198 Chapter 10 opinions and thoughts regarding this subject. Additionally, the role of the media and case law are increasing. With this, the debate seems to have become harsher, the controversy appears to have increased, and the people criticizing the use of early medical treatment and the people supporting it seem to be driven apart even further. These changes and the associated ethical dilemmas, require the clinician to take an adjusted role with regard to (medical) treatment for transgender minors. Previously, the clinician needed to take into account predominantly the minors’, the minors’ parents’, and their own professional standards, perspectives, thoughts, and wishes. Today, the voices of other influences, such as professional associations, the media, and case law seem to have become louder. Nowadays, clinicians should be aware of these increased ‘societal forces’. Therefore, clinicians in treatment teams providing care to transgender minors can be seen as balance artists; they need to balance the treatment wishes, demands, and voices from different influences which exert their influence on the clinicians’ work at different levels (M. de Vries, 2020). Roughly speaking, these forces can be classified into three ‘shells’ (figure 6). The outer layer that influences and impacts the work of the clinician, and therefore needs to be taken into account by the clinician nowadays, is broadly speaking: ‘society’; for example, the media and all people who are not directly linked to the care of individual transgender children and adolescents, but who nonetheless express their opinions and ideas regarding the treatment approaches (M. de Vries, 2020). The middle layer consists of ‘professionals’; for example professional associations, parent support groups, adult activists, clinicians who used to work in the field of transgender care, and case law (e.g. Gilligan, 2019a; Gilligan, 2019b). For most of them, the most important aspect is that the care provided to the minors is as much evidence-based and legally justified as possible. However, since the (medical) treatment for transgender children and adolescents is relatively new and some outcome concerns may only evolve many years after initiation of treatment in late adulthood (e.g. regret about infertility, low bone density), some of this care is not yet examined using large, long-term follow-up study designs, and therefore not (yet) evidence-based. The ‘forces’ of this layer can result in ethical dilemmas with which the clinician needs to deal. The last layer, in the specialized gender identity clinics, consists of the transgender children or adolescents themselves, and their parents. Despite that the clinician has always had to deal with the children, adolescents, and their parents, the way of dealing with the people in this central layer has changed over the years. The children, adolescents, and their parents referred to the gender identity clinic in the late 1990s and early 2000s, when the protocol for diagnostic assessment and treatment was drawn up, were mainly overwhelmed and ‘confused’ by the gender non-conforming feelings of the child and the situation. They mostly wanted support in their search for a way to help the child. Most of them saw the clinician working at the gender identity clinic as someone