CASE 1: DIVORCED PARENTS, PARENTING PLAN, ONE SUPPORTIVE PARENT: Rae, age 11, is interested in starting puberty blockers. He is using he/him pronouns at school and at home, but his parents have not allowed him to get a whole new wardrobe yet. His parents are divorced, and both have equal medical decision-making rights. He has started developing breasts but has not had a period yet. The parents do not get along. However, mom, who is in clinic, and Rae both report that dad is “on board,” but he is regularly hard to reach due to his work schedule. What issues should you consider in determining whether to prescribe today?

Discussion

Legal: If the clinic’s policy requires two-parent consent, and it is unlikely that you will get written/verbal consent from the father, the supportive parent can petition the court for a change in the parenting plan that would allow them to make unilateral decisions about gender care. However, this can be a long and costly process, and a positive outcome is not guaranteed.

Medical: Requiring two-parent consent can prolong the time to starting treatment, which can be very distressing for the adolescent. Rae may grow increasingly anxious about beginning menstruation. While hormonal birth control methods are a route for suppressing menstruation, these come with their own risks and not all are as effective as a GnRH agonist. Further, only GnRH agonists can halt the other changes such as breast development, and GnRH agonists have a positive safety profile. GnRH agonists are typically given in the form of a shot or an implant, which can be stopped or removed to allow natal puberty to proceed if desired.

CASE 2: DIVORCED PARENTS, PARENTING PLAN, ONE SUPPORTIVE PARENT, OLDER TEEN: Jamie is 16 and has autism spectrum disorder. She lives with her dad 90 percent of the time in Spokane. Her mom took a job in Seattle to finance a special aide Jamie has at school. Jamie comes in with her mom to your clinic in Seattle on the one weekend per month she lives with her mom. Mom supports Jamie starting estrogen, but Jamie says her dad probably “wouldn’t love the idea” since he laughed at the drag queens in the TV show “POSE” that Jamie was watching. What issues should you consider in determining whether you should prescribe today?

Discussion

Legal: The legal obstacles here are similar to those of the previous scenario. Getting two-parent consent may require changing the parenting plan in court, which will cost time and money, and there is no guaranteed positive outcome. Since Jamie is an older teen, however, the provider may want to analyze her under the mature minor factors (see next scenario), to determine whether they believe she is mature enough to make her own gender-affirming medical decisions.

Medical: The rate of autism spectrum disorder is higher in the TGNB population than the cisgender population. Some clinics are prepared for assessing for persistence of gender identity diversity in neuro-atypical youth while others refer out to other providers to assess this, which can delay care. Issues with dual parental consent could also delay care. Additionally, it is important to not put Jamie in harm’s way if she returns to a father who would discard, humiliate, or harm her if or when he notices Jamie developing breast tissue. Some ways to mitigate this: suggest Jamie wear looser clothing in Spokane; seek out support from a school counselor; or join an extracurricular activity that allows for playful gender expression, such as a drama club. Since Jamie cannot change schools easily due to the intact support of the educational aide, she can be started on low doses of estrogen and testosterone blockers so that changes are more gradual until there is a safe time or way to come out to her dad. The physician could also inquire about other supportive adults Jamie has in Spokane. Finally, a hormonal implant may be a more discrete route of administration for a teenager who is concerned about prescription bottles being found at home.

CASE 3: NO CONSENTING PARENTS, OLDER TEEN: Carter was living with his mom until age 13 when he and his mom were in a car accident. His mom died, and he had severe injuries. He moved to Blaine to live with his dad, whom he hadn’t spoken to in a few years. Things went well while Carter was healing, but two years later, they started fighting about his long hair and the tight colorful sweaters he wore to school. Carter’s dad eventually threw him out of the house after finding him cuddling with a boy in his bedroom and shouting, “No gays in my house!” Carter stayed at a friend’s house that night. His dad would not let him come back, despite trying multiple times. He bounced between friends’ houses until he finished his junior year of high school and plans to take his GED soon. Now 16, he comes into the youth homelessness clinic because he has realized that, even though his dad thought he was gay, Carter now knows he is non-binary. He does not care what pronouns you use, but he does want to start estrogen.

What issues should you consider in determining whether you should prescribe today?

Discussion

Legal: Considering the lack of parental involvement and Carter’s age, Carter is a good candidate for analysis under the mature minor doctrine, depending on whether the practice’s policies allow this. To meet the standards established in Smith v. Seibly, the physician must document which mature minor factors are met when writing the clinic note:

• Freedom from parents or guardian: lives apart, manages their own affairs
• Age and maturity
• Self-supporting
• Training and experience
• General conduct as an adult

Since there are no clear legal criteria yet, it will be up to the risk management policies of each institution to determine how many factors will be sufficient, and how factors are weighed against each other. If he is not considered a mature minor, his path to care will be impeded by the lack of parental consent. He may choose to seek emancipation, which would require going to court.

Medical: While safe and secure housing are priorities for Carter, his estrogen therapy should not be contingent on that. As a minor who has experienced homelessness and family rejection, Carter probably has many coping skills developed to be mature and organized enough to walk into a clinic and ask for health care. A team-based approach with him is important to best ensure Carter is supported and can safely begin estrogen therapy. As the team gets to know Carter, they can start him on a low dose of medication and continue to stress the importance of follow-up meetings and communication at least via the patient portal. With good coordination by a social worker assisting Carter with housing, getting a phone, and enrolling in Medicaid, the physician would have many reasons to believe that Carter can follow up with questions and side effects of hormone therapy. Additionally, there would be no therapeutic benefit to Carter in trying to contact his dad for consent and doing so may put the patient at increased risk of harm.

CASE 4: SUPPORTIVE PARENTS, MEDICAID COVERAGE: Max, age 15, is seeking chest reconstruction and is on Medicaid. They have used a binder to flatten chest tissue since age 12. Max has given this considerable thought and even brought a list of surgeons to clinic.

What issues should you consider in determining whether you should refer to surgery today?

Discussion

Legal: Two-parent consent plus Max’s consent certainly meets consent requirements. [1] Additionally, according to the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) rules, youth on Medicaid have a right to comprehensive coverage of medically necessary care until the youth turns 21. Youth who are on Medicaid should be counseled on their options early to establish a care plan that suits their goals, their timeline, and the medical interventions related to their gender care needs. More information about this can be found in the “EPSDT: A Guide for States” document available at: https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf

Medical: With two parents supporting Max’s decision, they are likely to have good surgical outcomes and assistance during recovery. Max also shows dedication and education about the surgery by bringing a list of surgeons. Max’s binding may be benign but, depending on how long the binder is worn and how tight the binder, it may be limiting their breathing and contouring rib growth and final lung capacity. Proceeding with surgery could prevent the side effects of binding for additional years, even though the adolescent may still be growing chest tissue. Shared decision making between the physician, the patient, and the family about the risks and benefits of surgery would best help the family make an informed decision. The greatest challenge may be obtaining preauthorization for the procedure from the health insurance carrier, but Max should be able to get coverage for his needs if they are medically necessary, safe and effective, and not experimental.

Next Steps

Gender identity development begins in infancy. Thus, the age to allow youth to begin to seek services for gender-related medical care can be as soon as the child can express their thoughts about their gender. While some may say that preteens are not ready to make complex health decisions, it is worthwhile to remember that the youngest patients would be making a decision about the most reversible treatment (puberty blockers) and youth would be making such a decision with a trained medical provider.

Individual case solutions to establishing legal consent typically delay time to treatment. This can cause distress to a patient and in some cases constitutes a form of discrimination. Youth with the mature minor status can avoid such delays.

In order to provide clearer guidance to providers while expanding access to gender-affirming care for youth, the Washington state legislature would need to clarify consent rules for minors seeking gender-related health care services, as it has done with abortion, birth control, mental health, and emergency services. Legislative action is needed to help care teams, clinics, adolescent patients, and their families understand the rules, and to help patients to know their rights. Until legislative change occurs, The National Center for Medical-Legal Partnership [2], legal aid offices, and other community-based organizations should offer guidance for navigating the unique patient and family logistics complicating consent for TGNB minors.

[1] RCW 70.02.130

[2] See, for example, https://medical-legalpartnership.org/ and http://www.washingtonmlp.org/