Update on bioethical, medical and fertility issues in gender incongruence during transition age

Abstract

Purpose Many issues still remain unresolved in the management of pubertal patients with gender incongruence (GI). The aim of this review is to discuss the main aspects of the treatment of these patients to provide a practical approach for clinicians. Methods A comprehensive literature search within PubMed was performed to provide updates of available evidence regarding the impact on bioethical, medical and fertility issues in gender incongruence during transition age. Results Gender Affirming Hormone Treatment (GAHT) and Gender Affirming Surgery (GAS) can induce unsatisfaction with change, future regrets, and the risk of infertility. This raises ethical issues especially in the management of pubertal patients that remain unresolved. Therapy with GnRH analogues (GnRHa) is intended to delay puberty, so as to give the adolescent a longer period of time to decide whether to continue with the treatments. At the level of physical changes, this therapy may have an effect on bone mineralization and body composition; however, long-term longitudinal data are not yet available. An important feature related to the use of GnRHa is the risk of fertility. Gamete cryopreservation is the most established method of fertility preservation (FP) and should be counselled to transgender adolescents. However, these patients are not always interested in having biological children. Conclusion Based on the current evidence, there is a need to conduct further research to clarify certain issues and to standardize clinical practice and improve counselling in transgender adolescent decision making and avoid regrets in the future.

Fertility Preservation Options for Transgender Patients: An Overview

“…While the characteristics of transgender women's semen specimens may not be optimal [16], there is evidence that such samples can, nevertheless, be used to initiate conception [17,18]. Transgender individuals face unique challenges with sperm quality: transgender women taking hormone therapy have been observed to have significantly altered sperm parameters, which may persist for months after treatment discontinuation [19]. Even individuals not taking hormones may experience difficulty: genital tucking and/or wearing tight undergarments is common among transgender women, and these practices negatively impact sperm quality due to increased heat stress and greater production of reactive oxygen species [20,21].…”

Medical care for children and adolescents with gender dysphoria and gender inconsistency in the light of current recommendations - how to implement the "primum non nocere" principle?

“…The need for further studies assessing the effects of gender-affirming hormone administration on physical and mental health of transgender patients is underlined even by advocates of these therapies (Coleman et al 2022;Salas-Humara et al, 2019). In a very recent paper, Conflitti, Spaziani, Pallotti, Tarsitano, Di Nisio at al. (2023) have pointed at the risk of unsatisfaction with the results of changes and future regrets related to gender-affirming hormone treatment and surgery, especially in the context of the lost fertility.…”