196 Chapter 10 alterations of referrals (Indremo et al., 2022). In this regard, one should keep in mind that a decrease of referrals does not necessarily mean that there are less children and adolescents with gender incongruent experiences. Therefore, a decrease of referrals might even lead to worse mental health among a group of minors not seeking care because of the risk and barriers in accessing the care they actually need (Pang, Hoq, & Steensma, 2022). Changes in the social context, such as the increased media coverage of transgender children and adolescents, therefore entail ethical challenges to clinical practice. People criticizing the use of early medical treatment and advocates of it speculate about the positive and/or negative influence the increased media attention might have, and how to cope with it in clinical practice (e.g. Indremo et al., 2022; Pang et al., 2020; Vrouenraets et al., 2015). More research on the role and influence of the increased media attention is needed to better understand its impact. 5. CLINICAL ETHICS SUPPORT The studies included in this thesis address several ethical dilemmas surrounding early medical treatment for transgender minors. In the studies described in this thesis we sought to further explore various themes that play a role in the care of transgender minors, and provide more substantiation regarding these ethical dilemmas. This, in order to ensure that the debate is scientifically knowledge-based instead of primarily assumption-based. However, our studies show that ethics is an inherent dimension of transgender care, especially in the care for children and adolescents in which the treatment can have life-long consequences, and where treatment decisions made in minors are often surrounded by complex ethical controversies and uncertainties (Vrouenraets et al., 2020). Several clinicians who were interviewed in the context of the interview study described in chapter 2, mentioned that participation in that interview study made them think more explicitly about various ethical themes related to the care of transgender minors (Vrouenraets et al., 2015). It encouraged them to discuss the issues in their multidisciplinary treatment teams. Furthermore, they reported a need to structurally discuss ethical challenges among their teams. Something which is mentioned in another study regarding moral challenges in transgender care as well (Gerritse et al., 2018). This led to the initiative of using moral case deliberation (MCD) as one of the clinical ethics support methods for dealing with ethical and moral challenges in transgender care in the Netherlands. Moral case deliberation Moral case deliberation (MCD) is a relatively well-established form of clinical ethics support and may help clinicians deal with ethical and moral challenges more effectively