In the UK, Children as young as three years of age are now being admitted to state medical clinics for “corrective treatment” of sex-role noncompliance, with the aim of upholding social norms of gender and to prevent the development of “visibly transgendered” adults. Such treatments involve administration of drugs which halt normal child development (“Puberty Blockers”) followed by the lifetime administration of cross-sex hormones, resulting in sterilization. In the US, the first federally-funded state eugenics program in over thirty years will be launched in Oregon on October 1, 2014, specifically targeting pre-pubertal children deemed by parents and providers to be “transgender”. Surgeons now routinely perform complete “Sexual Reassignment Surgeries”: removing the genitals and reproductive systems of children as young as sixteen.
The following are excerpts from an interview featured in this month’s issue of LGBT Health Journal, discussing the “Current Practice and Future Possibilities” of sterilized transgender children:
“Dr. Eyler: So there are treatments for trans adults who want to become parents. Would the two of you like to discuss the needs of transgender youth, particularly children who may not complete pubertal development in the natal sex, and possibilities for future fertility for them?
Dr. Pang: My experience has been only with postpubertal individuals. The youngest transgender person whom I have treated was 22 years old, so I do not have any experience with children who are either early postpubertal or prepubertal. I think that more transgender young people are becoming interested in potentially being parents. Last year, I was contacted by the mother of a transgender teenager, a 15-year-old transgender son. Her son is interested in fertility preservation; they had questions so I explained to them what it would involve. The technologies that I have to offer are useful only for postpubertal youth, such as someone his age, but I am sure that you, Anderson, might have ideas about how to help prepubertal children.
Dr. Clark: In the trans community, more and more trans youth are being treated at younger ages, such as at Dr. Norman Spack’s clinic at Children’s Hospital in Boston. Some gender variant children are treated with puberty suspending medications, GnRH analogs, similar to the treatment of children who are experiencing precocious puberty. This keeps them from going through the full puberty of the birth sex, spares them from developing secondary sex characteristics that are misaligned with their psychological gender, and gives them some time to mature.
Dr. Eyler: Cognitively and emotionally.
Dr. Clark: Yes, to be able to decide, when they get older, whether they want to medically transition. Some gender variant children are not actually transsexual or transgender as such, and will eventually decide to stop treatment and experience the puberty of the birth sex. Others, with the support of their parents and clinical team, find that they need cross-sex hormone treatments to proceed with the puberty that is aligned with their gender.
The Endocrine Society Guidelines1 support puberty-suppressing treatment beginning as early as Tanner (sexual maturity rating) stage 2, so this can precede significant hormonal and sexual development. Some adolescents, therefore, don’t develop the ability to produce viable gametes (eggs and sperm). Adolescent trans girls may lose fertility from estrogen treatment, even if they developed the ability to produce sperm before this was started. When they reach the age of majority, trans youth may also proceed with gender-affirming surgery that includes removal of the gonads.
For children and young adolescents, it is often the parents who are thinking about future reproductive capacity, because they would like the possibility of grandchildren, and because they are looking after the future interests of their children. When I speak at community conferences, they often come to ask about reproductive options for their children.
Dr. Eyler: Yes, and as a biologist, you are prepared to discuss the significance of the gametes not maturing and what future reproduction might involve.
Dr. Clark: Yes. The most applicable research has been performed on behalf of children who are treated for cancer and are rendered infertile. The Society for the Preservation of Fertility focuses on the needs of both postpubertal and prepubertal youth who may experience sterility from cancer treatments.
Techniques for cryopreservation of postpubertal ovarian cortex are showing a lot of promise. In the case of cancer patients, the ovarian cortex is transplanted back to the young woman after she undergoes chemotherapy and/or radiation treatment. Babies have been born through this technique.
Some trans boys receive puberty-suppressing treatment and never produce mature ovarian follicles that could be stimulated for harvest and cryopreservation of eggs. They therefore could not use the techniques that Samuel described earlier for transmen. If they later decide to have their ovaries removed as part of their transition, the ovarian cortex could be cryopreserved at that time. The desired use of the tissue would be to culture the ovarian fragments in vitro (outside the body) for maturation once the individual is ready to have children so that viable eggs could be produced and used for IVF. This technique has been used successfully with mouse ovaries.
Dr. Eyler: It should be technologically possible to use the same technique, or a similar technique, for humans.
Dr. Clark: I’m optimistic that it will eventually be used as a fertility preservation treatment for trans boys.
Dr. Eyler: Would a similar technique be available for preservation of fertility of trans girls?
Dr. Clark: Unfortunately, deriving mature sperm cells from cryopreserved testicular tissue is more complicated, so for trans girls, early collection of sperm for freezing is important when this is possible and future fertility is desired. There are case reports in the scientific literature documenting viable sperm collection from adolescents as young as 11 years of age.
Dr. Eyler: So it might be possible, for some trans girls, to collect sperm very early.
Dr. Clark: Yes, although the collection would need to take place prior to treatment with puberty-suppressing medications. The quantity of sperm collected from someone this young would likely be low and, for some individuals, may not be mature enough to fertilize an egg. But those sperm might be used with intracytoplasmic sperm injection (ICSI), a well-developed fertility treatment, once the individual is ready to have children. Even immature sperm cells, such as round spermatids, have been used during ICSI, although I believe that the success rate is lower than with mature sperm.
Dr. Pang: That procedure has been called ROSNI (or ROSI, for round spermatid injection), where precursors of mature sperm are injected directly into oocytes. This has been proposed as a treatment for men in whom mature sperm cannot be identified due to complete meiotic arrest, but it is still considered experimental. ICSI with mature sperm is commonly used and has a much better success rate.
Dr. Clark: In vitro development of immature cells into mature sperm is very difficult, but it has been done with mice. So in the future, that may become a fertility preservation technique for trans girls as well.
Dr. Eyler: Those techniques would be needed only for trans girls who were too young to produce viable sperm at the time of pubertal suppression. If a trans girl experienced male pubertal development that included spermatogenesis, which for some could be as early as 12 or 13 years, then the sperm could be cryopreserved without the need for advanced techniques. But it would be useful to have the more technically sophisticated options for youth for whom progression of puberty to that point really is not an option due to psychological or medical reasons.
Dr. Clark: Yes. The procedures I am describing would be for use in early puberty.
Dr. Eyler: But ICSI is available now. Could you describe this procedure in more detail?
Dr. Pang: ICSI is a procedure whereby a single sperm is picked up using a microscopic needle and injected directly into the human oocyte. That technology was developed in the early 1990s, and has been used successfully for over 20 years. It is used primarily in situations where infertility is associated with a severe male factor, usually involving very poor sperm motility or a very low sperm count. It is also used in situations of sperm dysfunction, where we discover, during a regular IVF cycle, that fertilization does not occur with the conventional insemination methods.
More and more people are doing ICSI electively with sperm that would otherwise fertilize eggs normally, to maximize the numbers of eggs that fertilize. When we do elective ICSI with normal sperm, the average fertilization rate is well over 90%. So it is a very good strategy to increase the number of eggs that fertilize.
Dr. Eyler: Retrieving eggs requires a surgical procedure every time, so a couple struggling with infertility would want to minimize the number of cycles they would need to do that.
Dr. Pang: Yes, by maximizing the number of eggs that fertilize so that they get the maximum number of embryos from each treatment cycle.
Dr. Eyler: As we are having this discussion, I am struck by the history of this subject. It was not all that long ago that lesbian couples with no infertility problems, simply needing donated sperm, were denied services on moral or religious grounds. At this point, lesbians without infertility problems are getting pregnant with donated sperm, and the type of work that you are describing is opening up additional options: Having one partner be the egg donor and the other partner carry the pregnancy, so that both have a biological relationship to the child, or maximizing fertility for lesbian and bisexual women who have infertility problems.
Efforts focused on finding options for male couples to have their own biological children have also had some reasonable success. At this point, some couples with a transgender partner are getting fertility services, and transgender youth who are not yet at the point of considering reproduction are beginning to have options for fertility preservation. Most of the trans children and trans teens are not thinking about fertility preservation because of their youth, so it is the parents who are inquiring about these services in many cases, and you are discussing options with them.
I am impressed by how far this field has come in just a couple of decades, both technically and politically.
Dr. Pang: I think it is really important to educate people about the treatments that are already available, though more will be developed in the future. I have been encouraging Greater Boston PFLAG (Parents and Friends of Lesbians and Gays) to set up educational seminars for parents of LGBT youth, so that they can learn about these options. One of the things that many parents grieve, when their child comes out to them as gay or transgender, is the loss of the possibility of having grandchildren from that child. That was what my mother said to me when I came out. And I have heard this from many, many gay men and some people who are transgender.
We need to let people know that that is no longer necessarily the case. For transgender individuals, it is particularly urgent, because the window of opportunity for fertility preservation will close if they have surgeries that remove the gonads, or take estrogen for a substantial period of time. Ovulation is more likely to resume if testosterone treatment is suspended than effective production of sperm is if estrogen treatment is suspended.
Dr. Clark: I think there is a strong need to educate the primary care physicians and other clinicians who work with trans people so that they can explain the options to them, because, when trans people are dealing with their transition, preserving their fertility may not be something that they are thinking about at that time. And we need to educate the therapists, who are sometimes the first people who are in contact with trans people when they start to consider transition.
Dr. Pang: It should be part of the counseling. We cannot count on the transgender children and teens to think about it, because, when they are going through the crisis of gender identity, the last thing on their minds is having children in the future. They have much more pressing issues to deal with.
Dr. Eyler: And for children and young teens, it’s sometimes not a developmentally appropriate concern, whether or not gender identity questions are present.”
“Dr. Eyler: What about future fertility preservation for transgender youth? Has there been any progress with insurance coverage for those services?
Dr. Pang: In the practice of fertility preservation for cancer, some insurance companies will provide coverage and some will not. Whether or not they will extrapolate coverage for fertility preservation for cancer patients to transgender individuals has not yet been determined.
Dr. Eyler: The medical necessity agreements [sic-GM] can certainly be made, but this remains an untested area. In the meantime, it might well be worth it to many families to pursue this independently.
Dr. Pang: Yes. My passion, if you will, at this point in time, is to get the word out to the LGBT communities that there are options available if people want to have genetically related children. More work needs to be done in terms of achieving equality in insurance benefits, but this is more likely to happen if people are aware that treatments exist and press the health insurance companies to cover them. The problem is that most people have no idea that these options are even possible for them.
Dr. Clark: I would also like to mention the practical and ethical aspects of fertility preservation for transgender youth, because I think that there is a need for people to give this the consideration it warrants. In these cases, it would usually be the parents of the children who would be initiating inquiries, coordinating care, and paying the uninsured costs. While the children are still minors, the parents would also have control over the preserved gametes, the ova and sperm, for use by the children at a later date.
Dr. Eyler: As the guardian of the minor child and his or her decision maker.
Dr. Clark: So what will happen to the gametes if those children grow up and choose not to have children? Can the parents use the gametes without the permission of their children, either before or after they reach the age of majority?
Dr. Eyler: One would hope that after the age of majority, the adult children would be in control of their own tissue products and their use, if any, and that the parents would not be allowed to make use of them while the child was still a minor.
Dr. Pang: Following the inquiry last year from the parent of the transgender son, our clinic revised our oocyte cryopreservation consent form to include signatures for guardians in the event that the patient is a minor. I need to check to see whether or not it addresses the question that you brought up; it may not. This is new ground for our profession, just as the other treatments were when they were first being done.
Dr. Eyler: Ethically and legally, minors do not consent to most medical procedures; they assent to treatment and the guardian consents on their behalf. Then, at the age of majority, they consent for themselves.
Dr. Pang: We may need to add a paragraph to this consent form stipulating that, when the child reaches the age of majority, he or she assumes ownership of his or her cryopreserved gametes, and that they will not be used before that time.
[Images added by me-GM]
Read more here:
Eyler A. Evan, Pang Samuel C., and Clark Anderson. LGBT Health. September 2014, 1(3): 151-156. doi:10.1089/lgbt.2014.0045.