207 Summary 11 The discussion regarding the use of PS is in full swing. Some consider the established international transgender guidelines too liberal, while others find them too conservative. Additionally, more and more treatment teams embrace the Dutch protocol, but still retain a feeling of unease. Discussion of the diverse themes needs to continue based on research data as an addition to merely opinions. Otherwise ideas, assumptions and theories on GD treatment will diverge even more, which might lead to (even more) inconsistencies between approaches recommended by clinicians across different sites/countries. Moreover, participation in the study encouraged several clinicians in thinking more explicitly about the various themes and to discuss the ethical issues in their teams. Chapter 3 In chapter 2 we described the considerations regarding early medical treatment of 36 professionals from 17 treatment teams worldwide. Nevertheless, little is known about the way transgender adolescents themselves think about early medical treatment. The third chapter therefore describes a study on the considerations and opinions of transgender adolescents concerning the concepts of ‘sex’ and ‘gender’, and the use of PS in GD. Furthermore, we compared the considerations on the use of PS of the adolescents with those of professionals, using the data collected in chapter 2. Informants were 13 adolescents, between the ages of 13 and 18, diagnosed with GD recruited from the gender identity clinic in Leiden, the Netherlands. All adolescents, except for one, were treated with PS. The adolescent who was not treated with PS immediately started treatment with gender-affirming hormones (GAH) because she was above the age of 18 when treatment was indicated, which is in line with the Dutch protocol. The mean age at which the participating adolescents started PS was 15 years and 10 months. Individual semi-structured interviews, containing general topics and no close-ended questions, were conducted (30-40 minutes). After no new content was found in the interviews, subject enrolment was stopped, this is called data saturation (Guest et al., 2006). Three themes emerged from the interviews; the first theme regards the difficulty of determining what is an appropriate lower age limit for starting PS. Most adolescents found it difficult to define an appropriate age limit and saw it as a dilemma. The adolescents seemed to be more cautious than some professionals, for example regarding the minors’ MDC in this context; most adolescents had doubts about whether minors are capable of making decisions regarding medical treatment at the age of 12 or younger, while some treatment teams are exploring the possibility of lowering the current age limit for PS. The second theme regards the lack of data on the long-term effects of PS; this lack is not a reason to not start PS in most adolescents. However, this was a big issue for the professionals. The third theme, the role of the social context, consisted of two subthemes: the first one was the increased media-attention, on television and on the internet, the
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