A Personal Lens on the Dutch Protocols: Secondary Hypogonadism and the Limits of Puberty Blockers
Calling for Retraction: Exposing Negligent Research in Transgender Medicine
In the realm of gender-affirming care, the Dutch protocols stand as a celebrated blueprint, guiding adolescents with gender dysphoria through a carefully staged journey of puberty suppression, hormone therapy, and surgery. But as someone who faced secondary hypogonadism in the 1980s, I can’t help but see this framework through a different lens—one shaped by urgent warnings from my pediatric endocrinologists and a treatment path that diverged sharply from what the Dutch model offers. Both my experience and the protocols share a critical pivot point: the need for hormone replacement therapy (HRT) around age 16. Yet, while my androgens fueled a puberty aligned with my male biology, the cross-sex hormones in the Dutch protocols—though effective for bone strength or cosmetic changes—fall short of fostering full sexual and mental maturity, leaving adolescents in a prolonged state of arrested development. Worse, the protocols obscure these shortcomings by leaning on an unrelated condition, precocious puberty, while sidestepping the stark inability of cross-sex hormones to ignite sexual function in natal males. Here’s my story, interwoven with a critique that demands attention.
The Dutch Protocols: A Roadmap Under Scrutiny
It’s not just about appearance; it’s about a fundamental piece of human development left unaddressed.
The Dutch protocols unfold in three distinct phases for teens diagnosed with gender dysphoria:
Puberty Suppression: Around age 12, gonadotropin-releasing hormone analogues (GnRHa) slam the brakes on natural puberty, halting developments like breast growth or a deepening voice.
Cross-Sex Hormones: At 16, the regimen shifts—estrogen for those transitioning to female, testosterone for those transitioning to male—while GnRHa keeps natural hormones at bay.
Surgical Intervention: By 18, genital surgery becomes an option for those who qualify.
Advocates champion this as a reversible pause, a chance for adolescents to explore their gender identity without permanent physical shifts. It’s a compelling pitch—but one that unravels when you dig deeper, especially through the lens of my own medical history and the medical histories of the individuals who were born with my rare disorder.
My Battle with Secondary Hypogonadism
Back in the 1980s, I was a teenager grappling with secondary hypogonadism—a condition where my pituitary gland failed to cue my gonads, leaving puberty on indefinite hold. My doctors didn’t mince words: without intervention, I’d face a future devoid of sexual function, and I would be stuck in adolescence as well as bone decalcification and stunted growth. Their solution? Medically induced puberty with androgens, the hormones my body was meant to produce. They were adamant that HRT had to kick in around age 16 to dodge irreversible damage—physical deficits like underdeveloped genitals and psychological gaps in emotional maturity. Thankfully, the treatment worked, steering me toward a normal adolescence. That urgency, that timeline, echoes in the Dutch protocols—but the parallels stop there.
Where the Dutch Protocols Diverge
Here’s the rub: the Dutch protocols use GnRHa to suppress puberty in kids with perfectly functioning endocrine systems, creating a hypogonadotrophic state that mimics my secondary hypogonadism.
For me, this was a disorder to correct; for them, it’s a deliberate step. At 16, both paths turn to hormones—my androgens restored what my body needed, while their cross-sex hormones chase a different goal. But this switch reveals a chasm in outcomes.
Sexual Function: A Missing Spark
Cross-sex hormones can sculpt the body—breasts for natal males, facial hair for natal females—but they don’t ignite the sexual machinery tied to one’s biological sex. Take a natal male on GnRHa and estrogen: his testes stay dormant, fertility fades, and libido never wakes up. My endocrinologists drilled into me that sexual function hinges on timely, sex-specific hormones. Without them, I’d have been left incomplete—a fate the Dutch protocols risk locking in permanently. It’s not just about appearance; it’s about a fundamental piece of human development left unaddressed.
Mental Maturity: Stuck in Limbo
The brain doesn’t mature in a vacuum. Adolescence is when sex hormones sculpt neural pathways, sharpening cognition and emotional depth. By stalling puberty until 16, the Dutch protocols delay this process. Cross-sex hormones step in, sure—they bolster bones and tweak the body’s surface—but they don’t replicate the intricate dance of natural puberty. My doctors warned that missing this window could leave lasting echoes, subtle deficits in how I’d think and feel. The protocols’ patients, caught in this hormonal limbo, might never fully step out of adolescence.
Precocious puberty kids get their biology back on track; Dutch protocol kids don’t.
The Precocious Puberty Mirage
To justify this, the Dutch protocols point to precocious puberty, where GnRHa safely pauses early puberty until the right time. But that’s a false parallel. In precocious puberty, suppression is brief—stopping at, say, 10 or 12—then nature takes over, hormones flow, and puberty unfolds as it should. The Dutch approach, though, clamps down during the normal pubertal years, stretching that pause far longer. And when it lifts, cross-sex hormones redirect the body, not restore it. Precocious puberty kids get their biology back on track; Dutch protocol kids don’t. Leaning on this unrelated condition blurs the risks—like the permanent sexual stunting my doctors fought to prevent—and it’s a negligence that demands reckoning.
A Call to Reconsider
The Dutch protocols have carved a path for gender-affirming care, but my journey with secondary hypogonadism exposes cracks in their foundation. We both needed HRT at 16—a shared lifeline—but where my androgens built a bridge to adulthood, their cross-sex hormones offer a partial fix, cosmetic more than complete. Sexual function stalls, mental maturity lags, and the precocious puberty excuse papers over these gaps with a flimsy analogy.
My treatment, a decade before puberty blockers hit the scene, proved what’s at stake when hormones don’t align with biology. The authors of this protocol dodge these truths, ignoring the known fallout of an induced hypogonadotrophic state and misusing an unrelated condition to prop up their case. I’m calling for a retraction—not out of spite, but because leaving a child underdeveloped with severe, lifelong complications is a human rights violation.
Biography of two people talking in the video
Joshua Safer, MD, FACP
Title: Executive Director, Center for Transgender Medicine and Surgery, Mount Sinai Health System
Specialty: Endocrinology, Transgender Medicine
Bio:
Dr. Joshua Safer is a leading expert in transgender medicine and serves as the Executive Director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City. He is also a Professor of Medicine at the Icahn School of Medicine at Mount Sinai. Dr. Safer has played a central role in developing clinical guidelines for transgender healthcare and is a founding member of the U.S. Professional Association for Transgender Health (USPATH). His work focuses on evidence-based care for transgender and gender-diverse individuals, particularly in hormone therapy and medical transition pathways.
Marci Bowers, MD
Title: Surgeon and President, World Professional Association for Transgender Health (WPATH)
Specialty: Gynecology, Gender-Affirming Surgery
Bio:
Dr. Marci Bowers is an internationally renowned surgeon and a pioneer in gender-affirming genital surgery. She is widely recognized as the first transgender woman to perform such surgeries and currently practices in California. Dr. Bowers has performed thousands of gender-affirming procedures and has trained surgeons around the world. She is also the current President of WPATH and is actively involved in advancing transgender health policy and medical education. Her work bridges surgical innovation with compassionate, affirming care for transgender individuals.
References
Long-term effects puberty blockers sexual function Mayo Clinic
Puberty blockers gender dysphoric youth lack sound science JACCP
Gender-affirming treatment gender dysphoria youth research implications NCBI
Harvard Health Publishing (2005). The adolescent brain: Beyond raging hormones. Highlights differences in teen decision-making and impulse control relative to adults, linked to uneven brain maturation health.harvard.eduhealth.harvard.edu.
Claney, C. (2023). Understanding How Hormonal Changes Impact Emotional Health for Teens. Relational Psych. Explains the mood effects of estrogen and testosterone surges during adolescence relationalpsych.group.
Delemarre‑van de Waal, H. A., & Cohen‑Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: A protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, 155(Suppl_1), S131–S137. https://doi.org/10.1530/eje.1.02231
Sisk, C. & Zehr, J. (2005). Pubertal hormones organize the adolescent brain and behavior. Frontiers in Neuroendocrinology, 26(3), 163–174. Discusses “organizational” effects of hormones on brain development.
Peper, J.S., et al. (2013). Development of Risk Taking: Contributions from Adolescent Testosterone and the Orbito-frontal Cortex. Journal of Cognitive Neuroscience. Found that higher testosterone in adolescents is linked to increased risk-taking behavior, in both boys and girls cogneurosociety.org.
Dwyer, A.A., Smith, N., & Quinton, R. (2019). Psychological Aspects of Congenital Hypogonadotropic Hypogonadism. Frontiers in Endocrinology, 10:872. Reviews the cognitive and emotional impacts of absent puberty in CHH patients pmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov.
Abdulmaged, T.R. (2016). Unmanned: An Unnatural History of Human Castration. Psychology Today. Describes historical practices of castration and common traits of eunuchs (e.g. physical changes, perceived docility) psychologytoday.com.
Min, K.J., et al. (2012). The lifespan of Korean eunuchs. Current Biology, 22(18), R792-R793. Historical analysis showing significantly extended longevity in Korean eunuchs, who were often castrated before puberty pmc.ncbi.nlm.nih.gov.
Thank you for the reality check, James, there are too many people like myself who think we know when we don't. I do, however, still enjoy deferring to women, j.k., just kidding, or Rowling? I'll never know...