Decisional Capacity: A Guide for Well-Meaning Therapists

In May, I attended the 36th Annual Trauma Research Foundation's International Conference in Boston. For 4 days, I commuted to Back Bay, joining hundreds of therapists, physicians, and researchers in keynote and breakout sessions on topics ranging from working with families affected by generational trauma to the neurobiological impacts of trauma on early development – you know, the usual light topics.

During a presentation about the treatment needs and diagnostic considerations of LGBTQ individuals, the focus turned to gender-affirming care (GAC). In particular, the presenter, a trans clinician and researcher, outlined the info providers should include in any support letter they may be asked to write for their trans clients seeking GAC.

Most medical establishments and insurance companies require these letters (and sometimes ask for 2 letters from 2 different providers) to authorize care. In other words, before trans individuals can access medical procedures such as surgery or interventions such as hormones, they must meet with a provider who will write a letter documenting the following:

1. The client’s diagnosis.

2. Background information on the client's ability to cope with the intervention (such as doing injections or tending to their recovery), as well as identification of their support system.

3. Decisional capacity, aka the client's ability to discern the risks and benefits of the intervention and make a decision in their best interest and with minimal or no regret.

4. Statement regarding the medical necessity of the intervention in support of the overall health outcomes of the client.

A man sitting behind me raised his hand to ask a question about "decisional capacity" as it applies specifically to trans teens seeking medical intervention. He asserted that adolescents, in general, do not demonstrate this trait and that in the case of something "as serious as changing one's biology," providers should practice restraint in affirming a young person's ability to make this decision.

This is not a new challenge or idea. It's a longstanding favorite claim in defense of the belief that gender diversity (or same-sex attraction) is a passing phase. But this man took it one step further, reminding the audience that the adolescent brain is still in development, that the prefrontal cortex is estimated to still be growing until age 25. With that in mind, he suggested that any form of intervention should be delayed until the client has a fully functioning brain with which to make such a serious decision.

The presenter, no doubt having heard this question a thousand times before, not only in this context, but regrettably also in response to his pursuit of GAC, took a beat. And then he asked the audience, "For those here who identify as cis, when did you know you were cis?" I smiled. He then asked, "How many of you have ever questioned your gender identity? Or experienced someone else questioning it?"

Thinking this rebuttal had done the trick, I was surprised that the man in the back was undeterred. He persisted in his reasoning, stating that of the 4 trans youth he'd seen in his practice, 3 of them regretted steps they'd taken to transition socially (not medically), ultimately resuming living in line with their sex assigned at birth. With this limited sample and his privileged position as a white, cis male, he assumed authority on when and how a trans person could know themselves. More authority than the white trans man presenting at the front of the room.

I was witnessing well-intentioned gatekeeping. This practice protects the interests of the provider, shielding him from his fear, unfamiliarity, and biases while claiming it protects his young clients from making so-called irreversible, biological mistakes in judgment. It centers his cisnormativity, not to mention his age, and grants him authority.

I approached the man after the conclusion of the presentation, introduced myself, and asked if I could comment on his question. He agreed. I asked him if he was familiar with the large body of research demonstrating the tremendous health benefits to young people in receipt of gender-affirming care. Study after study demonstrates that youth with access to GAC have significantly lower rates of depression, anxiety, and suicide. He said he was. I asked how he reconciled this best-practice data with his clinical beliefs. He said he wanted to prevent kids from doing "irreparable harm to their bodies."

I took a beat.

I told him that as both a mom and a provider, I have realized that we adults woefully underestimate the calculus a young person performs before telling us who they are. They have considered the repercussions, the costs, AND the gains. Because of this realization, I have landed on believing the young person knows who they are.

Another man, standing near us, then piped up that he was the dad of a trans kid and that maybe I didn't appreciate the weight a parent feels in guiding their kid. "It's different when it's your kid," he said, "your level of responsibility is different than that of a therapist."

I looked him in the eye and said, "I'm well aware. I'm the parent of a trans kid. And I believe them."

They had nothing to say.

"We'll have to agree to disagree then," I said. They both nodded, and I walked away.

While this sentiment, live and let live, was functional in this micro exchange, it is harder to swallow at the macro level. There's too much at stake.

Maintaining an air of professional superiority in the name of protecting kids from doing irreparable harm to themselves ignores heaps of evidence to the contrary not to mention a host of other laws and practices that assert a kid's accountability for their bodies and minds: military service and the age of majority, to name a few.

The question of decisional capacity can be handled differently, and, as therapists, we can and we should do better.

• For one, we can and we should ask lots of questions about what the young person imagines for themselves living as a man, a woman, or as nonbinary.

• We can and we should troubleshoot potential obstacles and challenges related to their gender identity, inasmuch as we also talk about potential joy.

• And we can, and we should get real about their existing coping strategies or the availability of support. And then get to work on building more.

By doing those things, we achieve at least two goals:

1. We ensure our young clients are processing their gender identity as fully as possible.

2. We protect their integrity and dignity as a person to make decisions for themselves and to know themselves.

   
   

   In other words, we contribute to the development of their decisional capacity rather than stripping young people of their right to know who they are.