114 Chapter 6 an appointment. Adolescents who had started treatment with GnRHa and had stopped this treatment were included in a detailed review. Baseline characteristics such as age and gender and data on the start, duration, and discontinuation of treatment were recorded from the medical files, as well as reasons given for the discontinuation of treatment with GnRHa and the adolescents’ and parents’ views on the treatment. Procedure Before the start of treatment with GnRHa, all adolescents had a diagnostic evaluation by a paediatric endocrinologist and mental health professional (MHP) to confirm the diagnosis of gender dysphoria according to the DSM-5 criteria (American Psychiatric Association, 2013), to assess the presence of any medical, psychiatric, or psychosocial problems that might interfere with treatment, to assess if the adolescent was able to give informed consent for the treatment and to confirm that puberty had started, as recommended by current guidelines (Hembree et al., 2017). This evaluation usually consisted of approximately six visits (more if necessary) of the adolescent with an MHP in six to 12 months in addition to interviews with parents/guardians. All adolescents gave written informed consent for the treatment. Informed consent from parents/guardians was also required if the adolescent was <16 years old. After the start of treatment with GnRHa, follow-up visits were scheduled with the paediatric endocrinologist and MHP, usually every three months in the first year and every three to six months thereafter, to evaluate satisfaction with the treatment, adequacy of PS, and any side effects. In the case of mental health issues (psychiatric morbidity but also issues such as difficulty to express oneself and doubts about one’s gender identity), adolescents were either seen more frequently by the psychologist of the gender team or referred to a local MHP for therapy. According to the local protocol, adolescents were eligible for treatment with GAH from the age of 16 years and after at least six months of treatment with GnRHa. No maximum time of use of GnRHa was defined in the protocol. From 2016, adolescents who had already been treated with GnRHa for at least three years were eligible for treatment with GAH from the age of 15 years. From 2017, those who had been treated with GnRHa for at least two years and were 15 years old were eligible. Before the start of GAH, evaluation by a MHP and paediatric endocrinologist took place to assess the indication, any contraindications, and ability to give informed consent for this treatment. If adolescents had discontinued treatment with GnRHa, there was a follow-up appointment at which adolescents and parents were asked about current feelings regarding gender identity and how they looked back on the treatment.
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