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

• Amerikaanse richtlijnen steunen puberteitsblokkers, cross-sex hormonen en operaties voor jongeren met genderklachten, maar Engeland, Zweden en Finland trokken zich terug nadat reviews zwak bewijs van voordeel vonden.
• De oorspronkelijke Nederlandse studies waarmee transitie bij jongeren begon, hadden ernstige gebreken: geen vergelijkingsgroep, een gebrekkige manier om genderklachten te meten, en patiënten die sterk verschilden van die van nu.
• Sommige ethici betogen dat jongeren recht zouden moeten hebben op deze behandelingen op basis van hun eigen lichaamsdoelen en keuzevrijheid, zonder bewijs van voordeel voor de geestelijke gezondheid of zelfs een diagnose.
• Gorin betoogt dat dit botst met de basisplicht van de geneeskunde om geen schade te doen: een lichaamsverandering willen is geen voldoende reden voor risicovolle behandeling zonder bewijs dat die de gezondheid helpt.
• Hij zegt dat landen verschillen deels omdat ze bewijs verschillend beoordelen (zorgvuldige systematische reviews tegenover losse samenvattingen van experts), en deels omdat ze het oneens zijn over de vraag of de geneeskunde de gezondheid moet verbeteren of identiteitsdoelen moet vervullen.

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.