193 General discussion 10 account, and therefore leaving room for more customized care. In doing so, clinicians will be able to provide the transgender adolescents and their parents information about PS that is relevant for the adolescents and parents, and is more in line with the adolescents’ and parents’ considerations and ideas. This in turn will lead to better mutual understanding, and therefore will lead to better grounded informed consent of these adolescents and parents, preventing the risk of eroding into a merely legal and formalistic form of protection (Vrouenraets et al., 2022b). Consequences when refraining from treatment with puberty suppression Furthermore, besides the possible harmful consequences of the earlymedical interventions, informants of our 2015 study also mentioned the possible harmful consequences of refraining from interventions (Vrouenraets et al., 2015). Refraining from intervening is not a neutral option; not permitting transgender adolescents access to medical interventions may be accompanied with the risk of poor mental health outcomes, for example suicidal ideations, suicidality and/or harassment (e.g. Bauer, Scheim, Pyne, Travers, Hammond, 2015; Olson-Kennedy, Rosenthal, Hastings, & Wesp, 2016; Tucker et al., 2018; Turban, King, Carswell, & Keuroghlian, 2020). Therefore, for each individual person the right balance needs to be struck between the possible, partly still unknown consequences of treatment with PS, and the possible unknown consequences of refraining from this treatment, and take into account what is best for that individual person. 3. CO-OCCURING PSYCHOSOCIAL CHALLENGES Gender dysphoria in minors is associated with a range of co-occurring psychosocial challenges, and the risk of co-occuring psychiatric difficulties in these minors is high. This is a finding that reveals ethical and clinical challenges as to how to perceive and address these vulnerabilities when transgender adolescents apply for GAMT (Bechard, VanderLaan, Wood, Wasserman, & Zucker, 2017; Holt, Skagerberg, & Dunsford, 2016; Spack et al., 2012). A recent review study, including 32 studies, shows that adolescents presenting for an intervention regarding their gender dysphoria, experience high rates of mental health problems (Thompson, Sarovic, Wilson, Sämfjord, & Gillberg, 2022). The most frequent co-occuring psychopathologies are depression, anxiety, and attention deficit disorders. Furthermore, the prevalence of autism spectrum disorders, schizophrenia spectrum disorders, self-harm, psychoses, and suicidal ideations is higher in transgender adolescents compared to the cis population (Thompson et al., 2022). To date, the precise association between gender dysphoria and co-occuring psychopathology is unknown. However, a review study Paz-Otero, Becerra-Fernández,