over a
longer period of time are allotted to prepubertal children below age 12 for
diagnosis. This is done to gain insight into how the gender dysphoria devel-
ops over time. The children and their parents are seen at least once together,
each of the parents is interviewed individually, and the child is observed a
number of times and subjected to an extensive psychodiagnostic assessment.
The procedure is concluded with an advisory consultation.
One aim of the examination is to determine whether the criteria for
a GID diagnosis have been met. This can be rather simple with children
demonstrating an extreme degree of gender dysphoria or who are very
explicit in their desire for gender reassignment. However, the clinical picture
is not always that clear. Gender dysphoria is a dimensional phenomenon and
can exist to a greater or lesser degree. This is something to be taken into
greater account in DSM-5 (APA, for proposed revision see www.dsm5.org)
than is presently the case (Zucker, 2010). In addition, it can also manifest
itself in various ways. One child with a strong gender dysphoric feeling
may be very sensitive to his or her surroundings and only dares to come
out at certain times and under certain circumstances. In another child, we
can see very openly expressed gender dysphoria (Meyer-Bahlburg, 2002). In
other cases, a child can show gender variant behavior without suffering from
 Dutch Approach to Gender Dysphoria in Children and Adolescents 307

actual gender dysphoria. In those cases, the reason for referral usually lies
more in the environment (e.g., parents struggling with their child’s behavior)
than in the child.
All kinds of aspects of the children’s functioning are subsequently eval-
uated, such as their cognitive level, psychosocial functioning, and scholastic
performance. For example, a boy may like playing with girls, not because
he is unhappy being a boy, but because he has difficulty joining in with
other boys of his age due to limited cognitive faculties and immaturity. Any
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other possible psychopathology is dealt with extensively (Wallien, Swaab, &

Cohen-Kettenis, 2007). If any is found, the possible relationship between
the gender dysphoria and other diagnoses is investigated. In this way,
for example, one can investigate whether an autistic boy’s fascination for
fancy dresses and long hair is more part of his autism or whether his
autism reinforces certain aspects of his gender dysphoria (de Vries, Noens,
Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010). Some psychi-
atric diagnoses may be unrelated to the gender presentation but still need
attention (e.g., tic disorders). There are also problems or psychiatric disor-
ders that can arise as a consequence of the gender dysphoria (social anxiety,
depression, oppositional defiant disorders).
Furthermore, a good assessment of family functioning as well as the
role of the child’s gender variant behavior on family functioning is useful in
order to gain a complete clinical picture.

Treatment
The Dutch approach to clinical management of children with GID con-
tains elements of a therapeutic approach but is not directed at the gender
dysphoria itself. Instead, it focuses on its concomitant emotional and behav-
ioral and family problems that may or may not have an impact on the child’s
gender dysphoria.

PARENT COUNSELING

After the evaluation described above, the results of the assessment and diag-
nostic procedure are discussed with the parents (and partially with the child)
and an ensuing individual recommendation is given. For children in whom
no concomitant problems have been observed, who have sensitive parents
with an appropriate style of child rearing, advice aimed at dealing with the
gender dysphoria is sufficient. This sometimes results in more counseling at
a later point in time when the family again needs support or advice or finds it
increasingly difficult to deal with the uncertainties with regard to the child’s
psychosexual outcome. Because most gender dysphoric children will not
remain gender dysphoric through adolescence (Wallien & Cohen-Kettenis,
2008), we recommend that young children not yet make a complete social
 308 A. L. C. de Vries and P. T. Cohen-Kettenis

transition (different clothing, a different given name, referring to a boy as

“her” instead of “him”) before the very early stages of puberty. In making
this recommendation, we aim to prevent youths with nonpersisting gender
dysphoria from having to make a complex change back to the role of their
natal gender (Steensma & Cohen-Kettenis, 2011). In a qualitative follow-up
study, several youths indicated how difficult it was for them to realize that
they no longer wanted to live in the role of the other gender and to make
this clear to the people around them (Steensma, Biemond, et al., 2011).
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These children never even officially transitioned but just were considered
by everyone around them as belonging to the other (non-natal) gender.
One may wonder how difficult it would be for children living already for
years in an environment where no one (except for the family) is aware of
the child’s natal sex to make a change back. Another reason we recommend
against early transitions is that some children who have done so (some-
times as preschoolers) barely realize that they are of the other natal sex.
They develop a sense of reality so different from their physical reality that
acceptance of the multiple and protracted treatments they will later need is
made unnecessarily difficult. Parents, too, who go along with this, often do
not realize that they contribute to their child’s lack of awareness of these
consequences.
Parents are furthermore advised to encourage their child, if possible, to
stay in contact with children and adult role models of their natal sex as well.
Moreover, we advise them to encourage a wider range of interests in objects
and activities that go with the natal sex. Gender variant behavior, however,
is not prohibited. By informing parents about the various psychosexual tra-
jectories, we want them to succeed in finding a sensible middle of the road
approach between an accepting and supportive attitude toward their child’s
gender dysphoria, while at the same time protecting their child against any
negative reactions from others and remaining realistic about the actual situa-
tion. If they speak about their natal son as being a girl with a penis, we stress
that they have a male child who very much wants to be a girl, but will need
an invasive treatment to align his body with his identity if this desire does not
remit. Finding the right balance is essential for parents and clinicians because
gender variant children are highly vulnerable to developing a negative sense
of self (Yunger, Carver, & Perry, 2004). This goes especially for situations of
social exclusion or teasing and bullying (Cohen-Kettenis, Owen, et al., 2003).
Fortunately, social exclusion does not invariably take place, as can be seen
from a recent study of gender dysphoric Dutch children (Wallien, Veenstra,
Kreukels, & Cohen-Kettenis, 2010).
Parents can play a significant role in creating an environment in which
their child can grow up safely and develop optimally. In this regard, it is
also important that appropriate limit setting is part of the parent’s style of
raising their child. For example, if a young boy likes to wear dresses in a
neighborhood in which aggression can be expected, they could come to an
 Dutch Approach to Gender Dysphoria in Children and Adolescents 309

understanding with their son that he only wears dresses at home. In such a
case, it is crucial that the parents give their child a clear explanation of why
they have made their choices and that this does not mean that they them-
selves do not accept the cross-dressing. The child will, thus, sometimes be
frustrated and learn that not all of one’s desires will be met. The latter is an
important lesson for any child, but even more so for children who will have
a gender reassignment later in life. Although hormones and surgery effec-
tively make the gender dysphoria disappear (Murad et al., 2010), someone’s
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deepest desire or fantasy to have been born in the body of the other gender
will never be completely fulfilled.

TREATMENT OF NON - GENDER DYSPHORIA RELATED PROBLEMS

If concomitant problems are observed (e.g., substantial problems with peers,

psychiatric problems, or conflicts with parents or siblings), the child may be
referred to a local mental health agency. The primary aim is for the child and,
if necessary, the family to function better. If these problems have contributed
to causing or keeping up some gender dysphoria, the dysphoria will likely
disappear by tackling these other problems. Although there is little evidence
that psychotherapeutic interventions can eliminate gender dysphoria in gen-
eral, it is conceivable that in some cases gender variant behavior can change
as a result of therapy. In our own practice, a reduction or disappearance of
gender variant behavior seems to take place particularly when this behavior
appeared to be a clear reaction to certain events or situations which in them-
selves are amenable to therapy (e.g., a boy suddenly dressing up and saying
he wants to be a girl as an expression of extreme jealousy after the birth
of a younger sister). There are, however, no controlled studies that have
investigated psychological interventions aimed at influencing certain types
of gender dysphoria. It remains for the most part unclear if “treated” children
have been “cured” through interventions or just “grew out of” their gender
variance. Yet, even if there is no change in the gender dysphoria, many chil-
dren with gender dysphoria can benefit from psychotherapy or counseling
aimed at securing a positive self-image or dealing with negative reactions
from others. Without such support, these children run the risk of develop-
ing social relationship problems, emotional problems such as anxiety and
depression, behavioral problems, or problems at school due to difficulties
with concentration, or a low self-esteem.

PHYSICAL MEDICAL INTERVENTIONS

The Amsterdam gender identity clinic does not provide any physical medical
interventions before puberty. Parents are advised to adopt an attitude of
watchful waiting. Not until the child arrives at puberty and is still gender
 310 A. L. C. de Vries and P. T. Cohen-Kettenis

dysphoric will he or she be seen again in our gender identity clinic. Parents
and child are informed about this possibility.

ADOLESCENTS
Diagnosis
In nearly all cases seen, adolescents age 12 and up come to the Amsterdam
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gender identity clinic with a desire for gender reassignment. While gender
dysphoric feelings in younger children will usually remit, in adolescents this
is rarely the case. Similar to the children, a diagnostic trajectory is initiated
that is spread out over a longer period of time. Here, too, there is an intake
session with the adolescents and their parents, followed by individual talks
with the parents and the youths and a psychodiagnostic assessment. Shortly
before the start of any physical medical treatment, adolescents will also
have a child psychiatric examination by a member of the team other than
the diagnostician and a medical screening by the pediatric endocrinologist.
Finally, a recommendation concludes the procedure. When an adolescent
is considered eligible for puberty suppression, the diagnostic trajectory is
extended, as the puberty suppression phase is still considered diagnostic.
This medical intervention puts a halt to the development of secondary sex
characteristics. It has been used for over 20 years now in the treatment of
precocious puberty and there is evidence that gonadal function is reactivated
soon after cessation of treatment (Mul & Hughes, 2008).
The Amsterdam gender identity clinic follows the international
Standards of Care of the World Professional Association for Transgender
Health (WPATH, 2011), which advises that the decision to undergo gender
reassignment be taken in several steps. In the Standards of Care, the diag-
nostic phase is followed by the real-life experience stage in which cross-sex
hormones are prescribed and, eventually, the subject can undergo gender
reassignment surgery.
In developing a rapport with adolescents and their parents, particu-
lar attention is paid to obtaining open and nonjudgmental contact with
the youths and their parents. Many elements of this are recognizable as
the developmental approach described by Di Ceglie (2009). In a number
of sessions, the diagnostician tries to gain a picture of the youth’s gen-
eral and psychosexual development. Information is gathered about current
functioning, individually, with peers and in the family. As to sexuality, the
subjective meaning of dressing up or the type of clothing, sexual experience,
sexual behavior and fantasies, sexual orientation and body perception are
discussed.
Adolescents are considered eligible for puberty suppression when they
are diagnosed with GID, live in a supportive environment and have no
serious psychosocial problems interfering with the diagnostic assessment
 Dutch Approach to Gender Dysphoria in Children and Adolescents 311

or treatment (Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008;

Delemarre-van de Waal & Cohen-Kettenis, 2006). During the diagnostic tra-
jectory, information is obtained from both the adolescents and their parents
to assess whether the adolescents meet the eligibility criteria. Therefore, first
it is ascertained whether adolescents are suffering from a very early onset
gender dysphoria that has increased around puberty, or whether something
else brought them to the clinic (e.g., confusion about homosexuality or
transvestic fetishism). About one quarter of the referrals in Amsterdam do not
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fulfill diagnostic criteria for GID and most of them drop out early in the diag-
nostic procedure for this reason or because other problems are prominent
(de Vries, et al., 2011). Second, the youth’s further general and psychological
functioning is assessed. Are there psychiatric problems or other issues that
could hinder a correct assessment or future treatment compliance? Third,
an assessment is made of the adolescent’s social support. As puberty sup-
pression and subsequent hormone treatment and surgery have far-reaching
implications, an adolescent needs adequate support.
The diagnostic stage does not only focus on obtaining information.
To prevent unrealistically high expectations from gender reassignment in the
future, all the possibilities and impossibilities of the treatment are discussed
extensively with the adolescent and the family. Giving such information
starts early in the trajectory. Sometimes, the way in which the youth responds
to this information is also diagnostically informative.
If the eligibility criteria are met, gonadotropin releasing hormone ana-
logues (GnRHa) to suppress puberty are prescribed when the youth has
reached Tanner stage 2–3 of puberty (Delemarre-van de Waal & Cohen-
Kettenis, 2006); this means that puberty has just begun. The reason for this
is that we assume that experiencing one’s own puberty is diagnostically use-
ful because right at the onset of puberty it becomes clear whether the gender
dysphoria will desist or persist. Starting around Tanner stages 2–3, the very
first physical changes are still reversible (Delemarre-van de Waal & Cohen-
Kettenis, 2006). Because the protocol for young adolescents had started in a
period when there were no studies on the effects of puberty suppression, the
age limit was set at 12 years because some cognitive and emotional matura-
tion is desirable when starting these physical medical interventions. Further,
Dutch adolescents are legally partly competent to make a medical decision
together with their parent´s consent at age 12. It is, however, conceivable
that when more information about the safety of early hormone treatment
becomes available, the age limit may be further adjusted (de Vries, 2010).

Treatment
When it appears from the advisory consultation that there are concomitant
psychiatric or family problems, some form of psychological treatment will
be sought. This treatment is usually given close to the youth’s home rather
 312 A. L. C. de Vries and P. T. Cohen-Kettenis

than at our clinic. Certainly, when the problems are destabilizing and there
is an insufficient guarantee that the youth is committed to the therapeutic
relationship necessary for a physical medical intervention, the treatment will
be postponed. In a study investigating the extent of psychiatric problems in
gender dysphoric adolescents, it appeared that the diagnostic stage in some
cases may take more than one and a half years before physical medical
intervention actually can begin (de Vries, Doreleijers, et al., 2011). This was
the case in about one third of the youths with a GID diagnosis. These youths
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more frequently suffered from an oppositional defiant behavioral disorder

or more than three psychiatric diagnoses (in addition to the GID diagnosis)
compared with adolescents who were considered immediately eligible. They
also were less likely to live with both biological parents and on average had
a lower intelligence. Furthermore, they were, on average, older at the time of
referral (de Vries, Doreleijers, et al., 2011). Clearly, psychiatric problems were
not the only factor influencing the delay in starting puberty suppression.
However, for many of the gender dysphoric youths, there are no psy-
chological problems other than the gender dysphoria. Yet, these adolescents
do need good counseling. Some themes need repeatedly to be touched
upon, because they gain a new dimension as the adolescents grow older,
for example, dating when you have a body that has not yet been operated
on, or infertility. Regular contact with the psychologist is also necessary for
adequate preparation for the next treatment steps. An increasing problem
is that many adolescents do not realize that an unhealthy lifestyle (smok-
ing, obesity) has a negative influence on the treatment, surgery in particular.
In addition to a preparation for the future, some profit from a form of psy-
chotherapy. This may be because they are anxious, need to become more
assertive or feel insecure. For those who do not easily verbalize their con-
cerns, psychomotor therapy can be helpful to let them feel more at ease
with their bodies and to learn to talk more easily about their problems.

TRANSITIONING
Many gender dysphoric youths choose to begin living in the desired gender
role simultaneously with the beginning of puberty suppression. The ado-
lescents and their families are then supported in this process so that it can
be achieved successfully. Many youths also obtain help from Transvisie, the
only self-help organization working with trans youth in the Netherlands. It is,
however, not a requirement to begin with the real life experience as long as
cross-sex hormones are not taken.

PHYSICAL MEDICAL INTERVENTIONS

Physical medical interventions can be divided into completely reversible

interventions (puberty suppressors such as GnRHa), partially reversible
 Dutch Approach to Gender Dysphoria in Children and Adolescents 313

interventions (cross-sex hormones) and completely irreversible gender

reassignment surgery (WPATH, 2011).
Completely reversible interventions. Puberty suppression has two aims.
First and foremost, they offer the adolescent time to smoothly explore his
or her gender identity and to find out if a gender reassignment trajectory
is really what the youth wants. Moreover, the knowledge that their bodies
in this stage will not continue to develop in the undesired direction often
results in a vast reduction of the distress they have been suffering from
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since the onset of puberty. Second, stopping the development of secondary

sex characteristics makes passing in the desired gender role easier than
delaying treatment until adulthood. This entails advantages for functioning
throughout one’s life (Ross & Need, 1989). The team’s view that puberty
suppression does not automatically have to lead to actual treatment (gen-
der reassignment) is explicitly discussed with the youths and their parents.
While with some adolescents it is clear early on that there is only a very small
chance that they will abandon this trajectory, they still have to see their psy-
chologist or psychiatrist regularly in the years that they are on GnRHa or
cross-sex hormones. Each adolescent is also regularly given consideration in
the weekly multidisciplinary conferences in which the pediatric endocrinol-
ogist also participates. As soon as necessary, extra help is deployed or the
trajectory is adjusted.
Youths with psychiatric or family problems can also become eligible for
puberty suppression if the mental health treatment they receive is adequate
enough to ensure that the diagnostic or treatment process is not unduly dis-
turbed. To achieve this, good, regular contact with their external therapists
or counselors is necessary. Special attention is given to gender dysphoric
adolescents with an autism spectrum disorder. It is certainly the case for
them that the treatment has to be introduced calmly and each step must
take place in close consultation with the other mental health clinicians (de
Vries, Noens, et al., 2010).
Partially irreversible interventions. Gender dysphoric adolescents are
eligible for the first step of the actual gender reassignment when they have
reached the age of 16. This age has been chosen because in the Netherlands
(as well as in many other countries), young people are then considered
to be able to make independent medical decisions. While their parents do
not have to approve, the Amsterdam clinic prefers their approval, as most
adolescents are still very much dependent on their caretakers. Furthermore,
adolescents have to meet the same criteria as at the onset of puberty sup-
pression (except for the Tanner stage criterion). Although most of the youths
will have already made a social transition, this is now a requirement because
sex characteristics of the desired gender will become visible to others.
Cross-sex hormones will result in a start of puberty of the desired gen-
der. Male-to-females (MTF) or trans girls receive estrogens which result in
breast growth and female fat distribution. Female-to-males (FTM) or trans
boys receive androgens, and will become more muscular and develop
 314 A. L. C. de Vries and P. T. Cohen-Kettenis

a low voice and facial-and body hair growth (Delemarre-van de Waal &
Cohen-Kettenis, 2006).
In addition, new themes will be brought up in sessions. In this stage,
some of the youths will start going out with someone for the first time and
they will be more consciously dealing with dating, romantic relationships,
partner choice, careers, and having children. Because the operations
suddenly seem to be close at hand, the possibilities and limitations of the
gender reassignment surgery, about which they will gradually have to make
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choices (e.g., various types of metaidoioplasty or phalloplasty, or no genital

surgery for trans boys), are once again discussed (Cohen-Kettenis, 2006).
Completely irreversible interventions. When the adolescent has come
of age at 18 and still meets all the eligibility criteria, he or she can be eligible
for the last step of the gender reassignment treatment trajectory, the gen-
der reassignment surgeries. Trans boys may undergo several operations: (if
they came relatively late to the clinic and already had some breast develop-
ment) mastectomy, hysterectomy or oovariectomy, and, if desired, genital
operations (metaidoioplasty or phalloplasty). Trans girls usually undergo
vaginoplasty and, if necessary, at their own financial expense, augmenta-
tion mammoplasty. Trans girls who began puberty suppression at a young
age often have insufficient penile skin for a classical vaginoplasty and need
an adjusted surgical procedure using colon tissue.

TREATMENT EVALUATION

While there are still reservations about physical medical interventions in

youths under the age of 18 (e.g., Korte et al., 2008; Meyenburg, 1999; Viner,
Brain, Carmichael, & Di Ceglie, 2005), many clinicians are changing their
views on this (Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008).
There are indications that starting cross-sex hormones early (under 18 but
over 16 years of age) followed by gender reassignment surgery at 18 can be
effective and positive for general and mental functioning (Cohen-Kettenis &
van Goozen, 1997; Smith, van Goozen, & Cohen-Kettenis, 2001; Smith, van
Goozen, Kuiper, & Cohen-Kettenis, 2005).
By now, two studies have been performed evaluating the effects of
puberty suppression. Psychological functioning of the first 70 gender dys-
phoric adolescents eligible for puberty suppression was measured twice: at
their attendance at the clinic and shortly before the start of cross-sex hor-
mones. Their behavioral and emotional problems and depressive symptoms
decreased, while general functioning as measured by the Global Assessment
Scale (Shaffer et al., 1983) improved significantly during puberty suppres-
sion. No adolescent withdrew from puberty suppression and all started
cross-sex hormone treatment, the first step of the actual gender reassign-
ment (de Vries, Steensma, Doreleijers, et al., 2010). A second group, assessed
postoperatively, appeared to be satisfied with their lives and no longer
 Dutch Approach to Gender Dysphoria in Children and Adolescents 315

gender dysphoric (de Vries, 2010). Many studies in gender dysphoric adults
have demonstrated that gender reassignment treatment is effective. These
initial results demonstrate that this is also the case in young people who
have received GnRHa to suppress puberty at an early age, followed by the
actual gender reassignment (de Vries, 2010).
The concern that early physical medical intervention has unfavorable
physical effects has to this date not been confirmed (Delemarre-van de
Waal & Cohen-Kettenis, 2006). Initial studies on, for example, bone devel-
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opment and insulin sensitivity demonstrate favorable results (Schagen et al.,

in press; Vance, et al., in press).

SUMMARY AND CONCLUSIONS

At the Amsterdam gender identity clinic the clinical approach to prepubertal

children under the age of 12 is different from the approach to adolescents
starting at age 12. In children, the diagnosis is focused on elucidating
all possible factors that could play a role in gender dysphoria, but the
gender dysphoria itself is not actively dealt with in treatment. A general
recommendation is given not to have transitioning take place too early, but
to carefully observe how the gender dysphoria develops in the first stages
of puberty. Parents and child are supported in tolerating the uncertainty
about the outcome. Of special concern are concomitant problems and,
whenever present, necessary help is actively sought so that the child can
develop in an optimal way.
Gender dysphoric adolescents who have reached puberty also undergo
meticulous diagnosis, but, in contrast to prepubertal children, they can be
considered eligible for physical medical interventions under strict condi-
tions. This does not, however, rule out parallel psychotherapy or other
psychological interventions. Any vulnerable aspects of the youth’s func-
tioning or circumstances deserve thorough concern. These need not be
contraindications to physical medical interventions, but they do need due
attention. Using an approach that cares for every aspect of the adoles-
cent´s psychosocial functioning and not only aims at eliminating the gender
dysphoria, we try to provide the future young adult with the necessary
resources for an optimal psychological development and a good quality of
life. Despite the understandable concern about potential harm that could be
done by early physical medical interventions, it seems currently that with-
holding intervention is even more harmful for the adolescents’ wellbeing
during adolescence and in adulthood. It is fortunate that nearly all diag-
nostic and treatment aspects, except for breast enlargement, are covered by
insurance. Transgender individuals in the Netherlands do not need to suffer
from incomplete or inadequate treatment because of financial problems.
 316 A. L. C. de Vries and P. T. Cohen-Kettenis

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