48 Chapter 3 processes of data gathering and analyses were used: (1) interviews; (2) transcription of the interview data; (3) open coding, which involved identifying relevant concepts in the text; (4) constant comparison of open codes, looking for conceptual similarities and differences; (5) identification of emerging themes; (6) continued sampling and interviewing as theoretical categories emerged and novel questions arose; and (7) continued coding and comparison of codes until nothing new was added to the theoretical categories. Data collection continued as long as new information came up. After no new content was found in the interviews, subject enrolment was stopped. This process, called thematic saturation, is a well-described qualitative method to avoid unnecessarily large and repetitive data sets (Guest et al., 2006). The methodology and results of the interviews with professionals were previously described in chapter 2 of this thesis. RESULTS From the interviews with the gender dysphoric adolescents three themes emerged: (1) the difficulty of determining what is an appropriate lower age limit for starting PS; (2) the lack of data on the long-term effects of PS; (3) the role of the social context; this item consisted of two subthemes: (a) increased media-attention, on television and on the internet, (b) an imposed stereotype. Representative quotations were chosen to illustrate the themes identified. The difficulty of determining what is an appropriate lower age limit for starting puberty suppression The guidelines published by the WPATH and the Endocrine Society recommend the use of PS in adolescents when GD persists at the beginning of puberty (Coleman et al., 2012; Hembree et al., 2009). In principle, Dutch adolescents need to be 12 years of age and in pubertal Tanner stage 2-3 to be eligible for treatment with PS. Most adolescents found it difficult to define an appropriate lower age limit. They saw it as a dilemma. On the one hand they thought it was important that children have the possibility of treatment with PS at the moment secondary sex characteristics of the natal sex start to develop, in order to prevent irreversible body changes like growth of breasts or breaking of the voice. This opinion is illustrated by the following quote: “I think it is hard to set an age requirement. On the one hand I think 12 years is a good age minimum, on the other hand I think that a transgender [individual] whose puberty started earlier should have the possibility to start treatment with puberty suppression before the age of 12.” - Interview with a transgirl; age: 13;11
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