45 Perceptions of sex, gender, and puberty suppression: a qualitative analysis of transgender minors 3 INTRODUCTION Gender dysphoria (GD) is a condition in which individuals experience distress, because their gender identity (the psychological experience of oneself as male, female or otherwise) is incongruent with their gender assigned at birth (American Psychiatric Association, 2013). GD may exist in childhood, but only in a minority of prepubertal children will persist into adolescence. The percentage of ‘persisters’ appears to be between 10 and 27% (Drummond et al., 2008; Steensma et al., 2013; Wallien & Cohen-Kettenis, 2008). Treatment for prepubertal children consists of providing information, advice, psychological support, and/or family counselling. Those children who still experience GD when entering puberty, almost invariably will become gender dysphoric adults (de Vries et al., 2011a). They may seek hormonal interventions such as puberty suppression (using gonadotropinreleasing hormone analogues (GnRHa)) to suppress the development of secondary sex characteristics. In recent years, the possibility of puberty suppression (PS) has generated a new but controversial dimension to the clinical management of adolescents with GD (Vrouenraets, Fredriks, Hannema, Cohen-Kettenis, & de Vries, 2015). The purpose of PS is to relieve suffering caused by the development of secondary sex characteristics, to provide time to make a balanced decision regarding the actual gender-affirming medical treatment (GAMT; by means of treatment with gender-affirming hormones (GAH) and/or surgery), and to make passing in the new gender role easier (Cohen-Kettenis, Steensma, & de Vries, 2011). In the Netherlands, PS is part of the treatment protocol and as a rule possible in adolescents aged 12 years and older who are in or beyond the early stages of puberty and still suffer from persisting GD (Cohen-Kettenis et al., 2011). Occasionally, it is acceptable to start treatment at a (slightly) younger age than 12, if puberty has already started and is progressive. Earlier intervention might then make sense and, in fact, does already happen in practice. An increasing number of gender identity clinics, including initially reluctant treatment teams, have adopted the Dutch strategy of PS (Vrouenraets et al., 2015), and international guidelines exist in which PS is recommended as a treatment option (Coleman et al., 2012; Hembree et al., 2009). Nevertheless, the use of PS is still controversial. Recently, we studied the opinions of 17 treatment teams worldwide. It was striking that the Standards of Care for GD of the World Professional Association for Transgender Health (WPATH) and the guidelines for the endocrine treatment for individuals with GD of the Endocrine Society were considered too liberal by some teams, but at the same time too conservative by others (Vrouenraets et al., 2015). Many professionals working with gender dysphoric minors remain critical about the use of PS because of the lack of long-term physical and psychological outcomes (Korte et al., 2008; Viner et al., 2005). Concerns have been raised