Research report: Reply to: 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

A published reply in the journal BMC Medical Ethics has restated the central claims of an analysis examining how “effectiveness” is conceptualized in research on gender-affirming medical treatment for adolescents. The response, published on 12 October 2026 as a Matters Arising item, addresses critiques from Zepf and colleagues and clarifies what the original authors argue about the evidence base cited in the World Professional Association for Transgender Health Standards of Care 8. The reply is authored by Skye Stanwich, Ezra D. Oosthoek, Karl Gerritse, David Matthew Doyle and Annelou L. C. de Vries, and it aims to correct what the authors see as misunderstandings of their original paper rather than to introduce new empirical findings.

The original article, according to the reply, examined how effectiveness has been conceptualized and operationalized in the empirical literature on gender-affirming medical treatment for adolescents, specifically within the evidence base cited in the WPATH Standards of Care 8. The authors say their goal was not to dismiss that literature but to ask how effectiveness and improvement are defined, operationalized and evaluated in the first place, and by whom. In their reply, they restate the central claims of the article, clarify contested points and briefly reflect on ongoing discussions about evidence and outcomes in this field.

A key clarification concerns traditional clinical outcomes. The authors emphasize that they do not argue that outcomes such as gender dysphoria, mental health, global functioning or quality of life are irrelevant to adolescent transgender care. Instead, they question how these particular outcomes become established as the primary indicators of “successful” treatment, and they seek to highlight normative assumptions underlying these measures that they say are often taken for granted. Their argument targets the process by which certain measures are prioritized, not the measures themselves.

The reply also addresses claims about autonomy and embodiment. The authors state that they do not propose replacing established clinical outcomes with concepts such as autonomy or embodiment. Their discussion of autonomy, they explain, is intended to foreground the ethical relevance of trans youths’ own experiences and interpretations, both within clinical care and research. In line with this, they advocate for greater inclusion of trans youth in shaping research agendas and identifying which outcomes of gender-affirming medical treatment are meaningful in their lived experience. They describe such participatory approaches as intended to complement and enrich clinical and ethical considerations, not to replace them.

Another clarification involves the analytical lens the authors call trans negativity. They explain that a trans negativity perspective highlights the normative and curative idea that negative affect is a problem that should be resolved through gender-affirming medical treatment. They stress that they do not propose trans negativity as a new clinical paradigm to organize adolescent care, nor do they deny the importance of alleviating suffering and supporting well-being through such treatment. Rather, the concept functions as a conceptual framework for examining how dominant narratives shape expectations around transition and successful treatment outcomes in adolescent transgender care.

Within this framework, the authors identified what they term a “logic of improvement”: a tendency within the clinical academic literature on gender-affirming medical treatment to frame successful transition as a largely linear journey, moving from distress toward quantifiable improvement across a range of standardized psychological and psychosocial measures. They argue that improvement is not unimportant, but that experiences of transition may be more complex, ambivalent or non-linear than this framework readily accommodates. Young people, they note, may continue to experience forms of distress, uncertainty or evolving self-understanding during or after transition-related care, and still find the treatment meaningful or beneficial.

The authors contend that recognizing this complexity does not undermine clinical care. In their view, it may instead support more honest communication during consultations, clearer expectation-setting and a broader understanding of what care experiences can involve. The broader aim of their article, they write, was not to reject research on outcomes of gender-affirming medical treatment, but to encourage greater reflection on how these outcomes are selected, interpreted and prioritized within adolescent transgender care. Through the lens of trans negativity, they examined how particular understandings of successful transition become dominant within research and clinical discourse, and what experiences may become less visible as a result.

The reply also engages with the principles of beneficence and non-maleficence raised by Zepf and colleagues. The authors agree that these principles are central to adolescent healthcare, including transgender care, but argue that the principles do not function independently of broader assumptions about risk, benefit and uncertainty, and rely on particular interpretations. Considerations of harm, they note, apply not only to medical interventions but also to delayed, deferred or withheld care. They further point out that non-medical interventions also operate under conditions of limited evidence, and that “waiting” is not simply the absence of intervention, a safer first-line option or a neutral baseline, but a clinical and ethical choice with its own potential benefits and risks. If non-medical approaches such as psychotherapy were associated with worsening mental health or functioning in treatment-eligible adolescents, they argue, this would equally raise concerns under the principles of beneficence and non-maleficence.

The authors also find common ground with their critics on one point. They agree with Zepf and colleagues that gender-affirming medical care should benefit young people overall and should not be understood as a “cure-all” for global psychological or social difficulties. Their point, they write, is that recognizing and attending to the complexity and variability of young people’s experiences of treatment may support more individualized and responsive care, which may include both medical and psychosocial interventions if indicated. This framing positions their argument as a call for nuance in how treatment success is discussed rather than a rejection of any particular care pathway.

Looking forward, the authors note that research in this field continues to evolve, and that a growing body of work is exploring how treatment outcomes might be conceptualized differently or more expansively, in line with a broader movement toward patient-reported outcomes in medicine. This includes research using participatory methods to examine what trans people themselves consider meaningful outcomes of care, including for adolescents. At the same time, they emphasize that gender-affirming medical treatment should not be completely halted pending some future ideal evidence base, particularly given the lack of clarity regarding exactly what evidence and outcome measures would be sufficient. This returns them to what they identify as a central point of their original article: what counts as adequate evidence, for whom, and under what conditions. These questions, they conclude, are not solely empirical; they also require ethical and conceptual reflection on how effectiveness is defined, whose perspectives are included in that process, and what forms of flourishing or difficulty are acknowledged, and they believe these questions remain important for the field moving forward.

Subject of Research: How effectiveness is defined and evaluated in research on gender-affirming medical treatment for adolescents

Article Title: Reply to: 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: Stanwich, S., Oosthoek, E. D., Gerritse, K., Doyle, D. M., & de Vries, A. L. C. (2026). Reply to: 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 215. https://doi.org/10.1186/s12910-026-01632-y

Image Credits: AI Generated

DOI: 10.1186/s12910-026-01632-y

Keywords: gender-affirming care, adolescents, medical ethics, effectiveness, WPATH Standards of Care 8, trans negativity, beneficence, non-maleficence, patient-reported outcomes, BMC Medical Ethics, participatory research, clinical outcomes