How to Provide Care, Not Whether: Why Trans Healthcare Belongs in the Consulting Room
Dr Scott Leibowitz reminds us that medical decisions should be made by doctors and patients, not politicians offering false choices.
I want to talk about a 2023 article1 I came across recently from Dr Scott Leibowitz. He is a child and adolescent psychiatrist and one of the people who wrote the WPATH Standards of Care chapter on adolescents. He is someone who actually works with trans young people every day, and what he says really resonated with me because it is something I have been trying to articulate for years.
The Real Question
His central point is this: the question we should be asking is how to provide care, not whether to provide care. These decisions belong in what he calls the doctor’s office, the consulting room with patients and their families and their healthcare professionals, and not with politicians.
What frustrates me so much about these current debates is that we are constantly being offered this false choice between two extremes. On one side, ban all care for trans young people. On the other side, provide immediate access to everyone who asks without any assessment. Neither of those positions actually serves young people, and neither of them reflects how medicine actually works.
Good Medicine is Individual
In every other area of medicine, we assess individual patients and we make individual decisions. We do not ban treatments because some people do not need them. We do not hand out medications to everyone who walks through the door. We have clinical guidelines developed by experts who understand the evidence and the complexity, and we use those guidelines to help us make thoughtful decisions about each person’s care in line with what that person needs and wants and deserves.
All or Nothing?
Dr Leibowitz asks a really important question in his article: in what other field of medicine do we see calls for all or nothing approaches to treatment? The answer is none. We do not do this anywhere else. The fact that it is happening with trans healthcare tells you that something other than medicine is driving the conversation. And what is that? Politics.
The WPATH Standards of Care were developed by 119 experts from 18 countries over five years. These are people who have dedicated their careers to understanding transgender health, and the guidelines they have produced provide a framework for how to deliver care ethically and safely. They address things like assessing co-occurring mental health conditions, ensuring young people have sufficient maturity to understand what is being proposed, and of course, involving parents and caregivers in that process. That is not controversial, that is not groundbreaking, that is not new. That is just good medicine.
Honesty About the Evidence
One of the things I really appreciated about this article is the honesty about the evidence. Dr Leibowitz does not claim that the science is completely settled and he does not dismiss it as insufficient either. He describes it as evolving, which is exactly what you would expect for a field of medicine that is still developing.
There are studies showing clear benefit, including research in the New England Journal of Medicine, not leaked stuff in the Guardian. There is also ongoing research looking at different outcomes for different groups of young people. What does not exist is any evidence that withholding care leads to better outcomes.
Do Not Make Them Wait
Nobody has shown that making trans young people wait until adulthood improves their wellbeing, because that would be a very unethical study to conduct. But what we do know is that going through the wrong puberty causes real, immense distress, and that young people who receive support do way better than those who do not.
Can Young People Decide?
The question of whether adolescents can make these decisions is one I hear constantly, and I think we just need to be more nuanced about it. Some can, many can, lots can, some maybe not, and that is why we do those individual assessments. We trust young people to make significant decisions in other medical contexts all the time. A teenager with cancer can consent to chemotherapy. A young person with a chronic illness like diabetes can agree to lifelong medication.
The question is not whether adolescents can ever make important decisions. It is whether this particular young person, with this particular support system, has the capacity to understand what is being proposed. And it is a continual and individual assessment, not a one-off and not a blanket rule. That is what clinical guidelines help us do.
The Real Problem
What Dr Leibowitz makes very clear is that the politicisation of care is itself the problem. When legislators try to make highly complex medical decisions, they create a dangerous situation for the young people who actually need help.
Trans people deserve the same standard of care as everyone else: individualised assessment by qualified professionals who understand both the benefits and the risks and who can help each young person and their family make the right decision for them.
Medicine is a discussion between the patient and the doctor. It always has been, and we need to keep it that way.
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What do you think? I would love to hear your thoughts in the comments below.
https://www.psychiatrictimes.com/view/gender-affirming-care-for-adolescents-separating-political-polarization-from-medicine
https://www.psychiatrictimes.com/view/gender-affirming-care-for-adolescents-separating-political-polarization-from-medicine