78 Chapter 5 good to keep in mind that these studies do not tell us anything about the exact causes of these increased risks; some of the outcomes might be related to, for example, transgender people’s experiences of living in a discriminatory and rejecting society (i.e. minority stress) instead of solely being related to post-surgical outcomes (e.g. Poštuvan, Podlogar, Šedivy, & Leo, 2019). Adolescents may present or be diagnosed with gender dysphoria during or after the completion of endogenous puberty and may therefore start PS at various stages of pubertal development. Most adolescents who start treatment with PS subsequently start treatment with GAH and surgery afterwards (Brik, Vrouenraets, de Vries, & Hannema, 2020). Some adolescents discontinue their PS treatment. Of the latter group, most no longer wish gender-affirming medical treatment (GAMT), while some commence treatment with GAH and/or surgery later in life, such as in adulthood (Brik et al., 2020). Besides, providing solely psychological support, and see if adolescents can accept themselves without any medical intervention, is always considered when working according to the international guidelines too (Coleman et al., 2012; Hembree et al., 2017). Research shows that about 22 percent of the minors referred to a Dutch specialized gender identity clinic do not start affirmative medical treatment, being PS and/or GAH (Arnoldussen et al., 2020; Arnoldussen et al., 2022b). As far as currently known, the effects of PS on the development of secondary sex characteristics and gonadal function are reversible when discontinued (Hembree et al., 2017). Nevertheless, transgender adolescents who start PS at a young age and subsequently start treatment with GAH and undergo a gonadectomy, may not be able to pursue fertility preservation since these adolescents never undergo their endogenous puberty (Brik et al., 2019; Health, 2021; Hudson, Nahata, Dietz, & Quinn, 2018). On the other hand, one should keep in mind that refraining from PS could be harmful as well, with potential life-long psychological, medical, and social consequences, such as personal physical discomfort, stigmatization, and difficulties with social integration and social function (de Vries et al., 2021; Giordano, 2008b; Giordano & Holm, 2020; Kreukels & Cohen-Kettenis, 2011). So, these young adolescents make decisions that may have life-long consequences. Even though it is recommended to involve parents when adolescents decide on starting PS, the issue whether these adolescents are capable of making these decisions is an important one (Coleman et al., 2012; Byne et al., 2012). According to international guidelines, one of the criteria for treatment with PS is that adolescents are competent to give informed consent (Coleman et al., 2012; Hembree et al., 2017). However, in society, there is doubt about this competence (e.g. Baron & Dierckxsens, 2021; d’Abrera et al., 2020; Giordano et al., 2021; Health, 2021; Levine, 2019; Levine, Abbruzzese, & Mason, 2022; Pang et al., 2021). Furthermore, both transgender adolescents themselves and clinicians mention medical decision-making competence (MDC) as one of the main topics in the debate regarding treatment with PS (Kerman et al., 2021; Vrouenraets et al., 2015; Vrouenraets et al., 2016).
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