Reassessing Capacity Assessments in Adolescent Consent to Gender-Affirming Care

Abstract

Assessing whether an adolescent has the decision-making capacity to consent to gender-affirming care has become one of the most contested procedural questions in pediatric bioethics, yet the doctrine most jurisdictions rely on -- mature-minor or Gillick competence -- was developed for discrete, low-stakes interventions rather than staged, partially irreversible treatment pathways. This review examines how capacity assessment is structured and practiced across informal clinical judgment, multidisciplinary assessment protocols, and the more centralized, gatekept model that followed the Cass Review in England, alongside the methodological controversy that review has generated. It then considers the harder cases in which an adolescent judged competent and a skeptical parent reach opposite conclusions, and the structural gap in mature-minor doctrine that such disagreements expose. We argue that much of the present conflict is fought on the wrong terrain, with disputes over the strength of the underlying clinical evidence and the appropriate scope of parental authority often presented as disputes about capacity itself. We conclude that a more defensible process would require staged, intervention-specific assessment, transparency about clinicians' evidentiary assumptions, and an explicit, disclosed procedure for resolving adolescent-parent disagreement.