32 Chapter 2 RESULTS From the literature, interviews, and questionnaires, seven themes emerged that lead to different, and sometimes even opposing, views on the treatment for adolescents with GD. Representative quotations were chosen to illustrate the themes identified. The availability or nonavailability of an explanatory model for gender dysphoria With regard to the causes of GD, no single cause has been found so far. In the literature, genetic, hormonal, neurodevelopmental, and psychosocial factors have been suggested to play a role (de Vries & Cohen-Kettenis, 2012; Meyer-Bahlburg, 2010). Most of our informants believe that a single cause is unlikely, but they see GD as influenced by diverse factors. Some put forward the possibility of a (slightly) different aetiology for different subtypes. Others think that biological, for example, neurodevelopmental, factors play a dominant role and believe that psycho-familial factors have very little or no influence. Altered hormone exposure during foetal development was also suggested as a potential cause. “I think that nature and nurture both contribute to the development and expression of gender dysphoria. The role of each is different in each individual and this explains the heterogeneity of gender dysphoria expression.” - Interview with an endocrinologist “I believe biological factors play the predominant role. In my work, I have not found psycho familial or social factors that children and adolescents with gender dysphoria have in common, which is also known in scientific literature.” - Interview with a psychologist We asked the informants whether an explanatory model for GD would affect ideas regarding treatment options for adolescents. Many, including some informants who are sceptical about early medical treatment for GD, stated that the aetiology does not affect the way adolescents with GD should be treated. Furthermore, most respondents think that not knowing the aetiology should not prevent providing care and understanding of the person’s predicament. One respondent compared it to having a broken leg: “[It is possible to] understand that it is painful and impairs function even if you do not know exactly why or how that person has broken his leg.” - Interview with a psychiatrist