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Members of our GenderGP team attended an event run by the University of California San Francisco on Fertility Issues for Transgender and Non-binary Youth. Offering a “medical, mental health, and interdisciplinary perspective” on what has become a hot button issue in mainstream media, Drs. Diane Ehrensaft and Jen Hastings presented the latest medical findings and grappled with the thorny issue of how to talk to trans youth about their futures.

Here’s what we learned:

The current state of play around fertility in trans healthcare is a complicated one, characterised by a lack of proper understanding and education. Healthcare professionals and trans people themselves may fall prey to common assumptions, like puberty blockers causing permanent infertility, or even sterilisation being a necessary part of the gender transition process.

Diane Chen et al. have identified that although 36% of trans and gender expansive youth want to consider biological parenthood, they get most of their information from the internet, which can lead to misconceptions about fertility.

This situation isn’t helped by the frequent media portrayal of trans youth healthcare as an irrevocable, even damaging intervention. In fact, the culture of misinformation and discrimination surrounding trans issues in the UK makes talking about fertility that much harder.

Let’s examine this idea of ‘irreversibility’, for example. Not only is it not the case that puberty blockers negatively impact fertility (as evidenced by the use of blockers to treat idiopathic precocious puberty outside of the context of trans medicine), but the conflation of blockers with cross-sex hormone therapies and surgical interventions makes it harder for young people to make informed decisions about their fertility.

If the choice is presented as an ultimatum – fertility or affirmation (pick one!) – then the young person is subjected to a tremendous degree of unnecessary stress that is likely to affect their decision, their mental health, and their future. Furthermore, as Ehrensaft and Hastings point out, the emphasis on the question of reversibility in the narrow context of blockers and fertility ignores other, genuinely irreversible choices. For trans youth, the permanent physical changes of puberty can lead to gender dysphoria and the need for further medical interventions later in life. If we want to build an informed, patient-centred trans healthcare, we have to consider the long-term consequences not just on fertility, but on the individual as a whole.

So how do blockers work, and what differentiates them from gender-affirming hormone therapies? Puberty blockers work by interfering with Gonadotropin Releasing Hormone (GnRH), a hormone produced in the hypothalamus that stimulates the production of sex hormones. Although the initial infusion of puberty blockers causes an increase in sex hormones, continued use inhibits further production and leads to a corresponding decline in estrogen or testosterone, respectively. This has led to their use off-label in a wide range of therapies outside of trans healthcare, including endometriosis, infertility, and precocious puberty. In pre-pubescent trans youth, this has the effect of preventing the onset of endogenous (naturally occurring) puberty, which may then be followed by gender-affirming hormone therapy to enable the individual to progress in the gender with which they identify, through the introduction of appropriate levels of the correct gender-affirming hormone.

Where puberty has been suppressed through the use of blockers there are no immediate fertility options, as the sperm and eggs have not matured. However, this is not a permanent state of affairs (and, as Ehrensaft and Hastings remind us, no one – regardless of gender identity – has ‘guaranteed’ fertility options.)

In Australia, Norway, and some US research institutions, trans youth who choose to use blockers to suppress puberty may be able to pre-emptively freeze a biopsy of the ovaries/testicles for future maturation. Where this isn’t an option it is still possible to stop the blockers at a later date and either allow endogenous puberty to restart or retrieve an egg via follicle stimulation and then restart the blocker and hormones.

Once we get away from the idea that trans fertility is an on/off switch and start looking at the options available we are able to confront another important but overlooked issue: how does the individual relate to different fertility procedures? Is there a potential source of gender dysphoria here that might need to be anticipated and managed?

Chen et al. have identified that relatively few trans youth – 13 of 105 – seek out fertility preservation, with others citing cost, invasive procedures, and not wanting to delay medical transition any longer than necessary as reasons. In the case of post-pubescent trans people who undergo gender-affirming hormone therapy, the option of preserving genetic material (eggs or sperm) is typically offered before hormone therapy. However, both the means and desired outcomes of this preservation need to be carefully considered. Transfeminine people for whom ejaculation is a source of gender dysphoria may require medical extraction. Transmasculine people may be interested in preserving eggs for future fertility but experience gender dysphoria at the idea of pregnancy. Gender dysphoria around fertility options does not mean that a person doesn’t want a family – and likewise, part of providing affirming trans healthcare is helping manage dysphoric responses without closing off potential family pathways.

So far this conversation has been centred largely on physical development. However, this runs the risk of ignoring the important issue of how the fertility question intervenes in the psychological and emotional development of trans youth. As anyone who is a parent (or, for that matter, who was once a child) knows, having any conversation about sex with a child is a difficult, sensitive issue. And although in the UK, children have typically received some basic sex education by early puberty, this tends to combine basic education about the facts of life (a sperm and an egg make a baby) with information about puberty, and possibly contraception.

The conclusion, quite rightly, is that fertility needs to be understood in general terms but that decisions about it are the province of adults. As such, when trans youth consider blockers we need to be careful to minimise developmental disruption alongside gender-affirming intervention. For instance, trying to impose on an early adolescent youth that they need to be thinking about whether they want children or not now, or that their decisions now will rule out the possibility of a genetically-related baby, places a heavy burden on them that is more likely to pressure them into a poorly-informed decision.

Ehrensaft and Hastings emphasise that although disruption cannot be avoided entirely, only minimised, it still outweighs the risks of non-intervention. For instance, a trans youth who is ill-informed or feels pressured by questions of fertility may be discouraged from using blockers to provide continuity of gender-affirmation, or may experience further complications from gender dysphoria by delaying into the physiological changes and emotional stresses of later puberty.

 

In all these cases the outcome for the trans youth are substantially worse: there is a 41% risk of suicidality in transgender individuals with a strong basis in gender dysphoria, and “very few people become suicidal about medical infertility, but many do about gender dysphoria”.

 

As part of their presentation they shared the experiences of Logan, a young trans man on blockers who had decided to undergo oocyte cryopreservation – freezing eggs to be matured at a later date. Logan removed his puberty blocking implant to enable an ovarian stimulation cycle while controlling estradiol production with letrozole, and although he experienced some features of endogenous puberty during the process – onset of menses, early breast development – his gender dysphoria was controlled by careful management of his estradiol levels and the support of a multidisciplinary team during the process. Asked about the process afterwards both Logan and his mother were satisfied with the decision and the outcomes and branded it a success story.

So how do we talk to young trans people about future fertility? A key issue is how we talk about sex vs reproduction. It’s important that young people considering blockers are able to make as informed a decision as possible regarding their options, but – particularly with younger individuals – frank conversations about sex are more likely to provoke confusion, or even revulsion.

Trans adolescents in particular may find relatively new physiological developments dysphoric and want to separate their understanding of sexual reproduction from their gender. This is particularly important to bear in mind if we consider that most trans youth will be going through this decision process with their parents/families. Even in a supportive family environment there may be pressure from family to make certain decisions (parents might want grandchildren, for instance), and trans youth might (entirely understandably!) feel reluctant to discuss matters of sex and sexuality in a family context.

We can progress by being clear without giving Too Much Information, and by clarifying the young person’s options both in and outside of a medical context. For instance, besides preservation strategies we can offer discussions of family structures beyond conventional ‘biological’ reproduction, and challenge what is considered ‘natural’. For instance, young trans people (and their families) who are concerned about future family options can consider adoption, surrogacy (in countries where this is legal), co-parenting, and other non-traditional means of creating a family. These may be particularly appealing to young people with a strong sense of LGBTQ+ community, following the map of the non-traditional ‘queer family’. As with the personal medical choices around fertility, it is important that trans youth understand that they will have options.

If we can achieve a standard of care that is fully informed of the choices around fertility for trans youth and have a model for approaching these discussions that minimises stress to the individual, we can substantially improve patient outcomes and ensure that all young people get the affirming journey that they deserve.

 

Photo by Christian Joudrey on Unsplash