A scoping review of the ethical issues in gender-affirming care for transgender and gender-diverse individuals

Abstract

Background

Globally, there is a notable increase in recognising the health needs of transgender and gender-diverse individuals. As a result, gender-affirming care services are evolving and expanding in many parts of the world, and this has provoked increased debate on various aspects of the interventions that comprise such care. Resolution of these debates depends on addressing important ethical issues. This scoping review aims to identify the key ethical issues and arguments regarding gender-affirming care across various medical interventions.

Methods

We searched Embase, PubMed and SCOPUS to identify peer-reviewed publications that could meet some eligibility criteria such as publications presenting an ethical issue, argument, or principle related to gender-affirming care for transgender and gender-diverse individuals and having been published from 2012 to 2023. We applied Arksey and O’Malley’s scoping review framework. The text of included publications was analysed inductively.

Results

Eighty-two publications were identified for inclusion. Sixty-two publications (76%) were published in or after 2019, and 20 (24%) between 2012 and 2018.

Five aspects of gender-affirming care that draw ethical analysis or debates were identified: decision-making process, guideline and model of care, deletion of health data, funding, and fertility preservation and services. Ethical issues and arguments were identified within each aspect of care. The arguments are organised according to the four principles of biomedical ethics: autonomy, beneficence, non-maleficence and justice.

Conclusion

This scoping review captures the key ethical issues in various aspects of gender-affirming care. There were substantial differences in the depth to which each aspect of gender-affirming care was discussed, with ethical issues in decision-making processes receiving the most attention, and deletion of health data given the least attention. This review also characterises the dominant ethical arguments and underlying principles used to justify positions on the issues. Within each ethical issue, the four principles of biomedical ethics featured commonly, but were applied very differently and accorded unequal weighting. Additionally, in some discussions, arguments supporting medical interventions were given more attention; in others, the rationales opposing medical interventions were dominant. Perhaps unsurprisingly, there was limited resolution and increasing disagreement. Important constraints in the methodologies of argumentation used to support or oppose aspects of gender-affirming care were also identified.

Introduction

Globally, there has been a notable increase in societal acceptance of transgender and gender-diverse individuals. However, there exists challenges in different domains across various national contexts. Laws regarding legal gender recognition has not been the same across countries. For instance, while countries like Argentina, Denmark, and France allow individuals to change their legal gender without requiring surgery; some other countries require transgender individuals to undergo gender-affirming surgeries before they can legally change their gender [1, 2]. This requirement can undermine their autonomy because transgender individuals are pressurised to undergo invasive and costly procedures which they may not desire [2].

Clinical and ethical guidelines for gender-affirming care have not been the same across countries. For example, some countries in Asia, Africa and Europe lack national-level clinical and ethical guidelines from their Ministry of Health for gender-affirming care [3]. On the other hand, countries such as Finland, Australia and New Zealand have developed national clinical guidelines that explicitly outline the legal and ethical considerations for gender-affirming care [4,5,6]. Furthermore, the World Professional Association for Transgender Health (WPATH) Standards of Care Version 8, an international clinical guideline that offer evidence-based guidance on best practices for gender-affirming care is also not universally adopted across all countries. The significant differences in gender-affirming care practice between countries can create a patchwork of care quality and availability and raise ethical questions on equity, fairness and justice that warrant careful consideration. In the United Kingdom, the recent high-profile case of Keira Bell has ignited debates over the provision of gender-affirming care to minors, prompting discussions about informed consent and decision-making, and the balance between protection of minors’ rights and protection of their well-being [7]. Policies surrounding puberty blockers have since become more restrictive in the United Kingdom [7].

Further complicating these disparities are variations in health insurance policies. Some insurance policies deny coverage for gender-affirming procedures, labelling them as cosmetic or medically unnecessary despite their critical role in the mental and physical well-being of transgender individuals [8, 9]. Even when coverage is provided, inconsistencies exist—some policies fund mastectomies for trans men but not breast augmentation for trans women [10]. This inconsistency not only reflects a misunderstanding of the essential nature of gender-affirming care but also raises ethical questions that warrant careful consideration.

The evolving landscape of gender-affirming care in many parts of the world, its barriers and challenges, and the ethical debates surrounding these issues, have led to an exponential growth in the ethics literature on the topic. However, there has been no systematic and comprehensive attempt to synthesis the existing literature to identify the key ethical issues and the existing arguments for and against these issues. It is timely and important to bring together all existing work on this topic to provide a clearer understanding of the ethical issues, enrich academic and healthcare policy debates, identify gaps in knowledge and set an agenda for future research on the ethics of gender-affirming care. Accordingly, we undertook a scoping review to identify the key ethical issues and arguments put forward by authors to address these issues in gender-affirming care for transgender and gender-diverse individuals across the range of medical interventions. Our focus is not to criticise the arguments presented by the authors, but to solely present them.

Methods

Overview of scoping review methodology

We conducted a scoping review because scoping reviews in bioethics have been robustly defended as providing an optimal approach to reviewing normative ethics literature and providing the correct balance between taking a systematic approach to collating insight across significant bodies of literature and its wide-ranging utility in shedding light on the nuances of ethical argumentation within and across specific papers [11]. For the scoping review we applied Arksey and O’Malley’s scoping review framework consisting of five stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarising, and reporting the results [12].

Step 1: Identifying the research question

The main research question is to identify the key ethical issues and arguments put forward by authors to address these issues in gender-affirming care for transgender and gender-diverse individuals across the range of medical interventions.

Step 2: Identifying relevant studies

First, we searched a preliminary database to get a superficial understanding of the existing publications on the topic. We examined the titles and abstracts of various publications and summarised the keywords and vocabulary terms used in these publications. After that we adapted these terms to relevant databases (e.g., MeSH and keyword terms in PubMed, Emtree and keyword terms in Embase, and keyword terms in Scopus). The search terms were developed for two concepts: gender dysphoria and ethics. Boolean operator AND was used to separate search concept while the Boolean operator OR was used to separate subject headings and keywords within the concept. We searched for relevant publications in Embase, PubMed, and Scopus. The following search strategy was used in Embase:

(‘gender dysphoria’/exp OR ‘gender identity’/exp OR ‘gender nonconformity’/exp OR ‘lgbtqia + people’/exp OR ‘gender dysphoria’:ab,ti OR transsexualism:ab,ti OR ‘sexual dysphoria’:ab,ti OR ‘gender identity*’:ab,ti OR transgenderism:ab,ti OR ‘gender self-identification’:ab,ti OR lgbtqia:ab,ti OR asexual:ab,ti OR transgender:ab,ti OR ‘gender nonbinary’:ab,ti OR ‘gender nonconformity’:ab,ti) AND (‘ethics’/exp OR ethic*:ab,ti OR bioethic*:ab,ti OR casuistry:ab,ti OR complicity:ab,ti OR consequentialism:ab,ti OR deontology:ab,ti OR ‘moral hazard’:ab,ti) AND [english]/lim AND [2012–2023]/py.

This search strategy was adapted to align with PubMed and Scopus’s search function. We developed our search strategy with support from our institution’s experienced librarian. Our strategy in developing and using search keywords was kept broad and flexible to increase the chances of getting relevant publications. We did not restrict our search terms to the health domain. This is because we were concerned that publications examining the ethical issues in non-health domains could have stated implications for gender-affirming care relevant to the authors’ ethical analysis which may have otherwise been excluded if narrower search terms had been used.

Step 3: Study selection

The inclusion criteria for the publications were as follows: (1) publications focusing on transgender and/or gender-diverse individuals; (2) any publication type was chosen in recognition of the value of ethical discussion in a variety of publication types, such as letters, commentaries, opinion pieces etc. [13]; (3) publications presenting an ethical issue, argument, or principle related to gender-affirming care of transgender and gender-diverse individuals. Our focus is on the ethical issues that arise within the direct practice of gender-affirming treatment and healthcare, and not on indirect and corollary concerns that emerge following such practice; (4) publications in English because (a) studies have found that excluding non-English publications did not markedly change the conclusions of reviews of these kind [14, 15], (b) it is common practice to include language restrictions in reviews of these kind due to practical considerations, such as lack of time, and difficulty in publication translation and its interpretation by reviewers [16], (c) English is predominantly the central scientific language [17] and (d) it is the shared working language of the research team; (5) publications from 01 January 2012 to 31 December 2023 because a preliminary scan of the literature revealed that discussions on this topic have gained global attention only in recent years. However, to ensure a comprehensive review and avoid overlooking any relevant publications, we opted for a broader search timeframe; (6) publications from all countries and jurisdiction (7) publications from peer-reviewed journals (8) publications available in full text; and (9) publications having substantive ethical discussion of the issue, argument or principle presented.¹ This could be a section, or the entire publication and the issues and principles must be explicitly identified as ethical by the publication’s authors and substantively discussed. Additionally, ethical claims should also be supported by arguments. The inclusion and exclusion criteria for the scoping review are detailed in Table 1 below.

Table 1 Inclusion and exclusion criteria

The study selection process happened in three stages. First, all 3619 publications found were uploaded into Zotero software. Then the first author (SS) removed 833 duplicates. Second, the first author screened the titles and abstracts of the remaining 2786 publications. At this stage the following inclusion criteria were applied: (1) publications focusing on transgender and/or gender-diverse individuals; (2) publications in English; (3) publications from 01 Jan 2012 to 31 Dec 2023; (4) publications from peer-reviewed journals and (5) publications presenting an ethical issue, argument, or principle related to gender-affirming care for transgender and gender-diverse individuals. When it was unclear whether a publication should be included, this was resolved through discussion with two co-authors (HJ and CD) until consensus was reached. Additionally, two co-authors (HJ and CD) independently reviewed the publications removed at this stage to reduce bias and enhance the objectivity of the selection process. This screening resulted in 275 publications that were distributed between three co-authors (SS, HJ and CD) for full-text review, constituting the third stage. At this stage, additional inclusion criteria, i.e., (6) publications available in full text; and (7) publications having substantive ethical discussion was also applied. Full-text review happened in two phases.

In the first phase of the third stage, the objective was to identify the ethical topics surrounding gender-affirming care of transgender and gender-diverse individuals. Three authors (SS, HJ and CD) identified the ethical issues inductively and discussed amongst themselves and later with two co-authors (TC and MD). This process ensured inter-rater reliability.

In the second part of the third stage, the objective was to identify how authors have sought to address the ethical issues identified in the first phase, that is, the arguments presented in favour of and against the resolution of the identified ethical issues. Similar to the first phase, three authors (SS, HJ and CD) reviewed the arguments and discussed them with the other two co-authors (TC and MD) for reliability. After the full-text review, 193 publications were removed for not meeting one or more of the eligibility criteria. It was at this stage that publications that did not contain substantive ethical discussion were explicitly identified, and decisions on whether to exclude these publications were extensively discussed between all the authors before a final decision was made. Finally, 82 publications were selected for inclusion (Fig. 1).

Fig. 1

Flow diagram

Step 4: Charting the data

Data from the publications were extracted using a template (Table 2) in Microsoft Excel version 2401 created by the first author (SS) and reviewed by a subset (TC and MD) of the team. The charting form was kept flexible and was updated as necessary throughout the charting process.

Table 2 Categories of information extracted from the publications

Step 5: Collating, summarising, and reporting the results

The Qualitative Analysis Guide of Leuven guided data analysis and synthesis, a methodology designed initially for qualitative data analysis but increasingly applied in recent years to synthesise normative literature [13, 18,19,20]. We (SS, HJ and CD) read the publications many times and analysed the publications thematically. Then, we made a summary report for each publication. The summary report tracked the authors’ main messages and how they defined ethical considerations. Next, we drafted a higher order summary report for each publication which tracked the authors’ logic of arguments. After that, we (all authors) did interpretative analysis. Here, we questioned the authors’ interpretations using our own arguments to test the strength of the authors’ conclusion. We also considered the possibility of potential biases of the author. We present an example of our analytic process in Table 3.

Table 3 Excerpts from critical appraisal, summary report, and ongoing reflection stages of analysis

Overarching focal points of analysis (or ‘ethical topics’) are reported as themes. Each theme is broken down into a set of sub-questions that highlight specific ethical uncertainties within that theme. For each sub-question, we summarise arguments both in favour and against. These arguments are organised in a broadly principle-driven fashion, which reflects the dominant mode of ethical analysis undertaken within the body of literature. As we will go on to show, in some cases the same ethical principle may encompass arguments supporting and opposing the same claim within the ethical topic being scrutinised. This method of reporting our findings aligns with our previously outlined process; that is, identifying ethical topics during the first phase of the third stage of study selection and subsequently, examining how authors construct arguments on these topics by analysing the form and content of these arguments during the second interpretative phase of the same stage. Importantly, our overarching aim here is descriptive not normative. We intend only to provide a full picture of the argumentative terrain in the ethics literature regarding gender-affirming care as a way of marshalling what broad topics are being scrutinised in ethical terms, what predominant ethical issues have been identified as worthy of further analysis, and what arguments have been constructed to address these issues.

Results

Our final sample comprised 82 publications (See supplementary file 1 for the general characteristics of included publications). A total of 62 publications (76%) were published in or after 2019, and 20 publications (24%) between 2012 and 2018, reflecting the recent growth of interest in this area of healthcare. Nearly half of the publications (n = 40) were written by authors from the United States of America. Other countries represented were United Kingdom (n = 20), Canada (n = 7), Australia (n = 5) and some countries from Europe and South America (n = 10). Ethics journals provided 57% of the publications, while the rest came from clinical journals. Six publications included primary empirical data collected by the authors in support of their ethical claims. The empirical data were gathered from transgender youth, their parents, and healthcare providers. The remaining publications included journal articles, commentaries, reflections, viewpoint articles, and letters, all of which made normative ethical claims without presenting new primary empirical data (though they often drew on secondary sources of data in support of the arguments presented). Out of the 82 publications analysed, a significant majority, comprising 65% (53 publications), centred their discussions around matters pertinent to adolescents or younger children. Conversely, only 14 publications discussed issues pertinent to adults. Additionally, 15 publications within the sample did not explicitly specify the age category but broadly referred to transgender persons, indicating a broader scope that likely encompassed individuals across various age groups.

We identified five themes and associated ethical arguments in response to these issues. The ethical topics are: (1) decision-making process, (2) guideline and model of care, (3) deletion of health data, (4) funding, and (5) fertility preservation and services.

For children, youth, and adolescents, the discussions primarily centred on issues related to medical decision-making processes. These discussions often revolved around fundamental questions such as who should make decisions, and what factors should be considered when making decisions. Discussion around i) which guideline and models of care should be endorsed in practice, ii) the provision of, and access to, fertility services, iii) funding, and iv) the deletion of health data were not limited to any age category.

The results section is laid out in a hierarchical structure. It starts with a sub-heading (e.g., theme 1) that introduces a specific ethical topic. Under each ethical topic, there are sub-sub-headings (e.g., 1.1) that are the ethical uncertainties related to the ethical topic. Under each ethical uncertainty there are sub-sub-sub-headings (e.g., 1.1a) that are the ethical principles applied to the ethical uncertainties. For each ethical principle, arguments for and against it are presented.

Rationale for presenting arguments in a dichotomous format – positions for and against

• 1. The purpose of a bioethics scoping review is to map ethical issues, arguments, and their underlying principles rather than to resolve ethical dilemmas normatively. As such, bioethics scoping reviews maintain a descriptive and analytical stance rather than a prescriptive one, ensuring that ethical positions are represented without assigning value judgments [11]. In alignment with this, our approach does not seek to oversimplify ethical debates but rather to provide a structured way for readers to navigate the complexity of these discussions.

• 2. It can help illuminate the diversity and intricacies of ethical debates without reducing them to simplistic binaries [11]. It enables readers to engage with and critically reflect on the range of positions presented.

• 3. Ethical arguments, even when highly nuanced, generally take a stance in one direction or another [11]. Presenting arguments in this way will provide a clear entry point for readers to navigate and assess the reasoning behind different perspectives while preserving the depth and complexity of the discussions.

Theme 1: Decision-making process

The decision-making process regarding gender-affirming care for minors is a multifaceted topic. Ethical considerations that arose in discussion included concerns about maximising treatment benefit (beneficence), minimising harm (nonmaleficence) and supporting autonomy for minors. Concerns about whether minors should have the authority to make treatment decisions were also discussed. Here, minors’ authority to make decisions was taken to be complicated by factors such as age, cognitive maturity, social vulnerabilities, and the evolving nature of their identity and self-understanding. While granting minors autonomy acknowledges their agency, it also raises concerns about their ability to fully comprehend the consequences of treatment decisions and navigate complex medical processes. Furthermore, considerations extend beyond individual autonomy to encompass broader questions of parental involvement.

1.1 Who should decide?

1.1a Autonomy-based arguments

Arguments in favour of minors making decisions instead of parents and other adults

Some authors argue that minors should make decisions for hormonal therapy and surgical therapy, drawing attention to the fact that many minors possess cognitive decision-making abilities like adults [21,22,23,24,25]. To support this, empirical evidence was presented to suggest that minors who have commenced these treatments perform thorough research over many years to inform their decisions, deliberate by weighing the risks and benefits of treatment, non-treatment and alternatives, consult trusted sources before making decisions and even clear their parent’s doubts [26, 27].

Beattie explains this using an analogy: “The context of taking combined oral contraceptive pills and puberty blockers is not different. It is accepted that children can consent to combined oral contraceptive pills. So, it would seem inconsistent to restrict children from consenting to puberty blockers over potential side effects while permitting them to consent to combined oral contraceptive pills with confirmed side effects” [22]. For surgical therapy, some authors argued that minors might opt not to reveal their transgender identity openly [28]. Thus, facilitating chest surgery was viewed as offering them more control in managing the disclosure of their transgender status [28]. Furthermore, proponents argue that minors should have the autonomy to make choices about their bodies, as all individuals possess fundamental rights to self-determination [26, 29,30,31,32,33,34]. Some authors also supported penis transplantation surgery due to this aspect [34]. Even if regret arises, it does not necessarily invalidate their autonomous decisions since all individuals have a right to make wrong decisions and individuals regret their decisions all the time [23, 33, 35]. For example, Notini et al. states that ‘in other areas of life and medicine, individuals are permitted to make lifestyle choices or engage in certain activities they deem worthwhile, even though the activities may increase their physical risks’ [33]. Some authors also point out that regret is an inherent risk in any irreversible intervention and cannot be entirely avoided. Moreover, it is unclear whether delaying gender-affirming surgery actually reduces the likelihood of regret. Therefore, the possibility of regret alone does not justify delaying treatment, as there is no evidence that postponement decreases its occurrence. Additionally, there is no indication that adolescents experience regret over GAS differently than adults [36].

Some authors bolster their argument that minors should be the ones to make decisions by providing reasons why parents and other adults may not be better equipped to do so. These authors argue that minors seek gender-affirming care based on a well-informed understanding of their authentic selves and lived experiences [21, 26, 37]. They claim that parents and other adults lack an intimate understanding of trans experiences and gender-affirming care transcends conventional medical care due to the unique subjectivity of gender experiences [37]. As a result, only minors possess comprehensive insight into their need and motivations for seeking treatment [26, 37, 38]. Moreover, the lack of scientific predictors of regret, and the difficulty in ascertaining that a transgender minor would make decisions against their best interest, makes the case that minors should make decisions [35, 37]. Furthermore, many transgender adults and medical experts support hormonal therapy, underscoring its reasonableness [37]. Proponents emphasise that minimal autonomy in decision-making for minors is sufficient [33, 37]. According to Lindemann et al., minimal autonomy means that the individual is guided by their gender identity and other values, acts on these reasons, and is open to considering alternative perspectives [39]. Insisting on full autonomy in decision-making would set an unreasonably high standard, especially considering that similar standards are not applied in other areas of healthcare [24, 33, 40]. Milrod explains this for genital surgery using an analogy. He states that “Can anyone ever give a full informed consent for irreversible procedures, as no surgeon can guarantee an exact outcome. If genital surgery was so fraught with risk that no “sane” individual would consent, then the procedure would not be provided to anyone including adolescents” [24]. Giordano and others compare sex-reassignment surgeries to surgeries done for disorders of sex development. According to them, for disorders of sex development, surgeries are often performed on infants and children before they can consent and are considered as medically necessary treatment. However, transgender minors face ethical scrutiny regarding consent for sex-reassignment surgeries and the medical necessity of these procedures is still debated [41,42,43].

Arguments against minors making decisions

Opponents argue by supporting normative claims with empirical evidence that minors’ biologically immature brains might affect their ability to fully comprehend the potential consequences of hormonal therapy, and their social immaturity may drive them to make impulsive decisions [26, 44,45,46]. For example, Clark et al.’s qualitative study found that, some healthcare providers were concerned about youths’ maturity. According to one healthcare provider “youth don’t think a lot about what this actually means, to transition at home without their parents knowing”. Additionally, one parent mentioned that “at twelve, even at fourteen, developmentally you have limited ability to process really the full impact of that…” [26].

Authors also discuss about the circumstances in which minors make decisions, for example their urgency to transition without taking future orientation, their preconceived course of action, the presence of pre-existing psychological comorbidities, the complexity of the decision, being emotionally involved, the role of peer influence and unconscious drivers, and the evolving nature of their authentic selves [21, 23, 26, 41, 44, 45, 47,48,49]. They also express concerns about the potential for regret, experimental nature of puberty blockers and potential for coercion [26, 44, 47].

Further, on the opposing side, authors argue that the integrity of diagnosis can affect minors’ autonomy affecting their ability to make decisions. They point to issues like inadequate training among healthcare providers and their heavy reliance on parental reports, the lack of scientific predictors for ‘persisters’ and ‘desisters’ in transitioning, cultural stereotypes, and minors’ self-ascribed histories [22, 30, 41, 49,50,51]. Additionally, authors also highlight concerns about the integrity of informed consent compromising minors’ autonomy [50]. They note that this may arise when activists and gender clinics’ agenda pressure healthcare providers to adopt affirmative pathways due to increased demand in services [50]. They also highlight cases where healthcare providers may share inaccurate or incomplete information with transgender minors, complicating the decision-making process [50]. Moreover, healthcare providers’ reliance on their clinical experiences as evidence and their own beliefs on therapy adds to the complexity of informed consent for minors [50].

1.1b Beneficence and non-maleficence-based arguments

Arguments in favour of parents making decisions instead of minors

Some authors argue in favour of parents making decisions instead of minors for gender-affirming care. For example, Dubin et al. and a few others argue that minors require social and financial support throughout their gender-affirming journey [52,53,54]. Coleman mentions that “parental consent is not required when minors seek treatment for sexually transmitted diseases because these treatment laws are public health measures designed to stop the spread of disease and this rule is not based on the concern for the individual’s health. On the other hand, gender-affirming care affects the individual. Coleman also adds that gender-affirming care is different from the treatment of sexually transmitted diseases because it requires constant procurement of medications and financial support” [53]. They emphasise that parents can provide such support which has been shown to provide positive mental health outcomes and wellbeing for minors [52, 55]. Authors also add that since gender transition affects both the minor and their family, it is important to involve parents to encourage understanding and cooperation [50]. The literature also highlights that involving parents in healthcare decisions is standard good practice [52]. Moreover, parents would often become aware of their child’s use of hormonal therapy through insurance notifications [56]. Not involving parents risks parent–child conflicts which could expose children to homelessness, harassment, and violence [56].

Arguments against parents making decisions

Authors argue that parents should not make decisions especially when there is disagreement between them and their child because it may delay starting treatment, or minors may resort to accessing treatment without parental consent [57]. Priest uses an analogy to support this argument: ‘Transgender children seeking puberty blockers via their own means is clearly not an outcome any decent parent would want, even parents who disapprove of puberty blockers in general. Parents who disapprove of their children having sex but would never wish that their children contract a sexually transmitted disease if they did’ [30]. Disagreements often stem from parents questioning their child’s ability to make decisions for gender-affirming care, struggling to accept their child’s transgender identity, or worrying about the long-term effects of hormone treatment [26, 57].

Additionally, disagreements between parents themselves can arise, especially in cases involving family violence [50]. If parents make decisions despite these disagreements, it can lead to both material and psychological harm for transgender minors [29, 30, 52, 58]. It may also worsen past traumatic experiences for the minor [57]. Kelly et al. states ‘some parents may refuse consent not because of concerns around the child’s interests but they want to harm the other parent and the child because they are preparators of family violence’ [57]. Moreover, requiring parental consent can result in a loss of privacy and confidentiality for minors, as they may be forced to disclose their identity to seek parental approval [57].

1.2: What factors should be considered when making decisions?

1.2a Beneficence and non-maleficence-based arguments

Arguments in favour of providing gender-affirming care considering the benefits of treatment

Decision-making on gender-affirming requires an assessment of the dimensions of benefits it may bring. Authors suggest that one benefit of puberty blockers is that they give minors the time to explore their gender identities while preventing the development of unwanted secondary sex characteristics [32, 44, 47, 58,59,60]. Some authors added that it is difficult to see how some aspect of puberty can be considered an objective good for everyone when some individuals perceive it as distressing [61]. Thus, even if these objective goods are acknowledged, they must be weighed against other objective goods, such as the avoidance of severe distress, in such complex cases [61]. According to some authors, for those still exploring their gender identity, hormone therapy can provide a deeper understanding of their relationship with their body’s gendered characteristics and within this framework, fears of desistance are unfounded [40, 60]. Furthermore, puberty blockers enable minors to have an open future, which in this context means keeping their future treatment options open until they become capable of making their own decisions [29, 33, 60]. Without puberty blockers, irreversible physical changes may occur, limiting individuals’ options for making autonomous decisions later in life [29, 32, 60]. Some authors add that puberty will resume once the minor decides to stop treatment [22, 41, 44]. Therefore, by temporarily halting the development of unwanted secondary sex characteristics, puberty blockers reduce the need for costly surgical interventions and lead to more satisfactory surgical outcomes [29, 32, 41, 60]. Moreover, studies have shown that the use of puberty blockers is associated with decreasing dysphoria, suicide attempts and suicide, and self-harm and risky behaviours among transgender minors [32, 41, 44]. Authors also mention that hormonal therapy can assist in “passing,” which is crucial for the safety, survival, and social integration of transgender individuals [29]. Additionally, they argue that if hormonal therapy brings pleasure or helps the individual achieve personal goals related to self-development, it should be considered a valid option [22, 29, 33, 41, 44, 62]. Furthermore, some authors emphasise that both hormonal therapy and chest surgery carry a low risk of regret [28, 35]. Moreover, these treatments including sex-reassignment surgeries often result in significant subjective improvements in various aspects of individuals’ lives, including psychological functioning, body image, treatment satisfaction, quality of life, and overall satisfaction [22, 28, 29, 41, 42, 44, 58, 62]. However, there is lack of consensus on whether these factors constitute wellbeing [63]. In addition, authors point out that the benefits of chest surgery outweigh its burdens. While there are risks associated with chest surgery, such as loss of sensation in the nipple area and scarring, chest surgery is actively sought after by many patients based on willing acceptance of the potential risks in exchange for the benefits and improvements in physical and emotional well-being following surgery [28]. Some authors also add that many medical treatments are routinely prescribed by physicians despite having a low level of evidence [64].

Furthermore, D’Angelo supports gender-exploratory therapy as an essential component of gender-affirming care because according to the author gender-exploratory therapy helps to uncover the underlying psychological, social, or emotional factors contributing to gender dysphoria, and provides a holistic approach that addresses mental health conditions, family dynamics, and external stressors, ultimately fostering coping strategies, resilience, and emotional well-being [65].

Arguments in favour of providing gender-affirming care considering the harms of non-treatment

Besides the potential harms of treatment, authors claim that the potential harms of non-treatment should also be considered in the harm-benefit assessment of whether to allow a gender-affirming medical intervention. For some, not treating with hormonal therapy or surgical therapy can exacerbate gender dysphoria, suicidal attempts and suicide, push individuals to source for medications from unregulated markets, subject individuals to the potential physical health risks of chest binding and mental health risks of bullying and social isolation, and create a greater need for more invasive surgeries in the future to align their bodies with their gender identity [24, 26, 28, 34, 54, 55].

Arguments against providing gender-affirming care considering the harms of treatment

Benefits must be weighed against the harms of treatment. Puberty blockers, for example, have been linked to several adverse effects, such as decreased bone mineral density, and interference with brain development and cognition [28,29,30, 32, 41, 62, 66]. Against these risks, some authors mention that low bone mineral density can be mitigated by exercises and calcium and vitamin D intake [33]. According to Beattie, “the risk–benefit profile of combined oral contraceptive pills and puberty blockers are comparable and taking puberty blockers poses no greater risk than that of a minor subjecting themselves to the risk of combined oral contraceptive pills side effects” [22]. On the other hand, some authors argue that the asynchrony or mismatch between physical development and gender identity can affect social health because individuals may face stigmatisation or ill-treatment since people may not be able to categorise the transgender individual as male or female readily. Asynchronous physical development can also challenge forming romantic relationships [33, 41, 44, 46]. However, some authors argue that some of these potential harms are dependent on individual subjective needs and wants. For example, difficulty forming romantic relationships is harmful only if an individual wishes to have a romantic partner and biological children [33]. Some authors contended that by using puberty blockers to halt the onset of puberty, the natural hormonal changes that typically contribute to the process of desistance are disrupted [41, 44, 45, 47, 51, 67]. However, in contrast to this view, others argue that puberty blockers may alleviate distress even in those who may later desist [22]. They also added that preventing harm should not be founded on ‘reducing the number of people susceptible to harm,’ but instead on ‘reducing the overall harm to each individual’, i.e., by permitting access, to ensure that persisters do not suffer greater harm due to restricting access [22].

Authors also countered the presumed advantage of puberty blockers by asserting that it may lead to a requirement for invasive surgeries due to the absence of sufficient genital tissues for reconstruction [44, 58]. Additionally, the medicalisation of transgender identity through blockers may cause psychological harm [44]. While some studies suggest that blockers improve psychological well-being, others indicate worse mental health outcomes [44, 58]. Authors add that blockers are still considered experimental and there is limited and unknown evidence of their effects on other health risks and long-term consequences [44,45,46].

Additionally, some authors raise concerns that puberty blockers might pressure minors into taking treatments with irreversible side effects. However, others argue against this notion by suggesting that the high progression rates to more invasive treatments may not be due to puberty blockers directly promoting persistence. Instead, they propose that the high progression rates might reflect the successful identification of persistent gender dysphoria in those individuals who initially sought puberty blockers [22, 49]. They also add that puberty blockers and cross sex hormones are separate stages and patients can cease puberty blockers and not progress to cross sex hormones [22, 49].

Authors also motivate concerns about cross sex hormone and surgical therapy’s irreversible effects, effects on fertility, lack of long-term data on efficacy and safety, potential for regret, hormone-dependent cancers, and cardiovascular diseases [29, 41, 44, 46,47,48, 51]. Nevertheless, a long-term longitudinal study conducted among adolescents shows that none regretted after undergoing medical and surgical transition [35]. McDougall et al. states, ‘in many medical conditions, decisions are made based on the current available evidence, despite uncertainty in their long-term efficacy and safety’ [28].

Additionally, Ashley argues against gender-exploratory therapy by saying that it focuses on exploring the potential pathological roots of trans identities through talk therapy. According to the author, gender-exploratory therapy claims to be neutral by not affirming or denying an individual’s gender identity outright. However, neutrality may mask underlying biases or pathologising assumptions about transgender experiences. The author adds that due to this, gender-exploratory therapy may lack the loving attention necessary for positive therapeutic outcomes, may strain the patient-physician relationship, and may not align with patient-centred care [68].

1.2b Justice-based arguments

Arguments in favour of providing gender-affirming care

Issues of justice for hormonal therapy revolve predominantly around systemic issues. These include lack of resources for gender-affirming care such as inadequate training of healthcare providers, uncertainties regarding their ability to accurately differentiate between ‘persisters’ and ‘desisters’ of gender dysphoria, and the costliness of treatment exacerbated by its potential lack of insurance coverage that may unfairly exclude transgender minors from such care [41, 47, 69]. For surgical therapy Mc Dougall et al. use an analogy to describe not treating like cases alike, that is, failure in formal justice. They state that ‘while chest surgery is performed on cisgender males with gynecomastia to relieve their distress, the same principle applies to transgender males, and withholding surgery from them is gender identity-based discrimination’ [28].

Other authors argue that transgender individuals deserve access to treatment to protect them from unfair discrimination. Based on empirical evidence, it is emphasised that transgender individuals belong to multiple group memberships, such as being minors and having a transgender identity. The recommendation is made to use an intersectional approach in decision-making which involves considering all aspects of a person’s identity simultaneously, rather than prioritising one aspect over the others. This approach allows for a more comprehensive understanding of the individual’s needs and circumstances, to help ensure that decisions regarding treatment are made in a fair and equitable manner [70]. A few authors employ a disability justice lens to argue that the distress experienced by trans individuals is rooted in societal factors rather than being seen as a pathology. This perspective helps frame gender-affirming care as a specific access need for which individuals may seek support [40].

Theme 2: Guideline and model of care

The WPATH guideline and the ‘informed consent model of care’ are the two prominent international frameworks guiding healthcare providers on the provision of gender-affirming care. Both these frameworks approach the process differently. For example, in WPATH, mental health professionals are required to play an explicit role in the diagnosis of gender dysphoria prior to providing treatment. On the other hand, in the informed consent model of care, diagnosis of gender dysphoria is not a necessary requirement for accessing gender-affirming care. Because of these differences, ethical uncertainties arise in which framework should be endorsed in practice.

2.1 Which framework should be endorsed in practice?

2.1a Autonomy-based arguments

Arguments against endorsing informed consent model in practice

Opponents argue that political pressures and gender clinics’ agendas may push healthcare providers toward affirmation, potentially limiting their freedom to thoroughly explore the complex relationship between the patient’s symptoms, trauma, social anxieties and wish to transition [71, 72]. Evans uses an analogy to motivate this concern: ‘We do not just affirm a patient with anorexia and agrees with her plan to diet further. Instead, we take it as our duty to try to understand what it is that is driving that belief while persuading her that she needs to eat’ [71]. According to D’Angelo, the reason why ‘more females are transitioning than males could be because women earn less money, are more likely to be victims of sexual assault, and of violent assault by their partners’ [72]. Opponents to this model also assert that it relegates other emotional experiences to the status of co-morbidity or as secondary to the experience of gender incongruence [71, 72]. Additionally, opponents argue that without thorough assessment, minors’ autonomy can be undermined because it could potentially lead them to misconstrue that their self-representation issues can be resolved through hormonal therapy, which may be misleading, because even surgical procedures cannot entirely erase traces of one’s natal sex [71, 72]. Additionally, there is evidence that children will change their minds when time and space is given [71]. Some authors also add that lack of thorough assessment could send minors down a path towards irreversible medical interventions with uncertain effectiveness [45, 46, 49, 71]. Therefore, some gatekeeping measures are necessary to protect the (developing) autonomy, health and well-being of minors and to ensure public trust in clinical decision-making and practices in this area [73].

2.1b Beneficence and non-maleficence-based arguments

Arguments in favour of endorsing WPATH guideline in practice considering its benefits

Proponents argue that the diagnostic model in gender-affirming care helps healthcare providers to decipher the intricate clinical presentation of individuals seeking therapies [62, 74, 75]. It will help identify each patient’s unique capacities, which can play a pivotal role in reconstructing the individual’s identity, determining their gender transition journey’s success and facilitate a comprehensive understanding of the type of therapy necessary to enhance their overall well-being [74, 76,77,78]. Since the therapies are complex, with various options and approaches leading to different functional and aesthetic outcomes, the authors contend that mental health professionals’ assessment will assure that therapies and their potential risks and benefits have been meticulously evaluated [74, 77, 78]. This will also serve as a protective measure, ensuring that individuals who may not genuinely identify as transgender are not rushed into gender-affirming interventions, especially irreversible procedures [73]. Additionally, mental health professionals can address the concerns of transgender minors and their parents since they recognise the diversity of transgender experiences [79]. Furthermore, in cases where the primary healthcare provider may not be supportive due to personal beliefs regarding gender identity, the diagnostic model can act as a safeguard, ensuring that patients receive the care they need.

Supporters also underscore the significance of gatekeeping to protect public trust in clinical decision-making, protect patients and their dear ones from direct and indirect harm respectively, particularly in the context of sex reassignment surgery [34, 73, 75, 80]. They mention that these surgeries are irreversible medical interventions aimed at treating gender dysphoria rather than being undertaken solely for cosmetic or non-essential purposes [80]. Some authors challenge this. According to them, the newly constructed genitals can be removed, and certain labial and vaginal reshaping procedures are possible [74]. Some authors also mention that sex reassignment surgery may alter or de-enhance certain functions, such as sexual intercourse capacity. They also question the empirical evidence supporting sex reassignment surgery, citing methodological biases and high loss-to-follow-up rates in studies [80].

Arguments against endorsing WPATH guideline in practice considering its harms

Opponents of WPATH guideline argues that it pathologises care since it necessitates a diagnosis from a mental health professional and can affect access to gender-affirming care due to discrimination, a need for asking invasive questions and mistrust in trans voices [31, 40, 63, 76, 81,82,83,84]. Ashley uses an analogy: ‘If someone says, ‘my arm hurts’, we typically grant credence to their claim, trust people’s self-reports of their mental states because we hold mental states to be within the purview of people’s epistemic authority. Similarly, experiences of gender dysphoria are part of the mental experiences over which we have epistemic authority. By asking for referral, physicians deny the authority trans people have over their own mental experiences, an authority that should be granted to everyone by virtue of being persons’ [81]. Some also add that it could be burdensome for transgender individuals to find a suitable mental health professional [84].

By framing gender dysphoria as a collective issue, this approach risks overlooking the self-determination of individuals who do not experience distress and could push individuals to engage in stereotypical narratives [32, 40, 63, 81, 84]. Wenner et al. explains this using an analogy “patients are given effective treatments for coronary artery disease even before they have experienced myocardial infarction” [32]. Such categorisation may strain the patient-physician relationship [32, 40]. The patient-physician relationship could also be affected because the diagnostic model reproduces gender binary within the clinical environment and society and erases the gender constellation of those who are non-binary [40]. Moreover, some author mention that the model’s emphasis on addressing co-existing health conditions may overshadow external factors contributing to distress [63]. Although this model has been implemented in part to safeguard those children who may not ultimately identify as transgender, it raises ethical concerns as it inevitably results in delays for individuals experiencing persistent gender dysphoria who genuinely require treatment [73]. Moreover, the authors also state that there is a lack of scientific evidence supporting the benefit of referral letters for surgical therapies and this lack of evidence can also be extended to hormone replacement therapies [76, 84].

Some authors argue against endorsing WPATH guidelines by citing other several points. They mention that sex reassignment surgery is considered a non-therapeutic enhancement, since cross-sex hormones, a necessary precursor to surgery, may enhance certain cognitive and behavioural traits [80]. Authors also point to a double standard, noting that heterosexual individuals can undergo body modifications, such as cosmetic surgery, without the same level of scrutiny [74, 84]. They argue that assessment and counselling should be optional rather than obligatory, as they may not be equally valuable or necessary for everyone [74, 83]. Another double standard they highlighted is the lack of mandatory psychological assessments prior to abortions or for cisgender adolescents seeking hormone-induced puberty consistent with their presumed gender [74, 76, 81, 82]. Furthermore, some authors assert that surgeons providing surgical therapy can often accurately assess candidacy through patient history and rapport building without additional health professional input, as transgender adults seeking surgery have often already engaged in other forms of affirmation, such as hormone therapy, changing their name and gender markers on government-issued identification, chest binding, genital tucking [84].

2.1c Justice-based arguments

Arguments in favour of endorsing WPATH guideline in practice

Justice-based arguments revolve mainly around sex-reassignment surgeries. Proponents argue that gender reassignment surgeries represent more than just physical reconstruction; they involve reconstructing a person’s identity. From this, they assert that the involvement of mental health professionals in the surgeon–patient relationship is not discriminatory [77]. The authors argue that although the surgical techniques employed for individuals with gender dysphoria may parallel those used in other contexts for cisgender individuals, their objectives, patient expectations, and life consequences differ significantly. Therefore, patients should not be treated the same way because equity in healthcare does not equate to treating everyone the same but rather addressing their distinct needs and helping them achieve their individual goals [77].

Moreover, proponents of the diagnostic care model assert that it aligns with principles of distributive justice, in the context of hormonal therapy and sex-reassignment surgeries [63, 80]. They argue that diagnosis is a crucial indicator of how profoundly an individual’s life might deteriorate without appropriate treatment [56]. In resource-constrained settings, the diagnostic model enables the prioritisation of individuals experiencing gender dysphoria, distinguishing them from those seeking treatment without significant distress [63]. This allocation of resources helps promotes healthcare delivery to those most in need [63]. In the case of sex-reassignment surgeries, it reduces strain on public healthcare systems, especially considering the long-term preventive and primary care needs of transgender individuals post-sex-reassignment surgeries [80].

Theme 3: Deletion of health data

The issue of deleting health data after gender transition reflects the complex intersection of gender identity affirmation and medical record management. While deleting health data may help individuals achieve greater congruence between their gender identity and medical documentation, healthcare institutions may face challenges in implementing such requests due to risks such as incomplete medical histories and potential gaps in care. Health data encompasses a wide range of medical and administrative records associated with gender-affirming care. This includes medical diagnoses, treatment plans, hormone therapy records, surgical procedures, psychological evaluations, and other relevant documentation pertaining to an individual’s gender transition [85].

3.1 Is it ethical to delete health data after transition?

3.1a Autonomy-based arguments

Arguments in favour of deleting health data

Some authors mention that deleting health data after transition can promote autonomy from a certain perspective. Firstly, it aligns with the principle of the right to identity and self-determination, which is considered a fundamental human right [85]. They argue that individuals should have the autonomy to decide about what information they wish to know about their genetic heritage [85]. They also add that deleting health data post-transition respects individual autonomy by allowing individuals to control the dissemination of sensitive personal information [85]. Proponents also stress that individuals should be free to pursue their own interests such as minimum conditions for promoting happiness and desires as long as they do not infringe upon the rights and well-being of others [85].

Arguments against deleting health data

According to some authors, deleting health data after transition could affect individual autonomy for several compelling reasons. Firstly, autonomy encompasses the right to identity and self-determination, which are fundamental human rights [85]. Individuals have the inherent right to be informed about their biological ancestry and to have access to their complete medical history [85]. Deleting health data post-transition not only undermines this right but also makes it challenging to trace genetic diseases, a crucial consideration, especially for trans individuals and their biological offspring [85]. Preserving health data promotes autonomy by affording individuals control over their medical narratives and empowering them to make informed decisions about their health and well-being [85]. Additionally, autonomy extends to the capacity for change and self-revision. According to some authors, in the context of gender identity, individuals may undergo transitions and subsequently experience changes in their perspectives and self-understanding [85]. Deleting gender-affirming health data could inhibit individuals from exercising their autonomy in revising or reconsidering their gender identity, should they experience feelings of repentance [85].

3.1b Non-maleficence based arguments

Arguments against deleting health data considering its harms

Some authors are against the deletion of health data after transition as it may result in a multifaceted array of harms that echoes throughout the healthcare landscape. They mention that, firstly, this practice can compromise the integrity of medical research by depriving researchers of invaluable insights into how health issues may manifest differently based on biological sex at birth [85]. Secondly, deleting health data appears to downplay the significance of sex in clinical practice, overlooking the pivotal role it plays in shaping healthcare outcomes [86]. Lastly, it could introduce perplexity and disruption for patients and practicing doctors alike. Practicing doctors, committed to delivering excellent and compassionate care could be confronted with the challenge of navigating incomplete patient records, which can breed confusion and frustration, ultimately compromising the quality of care delivered [86].

Theme 4: Funding

The discussion regarding the issue of funding for gender-affirming care centres on the dual considerations of its classification as either a cosmetic or medical procedure and the economic costs associated with performing the procedure. Additionally, the discussion also revolves around whether gender-affirming care procedures are a matter of clinical necessity and justice.

4.1 Should gender-affirming care be funded?

4.1a Beneficence-based arguments

Arguments in favour of funding gender-affirming care procedures such as gender-affirming surgeries, facial feminising surgery, and assisted reproduction considering their benefits

Authors support for the funding of gender-affirming surgeries, whether through public funds or insurance coverage, based on the multitude of benefits they offer to transgender individuals. They state that, firstly, many public health systems already fully fund procedures such as breast reconstruction surgery for women who have undergone mastectomy, recognising the importance of improving patients’ mental well-being [87,88,89]. Similarly, gender-affirming surgery is performed with the same intent, addressing gender dysphoria [87, 88]. Go JJ states that ‘breast reconstruction surgery for women who have undergone a mastectomy is fully funded in many public health systems. This procedure is performed on the grounds that it will improve the patient’s mental well-being, and gender reaffirming surgery is also done for the same reason’ [87]. Secondly, gender-affirming surgery is supported by evidence-based practices and clear guidelines such as the WPATH [87]. They also add that gender-affirming surgeries can be lifesaving, as statistics suggest that without it, a significant percentage of transgender individuals may attempt suicide [87]. From an economic standpoint, the cost of one death by suicide far outweighs the cost of providing gender-affirming surgeries, underscoring the imperative of publicly funding treatments that prevent serious harm [87].

Authors also advocate for the funding of facial feminising surgeries. Firstly, they state that facial features that deviate from traditional gender norms can subject trans feminine individuals to risks of violence and discrimination [90, 91]. Facial feminising surgeries can help them to align their appearance with their gender identity and enhance personal safety [89, 90]. Secondly, the congruence between one’s outward appearance and gender identity can alleviate anxiety and depressive symptoms, promoting mental well-being and psychological resilience [90]. Lastly, facial feminising surgeries achieves outcomes that gender-affirming surgeries alone cannot deliver, as it directly impacts how others perceive and respond to an individual’s gender in daily interactions [90].

Authors also support for funding of assisted reproduction. For social well-being they argue that assisted reproduction should be publicly funded based on reproductive rights [92]. They mention that public funds are limited. Therefore, government will prioritise spending. In the context of choosing between funding life-saving treatments or assisted reproduction, funding life-saving treatments might be more justifiable. Nonetheless, the state may allocate public money for social beneficence, not strictly tied to rights [92]. In this case assisted reproduction is eligible for funding recognising that it can enhance social well-being [92].

4.1b Justice-based arguments

Arguments in favour of funding gender-affirming care procedures such as gender-affirming surgeries and facial feminising surgery

Authors advocate for the funding of gender-affirming surgeries and facial feminising surgeries based on principles of justice. They argue that singling out a minority and marginalised population, such as transgender individuals, for denial of medical services only serves to perpetuate and reinforce existing social and religious discrimination against them [91, 93]. Such discriminatory practices not only violate the principles of justice but also contravene the principles of beneficence and nonmaleficence by causing harm to them. They add that historically, healthcare standards have been established based on norms associated with cisgender identity [93]. For example, health insurance companies often refuse to acknowledge the medical necessity of gender-affirming procedures, categorising them as cosmetic and denying coverage [93]. However, the authors contend that cisgender and transgender individuals have distinct health needs, and treating these needs equally without considering their differences constitutes discrimination [93]. Rabelais states that “For example, whereas permanent hair removal might be cosmetic for the majority of cisgender women, it is medically necessary for trans feminine people… Applying a label of cosmetic care onto hair removal and facial feminisation for trans feminine people is discrimination because doing so sets cisgender as the standard for normal appearance” [93]. Additionally, for assisted reproduction services, addressing financial barriers to accessing them is recognised as an issue of reproductive justice. Harris et al. state that ‘since justice considerations have already led some jurisdictions to mandate insurance coverage for fertility preservation for cancer patients, similar provisions should be available for transgender patients’ [94].

Arguments against funding gender-affirming care procedures such as gender-affirming surgeries and facial feminising surgery

Authors present several arguments against publicly funding or insurance coverage of gender-affirming surgeries and facial feminisation surgeries. Firstly, they assert that these surgeries are often viewed as cosmetic procedures rather than medically necessary treatments, leading to questions about the allocation of limited public health resources [87, 90]. Additionally, not all transgender individuals desire to conform to societal norms of gender presentation [89]. Moreover, funding gender-affirming surgeries may set a precedent for funding other procedures, straining public health resources further [87]. Authors also add that, from a human rights perspective, funding these surgeries can be seen as reinforcing binary social constructs of gender and implying that binary forms of gender identity are socially acceptable [40, 88]. Furthermore, offering special treatment to transgender individuals over others with similar dissatisfaction with their appearance may perpetuate inequality within society [88]. Authors also argue that according to some transactivists, gender-affirming care surgeries should not be publicly funded [86]. To support their claim, transactivists compares gender-affirming care surgeries to changing one’s religion which are deeply personal and identity-related choices. Just as changing religious beliefs is not considered a medical issue even if it could enhance personal wellbeing, the argument is that gender transition should be viewed similarly [86].

Theme 5: Fertility preservation and services

The debate surrounding the issue of provision of fertility preservation services to transgender youth and other fertility services like uterine transplants for transgender women revolves around several key concepts. One concept is based on the notion of ensuring individuals’ right to an open future. Concerns regarding the experimental nature of these procedures, questions about safety, feasibility, and the potential anatomical challenges involved are also discussed. Moreover, discussions also encompass considerations about the well-being of offspring raised by transgender parents.

5.1 Should fertility preservation and other fertility services be provided?

5.1a Autonomy-based arguments

Arguments in favour of providing fertility preservation and other fertility services

Authors advocate for providing fertility preservation services to transgender youth on the basis of their right to an open future [54, 95]. They mention that most youth possess cognitive capacity by the age of 14 but may not have enough life experience to fully understand and anticipate their future desires regarding parenthood and family-building [54, 94, 95]. Therefore, providing fertility preservation services to transgender youth will give them an opportunity to safeguard their ability to make choices about genetic parenthood and family-building in the future, aligning with their personal aspirations and values [54, 94, 95]. Harris et al. write, ‘Can these minors make adequately autonomous decisions in the present that may impact their opportunities in the future? This is less a question of decision-making capacity, as by age 14 years most youth have fully developed logical thinking, than a matter of sufficient life experience to know their future desires’ [94]. They also add that the principle of autonomy applies universally, without regard to gender. Hence, the desire of transgender women to conceive a child should be afforded the same level of consideration as that of cisgender women [96].

Some authors also argued on parenthood designation in this context. According to them, assigning parenthood titles based on genetic contribution might propose defining a transgender woman as the child’s “father,” which could discourage designating a child with two mothers or two fathers and risk unintentionally disclosing one’s transgender status without consent. They also add that it might confuse children if their mother, who has fulfilled the maternal role, is legally designated as their father, leading to potential distrust or resentment. However, it will support the child’s right to know their legal biological ancestry. Conversely, assigning parental titles based on birthing experience could validate transgender women as mothers following a uterus transplantation. However, this may invalidate the male gender identity of trans men [97].

5.2 What factors should be considered?

5.2a Non-maleficence-based arguments

Arguments in favour of providing fertility services considering its feasibility and safety

One of the central arguments the authors make in favour of uterine transplant for trans women is the absence of anatomical concerns that would hinder pregnancy [98]. This is supported by the fact that delivery can be achieved via the abdomen, mitigating any potential issues related to the neo-vagina or a virilised pelvis [98]. Additionally, the authors state that the pelvic cavities of both cisgender and transgender women share nearly identical vasculatures, potentially facilitating successful implantation and pregnancy following uterine transplant [98]. Despite the theoretical nature of uterine transplants in transgender patients, the discussion also encompasses considerations of risk and safety. The authors acknowledge that the added risk, if any, for transgender women undergoing uterine transplants compared to cisgender women is not accurately quantifiable [98]. However, they state that any potential risks associated with immunosuppressant use post- uterine transplants should be comparable between cisgender and transgender women [98]. Furthermore, they add that achieving pregnancy post-uterine transplants may be feasible with the utilisation of hormone regimens proven successful in women with premature ovarian insufficiency or following physiological menopause [99].

Arguments in favour of providing fertility services considering well-being of offspring

The second facet of the discussion revolves around the well-being and development of offspring raised by transgender parents. The Ethics Committee of the American Society for Reproductive Medicine state that ‘Current evidence does not substantiate concerns regarding compromised welfare or developmental outcomes for children raised by transgender parents’ [100]. Similarly, some authors argue that there is no evidence suggesting harm to children raised by transgender parents [100]. The evolving notion of parenthood, with the acceptance of single-parent and non-traditional family structures, underscores the broader acceptance of diverse family structures and dynamics [101]. Moreover, various authors mention that studies have shown that children raised by transgender parents do not exhibit gender variant behaviour or disturbances in gender identity [100]. Furthermore, these children typically demonstrate acceptance of their parents’ gender transition and express a desire to maintain close relationships [100]. The principle of treating like cases alike, unless there is a morally relevant difference, also prompts reflection on what distinguishes trans-parenthood from heterosexual parenthood [101]. The authors state that currently, there is limited data that suggests negative consequences for both children and parents in trans-parenthood cases and there is no evidence suggesting that being transgender impedes the ability of parents to establish caring and responsive relationships with their children [100, 101]. They also add that some states do not prohibit parenting by transgender persons, although there are no strong policies to protect that right [100].

Arguments against providing fertility preservation and other fertility services considering its harms

The authors cite that the experimental nature of ovarian tissue banking and prepubertal testicular cryopreservation and the absence of legal policies in some states and standardised practice guidelines for physicians offering fertility services, preservation and reproductive care to transgender individuals, can cause harm to transgender individuals and offspring [98, 100, 102]. They also state that youth may need to undergo undesired pubertal development [94, 102]. Moreover, authors also underscore the significant social risks such as the potential for stigma and discrimination associated with fertility preservation for transgender youth. The Ethics Committee of the American Society for Reproductive Medicine highlights that social risks stem from doubts about transgender individuals’ suitability for parenthood [102].

Specific concerns about uterine transplants for both recipients and donors are also raised [103]. Authors like Hammond-Browning emphasise the importance of not unduly exposing living donors to risks in an effort to maximise benefits for recipients, highlighting the ethical complexities inherent in uterine transplantation procedures [103]. Furthermore, Lefkowitz et al. point out that transgender women undergoing uterine transplant procedures driven by desires for bodily completeness rather than gestational purposes could potentially be subjected to the adverse effects of long-term use of anti-rejection hormones [96]. If the intent is to give birth because transgender may also want to have children for the same reasons as others, for example, intimacy, nurturance, and family, then the transplanted uterus would be removed after a successful pregnancy [96, 98, 100, 102]. Additionally, the potential harms of prolonged exposure to anti-rejection medications and hormones on gametes and the future offspring of transgender individuals remain unknown [102].

5.2b Justice-based arguments

Arguments in favour of providing fertility preservation and other fertility services:

The literature does not support denying access to uterine transplant for transgender women based on the principles of justice. Some authors mention that pregnancy, regardless of whether it involves a uterine transplant carries substantial risks, as evidenced by the challenges faced even by non-uterine transplant cisgender women [98]. Therefore, it is unreasonable to expect that a transgender uterine transplant pregnancy be completely risk-free [98]. Instead, the principles of equity and justice dictate that any risks encountered should fall within the range experienced during adverse conventional pregnancies, which are considered normative [98]. According to Balayla et al. ‘if a cisgender woman who lacks a uterus is ethically permitted to pursue uterine transplant procedures, then this opportunity should be equally accessible to all individuals in similar circumstances, regardless of the circumstances of their birth. This is especially salient for transgender women who may experience psychological distress stemming from feelings of bodily incompleteness’ [98]. Furthermore, some other authors state that gender and sexuality are increasingly understood as facets of a continuous spectrum rather than discrete categories [101]. Hence, it is unethical to deny fertility services solely on the basis of an individual’s gender identity, which is prohibited by law in some jurisdictions [100]. A few authors also add that if a cis-gender person who identifies as female but lacks a uterus can ethically obtain one, the principle of justice supports extending this opportunity to trans women who may experiencing psychological distress from feeling body-incomplete [95, 98, 102].

Discussion

To our knowledge, this is the first review that has sought to scope out and shed light on the ethical issues relating to the spectrum of medical interventions in, and aspects of, gender-affirming care. The analysis presented has systematically identified distinctive ethical issues, and distilled the dominant arguments presented in the publications to provide ways of addressing each issue. In this way, this review makes a significant contribution to our understanding of the ethical landscape of gender-affirming care. Our focus is not on critiquing the arguments, but on discussing the methodologies the authors used to discuss the ethical issues and the weaknesses of those methodologies. There were substantial differences in the depth to which the ethical issues in each aspect of gender-affirming care were discussed, with decision-making processes receiving the most attention, and deletion of health data the least attention. Among the 82 publications analysed, a notable majority—63% (53 publications)—focused on topics related to adolescents or younger children. This emphasis may explain why the decision-making process was explored more extensively than other ethical issues. Across all ethical issues, the principle of justice received significantly less attention compared to the principles of autonomy, beneficence, and non-maleficence. In many cases, the principle of justice was either entirely absent from discussions or addressed only briefly. Within each ethical issue, the four principles of biomedical ethics were not given equal consideration. For example, in discussions surrounding the ethical issue of the decision-making process in gender-affirming care, the principles of autonomy, beneficence, and non-maleficence were used by authors far more frequently than the principle of justice. This suggests that while discussions on decision-making emphasised personal choice and minors’ well-being, broader considerations of justice-related issues, such as social fairness and equity in access to care, were less frequently explored. On the other hand, when the ethical issue of funding for gender-affirming care was examined, authors applied the principle of justice more compared to the principle of beneficence. This suggests that considerations of fairness and equitable access were particularly relevant in discussions about financial support for gender-affirming care. Additionally, in some discussions, arguments supporting the ethical issue were given more attention, while in others, the focus was on arguments opposing the issue. Nevertheless, there was limited resolution and increasing disagreement. Recently, in the United Kingdom, the Cass review was completed in response to growing concerns about the safety and evidence base for gender-affirming care for minors [104]. The review highlighted significant gaps in the scientific evidence regarding the long-term outcomes of gender-affirming care and recommended a more cautious approach, emphasising the need for further research [104]. With the Cass review providing more guidance, more arguments and discussions need to come about which can potentially help to resolve some of the ethical issues surrounding gender-affirming care.

Principlism, commonly referred to as the four principles of biomedical ethics, was a common methodological tool the authors used to discuss the ethical issues [105]. Principlism serves as a valuable framework for identifying and navigating ethical issues. However, its application is limited by certain drawbacks [106,107,108]. First, in genuine ethical dilemmas the principles will pull in different directions and can only offer limited guidance on how to settle these dilemmas [107]. For instance, consider the scenario of a transgender minor with decision-making capacity requesting cross-sex hormones. Here, respect for autonomy and beneficence may support providing assistance, while non-maleficence could point against offering cross-sex hormones due to its potential clinical side effects. Additionally, this complexity further deepens when the same principle can support opposing positions, depending on how the principle is detailed and applied in practice [107]. For example, non-maleficence might stress the need for healthcare providers to avoid providing cross-sex hormones due to its the side effects.

On the other hand, non-maleficence might also support giving cross-sex hormones to reduce psychological and social harm caused by gender dysphoria. These drawbacks of principlism risk subjectivity and unjustified variation in healthcare and bioethical decision-making.

Second, by using a principlist lens (either explicitly or implicitly) for reasoning, the authors risk overlooking the intricate interplay of cultural diversity and contextual nuances in their arguments for and against a certain aspect of gender-affirming care [106, 108]. The assumption that the four principles hold uniform weight and significance across all cultural and social contexts (or that they ought to be explicated and applied in the same way across these contexts) fails to acknowledge the diversity of ethical perspectives and priorities present among different communities [108].

This oversight may undermine the depth and inclusivity of socio-cultural perspectives necessary for a more robust ethical analysis, potentially leading to incomplete conclusions regarding the complexities of gender-affirming care and its ethical implications within diverse societal contexts.

Analogical reasoning was another methodological tool the authors used to discuss the ethical issues. Broadly, analogical reasoning in bioethics involves drawing comparisons between similar situations to apply moral principles or justify ethical decisions. However, its application is limited by certain drawbacks [109, 110]. First, analogies can oversimply complex issues. If the situations being compared are not sufficiently similar, the analogy may be misleading [109]. For example, let us consider Mc Dougall’s analogy ‘while chest surgery is performed on cisgender males with gynecomastia to relieve their distress, the same principle applies to transgender males, and withholding surgery from them is gender identity-based discrimination’ [28]. For some, this comparison might seem straightforward consideration of justice as formal equality (like cases should be treated alike and unlike cases treated unalike). However, for others, especially those who understand the complexities of transgender healthcare, such analogies may be regarded as highlighting specific moral aspects from both situations while overlooking other important moral factor [109]. For example, in the analogy mentioned above, the authors selectively focus on the moral aspect of alleviating distress through medical intervention and overlooks other moral considerations such as the person’s right to self-identity and the social implications of gender transition. Third, even when focusing on the same moral aspects, different interpretations using various ethical theories can result in different moral judgments [110]. For instance, in the analogy mentioned above, if we consider the same moral aspect (alleviating distress) from a utilitarian perspective (maximising overall happiness), the analogy might seem valid as surgery could potentially increase happiness for both groups. However, from a deontological perspective (duty-based ethics), one might argue that the duty of a doctor is to treat medical conditions (like gynecomastia), and not to perform surgeries for identity reasons. Therefore, we need to be careful when using analogical reasoning and make sure we are rigorous and thoughtful in how we apply it.

This scoping review uncovered three significant gaps in the literature. First, there is a paucity of analysis on the role of care pathways and the broader care relationship within decision-making contexts. The analyses of decision-making primarily focused on decision-making authority and the factors influencing decision-making. Second, none of the publications discussed voice treatment for individuals undergoing transition. Individuals seeking voice-related support frequently encounter barriers when accessing appropriate care [111,112,113]. Voice and communication being a crucial aspect of daily life for most people, such treatment is important to their well-being and other considerations such as mitigation of stigma and harms [111,112,113]. Third, a geographical disparity in the literature produced. The publications reviewed were predominantly from a small number of Western countries. There were no publications that originated from authors based in Asia and Africa. This is important because normative claims derived from Western publications may not seamlessly apply to Asian and African contexts because of cultural and other differences. Additionally, countries within Asia and Africa exhibit considerable diversity among themselves, both culturally and otherwise. This highlights that country-specific ethical analysis of gender-affirming care is needed. Empirical bioethics research to understand the experiences of healthcare providers, parents and transgender individuals in relation to the ethical issues discussed in this paper would also be highly valuable.

Limitations

A limitation is that we excluded publications that do not extensively discuss the ethical topics. As a result, publications that identify or mention ethical topics without thorough exploration are omitted from our analysis. Nonetheless, our analysis successfully captured a diverse array of ethical topics and corresponding arguments.

Conclusion

This scoping review has identified the ethical issues and arguments put forward by authors to address these issues in gender-affirming care for transgender and gender-diverse individuals across the range of medical interventions. Our objective is not to evaluate the validity and soundness of these arguments but to provide a foundation for further critical engagement. By mapping this argumentative landscape, we offer readers an entry point to navigate and assess for themselves the reasoning behind different perspectives.

There is a substantial body of publications examining the wide range of ethical topics involved in the medical interventions used in gender-affirming care for transgender and gender-diverse individuals. These publications focus on five main ethical topics: the decision-making process, guidelines and models of care, deletion of health data, funding, and fertility preservation and services. The authors of these publications explored the ethical issues in each topic to varying degrees, presenting both supporting and opposing viewpoints. Despite extensive discussion, there remains significant disagreement and a lack of resolution on these ethical issues, underscoring their complexity. Continued dialogue and debate are necessary to address and potentially resolve some of the ethical challenges associated with gender-affirming care for transgender and gender-diverse individuals.

Table 3 should appear at under the section ‘Collating, Summarising, Interpreting and Reporting the Results’ in the text file. Table 3 heading is mentioned in the text file where it should be placed.