Our Ethical Obligation to Provide Comprehensive Fertility Information to Transgender Patients Beginning Hormone Therapy


Carolyn Baker Ringel, JD, MBE

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Our Ethical Obligation to Provide Comprehensive Fertility Information to Transgender Patients Beginning Hormone Therapy
Topic(s): Clinical Ethics LGBTQ ethics

When my son was 18, he decided to start hormone therapy as part of the process of transitioning from female to male. I was under the impression that such a decision would permanently impact his fertility, and I asked him to freeze his eggs so that if he wanted to have biological children in the future, he might still have that option. He pretended to consider it and like many teenagers, proceeded to do what he wanted.

The reality is I am not a doctor, and my information wasn’t even correct. As a candidate for a master’s degree in bioethics, I looked at the issue of whether, how much, and what kind of information doctors who treat transgender patients were giving them about how hormone therapy could affect their fertility. What I found was an alarming nest of inconsistencies. The World Professional Association for Transgender Health (WPATH), in its manual of recommended standards of care for transgender individuals, considers it imperative that transgender patients be informed regarding options for fertility preservation. However, based on conversations I had with doctors treating transgender patients in Massachusetts and New York, it became clear that some doctors abided very strictly by this recommendation while others considered fertility preservation to be an optional consultation. I argue that doctors treating trans patients have an ethical obligation to inform in the same way they do all other patients what effects of hormone therapy have on fertility.

This statement is easier said than done, as the science in this area is ever-evolving. Many clinical guidelines assume hormone therapy will result in a loss of fertility when determining whether a clinician should discuss fertility preservation before starting a patient on hormones. Trans male patients who are actively taking testosterone generally experience amenorrhea, and trans female patients actively taking estrogen have smaller testes and reduced sexual function. Therefore, injecting hormones may have an impact on a transgender person’s ability to conceive or bear a child.

However, research does not necessarily bear this conclusion out. Treatment in transgender men seems to have a reversible effect on ovulation once hormone treatment is suspended. One study of the effects of testosterone treatment on live births found that 84% of the transgender men in the study could conceive using their own eggs, and another study found that transgender men who paused hormone therapy for four months were able to produce the same number of eggs for IVF as cisgender patients. A recently published study showed that doctors were able to retrieve eggs from transgender men who did not stop taking testosterone during the egg retrieval process.  It is less clear the effect that estrogen treatment has on future sperm quality and production, and some studies have indicated that estrogen treatment results in a diminution of sperm quality and production. There is evidence that a technique called “extended sperm search and microfreeze” can be helpful for sperm retrieval, but it is still uncertain how likely it is that this will produce a viable pregnancy. Thus, it seems that the effects of hormone therapy on fertility are likely reversible for transgender men, while we cannot necessarily draw the same conclusion for transgender women. Finally, experimental treatments such as testicular tissue cryopreservation and ovarian tissue cryopreservation may provide yet more options for both groups in the future. However, all these interventions need to be studied more for any definitive statements to be made about the impact of hormone treatments on the ability of a trans person to conceive a biological child. It may be problematic to argue that there is one clear message that can be transmitted regarding the impact of hormone therapy on fertility.

The second big question when stating all patients need to be informed is, what does it even mean to be informed? Informed consent is a linchpin of modern bioethics. Patients have a right to decide what is best for their medical health, and to make that choice, patients must have complete information about the choice they are facing.

Beauchamp and Childress lay out a seven-part definition of what constitutes informed consent. Two components of Beauchamp and Childress’s definition that are particularly relevant to this project are the requirements of disclosure and understanding.  Disclosure typically refers to the information given to the patient, and understanding refers to whether the patient comprehended what that information meant. In much of the literature and court decisions surrounding informed consent, what has remained undefined is how much disclosure and how much understanding is required for consent to be considered informed. On the one hand, a patient should be informed of all the ramifications of a procedure or medication before making a decision about whether he wants to proceed. On the other hand, if a consent form is too long and detailed, it is possible the patient will not be able to digest all of the information and actually will be less informed than if the form were simpler and contained less information. Doctors giving information to transgender patients need to be careful to give the “right” amount of information so that patients can make an informed choice, a tricky task given the discussion of the evolving nature of the science, above. 

Fertility preservation for transgender patients is a complicated topic with a lot of uncertainty both as to what message to deliver to these patients and how to deliver that message. Moreover,  in today’s political climate, there may be an understandable wariness on the part of doctors to be perceived as adding obstacles to care for patients who may be suffering. But none of these reasonable concerns is a reason to withhold relevant medical information from patients. It is expected that doctors will give patients full information about the side effects of any medication they prescribe. It is, in fact, a sign of respect for the ability of transgender patients to make informed decisions about their own bodies to do the same here.

Acknowledgement of input from:
David A. Diamond, MD, University of Rochester; David Sontag, JD, Beth Israel Lahey Health

Carolyn Baker Ringel, JD, MBE is a Faculty Assistant at the Center for Bioethics, Harvard Medical School.

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