Questions related to all things trans remain one of the most virulent controversies in contemporary western society. One particular point of contention is over the question of medical transition (hormones and surgery, etc.) and, in particular, medical transition for minors. Is medical transition something that doctors should be doing, or not? People disagree! I won’t try to answer that question in this post, but I hope to do a bit of clarification of the debate by looking at three arguments for medical transition which seem largely conceptually independent of one another. I’ll say what’s good about each of them, and what’s bad. Hopefully this can help clarify your thinking on the matter.
The Medical Argument
According to the Medical Argument, medical transition is a safe and effective treatment for improving the lives of the people who suffer from gender dysphoria, the psychological condition whereby people feel distress about their body’s sex. This argument understands the case for medical transition to be effectively the same as the treatment one might receive for any other medical condition. Something is wrong that is causing pain or distress; that pain or distress can be relieved by a suitable course of medical treatment; therefore, that medical treatment should be available.
The advantages of this argument are obvious. First, it adopts a well-accepted justification for providing medical care, in general, to this specific context. There’s no need to adopt any controversial moral principles here (as later arguments will). This is all straight down the middle. A related advantage is that this provides a justification for funding medical transition. One of the problems with discussing “access” to medical care is that that term is (sometimes deliberately) vague about whether we’re talking about doctors being allowed to provide a service by relevant laws and regulations, or talking about the provision of those services being covered by insurance (in the US, e.g.) or directly provided by a national health service (in the UK, e.g.). So it’s possible that we could decide that medical transition should be allowed but not covered. Arguing that medical transition should be covered is a bigger lift. And the Medical Argument provides a justification for thinking that medical transition should be covered. Insurance companies and national health services, in general, cover safe and effective treatment of painful medical conditions. If medical transition is a safe and effective treatment of a painful medical condition, it should therefore be covered.
The problem with the Medical Argument is that it rests on the empirical premise that medical transition is, in fact, a safe and effective treatment for gender dysphoria. This is a controversial empirical question. Many activists claim that the science on this is “settled,” but this claim seems more driven by the desire to accept the medical argument (because of its good qualities) rather than driven by an impartial evaluation of the empirical data. Studies of the effectiveness of medical transition tend to be of rather low quality. This is particularly true of the empirical data on youth transition, which is a much newer phenomenon with a correspondingly more scant evidence base. The governments of Norway, Finland, Sweden, and the UK have recently classified youth medical transition as an experimental procedure lacking adequate evidential support after extensive review of the existing literature.
Another problem, more internal to the trans activist community, is that the Medical Argument enshrines what is sometimes known as “transmedicalism,” the idea that you are transgender if and only if you have the diagnosable medical condition of gender dysphoria. But some individuals consider themselves to be transgender (and may in fact be transgender; I don’t want to take a stance on the issue of who really is and isn’t trans) not because they suffer from a medical condition of gender dysphoria but because they regard living as trans as an expression of their most authentic self, or something like that. For this reason, many trans activists are vehemently opposed to viewing transgenderism as essentially a medical condition in need of treatment. But that’s precisely what the Medical Argument does.
The Libertarian Argument
The Libertarian Argument understands the decision to pursue medical transition as a personal choice that anyone should be allowed to pursue. For analogy, breast enhancement and reduction are fairly common surgeries among women for aesthetic and comfort reasons, not medical reasons. If a male wants breast enhancement surgery, for whatever reason, there’s no reason not to allow that. And if women want radical breast reduction to become flat-chested, then there’s no reason not to allow that. And so on for any number of other medical procedures. “My body, my choice,” as they say.
The advantages to this argument are, again, obvious. We generally allow people to have medical autonomy, provided that they have given their informed consent. Again, breast enhancement and reduction are quite common. The Libertarian Argument just says that we should adopt this generally-accepted model in the realm of medical transition. As someone with rather libertarian instincts, I find this pretty compelling.
There are problems here, too, though. First comes from the distinction between allowing and covering medical treatments. The Libertarian Argument provides a strong case that medical transition should be allowed. It provides a much weaker case that medical transition should be covered. Breast enhancement and reduction surgeries are considered to be cosmetic surgeries, and are thus not routinely covered by insurance or other health services. If you want a boob job but can’t afford one, that’s unfortunate, but it’s not in any way unjust. If we think of medical transition as basically the same as a boob job, then it is similarly not unjust to fail to cover medical transition services. But this is not the position of most trans activists. When trans activists say that they are “fighting to ensure access to healthcare for transgender individuals,” what they mean is that they are trying to get medical transition covered, not just allowed. The Libertarian Argument is insufficient to that end.
A second problem is that the Libertarian Argument might conflict with the Hippocratic Oath. We do generally grant people a great deal of medical autonomy. But if someone wanted to amputate a healthy limb, their doctor would be much more likely to refer them to a psychologist than a surgeon. Most surgeons feel, quite understandably, that amputating a healthy limb would violate their oath to do no harm. And the same concerns arise around certain forms of medical transition, like vaginoplasty and phalloplasty. This might not be a good objection; a lot depends on what “harm” consists in, and some subjectivist accounts of harm would deny that any harm has occurred here; if the patient is happy with the procedure, no harm has been done. So perhaps we must understand advocates of the Libertarian Argument as also committed to a subjectivist account of harm. Or perhaps they’re just opponents of the Hippocratic Oath.
The third problem is that the Libertarian Argument doesn’t provide a strong case for medical transition for minors. The whole idea of a legal minor is that children do not, and should not, have full autonomy. Autonomy develops over time with both knowledge and mechanical brain development. Children are too ignorant and too cognitively undeveloped to make important decisions for themselves, particularly medical decisions. If a teenage girl wants breast enhancement surgery, her parents might very well respond “not in my house, young lady; you can pay for that yourself when you’re on your own” and not wrong her in any way by so doing. If we understand medical transition as basically the same as breast enhancement, parents of trans kids may say precisely the same thing to their children that desire medical transition, and not wrong them in any way.
The Teleological Argument
The Teleological Argument is the most ambitious of our three arguments for medical transition. According to the Teleological Argument, trans individuals are those who have a gender identity that doesn’t match their body. This is, by itself, a problem with their body. Individuals with a certain gender identity are supposed to have a body that matches their gender identity. Cisgender people have this naturally. Transgender people don’t. Medical transition is an effective means to allowing those transgender people to have the body that they are supposed to have, and so they are entitled to medical transition.
The Teleological Argument promises to remedy all the defects of the Medical Argument and the Libertarian Argument. Unlike the Medical Argument, the Teleological Argument relies on no diagnosis of gender dysphoria or the empirical premise that medical transition is an effective way to alleviate the distress of dysphoria. Instead, one qualifies for medical transition in virtue of their gender identity, and transition is justified not on the grounds that it is effective but on the grounds that it is suitable. And unlike the Libertarian Argument, transition is not a choice that adults make, but instead a fitting remedy to a flaw in the natural order. As such, this flaw should be corrected in children as much as adults. And much of medicine is teleological: the body is supposed to be healthy, in a sense. And if medical transition is just another way of making the body the way that it is supposed to be, then doctors need feel no qualms about assisting medical transition, and society may well have a positive right to fund medical transition procedures the same was as any other medical procedure.
But of course, there are problems. The most egregious concern is the novel conceptual framework that is being appealed to here. The Medical Argument and the Libertarian Argument both appeal to concepts (effective relief of suffering, medical autonomy) that are well-understood and widely accepted. That is the source of their weaknesses (those models don’t apply in exactly the way that trans activists would typically like), but also their strengths (there’s a straightforward justificatory framework that’s just being applied in a new case). The Teleological Argument, by contrast, attempts to introduce a whole new framework that gets trans activists everything they want, but that framework is itself dubious. First, it relies on the incredibly vague and highly contested notion of “gender identity.” As I’ve argued before, the most popular accounts of that term end up being circular or incoherent. The most intelligible definition of gender identity is just “the sex that someone desires to have, in perhaps some deep way.” But if that’s what gender identity amounts to, then we’re back to dealing with the Libertarian Argument; if we understand gender identity simply as a kind of desire, it won’t do the teleological heavy-lifting it’s supposed to.
Equally dubious is the teleological conceptual framework that the argument relies on. The idea that we can describe not just how a body is, but the way a body is supposed to be, is a controversial one in the philosophy of biology. The least controversial versions of that doctrine are pretty reductively naturalistic. The body is supposed to be healthy, in the way that doctors recognize. The idea that someone might have a healthy male body, but not have the body that they’re supposed to have because they are supposed to have a healthy female body, is one that is difficult to square with contemporary accounts of biological teleology.
And even if it were true that there are some healthy males that are supposed to be healthy females (and vice versa), it’s not clear that this provides a justification for medical transition as it exists today. Many trans individuals dream of some intervention by God or magic or sci-fi technology that will completely remake their body at the molecular level as though they were born as a member of the other sex. Medical transition technologies have advanced substantially over the last six decades, but we’re nowhere near that point. There’s no way to give a healthy male a healthy female body, or vice versa. At least not yet. If some healthy males are supposed to have healthy female bodies, it’s unfortunately not possible for them to have the kind of body they’re supposed to have. So the Teleological Argument doesn’t really provide a justification for medical transition as it exists today.
There’s more that could be said about the considerations for and against each of these arguments. Perhaps some of these objections can be answered. Surely there are some objections, or some virtues of the various arguments, that I haven’t thought of. Feel free to sound off in the comments. But hopefully this discussion was clarifying and useful.
Hey, thanks for your insights - totally vibing with your thoughts and concerns about the teleological argument, nothing more to add there. Few additional thoughts:
In invoking the medical argument, it may not be necessary to categorize transgenderism solely as a medical condition to draw conclusions on permissibility or insurance coverage. Recognizing that transgenderism or gender dysphoria can cause significant mental distress for some individuals may suffice. While some may seek medical changes due to cosmetic concerns rather than mental distress, akin to cosmetic interventions typically not covered by insurance, specific cosmetic procedures may be covered in jurisdictions where there's significant psychological distress. For instance, corrective surgeries like pinning protruding ears in children or breast reconstruction post-breast cancer are covered in some geographies.
Invoking the Hippocratic oath, especially in its entirety, may be misleading in this context as many of its principles are pretty much outdated in modern medicine. For instance, the oath's prohibition of interventions like cutting for those with stones conflicts with contemporary surgical practices. Similarly, actions such as abortions and end-of-life care, including assisted dying, contradict traditional teachings of the oath. However, the core principle of 'do no harm' is what you likely refer to. The discussion then hinges on our definition of harm, as you rightly point out. Allowing people to die in extreme agony may constitute far more harm than providing compassionate assistance to terminally ill patients who wish to end their suffering. Medical practice demonstrates that sometimes objective harm must be accepted to safeguard patient autonomy. This principle is widely recognized and enshrined in medical regulations across various jurisdictions.
Ultimately, it seems that the arguments presented are intricately intertwined. Deliberating between the medical and libertarian perspectives is a very common focal point in the realm of medical ethics. Even when a particular medical procedure is deemed safe, effective, and likely to substantially benefit an individual patient, its administration hinges upon the patient's consent. For instance, a Jehovah's Witness would not undergo a blood transfusion against their beliefs, even if it meant facing death otherwise. In most scenarios, autonomy typically outweighs medical considerations. Of course, exceptions exist, particularly in global or public health contexts, where individual liberties may be curtailed for the collective good. Examples include mandates for vaccinations, quarantines, or mass drug application programs, where broader public health concerns supersede individual freedoms.
So perhaps utilizing established medical ethics frameworks could still offer valuable insights into addressing the complexities of transitioning. I resonate with the emphasis on libertarian arguments, evident in other medical domains where even concerns about minors' ability to consent are usually very carefully managed. Applying the ethical and medical rigor of other domains in medicine to transitioning could elevate the quality of care and safeguard individual autonomy.
“There’s no way to give a healthy male a healthy female body, or vice versa. At least not yet.”
This worries me most, as I think many people with strong opinions don’t realize quite how far we are from being able to actually, fully transition medically.
To take an imperfect, but less controversial analogy: If someone wanted desperately to be 10 inches taller, and we could do that, but only at the cost of them being wheelchair-bound for the rest of their lives, I don’t think many would argue that we should cover or endorse that, or allow it for teenagers who are still developing. But if the cost is that their legs will occasionally feel a bit numb, that’s a different consideration altogether. So what cost is acceptable? To me more openness around the tradeoffs, and the evolving capabilities of modern medicine, and thus being able to discuss, if not answer, these questions better, would probably do more to change my mind on the issue of medical transition than anything else.
However, it is still a tragedy to me that children grow up with models of what it means to be male or female that are so limited that they feel incompatible with those roles. Identity is created in “dialogue” with society at large. And our society has made it very hard – for some, nearly impossible – to fit the standard of what it means to be a woman (and, to a lesser degree, what it means to be a man). So of course young people will go to extreme lengths to try to find a way to fit in, make sense of who they are, and find new meaning.
We’ve always been willing to edit our bodies, and those of our children, in order to fit with who we think society wants us to be – they range from fairly benign, like tattoos, piercings and scarification, to potentially crippling or even lethal, tying of feet, elongation of neck (e.g. Kayan), FGM, and circumcision (e.g. Ulwaluko). I think anyone can recognize those things as downstream of culture, while also often very deeply and inextricably tied to people’s identities. And they can see that proper, safe medicine is not a solution as much as it is a way to minimize harm once people have already committed to the procedure.
I sympathize deeply with people who feel like they don’t fit into the world they were born into – that even their bodies are wrong. When that happens, it shouldn’t be the person’s responsibility to take such extreme measures as medical transition is to feel at home. When so many people want medical transition, that’s an indictment of the rest of us (and not just the progressives). We – all of us, but particularly culture shapers – should take far more responsibility for our expectations for others, and not manipulate kids into self-selecting into some camouflaged social-darwinistic/eugenics program aimed at turning all of us into Kardashians. (Oh, irony of ironies!)