Fertility Desires and Reproductive Needs of Transgender People

Challenges and Considerations for Clinical Practice

Eva Feigerlová; Véronique Pascal; Marie-Odile Ganne-Devonec; Marc Klein; Bruno Guerci

Disclosures

Clin Endocrinol. 2019;91(1):10-21. 

In This Article

Abstract and Introduction

Abstract

The majority of transgender and gender nonconforming persons seeking medical care are of reproductive age. Hormonal treatment and sex reassignment surgery, which are used in the management of gender dysphoria, compromise fertility potential. Children and adolescents with gender dysphoria have specific treatment regimens starting with puberty-blocking medications. According to international guidelines, fertility preservation should be discussed before any hormonal treatment, although our knowledge on the reproductive needs of transgender and gender nonconforming persons is limited. Recently, some data have emerged on fertility management in some centres for the adult population with gender dysphoria. The goal of this review was to summarize the available evidence on the fertility desires and parental roles of transgender and gender nonconforming people. In light of newly emerging societal challenges, we aim to provide some considerations for clinical practice and suggest further areas of research.

Introduction

Gender dysphoria is characterized by a persistent incongruence between an experienced gender and the assigned sex of an individual at birth.[1,2] A transgender person presents a strong desire to modify her or his appearance and express themselves through dress and/or hormones and/or surgical procedures to be consistent with her or his gender identity. A transgender male is assigned as female at birth but self-identifies as a male. A transgender female is assigned as male at birth but self-identifies as a female. When self-identified gender identity does not fit the male/female dichotomy, the term a nonbinary gender identity is employed.

The literature data show the social and health disparities experienced by transgender people, including social harassment and discrimination, abandonment by family or friends, and poor access to health care.[3–5] Gender-affirming treatment has been shown to decrease the psychological suffering and psychiatric morbidity of transgender persons, such as self-harming behaviours, depressive symptoms and suicidal ideas.[6,7] Gender transition is a period characterized by physical, psychological, emotional and socio-cultural changes; these changes are highly variable from person to person. Whereas many transgender people will desire to start hormonal therapy followed by gender reassignment surgery, not all transgender people do. A role of the medical team is to provide support and supervised follow-up.[8,9] The care of transgender and gender nonconforming persons requires monitoring and treatment strategies that are not familiar to most health practitioners, as little training is provided at present.[10,11]

The majority of gender nonconforming people seeking medical care are of pubertal and reproductive age. Cross-sex hormones may compromise fertility, especially when preceded by a puberty-blocking regimen.[12] Transgender and gender nonconforming people express the desire for fertility preservation,[13–15] and these individuals therefore have families and raise children.[3,4] Nevertheless, our current understanding of the experiences and needs of transgender parents and their children is insufficient.[16,17]

Respect for the autonomy of an individual to decide whether to become a parent or not is among the central principles in reproductive ethics. Reproductive rights were formally stated by the 1968 Final Act of the Tehran Conference on Human Rights.[18] Universal access to reproductive health is among the goals of the Millennium Declaration 2000 and the World Summit 2005 of the United Nations.[19] Based on these principles, the same rights to sexual and reproductive health should be guaranteed to transgender persons.[20] According to the statement of the Ethics Committee of the American Society for Reproductive Medicine,[21] the Endocrine Society Guidelines[22] and the guidelines of the World Professional Association of Transgender Health,[23] fertility preservation should be discussed before any hormonal treatment. Recently, some data have emerged on fertility management in several centres for the population of adults with gender dysphoria.[24,25] However, there are some concerns regarding potential medical risks. Little is known about the consequences of the psychosocial development of the child, the health of surrogate mothers and society. It can be challenging for a healthcare team to approach these situations in everyday practice.

Here, we will address the questions regarding the effects of cross-sex hormonal treatment on fertility and discuss the available evidence on the fertility desires and parental roles of transgender and gender nonconforming people.

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