36 Chapter 2 Delemarre-van de Waal & Cohen-Kettenis, 2006; Klink, Caris, Heijboer, van Trotsenburg, & Rotteveel, 2015). In the interviews and questionnaires, the loss of fertility was often mentioned as a major consequence of treatment. In addition, various informants stressed the importance of the fact that the penis and scrotum should be developed enough to be able to use this tissue to create a vagina later in life. Very early use of PS impairs penile growth and consequently makes certain surgical techniques impossible. Although (the sparse) research until now mostly shows no negative, and even positive results regarding the consequences of treatment with PS (Cohen-Kettenis et al., 2008; de Vries et al., 2014), proponents remain cautious and opponents sceptical because of the fact that (long-term) risks and benefits of available treatments have not been fully established. “The positive attitude of many clinicians in giving hypothalamic blockers [...] is based on the need to conform to international standards, even if they are conscious of a lack of information about medium and long-term side effects.” - Interview with a psychiatrist In the interviews and questionnaires, harmful effects of refraining from interventions are mentioned too. Multiple professionals state that many young gender dysphoric people will harm themselves without intervention or at least the promise of future treatment options. Some professionals mention that nowadays the average age at which puberty starts is earlier than a few decades ago. This makes them wonder whether the age criterion of 12 years, that many treatment teams use, is still suitable. “The question cannot be posed as ‘do something which may cause harm’ against ‘doing no harm’, as doing nothing results in very high levels of distress and poor outcome as well.” - Interview with a psychiatrist “So why are we saying 12? It is arbitrary if the average age for the start of puberty in the UK or in Northern Europe is now eight or nine. […] this is a very lively debate in our team. […] It [lowering the age of starting with puberty suppression] is for the younger ones, who are going into puberty at 10 or 11. I mean I think we probably have to extend it to them.” - Interview with a psychologist Ideas about child competence and the decision-making authority Competence is an important point of disagreement when PS is discussed. In the literature, proponents have concluded that relatively young children can participate meaningfully in the consent process, whereas opponents raise doubts about what children can understand (Abel, 2014; Mann, Harmoni, & Power, 1989; Sadjadi, 2013). Most informants state that competence should be determined for every single case individually. Most state that children develop at different rates in terms of their physical, mental, emotional, and sexual