Fertility options in transgender and gender diverse adolescents

Transgender coverage in the media is becoming more commonplace and children and adolescents from resource-rich countries are accessing transgender healthcare at an exponentially increasing rate. What factors should care providers, adolescents and parents/guardians or caretakers take into consideration with respect to fertility? The World Professional Association for Transgender Health (WPATH) is the only global interdisciplinary association that is solely devoted to transgender health. WPATH's mission is to promote evidence-based care, education, research, advocacy, public policy and respect in transgender health. WPATH has produced seven versions of the Standards of Care (SOC) with the most recent version (SOC 7) released in 2012 1. SOC 7 includes a chapter on adolescent medical transition, as well as a chapter on transgender fertility. The latter marked a milestone in moving transgender healthcare forward, as discussing fertility options did not feature as prominently in earlier versions. In 2001, reproductive endocrinologist Petra De Sutter stated in her seminal paper that trans people should not have to forego reproductive options in exchange for medical transition 2. This is still the case in many countries, but the tide is shifting as individuals who identify as transgender and/or gender-diverse are gaining ground in the human rights area. Three areas of intervention can affect fertility in the person who is undergoing medical transition. The first is hormone blockers; the second, hormone therapy; and the third, gonadectomy, where gametes can be retrieved and stored before the procedure. The criteria for hormone therapy for adults include the following: the patient should have persistent, well-documented gender dysphoria; be of the age of consent in a given country; be in reasonable control of any medical and mental health conditions; and have the capacity to consent to treatment. Adolescents may be eligible to begin feminizing/masculinizing hormone therapy, preferably with parental consent. In many countries, 16-year-olds are legal adults for medical decision-making and do not require parental consent. Ideally, treatment decisions should be made among the adolescent, the family and the treatment team 3. Many younger adolescents may benefit from pubertal suppression 3. Pubertal suppression reversibly buys time for these individuals before a decision regarding more irreversible interventions can be made. It also prevents the development of unwanted secondary sex characteristics of the sex assigned at birth – often preventing the need for invasive procedures later on. The options for retrieving sperm or eggs in children this young often depends on how mature the individual is at the time pubertal suppression is initiated. Although reversible, should an adolescent pursue cross-gender hormones after pubertal suppression, it is unlikely that eggs or sperm can be retrieved, and therefore conversations about fertility are being held with families of adolescents who are younger and younger. Feminizing hormones in people assigned male at birth block testosterone production, and the results are variable as to whether sperm production will resume, based on the amount of time that the person has been taking hormones. Sperm cryopreservation is therefore recommended before the initiation of hormone therapy. With individuals for whom self-stimulation is difficult, testicular sperm extraction is a possible alternative method for sperm retrieval; although potentially costly and not covered by insurance. Masculinizing hormones in people assigned female at birth block estrogen production, which causes a cessation in ovulation, but does not necessarily affect the quality of the eggs, which is determined more by the age of the individual. Some trans masculine people are choosing to discontinue testosterone therapy for a period of time to carry a pregnancy and deliver and then resume therapy. It is not always guaranteed that the person is able to become pregnant after discontinuing testosterone. Adolescents and adults alike should be counseled on fertility preservation, with more robust discussion taking place with adolescents on a number of occasions. Do younger adolescents have the capacity to discuss fertility options before initiating pubertal suppression? Similarly, are slightly more mature adolescents able to consent for masculinizing/feminizing hormone therapy that may disrupt their reproductive potential? It is an interesting question, as adolescents in this stage of development are often prioritizing their need to present in a way that is authentic to themselves and which allows others to perceive them as the gender they affirm, vs. preserving their reproductive potential. Are adolescents able, at this stage, to predict whether they wish to have their own biological children in the future? This must be balanced with the danger of withholding treatment, which is not a neutral option for adolescents, as it “might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization” 3. A number of organizations, in addition to WPATH, strongly state that conversion therapy, an a priori attempt to change an individual's gender identity and/or sexual orientation, is no longer considered ethical. Not only can fertility be affected by introducing hormones, changes can also be irreversible through gonadectomy. Genital surgery is usually delayed until the person is over the age of majority in a given country. However, the age of majority does not necessarily correlate with healthcare decisions that adolescents are able to make without the consent of their parent or guardian. Very few case reports exist on the outcome of individuals under the age of 18 years having surgery, and this is an important area for future research. The age criteria for lower surgery will most likely decline in the subsequent version of the Standards of Care, and a question that emerges is: what factors will be used to determine that an adolescent has the capacity to consent for gonadectomy? Should the adolescent have the capacity to consent for gonadectomy and has good parental/guardian/caretaker support, their quality of life in many cases will improve. Gender dysphoria is a condition where a person experiences distress because there is an incongruence between their assigned sex and their gender identity 1. Biological sex is assigned at birth depending on the appearance of the genitals while gender identity is the gender that a person identifies with or feels themselves to be. Some people with gender dysphoria experience a strong desire to align their gender expression with their gender identity, which is different than the sex assigned to them at birth. Gender dysphoria is a recognized medical condition, for which treatment is sometimes appropriate. Most psychologists and medical professionals do not consider it a mental disorder although it is still classified as one, nor is it a sexual disorder 2. The World Health Organization′s scheduled update of their diagnostic tool in 2018 (ICD-11) plans to reclassify it as “Gender incongruence of adolescence and adulthood” 3. The exact percentage of people who experience gender dysphoria is not known as the condition is highly stigmatized in many societies, but in many countries the number of people being diagnosed with the condition is increasing, due to growing public awareness. Estimated rates range from about 0.3–0.5% (25 million) of the global population 5. The first signs of gender dysphoria can appear at a very young age and may continue through childhood and into adulthood. (DSDs, also referred to as diversity of sex development or intersex) are a group of rare conditions in which the reproductive organs and genitals don't develop as expected. People with DSD will have a mix of male and female sexual characteristics 4 and in some cases they may be infertile. This may be genetic (such as in Klinefelter syndrome or XXY) and/or because of how the body responds to sex hormones. It can be inherited but often is not. Some DSDs are suspected soon after birth and others are often diagnosed in puberty. As the child grows, they may need hormone therapy and psychological support. In some cases of DSD, gender dysphoria may also be present and the person may want to change their appearance. Treatment for gender dysphoria aims to help reduce or remove the distressing feelings of a mismatch between assigned sex and gender identity and help people live as their preferred gender identity 3. The World Professional Association for Transgender Health (WPATH) Standards of Care are used by many clinicians as treatment guidelines 6. Treatment may include mental health services (for example assessment, counseling, psychotherapy), primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, and hormonal and surgical treatments. Treatment options vary between countries. Youth treatment should be arranged with a multi-disciplinary team that would include mental health professionals and pediatric endocrinologists. When a youth with gender dysphoria and a strong desire to change their gender presentation to align with their gender identity reaches Tanner Stage 2 of puberty, one (fully reversible) treatment option is taking gonadotrophin-releasing hormone (GnRH) analogues that suppress the naturally produced hormones driving pubertal changes. By suppressing puberty, GnRH analogues can help delay potentially distressing physical changes until the person is ready for further treatment options. Teenagers who reach the age of medical consent are entitled to consent to their own treatment and follow standard adult protocols. Besides offering ongoing assessments, treatments and advice, specialist care should include mental health support, cross-sex hormone treatment, speech and language therapy and support groups. The amount of treatment needed depends on the individual and some patients will choose more extensive treatment including surgery. Adult hormone therapy entails taking the hormones of the preferred gender. Hormone therapy usually needs to be taken indefinitely, even if genital reconstructive surgery is undertaken. Hormonal treatment can be stopped although some changes are irreversible, such as a deeper voice in trans men and breast growth in trans women. There is some uncertainty about the possible risks of long-term masculinizing and feminizing hormone treatment. Some of the potential side affects include: blood clots, gallstones, weight gain, acne, hair loss from the scalp and sleep apnoea. Hormone therapy has variable effects on trans women and trans men. For trans women, there is no guarantee that sperm production will resume after cessation of hormone therapy, and it is very unlikely after 18 months on hormone therapy. Trans men may become pregnant after stopping testosterone. However, ovulation may not be completely suppressed while on testosterone so preventative options are necessary. Discussion of implications with fertility before starting treatment is paramount, including the storing of eggs or sperm (gamete storage), if this is a viable option. For trans men, surgery may involve removal of breasts, removal of the uterus, removal of the fallopian tubes and ovaries, construction of a penis, construction of a scrotum and testicular implants and a penile implant. The aim is to create a functioning penis that allows passing urine standing up and to retain sexual sensation. For trans women, surgery may involve removal of the testes, removal of the penis, construction of a vagina, construction of the labia, construction of a clitoris with sensation, breast implants and facial feminization surgery. The aim of this type of surgery is, to create a vulva and vagina but in some cases a vagina is not desired. Fact sheet compiled by Maya Acharya and Susana Benedet.

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