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

• As diretrizes dos EUA apoiam bloqueadores da puberdade, hormônios cruzados e cirurgia para jovens com sofrimento de gênero, mas Inglaterra, Suécia e Finlândia recuaram depois que revisões encontraram evidências fracas de benefício.
• Os estudos holandeses originais que deram início à transição de jovens tinham falhas graves: nenhum grupo de comparação, uma forma falha de medir o sofrimento de gênero e pacientes muito diferentes dos atendidos hoje.
• Alguns eticistas argumentam que os jovens deveriam ter direito a esses tratamentos com base em seus próprios objetivos corporais e liberdade de escolha, sem prova de benefícios para a saúde mental ou mesmo um diagnóstico.
• Gorin argumenta que isso entra em conflito com o dever básico da medicina de não causar dano: querer uma mudança no corpo não é razão suficiente para um tratamento arriscado sem evidência de que ajuda a saúde.
• Ele diz que os países diferem em parte porque avaliam as evidências de forma diferente (revisões sistemáticas cuidadosas versus resumos mais soltos de especialistas) e em parte porque discordam sobre se a medicina deve melhorar a saúde ou realizar objetivos de identidade.

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.