Transgender Persons Applying for Euthanasia in Belgium: A Case Report and Implications for Assessment and Treatment

Gender confirming treatment has proven to relief gender dysphoria as a symptom and to improve psychological functioning in transgender persons. Nevertheless, a small percentage shows regret after their surgical treatment. Risk factors for regret are the presence of psychiatric problems, dissatisfaction with the results of surgery and poor socializing. In Belgium, euthanasia can be applied for in a situation of constant and unbearable mental or physical suffering. In recent years, three patients applied for euthanasia in the Gender clinic of the University Hospital Ghent, Belgium. We report on one case of a trans-woman applying for euthanasia and discuss on implications for assessment and treatment.


Introduction
According to DSM-5, persons with gender dysphoria suffer from a marked incongruence between their experienced/expressed gender and assigned gender [1]. Gender confirming treatment is considered to be the first choice of treatment in terms of effect on gender dysphoria (as a symptom) and psychological functioning [2].
Procedures for assessment and criteria required for hormone therapy and surgical treatment regarding gender dysphoria are extensively described in the Standards of Care [3]. One of the criteria required for hormone therapy as well as for surgical procedures is "If significant mental health concerns are present, they must be reasonably well controlled". Compared to the general population, mental health problems (e.g. depression and anxiety) are found more frequently in persons with gender dysphoria applying for treatment [4]. Probably, this is partial due to long-lasting stigmatization and discrimination. Nevertheless, regret post-treatment is rare as it occurs in 1 to 2% of persons with gender dysphoria [5]. Risk factors for regret are the presence of psychiatric problems, dissatisfaction with the results of surgery and poor socializing [6]. Compared to the general population, suicide rates remain still higher after completion of treatment [7,8]. Motives for suicide in patients after they had gender confirming treatment are often unknown [6].
In general, the relationship between gender dysphoria, regret after gender confirming treatment and the patients' will to end their lives by means of suicide or euthanasia remains unclear.
In Europe, active euthanasia -where instead of simply prescribing lethal medication, the doctor administers the lethal injection -is legal in the Netherlands, Belgium, Luxembourg and Switzerland [9]. Because of differences between countries with regard to legal issues, the Belgian situation is shortly explained. According to the Belgian Act on Euthanasia of 28 May 2002, the physician who performs euthanasia does not commit a criminal offence when he/she ensures that the patient is in a medically futile condition of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident [10]. When a non-terminal adult asks for euthanasia two extra procedural conditions have to be met next to a first second opinion, which is required for all euthanasia requests. Firstly, the physician who performs euthanasia has to consult a colleague, who is a psychiatrist or a physician who is specialized in the disorder in question, and inform him/her of the reasons for such a consultation. The consulted physician reviews the medical record, examines the patient and must be certain of the constant and unbearable character of the physical or mental suffering, which cannot be alleviated, and of the voluntary, well-considered and repeated character of the euthanasia request. Secondly, the physician who performs euthanasia must allow at least one month between the patient's written request and the act of euthanasia.
The Gender Clinic of the Ghent University Hospital, Belgium, has a tradition of thirty years of providing health care for persons with gender dysphoria. In the last 5 years (2010 -2014) 490 new applicants attended the clinic. Although long-term follow-up studies of persons with gender dysphoria treated in our own clinic show that there are no more regrets than mentioned in the literature [7], three persons applied for euthanasia in the last two years. We want to report on one of these transgender persons. The data of the 2 other persons with gender dysphoria who applied for euthanasia cannot be disclosed due to privacy issues.
The goal of this article is twofold: first, to shed light on the specific situation in Belgium regarding the possibility to apply for and undergo euthanasia in situations of constant and unbearable physical or mental suffering in general and more specifically applied on a case of a patient with gender dysphoria and to discuss on the implications of these findings on the assessment and treatment of transgender persons.
to be evaluated with regard to the possibility of euthanasia. She had been through her diagnostic phase at the end of the 60's in another gender clinic and underwent mammoplasty and vaginoplasty in 1972. Afterwards, multiple surgical corrections were needed because the mammal prostheses were leaking and sexual intercourse was very difficult and painful. In the end, 11 operations were performed without a significant improvement at the esthetical and functional level. Currently, she suffers from constant vaginal pain and blood loss when voiding. During her life, she had several intimate relationships, none of which were satisfactory because of the above-mentioned problems. At the moment, she is single and works as a hypnotherapist. Her parents had died; she has one sister with whom she occasionally has contact and she feels lonely most of the time. Furthermore, she has several other physical complaints and was diagnosed with chronic fatigue syndrome. She never applied for psychological help and stopped hormonal replacement therapy over 15 years ago. Mental state exam by means of the Mini International Neuropsychiatric Interview Plus (5 th version) shows no signs of vital depression, psychosis or body dysmorphic disorder. There are no clinical arguments for severe impairment of cognitive functioning. Her demand for euthanasia is authentic and well considered. She was referred for second opinion towards a psychiatrist that is familiar with the evaluation of persons applying for euthanasia. Her general practitioner agreed to act as 3th evaluator. Both physicians supported her wish for euthanasia. At the time of publication, euthanasia was not yet carried out. Patient was still convinced to continue with the procedure, but had to make several arrangements (e.g. financial).

Discussion
As this is the first report to be published about euthanasia in persons with gender dysphoria, comparison with other data is not available. With regard to risk factors for regret, our patient shows an extreme dissatisfaction with the results of surgical treatment and expresses feelings of loneliness most of the time. Although she didn't seem to suffer from any severe mental health problems, she showed many psychosomatic complaints.
Due to the legal framework that allows patients to obtain euthanasia for psychiatric reasons, one hypothesis could be that some transgender persons in Belgium apply for euthanasia instead of committing suicide.
The authors would like to emphasize that the decision for euthanasia was based on the persistent and unbearable suffering as a consequence of the psychosocial problems combined with poor surgical outcome. This is important to avoid the misunderstanding that euthanasia is carried out merely due to suffering caused by gender dysphoria. As in all patients presenting with constant and unbearable suffering, the possibility of applying for euthanasia should be discussed in an open way. Persons with gender dysphoria should not be treated differently in this regard. This could prevent them from committing suicide, which has a more negative impact on surviving relatives compared to euthanasia. The mere possibility to communicate about their psychological and physical burden could be protective against suicide. All care providers dealing with gender dysphoric patients should be aware of these issues and have the skills to properly assess patients applying for gender confirming treatment.
As risk factors for regret are well-known, the authors would like to emphasize the need for a thorough assessment at the start of the treatment and follow-up counselling after treatment has been started, and even when accomplished [3,5,6]. Although the impression that the number of genderdysphoric patients showing regret has diminished in recent time due to better surgical outcome, the risk for regret after gender confirming treatment will probably never be reduced to zero.

Conclusion
Further registration of similar cases could lead to more insight into the relationship between gender dysphoria, regret after gender confirming treatment and the patients' will to end their lives by means of suicide or euthanasia.

Informed consent
Patient was informed and has given explicit consent to report on her case.

Conflicts of interest
None