187 General discussion 10 Boogers and colleagues shows that adult height in transgirls was slightly lower than the height predicted at start of PS, but there was no significant difference from target height (2022). Furthermore, with regard to the psychological aspects of PS in care for transgender minors, several studies show that the use of PS is associated with improvement of affect, psychological functioning, and internalising psychopathology by improving depression and anxiety symptoms, controlling self-mutilation episodes, and reducing suicidal thoughts and suicidality in adulthood (e.g. Costa et al., 2015; de Vries et al., 2011a; Khatchadourian et al., 2014; Rew et al., 2021; Tucker et al., 2018). In addition, PS is associated with improvement of quality of life and social life (e.g. Schneider et al., 2017; White Hughto & Reisner, 2016). One of our early studies found that clinicians should take the possible physical and/ or psychological harmful consequences of treatment with PS into account when considering starting treatment with PS for transgender adolescents (Vrouenraets et al., 2015). Concerns were mentioned regarding, among others, consequences for cognitive and brain development, and fertility (Vrouenraets et al., 2015). These concerns still exist. Despite increasing research into the possible consequences of PS for, among others, neurodevelopment, bone mineral density, and fertility, the full consequences (both adverse and beneficial) of the use of PS are not yet known (e.g. Arnoldussen, Hooijman, Kreukels, & de Vries, 2022a; Chen et al., 2020; Cheng et al.,, 2019; Schagen et al., 2020; Vlot et al., 2017). This lack of large long-term studies causes many stakeholders to worry and speculate about harmful long-term consequences (Giordano & Holm, 2020; Kimberly et al., 2018). In fact, these concerns have led some countries, for example England and Sweden, to limit access to care and allow treatment with PS for transgender minors only in research settings (Cass, 2022; Socialstyrelsen (National Board of Health and Welfare), 2022). Important to realise is the fact that most transgender adolescents who participated in our 2016 study stated that the lack of long-term physical and psychological outcomes did not, and would not stop them from wanting treatment with PS (Vrouenraets et al., 2016). Furthermore, many adolescents, both adolescents who proceeded to GAH after PS, and adolescents who discontinued treatment with PS, and their parents stated that they simply accepted possible negative consequences of the treatment with PS and mentioned that they did not really take them into consideration (Vrouenraets et al., 2022a). The role of physiological puberty in developing a consistent gender identity One possible consequence of PS that causes worries in some, regards the idea that interrupting the development of secondary sex characteristics, by means of PS, may disrupt the development of a gender identity that is congruent with the assigned gender