209 Summary 11 judgements of MDC. A panel of 12 experts - including child psychiatrists and psychologists, paediatric endocrinologists, and master thesis medical students - was trained in judging MDC. The adolescent’s MDC in each IC video was judged by two expert and the clinician involved in the adolescent’s diagnostic trajectory. The MDC in each MacCAT-T video was judged by three experts. We found that 93.2% and 89.2% of the transgender adolescents who were about to start PS and were participating in this study, were assessed competent to give IC on the basis of the standard clinical assessment and when using the MacCAT-T interview, respectively. The intermethod agreement was 87.8%. The interrater agreements of the reference standard and MacCAT-T-based judgements were 89.2%, and 86.5%, respectively. Furthermore, full scale IQ-score and sex were both significantly related to MacCAT-T total score; birthassigned girls showed a higher total MacCAT-T score, as did adolescents with a higher full scale IQ-score. Age at the IC session, level of emotional and behavioural challenges, and the duration of the diagnostic trajectory were not significant related to the MacCAT-T total score. It is reassuring that the majority of the transgender adolescents participating in this study seem to have thoroughly thought about PS, understand what PS involves, and are deemed competent to decide. However, this might not be similar for all other contexts, particularly because our study cohort had extensive and thorough diagnostic evaluation before the MDC assessment, as opposed to adolescents without this support. Additionally, the study results indicate feasibility and validity of the MacCAT-T in clinical practice. However, these results do not answer questions on how to respect the developing autonomy of incompetent adolescents ethically. We conclude that as long as there are only limited data on transgender adolescents’ MDC regarding starting PS, an individualized approach is highly important for this group. Chapter 5 Chapter 5 reports on the perceptions on medical decision-making competence (MDC) to start PS of transgender adolescents who proceeded with gender-affirming medical treatment (GAMT) after PS, adolescents who discontinued treatment with PS, their parents, and clinicians. According to international transgender guidelines, one of the prerequisites for PS is that adolescents have MDC (Coleman et al., 2012; Hembree et al., 2017). As described earlier, chapter 4 describes an assessment of 74 transgender adolescents’ MDC regarding starting PS, showing that the vast majority (about 89%) of these adolescents is competent to consent to this treatment. Nevertheless, little is known about the considerations and ideas of transgender adolescents themselves, their parents, and clinicians regarding adolescents’ MDC to start PS.
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