Access to fertility preservation

Arguments for and against the right to access fertility preservation are presented in the literature. However, there is consensus that fertility preservation should not be denied solely due to gender identity.5 7 12 16 27 36–40 The Ethics Committee of the American Society for Reproductive Medicine affirm that “transgender identity/status by itself should not automatically bar a person from accessing fertility preservation” (p1114).39 Similarly, various authors argue for equity of access to fertility preservation services, specifically that transgender individuals deserve access to such services equal to that of others experiencing infertility.16 36 39 While there is consensus that access to fertility preservation should not be denied on the basis of transgender identity, the literature provides three different justifications for this position, described below.

First, a transgender young person’s right to access fertility preservation is justified by some authors on the basis of bodily autonomy or the child’s right to an open future.6 8 12 16 17 28 41 Clark and Virani note that “trans youth have the right to bodily autonomy, which includes decisions about… reproductive care” (p298).17 Quinn et al. highlight that “there is established support for fertility preservation for minors because it will ensure them an open future (that is, the possibility for biological children)” (p263).6 However, Clark and Virani argue that “it is not possible to preserve all open futures for all [transgender] youth. Therefore, caution must be exercised in privileging one future over another, as the harms caused by holding a particular future open may be significant” (p297).17

Second, possible harms to the transgender child or young person are considered as potential arguments against offering fertility preservation.5 7 12 16 27 36 39 40 While medical risks inherent to the fertility preservation process are noted, authors suggest these risks are negligible and could be addressed through the informed consent process.12 16 27 39 Saraf and Nahata argue that while “the fertility preservation procedure itself… may potentially cause harm… Detailed discussions should occur with patients and families about potential risks vs benefits” (p318).27 Authors also identify the potential for social stigma and discrimination following fertility preservation as significant risks for transgender young people.16 40 De Wert et al. support that “risks [from fertility preservation] for applicants themselves are primarily social… transsexual parenthood may meet severe criticism and opposition” (p1861).16 However, Murphy argues that “given the vast array of parent–child relationships… it is unlikely that anyone could show that [transgender parenthood] ought to be prohibited because it poses harms to parents” (p314).7 Authors thus consider current and future risks associated with fertility preservation for this group, but overall suggest that these risks could be mitigated and/or do not justify denying access.

Third, the potential harm to future offspring resulting from transgender parenthood is acknowledged in the literature as a possible objection to enabling access to fertility preservation.3 5 7 16 37–39 41 42 Some authors note this harm may arise from discrimination towards the future offspring due to their parent’s transgender identity.16 37–39 42 De Roo et al. confirm this, stating “that a child having a transgender parent may experience more transient and mild harassment than those who do not have a transgender parent” (p117).42 De Sutter additionally cites concerns around the transgender identity of the parent potentially influencing the gender identity of the future offspring.37 While Hudson et al. suggest the transgender identity of a parent is not inherently harmful,5 Murphy argues that, “in reproductive liberty, there is enough leeway for transgender parents to have children, even if there were some kind of undesirable outcome as a result” (p314).7 The literature does not support denying access to fertility preservation for transgender young people as a result of the potential harms to the transgender person themselves or their future offspring.

Alongside arguments for and against the right to access fertility preservation, the potential for fertility preservation to be financially prohibitive is noted in the literature.5 6 8 12 27 28 40 43 44 Hudson et al. state that cost may present a “significant [obstacle] to fertility preservation for transgender adolescents” (p89).5 Financial barriers to accessing fertility preservation are recognised as an issue of reproductive justice.8 Tishelman et al. highlight the need for further guidance around counselling families without the financial resources for fertility preservation.45

Conscientious objection

The literature explores the issue of conscientious objection among health professionals in relation to fertility preservation for transgender young people.16 The American Medical Association states that physicians in public settings cannot object to treating patients on the basis of gender identity as this violates their greater duty to treat all individuals equally.39 Despite this obligation, authors note that the personal beliefs of physicians may still act as a barrier to fertility preservation services.39 40 43 Mitu argues that “if clinicians believe that transpeople are unfit for parenting and should not be allowed to reproduce, this might prevent transpatients’ access to relevant information about fertility preservation” (p1122).40

While some authors suggest that a physician’s ethical entitlement to conscientiously object is outweighed by a greater duty of care, others suggest that conscientious objections should be respected. In contrast to the views of the American Medical Association, De Wert et al. argue that physicians’ conscientious objections should be respected and that these physicians are obligated to refer patients to another clinic known not to hold such an objection.16 The ethical obligation to refer patients to alternate clinics is also recognised when providers lack sufficient resources to provide age-appropriate fertility preservation and/or counselling.5 39 These resources include training related to the provision of fertility services to young transgender people.5 39 Inadequate training is associated with provider discomfort and embarrassment which obstructs access to appropriate healthcare.5 8 39

Decision-making capacity of children and young people

In the included literature, age is highlighted as influencing the capacity of transgender young people to make fertility decisions. Many authors consider the circumstances in which a young person is able to consent or assent to medical procedures, including fertility preservation.3 5 8 11 16 28 44 46 47 Some authors also argue that fertility preservation decisions may be difficult for young people given their lack of concern about future fertility.8 28 37 40 Chen and Simons write that “transgender adolescents must consider desires for biological parenthood during a period in which thinking about family formation is developmentally non-normative” (p95).8 While determining decisional capacity can be complex, Nahata et al. note the discordance between allowing young people to make decisions about their transition but not participate in fertility-related choices, stating that “it would be hypocritical to deny [a transgender young person’s] decision to refuse [fertility preservation]” (p4).28

The literature highlights the potential effect of psychological comorbidities on a young person’s decisional capacity.5 8 28 Some authors argue that the urgency to transition created by gender dysphoria can compromise a young person’s decisional capacity.8 11 28 Several authors argue that transgender young people can be additionally deterred by the distressing and/or invasive nature of the preservation itself.3 5 8 12 17 28 Hudson et al. acknowledge that “the focus on parts and functions of the body typically associated with motherhood can heighten feelings of dysphoria” during fertility preservation for transgender men (p89).5 Authors also argue that other psychological or cognitive comorbidities can influence an individual’s ability to make fertility-related decisions.5 8 27 28

Roles in shared decision-making

Many authors acknowledge the ethical challenges that arise for providers from shared decision-making with the transgender young person’s parents, particularly when guardians and young people disagree.3 5 6 12 16 27 28 43 44 46 Johnson et al. articulate a key question facing clinicians: given “patient wishes may be at odds with parental wishes—how to proceed?” (p192).12 The literature identifies the involvement of parents in decision-making as particularly ethically challenging given the young person may be dependent for care and financial resources.6 8 47 Some authors also acknowledge ethical challenges arising from decisional conflict between parents.6 12 46 Kimberley et al. argue that “dual parent consent may be unnecessarily prohibitive for adolescents who come from households with only 1 parent who is actively involved in the child’s life or in situations in which there may be interparental conflict” (p5).44 Authors note that navigating shared decision-making may be particularly complex for providers when parents refuse fertility preservation desired by the young person or are generally unsupportive of their child’s gender transition.5 6

Given the significant involvement of parents in the fertility decision-making process, some authors argue that ownership of preserved tissue should be considered and established prior to fertility interventions.12 27 44 46 Eyler et al. raise the question “can the parents use the gametes without the permission of their children, either before or after they reach the age of majority?” (p155).47,iii The majority of ethical challenges identified by the literature related to the involvement of parents in shared decision-making.

Broader ethical challenges related to shared decision-making in fertility preservation for transgender young people are also raised. Authors argued that the complexities and costs associated with future methods of achieving parenthood, such as the use of assisted reproductive technologies (ART), are an influential part of shared fertility-related decisions.5 6 8 28 40 Some authors suggest that a young person’s value of genetic filial relations could influence their selected method of future parenthood.5–7 28 Hudson et al. argue that physicians “should also help [transgender youth] to explore how much [they value] the idea of a genetic relationship between [themselves] and any potential offspring as that is a salient difference between [ART and adoption]” (p89).5 For transgender young people who desire genetic parenthood, the literature argues that barriers to the use of preserved tissue should be discussed.7 8 12 16 41 Johnson et al. suggest that “families should… be informed of the future costs of reproductive medicine services” (p192),12 while Mitu notes that “the social… stigma and discrimination against gender and sexual minorities” is a challenge when accessing ART (p1122).40 Alongside exploration of future ART use, the lack of medical data related to the outcomes of tissue cryopreservation is identified as complicating shared fertility-related decisions.11 12 17 30 38 39 43 44 46 Quinn et al. state that “the ambiguity of available medical information can lead to anxiety and distress and complicate decision-making” (p299).30 Experimental methods of fertility preservation may be “the only chance to preserve the possibility of biological parenthood” for transgender children (p192),12 while simultaneously exposing them to “surgical risk and storing gonadal tissue without the guarantee of future fertility” (p42).3