Guidelines for Pubertal Suspension and Gender Reassignment for Transgender Adolescents

Menstruation is a female normative process. Physiologically, it indicates that the hypothalamic-pituitary-ovarian axis is functioning appropriately, and all the correct female end-organs are intact. Menarche also heralds a girl's arrival into womanhood, which culturally is often celebrated. It is a sign of the possibility of fertility, pregnancy and motherhood. However, menstruation for transgender males, and other gender diverse individuals assigned female at birth, may be anything but celebratory. For these adolescents, menstruation is an indication that one's body is not functioning appropriately and that one does not have the correct organs congruent to their gender identity. Menstruation or the anticipation of menarche for many transgender males is often met with worsening of dysphoria, anxiety, depression and suicidal ideation. Therefore, to meet the physiologic and psychologic needs of transgender males, one needs to be aware of issues that may be present in relation to menstruation and be knowledgeable on how to medically proceed with sensitivity and respect toward one's gender identity. Research on menstruation, both from a physical and psychologic perspective, has been historically based on women and cannot be simply extrapolated to be the same for transgender males. Although there is a paucity of literature on the subject, over the past decade there has begun to be a great interest in the care of transgender individuals. This article focuses on concerns related to menstruation among transgender adolescent males and gender diverse individuals assigned female at birth, including suppression of menses, fertility, contraception, and pregnancy.

Cada vez mais, jovens transgénero procuram ajuda médica para os auxiliar na transição de género, com terapia hormonal e/ou cirurgia de redesignação sexual. Contudo, estes tratamentos limitam a fertilidade, podendo deixá‐los irreversivelmente inférteis. Estudos demonstram que a população transgénero deseja ter filhos biológicos e, para os auxiliar na concretização deste desejo de paternidade, existem técnicas de preservação da fertilidade, como a criopreservação de gâmetas, de embriões e de tecido ovárico ou testicular. Todavia, a par destas técnicas, existem questões éticas e vários desafios antes, durante e após estes procedimentos, que podem levar à rejeição destes métodos de preservação da fertilidade por parte dos jovens transgénero. Em suma, os profissionais de saúde devem estar devidamente informados sobre toda esta dinâmica, entre as terapias de transição de género e o seu impacto na fertilidade, para conseguir orientar melhor estes indivíduos na sua decisão.

Young transgender people increasingly seek medical help to assist them in their gender transition with hormone therapy and/or sex reassignment surgery. However, these treatments limit fertility and may make them irreversibly infertile. Studies show that the transgender population wishes to have biological children and, to help them achieve this desire for parenthood, there are techniques for preserving fertility, such as cryopreservation of gametes, embryos and ovarian or testicular tissue. However, alongside these techniques, there are ethical issues and several challenges before, during and after these procedures, that may lead young transgender people to reject these methods of preserving fertility. In conclusion, health professionals should be informed about all these dynamics between gender transition therapies and their impact on fertility, in order to better guide these individuals in their decision.

International guidelines in transgender health recommend fertility counseling before the commencement of puberty suppression, estrogen, or testosterone, given the potential for these treatments to impair fertility. However, these recommendations provide little actual guidance to clinicians. Consequently, differences in knowledge and attitudes may lead to clinicians adopting different approaches and goals in the fertility counseling they provide. This review draws attention to the disparity between the rates of desire for genetic parenthood among transgender individuals and the actual rates of fertility preservation (FP) and examines different factors in fertility counseling that affect clinical practice and contribute to this disparity. These factors include how a lack of strong evidence—for the effects of hormone therapy on future fertility and success rates of some FP options—impacts upon counseling, transgender peoples' experiences of fertility counseling and preservation, consideration of a young person's developmental stage and the roles of parents and clinicians in the decision-making process, considerations shaping transgender adolescents' decisions to preserve fertility, and access barriers to FP. In doing so, this review highlights the complexities and issues that clinicians must consider when providing fertility counseling to transgender adolescents and—in part—helps to address the lack of detailed clinical guidelines in this area.

Pubertal suppression with gonadotropin-releasing hormone analogues (GnRHa) is considered a reversible treatment that has been associated with improved psychosocial outcomes among transgender and gender-nonconforming youth. However, there has been debate regarding whether GnRHa is truly reversible, with some arguing that certain psychosocial risks or “side effects” warrant consideration. The goal of this chapter is to highlight these psychosocial considerations, including (1) controversy surrounding the possible effects of GnRHa on gender identity and/or sexuality development, (2) unknown neurocognitive sequelae of GnRHa, (3) psychosocial implications of medical side effects (e.g., fertility, sexual functioning), and (4) family factors related to GnRHa.

This review provides an overview of pediatric fertility preservation. Topics covered include the patient populations who could benefit, the current state of fertility preservation options and research, and considerations related to ethics and program development.

A broad Embase® and PubMed® search was performed to identify publications discussing investigational, clinical, ethical and health care delivery issues related to pediatric fertility preservation. Relevant publications were reviewed and summarized.

Populations who could benefit from fertility preservation in childhood/adolescence include oncology patients, patients with nononcologic conditions requiring gonadotoxic chemotherapy, patients with differences/disorders of sex development and transgender individuals. Peripubertal and postpubertal fertility preservation options are well established and include cryopreservation of oocytes, embryos or sperm. Prepubertal fertility preservation is experimental. Multiple lines of active research aim to develop technologies that will enable immature eggs and sperm to be matured and used to produce a biological child in the future. Ethical challenges include the need for parental proxy decision making and the fact that fertility preservation procedures can be considered not medically necessary. Successful multidisciplinary fertility preservation care teams emphasize partnerships with adult colleagues, prioritize timely consultations and use standardized referral processes. Some aspects of fertility preservation are not covered by insurance and out-of-pocket costs can be prohibitive.

Pediatric fertility preservation is an emerging, evolving field. Fertility preservation options for prepubertal patients with fertility altering conditions such as cancer and differences/disorders of sex development are currently limited. However, multiple lines of active research hold promise for the future. Key considerations include establishing a multidisciplinary team to provide pediatric fertility preservation services, an appreciation for relevant ethical issues and cost.

Les dysphories de genre à l’adolescence et durant l’enfance sont étudiées depuis de nombreuses années dans la littérature médicale. En France, les demandes émanant d’adolescents et de leur famille sont de plus en plus fréquentes et l’âge de cette demande de plus en plus jeune, avec une demande de prise en charge spécialisée par les équipes pluridisciplinaires s’occupant du transsexualisme. Dans une première partie, nous exposerons la revue de la littérature de ce thème. Notre recherche s’est appuyée sur les termes : gender identity and adolescence ou dysphorie de genre et adolescence ou encore trouble de l’identité de genre et adolescence avec les moteurs de recherche Pubmed, Psychinfo et Elsevier. Puis, un paragraphe sera consacré à la prise en charge spécifique des enfants, qui diffère de celle des adolescents. Enfin, nous informerons le lecteur des recommandations actuelles de la World Professional Association for Transgender Health (WPATH, 2012). Pour finir, dans une autre partie, nous étudierons la construction de l’identité sexuée selon les différents modèles théoriques. Trois modèles seront abordés, le modèle psychanalytique, le modèle socio-cognitif pour finir par le modèle intégratif. Pour conclure, il est nécessaire que des professionnels du secteur infanto-juvénile interviennent sur ce champ. Dans les années à venir, le trouble de l’identité de genre chez l’enfant et l’adolescent est une problématique diagnostique qui va prendre de l’ampleur sur le territoire français. Il faut tenir compte des articles et revues internationales, des pratiques de nos collègues à l’international qui ont déjà de l’expérience et un peu de recul concernant ces cas. Il faudra donc « développer des équipes mixtes pédiatres/pédopsychiatres » pour accompagner ces jeunes et leur famille. Néanmoins, la question fondamentale sera de savoir comment la France se positionnera dans cette prise en charge spécifique. Les équipes françaises vont-elles suivre les recommandations de la WPATH ?

Children and adolescents’ gender identity disorders have been studied for years in medical literature. In France, demands from young people and their families are becoming more frequent and the demand is sooner, carrying giving by specialized multidisciplinary teams dealing transsexualism. In the first part, we will explain the articles on that theme. Our research is based on those keywords: gender identity and adolescence or dysphorie de genre et adolescence or encore trouble de l’identité de genre et adolescence. Then, a paragraph will focus on the specific caring of the childhood that is different than adolescence. At last, we will inform our readers of the World Professional Association for the Transgender Health (WPATH) actual recommendations. And finally, in another part, we will study the sexual identity construction within three therotical models: the psychoanalysis, the social cognitif and the integrative one. To finalized, it is necessary that professional from the youth department take action. In the upcoming years, the gender disorder in childhood and adolescence is a diagnosis problematic that will increase on the French territory. We need to look at the articles and international revues, the practice from our internationale colleges that already have experience and also that a step back on those cases. We will need to develop “mixte pediatric-psychiatrist” team to guide those children and their families. However, the main question will be how France will position itself in this specific care. Will the French team follow the WPATH recommendations?