Medicine as Restoration or as a Well-Being Project: What Does This Mean for Gender-Affirming Care?

What does medicine actually owe patients? The obvious answer is: treating illness and restoring health. But modern medicine does much more. It relieves pain, prevents risks, supports people with irreversible disabilities and sometimes offers interventions intended not so much to make someone’s life “more normal” as to make it more bearable or fulfilling. This raises a fundamental question that is often overlooked in the debate about gender-affirming care: is the primary aim of medical intervention to restore normal human functions, or may it also directly promote positive well-being and happiness?

This is not a matter of semantics. The answer determines how we discuss indications, evidence, public funding, consent and caution regarding irreversible treatments. The question is unavoidable when it comes to puberty blockers, hormone treatment and surgery for gender dysphoria. Not because gender dysphoria or the suffering of trans people would be unreal, but because the nature of the medical goal partly determines which benefits must be shown to outweigh the risks.

Normal function as a guiding principle

An influential, relatively narrow conception stems from Christopher Boorse’s biostatistical theory of health. In his 1977 article “Health as a Theoretical Concept”, Boorse describes health in terms of statistically normal biological functions within a relevant reference class, such as age and sex. Disease is then an internal condition that brings a typical biological function below the normal level. The appeal of this approach lies in its attempt to distinguish biological dysfunction from social disapproval or personal dissatisfaction.

Norman Daniels built on this premise but gave it a political and moral function. In Just Health Care (1985), he links normal functioning to fair opportunity. Poor health is not merely unpleasant; it limits a person’s normal opportunities to pursue education, form relationships, work and participate in social life. A just society therefore has a particular reason to make care available that preserves or restores normal functions.

This also leads to Daniels’ well-known distinction between treatment and enhancement. Treatment targets disease, disability or dysfunction: it prevents, cures or reduces a deviation from normal functioning. Enhancement, by contrast, improves an attribute or function that is already normal. Glasses for severe myopia intuitively count as treatment; an intervention to make already normal vision superhumanly sharp counts as enhancement. Daniels’ point is not that enhancements are always immoral. Rather, he argues that there is a stronger basis in justice for organizing treatment collectively than for using medical resources for optimization.

This model has clear limitations. What if a condition primarily causes psychological suffering without an identifiable disorder in a distinct bodily function? What if social exclusion, trauma or stigmatization limits a person’s opportunities? And what is “normal” when the relevant reference class itself is contested? Critics have therefore rightly argued that an exclusively biostatistical concept of disease leaves too little room for mental health, lived experience and the social dimension of disabilities. The model is not a neutral decision-making machine.

Callahan: medicine cannot solve all human discontent

Daniel Callahan placed the question in a broader context. The project organized by the Hastings Center, The Goals of Medicine, identified four main goals: preventing disease and injury, relieving pain and suffering, curing or caring for the sick when cure is not possible, and avoiding premature death while paying attention to a peaceful death. This is considerably broader than merely restoring biological function. Relieving suffering is explicitly a core task.

But Callahan also warned against a form of medicine that begins treating the human condition as a technically solvable problem. Aging, mortality, imperfection, disappointment and existential uncertainty do not disappear as medical capabilities expand. Anyone who expects medicine to eliminate every discomfort places a burden on doctors and patients that they cannot bear. Moreover, care then risks claiming ever more resources at the expense of other human goods: social support, housing, education, community and meaning.

This warning connects with recent work on the “moral expansion of medicine”. Philosopher Bjørn Hofmann describes how medicine’s mission can shift from reducing present pain and suffering to realizing positive well-being, future happiness and optimal quality of life. In his article “Managing the moral expansion of medicine” (2022), he identifies risks such as medicalization, overdiagnosis, overtreatment, health anxiety and unclear professional responsibility. His central point is not that well-being does not matter, but that a promise of happiness can be epistemically more uncertain and morally more dangerous than relieving concrete, existing suffering.

Gender dysphoria: restoration or well-being?

Applied to gender-affirming care, this does not produce a simple yes-or-no answer. In gender dysphoria, the central clinical problem is not necessarily a defect in puberty, hormone balance or the sex organs. In a physically healthy child or adult, puberty blockers, sex hormones and surgery therefore do not automatically restore a biological function that has been lost through disease. Puberty blockers instead temporarily interrupt an otherwise normal development; hormones and surgery alter physical characteristics.

From a strict Boorse-Daniels perspective, it therefore seems reasonable not to characterize these interventions as restoring normal physical function. They appear more like interventions that adjust physical characteristics in pursuit of experienced congruence, reduced dysphoria or an improved life. This places them in the broader category in which well-being, identity and quality of life are central. That category is not illegitimate, but it requires additional clarity: what problem is being treated, which outcome counts as success, how lasting is the effect, what alternatives exist and how are physical risks weighed?

This question is particularly urgent for minors. The Cass Review, published on April 10, 2024, concluded that, in English pediatric care, the evidence for the benefits and risks of medical interventions for young people with gender dysphoria is limited and that care should be organized in a more holistic and research-oriented way. An explanation of the report can be found in The Cass Review explained. This is not evidence that every individual treatment is harmful or ineffective. It does, however, undermine the categorical presentation of the medical pathway for young people as an established restoration treatment. If the intended outcome primarily concerns future well-being, while long-term effects remain uncertain and interventions may be partly irreversible, caution is more appropriate than language of certainty. What can no longer be reversed after transition is described on transethiek.nl.

The strongest counterargument

Nevertheless, it would be wrong to dismiss gender-affirming care simply as cosmetic “happiness optimization”. Gender dysphoria can cause intense and persistent suffering, affecting daily functioning, relationships and participation. Within Callahan’s framework, relieving that suffering can be a legitimate medical goal, even when no classic physical defect is being restored. The relevant distinction is therefore not between “real illness” and “mere preference”, but between an identifiable clinical problem and an unsubstantiated promise of improvement.

Daniels’ framework also allows for more than a superficial reading might suggest. His central concern is fair access to normal opportunities. If severe dysphoria obstructs those opportunities, psychological, social and sometimes medical interventions may in principle be justified. But this does not automatically follow for every intervention, every age group or every patient. A focus on opportunity precisely requires careful diagnosis, attention to comorbidity and context, realistic information about uncertainty and long-term measurement of outcomes.

The mature position is therefore neither denial of suffering nor limitless medicalization. Medicine should take pain and dysphoria seriously, but it need not promise that physical change will produce happiness or definitively resolve identity. In gender-affirming care, the decisive question is not whether care is “affirming” or “critical”. It is whether a specific intervention, for this person and at this point in time, with sufficient evidence and proportionate risks, genuinely reduces suffering and supports functioning. That is a more modest goal than guaranteeing happiness, but it is morally stronger and medically more honest.