158 Chapter 9 Professionals at gender identity clinics are frequently confronted with controversies and moral challenges arising from the care they provide for minors (Drescher & Pula, 2014; Vrouenraets et al., 2015). In general, moral challenges arise when professionals doubt as to the morally right course of action to take (Molewijk, Hem, & Pedersen, 2015). One type of moral challenge is a moral dilemma. In moral dilemmas, there are two mutually exclusive moral imperatives, neither of which is unambiguously desirable or acceptable (Stolper, Molewijk, & Widdershoven, 2016). Many clinical dilemmas fall into this category because they have a moral dimension. The moral dilemmas often faced by treatment teams working with transgender children and adolescents (and adults) include: (1) What should the professional do if the he/she is in doubt whether the adolescent fully comprehend the implications of gender-affirmative treatment?; (2) When is a psychiatric disorder so serious that we should not start gender-affirmative treatment?; and (3) Must we reach a multidisciplinary team consensus about the whole treatment before treatment commences, or is it justifiable for discipline X to start part Y of the whole genderaffirmative treatment before a consensus has been reached? (Byne et al., 2012; Gerritse et al., 2018; Milrod, 2014; Stein, 2012; Vrouenraets et al., 2015). Several reasons exist on why care for transgender adolescents entails a particularly large number of moral challenges. To begin with, care for transgender minors is a relatively new domain, on which there are many different normative views. These exist at both a professional and societal level (Byne et al., 2012). In addition, the normative views on the treatment for child and adolescent with GD are continuously evolving (Byne et al., 2012). Another common source of moral challenges in transgender care is the multidisciplinary nature of such care and the resulting divergence of professional views on the appropriate treatment criteria. Also, many of the long-term effects of administering medications or refraining from PS are as yet unknown, causing treatment uncertainty (Stein, 2012; Vrouenraets et al., 2015). Furthermore, medical treatment for transgender adolescents is seen as an intervention in a physically healthy and, in most cases, still developing body. Lastly, the adolescents undergoing such treatment are considered to be not yet fully developed in a psychological and cognitive sense (Byne et al., 2012; Crone, 2016; Moshman, 2017). These factors raise doubts about the potential risks of suppressing pubertal development in terms of physical development, brain growth, and the building of a consistent gender identity (Cohen-Kettenis et al., 2008). In many clinical settings, clinicians are assisted in dealing with moral challenges and questions through structural clinical ethics support (CES) (Schildmann, Gordon, & Vollmann, 2010). Various CES methods are available, including individual consultations with an ethicist and ethics committee meetings. None of the current CES methods are versatile enough to cover the entire range of challenges and questions debated in the clinical context (Steinkamp & Gordijn, 2003). In the Netherlands, a relatively well-established type of CES is moral case deliberation (MCD) (Dauwerse, Weidema, Abma, Molewijk, & Widdershoven, 2014; Molewijk et al., 2008a). MCD is a facilitator-led, collective
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