7 CONTENTS Chapter 1 General introduction 9 Part 1 Setting the scene: perceptions of stakeholders on ethical issues 25 Chapter 2 Early medical treatment for transgender children and adolescents: an 27 empirical ethical study Chapter 3 Perceptions of sex, gender, and puberty suppression: a qualitative analysis 43 of transgender minors Part 2 Medical decision-making competence 57 Chapter 4 Assessing medical decision-making competence in transgender minors 59 Chapter 5 Medical decision‑making competence regarding puberty suppression: 75 perceptions of transgender adolescents, their parents and clinicians Part 3 Significance of puberty suppression and use of fertility preservation 107 Chapter 6 Trajectories of adolescents treated with gonadotropin‑releasing hormone 109 analogues for gender dysphoria Chapter 7 Perceptions on the function of puberty suppression of transgender 123 adolescents who continued or discontinued treatment, their parents, and clinicians Chapter 8 Use of fertility preservation among a cohort of transgirls in the Netherlands 141 Part 4 Clinical ethics support 153 Chapter 9 Dealing with moral challenges in treatment for transgender children 155 and adolescents: evaluating the role of moral case deliberation Chapter 10 General discussion 181 Chapter 11 Summary 203 Addendum 221 Appendices 222 References 226 List of abbreviations 254 Nederlandse samenvatting 255 Curriculum vitae 273 Publications 275 Dankwoord 277