July 6, 2022

The ethics of transgender fertility

This month’s issue of LGBT Health contains a fascinating interview with two Boston fertility specialists who cater for gays and lesbians who want to become parents.

This month’s issue of LGBT Health contains a fascinating interview with two Boston fertility specialists who cater for gays and lesbians who want to become parents. Dr Samuel Pang, one of the first doctors to help gays have biological children through gestational surrogacy, says that his passion “is to get the word out to the LGBT communities that there are options available if people want to have genetically related children”.

Perhaps the most controversial aspect of their work is provisions for the fertility of boys and girls who are transitioning to the opposite sex. “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,” says Dr Anderson Clark, a reproductive biologist.

The problem is that puberty-suppressing treatment also impairs the children’s reproductive capacity. “Some trans boys (ie, girls) receive puberty-suppressing treatment and never produce mature ovarian follicles that could be stimulated for harvest and cryopreservation of eggs,” says Dr Clark. And the problem is accentuated with trans girls (ie, boys) because their spermatozoa are still developing. However, it has been done on individuals as young as 11. “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,” says Dr Clark.

And the interviewer, Dr Evan Eyler, of the University of Vermont, remarks on the progress which has been made in the past 20 years:

“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.”

However, there are still ethical issues. The weightiest is the doctor’s responsibility for the fertility of young trans patients. “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,” says Dr Pang.

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