Yes, young people can consent to gender-affirming care in exactly the way they consent to any other treatment, by showing they understand what it will do and what will happen without it. Consent depends on capacity, not a birthday. The test is the same as for diabetes, heart or cancer care.
This question comes up all the time, and it comes up especially loudly when the care is gender-affirming. It is also a question with a very ordinary answer, because the principles involved are the ones that run through the whole of medicine.
What is informed consent?
Informed consent means you have enough information to give your permission to a treatment that is being requested or proposed. It is a two-way conversation. You ask the questions you need to ask, and the doctor gives you the information they think you need in order to decide whether to go ahead. Information travels from the person to the doctor and from the doctor to the person, and the two of you come to a shared view of what is best for that particular person.
That is how it works across all of medicine. Doctors do not force treatment on people, and people do not demand treatment from doctors. It is a joint decision, and the person receiving the care comes first.
How old do you have to be to consent to treatment?
It depends on where you live, so check the rules in your own country. Some places set an age of majority, say 16, and below it somebody else has to consent on your behalf. The United Kingdom works differently. From 16 you are presumed to be able to make informed decisions about your own health care, which is why a 16-year-old can go to a doctor alone and ask for the contraceptive pill, the morning-after pill, or treatment for an infection. A parent cannot walk in and say you are not old enough.
Under 16, you can still consent to your own treatment in the UK as long as you can show that you understand it.
What are Gillick competence and the Fraser guidelines?
Gillick competence is the name most people know this by, and the Fraser guidelines are the term doctors often use. It comes from a case in which Victoria Gillick tried to stop her daughter being given the contraceptive pill because, in her mother's eyes, she was too young. The law said no: the young person was able to understand the ramifications of going on the pill, and of not going on it, so she could make that decision for herself.
In practice it works like a checklist, and the questions are plain ones.
- Does this young person understand what the treatment will do?
- Do they understand what will happen if they do not have it?
- Do they understand what will happen if they do have it?
- Can they hold on to that information, so that what they grasped today they still understand tomorrow?
- Can they take it in, process it and work out what it means for them?
Those questions are about understanding. They are not about age and they are not about anyone else's approval.
Is gender-affirming care any different?
No. Absolutely no different. It would be lovely if every young person had supportive parents who understood what was best for them, but that does not always happen. Sometimes young people are left to make their own decisions, and then the doctor's job is the same as it is anywhere else: to talk it through and check that the young person understands the implications of having the treatment and of not having it.
Some people picture doctors rushing about picking children off the streets and telling them they need puberty blockers. It does not work like that. It is the same as any other medicine. The person comes to the doctor and says they would like a treatment, that they understand what it will do for them, and that they understand what will happen if they do not have it. Then there is a discussion, and that discussion is what we call giving informed consent.
If you ever wonder whether a ten-year-old can consent to puberty blockers, ask whether a child can consent to having an elbow fixed, to open heart surgery, or to chemotherapy. Children make difficult decisions about their health, sometimes very young, and we generally do not question that. We only question it here, and I think that tells us more about social and political views creeping into the doctor and person relationship than it does about the child.
What about much younger children?
Take a six-year-old who crashes his bike and breaks his elbow. He might say no, do not touch me, it hurts. His mum will say that we are going to get something to mend your elbow, and you might need an operation. Parents and children disagree sometimes, but the general view is that the elbow needs fixing, and a six-year-old probably does not have the capacity to make that decision alone. Capacity grows. It is assessed in the person in front of the doctor, and it is not switched on at one fixed age for everybody.
Does starting treatment mean you have to carry on?
No. Having a treatment on your tenth birthday does not mean you must continue it for ever. Every time a prescription is signed there should be a re-evaluation. Are you still happy to take this? Do you still want it? Do you still understand it? Informed consent is an ongoing, long-term relationship with the person giving you care, and it is the same whether that care is gender-affirming, diabetes, heart, cancer or orthopaedic. A pause or a change of direction is part of that relationship working properly.
What if my parents do not support me?
A supportive parent makes everything easier, and plenty of young people do not have one. That does not on its own put care out of reach, because consent is about whether you understand the treatment, not about whether your family agrees. Having a trusted adult around you helps, and it is a good thing to work towards, but it is not the price of being taken seriously by a doctor.
What has the law taken away, and who pays for it?
The principle of consent has not changed, but access has been squeezed hard. In the UK, the sale and supply of puberty blockers on private prescription to trans young people has been banned, and other countries have followed. NHS prescriptions are almost impossible to obtain because the services and the expertise are not there. Puberty blockers are medications that pause puberty, and they have been used for decades, including in precocious puberty care.
That is a law closing a route, not a finding that young people lack capacity. The cost is paid by trans young people and their families: puberty does not pause while they wait, and every month of an unwanted puberty is a permanent physical change they did not choose.
Where can I take this next?
If you want to look at the medical side, GenderGP can help with access to affirming medical care, including hormones, blockers, prescribing and monitoring. A doctor there can look at where you actually are, which is something I cannot do from here. And if you have questions after reading this, Sammy is here to talk them through with you.
If there is a topic that you would like me to cover, just let Sammy know.
Dr Helen Webberley, Gender Specialist, Medical Educator and advocate.
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