The Myth of Belgium’s ‘Cautious Approach’

In the first of two articles about Belgium, Margrit Seiler examines how gender clinics pay lip service to the Cass Review, yet refuse to change course.

Dutch-language gender clinics in both the Netherlands and Flanders (Dutch-speaking Belgium) responded to the Cass Review with lip service (endorsing the call for more resources for ‘gender care particularly’) but no change in practice. They justified this by claiming that their approach is more careful than that of clinicians in the UK or the US. This claim is both self-serving and baseless.

The prominence of Dutch practitioners—inventors of the ‘Dutch protocol’— for pediatric gender transition has fueled sustained interest in gender medicine in Flanders, the Dutch-speaking part of Belgium. With a population of 6,7 million (thus less than Greater London), the region now has seven (!) gender clinics. The ‘CSG’ (Centrum voor Seksualiteit en Gender) at the Ghent University Hospital is the largest and the only one with a specialized pediatric service. It plays a prominent role in what little public discussion of gender medicine in Flanders there is. One of its members, the urologist Piet Hoebeke, has recently published a book in praise of the clinic’s work, chronicling the ‘authentic search’ of a dozen clients after their true medicalized selves. The first reviews in the Flemish press are positive.1

As the mother of a daughter who has been severely depressed and gender-dysphoric for years following a childhood sexual assault (we only just learned of), I observe the plaudits for Hoebeke with incredulity. After years of interaction with dysfunctional youth mental health services and drawn-out efforts to get answers on safeguards and screening processes from CSG, I can state with confidence that Flemish gender clinicians’ assertions about their ‘careful approach’ are devoid of credibility. True, health services in general are under less strain here than in the UK and less commercialized than in the US. But that is not enough to give credence to Flemish practitioners’ claim that their practice is therefore safer. While I am not a medic or a biologist, I have first-hand experience of gender distress in adolescence, and I assess and make complex arguments for a living. As will be seen, that is quite enough to spot the glaring problems at hand.

Rhetorical Endorsement, Failure to Act — The Response to the Cass Review

A first reason to disbelieve gender practitioners’ assertions about the care they take lies in CSG’s failure to provide a clear account of what their supposed careful assessment consists of and, crucially, what it actually assesses. About this, I first contacted both CSG and its public-facing ‘transgender Infopunt’ (roughly, information centre) after the publication of the Cass Review, asking what its findings meant for them. Both responded with reasonable-sounding emails, stating that they endorsed the review. The devil was in the details.

Among the links on Cass that the Infopunt had put up on its website, there was one to the response by GenderGP, the Singapore-based practice run by two former British GPs, known for dubious practices, such as using chatbots to interact with patients, prescribing blockers and hormones without face-to-face consultations, and prescribing exorbitant hormone doses.2 It calls the Cass Review ‘unscientific and unethical’ and accuses it of endorsing transphobia.3 When I raised this with the Infopunt, I was informed that putting the link on their website did not mean that they endorsed its content. But shouldn’t ‘a careful approach’ extend to the information provided to the public?

The gender clinic itself also provided a link to a statement by EPATH, co-written by one of their doctors, and they endorsed the statement by Amsterdam University Medical Clinic (UMC), originators of the ‘Dutch protocol’, both of which were cited by the infopunt.4 The fine print of these statements showed that the supposed endorsement of the review was limited to its call for more resources for gender clinics and gender-related research. They actually rejected Cass’s call for a moratorium on the use of blockers and for extreme caution with cross-sex hormones. Moreover, they actively misread Cass’s observation that the evidence for pediatric gender transition was ‘remarkably weak.’ Instead, they focused on her comments about a lack of integration and coordination of care, and asserted that their interdisciplinary teams do much better. But the involvement of different specialisms does not in itself equal a careful assessment if all work to the same conceptual framework.

I wrote back, explaining my personal involvement (my daughter was on their waiting list) and asking how they approached a central problem identified by Cass: the impossibility of distinguishing between kids who would desist from their trans-identification and those who would develop ‘a stable trans identity’ in Cass’s words. I asked whether they helped girls explore possible reasons for rejecting their femaleness other than gender incongruence, such as experiences of domestic abuse, encounters with pornography or objectification by male peers, and whether they had any provisions for detransitioners.

I received no answer. Over the next year or so, I resent the email a few times, more or less begging for reassurance that practitioners at the clinic actually thought about these pressing matters. Silence. Only when I stated that I had contacted a journalist interested in investigating their practice did an answer materialize. It consisted of a recent publication in the ‘Journal of Transgender Health’ outlining developments at the clinic and the assertion that they would not engage further with my questions because they were of a personal nature. This is remarkable, coming from a representative of a branch of medicine that relies entirely on its patients’ introspection and personal narratives.

The Absence of Conceptual Reflection or Clarity

This cop-out —‘we don’t answer personal questions’ —was a reference to me basing my questions partly on my own experience as an anorexic and what we would now recognise as a severely gender-distressed teenager in the 1980s. When my breasts started growing, I had nightmares recasting them as boils. But fast forward twenty years, and I loved them: they turned out to be extremely useful once I had children. Evidently, this experience leaves me immune to the suggestion that adolescents or, for that matter, young adults, are competent judges of their ‘need’ for a mastectomy. But I had also made it quite clear in my communications with the CSG that my concerns were also conceptual. Sex is a characteristic of bodies, not minds. I cannot see how people too young to fully comprehend the capacities of the sexed bodies they do not yet possess could in any meaningful way ‘know’ that they have non-corporeal selves of the opposite sex, both sexes, or even no sex at all (!), much less that their bodies must be medically adapted to align with them. It is difficult enough to see how grownups could be certain about this, let alone children in the turmoil of adolescence.

Careful practitioners should long since have developed ways to respond to concerns of this kind. They should have protocols for exploring alternatives to ‘gender incongruence’ as explanations for their patients’ gender distress. They should be able to give concerned parents an account of what they look for in patients’ self-descriptions and symptoms to identify those most likely to benefit from medical transition (whether ‘most likely’ is a strong enough motivation to proceed with irreversible modifications is its own question). They should be able to confirm that they screen for trauma, especially sexual trauma, and autism.

Instead, the CSG’s public announcements fall back on the same vague, fluffy language about trans-identification being ‘a routine part of human diversity’ as anglophone activists. They, too, have no definition of ‘gender identity’ that is not circular (that does not rely on existing cliches of masculinity and femininity in order to describe male vs female gender identities). They offer no explanation as to why body modifications should be required to live in one’s ‘true gender’ if gender fluidity is a desirable norm to work towards, or gender, which is widely understood to be “the totality of social and cultural characteristics associated with a particular sex’, can be at the core of an innate identity. Their supposed careful approach is asserted, but not practiced.

The Unacknowledged Incentives and Scope for Over-Diagnosis of ‘Gender Incongruence’

This is all the more concerning because of a lesser-discussed aspect of ‘gender-affirming’ medical practice, namely that practitioners have every incentive and have plenty of scope to over-diagnose. They have the incentive because their careers are built on medically transitioning people, and their field disappears if no one is diagnosed with ‘gender incongruence’. In Flanders, as elsewhere, gender medicine is by now a well-established cottage industry, and everyone who works in it needs patients to keep them busy. For clarity, there is no shortage of demand; practitioners simply compete with one another to be seen as the best—or at least a viable—treatment option for these patients.

They have the scope to overdiagnose because of the nature of psychiatry. As I have learned in the course of my daughter’s odyssey through therapy-land, of all the branches of medicine, psychiatry struggles the most to understand the causes and processes behind the illnesses it treats. Granted, few medical specialties are as clear-cut as infectious diseases, where the infective agents and their effects can be empirically traced (though COVID reminds us that even this leaves plenty of uncertainty). Still, other specialists can observe somatic mechanisms such as rogue antibodies, overactive cells, and so forth, and make plausible connections with patients’ symptoms. In psychiatry, the relationship between observable brain-physiological or other somatic abnormalities and the complex mental and behavioural problems that patients struggle with remains particularly nebulous. Psychiatric diagnoses, therefore, remain predominantly taxonomic: they are based on describing symptoms and grouping them together under ever-evolving labels; a tentative process that is wide open to fanciful and possibly self-serving innovation.

This makes gender-affirming medicine specialists very different from, say, cardiologists or oncologists. If the latter starts a trial and it fails, they may need to try another approach, but nobody doubts that cancer or heart disease exists, or that treatments of the kinds that oncologists or cardiologists pursue are needed. By contrast, gender specialists risk doing themselves out of their jobs if they admit to any serious doubt either about the appropriateness of ‘gender incongruence’ as a descriptor for their patients’ distress, or about the appropriateness of transition as a treatment for it.

In fact, though, what is now called ‘gender incongruence’ and was earlier called ‘gender dysphoria’ and even earlier ‘transsexualism’ remains a psychiatric diagnosis. As with other psychiatric diagnoses, it is approximate and preliminary, and it has no clear physical correlate. This is why no gender clinician proposes using physical tests, which would clearly be in their interest to do if such correlates could be found. Yet this diagnosis must still be made in order to trigger the cascade of physical interventions that doctors like Hoebeke present as their pride and joy.

It is hard to see what use diagnostic caution is to people in this field; it is easy to see how a loose use of diagnostic criteria benefits them. But this problem is never even acknowledged in practitioners’ pronouncements. Also unacknowledged are its implications for adult gender medicine, especially if performed on patients who were in the psychiatric machine since adolescence. Does an 18-year-old really choose mastectomy freely if they have been told that it will help them since the age of 12 or 14? How do ‘affirming’ gender specialists make sure they do not, in effect, groom young patients into desiring what is good for their doctors’ careers?

The paper that the CSG representative provided put the lack of careful thought about these fundamental issues on clear display.5 It contains a couple of formulaic mentions of ‘thorough psychological assessment’ and ‘multidisciplinary team’, with no elaboration. What it does show is that CSG accepts self-referrals by minors, with no need for involvement of other doctors or, indeed, parents. There is one sentence that jumps off the page: ‘A limited number of individuals decided to stop (partially or completely) the gender transition trajectory and, unfortunately, five RFAB individuals died by suicide, see Figure 6. The median age at which suicide was committed was 18.6 years (range 17.9–20).’

It is an odd way to bracket stopping treatment with ending one’s life. All five suicide victims were young women who had undergone hysterectomy, which implies that at least one hysterectomy was performed before age 18 (since the youngest suicide victim was under 18). These were five suicides in a total patient population of fewer than 900 patients. This amounts to about 1.5 suicides per 1,000 patients over ten years (the period considered in the paper), which is in line with Belgium’s average suicide rate of roughly 15 per 100,000 persons per year. Normally, however, men outnumber women at least two to one in completed suicides, and considering the total number of hysterectomies performed (147), the five suicides constitute a mortality rate by suicide of 3.4 percent for this group. Might sending teenage women into early menopause be a bit ill-advised, then? I put the issue of these suicides to the CSG spokesperson who sent me the paper. I received no response. The paper itself, purely descriptive, contains no self-reflection on the point, or indeed any other. ‘Careful’? Such self-congratulation would be laughable if its context weren’t so serious.

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1 Trans… et alors?, Piet Hoebeke | 9789465302430 | Boeken | bol – the phrase ‘authentic search’/ authentieke tocht is in the blorb at the bottom of this page.

2 GenderGP clinic has betrayed us with AI rip-off, say trans patients, Judge warns over “dangerously high” hormone dose prescribed to teenager by online gender clinic | The BMJ

3 Cass review in de UK is scherp voor transgenderzorg bij minderjarigen | Transgenderinfo – this is the link to the response to Cass by the transgender infopunt. The link to the GenderGPs screed is still up as of 25/5/26. – Response to the Cass Review – GenderGP

4 Response Cass Review on Transgender Care for Adolescents – EPATH (note: this leads to the opening page; the more detailed statement that reveals how hollow the endorsement of Cass is sits behind the link at the bottom of the page (’for full statement click here’). Een reactie van Amsterdam UMC op de Cass review over transgenderzorg | Amsterdam UMC – statement from the Amsterdam clinic.

5 Ciancia_Evolution of pediatric TG healthcare in Flanders_IJTG_2025 (2).pdf