A 44-year-old man in Belgium chose to end his life via euthanasia on Monday after a series of failed gender reassignment surgeries. “I was the girl no one wanted,” Nathan Verhelst told the Flemish newspaper Het Laatste Nieuws[1] , mere hours before his death.


Verhelst, who was born female, told the paper’s reporters he grew up in an unloving family, feeling like a boy trapped in a girl’s body. He finally started hormone therapy in 2009 and underwent several reassignment surgeries in 2012. While doctors did not publicly share the specifics of the surgeries, Verhelst told Het Laatste Nieuws that after the procedures, he felt like a monster. “I was ready to celebrate my new birth. But when I looked in the mirror, I was disgusted with myself,” he told the newspaper. “My new breasts did not match my expectations and my penis had symptoms of rejection.”


Verhelst applied for euthanasia several months ago and finally died on Monday in a Brussels hospital. His request was approved based on a 2002 law[2] that makes Belgium one of only three countries in the world that have legalized euthanasia, along with Luxembourg and the Netherlands.


According to the latest report[3] by the Belgian Evaluation Commission for Euthanasia, released in May 2012, more than 2,000 of the country’s citizens opted for euthanasia in 2010 and 2011, accounting for 1 percent of deaths in the country.


Evelien Delbeke, a visiting professor at the University of Antwerp, told The Huffington Post that individuals approved for the procedure must meet strict criteria. “It’s not like people in Belgium can just be killed without protection. Our legislation is pretty strict,” she said in Dutch. “A strict set of conditions needs to be met and several doctors are involved in each case.”


Delbeke explained that in order to file a request, applicants need to be of age, mentally competent and suffering from an incurable condition that causes continuous and unbearable suffering. The disease can be physical as well as psychological.


Applicants must go through several consultations with their doctor to ensure that the request is not an impulsive decision, and at least a month must pass between the application and the procedure. The doctor needs to consult with a second independent physician. In cases without a physical disease, a third doctor has to be consulted as well.


Usually, doctors inject patients with a lethal dose[4] through an IV. They lose consciousness within a couple of seconds, then become comatose and die quietly within five minutes.


Separately, Belgians can also sign an advance directive that allows a doctor to administer euthanasia in case they end up in an irreversible coma. Not all Belgian hospitals agree to euthanasia requests, and doctors are not legally required to administer applications.


“The law is about giving people the final choice in how they envision a dignified end of life,” said Hannie Van den Bilcke, a consultant at Huis Van De Mens, a humanist organization.


“I want to emphasize ‘dignified,’” she added. “Any person can make the decision to end his or her life, but this law guarantees that it can happen in a dignified way, if you want to.”


The majority of applicants in 2010 and 2011 were between 60 and 79 years old, and more than 75 percent suffered from a severe form of cancer, according to the Belgian Evaluation Commission for Euthanasia.


The commission's 2012 report shows that non-terminally ill patients, like Verhelst, account for less than 10 percent of cases.


While extremely rare, Delbeke does welcome the option for these cases. “Psychological suffering is often underestimated,” she said. “People often consider the cases of terminally ill patients or patients who are suffering physically ‘worse’ than those of psychiatric patients whose suffering may continue for years. But does that mean that patients who don’t have a physical condition or patients with a very serious physical condition but who aren’t terminally ill have to go through an entire disease process and see themselves regress?”


Eddy and Marc Verbessem[5] , Belgian twins who had been born deaf and had spent most of their lives together, relied on that aspect of the Belgian law when they chose to die through euthanasia in January 2013. The 45-year-old brothers suffered from an incurable disease and were slowly losing their sight in addition to their hearing.


"Many will wonder why my brothers have opted for euthanasia because there are plenty of deaf and blind that have a 'normal' life," Dirk Verbessem[6] , their older sibling, told The Telegraph at the time. "But my brothers trudged from one disease to another. They were really worn out."


Euthanasia is illegal in the U.S. Some states, such as Washington, Oregon, Montana and Vermont, do allow for physician assisted suicide[7] , in which doctors provide terminally ill patients with the means to end their own life but do not administer the lethal dose. Physician assisted suicide is not available for non-terminally ill patients.


Since Belgium adopted the law in 2002, reports indicate that the number of requests has risen each year. One of the country’s most famous authors, Hugo Claus, who suffered from Alzheimer’s disease, died by euthanasia in 2008.


Lawmakers in the country are currently looking into expanding the legislation to include minors, with written approval of their parents or legal guardian. The proposal is controversial[8] , with opponents questioning children's ability to make such a hefty decision.


Van den Bilcke notes that the number of children that would qualify for euthanasia would be extremely low, given that they would have to have a terminal condition that causes them unbearable physical or psychological suffering. She wonders, then, why terminally-ill children who sometimes have been fighting for years should be forced to continue a futile battle.


“Not a single parent will consent to euthanasia without the feeling that this is the final step,” she said. “What parent gives up on his child?”