73 Assessing medical decision-making competence in transgender minors 4 Of note, the focus of this study was not on the putative association between MDC and having no regrets later in life about the decision to start PS. Competent transgender adolescents who begin PS may still potentially have regrets about the decision. There are strengths and limitations to the current study. The study’s standardized nature provided a reproducible and interrater-reliable method for assessing MDC in transgender adolescents who were about to start PS. Nevertheless, because of the study’s design to only include adolescents who were about to start PS after a diagnostic trajectory, the sample contained relatively few adolescents aged <12 years, with low intelligence, showing serious (interfering) psychiatric conditions or psychopathology, and relatively few birthassigned boys. Additionally, adolescent’s Tanner stage was not investigated in this study as a potential associated variable on MDC. Furthermore, on the basis of the current results, one cannot conclude with certainty whether the exploration and explanation during the diagnostic trajectory is essential in helping the transgender adolescents becoming competent to consent to PS or that MDC was already reached before the diagnostic trajectory. In future work, researchers should especially focus on transgender adolescents aged <12 years starting this treatment, particularly birth-assigned girls who may benefit from PS as early as nine years of age. Additional research is needed for adolescents with lower intelligence, serious developmental conditions, or psychopathology, for birth-assigned boys, and participants in early stages of puberty. More research is needed regarding the question what to do when an adolescent is incompetent to consent to the treatment; for example, what are the parents’ and the involved clinician’s role and responsibility in such a situation? In addition, qualitative research focused on the role of MDC in clinical practice and the principle of best interest are encouraged. CONCLUSION 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. Nevertheless, as long as there are only limited data on transgender adolescents’ MDC regarding starting PS, an individualized approach is highly important for this group.
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