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

• Amerikanska riktlinjer stöder pubertetsblockerare, korskönshormoner och kirurgi för unga med könsrelaterat lidande, men England, Sverige och Finland drog sig tillbaka efter att granskningar fann svag evidens för nytta.
• De ursprungliga nederländska studierna som startade transition för unga hade allvarliga brister: ingen jämförelsegrupp, ett bristfälligt sätt att mäta könsrelaterat lidande och patienter som skilde sig mycket från dem man ser idag.
• Vissa etiker hävdar att unga bör ha rätt till dessa behandlingar utifrån sina egna kroppsmål och frihet att välja, utan bevis för psykiska hälsofördelar eller ens en diagnos.
• Gorin hävdar att detta krockar med medicinens grundläggande plikt att inte skada: att önska en kroppsförändring är inte ett tillräckligt skäl för riskfylld behandling utan evidens för att den hjälper hälsan.
• Han säger att länder skiljer sig delvis för att de bedömer evidens olika (noggranna systematiska översikter jämfört med lösare expertsammanfattningar), och delvis för att de är oeniga om huruvida medicin ska förbättra hälsan eller uppfylla identitetsmål.

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.