Pediatric Fertility Preservation for Hormone Suppression in Transgender Youth

Last week, I received an e-mail update on current research and treatment being performed at the institution where I did my residency training. One of the interesting research areas was in the discipline of pediatric fertility preservation. Pediatric patients who undergo cancer treatments often take medications which cause destruction of their testicles or ovaries, not uncommonly resulting in infertility problems when the patient reaches adulthood. Advances in cryopreservation techniques of reproductive tissues are offered as a solution to preserving one’s fertility after pediatric cancer treatment.

The cryopreservation technique in the pediatric population is not limited to cancer treatment. There have been advances in providing fertility to non-cancer medical conditions that previously caused infertility. Two such conditions are Klinefelter syndrome and Turner syndrome which affects sex chromosome anomalies male and female patients, frequently resulting in infertility problems in those patients. By cryopreserving these patient’s testicular or ovarian tissue when they are children, when the number of the reproductive cells are in larger number and/or have the best potential for future reproductive function, in vitro fertilization techniques using these preserved cells when these patients reach adulthood can improve fertility.

The same pediatric fertility preservation treatment is now being offered prior to the hormone medication used to assist pediatric transgender youth transition from their birth sex to the opposite gender. Hormone treatments are used to intentionally suppress the transitioning person’s natural sex hormone production. This causes body habitus transformation to the desired gender. Continuous hormone suppression severely reduces (and can eliminate) baseline anatomic testicular or ovarian function causing permanent infertility in the transitioning patient. There is additional concern that the infertility persists even if that hormone treatment is later discontinued. Limited data exists to make conclusive statements on this subject as studies on long-term physiologic effects of hormone treatment used to transition pediatric patients are lacking; this is true even in the adult population where the number of patients who have transitioned is much larger.

Bioethically, we have moved beyond the question of whether we should be doing hormone suppression to assist in gender transitioning in the pediatric population and begun to discuss whether that child’s fertility ought to be preserved following such hormone administration. A simple Google search for non-hormone treatment of gender dysphoria in the pediatric population shows mostly hormone-based treatments for the first pages of results. With more effort, non-hormone options can be found.

The Mayo Clinic update that I received describes the transgender fertility preservation treatment along with a constellation of other pediatric medical conditions whose treatments potentially cause infertility (i.e. the cancer chemotherapy treatment causing infertility described earlier) as if all of these programs should be considered medically (and ethically) equivalent.

Are they?

If they are not, shouldn’t we be debating the medical and ethical pros and cons of pediatric transgender hormone administration more thoroughly before we consider how (and why) to preserve the very fertility of the pediatric patients we are altering by intentional hormone suppression?

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