33 Early medical treatment for transgender children and adolescents: an empirical ethical study 2 The nature of gender dysphoria Is GD a normal variation of gender expression, a social construct, a medical disease, or a mental illness? In the DSM-5 and the to-be-released ICD-11, the main challenge in classifying GD has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to health care, payment by insurance companies, and the communication between diverse professions (American Psychiatric Association, 2013; Drescher, Cohen-Kettenis, & Winter, 2012; World Health Organization, 2022). “I think the focus should be on getting rid of the stigma that accompanies psychiatric disorders instead of on saving specific disorders from the psychiatric disorder group.” - Interview with a psychiatrist According to the literature, some authorities classify GD as a mental illness (Giordano, 2011; McHugh, 2004), whereas various scholars state that the diagnosis of gender-variant children with GD is a prime example of a conflict between the individual and the society in which he or she lives (Vasey & Bartlett, 2007; Drescher, 2014). The interviews and questionnaires show that most informants find it difficult to articulate their thoughts about this aspect. Most see GD as neither a disease nor a social construct, but as a normal, but less frequent variation of gender expression. However, some note that you would not need medical procedures to make the lives of people with GD more satisfying if it were merely a normal variation. The need for treatment is what defines GD as a disorder, they state. Others state that it is a disease in the sense that there is a disconnection between body and mind, which causes suffering. “Even in the most gender dysphoria benevolent society many individuals with gender dysphoria would still need medical procedures to make their lives more satisfying, and I think that this is what makes gender dysphoria a disorder, but not a mental one.” - Interview with a psychiatrist We asked whether these diverse ideas and theories about the nature of GD affect the decision whether to use puberty suppression in adolescents with GD. Most informants state that a classification in itself should never be a factor in deciding what treatment to follow. However, one informant stated: “I find it extremely dangerous to let an adolescent undergo a medical treatment without the existence of a pathophysiology and I consider it just a medical experimentation that does not justify the risk to which adolescents are exposed […] Gender dysphoria is the only situation in which medical intervention does not cure a sick body, but healthy organs are mutilated in the process of adapting physical and congruent psychological identity.” - Interview with a psychiatrist