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Dec 15, 2023
When I was in high school, my brother Theo was undergoing his medical transition as a transgender man.
Since he came out at 14, he’s had two chest surgeries, a hysterectomy, and over a hundred testosterone shots. In his medical transition, Theo says he felt like he was in charge of his choices, but he needed a large team of doctors, mental health professionals, and our parents to get him here.
Trans youth face additional gatekeepers as they seek medical care — they must articulate their experience to justify their requests to parents and healthcare professionals. Doctors often use inconsistent frameworks in medical settings to decide if a patient needs care.
Gillick Competence is one framework used in the United Kingdom, New Zealand, Australia, and Canada that has been applied to trans youth. It originates from the issue of contraceptive care, another critical issue for LGBTQIA+ youth as they become sexually active. This framework may also apply to youth seeking mental health.
Gillick Competence only applies to situations where doctors treat children without parental consent and applies to children under the age of 16, while there are other legal and medical frameworks used for minors between 16 and 18 years old.
The choice to medically transition is a personal one, and many trans people do not medically transition at all. Though this is a sliver of the challenges and triumphs that make up the trans experience, the health care of trans youth dominates the media coverage of gender diversity. As transgender youth have entered the political and cultural fray, media coverage has often fallen short by using the medical transition to sensationalize and pathologize transness.
Gillick Competence itself is one concept that has been sensationalized in the British media, often to question transness more broadly. It applies to a small fraction of youth seeking trans care.
For doctors, parents, and other decision-makers, it takes time and effort to unlearn cisnormativity and heteronormativity in medical settings. To parents of trans youth, many of them loving and supportive, they also need to reconcile with their role as gatekeepers to their child’s transition.
Source: Wikimedia commons
While often used interchangeably, Gillick Competence, Fraser guidelines, and age of consent are all distinct but related terms. The Gillick decision is also specific to the UK and has been adopted to a certain extent in Australia, New Zealand, and Canada.
No international law determines the minimum age of medical consent without parental support. However, children under 18 are protected by the Convention on the Rights of the Child, which states, “Children shall be provided with the care and aid they require.”
Age of consent or minor consent to care describes the age when someone is permitted to make decisions for their own body. Parental consent is required in the majority of countries worldwide for children under the age of 18. Still, once someone reaches 18, they are legally considered adults capable of making health care decisions.
For 16 and 17–year–olds, they have more autonomy to make medical decisions independent of their parents — Gillick Competence and Fraser guidelines apply to children under 16.
Under some circumstances, young adults can make their own healthcare decisions, especially for their sexual health. The law varies from country to country and even state to state in the US.
Gillick Competence is a medical and legal standard that originated in the UK and has now been adopted to some extent in New Zealand, Australia, and Canada. To determine “Gillick Competence,” children under 16 can consent to care if a medical professional determines that they have sufficient intelligence and awareness to understand the proposed treatment. Consent is only valid if voluntary and not under “undue influence” from anyone else. Children may also be able to consent to some treatment and not others.
The concept originated from a 1983 court case in the UK, where Victoria Gillick challenged a Department of Health guidance that enabled doctors to provide contraception to people under 16. Over the past five years, Gillick Competence has reemerged in the British media in reference to trans youth and the COVID-19 vaccine.
Fraser guidelines are specific to contraception and sexual health, named for one of the Lords responsible for Gillick judgment. The House of Lords specified that contraceptive advice and treatment can be provided as long as the patient is mature enough to understand the proposed treatment, they feel strongly about not sharing with a parent or guardian, they are very likely to begin or continue being sexually active without contraception, their mental health is likely to suffer without it, and the advice or treatment is in the young person’s best interest.
Fraser guidelines originally applied to only contraception, but following a case in 2006, they now apply to decisions about STIs and abortion. Unlike Gillick Competence, the Fraser guidelines do not allow a child to give consent in their own right — they are a specific set of parameters to provide sexual health care.
Parents of LGBTQIA+ youth have a responsibility to educate themselves on trans health care, but these concepts are complex and evolving. The mixed emotions, goals, and identities involved in a trans child’s health can be complicated for even the most accepting parents to navigate.
As the demand for trans adolescent health services have skyrocketed, there are still not enough doctors to keep up. In the US, as state legislatures have targeted LGBTQIA+ health care, 1 in 4 youth now live more than four hours from the closest clinic that can offer medication and hormones, according to a 2023 study from the University of Michigan.
Dr. Daniel Reirden, the medical director at TRUE Center for Gender Diversity and one of my brother’s doctors, told me in an interview that his clinic serves all of the Rocky Mountain region, with some patients traveling up to 10 hours for appointments.
Of course, transgender care is fundamentally different for children, adolescents and adults, he said. Doctors like Reirden take into account the different developmental stages that affect self-concept and gender identity.
However, Reirden emphasizes how impressed he is with his patients as they seek care:
“My job is just watching young people blossom into individuals who are comfortable in their own skin and their own experience.”
Reirden
Outside of medical settings, parents have taken a large role in activism and advocacy, often overshadowing other trans voices.
“In contrast to transgender activism over the past 50 years, which has sought transformative ways around binary definitions and the systems of control that such binaries impose and uphold. New activism on the behalf of young children by their parents seeks mostly to normalize the child and keep radicalization at bay.”
Author and activist Jack Halberstam
As queer children of queer parents, my brother and I have had this conversation many times. Our parents want us to be safe, and that often means less visibly gay and trans. Of course we understand our parents’ fears, and we have them too. But safety is a thorny subject, intrinsically tied with our identities, and there is also a difference between individual safety and collective safety. We protect each other and our queer communities by being authentically ourselves.
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Gillick Competence has entered the conversation around LGBTQIA+ health care, as doctors have given trans health care to youth under the age of 16. However, it is a narrow medical and legal framework that applies to a fraction of the cases of trans health care in the world.
Many depictions of adolescent transgender health in British and American media have lost the nuance of the transition process. Trans youth face gatekeepers such as gender therapists, doctors, and their own parents to initiate the process. However, many trans youth have the resilience and self-concept to articulate what they need and tackle the red tape to access care.
Parents — listen to trans advocates and your own children. For liberation, the most important thing is not existing in cis spaces like bathrooms or sports teams, but rather creating new visions of a world designed for trans and gender nonconforming people. I would argue this is far more important than understanding the difference between Gillick Competence and Fraser guidelines.
Catherine Henderson is a journalist based in Chicago. She has worked at a wide variety of newsrooms, including The Denver Post, Chalkbeat, Business Insider and In These Times, covering education, career development and culture. Catherine holds a master’s and bachelor’s degree in journalism from Northwestern University. Outside of work, she enjoys traveling, exploring Chicago, reading LGBTQ lit, and analyzing internet trends.
