87 Medical decision‑making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians 5 One adolescent mentioned that his parents were involved and supported him in the decision-making process, but that the decision whether or not to start the treatment was made entirely by himself. “It was entirely my own choice [to start treatment with puberty suppression]. My father and mother had virtually nothing to do with it. Yeah, of course they were there for support and things like that, but the choice was really my own.” - Interview with a transboy who continued PS; age at start PS: 12.0; age at interview: 16.3 All clinicians stated that most children and adolescents need support when going through the decision-making process, from either their parents or clinicians, and that parents and/ or clinicians have an important role in the decision-making. “The point is that you [the adolescent deciding about puberty suppressing treatment] are then at an age at which you cannot yet understand and appreciate [the consequences of the treatment], and [that you as a clinician] basically make a choice for them [the adolescents].” - Focus group with clinicians Clinicians mentioned the role and sometimes strong influence parents can have in the diagnostic process and in decision-making. “It is more the anticipated fear or agony of the parents. In these cases, I sometimes feel that the parents are urging to start the treatment [with puberty suppression] more than the adolescents themselves, because they [the adolescents] are not yet so concerned with the puberty suppression, and whether or not it [starting this treatment] is possible. Sometimes it is difficult when I have the feeling that the parents are very much in a hurry and ‘pushing’.” - Focus group with clinicians “I think that parents are very influential in that. How do parents talk about it [the treatment with puberty suppression]? How do they talk to each other [parents together]? I think that at that age [when the child is 10 or 11] that is very closely connected to how the child thinks about treatment.” - Focus group with clinicians The clinicians stated that in some of these cases they find it hard to distinguish between the adolescent’s wishes and the parents’ suffering or anticipated fear. “On the other hand, it is very complicated [...] when parents have already started that [social] transition against the advice [of the clinicians] and when they are so on top of it [starting the treatment with puberty suppression], that you wonder to what extent the child’s agony is his/her own.” - Focus group with clinicians