The Equality and Human Rights Commission (EHRC) has threatened the NHS with legal action if access to fertility preservation services is not offered to transgender people awaiting gender reassignment treatments. The EHRC says that ‘outdated’ NHS policies discriminate against transgender people according to this report in the Observer.

Rebecca Hilsenrath, the chief executive of the EHRC, stated:

A choice between treatment for gender dysphoria and the chance to start a family is not a real choice.

This is an interesting time for the EHRC to suddenly emphasise ‘gender dysphoria’ just as the government is proposing to get rid of it for the purposes of gaining a Gender Recognition Certificate. The EHRC itself supports this change to a ‘demedicalised’ system of Self-ID according to their response to the Scottish consultation.

How can we square the circle and connect “demedicalisation” with the urgent need for fertility preservation rights? The EHRC must also be aware that ‘gender dysphoria’ is due to be removed from the ICD-11 and replaced with ‘gender incongruence’ – and moved from the ‘mental disorders’ section to a new section on ‘conditions related to sexual health’. How do we justify expensive NHS treatments for patients who are suffering neither a mental nor a physical disorder of any description?

As we move towards the ‘normal variation’ model of understanding gender identity (“some women have penises”) gender reassignment treatments may in the future be seen as a personal choice rather than as a necessary treatment for debilitating dysphoria, and the connection with NHS Health services becomes more tenuous. However, as transgender activism moves in one direction for adults, it is shooting along the opposite trajectory for children and young people, towards ever earlier prescribed medical intervention.

If we are to meet all the demands of the transgender lobby (and it seems that we must) it becomes an ethical imperative to establish fertility preservation rights for these young people, lest we are accused of being careless about children’s fertility. Previously, fertility preservation has been offered to children suffering life-threatening conditions such as cancer, before embarking on a course of chemotherapy. To justify the necessity of these procedures for children who identify as transgender we must establish that ‘gender-affirming’ treatment is equally as ‘life-saving’ as chemotherapy is for the child who is suffering with cancer.

Lui Asquith, spokesperson for the charity Mermaids, goes one step further, describing ‘gender affirming’ treatment as “often life-saving” whereas other treatments which may impact the fertility of children as merely “life-enhancing”.

Although the establishment of fertility preservation rights may soothe our collective conscience and look good on paper, in practice what actual difference does it make for children and young people?

Children may be started on puberty blockers at Tanner stage 2 of puberty, the age at which physical signs of puberty are beginning to be visible (pubic hair, breast buds etc) but reproductive development has not matured. Immature gonads cannot produce viable gametes (eggs or sperm) so fertility preservation options at this age (which may be as young as nine or ten) are experimental. Cryopreservation of ovarian tissue is an emerging technique which has resulted only in a very small number of live births worldwide but ovarian biopsy is not a routinely available treatment. Cryopreservation of testicular tissue is still at the research stage.

Semen harvesting is only possible from Tanner stage 3 of puberty when a male can ejaculate, although the sperm count may still be low. For a female, freezing eggs is only possible after menarche at Tanner stage 4. We don’t know what percentage of children who start blockers at Tanner stage 2 progress to cross-sex hormones, but we do know that overall the figure is over 90% at the Tavistock clinic.

However, it can still be claimed that the introduction of blockers at Tanner stage 2 does not sterilise children, because if they want their fertility to be preserved they can always go off blockers before progressing to cross-sex hormones: therefore technically we have not yet shut down their fertility options completely. In reality, puberty would take some time to recommence, possibly 6 months to a year, but of course it resumes at the stage the child was at when puberty was blocked. So the child must wait even longer for gonads to develop and reach full maturity, as explained here in an article in the British Medical Journal (Butler et al, 2018):

“Some young people, whose primary objective is to halt the pubertal progress, will choose to postpone the fertility preservation decision until older. If they want to preserve fertility after having started GnRHa, it may take 6 months or more for the reproductive axis to recover, and the reproductive capacity will only be the same as at the point of starting blocker treatment. The need to stop the GnRHa in itself may be a barrier to pursuing gamete harvesting for some young people as endogenous sex hormone effects will return, although temporarily”.

How many children on puberty blockers would take the option of halting treatment to allow their body the time to develop naturally according to the sex they were born, for long enough to be able to harvest eggs or sperm? How possible would it be for children in reality to start physically developing in the opposite direction to the sex they have been affirmed as, sometimes for years, at home and at school?

The rationale for blockers at the start of puberty is a prioritisation of cosmetic results over fertility preservation. From the same article:

This treatment is also requested in early pubertal children as a way to prevent the development of those unwanted bodily characteristics that may make ‘passing’ in the preferred sex difficult in later life (deep voice, facial hair and changes, breasts and so on) should this be their wish, and to render unnecessary certain surgical interventions such as mastectomy.

This is a treatment based on presumed persistence. From affirmation to social transition to blockers at Tanner stage 2, we are stacking up the odds against desistance and placing persistence as the natural default. Not only are we withholding psychotherapeutic support to help a child manage their dysphoria without medical intervention, we are treating a mind-body split as the normal state and facilitating its progression.

So what does the research say about the take-up of fertility preservation options among adolescents who have reached a late enough stage of puberty to be eligible for this treatment? All published studies show that take-up is very low, despite fertility counseling prior to initiation of hormone therapy.

In this 2016 study a retrospective review was conducted at a single large pediatric academic centre of patients referred to Pediatric Endocrinology for hormone therapy over the period January 2014 to August 2016. All patients had been diagnosed with gender dysphoria by a child psychiatrist. Of 73 patients (50 natal females and 23 natal males) only 2 subjects attempted fertility preservation, both natal males. One produced a sample with low volume and no viable sperm at age 13 and the other produced a sample with viable sperm that was banked at age 15.

Of the young people studied, 92.3% had one or more of the following psychiatric diagnoses (past or current): major depressive disorder, bipolar, generalized anxiety disorder, social anxiety, and/or post-traumatic stress disorder.

Out of 73 subjects, 15 were noted to have been adopted or living in foster care (20.5%).

The authors of the study comment:

Of note, in prior adult studies, 51% of transgender females would have considered sperm banking if it had been offered; 54% of transgender men reported a desire for children, and 37.5% would have considered freezing germ cells had it been offered.

And they note:

This discrepancy between our findings and these studies raises a question as to whether these transgender youth may change their perspectives about FP later in life, particularly after transitioning to their affirmed gender.

In other words, teenagers are too young to really understand the consequences of the decision they are making, nor the possibility that they may change their minds in the future.

Notably, nearly one-fourth of the subjects with a documented reason for declining FP stated that they “never wanted to have children.” This was noted more frequently in those identifying as female, which is interesting and a topic for further investigation. Despite the fact that youth in general may have difficulty envisioning future parenthood, it is uncommon to see reports of adolescents in other populations commenting that they know they “do not ever want to have children.”

A further 45.2% of subjects mentioned that they were considering/planning to adopt. These statistics are hardly surprising. The importance of fertility is routinely minimised in comparison to the message that is pushed onto young people (and their parents) that medical transition is crucial to save their lives. Teenagers don’t think of the future, they are not equipped to make benefit and risk calculations, particularly not the vulnerable teens typically presenting at gender clinics now. From the study again:

A number of hypotheses for the low FP utilization rates in transgender youth can and should be prioritized for future research. These may include the impact on decision-making of the mental health morbidities reported in our cohort and in other studies, such as low self-esteem, depression, self-harm, and suicidality. All of these factors can be linked to a sense of a foreshortened future and hopelessness regarding potential for adult happiness and family satisfaction. Finally, some youth presenting in gender clinics may feel an urgency to obtain hormonal intervention to reduce gender dysphoria, and these feelings may override other considerations.

A 2017 report from Lurie Children’s Hospital of Chicago, published in the Journal of Adolescent Health, reflected similar findings. A retrospective chart review of all patients initiating hormones with the Gender & Sex Development Program between July 2013 and July 2016 found that out of 105 transgender adolescents, 13 (12%) saw a fertility specialist for formal consultation and only five (less than 5%) underwent fertility preservation.

“In our study, transgender youth decided to pursue fertility preservation at much lower rates than we would have expected from research on reproductive desires of transgender adults, which suggests that about half want biological children and over a third would have considered preserving their fertility if techniques had been available and offered to them,” said lead author Diane Chen, PhD, a pediatric psychologist with the Gender & Sex Development Program at Lurie Children’s Hospital.

Chen and colleagues identified the major barriers to fertility preservation in transgender youth between the ages of 14 and 20 as cost, invasiveness of procedures and reluctance to delay initiating hormone therapy for medical transition.

In a recent study of 66 young people (63% natal female, average age 16) receiving hormone treatment at the Children’s Hospital of Philadelphia’s Gender and Sexuality Development Clinic in Canada, 20% found it important to have biologic offspring, but only 4.5% reported that they would be willing to delay hormone treatment to undergo fertility preservation.

This study earlier this year from the University of Virginia School of Medicine reviewed a total of 52 patients, 23 natal male and 29 natal female, age 8 – 27 years, over the period Jan 2010 – Dec 2016 and found that there were only 7 (13.5%) referrals for fertility preservation (1 natal female, 6 natal males).

‘Fertility preservation’ may sound like a simple solution to the risk to fertility of hormone treatments but in reality the procedure is by no means an easy option. From the Butler et al article above:

Phenotypic males are counselled about semen harvesting, The dysphoria however may be too extreme to consider semen collection by masturbation. Electroejaculation may then be helpful.

For females the procedure is more prolonged and complicated. From the 2017 report above:

Not surprisingly, procedure invasiveness was a frequent concern for transgender men, who are assigned female at birth and identify as male. They often experience significant body dysphoria that can be exacerbated by fertility preservation procedures,” said Chen. Fertility preservation for transgender men requires 10-14 days of daily hormone injections, monitoring via transvaginal ultrasounds, and oocyte (egg) retrieval using ultrasound-guided transvaginal aspiration of follicular fluid.

Women who have undergone this process of egg extraction by hyper-stimulation of the ovaries describe it as ‘torture’. These are procedures you would not want to put a child through unless it’s their one shot at preserving fertility because of their need for crucial life-saving treatment.

Anyone who has gone through IVF treatment knows of the inherent uncertainty of the procedure and that a positive result is not a foregone conclusion. One doctor who has seen the results in young people who have undergone medical transition is Professor Robert Winston who spoke about his concerns on the BBC Radio 4 Today programme last year, subsequently quoted in a Telegraph article:

“What I’ve been seeing in a fertility clinic are the long-term results of often very unhappy people who now feel quite badly damaged. “One has to consider when you’re doing any kind of medicine where you’re trying to do good not harm, and looking at the long-term effects of what you might be doing, and for me that is really a very important warning sign.” He added that the long-term effects of taking hormones “are likely to affect reproductive function”. He also warned that the public did not understand that egg freezing was often “extremely unsuccessful”. He added: “With freezing of sperm, there’s no question that freezing does damage sperm, and it makes less fertility and there’s a large number of people who have frozen sperm samples who never actually achieve a pregnancy after that freezing.

Added to all this is the fact that a growing number of areas in England have cut NHS IVF treatment services altogether, as reported by the Guardian recently:

A growing number of areas in England have axed IVF treatment on the NHS and the proportion offering the recommended three cycles of treatment has fallen to just over one in 10, the Guardian can reveal. Experts said patients now face a postcode lottery of services, with some families even moving across the country to find an area that offers three IVF treatment cycles. Others are travelling abroad for treatment.

Looking at that statement from Rebecca Hilsenrath again it starts to sound a bit hollow in regard to children:

A choice between treatment for gender dysphoria and the chance to start a family is not a real choice.

What real chance do these children and young people have of starting a family by having their own biological children? The odds are increasingly stacked against them as ‘affirmation’ replaces true diagnosis by elimination of underlying causes of dysphoria (such as pre-existing mental health disorders) and there is no option of a non-medical treatment pathway offered.

All children and young people undergoing treatment which will impact on their fertility deserve access to fertility preservation options as a matter of course. This does not absolve us of the responsibility of prioritising non-invasive treatments which don’t sterilise children in the first place, nor the responsibility for rigorous diagnostic assessment. Instead, activists have effectively shut down any real options for psychotherapeutic support which may help a child manage dysphoria without transition, by painting it as ‘conversion therapy’.

To grow up with fertility intact is a basic human right. Sterility is a risk we take with children only when there is no alternative. The campaigning by political activists for affirmation and medical transition is what needs investigation if the EHRC is truly concerned about children’s future right to start their own families. Otherwise it looks as if we as a society really are careless about the possible sterilisation of our most vulnerable and troubled young people.

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