Why can’t we agree on the science of gender-affirming healthcare?
Philosophy of science can provide us with some useful tools to understand how different values are evoked by both sides of the trans medicine debate
Psychology and psychiatry—the “psy” disciplines—have long carried the stigma of not being “real sciences,” partly because they come from philosophy rather than the natural sciences, and partly because they deal with less tangible phenomena—thoughts, emotions, behaviors.
From the beginning, this skepticism intrigued me and led me to think deeply about science itself: what counts as “real science” and what doesn’t? How does science work as a messy, collective human endeavor—including how it’s done, shared, and debated? And more importantly: what influences scientists themselves—the questions they ask, the methods they choose, and the standards they use to judge their work and the work of others?
These aren’t just abstract questions. They belong to a field called philosophy of science, which examines the very foundations, concepts, and methods of scientific inquiry.
After years of immersing myself in the complex world of trans health research—sometimes personally, sometimes witnessing its impact on others—I’m convinced that it’s a particularly potent area for this kind of philosophical reflection. It constantly bumps up against these fundamental questions about science.
Frankly, it surprises me that this lens isn’t used more explicitly in the academic conversation, because I think that the clues are hiding in plain sight, right at the heart of the heated debates about transition-related care.
Why is there so much disagreement about the evidence?
If you follow discussions about transition-related care for trans people, especially children and adolescents, you’ll have probably noticed a stark divide.
On one side, you hear powerful voices—often including major medical organizations, trans and human rights advocacy groups, trans parent advocates, and sometimes even clinicians and researchers—claiming that “the science is settled.” They argue that the evidence overwhelmingly shows that hormones and surgeries are categorically beneficial, even “lifesaving,” reducing depression, anxiety, and suicidality, and leading to improved functioning and quality of life. The logical conclusion from this perspective is that access to medical and surgical treatments should be protected and expanded.
On the other side are competing voices of trans-skeptical parents, researchers, clinicians, policymakers, and gender-critical advocacy groups concerned with gender medicine who argue the exact opposite. They contend that the evidence base is very weak, plagued by low-quality studies (often observational, lacking control groups, with high dropout rates), significant uncertainty about long-term effects, and conflicting results. From this perspective, the logical conclusion is that transition-related healthcare should be limited or subjected to more rigorous research protocols before being applied to more children or adolescents.
How can two groups looking at the same body of research come to such dramatically different conclusions? Are some people just ignoring the facts? Or is there something more profound going on?
This is where philosophy of science, especially the study of the roles of values in science, offers crucial insights.
Science is not value-free
We often imagine researchers as purely objective observers, impartially gathering facts about the world. While the pursuit of objectivity is a core scientific ideal, the idea that science can be completely free of human values is a myth, as philosophers of science have shown for decades.
Values inevitably creep into the scientific process in many ways. For example, deciding that research on trans health or detransition is important (or not) is itself a value judgment. Choosing qualitative face-to-face interviews with patients over randomized controlled trials or quasi-experimental designs with clinical data may well reflect radically different values about what kind of knowledge is most important.
But values also affect much more critical aspects of scientific inquiry, such as how we interpret existing data or set standards for evaluating evidence.
Evidence, especially in complex areas such as psychiatry, psychology, or trans medicine more specifically, rarely speaks for itself. There’s often ambiguity, uncertainty, gaps. As philosopher of science Kevin Elliot discusses, how researchers fill these gaps or weigh conflicting evidence can be influenced by their values. In addition, the thresholds of certainty we use to conclude that something is proven “effective” are also set by the scientific community, and these involve value judgments.
For example, ambiguous results can be described by two different researchers as negligible or meaningful, and they may also disagree on how much certainty we need before recommending an intervention. This will depend on their underlying values about what matters. This is not to say that values dictate factual conclusions, but that they inevitably play an indirect role in this process.
Epistemic vs. non-epistemic values
In general, philosophers of science distinguish between two types of values that influence science: epistemic and non-epistemic.
Epistemic values are values related to the goal of acquiring knowledge. Think of things like accuracy, consistency, scope, simplicity, predictive power, or methodological rigor.
Non-epistemic values, on the other hand, are not directly related to the acquisition of knowledge, but arise from our broader ethical, social, political, or personal commitments. Think of things like social justice, autonomy, well-being, public health, economic considerations, or the reduction of suffering.
(It’s worth noting that this distinction is not always clear-cut, and philosophers of science like Heather Douglas and Helen Longino argue that these values are often deeply intertwined, or that certain social values can even play a legitimate epistemic role [e.g., diverse perspectives helping uncover biases]. For the sake of clarity, however, this broad distinction is a useful starting point.)
The key point to remember here is that both types of values can legitimately play a role in science, but how they play a role, and which values are prioritized when they conflict, is central to understanding debates such as the one over gender-affirming care.
Values in the transition-related healthcare debate
My central argument is that the debate over the evidence for trans medicine is not really about the “facts,” but is largely about the different prioritization of epistemic and non-epistemic values in interpreting a complex—and imperfect—evidence base.
The “science is settled” camp prioritizes non-epistemic values. These include things like social justice (reducing discrimination against trans people), autonomy (respecting trans people’s identities and bodily choices), and reducing present suffering (for example, the distress caused by gender dysphoria and the psychological problems it usually carries with it).
These non-epistemic values lead members of this camp to view current evidence as sufficient to act, focusing on the potential harm and limitations to bodily autonomy in withholding medical interventions as a greater danger. In addition, the demand for randomized controlled trials—which face many ethical and practical challenges in this area—is seen as setting an unreasonably high bar compared to other areas of medicine. The available evidence strongly suggests benefit when viewed through the lens of non-epistemic values, and thus leads to demanding wider access.
The “evidence is weak” camp, on the other hand, prioritizes epistemic values. These mainly include things like methodological rigor (emphasizing the limitations of observational studies, risk of bias, or confounding factors) and certainty (emphasizing the lack of sufficient follow-up, long-term data, and high dropout/non-participation rates that often exceeds 20-30%). All of this poses questions to how reliable the evidence base truly is.
These epistemic values lead members of this camp to adopt a position of skepticism and caution, even opposition, because of the potential harm of (incorrectly) providing medical treatments based on what is perceived as “low quality” evidence. They generally see the possibilities for benefit to be unclear and the risk of harm (e.g., infertility, side effects, medical/surgical complications) to be a greater danger to children and adolescents. They see the current evidence as insufficient to declare the science “settled” and advocate restrictions—materialized through legal bans— or much higher standards of evidence, which involves providing access to interventions only through research protocols to build a “higher quality” evidence base.
(Note: The quotations are used here to indicate language that is utilized by members of this side, and to underscore that there are philosophical debates about what ought to be considered high or low quality of evidence.)
How do these values play out?
I’ve already mentioned how the two camps interpret and view data from observational studies, which are the most abundant in the field of gender-affirming care. But there are many other examples where we can see these values at play.
For example, the choice of what to measure (the primary outcomes) and what is defined as “success” embeds values. Researchers who prioritize non-epistemic values often focus on patient-reported outcomes such as satisfaction with gender transition, gender congruence, or quality of life.
(More recently, helping trans people achieve their “embodiment goals” has been proposed as the ultimate goal of medical/surgical treatments. This has led to interesting discussions about what “effectiveness” means in the context of gender-affirming care and what its true goal is, even questioning ideas about patients needing to benefit from treatment.)
On the other hand, researchers who prioritize epistemic values might emphasize the need for more objective, long-term tracking of physical or mental health data, and focus on detransition and regret as indicators of potential iatrogenic harm or to bolster informed decision-making.
As another example: why do different evidence reviews and care guidelines (think Cass Review vs. WPATH SOC 8) reach different conclusions despite looking at overlapping—often the same—literature? The answer is that each uses a different standard for evaluating the evidence, which boils down to values. Reviews and guidelines that prioritize epistemic values may exclude many observational studies that are deemed to be of low quality, thus concluding that the evidence base is weak.
Conversely, those that prioritize non-epistemic values might include a broader range of evidence (including observational data and expert opinion from both clinicians and patients) and conclude that there’s sufficient support for transition-related treatments.
Even the framing and existing discourses around detransition are influenced by values. Perspectives that prioritize non-epistemic values such as bodily autonomy and social justice to access care often frame detransition as resulting from discrimination or lack of support, or as part of a person’s gender identity evolution to authenticity. They also emphasize that regret rates seem low compared to other medical procedures (such as knee surgery).
Meanwhile, perspectives that prioritize epistemic values see the emergence of increased cases of detransition/regret as a signal of potential misdiagnosis or iatrogenic harm, emphasizing the need to understand more to better prepare clinicians and prospective patients.
(Another interesting example of the tension between epistemic and non-epistemic values is present in the recent US Health and Human Services document on the treatment of gender dysphoria, which prioritizes psychotherapy for gender dysphoria in minors. Dr. Sebastian Barr’s and S. Rudd’s insightful critiques of the document both illustrate how non-epistemic commitments may influence the assessment of evidence. Barr focuses on how the document selectively interprets research—citing studies of affirming therapy to support potentially non-affirming approaches—while downplaying the harms of therapies that pathologize trans identities. Rudd highlights an epistemic imbalance in which medical affirmation is subjected to intense scrutiny, but proposed psychotherapeutic alternatives are not. Both responses challenge the assumption that psychological care is a “low-risk” alternative to hormonal/surgical treatments.)
This value-laden interpretation is precisely what philosophy of science “predicts” when faced with data fields such as transition-related care.
This is because the data currently available are complex and ambiguous; they contain signals of benefit and harm, of certainty and uncertainty. As a result, it doesn’t always lead logically to a single conclusion. Subjective values are what brings researchers and clinicians to bridge the gap between ambiguous data and confident statements such as “the science is settled” or “the evidence is weak.” In the philosophy of science, this gap is called the underdetermination of theory by evidence.
But drawing conclusions from uncertain data also involves a degree of inductive risk: the risk of making mistakes in interpreting data. Researchers must make value judgments about the potential consequences of errors when considering the available evidence. Deciding which type of error is worse is itself a non-epistemic value judgment.
The “evidence is weak” camp fears the risk of “false positives.” This involves responding to a belief within some corners of mainstream gender-affirming healthcare that everyone who seeks it will benefit, when in fact it does cause harm to some. Conversely, the “science is settled” camp fears the risk of “false negatives,” that is, of concluding that there isn’t enough evidence to support the benefits of gender-affirming care when in fact it is highly beneficial or lifesaving for many.
Setting the evidence bar high (for example, by requiring randomized controlled trials) might minimize false positives but it will also increase the risk of false negatives. Setting it lower (accepting observational or qualitative data) does the opposite.
Deciding where to even set the bar is a value-laden decision, not a purely scientific one.
Why does this all matter?
Of course, I don’t pretend to resolve these disagreements about transition-related healthcare with this analysis through the lens of philosophy of science. But I do think it can change the way we approach or make sense of the debates and the politics involved.
For example, instead of accusing perceived opponents of being “anti-science” or “ideologically motivated,” we might instead ask what values they prioritize in interpreting evidence, or what potential harms they are most concerned about avoiding. We could focus on how conclusions are reached, rather than just what conclusions are presented. We could also ask researchers and clinicians to be more transparent about what values influence their standards of evidence and interpretation of the data. This is not a simple admission of bias, but a recognition of the central role that ethical considerations play in areas such as gender-affirming care.
We are all trying to make sense of difficult evidence characterized by ambiguity and uncertainty, guided by values that are different, often competing, and deeply held. Many of the major players driving these debates have “skin in the game”—their own children, their own healthcare, and/or their professional reputations. While their values may clash, I believe it’s possible for all of us genuinely committed to youth well-being to share common goals, such as wanting the best outcomes and flourishing of young people. Recognizing this can help open up small places of common ground—for example, agreeing on the need for better data, even as we disagree about current policies or practices.
I admit this framework doesn’t offer easy answers, but it does provide some tools for understanding why the debate around gender-affirming healthcare is so fraught. It can also help us navigate the claims and counterclaims with more nuance and intellectual honesty.
We should never lose sight of the fact that science, especially in complex areas of health, is rarely just about the facts—it’s also about what we value. This is especially true in an area like gender-affirming healthcare, because gender diversity and trans people have a long, persistent history of being under-valued in society.
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I greatly appreciate this post. As a member of the WPATH Ethics Committee, these are the issues we work to illuminate internally. Your articulate explanation of the value laden distinctions is very helpful. I have been ruminating lately on the idea that facts and values are not the same thing, and contemplating ways to encourage people to recognize the difference between these concepts in their own thinking. Thank you for writing and publishing this post.
This is all well said. "The science is settled" does seem pretty clearly false to me. I think there are decent reasons one can claim, on current evidence, that people should be allowed to undergo medical transition below legal age. But that's very different from the science being settled. There is evidence available for both sides, at least at present, and the question is how we interpret it.