Looking at Gender Affirming Care Through the Lens of Justice
- La Petite Sirène
- Jun 10
- 6 min read
Jilles Smids
Pages 84-87 - The American Journal of Bioethics - Volume 25, 2025
Publié en ligne : 6 juin 2025
Kirby’s target article rightly includes “justice” as an important ethical lens through which to look at issues and controversies around pediatric gender affirming care (GAC) (Kirby Citation2025). As Kirby notes, gender dysphoria (GD) is real, and youth suffering from GD have real health needs. As a matter of justice, therefore, societies ought to provide them with appropriate health care. Nevertheless, this commentary will discuss two fundamental problems with Kirby’s analysis. First, healthcare should be evidence-based for patients to have a justice-based claim to it, while the evidence supporting medical GAC is very poor. Second, Kirby’s most important application of the principle of formal justice with the aim to defend routine provision of medical GAC fails.
Theories of health justice generally just take it for granted that healthcare does indeed improve health (e.g. Daniels Citation2001). Healthcare justice is about meeting genuine health needs fairly by means of adequate healthcare. Accordingly, societies do not have justice-based obligations to publicly fund medical GAC when there is insufficient evidence that this care on balance improves the health and well-being of youth with GD. Quite the contrary: health justice entails an obligation for society to protect them from medical treatments that, on balance, would likely harm them.
Kirby tries to establish that GAC on balance improves youth’s welfare. Instead of relying on the expertise of those who already have performed the many systematic evidence reviews, he provides his own short narrative review. He starts this review with: “The following short and medium-term, observational studies have demonstrated that the use of GAC improves the well-being and mental health outcomes of transgender and gender-diverse persons:” (61, emphasis added). Here “demonstrated” expresses the idea that there is good quality evidence and the active verb “improves” implies that GAC causes improved well-being. Subsequently, the two seminal Dutch studies by de Vries et al. (Citation2011, Citation2014) are discussed. However, these are non-controlled studies, and therefore by definition cannot demonstrate causal effectiveness (Van Breukelen Citation2025). Moreover, these Dutch studies recently have lost their credibility because of several substantial methodological problems that have been identified, including severe selection bias and use of an invalid GD measurement scale (Abbruzzese, Levine, and Mason Citation2023). Similarly, several other studies cited by Kirby in his attempt to build his case for GAC have clear methodological limitations, e.g., three are cross-sectional studies. Had Kirby relied on the extant systematic reviews that take into account these study designs and limitations, his overall conclusion would have been very different. For example, the most recent one, by a team from McMaster University, concludes that “The best available evidence reporting the effects of puberty blockers in individuals with GD was mostly very low certainty and therefore we cannot exclude the possibility of benefit or harm” (Miroshnychenko et al. Citation2025, 6).
In the section “Justice,” the paper repeatedly employs the principle of formal justice, which requires that like cases be treated alike. Most importantly, it claims that “opponents of GAC” violate this principle by applying higher evidentiary standards to GAC than to other pediatric treatments (65). They are alleged to show “misunderstanding of” or engage in “the intentional promotion of mis/disinformation about, the nature and types of research that can and should inform gender-affirming care for youth” (65). Hillary Cass is specifically mentioned as one of these opponents claimed to problematize the lack of randomized controlled trials (RCTs) in GAC. Unfortunately, the paper does not provide references to back up this serious accusation. What the Cass review does is simply observe that RCTs are lacking and helpfully explain how this contributes to the poor state of the evidence (Cass Review Citation2024). Cass does not claim that only RCTs could deliver evidence of sufficient quality.
In fact, Cass and Kirby seem to agree on how the evidence base for GAC could be improved without RCTs. Cass emphasizes the importance of long follow-up and was clearly disappointed that the NHS adult gender services refused to cooperate with the large retrospective study into “9,000 young people who have been through [gender identity services]” (32), intended as part of her review. And according to Kirby, “The GAC for youth research agenda should be intentionally enhanced to encourage and support the conduction of rigorous, mixed-methods, longitudinal studies” (68). Indeed, what the field needs is more well-designed prospective long-term cohort studies with larger sample sizes (Cf. Cheung et al. Citation2025; Clayton Citation2025; Gorin, Smids, and Lantos Citation2025), utilizing existing large numbers of patient records such as these of the pioneering Amsterdam clinic for retrospective research (Abbruzzese, Levine, and Mason Citation2023), as well as considering novel research designs, such as quasi-experiments which compare patient cohorts in countries that prioritize non-medical interventions with countries that routinely offer puberty blockers (PBs) and cross-sex hormones as first-line treatments (Van Breukelen Citation2025). Therefore, contrary to Kirby’s claims, those concerned about the current state of evidence do not claim that only RCTs could provide sufficient evidence for GAC.
As part of its argument for the claim that it is a formal injustice to hold GAC to unreasonably high evidentiary standards compared to other pediatric care practices, the paper claims that “[a]pproximately 75% of the medications prescribed to children are used off-label without the support of RCT evidence,” without providing a reference (66). However, this argument does not recognize the crucial importance of taking into account the specific type of off-label use (Cf. Cass Review Citation2024). Kirby appeals to evidence on PBs prescribed for a different indication, precocious puberty. However, he overlooks crucial differences. Precocious puberty has a much better known natural history and unlike GD can be diagnosed based on measurable biological variables. Puberty suppression in children with precocious puberty reduces sex hormones to age-normal levels and is administered for a limited time, until natural puberty takes its course. In children with GD, age-normal hormone levels are suppressed, halting age-appropriate physical and psychosexual development, giving rise to the worry that PBs “lock” children in to their GD and set them on the train to cross-sex hormones.
The paper also distorts the literature on the risks and harms of PBs. It claims that for precocious puberty, PBs have been “extensively researched over many years,” citing Budge et al. (Citation2024). However, this is not a relevant medical paper on precocious puberty, but instead a commentary defending GAC as evidence-based. Checking relevant references in Budge et al. leads to a consensus statement by pediatric endocrinologists, stating that “[f]ew controlled prospective studies have been performed with [PBs] in children, and many conclusions rely in part on collective expert opinion” (Carel et al. Citation2009, e752). This is of course quite the opposite of Kirby’s claim. Similarly, Kirby claims that there are “no red flag reveals of dangerous side effects or negative health outcomes that would preclude [the use of PBs] as a component of GAC” (66). However, his source, Krishna et al. (Citation2019), raises clear concerns about bone development, stating that “it is unclear how long GnRHa can safely be administered,” and also expresses worries about brain development and fertility (365).
Returning to healthcare justice, an important observation has in fact been made by Hilary Cass. She notes “that this group of young people have been exceptionalised compared to other young people with similarly complex presentations” (66). So, in the past the focus has been too much on their gender problem, leading to a neglect of potential co-occurring problems. In addition, lower quality- and evidentiary standards have been applied to gender care than to other care domains. Cass stresses that adolescents with gender dysphoria deserve to receive holistic care of the same quality as other youth with other conditions receive. Given the weakness of the evidence for medical GAC, such holistic care will typically first prioritize non-medical interventions, such as psychosocial interventions aimed at reducing adolescent’s distress and treatment of co-occurring conditions. As Cass explains, these interventions do not constitute conversion therapy.
In conclusion, while Kirby’s inclusion of “justice” as a lens in the service of ethical analysis of GAC as such is certainly valuable, his actual analysis is deeply problematic. Societies have justice-based duties to meet the health needs of youth with gender dysphoria by providing best available evidence-based and holistic care. Given the current state of evidence, GAC does not qualify. Hence, restricting access to GAC to a research context is not only not a violation of health justice, but is rather required by it. Finally, this commentary has identified substantial problems with Kirby’s appeal to the medical literature and his clear lack of understanding of the principles and practice of evidence-based medicine. Kirby accuses Hillary Cass and her review of spreading “mis/disinformation” (65) and “ideological bias and disingenuity” (66). Yet, for his attack, he bases himself on the not peer-reviewed white paper by McNamara et al. (Citation2024), shown to be deeply flawed (see e.g. Cheung et al. Citation2025), while the thorough 263-page Cass review is supported by no less than eight specially commissioned peer-reviewed systematic reviews. Kirby should apologize.
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