210 Chapter 11 In order to obtain insight into these considerations and ideas, semi-structured interviews were conducted with eight transgender adolescents (10-15 years old) who proceeded with GAMT after PS (‘continuers’), six adolescents (10-17 years old) who discontinued treatment with PS (‘discontinuers’), and 12 of their parents. In addition, two focus groups with in total 10 clinicians from the gender identity clinics in Amsterdam and Leiden, the Netherlands, were held. The four criteria one needs to fulfil in order to have MDC - understanding, appreciating, reasoning, communicating a choice - were all, to a greater or lesser extent, mentioned by most participants, just as the relatedness to a specific decision and context (Appelbaum & Grisso, 1988). Most adolescents, parents, and clinicians find understanding and appreciating PS and its impact important for MDC. Most informants, including most adolescents themselves, stated that they thought that they themselves/ the adolescents did not fully understand and appreciate the treatment and its consequences. However, most of them estimated that they/the adolescents were nonetheless able to decide about the treatment. Most adolescents, parents, and clinicians stated that not being able to understand and appreciate the impact of certain consequences of PS is inherent to the adolescents’ age and/or developmental stage. Parents’ support was considered essential in the decision-making process. The fact that PS has effects that are largely medical reversible was a reassuring idea for some adolescents and parents, while other adolescents did not take this aspect into account when deciding about PS. Certain consequences of PS and uncertainty about long-term effects (e.g. potential loss of fertility when proceeding to GAH and gonadectomy) causes doubts for some. Most clinicians encounter difficulties defining MDC. Some mentioned that they assess MDC differently depending on the adolescents’ developmental age. Some adolescents, parents, and clinicians mentioned the role of age, intelligence, and mental health problems as possible variables associated with MDC. Some clinicians pondered whether too much importance is placed on the adolescents’ MDC. Although some stakeholders have in mind that there is an association between having MDC and not having regrets about a decision later in life, this is not endorsed by literature (Pang et al., 2021). We concluded that clinicians find it difficult to assess adolescents’ MDC regarding starting PS, and to put into practice in a uniform way. Dissemination of knowledge and support concerning assessment of MDC and encountered ethical dilemmas about transgender adolescents’ MDC is desirable in order for clinicians to adequately support adolescents and parents in the decision-making process. Chapter 6 Treatment with PS aims to give the transgender minors the opportunity to explore their gender identity, and time to consider if they wish to pursue GAMT while development of
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