Conditions for shared decision making in the care of transgender youth in Canada

Capacity to consent: a scoping review of youth decision-making capacity for gender-affirming care

BACKGROUND

Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments.

METHODS

Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed.

RESULTS

Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning).

CONCLUSIONS

For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.

"I Should've Been Able to Decide for Myself, but I Didn't Want to Be Left Alone." A Qualitative Interview Study of Clients' Ethical Challenges and Norms Regarding Decision-Making in Gender-Affirming Medical Care

This qualitative study aimed to map and provide insight into the ethical challenges and norms of adult transgender and gender diverse (TGD) clients in gender-affirming medical care (GAMC). By doing so, we seek to make an empirical and constructive contribution to the dialogue on and moral inquiry into what good decision-making in GAMC should entail. We conducted 10 semi-structured interviews with adult Dutch TGD people who received GAMC. In our thematic analysis, we (1) included both ethical challenges and norms, (2) differentiated between explicit and implicit ethical challenges and norms, and (3) ascertained the specific context in which the latter emerged. We identified the following themes: (1) clients should be in the lead, (2) harm should be prevented, and (3) the decision-making process should be attuned to the individual client. These themes arose in the context of (1) a precarious client-clinician relationship and (2) distinct characteristics of GAMC. Our findings highlight divergent and dynamic decisional challenges and normative views-both within individual clients and among them. We conclude that there is no single ideal model of good decision-making in GAMC and argue that elucidating and jointly deliberating on decisional norms and challenges should be an inherent part of co-constructing good decision-making.

Ethical and methodological challenges conducting participative research with transgender and gender-diverse young people: a systematic review

Introduction

Research with transgender and gender-diverse (TGD) young people is essential to understand their experiences and to be able to propose, implement and adapt 'services' in the broadest sense to meet their needs. However, research outside clinical settings on current experiences and needs of youth under the age of 18 is limited which hinders the development of knowledge on TGD, as well as the development of research informed support practices. Acquiring parental consent for participatory research may present ethical and logistical difficulties, as it could jeopardize the safety, well-being, or confidentiality of adolescent participants. This creates a tension between the adolescent's right to autonomy, privacy, freedom, and all aspects related to the consent of the underage on the one hand, and the parents' right to protect their child on the other hand. This review aims to identify the methodological and ethical challenges associated with participatory research with transgender and gender-diverse young people.

Methods

We systematically searched bibliometric databases for studies published between 2006 and 2022 and included 4 main conceptual groups: transgender and gender non-conforming, adolescence, qualitative research (including participatory research) and consent. This review was registered in PROSPERO (CRD42022368360) in November 2022.

Results

Of the 3,794 articles initially identified, 291 met the inclusion criteria and 48 were examined. The selected studies were analyzed in the light of four main ethical tensions: involving parents or a trusted person in the consent gathering process, ensuring the protection and safety of young people while respecting confidentiality, and ensuring that spaces are created for transgender and gender-diverse young people to express themselves freely as part of an empowering research process. At the same time, several methodological challenges concerning public and stakeholder participation and recruitment, data collection and analysis as well as research integrity emerged from the selected studies.

Conclusion & implications

The existing literature of participatory research involving young transgender and gender-diverse individuals underscores the intricate and conflicting aspects, especially concerning power dynamics, empowerment, and the researcher's role. The relevance of these findings extends across various legal frameworks and is applicable to multiple contexts and countries.

Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians

According to international transgender care guidelines, transgender adolescents should have medical decision-making competence (MDC) to start puberty suppression (PS) and halt endogenous pubertal development. However, MDC is a debated concept in adolescent transgender care and little is known about the transgender adolescents', their parents', and clinicians' perspectives on this. Increasing our understanding of these perspectives can improve transgender adolescent care. A qualitative interview study with adolescents attending two Dutch gender identity clinics (eight transgender adolescents who proceeded to gender-affirming hormones after PS, and six adolescents who discontinued PS) and 12 of their parents, and focus groups with ten clinicians was conducted. From thematic analysis, three themes emerged regarding transgender adolescents' MDC to start PS: (1) challenges when assessing MDC, (2) aspects that are considered when assessing MDC, and (3) MDC's relevance. The four criteria one needs to fulfill to have MDC-understanding, appreciating, reasoning, communicating a choice-were all, to a greater or lesser extent, mentioned by most participants, just as MDC being relative to a specific decision and context. Interestingly, most adolescents, parents and clinicians find understanding and appreciating PS and its consequences important for MDC. Nevertheless, most state that the adolescents did not fully understand and appreciate PS and its consequences, but were nonetheless able to decide about PS. Parents' support of their child was considered essential in the decision-making process. Clinicians find MDC difficult to assess and put into practice in a uniform way. Dissemination of knowledge about MDC to start PS would help to adequately support adolescents, parents and clinicians in the decision-making process.

GenderJourney: Participatory development of an ethics support tool to foster dialogue and reflection on shared decision-making in gender-affirming medical care

OBJECTIVE

To describe and reflect on the development process of GenderJourney: an ethics support tool that seeks to foster (dialogue and reflection on) shared decision-making (SDM) in gender-affirming medical care (GAMC).

METHODS

Part of a larger project, this study used a participatory design. We included transgender and gender diverse (TGD) clients and healthcare professionals (HCPs) throughout the study in co-creation workshops. In an iterative process, we (1) established stakeholders' needs, (2) reached a consensus on the aims, content, and design, (3) developed and tested successive renditions, and (4) presented the final version of the tool.

RESULTS

The final tool aims to (A) elucidate the client's care request and corresponding treatment preferences, (B) foster an explicit dialogue between TGD client and HCP about expected/preferred decisional roles and collaboration, (C) stimulate a systematic joint reflection on and handling of SDM-related ethical challenges.

CONCLUSION

The GenderJourney provides non-directive ethics support to jointly reflect on and foster good SDM, including its inherent ethical challenges. Future studies should focus on its implementation and actual contribution to good SDM.

PRACTICE IMPLICATIONS

GenderJourney may be used in GAMC to support the dialogue on what good SDM entails and the identification, discussion, and handling of SDM-related ethical challenges.

Patient Empowerment Among Transgender and Gender Diverse Youth

Purpose: Patient empowerment is becoming increasingly important as health care moves toward more collaborative models of care. The goal of this study was to evaluate and characterize patient empowerment in a sample of transgender/gender-diverse/nonbinary (TGDNB) youth aged 14-24 who have had at least one conversation with a medical health care provider about gender-affirming care. Methods: We adapted a health care empowerment scale for use with TGDNB young people and collected patient empowerment and sociodemographic data among TGDNB youth in the United States over an 8-week period in the spring of 2022. Overall and domain-specific empowerment (including knowledge and understanding, control, identity, decision-making, and supporting others) were assessed on a four-point scale from a low of 1 to a high of 4. Results: A total of 177 youth completed the survey. Mean age was 18.4 ± 3.0 years, the sample was 39.5% gender-diverse/nonbinary, 16.4% transfemme, 44.1% transmasc, and 81.9% White. Average empowerment was 0.22 points higher in youth with supportive caregivers than those without (99% confidence interval [CI] 0.05-0.38, p < 0.001) and 0.20 points higher in youth who sought gender-affirming mental health support (99% CI 0.04-0.36, p = 0.001). Caregiver support increased youths' sense of control over their health/health care (estimated increase 0.29, 99% CI 0.09-0.50, p < 0.001), and mental health support increased youths' decision-making agency by 0.30 points (99% CI 0.06-0.53, p = 0.001). Conclusions: This is the first study to assess patient empowerment in TGDNB youth. Several sociodemographic factors were significantly associated with overall and domain-level empowerment. Further work in this area, both longitudinal and in larger samples, is warranted.

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study

BACKGROUND

Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires.

AIMS

The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment.

METHODS

Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care.

OUTCOMES

Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth.

RESULTS

The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery.

CLINICAL IMPLICATIONS

A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth.

STRENGTHS AND LIMITATIONS

This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth.

CONCLUSION

This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.

Sexual & reproductive health information on minor consent forms for pubertal suppression and gender affirming hormones

Introduction

Transgender and Nonbinary (TNB) youth need specialized sexual and reproductive health (SRH) information and counseling. One avenue for providing this information is the use of informed consent documents before initiating pubertal suppression (PS) and/or gender-affirming hormones (GAHs). This study aims to compare the type and amount of SRH information included on informed consent documents used across clinical sites providing PS and GAH to youth.

Methods

As part of a larger, IRB-approved survey on informed consent, providers of gender-related care to youth uploaded informed consent forms used in clinical practice. Publicly available forms were also included in analysis. Content analysis of these forms was undertaken using published clinical guidelines to inform coding and reflect the SRH implications of starting PS and GAH.

Results

21 unique consent documents were included in the content analysis (PS = 7, Masculinizing = 7, Feminizing = 7). SRH information on consent documents fell into 4 broad categories: (1) changes in sexual organs and functioning; (2) pregnancy and fertility information; (3) cancer risk; and (4) sexually transmitted infections. Forms varied considerably in the level of detail included about these SRH topics and most forms included implicit or explicit acknowledgement of the uncertainty that exists around certain SRH outcomes for TNB youth.

Conclusions

There was substantial variability in both SRH content and context across consent forms. The role of consent forms in fostering TNB youth's understanding of complex SHR information when initiating PS and GAHs needs further clarification and development. Future research should focus on ways to ensure provision of adequate SRH information for TNB youth.

Supporting Gender-Related Medical Decision Making for Transgender and Gender-Diverse Individuals: A Scoping Review

Purpose

Transgender and gender-diverse (TGD) individuals and their families face numerous challenging decisions. To better understand their decision processes, we conducted a scoping review of the existing literature and of decision-support tools in use at pediatric gender-care clinics.

Methods

We searched PubMed, EMBASE, Scopus CINAHL, PsychINFO, and EBM Reviews for studies that were original research focused on decisions, decision making, or decision support for TGD individuals and/or their families. All studies were reviewed for inclusion by at least two researchers. Additionally, we reviewed clinical tools used to support decision making by TGD youth and their families.

Results

We retrieved 3306 articles. Thirty-two met criteria for data extraction. Studies focused on three major decisions: gender-confirming surgery, fertility preservation, and gender-affirming hormone therapy. Several themes that cut across clinical topics emerged: decision-making processes, decision-making roles, and sources of decision support. Only three articles focused on decision-support interventions, two of which discussed development of support tools and one evaluated a class designed to help with surgical decision making. None of the clinical tools reviewed met criteria for a decision aid.

Conclusions

There is a dearth of studies related to decision support interventions, an absence validated by the resources currently in clinical use. This scoping review suggests an opportunity for the development of tools to aid in the decision-making processes for TGD youth and their families.

Sharing decisions amid uncertainties: a qualitative interview study of healthcare professionals' ethical challenges and norms regarding decision-making in gender-affirming medical care

BACKGROUND

In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands.

METHODS

In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents' explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged.

RESULTS

Respondents' ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC's guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI.

CONCLUSIONS

This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise.

Positive patient-provider relationships among transgender and nonbinary individuals in New York City

Background: Transgender and nonbinary (TGNB) individuals have diverse health needs and may face disproportionate barriers to healthcare, including developing positive patient-provider relationships. While there is mounting evidence of gender-based stigma and discrimination in healthcare, little is known about how TGNB individuals develop positive patient-provider relationships. Aims: To examine TGNB individuals' interactions with healthcare providers and identify main characteristics of positive patient-providers relationships. Methods: We conducted semi-structured interviews with a purposive sample of 13 TGNB individuals in New York, NY. Interviews were transcribed verbatim and analyzed inductively for themes related to characteristics of positive and trusting relationships with healthcare providers. Results: Participants' mean age was 30 years (IQR = 13 years) and most participants were nonwhite (n = 12, 92%). Receiving peer referrals to specific clinics or providers helped many participants find providers perceived to be competent and created initial grounds for positive patient-provider relationships. Providers with whom participants had positive relationships commonly managed primary care and gender-affirming care and relied on a network of interdisciplinary providers for other specialized care. Providers who were positively evaluated were perceived to possess in-depth clinical knowledge on the issues they were responsible for managing, including gender-affirming interventions, particularly for TGNB patients who perceived themselves to be knowledgeable about TGNB-specific care. Provider and staff cultural competence and a TGNB-affirming clinic environment were also important, particularly early in the patient-provider relationship, and if combined with TGNB clinical competence. Discussion: Provider-focused training and education programs should combine components of TGNB clinical and cultural competence to facilitate development of positive relationships between TGNB patients and providers, thereby improving the health and wellbeing of TGNB people.

How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool

BACKGROUND

Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one's developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care.

METHODS

The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care.

RESULTS

Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions.

DISCUSSION

Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The 'Competence Consultant' for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.

Re Imogen: the role of the Family Court of Australia in disputes over gender dysphoria treatment

This article examines Re Imogen (No 6) (2020) 61 Fam LR 344, a decision of the Family Court of Australia, which held that an application to the Family Court is mandatory if a parent or a medical practitioner of a child or adolescent diagnosed with gender dysphoria disputes the diagnosis, the capacity to consent, or the proposed treatment. First, we explain the regulatory framework for the medical treatment of gender dysphoria in children and adolescents, including the development of the welfare jurisdiction under Section 67ZC of the Family Law Act 1975 (Cth). We then provide an overview of the Re Imogen decision, and discuss the balancing exercise involved in determining a child's best interests in the medical treatment context. We challenge the Family Court's conclusion that, in relation to a dispute about diagnosis or treatment, a finding that the child or adolescent is Gillick competent to consent to treatment is not determinative, and the Family Court must determine the dispute. We argue that this conclusion represents an unjustified incursion into the right of Gillick competent transgender children and adolescents to make decisions about their own bodies and identities, and that the protective role of parents and the Family Court cannot justify interfering with their bodily autonomy in this context. Finally, we propose an alternative regulatory framework that removes the Family Court from the medical treatment process for gender dysphoria in circumstances of dispute between a parent and their Gillick competent child.

Differences in Patient and Parent Informant Reports of Depression and Anxiety Symptoms in a Clinical Sample of Transgender and Gender Diverse Youth

Purpose: We assessed characteristics of patients at a pediatric gender clinic and investigated if reports of mental health concerns provided by transgender and gender diverse (TGD) youth patients differed from reports provided by a parent informant on their behalf. Methods: This cross-sectional study included 259 TGD patients 8 to 22 years of age attending a pediatric gender clinic in the southeast United States from 2015 to 2020. Pearson correlations and paired sample t-tests compared patient-reported mental health concerns at patient intake with those provided by a parent informant. Clinical symptom severity was assessed with standardized T-scores. Level 2 Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress-Depression Scale and Level 2 PROMIS Emotional Distress-Anxiety Scale assessed depression and anxiety symptoms of patients. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure was used with parents. Results: Patients had a mean age of 14.9 at first visit, with most identifying as White (85.5%), non-Hispanic (91.1%), and as a boy or man (63.6%). Half had moderate-to-severe depression (51.2%) or anxiety (47.9%) symptoms. There was a moderate, positive correlation between patient-reported and parent-reported depression symptoms, with no correlation for anxiety symptoms. Informant type differences were statistically significant (patients reporting greater depression and anxiety symptoms). Conclusions: TGD youth patients reported more severe depression and anxiety symptoms compared with parent informants. Despite moderate agreement on depression symptoms, parents did not accurately detect their child's anxiety symptoms. These discrepancies highlight a need for interventions which increase parental recognition of child mental health status.

This Wasn't a Split-Second Decision": An Empirical Ethical Analysis of Transgender Youth Capacity, Rights, and Authority to Consent to Hormone Therapy

Inherent in providing healthcare for youth lie tensions among best interests, decision-making capacity, rights, and legal authority. Transgender (trans) youth experience barriers to needed gender-affirming care, often rooted in ethical and legal issues, such as healthcare provider concerns regarding youth capacity and rights to consent to hormone therapy. Even when decision-making capacity is present, youth may lack the legal authority to give consent. The aims of this paper are therefore to provide an empirical analysis of minor trans youth capacity to consent to hormone therapy and to address the normative question of whether there is ethical justification for granting trans youth the authority to consent to this care. Through qualitative content analysis of interviews with trans youth, parents, and healthcare providers, we found that trans youth demonstrated the understandings and abilities characteristic of the capacity to consent to hormone therapy and that they did consent to hormone therapy with positive outcomes. Employing deontological and consequentialist reasoning and drawing on a foundation of empirical evidence, human rights, and best interests we conclude that granting trans youth with decisional capacity both the right and the legal authority to consent to hormone therapy via the informed consent model of care is ethically justified.