103 Medical decision‑making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians 5 late development of the control system reduces adolescents’ MDC in certain challenging contexts which are not supportive (Grootens-Wiegers et al., 2017). Therefore, children and adolescents of the same age may have different levels of maturity and there is no general clear cut-off at which all children or adolescents have MDC (Grootens-Wiegers et al., 2017). Furthermore, some experts argue that children who have personal experiences with ‘illness’, may have greater understanding and insight compared to children who do not have this experience (Alderson, 2007; Bluebond-Langner, Belasco, & DeMesquita, 2010; Larcher & Hutchinson, 2010). This may specifically play a role in the case of gender non-conforming minors, where most adolescents seen at a gender identity clinic have long lasting or even life-long gender incongruent feelings. However, research does not confirm this hypothesis (Hein et al., 2015c; Vrouenraets et al., 2021). It is worthwhile considering to assess MDC and maturity on an individual basis rather than using a fixed age criterium, although the fact that most participants in the current study experienced age as an important aspect concerning MDC, may support that for certain more irreversible components of GAMT (by means of treatment with GAH and/or surgery), age criteria should remain existing (Coleman et al., 2012; Coleman et al., 2022; Hein et al., 2015a). Relevance of medical decision-making competence Finally, in our study clinicians pondered whether too much importance is placed on the adolescent’s MDC. None of the adolescents and parents did mention this. So far, there is no direct correlation between having MDC and not having regrets about a decision later in life, something that some stakeholders seem to have in mind (Pang et al., 2021). Besides, respecting an individual’s autonomy encompasses one’s right to make a decision that is regretted later on in life (Glover, 1990). A balance that needs to be struck is between the risk of regret and the risk of not providing the treatment, since refraining from treatment might have harmful effects too (de Vries et al., 2021; Pang et al., 2021). Strengths and weaknesses There are some strengths and weaknesses to the present study. The qualitative nature of this study made it possible to find out, in depth, the ways in which transgender adolescents, their parents, and clinicians think about transgender adolescents’ MDC to start treatment with PS. Another strength of this study is that adolescents who did continue with GAH after PS as well as adolescents who did not proceed to GAH were interviewed. This allowed us to compare their considerations. Nevertheless, the retrospective nature of this study raises the possibility of recall bias and hindsight bias of the informants. In addition, the informants were recruited from two Dutch treatment teams using the same protocol prescribing that PS was required for all adolescents before any further affirming treatment was provided. Adolescents recruited from other gender identity clinics in other contexts might report different considerations regarding MDC (Levine et al., 2022).