118 Chapter 6 The adolescents and parents were also asked about their views on GnRHa in the treatment protocol for gender dysphoria. All of them saw it as the first step in treatment, but it was also clear that it was used as an extended diagnostic phase. They all felt free to stop GnRHa. They had varying visions on the role of GnRHa in the treatment for gender dysphoria. Some stated it gave them time to think and feel who they were and what they wanted in the future and felt that without treatment with GnRHa they would not have been able to make these decisions. Others stated that GnRHa should not be routinely offered before the start of GAH when adolescents are already fully matured, because of the lack of physical benefits. Instead, a consideration time of six months with psychological follow-up was suggested. DISCUSSION The great majority of adolescents who started GnRHa subsequently started GAH as soon as they were eligible for this treatment. Very few discontinued treatment, although slightly more than in previous studies in which cohorts of transgender adolescents were described. Out of 333 adolescents that had started PS at the VUmc gender identity clinic in the Netherlands up until December 2015, 1.9% stopped; reasons for discontinuation of GnRHa were not reported (Wiepjes et al., 2018). In the Canadian study by Khatchadourian and colleagues (2014), one of 27 individuals who started GnRHa stopped the treatment due to emotional lability, not because the wish to pursue transition had subsided. In the current study, 6% of those who started GnRHa discontinued and 3.5% no longer wished GAMT. Several studies reviewed by Ristori and Steensma (2016) have found that much higher percentages (61-98%) of prepubertal children no longer experience gender dysphoria (‘desist’) as adolescents. The period between 10 and 13 years seems to be a crucial period in which social changes (for example starting secondary school), the physical changes of puberty, and first romantic and sexual experiences may lead to either an increase or a decrease/resolution of gender dysphoria (Steensma et al., 2011). The adolescents that start treatment with GnRHa have entered puberty and are mostly older than 13 years and may be past this critical period so that gender dysphoria may be more likely to persist. This may explain the lower percentage of resolution of gender dysphoria found in the studies of treated adolescents. In addition, the groups that started treatment in previous studies and in the current study consisted of selected adolescents that had had an extensive diagnostic process to establish if they met the eligibility criteria for treatment as well as the diagnostic criteria for gender dysphoria (Wiepjes et al., 2018). Alternatively, concerns have been raised that treatment with GnRHa itself may increase the chances of persistence of gender dysphoria (Korte et al., 2008; Richards et al., 2019; Stein, 2012;
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