206 Chapter 11 about this aspect. Many see GD as neither a medical disease nor a social construct, but as a normal, but less frequent variation of gender expression. However, some state that the need for medical treatment in itself, to relieve the suffering, implies that GD is not merely a normal variation, and that that is what defines GD as a disorder. The role of physiological puberty in developing a consistent gender identity is the third theme that emerged. Most informants agreed on the fact that treatment with PS indeed may change the way adolescents think about themselves. However, most of them did not think that PS inhibits the spontaneous formation of a gender identity that is congruent with the assigned gender after many years of having an incongruent gender identity. Additionally, several endocrinologists mentioned that PS has been used for many years in precocious puberty, and no cases of GD have been described in that context, as far as they know. Also, most emphasized that they deliberately start PS only when the adolescents have reached Tanner stage 2 or 3, in order to give them at least some kind of ‘feeling’ with puberty before starting to suppress puberty. The fourth theme is the role of comorbidity. The prevalence of co-occuring psychiatric problems in transgender minors is high (de Vries et al., 2011; Meyenburg, 2014; Wallien, Swaab, & Cohen-Kettenis, 2007). The precise mechanisms that link GD and coexisting psychopathology are unknown. Most informants state that it differs between individuals, and depends on the comorbid problem whether GD and the co-occuring problem(s) are merely coexisting or interrelated. Some professionals stress the importance of addressing treatment of severe coexisting psychopathology before addressing GD-related medical interventions, while others state that it depends on the individual and specific comorbid problem. The fifth theme regards the possible physical or psychological harmful effects of early medical interventions for transgender minors, and of refraining from interventions. Although (the sparse) research until now mostly shows no negative, and even positive results regarding the consequences of PS, advocates of the treatment remain cautious and people criticizing the treatment sceptical because of the fact that (long-term) risks and benefits of available treatments have not been fully established. Possible harmful effects of refraining from interventions are mentioned too. The sixth theme regards medical decision-making competence (MDC) and the decisionmaking authority, which is an important point of disagreement in the discussion regarding early medical treatment for transgender minors. Most informants agreed on the thought that adolescents’ competence should be determined on an individual case by case basis. They did not agree on how to actually do this, for example regarding who should have final authority to make decisions regarding early medical treatment; the adolescents themselves, and/or the parent(s) and/or treatment team were mentioned. The last theme regards the role of the social context in the way gender dysphoria is perceived. Some think that the way gender incongruent behaviour of minors is perceived in a specific culture, largely influences whether it is pathologized or not. Furthermore, some speculate that the increasing attention in the media might lead to medicalization of gender incongruent behaviour.
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