185 General discussion 10 will be described how the considerations, ideas and newly obtained scientific data, when applicable, have changed and developed over the years. Furthermore, suggestions for future studies, and implications for clinical practice are given. 1. MINORS’ MEDICAL DECISION-MAKING COMPETENCE Transgender minors’ MDC to start PS is an issue which is given increasingly attention and importance over the years, and which is mentioned in almost all debates and discussions regarding the use of medical treatment for transgender minors (e.g. Downs, & Whittle, 2018; Ouliaris, 2022; Wren 2019; Levine et al., 2022). It is not only mentioned by those directly involved in the care of these minors, but also by influences not directly involved in clinical care, like society and the media (e.g. Cook, 2022; Robbins, 2022; Tampier, 2022). Furthermore, adolescents’ MDC appears to be a recurring and increasingly important issue in case law (e.g. Hughes, Kidd, Gamarel, Operario, & Dowshen, 2021; Kidd et al., 2021; Ouliaris, 2022). The lawsuit regarding Keira Bell, and the large-scale and profound consequences of the response to the verdict of this lawsuit show why it was so important to further research this topic (Barbi & Tornese, 2022; see the general introduction for more details about this lawsuit). From the start of this study project providers supporting the use of early medical treatment stated that research showed that relatively young children can meaningfully participate in the consent process, whereas people criticizing the use of early medical treatment raised doubts about what minors can understand (e.g. Abel, 2014; Giordano, 2008a; Giordano et al., 2021; Mann et al., 1989; Sadjadi, 2013). Some questioned whether the adolescents, at the time they decide on PS, actually have the mental competence to decide on starting that treatment (Vrouenraets et al., 2015). Of note, several clinicians, working in minors treatment teams of gender identity clinics, also questioned to what extent adolescents who are eligible to start PS are actually competent to make that decision (Vrouenraets et al., 2015). Furthermore, transgender adolescents themselves and their parents had doubts about the minors’ competence to make these decisions too (Vrouenraets et al., 2016; Vrouenraets et al., 2022a). Therefore, we conducted a study that aimed to determine whether the adolescents who were eligible to start PS were competent to make that decision. The Dutch version of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a validated semi-structured interview, modified for minors was used (Grisso et al., 1997; Vrouenraets et al., 2021). The results of this study are reassuring, showing that the majority (about 90%) of the adolescents participating in this study have thoroughly thought about PS, understand what the treatment involves, and are deemed competent to decide (Vrouenraets et al., 2021).