Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Ten years of experience in counseling gender diverse youth in Flanders, Belgium. A clinical overview


Research on gender variant children and adolescents has stirred debate on the increased amount of referrals, the sex ratio in referrals, the impact of trans care on their psychological well-being, and the amount of children/adolescents who stop treatment. This retrospective study includes the number of referrals, first contacts at the outpatient clinic and the amount of drop-outs between January 1st 2007 to December 31st 2016 from the sole Belgian Pediatric Gender clinic. Emotional and behavioral problems, measured by the Child Behavioral Checklist (CBCL) and the Youth Self-Report (YSR), were screened. The adolescents who ceased the counseling, were contacted for follow-up. We included 235 adolescents, referred to the clinic, and 177 (of 235) who had a first physical appointment with a psychologist. Almost one in four (24.5%) on the YSR and more than half (54.8%) on the CBCL fall within the clinical range on the total problem score. On the YSR, 40.4% reported having suicide thoughts and 32.1% reported self-harm behavior and/or at least one suicide attempt, all in the last six months. Five adolescents committed suicide. According to parents, more difficulties with peers predicts more emotional and behavioral problems (F(5, 36) = 3.539, p = 0.011). In this study group, 29 adolescents ceased the counseling, whereof 7 could be traced back in the adult gender clinic after 2016. Results are indicative of the need for mental support for trans youth and their families and moreover, highlight the need for longitudinal follow-up studies.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1
Fig. 2


  1. 1.

    Handler T, Hojilla JC, Varghese R, Wellenstein W, Satre DD, Zaritsky E. Trends in referrals to a pediatric transgender clinic. Pediatrics 2019;144:e20191368.

    Article  Google Scholar 

  2. 2.

    Spack NP, Edwards-Leeper L, Feldman HA, Leibowitz S, Mandel F, Diamond DA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129:2011–0907.

  3. 3.

    Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, et al. Evidence for an altered sex ratio in clinic‐referred adolescents with gender dysphoria. J Sex Med. 2015;12:756–63.

    Article  Google Scholar 

  4. 4.

    Chen M, Fuqua J, Eugster EA. Characteristics of referrals for gender dysphoria over a 13-year period. J Adolesc Health. 2016;58:369–71.

    Article  Google Scholar 

  5. 5.

    de Graaf NM, Giovanardi G, Zitz C, Carmichael P. Sex ratio in children and adolescents referred to the Gender Identity Development Service in the UK (2009–2016). Arch Sex Behav. 2018;47:1301–4.

    Article  Google Scholar 

  6. 6.

    Arnoldussen M, Steensma TD, Popma A, van der Miesen AIR, Twisk JWR, de Vries ALC. Re-evaluation of the Dutch approach: are recently referred transgender youth different compared to earlier referrals? Eur Child Adolesc Psychiatry. 2019;29:803–11.

  7. 7.

    Shiffman M, VanderLaan DP, Wood H, Hughes SK, Owen-Anderson A, Lumley MM, et al. Behavioral and emotional problems as a function of peer relationships in adolescents with gender dysphoria: A comparison with clinical and nonclinical controls. Psychol Sex Orientat Gend Diversity. 2016;3:27.

    Article  Google Scholar 

  8. 8.

    Holt V, Skagerberg E, Dunsford M. Young people with features of gender dysphoria: Demographics and associated difficulties. Clin Child Psychol Psychiatry. 2016;21:108–18.

    Article  Google Scholar 

  9. 9.

    T’Sjoen G, Arcelus J, de Vries ALC, Fisscher, AD, Nieder TO, Özer M, et al. ESSM Position Statement: assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction. J Sex Med. 2019;17:570–84.

  10. 10.

    Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57:374–80.

    Article  Google Scholar 

  11. 11.

    Aitken M, VanderLaan DP, Wasserman L, Stojanovski S, Zucker KJ. Self-harm and suicidality in children referred for gender dysphoria. J Am Acad Child Adolesc Psychiatry. 2016;55:513–20.

    Article  Google Scholar 

  12. 12.

    Arcelus J, Claes L, Witcomb GL, Marshall E, Bouman WP. Risk factors for non-suicidal self-injury among trans youth. J Sex Med. 2016;13:402–12.

    Article  Google Scholar 

  13. 13.

    Peterson CM, Matthews A, Copps-Smith E, Conard LA. Suicidality, self-harm, and body dissatisfaction in transgender adolescents and emerging adults with gender dysphoria. Suicide Life Threat Behav. 2017;47:475–82.

    Article  Google Scholar 

  14. 14.

    Khatchadourian K, Amed S, Metzger DL. Clinical management of youth with gender dysphoria in Vancouver. J Pediatrics. 2014;164:906–11.

    CAS  Article  Google Scholar 

  15. 15.

    Veale JF, Watson RJ, Peter T, Saewyc EM. Mental health disparities among Canadian transgender youth. J Adolesc Health. 2017;60:44–9.

    Article  Google Scholar 

  16. 16.

    de Graaf NM, Steensma TD, Carmichael P, VanderLaan DP, Aitken M, Cohen-Kettenis PT, et al. Suicidality in clinic-referred transgender adolescents. Eur Child Adolesc Psychiatry. Epub 2020.

  17. 17.

    de Vries AL, Doreleijers TA, Steensma TD, Cohen‐Kettenis PT. Psychiatric comorbidity in gender dysphoric adolescents. J Child Psychol Psychiatry. 2011;52:1195–202.

    Article  Google Scholar 

  18. 18.

    Clark TC, Lucassen MF, Bullen P, Denny SJ, Fleming TM, Robinson EM, et al. The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth'12). J Adolesc Health. 2014;55:93–9.

    Article  Google Scholar 

  19. 19.

    de Vries AL, Steensma TD, Cohen-Kettenis PT, VanderLaan DP, Zucker KJ. Poor peer relations predict parent-and self-reported behavioral and emotional problems of adolescents with gender dysphoria: a cross-national, cross-clinic comparative analysis. Eur Child Adolesc Psychiatry. 2016;25:579–88.

    Article  Google Scholar 

  20. 20.

    Fuller KA, Riggs DW. Family support and discrimination and their relationship to psychological distress and resilience amongst transgender people. Int J Transgenderism. 2018;19:379–88.

    Article  Google Scholar 

  21. 21.

    Riggs DW, Bartholomaeus C, Sansfaçon AP. ‘If they didn’t support me, I most likely wouldn’t be here’: Transgender young people and their parents negotiating medical treatment in Australia. Int J Transgender Health. 2020;21:3–15.

    Article  Google Scholar 

  22. 22.

    Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137:2015–3223.

  23. 23.

    de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 2014;134:696–704.

    Article  Google Scholar 

  24. 24.

    Steensma TD, Cohen-Kettenis PT. A critical commentary on “A critical commentary on follow-up studies and “desistence” theories about transgender and gender non-conforming children”. Int J Transgenderism. 2018;19:225–30.

    Article  Google Scholar 

  25. 25.

    Temple Newhook J, Pyne J, Winters K, Feder S, Holmes C, Tosh J, et al. A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. Int J Transgenderism. 2018;19:1–13.

  26. 26.

    Zucker KJ. The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender non-conforming children” by Temple Newhook et al (2018). Int J Transgenderism. 2018;19:1–15.

  27. 27.

    Drummond KD, Bradley SJ, Peterson-Badali M, Zucker KJ. A follow-up study of girls with gender identity disorder. Dev Psychol. 2008;44:34–45.

    Article  Google Scholar 

  28. 28.

    Steensma TD, Cohen-Kettenis PT. More than two developmental pathways in children with gender dysphoria? J Am Acad Child Adolesc Psychiatry. 2015;54:147–8.

    Article  Google Scholar 

  29. 29.

    Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013;52:582–90.

    Article  Google Scholar 

  30. 30.

    Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008;47:1413–23.

    Article  Google Scholar 

  31. 31.

    Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011;16:499–516.

    Article  Google Scholar 

  32. 32.

    Singh D. A follow-up study of boys with gender identity disorder. Toronto; 2012.

  33. 33.

    Achenbach TM, Edelbrock CS. Manual for the child behavior checklist: and revised child behavior profile. University of Vermont, Department of Psychiatry; 1983.

  34. 34.

    Achenbach TM. Manual for the youth self-report and 1991 profile: Department of Psychiatry, University of Vermont Burlington; 1991.

  35. 35.

    Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people. World Professional Association for Transgender Health; 2012.

  36. 36.

    Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society* clinical practice guideline. The. J Clin Endocrinol Metab. 2017;102:3869–903.

    Article  Google Scholar 

  37. 37.

    Verhulst F, Van der Ende J, Koot H. Handleiding voor de Youth Self-Report (YSR)[Manual for the Youth Self-Report (YSR)]. Sophia Children’s Hospital, Rotterdam; 1997.

  38. 38.

    Verhulst FC. Praktische handleiding voor de CBCL (Child Behavior Cecklist). van Gorcum; 1990.

  39. 39.

    de Graaf NM, Cohen-Kettenis PT, Carmichael P, de Vries ALC, Dhondt K, Laridaen J, et al. Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: a clinical comparison study between four clinics. Eur Child Adolesc Psychiatry. 2017;27:909–19.

  40. 40.

    Skagerberg E, Davidson S, Carmichael P. Internalizing and externalizing behaviors in a group of young people with gender dysphoria. Int J Transgenderism. 2013;14:105–12.

    Article  Google Scholar 

  41. 41.

    Zucker KJ, Bradley SJ, Sanikhani M. Sex differences in referral rates of children with gender identity disorder: Some hypotheses. J Abnorm Child Psychol. 1997;25:217–27.

    CAS  Article  Google Scholar 

  42. 42.

    Field A. Discovering statistics using IBM SPSS statistics. 4 ed. London: SAGE Publications Ltd; 2013.

  43. 43.

    Cohen-Kettenis PT, Steensma TD, de Vries AL. Treatment of adolescents with gender dysphoria in The Netherlands. Child and Adolescent Psychiatric. Clinics 2011;20:689–700.

    Google Scholar 

  44. 44.

    Zucker KJ, Bradley SJ, Owen-Anderson A, Singh D, Blanchard R, Bain J. Puberty-blocking hormonal therapy for adolescents with gender identity disorder: a descriptive clinical study. J Gay Lesbian Ment Health. 2010;15:58–82.

    Article  Google Scholar 

  45. 45.

    Motmans J, Defreyne J, Wyverkens E. Being transgender in Belgium. Ten years later. Brussel: Institute for the equality of women and men; 2018.

  46. 46.

    Zelfdoding per leeftijdsgroep [Online publication] [Internet]. 2017 [cited 25 February 2021]. Available from:

  47. 47.

    Dierckens M, De Clercq, B. & Deforche B. Studie Jongeren en Gezondheid, Deel 3: gezondheid en welzijn—Mentale en subjectieve gezondheid [Factsheet]. Ghent University; 2019.

Download references


We’d like to thank all adolescents who gave us consent to use their data. Also, thank you to our colleagues, Jolien Laridaen and Heidi Vanden Bossche, for helping with the collection and input of the data.


This research was funded by the department of Equal Opportunities from the Flemish government

Author information



Corresponding author

Correspondence to Gaia Van Cauwenberg.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Van Cauwenberg, G., Dhondt, K. & Motmans, J. Ten years of experience in counseling gender diverse youth in Flanders, Belgium. A clinical overview. Int J Impot Res (2021).

Download citation


Quick links