35 Early medical treatment for transgender children and adolescents: an empirical ethical study 2 The role of comorbidity The risk of co-occurring psychiatric problems in children and adolescents with GD is high. The percentage of children referred for GD who fulfilled DSM criteria of at least one diagnosis other than GD is 52% (Wallien & Cohen-Kettenis, 2007). The psychiatric comorbidity in adolescents with GD is 32% (de Vries, Doreleijers, Steensma, & CohenKettenis, 2011b). Another study shows that 43% of the children and adolescents seen in a gender identity clinic suffer from major psychopathology (Meyenburg, 2014). To date, the precise mechanisms that link GD and coexisting psychopathology are unknown. The interviews and questionnaires show that professionals think that it differs between individuals and it depends on the comorbid problem whether the GD and the co-occurring problem(s) are merely coexisting or interrelated. The impact of society is also mentioned as a mediating factor. Some professionals stress that we have to keep in mind that society marginalizes minority groups. “This [marginalization of minority groups] can lead to internalized self-hatred and many other mental health difficulties such as self-harm, depression, anxiety, isolation, suicide etc. Being picked on or being abused as minority groups leads to fear which is a mediating variable for mental health problems.” - Interview with a psychologist “I see gender dysphoria as a cause of reactive co-occurring problems [such as anxiety and depression]; nevertheless, comorbidity with other non-reactive psychiatric problems [such as attention deficit disorder with hyperactivity, bipolar disorder] can present in parallel.” - Interview with a psychiatrist We asked whether severe coexisting psychopathology influences the treatment for the GD, and in what way. Some professionals stress the importance of addressing treatment for severe coexisting psychopathology before addressing GD-related medical interventions for minors with GD. Others state that it depends on the specific comorbid problem whether it influences the treatment for the GD and in what way. They state that, although coexisting psychopathology may interact with GD and GD-related medical interventions, the GD and the comorbid problem may result from completely different underlying processes and should therefore have separate treatment plans, goals, and strategies. Possible physical or psychological harmful effects of early medical interventions and of refraining from interventions The possible consequences of suppressing puberty for cognitive and brain development are unclear and debated at this moment (Cohen-Kettenis et al., 2008; Hembree et al., 2009). The normal pubertal increase in bone mineral density may be attenuated by PS, and it is uncertain if there is complete catch-up after treatment with gender-affirming hormones (GAH) (Cohen-Kettenis, Schagen, Steensma, de Vries, & Delemarre-van de Waal, 2011;