72 Chapter 4 of) the usual implicit assessment of MDC. However, in individual cases of doubt on MDC, the MacCAT-T could be used as a structured tool to underpin MDC assessment more objectively. Therefore, the tool will not be a barrier for access to care but can be used for due diligence. In the MacCAT-T, contextual information is weighted in the assessment, which may include parental support. It is expected that these results will be generalizable to other clinics because findings are in line with other research on the use of the MacCAT-T in minors (e.g., in a population deciding on predictive genetic testing, in minors with HIV infection, and in a sample of adolescents with psychiatric conditions) (Chenneville et al., 2014; Hein et al., 2015d; Mandarelli et al., 2017). Findings regarding the age for established MDC are congruent. Although the study results reveal that most adolescents are considered competent to give IC for starting PS, nevertheless 6.8% to 10.8% are not, respectively, reference standard-based and MacCAT-T based. In all of these 11 adolescents assessed incompetent, except for one, the involved clinician had no doubts about the MDC. Possibly, the more positive judgement by these clinicians may be explained by their judgement on the basis of several sessions and not on a single assessment. In the one adolescent that was assessed incompetent by the involved clinician, the clinician added that she considered the adolescent’s mother competent to give (proxy) consent. So, in cases in which there is doubt regarding adolescents’ MDC, clinicians may more heavily depend on the parents’ IC (Giordano et al., 2021). Subsequently, time on PS could more explicitly be used to prepare MDC for treatment with lasting effects of gender-affirming hormones (GAH). This is in line with statements in a recent qualitative study that the best interest for an individual should be taken into account when deciding whether to start PS (Vrouenraets et al., 2015). Other research reveals also that MDC assessment is regularly influenced by the clinicians’ ideas of what is in the child’s best interest (de Vries, de Wit, Engberts, Kaspers, & van Leeuwen, 2010). This might mean that some clinicians start PS in transgender adolescents who are assessed incompetent to consent on the basis of the principle of best interest. In addition, the results of the current study do not answer questions on how to respect the developing autonomy of incompetent adolescents ethically. In the aforementioned qualitative interview study, some clinicians stated that transgender minors should at least partially depend on their parents to make decisions regarding PS (Vrouenraets et al., 2015). It could be that the parents’ role and responsibility should be more pronounced when an adolescent is deemed incompetent to consent (Giordano et al., 2021).