Summary

Philosopher Moti Gorin asks what gender medicine for young people is meant to achieve. The original Dutch treatment plan aimed to improve young people's mental and physical health. But reviews in England, Sweden and Finland found the evidence for those benefits is weak. Some ethicists, notably Florence Ashley, now argue that blockers, hormones and surgery are justified by patients' wishes for their bodies and their right to choose, not by health gains. Gorin argues this clashes with medicine's duty to do no harm. A patient's right to choose means choosing between options doctors can justify, not demanding any treatment they want. He concludes that serious treatments for minors need good evidence that benefits outweigh risks. This is a philosophical argument, not new data. He admits it mostly argues against a view, and the journal published several critical replies.

Key findings

• 미국 지침은 성별 불쾌감이 있는 청소년에게 사춘기 차단제, 반대 성 호르몬, 수술을 지지하지만, 잉글랜드, 스웨덴, 핀란드는 이익의 근거가 약하다는 검토 후 물러났습니다.
• 청소년 전환을 시작한 원래의 네덜란드 연구에는 심각한 결함이 있었습니다. 비교 집단이 없었고, 성별 불쾌감을 재는 방식에 결함이 있었으며, 환자가 오늘날 보는 환자와 매우 달랐습니다.
• 일부 윤리학자들은 정신 건강상의 이익이나 진단조차 증명하지 않고도 청소년의 신체 목표와 선택의 자유에 근거해 이런 치료를 받을 권리가 있어야 한다고 주장합니다.
• 고린은 이것이 해를 끼치지 말라는 의학의 기본 의무와 충돌한다고 주장합니다. 신체 변화를 원한다는 것만으로는 그것이 건강에 도움이 된다는 근거 없이 위험한 치료를 할 충분한 이유가 되지 못합니다.
• 국가들이 다른 이유는 일부 근거를 다르게 판단하기 때문이고(신중한 체계적 검토 대 느슨한 전문가 요약), 일부는 의학이 건강을 개선해야 하는지 정체성 목표를 실현해야 하는지에 의견이 다르기 때문이라고 말합니다.

Abstract

The original “Dutch Protocol”—the treatment model comprised of puberty blockers, cross-sex hormones, and surgery—was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions’ effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender-affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's “embodiment goals.” In this article, I raise objections to autonomy-based justifications for pediatric gender-affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision-making and, consequently, put patients at risk of medical harm.

Conclusion

This article argues that the autonomy-based view—according to which medical interventions for gender dysphoria in youth ought to be guided by patients' embodiment goals rather than measurable health outcomes—is misguided, as it conflicts with medicine's long-standing commitment to nonmaleficence. The author contends that transition-related medical treatments for youth are justified only if there is good evidence of a favorable risk-benefit profile in terms of measurable health outcomes; an adolescent's desire to obtain particular sex characteristics is not sufficient to establish a right to such interventions. The author critiques consequentialist arguments (including those appealing to gender euphoria, creative transfiguration, dehumanization, and social marginalization) and autonomy-based arguments (including the right to an open future and an analogy to reproductive healthcare), finding them all insufficient to justify departure from the traditional medical aim of protecting and promoting patient health. The practical upshot is that, absent compelling reasons to abandon this commitment, the medical profession should reaffirm that serious medical interventions require strong evidence of a favorable risk-benefit profile for treating physical and psychiatric morbidity and relieving suffering. The author acknowledges the limitation that this article is largely negative and does not fully articulate a positive philosophical account of health or the aims of medicine, but hopes to have surfaced conceptual and moral tensions in contemporary pediatric gender medicine.