20 Chapter 1 dysphoria regarding PS in gender dysphoria, and regarding the concepts sex, gender, child competence, and best interests? And do the perceptions, views and ideas of these adolescents differ from those of professionals, and if so, in what sense? (chapter 3); Part 2. Medical decision-making competence • Are transgender adolescents eligible for starting PS treatment competent to give informed consent to this treatment, andwhich variables are associatedwith adolescents’ MDC regarding starting PS? (chapter 4); • What are the perspectives on adolescents’ MDC concerning PS of transgender adolescents who proceeded with GAMT after PS, adolescents who discontinued treatment with PS, their parents, and transgender clinicians? (chapter 5); Part 3. Significance of puberty suppression and use of fertility preservation • How do the trajectories of transgender adolescents after the initiation of treatment with PS look like? How many adolescents discontinued PS treatment, how many adolescents had extended use of the treatment, and how long after starting PS did the adolescents start treatment with gender-affirming hormones (GAH)? And which reasons were there for extended use and discontinuation of treatment with PS? (chapter 6); • What functions does treatment with PS have for transgender adolescents who proceeded with GAMT after PS, adolescents who discontinued treatment with PS, their parents, and transgender clinicians? (chapter 7); • How many adolescents made use of fertility preservation in a Dutch cohort of transgirls who started treatment with PS? Had information about the risk of infertility been given to the transgirls? Was discussion of the option of fertility preservation documented in their medical files? What was the given reason for declining fertility preservation if the adolescent had not made use of fertility preservation? And what other factors were associated with the use of fertility preservation? (chapter 8); Part 4. Clinical ethics support • In what way can moral case deliberation (MCD) as clinical ethics support help clinicians in dealing with ethical dilemmas in transgender care? (chapter 9). OUTLINE OF THE THESIS This thesis consists of four parts. Part 1 sets the scene of the ethical issues regarding the use of early medical treatment for transgender children and adolescents according to the stakeholders. Chapter 2 explicates the considerations of people who support the use of PS and those who criticize it, regarding the use of PS in gender dysphoria. Moral intuitions on early medical treatment, and ideas, assumptions and theories about the
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