The fertility of transgender youths in Texas was thrust into the spotlight recently after state leaders issued a directive designating gender-affirming care as child abuse that infringed on a person’s “fundamental right to procreation.”
Medical interventions for transgender adolescents can have an impact on a person’s short- and long-term fertility.
But trans health experts say it’s a nuanced issue: New research into the preservation of fertility is opening doors for trans patients who may want to have biological children in the future.
State leaders have gone too far by prioritizing future fertility over the current health concerns caused by gender dysphoria, said Renee Baker, a professional counselor in Dallas who specializes in LGBT-specific care.
“It’s almost like you’re saying the life of an unborn possibility is more important than the existing life” of a transgender adolescent, she said.
Puberty can be a particularly scarring experience for trans youth. The body changes in a way that doesn’t align with a person’s gender identity, which can increase risk of mental distress or even suicide, experts say.
More than half of transgender youth seriously considered suicide in 2020, according to a 2021 national survey by the Trevor Project, a suicide prevention organization for LGBTQ youth.
Gender-affirming medical treatments, like puberty suppressants and hormone therapies, can temporarily pause puberty or initiate a puberty consistent with a person’s gender identity. In an analysis of a survey of more than 27,000 trans adults, Stanford University School of Medicine researchers found that starting hormone treatment during adolescence is linked to better mental health than waiting until adulthood.
The American Medical Association, American Psychiatric Association and American Academy of Pediatrics all support providing age-appropriate care, including medical treatments, for children experiencing gender dysphoria.
Texas Attorney General Ken Paxton said in his opinion that the critical question at stake is whether facilitating or conducting “medical procedures and treatments that could permanently deprive minor children of their constitutional right to procreate, or impair their right to procreate, before those children have the legal capacity to consent to those procedures and treatments, constitutes child abuse.”
Best practice states that gender-affirming surgeries should not be performed until a person has reached the legal age of maturity to consent to medical procedures.
Consideration of a trans adolescent’s ability to have children in the future has been a critical part of proper trans health care, medical experts say. Scientists are still researching the potential impact of gender-affirming medical care on fertility, and they say more data is needed to fully understand its implications.
“It is essential that a thorough discussion of fertility preservation and the options available are provided. Not to do that would be malpractice,” said Dr. Stephen Rosenthal, medical director of the child and adolescent gender center for the University of California, San Francisco Benioff Children’s Hospitals.
Patients and their families have to give informed consent, meaning that they’ve been given information about all the potential risks and benefits of a treatment before deciding whether to pursue it, Baker said.
Gender-affirming medical treatments can alter a person’s fertility, depending on when the treatments are initiated and whether they are continued. Such treatments are not started until a person has begun puberty. Puberty varies by person, but it can start as early as age 8 for people assigned female at birth and age 9 for people assigned male at birth, according to the Cleveland Clinic.
Most parents don’t anticipate discussing fertility preservation with their teenager. Most parents also don’t anticipate having to balance a transgender adolescent’s need for gender-affirming care with any potential risks to their future fertility.
“If you say that, ‘I’m not going to let you have access to pubertal blockers until you’re older, until you’ve gone through full puberty,’ well then [the adolescent] would experience all of these irreversible physical changes that can increase their risk for severe mental health problems, including suicide attempts,” Rosenthal said.
There are some options for transgender adolescents who want the opportunity to have biological children down the road, although those options look different for each case.
Puberty suppressants
Puberty suppressants are drugs that cause a temporary pause in a person’s puberty by blocking sex hormones, like testosterone and estrogen. The treatment was originally created outside the transgender health care setting to treat kids going through puberty at a very young age.
These drugs offer adolescents with gender dysphoria the opportunity to further explore their gender identity without the sometimes distressing effects associated with going through a puberty that doesn’t match how they identify.
They’re fully reversible, meaning that once someone stops taking them, their puberty will continue as normal. If someone chooses to come off puberty suppressants, “there is zero evidence that there would be any compromise in fertility,” Rosenthal said.
For adolescents in the later stages of puberty who have fully developed eggs and sperm, those cells can be extracted before the start of medical treatment and frozen to potentially be used at a later date.
The process of fertility preservation is trickier for adolescents who are in early puberty. But scientists are working on ways to create mature sex cells without causing someone to go through the full puberty process.
In 2019, a report published in the New England Journal of Medicine described a person assigned female at birth who, still in the early stages of puberty, was put on puberty suppressants. While the patient was still on the puberty suppressant, scientists were able to stimulate the person’s ovaries to create mature cells that were retrieved and frozen for future use.
“That is a very exciting advance, demonstrating that, in people with ovaries who go on puberty blockers before they would have otherwise reached a level of reproductive capability, there now is a very distinct possibility of being able to preserve their fertility while still being able to treat their gender dysphoria,” Rosenthal said.
There are no nonexperimental fertility preservation options for people assigned male at birth early in puberty, said Dr. Evelyn Mok-Lin, reproductive endocrinologist and infertility specialist at University of California, San Francisco Health.
Experts are studying ways to use biopsied testicular tissue from adolescents in early puberty to undergo maturation in a laboratory with the intention of generating mature sperm. “But it’s very much experimental,” Mok-Lin said.
Hormone therapy
During treatment, adolescents and their doctors may discuss beginning hormone therapy, which involves administering estrogen or testosterone to trigger a puberty that aligns with a person’s gender identity.
Hormone therapy in adolescents is started after a person’s gender identity stays consistent while on puberty suppressants.
While puberty suppressants simply pause puberty, hormone therapy can cause temporary or permanent changes to the body. Some changes, like the development of breasts caused by estrogen, may need reconstructive surgery to reverse, while other changes, like a deepening of the voice caused by testosterone, are not reversible.
Scientists don’t know how much, if at all, the treatment impacts a person’s fertility.
“We know that people who have been on [testosterone] can get pregnant and have gotten pregnant,” Mok-Lin said. “And when they do, their pregnancies and their babies are at no higher risk than anybody else, so that’s reassuring.”
Because scientists don’t know how many people previously on testosterone have tried to get pregnant, they can’t determine what the actual fertility rate is.
Testosterone probably doesn’t affect the quantity of eggs a person produces, Mok-Lin said, “but we don’t know what it does to the quality of the eggs.”
Researchers are increasingly studying how gender-affirming medical treatments impact fertility and what options there are for transgender patients pursuing fertility preservation.
“You might find 15 years from now when [patients] want to have kids that they just have to stop their testosterone and they’re fine. I mean, we have no idea that this will have any impact,” Mok-Lin said. “But until we have more data, we should have some backup options.”
