****DISCLAIMER***
This article was written for one of my classes in grad school. I was really passionate about the topic and felt the need to share. All words are my own, and references are listed at the bottom of this post. This work is being published to shed some light on the ethics of reproductive rights of transgender individuals as an information piece to the public. Therefore, please do not plagiarize this article.
According to The Human Rights Campaign, the term transgender is used to define people whose gender identity differs from the gender they were assigned to at birth. As a result, this population of individuals which comprises about 1.4 million adults in the United States of America, is said to suffer from gender dysphoria, where they do not feel comfortable in their assigned gender making life much more difficult (1),(2). In order to address gender dysphoria, gender-affirming therapy is available in order to improve way of life. Gender-affirming therapy also known universally as “the transition”, includes either a surgical removal of the male and female reproductive organs (gonadectomy) or exogenous hormone therapy which is known to disrupt their ability to reproduce. Normally, hormonal therapy with exogenous estrogen or testosterone helps the trans individual assimilate to their desired gender by depleting the circulating sex hormones already present in their bodies. Exogenous hormones allow for the induction of secondary sex characteristics associated with their gender of interest and improve mental well-being; however, long-term exposure to exogenous hormones may gradually limit the option of having genetically related offspring. Additionally, halting the use of hormones in between transition for the opportunity of having a child may induce psychological stress, as these individuals have to revert to their assigned gender at birth. Due to the paucity of information regarding reproductive health outcomes in the trans-community, a barrier exists between fertility preservation and transition reversal. As a result, counseling on preserving fertility prior to treatment is lacking, becoming a problematic issue for individuals with the desire to start a family of their own.
Management of gender dysphoria in the trans-population is a complex issue because its etiology is unknown, which makes treatment of dysphoria much more challenging. This raises an ethical argument on how clinicians treat trans-persons and manage preserving their fertility. Four ethical principles to consider are autonomy, beneficence, nonmaleficence, and justice. Individuals have the autonomy to make decisions regarding their reproductive health and seek the appropriate treatment. Transgender persons should be counseled on the risks and benefits of treatment prior to transition. The concept of beneficence places the patient’s best interest as priority and doing what is right to satisfy them. This concept continues to be controversial, especially in regard to gender dysphoria because gender assignment surgery alters the functionality and reproductive potential of healthy reproductive organs. Nonmaleficence ties into the concept of beneficence by ensuring no physical, mental, or emotional harm to the patient. And lastly, justice implies that above all else, trans-persons cannot be denied the right to make decisions regarding their reproductive health because of their gender identity. With that in mind, ethical considerations and a change in health plan coverage must be acknowledged to provide better alternatives for fertility preservation; granting these individuals the same reproductive rights that are awarded to the cis-gender community (3), (4).
Improving access to reproductive care for the trans-community is needed in order to help eliminate discrimination against this growing population of patients. The World Professional Association for Transgender Health, along with The Endocrine Society and The American Society for Reproductive Medicine (ASRM) has recommended that prior to surgical removal of reproductive organs and administration of exogenous hormones counseling about fertility preservation and the effects of treatment must be discussed in order to reduce dysphoria, and make the transition much easier (5), (2), (6). Studies have confirmed that approximately 40-54% of transgender adults have the desire of being parents, and that over half of those individuals stated that they would like the opportunity to sire biological children (7), (8), (9). It is not surprising, that fertility preservation is of high priority in regards to family planning; however, not many medical professionals consult their patients about this option (10), (11). These provider-patient related barriers, among many others creates a huge impact in the inability of patients to seek further fertility counseling (11). Nevertheless, there needs to be a consistent sense of advocacy for fertility care from medical professionals. One reason for the lack of counseling could be due to the limited knowledge there is regarding reproductive outcomes after an individual has already transitioned. Additionally, this is a highly controversial topic and it should be noted that fertility care for trans adolescents and adults may differ in other parts of the globe, resulting in limited and/or inefficient fertility preservation counseling.
Reproductive Potential of Trans-adolescents & Adults
In recent years, more adolescents are identifying as transgender and are seeking suppression of puberty and gender-affirming hormonal treatment. Because adolescents are under the legal guardianship of their parents, consulting both the adolescent and their parents regarding fertility preservation options prior to treatment is necessary. A main ethical concern, is that the decision-making process on when to start treatment and consequently preserve fertility depends on the parents (12), (13) due to the reason that the child may not fully comprehend the reproductive consequences of their decision. As a result, the decisions of the parent may not align with the child’s desire and cause stress and discourse between both parent and child. According to a medical law review, The World Professional Association for Transgender Health (WPATH) states that a minors interests should be respected and considered in their decision for hormonal treatment or surgery by their parents (14). Until a collaborative decision is made, the child can be administered GnRH agonists which work by preventing the development of secondary sex characteristics in an attempt to suppress puberty until the age of sixteen (2). Studies have shown reversible reproductive changes in men or women administered GnRH agonists for other medical conditions (15), (16). However, there is a lack of studies revealing whether GnRH agonist treatment prior to gender-affirming hormonal therapy in adolescents, impacts reproductive function. In addition, it is unknown whether transgender adults who started gender-affirming therapy as adolescents have naturally regained fertility or have regained fertility through exogenous hormone administration.
There is an argument of whether transgender adolescents have the right to make their own decisions regarding body modification. Currently, there is an age threshold for surgery, that may only be overridden by parental consent. Once an adolescent is ‘mature enough’ they are able to make decisions on their own, dictating their lives as they wish. When considering the ethics of body modification in a young adult, an argument arises as to whether adolescents should be prevented from making this life-changing decision. However, a qualitative study analyzing the persistence or desistence of gender dysphoria in male adolescents revealed that their gender identity shifted in regards to their changing social environment, pubertal changes, and sexual attraction throughout childhood (17). Interestingly, children who underwent puberty suppression were referred to gender identity clinics where persistence or desistence of gender dysphoria was investigated. As a result, persisted gender dysphoria was higher in individuals assigned female at birth (49.1%) compared to those assigned male at birth (33.6%) (18), (19). Overall these findings indicate that gender identity may fluctuate throughout childhood and as a result should be carefully decided with parental guidance. In another study, investigating the views of young people with gender dysphoria and their parents concerning fertility preservation, approximately 83% of individuals assigned female at birth, and 71% of individuals assigned male at birth were not inquired about preserving their fertility (20). Although a majority of individuals desire to become parents in the future, if fertility preservation required them to halt hormonal treatment, they would consider alternatives to family planning, like adoption or the use of a surrogate (20), (12). As a result, a majority of individuals feel uncomfortable with the idea of reversing their transition, thus potentially increasing their gender dysphoria. Therefore, it is critical that patients be advised of the interventions necessary for undergoing cryopreservation of gametes.
Communication of reproductive potential should be better discussed with adolescent and adult transgender persons prior to starting hormone therapy. One of the main reasons for this is the lack of knowledge regarding the long-term effects of estrogen in and testosterone treatment in transmen and transwomen respectively. The scientific community as a whole is at the forefront of understanding knowledge and complex ideas and thus is responsible for providing more evidence-based research regarding this issue and share that information with the public. As such, more research needs to be conducted on the gonadal effects of exogenous hormone administration. The data available regarding this matter was generated from small retrospective studies and case reports in which the reproductive organs of a transsexual male treated with estrogen for 18 months prior to orchidectomy and sex reassignment surgery resulted in impairment of spermatogenesis (21). Other studies compared short- and long-term effects of estrogen administration between 1.5 to 13 years on the testis. This data revealed that estrogen effects varied (22), and impaired Sertoli and Leydig cell morphology and function (23), and testicular atrophy with reduction of germ cells (24), (25), (26). Transmen administered testosterone therapy has led to distinct morphological changes indicative of polycystic ovaries, and follicular atresia (27). Ovarian morphology was also assessed using transvaginal ultrasound in transmen to determine whether hormonal therapy results in polycystic ovarian morphology, however, there was no statistical significance between the transmen and the control group (28). Fertility outcomes among transmen have revealed that those who have not undergone gender-reassignment surgery, were still able to conceive and maintain a pregnancy. In another study, 61% of transmen who underwent testosterone treatment prior to pregnancy, were able to use their biological ovaries (29). Overall these studies provide clear evidence of some of the long-term effects of hormonal therapy administration and reproductive outcome. Some transgender persons are able to conceive despite extended hormone treatment; however, complete restoration of spermatogenesis is uncertain therefore, a timepoint in which treatment can be stopped in patients desiring fertility preservation needs to be established.
Outcomes of Hormonal Therapy & Fertility Preservation Options
Fertility preservation options are commonly provided to cancer patients prior to undergoing gonadotoxic chemotherapy (30). However, it is equally important that trans-persons are counseled on the option of fertility preservation prior to gender-affirming procedures, due to the probable detrimental effects of hormonal therapy on spermatogenesis and ovarian reserve. Long-term exposure to gender-affirming therapy hormones has been shown to progressively impact spermatogenesis and semen quality (31), (32). Although halting treatment may restore spermatogenesis, the timepoint at which this restoration occurs is rather unclear due to limited studies regarding this matter. It is essential that clinicians provide fertility-preserving options during the transition or gender-affirming surgeries, which causes irreversible damage to the reproductive organs. Transwomen must be counseled on semen cryopreservation, which can be obtained through masturbation. However, a majority of these patients find the act of masturbation psychologically distressing because of their disconnect with their birth gender. If they are not able to provide a sample, there are other methods of retrieving viable sperm such as surgical sperm retrieval (SSR). This is an established method for fertility preservation amongst cancer patients who have undergone chemotherapy. During SSR, viable sperm is extracted from locations like the epididymis and or testis, and overall minimizes the psychological discomfort. Although this procedure can occur prior to gender-affirming surgery, it has yet to be performed on transgender women.
Transmen, on the other hand, are encouraged to undergo embryo, oocyte, and ovarian tissue cryopreservation. Of the three fertility preservation options, the best one for transmen would be oocyte cryopreservation, due to the fact that sperm is not required which provides these patients with the autonomous ownership as well as management of their gametes for future family planning, thus bypassing the multifactorial ethical ramifications (33), (34). In order to obtain mature oocytes prior to vitrification is to hyper-stimulate the ovary for retrieval of multiple oocytes. These individuals should be warned that ovarian hyperstimulation will increase their estrogen levels. Aromatase inhibitors may be used to decrease serum estrogen levels during stimulation which has also been administered to female breast cancer patients who have decided to preserve their fertility (35). Therefore, oocyte cryopreservation is the best approach for transmen who do not desire to carry their own pregnancy, or either have a partner with a uterus, decide to use a surrogate, or whom choose to undergo gender reassignment surgery. Unfortunately, transmen who are already transitioning with the aid of hormonal therapy and whom desire genetically identical offspring will have much more difficulty undergoing oocyte cryopreservation. This will lead to adverse effects caused by the cessation testosterone treatment such as the resumption of menses and feminizing physical changes associates with the female sex assigned to them at birth (9). In addition, gynecological procedures such as a transvaginal ultrasound, transvaginal oocyte retrievals, and pelvic exams to evaluate ovarian reserve and oocyte quality have been known to be emotionally and psychologically distressing to these individuals (36). In order for patients to feel more comfortable undergoing these procedures, it is best for clinicians to use the appropriate pronouns when addressing the transgender population. Another fertility preservation method is ovarian tissue cryopreservation (OTC) which can be performed at the time of gender reaffirming surgery without the need for ovarian stimulation. However, this method is still highly experimental which requires access to a research institution with an already established protocol for transgender patients. There are also considerable limitations such as the need to stop hormonal therapy in order to re-implant the cryopreserved ovarian tissue. Although a study investigating ovarian physiology and histology due to prolonged androgen treatment, revealed that androgen exposure in transmen did not alter the distribution of cortical follicle distribution (37). However, transplanted ovarian tissue may alter endocrine function in transmen. Other methods, such as in vitro maturation (IVM) may be performed however, it may not be as efficient or widely available. A group of researchers investigated the use of IVM with OTC in 40 transmen who were exposed to androgens for 58 weeks. This study revealed that cumulus oocyte complexes (COCs) from transmen had a 34.3% maturation rate, and a normal chromosomal pattern during spindle analysis (37). This data provides insight to the future use of oocytes obtained and stimulated by IVM from transmen. Due to the limited number of case studies regarding fertility preservation in transgender men and women, it is important for clinicians to aware patients that current studies are limited and are mainly taken from successful fertility preservation in cisgender populations.
Barriers & Future Changes
There is an inherent responsibility for not only medical providers but the government in recognizing the needs of transgender persons in healthcare. To help minimize the discrimination, healthcare policies need to be modified to better aid transgender persons in making decisions about their reproductive health. An overwhelming majority of transgender individuals have been denied access to medical care because their perceived sense of self is seen as a mental disorder. Therefore, in order to receive any form of medical care a diagnosis of gender identity disorder is needed for them to begin gender-affirming procedures (38). The reason for such strong discourse over providing transgender persons with the appropriate care is due to stigmatization by insurers and medical providers. Assisting these individuals to create their own families is an ongoing debate, especially when child well-fare is of high priority (39),(8). Unfortunately, lawmakers and medical professionals stigmatize transgender persons and question their ability to provide a safe and nurturing environment, to a child growing up in a non-heteronormative household. However, courts have long since established that reproduction, as well as transgender parenting, should not be prohibited (40). Members of the LGBT community must be guaranteed the same rights as cisgender individuals and should not be denied access to reproductive health care. As new gender and sexual identities emerge, reproductive healthcare should begin to be more inclusive and less discriminative of these identities in their decision to provide adequate care. However, there has been some dispute in support of the view that transgender persons, are not entitled to the same reproductive rights as cisgender persons (39) which becomes problematic because at the end of the day, we are all human and have the right to a supportive healthcare system.
The barriers related to transgender care are oftentimes not caustic of the care provided by medical professionals, but rather a collection of system barriers in clinical and laboratory settings that are gender-biased resulting in inadequate care provided to these individuals (41), (42). And as a result, many transgender persons become overwhelmed with the inability to access basic medical care and thus avoid seeking medical treatment (43), (44). Additionally, reference intervals that are currently established are defined by sex, making it harder to evaluate metabolic markers within transgender populations, without comparing normal ranges of these markers to their cisgender counterparts. Therefore, an interval range for transgender persons must be created to better serve this population more accurately and avoid discrimination (41). Health insurance policies oftentimes deny coverage of laboratory tests and procedures normally provided for the sex assigned at birth, making the treatment and care of trans persons much more difficult.
Healthcare policy concerning the care of transgender persons in the United States of America has been a long and tortuous battle of bias and discrimination. There needs to be an active shift in unlearning normative societal values to better encompass individuals who are known to deviate from those norms. Acknowledging the healthcare needs of the transgender community is essential for providing appropriate care to these individuals (45). In addition, the role medical professionals play in this situation will greatly change the way these individuals are perceived and currently perceive medical care. As a result, there needs to be an ongoing conversation on how to address the issues faced by the trans-community in regard to fertility preservation options. Enhancing medical care begins with physician exposure and acknowledgment of gender identity. Once this is understood and biases are placed aside, a supportive healthcare system can be achieved to better serve the transgender community.
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