29 Early medical treatment for transgender children and adolescents: an empirical ethical study 2 INTRODUCTION Gender dysphoria (GD) is a condition in which individuals experience their gender identity (the psychological experience of oneself as male, female, or otherwise) as being incongruent with their phenotype (the external sex characteristics of their body) (Besser et al., 2006). The most extreme form of GD, often called transsexualism, is accompanied by a strong wish for gender reassignment (World Health Organization, 1993). Of the individuals experiencing GD, a small number is children. Only in a minority of prepubertal children, GD will persist and manifest as an adolescent/adult GD. The percentage of ‘persisters’ appears to be between 10% and 27% (Wallien & Cohen-Kettenis, 2008; Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Steensma, McGuire, Kreukels, Beekman, & Cohen-Kettenis, 2013). Treatment for prepubertal children therefore is predominantly psychological. However, those children who still experience GD when entering puberty, almost invariably will become gender dysphoric adults (de Vries, Steensma, Doreleijers, & Cohen-Kettenis, 2011a). These young adolescents may demand hormonal interventions such as puberty suppression (using gonadotropin-releasing hormone analogues (GnRHa)) to suppress the development of secondary sex characteristics. In recent years, the possibility of puberty suppression (PS) has generated a new but controversial dimension to the clinical management of adolescents with GD. The purpose of PS is to relieve suffering caused by the development of secondary sex characteristics, to provide time to make a balanced decision regarding the actual gender reassignment (by means of treatment with gender-affirming hormones (GAH) and/or surgery) and to make passing in the new gender role easier (Cohen-Kettenis, Steensma, & de Vries, 2011). In the Netherlands, PS is part of the treatment protocol and as a rule possible in adolescents aged 12 years and older who are past the early stages of puberty and still suffer from persisting GD. When there are good reasons to treat an adolescent before the age of 12 years, for example, because of the height of the adolescent, treatment at a slightly younger age is acceptable. Although an increasing number of gender identity clinics have adopted this Dutch strategy and international guidelines exist in which PS is mentioned as a treatment option, many professionals working with gender dysphoric minors remain critical (Coleman et al., 2012; Hembree et al., 2009; Korte et al., 2008; Viner, Brain, Carmichael, & Di Ceglie, 2005). Concerns have been raised about the risk of making the wrong treatment decisions and the potential adverse effects on health and on psychological and psychosexual functioning. Proponents of PS, on the other hand, emphasize the beneficial effects of PS on the adolescents’ mental health, quality of life, and of having a physical appearance that makes it possible to live unobtrusively in the desired gender role (Kreukels & Cohen-Kettenis, 2011).