10 Chapter 1 INTRODUCTION In the last decades, in various parts of the world, the number of children and adolescents referred to gender identity clinics has increased enormously, and minors with gender incongruent experiences have increasingly become a subject of discussion (e.g. Arnoldussen et al. 2020; Arnoldussen et al., 2022b; Kaltiala et al., 2020; Pang et al., 2020; Wiepjes et al., 2018). The question how to best organize care for these children and adolescents has become very prominent and subject of public debate (e.g. The Observer, 2022). Determining what constitutes the best care inescapably involves thinking about ethical issues and dilemmas. The research described in this thesis explores ethical issues and dilemmas surrounding early medical treatment for transgender minors. This first chapter is an introduction to the topic. It describes the clinical characteristics of gender dysphoria and its treatment options, mainly focusing on treatment that includes puberty suppression (PS). Furthermore, adolescents’ medical decision-making competence (MDC) regarding starting PS, the role of media attention in referral rate and care of transgender children and adolescents, and legal and moral aspects are introduced. Finally, the overall aims and research questions of the thesis are described, and an outline of the other chapters is provided. GENDER DYSPHORIA Children and adolescents diagnosed with gender dysphoria experience an incongruence between their birth-assigned sex and their experienced gender, which is accompanied by distress (American Psychiatric Association, 2013). Table 1 shows the criteria for a diagnosis of gender dysphoria for children according to the 5th version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Table 2 shows the criteria for a diagnosis of gender dysphoria for adolescents and adults according to the DSM-5. Over the years and since the start of this research in 2013, terminology around gender identity related diagnoses has changed. The DSM-5 and the DSM-5-TR now use ‘gender dysphoria’, the 11th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) uses ‘gender incongruence’, while prior to these terminologies, the term ‘gender identity disorder’ was used (American Psychiatric Association, 2013; American Psychiatric Association, 2022; World Health Organization, 2022). While preparing the revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD), recommendations were made to replace ‘gender identity disorder’ by ‘gender dysphoria’, and ‘transsexualism’ by ‘gender incongruence’ respectively (Bedirhan Üstün, Jako, Çelik, Lewalle, & Kostanjsek, 2007; Cohen-Kettenis & Pfafflin, 2010; Drescher, Cohen-Kettenis, & Reed, 2016; Zachar, Regier, & Kendler, 2019). Reasons for these recommendations were that the condition can be
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