39 Early medical treatment for transgender children and adolescents: an empirical ethical study 2 DISCUSSION Using empirical methods, our project aimed to explicate the considerations of proponents and opponents of PS in GD. A representative international group of professionals participated, enabling us to identify ideas, assumptions, and theories on GD (treatment). These data give us unique insights in the GD practice and the way ethical concepts function in this field. The interviews and questionnaires show that the discussion regarding the use of PS goes in diverse directions and is in full swing. It touches on fundamental ethical concepts in paediatrics; concepts such as best interests, autonomy, and the role of the social context. It is striking that the Standards of Care for GD of the World Professional Association for Transgender Health and the Endocrine Society are considered too liberal and too conservative (Coleman et al., 2012; Hembree et al., 2009). Furthermore, since the start of this study, PS has been adopted as part of the treatment protocol by increasing numbers of originally reluctant treatment teams. More and more treatment teams embrace the Dutch protocol but with a feeling of unease. The professionals recognize the distress of gender dysphoric minors and feel the urge to treat them. At the same time, most of these professionals also have doubts because of the lack of long-term physical and psychological outcomes. Most informants acknowledge pro-arguments and counterarguments regarding the use of PS. Several teams, who work according to the Dutch protocol, are also exploring the possibility of lowering the current age limits for early medical treatment although they acknowledge the lack of long-term data. For several informants, a reason to use PS was the fear of increased suicidality in untreated adolescents with GD. Research shows that transgender minors are at higher risk of suicidal ideation and suicidal attempts (Grossman & D’Augelli, 2006; Wallien & Cohen-Kettenis, 2008). Nevertheless, caution is needed when interpreting these data because they do not show causality or directionality. Another aspect mentioned by various informants is that nowadays the average age at which puberty starts is earlier than a few decades ago. Indeed, there is a research showing earlier puberty in girls in the United States and Europe (Aksglaede, Sørensen, Petersen, Skakkebæk, & Juul, 2009; Euling et al., 2008; Talma et al., 2013). In U.S. boys, data were found to be insufficient to evaluate a secular trend (Euling et al., 2008). As still little is known about the aetiology of GD and long-term treatment consequences for children and adolescents, there is great need for more systematic interdisciplinary and (worldwide) multicentre research and debate. As long as there are only limited long-term