The Department of Health and Human Services released the report, The Treatment of Pediatric Gender Dysphoria (herein “the report”), in November of 2025. The report was the basis for the justification of the proposed rules in 42 CFR parts 441, 457, and 482—changes to Medicaid funding for “sex-rejecting” procedures for children with particular emphasis on its ethical analysis:.
The HHS Review makes clear that ‘‘the evidence for benefit of pediatric medical transition is very uncertain, while the evidence for harm is less uncertain.’’ The HHS Review cites widely accepted principles of medical ethics to conclude that when ‘‘medical interventions pose unnecessary, disproportionate risks of harm, healthcare providers should refuse to offer them even when they are preferred, requested, or demanded by patients.
The report’s ethical analysis, however, is based on a narrow and selective interpretation of the evidence. It then proceeds to gravely misunderstand and misapply key ethical principles. The report’s ethical flaws potentially stem from the lack of expertise of its authors, none of whom included pediatric bioethicists or clinicians who work in the field of gender medicine. This is particularly notable for a distinctly pediatric ethical question. There is legitimate concern that these experts were excluded from the process that generated the report because the report was never intended to be an objective scientific and ethical analysis of pediatric gender care. Rather, its commissioning Executive Order, entitled “Protecting Children from Chemical and Surgical Mutilation“, claims to issue a blanket ban on gender care for those younger than 19. The report’s ethical analysis thus proceeds from a political mandate and should be met with the strongest of skepticism. Additionally, there is a growing body of peer-reviewed analysis detailing the scientific and methodological problems in the report.
The report’s authors claim that care for transgender youth has received little critical attention from bioethicists. This is both patently false and also assumes that the provision of pediatric gender affirming care (GAC) is somehow novel or exceptional, rather than being consistent with established principles of pediatric ethics. We previously responded to the report’s misapplication of pediatric bioethics. The well established four principles of bioethics applied to the current facts of GAC lead to comprehensive and individualized care in determining which patient will benefit rather than total bans on care for all.
Respect for autonomy
Respect for autonomy is always a consideration in medical ethics and even in pediatrics. Beginning around the age of 13, adolescents have been shown to have a similar ability to make informed decisions as adults. Supported by parents, medical decision-making—weighing the burdens, benefits, risks, and alternatives—can be of equal quality to that of adults, even in GAC.
Adolescents have growing autonomy as they age, but there is still a need to support and constrain decision-making. The concept important to decision-making in ethics is capacity. Capacity is the ability to make decisions. It is decision-based, meaning the question is often “capacity for which decision?” As detailed by the AAP, but ubiquitous across medicine, capacity is demonstrated by the ability to evidence and communicate a choice, understand the relevant information and facts, appreciate the situations and consequences, and the ability to assess the information in a rational way.
Statements in the report such as “…young people cannot deliberate about the relevant considerations in a manner that is appropriately attentive to the seriousness and complexity of the decision…” are speculative, overgeneralized, and highly value-laden. It is true that with burgeoning autonomy we want to support and even temper adolescent decision-making. It certainly will be true that some young people will lack this ability, but to say they all do is a clear misunderstanding of adolescent ethics and development. Respecting adolescent autonomy is important, even if it is not fully adhered to, and their capacity to make decisions should be assessed like any adult patient.
Beneficence/Non-Maleficence
Beneficence and non-maleficence work together, in balance, to help determine where interventions fall within the spectrum of shared decision-making (SDM). The balance between these two principles can sometimes depend on patients’ and families’ values, or on how one views the amount or certainty of a treatment’s benefit relative to the potential burden it might bring. These considerations all works together to determine whether decisions in pediatrics fall within the zone of parental discretion.
The Report seems to suggest that no adolescent has ever benefited from gender affirming care. But many have benefited. The report argues that the benefits of GAC for adolescents are unreliable and that it has an unfavorable risk/benefit ratio. But this is an “…egregious misuse of the findings…” Gender affirming care has shown to benefit individuals who undergo care. Systematic reviews often assign the term low certainty to observational studies. Low certainty does not mean no benefit rather it means that SDM should occur to determine the benefit-to-burden ratio for an individual patient. In SDM, parents, the patient, and clinician decide together how the balance of benefits and burdens, along with the uncertainty fit for an individual patient in line with their individual values and preferences.
This is not unique in pediatrics. There are many interventions utilized through SDM that lack strong systematic review data. If everything done in medicine had such data, we would not need clinicians to synthesize the unique individual presentation, the current theory and evidence, the pharmacological and physiological data, and the unique values of the patient. And as such, it requires careful and thoughtful process by clinicians, along with parents and patients, to determine whether an individual child might benefit, when, and with what intervention. The data around GAC is similar to the data around many other types of medical care in pediatrics, for which patients find to be beneficial, even if not every patient will find it beneficial. It is important that good assessment, discussion, and decision-making are undertaken.
Justice
The report then applies justice to issues of diagnostic overshadowing for which other conditions may be present and symptoms may be misattributed to. The report makes a speculative claim that the “…gender clinic model of care becomes Maslow’s hammer to which every problem appears as a nail (233).” That GAC clinics are identifying every symptom as gender dysphoria is a significant and unsubstantiated accusation. The report’s source for this accusation is one clinician’s statement in a newspaper article and an op-ed for the Washington Post by that same clinician. The report claims, based on this one report, that this demonstrates an injustice being done by all GAC clinics. Yet, injustice seems more evident in condemning all care based on one unverified report. Justice in this case argues for what the Cass Review recommends is a coordinated and organized process to determine whether an adolescent may benefit from gender affirming care.
Conclusion
The report claims that bioethicists have not provided critical attention to pediatric GAC. Yet there have been pediatric bioethicists who have analyzed this care. These bioethicists overwhelmingly reject the report’s ethical conclusions based in the four principles of bioethics. Pediatric GAC is consistent with the four principles of bioethics. Adolescents have burgeoning autonomy and that should be respected as moral agents supported through SDM. The balance of beneficence and non-maleficence may be clinically different for different patients. Unreliable benefits in the evidence cannot be conflated with no benefits. In pediatric GAC the favorability of any treatment in terms of the proportion of benefit to burden will depend on many patient-specific factors. These require consideration through SDM that is utilized in nearly every clinical discussion in pediatrics. Justice in pediatric GAC argues for good process in determining which patient will benefit from which treatment. Justice requires access, not bans.
The public comment period for the two proposed CMS rules ends February 17th at 11:59 PM. However, the misapplication of pediatric bioethics framing the rhetorical narrative, along with an all-or-nothing, rather than a nuanced and thoughtful approach to this population, will continue to wield policy discussions.