The High Court heard an application by the parents for a declaration that their 17-year-old child lacked the capacity to consent to gender-affirming hormone replacement therapy (HRT).
Background:
B is a 17-year-old who was assigned male at birth but identifies as female. She has been prescribed “bridging prescriptions” for spironolactone and oestrogen by an NHS GP since October 2024, pending referral to specialist gender services. This was based on an "informed consent" model, although B had notably forged her mother's signature on a self-assessment form.
B's parents, ATN and NTT, disagreed with the GP's approach, arguing that B lacked the capacity to consent to such treatment and that a proper assessment of B's capacity and overall health had not been conducted, particularly in light of the Cass Review's recommendations and NHS commissioning policies.
The parents also requested permission to instruct expert psychiatric and endocrinological evidence. The father also initiated parallel judicial review proceedings, challenging the GP's decision to prescribe HRT to minors. B, supported by her Children's Guardian, asserted her capacity to make her own medical decisions and argued against the necessity of a psychiatric assessment.
Decision:
The High Court permitted the single joint instruction of a Consultant Endocrinologist, Dr. Cotterill, to provide the Court with more information to issue its decision, but refused permission for the expert psychiatrist.
Regarding the expert psychiatrist, the Court found no prima facie evidence that B lacked capacity. B directly instructed her solicitor, who, along with the Children's Guardian, was satisfied that B had the capacity to litigate and was eloquent, articulate, and well-presented. The Court highlighted B's strong feelings that her ability to make decisions was being questioned and that her personal story had become "highly politicised". While B had some past involvement with Child and Adolescent Mental Health Services (CAMHS) for depression and possible autism spectrum disorder (ASD), there was no cogent evidence that these impacted her capacity in the relevant decision-making domains. To allow an expert to weigh in, purely on the assertion of incapacity, without prima facie evidence, would thus have undermined the presumption of capacity.
Moreover, the Judge was not persuaded that a psychiatric expert was necessary to determine B's best interests or the risk of "grave and irreversible psychiatric harm". The Court accepted that directing a psychiatric assessment against B's vehement wishes, especially when there was no evidence of psychiatric illness or lack of capacity, would have an adverse impact on her welfare.
All parties agreed on the necessity of an endocrinologist due to the ongoing HRT and the need for expert understanding of the physical benefits and risks of continuing or ceasing the treatment. The Court went with B’s choice, Dr. Cotterill, noting his prior involvement in similar cases in England and Wales and his ability to report quickly. The Judge rejected the parents' argument for each side to instruct their own experts, reiterating the clear preference under the Family Procedure Rules for a single joint expert, wherever possible.
Implications:
This judgement strongly reiterates that the Court's jurisdiction to override a 16/17-year-old's consent to medical treatment is narrow, and may be triggered only by the need to protect such an adolescent from "grave and irreversible mental or physical harm". It reaffirms the stringent test that it is "necessary to resolve the proceedings justly" for admittance of any expert evidence under Section 13 of the Children and Families Act 2014. Mere parental "concern" or "disagreement" does not automatically warrant expert reports, especially in the absence of any prima facie evidence for a lack of capacity or grave harm.
This decision also highlights that the presumption that a young person over the age of 16 has capacity is robust. The Court will not lightly undermine this precept by directing assessments unless there is compelling evidence to suggest incapacity. The judgement explicitly states that the Court's role is to determine the individual child's best interests and not to engage in broader policy debates or the general psychiatric/psychological consequences surrounding gender-affirming treatment.
Finally, this ruling reinforces the Family Procedure Rules' preference for single joint experts, pushing back against the idea that "equality of arms" in such cases automatically necessitates separate expert instructions.
