184 Chapter 10 reducing their distress and the associated dysphoria (Kreukels & Cohen-Kettenis, 2011). However, of note, research shows that even though more and more treatment teams provide treatment with PS, they do that with a feeling of unease because of the relatively little data regarding long-term psychological and physical outcome available (Vrouenraets et al., 2015; Vrouenraets et al., 2022a). A challenge regarding the lack of evidence-base is that the golden standard of a randomized controlled trial is neither feasible nor ethical, leaving clinicians with unanswered questions and inherent ethical challenges about what is best practice in care for transgender minors. More insight in the core of the ethical dilemmas that play a role in the care of transgender minors, and more empirical data that could give direction in some of the ethical dilemmas are needed in order to give clinicians direction to deal with these issues, and to inform and guide minors referred to the gender identity clinic. Therefore, the first overall aim of this research was to gain more insight in the core of the ethical dilemmas that play a role in the care of transgender minors, and the underlying intuitions and considerations of stakeholders in the field regarding early medical treatment. The stakeholders are transgender adolescents who proceeded with gender-affirming medical treatment (GAMT) after PS, adolescents who were diagnosed with gender dysphoria but who did not proceed with GAMT after starting treatment with PS, their parents, clinicians working in gender treatment teams, and people who are critical about the use of early medical treatment for transgender minors. The second, subsequent aim is to provide empirical data regarding these ethical dilemmas. The starting point of this thesis was a broad interview study we conducted which gave insight into the ethical dilemmas that play a role in the use of early medical treatment for transgender minors according to the stakeholders (Vrouenraets et al., 2015; Vrouenraets et al., 2016). Clinicians working with transgender minors and people criticizing the use of early medical treatment for transgender minors from around Europe and North-America, transgender minors themselves, and their parents were interviewed. Multiple themes, described in chapter 2 and 3, emerged which gave rise to different, and sometimes even opposing, views on the treatment for transgender minors. In the subsequent chapters we examined several of these themes to gain deeper understanding of the controversies and possible solutions. In this general discussion we reflect on the meaning of our study outcomes to the broader context of the political and public discussions. We will do this by means of five themes that consistently emerged in these discussions: the minors’ MDC, considerations regarding starting or refraining from PS, co-occuring psychosocial challenges, the social context, and clinical ethics support. One by one, these themes will be discussed. For each theme, it
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