96 Chapter 5 “I also find very young children [...] aged 10 or 11 [...] tricky, the ones who do not necessarily have a low IQ, but are just very young. And how they consider it [the treatment with puberty suppression and its (possible) consequences].” - Focus group with clinicians Adolescents and parentsmentioned the role age plays when deciding about PS as well. Several adolescents stated that they thought they were not too young to decide about starting the treatment, but that as they grew older, their ability to make the decision improved. “In that case [if I had made the decision to start treatment with puberty suppression when I was 16 or above] it would have been different. Then I would have had better abstract reasoning, better than when I was, say 13 years of age.” - Interview with a transgirl who continued PS; age at start PS: 12.9; age at interview: 17.8 “I do not really think that I was too young to decide whether or not to start treatment with puberty suppression. Especially because that [the effects of the treatment] was [were] just reversible. Nevertheless, I do think that I was too young to completely understand it; the whole concept of transitioning, the social transition and the medical transition. Especially because I was only 14 [years of age] at the time, it was just like ‘this [treatment with puberty suppression] is the holy grail’. And only when I got older I grasped ‘hmm.. there is also another side to it [the treatment].” - Interview with an assigned female at birth who had discontinued PS; age at start PS: 16.7; age at discontinuation PS: 17.0; age at interview: 19.5 In addition, clinicians mentioned that adolescents with lower intelligence might be less likely to be able to understand and appreciate what the treatment and its consequences entail. For several clinicians, low intelligence might even be a reason not to start PS, despite the presence of gender incongruent feelings. One adolescent and one parent mentioned the role of intelligence too. They stated that she/her child was smart enough to be able to understand and appreciate the consequences of PS prior to starting the treatment. “I’m pretty smart so to say. So I could think of that [the effects of treatment and its (possible) consequences].” - Interview with an assigned female at birth who had discontinued PS; age at start PS: 12.1; age at discontinuation PS: 13.3; age at interview: 14.3 “How smart they [the adolescents] are, is of course an important part of their competence to make medical decisions.” - Focus group with clinicians
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