Ethicists Argue Evidence, Not Redefined Goals, Should Guide Gender Care

A commentary published in BMC Medical Ethics argues that proposals to redefine how gender-affirming medical treatment for minors is evaluated do not resolve what the authors describe as weak and inconsistent evidence of benefit. The piece, written by FD Zepf, M Ligges, C Ligges, L König, T Banaschewski, CS Monsalve, R Kaltiala and J Smids, appears as a Matters Arising article responding to a recent publication by Oosthoek and colleagues.

At the centre of the dispute is a proposed paradigm shift. Oosthoek and colleagues argue that instead of relying on traditional clinical outcome measures such as mental health, global functioning or quality of life, justification for gender-affirming medical treatment in adolescents with gender dysphoria or gender incongruence should rest on a patient-defined standard centred around embodiment goals and autonomy. The responding authors acknowledge the importance of incorporating patient perspectives and values, but raise what they call significant theoretical and clinical concerns about the implications of that approach.

The commentary’s central critique concerns a tension between the proposed framework and established principles of medical ethics, particularly beneficence and non-maleficence. The authors contend that abandoning the expectation of demonstrable clinical improvement undermines the professional ethos of health care and poses risks to vulnerable adolescents. They also caution against what they describe as using ethics as a rhetorical refuge to justify treatments for which evidence of benefit remains weak or inconsistent.

In their conclusion, the authors state that they were surprised by what they characterise as a frank admission in the original paper of the weakness of the evidence for the claim that gender-affirming medical treatment leads to improved outcomes for adolescents with gender dysphoria. While they fully agree that the evidence is poor, they argue that a different response is warranted than the one defended in the paper. Affected vulnerable minors, they write, deserve better than to see the goal posts for what counts as an effective treatment moved after the fact.

The responding authors further argue that justifying treatment on the basis of patient desires and autonomy profoundly contradicts established medical ethical principles of beneficence and non-maleficence, as well as clinicians’ professional ethos and responsibilities. They suggest that redefining effectiveness after the fact will neither improve knowledge nor clinical outcomes.

As an alternative, the commentary aligns itself with evidence-based guidelines from Sweden and Finland. It proposes that non-medical interventions should become the first line of intervention. These include psychosocial support, awaiting further gender identity development, which the authors note might actually constitute changes in self-interpretation, and treatment of co-occurring mental health problems.

The authors are careful to note that these non-medical interventions also have limited evidential support. They call for better research into both medical and non-medical treatment options that employs current and, in their view, perfectly reasonable mental and physical health-related outcome measures, describing such research as urgently needed.

The commentary also addresses suicide-related evidence in a footnote. It states that even though the best quality studies currently do not suggest higher suicide rates after treatment, some clinical samples show concerningly high rates of completed suicide. The authors cite this as context for their concern about the state of the evidence base surrounding treatment of this population.

The article is an open access Matters Arising piece, published on 12 October 2026 in BMC Medical Ethics, volume 27, article number 214. The original article it responds to was published on the same date, and a further Matters Arising response to the commentary was also published on that date. According to the journal’s data availability statement, no datasets were generated or analysed during the study.

The exchange highlights a continuing disagreement within clinical ethics over how treatment effectiveness for minors with gender dysphoria should be defined and measured. The responding authors’ position is that effectiveness should continue to be judged against established clinical outcome measures, and that shared decision-making should be careful and honest, with well-being prioritised, until stronger evidence for medical interventions emerges. Their critics in the original paper, by contrast, favour a framework anchored in patient-defined embodiment goals. The journal’s publication of further Matters Arising items indicates that this debate remains active.

Subject of Research: An ethical critique of proposed patient-defined evaluation standards for gender-affirming medical treatment of minors

Article Title: Moving the goal post and using ethics as a rhetorical refuge doesn’t change the evidence: About the debate on the best care for minors with gender issues

Article References: Zepf, F., Ligges, M., Ligges, C., König, L., Banaschewski, T., Monsalve, C., Kaltiala, R., & Smids, J. (2026). Moving the goal post and using ethics as a rhetorical refuge doesn’t change the evidence: About the debate on the best care for minors with gender issues. BMC Medical Ethics, 27(1), Article 214. https://doi.org/10.1186/s12910-026-01631-z

Image Credits: AI Generated

DOI: 10.1186/s12910-026-01631-z

Keywords: gender-affirming care, medical ethics, minors, gender dysphoria, beneficence, non-maleficence, clinical outcome measures, psychosocial support, evidence-based guidelines, shared decision-making, BMC Medical Ethics, Matters Arising