Protective Reassignment

Abstract

Transsexual people who want transition to their desired gender have to undergo hormonal and surgical treatments, which lead to irreversible loss of their reproductive potential. This paper argues that transsexual people should be offered the same options as any person that risks losing their germ cells because of treatment for a malignant disease. Indeed, transsexual women (male-to-female transsexual patients) may be given the option to store spermatozoa before they start hormonal therapy, so that their gametes may be used in future relationships. This may be especially important for the many transsexual women who identify as lesbians after their transition. Conversely, transsexual men (female-to-male transsexual patients) may be offered storage of oocytes or ovarian tissue, possibly obtained at the time of their oophorectomy. Current technology offers transsexual people the possibility to obtain children who are genetically their own in their future relationships and the option of gamete banking should therefore be discussed before starting hormonal and surgical reassignment treatment. This is particularly important for transsexual people who are diagnosed and treated at a young age.

gamete preservation, reproduction, sperm freezing, transsexual, transgender

Introduction

Transsexualism (Benjamin, 1966) is the most extreme form of gender dysphoria (Fisk, 1973), which means that an individual has a feeling of belonging to the gender opposite to his or her own gender, as determined by his or her primary and secondary sexual characteristics. Although transsexualism has long been thought of as a mental disorder, evidence clearly shows that this is not the case (Haraldsen and Dahl, 2000). The diagnosis `transsexualism' per se has been removed from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (APA, 1994) and replaced by the more general term `gender identity disorder'. Transsexualism is now generally recognized to be a condition that needs to be treated by state-of-the-art hormonal and surgical therapy to obtain reassignment to the desired gender [see also the standards of care in (Levine et al., 1998)]. Reassignment therapy normally only takes place after psychiatric evaluation to rule out co-morbidity, and surgery is moreover only performed after a successful `real life test', which means that the individual must have lived a specified amount of time (usually one or two years) in the desired gender role.

Until recently, transition to the desired gender and reproduction seemed to be mutually exclusive for transsexual people. To many, loss of reproductive potential seems the `price to pay' for transition. Even today, many medical experts—even those involved in the care for transsexual and transgendered people—are still critical when discussing possible procreation after gender reassignment. However, recent publications have opened the ethical debate as to whether transsexual people should be helped in their possible wish for children in relationships occurring after transition (Brothers and Ford, 2000; Jones, 2000). The debate has only just started amongst fertility experts and currently only deals with donor inseminations in female partners of transsexual men (female-to-male transsexual patients). The question posed is whether transsexual people can be `good' parents, without negative influence on the gender and/or sexual orientation of the child-to-be, a discussion that was held many years ago for homosexual people (Hanscombe, 1983). As it was to homosexuals then, this question may be considered to be an insult to transsexual people, and we rather believe that the debate should be broadened and discuss the possibilities of how to help fulfil the wish for children by transsexual people, rather than whether to help them or not. The overall wellbeing of transsexual people after gender reassignment therapy has been well documented in recent studies (Cohen-Kettenis and Gooren, 1999) and many of these people have normal relationships with children from their previous relationships or from their current partners.

More and more, people are diagnosed and treated for their transsexuality at an early age, when they still do not have any children nor possibly any wish for children. Recent reproductive techniques, however, have made it possible to preserve germ cells for future use, so that in theory transsexual people may make use of their germ cells after transition. A few years ago Lawrence et al. discussed the `reproductive needs' of the transsexual patient (Lawrence et al., 1996), taking Lawrence's ideas further, the purpose of this paper is to discuss what is already technically possible now, and what may be possible tomorrow. Of course, we may expect that the medical and ethical debate will continue before these new techniques may be implemented routinely.

The right to procreate

In modern reproductive medicine it is generally accepted that every person has the right to procreate (Robertson, 1987; Schenker and Eisenberg, 1997). For the transsexual patient this does not seem obvious. The problem is that hormonal and/or surgical treatments have rendered procreation biologically impossible. In daily infertility practice, however, there is another example where procreation is impossible by natural means. Reproduction within lesbian couples is nowadays more and more accepted and both simple donor inseminations and cross-over IVF (one woman provides the oocytes, which after fertilization in vitro are transferred to her partner) are performed to help fulfil the wish for children of lesbian women. Many studies have shown that the children are developing in exactly the same way as children from heterosexual parents (Brewaeys et al., 1997; Chan et al., 1998) and this has made homosexual procreation socially and medically more acceptable. The argument that the transitioning transsexual patient has deliberately chosen to abandon his or her reproductive potential, is of the same nature as saying that a woman becomes a lesbian by choice. If we accept that lesbianism is not a matter of choice and we accept that lesbian mothers-to-be may well be helped with their wish for children, the same should apply to transsexual people.

In short we will discuss the various theoretical options that are available. It is worthwhile to mention that although most transsexual people will form heterosexual relationships after transition, many will not, illustrating the well known fact that sexual orientation and gender identity are quite different entities. Therefore, not all options are available for all transsexual people alike.

Sperm banking in transsexual women (male-to-female transsexual patients)

It is well known that feminizing hormonal therapy will induce hypospermatogenesis in transsexual women, and ultimately will lead to azoospermia (Schulze, 1988; Lubbert et al., 1992). This azoospermia may be considered irreversible after some time, and furthermore gender reassignment surgery with removal of the testes obviously leads to irreversible sterility. The only option, therefore, is to perform sperm preservation by freezing a number of semen samples, preferably prior to starting hormonal therapy. This banked spermatozoa can then possibly be used later to inseminate a female partner if the quality is good, or else be used to perform IVF.

In case of a future male partner the situation is the same as with homosexual men today, and there is little help available except when an oocyte donor and surrogate mother are involved. Since many transsexual women are, however, sexually oriented towards women after transition (and therefore identify as lesbians), sperm banking should routinely be offered to people considering hormonal and/or surgical gender reassignment treatment. Any man undergoing a treatment that will damage his reproductive potential (such as chemo- or radiotherapy for a malignancy) is now offered the opportunity to bank spermatozoa, and the transsexual woman should be no exception to this.

Transsexual men

For transsexual men the same principles apply. Masculinizing hormonal therapy will lead to a reversible amenorrhea but ovarian follicles will remain in place. There is some discussion as to whether this leads to a condition similar to polycystic ovarian syndrome, (Pache et al., 1991). Of course castration will provoke irreversible ovarian failure. To preserve procreational potential three options are available: oocyte banking, embryo banking and ovarian tissue banking. We will only briefly discuss these options, since their technicalities do not belong to the scope of this paper.

Oocyte banking

Oocyte banking requires hormonal stimulation and oocyte retrieval (as for IVF) and subsequent freezing of the oocytes. Although this option would be very interesting, mature oocytes seem very vulnerable to chromosomal damage by the freezing and thawing process. The very poor survival of the oocytes after thawing, and poor fertilization and implantation results after IVF still make this a non-realistic strategy. Only a few births have been reported in the world (Chen, 1986) and oocyte banking besides would also require the use of donor spermatozoa and a recipient uterus of a future female partner on one hand, or a surrogate mother in case of a male partner. The latter case would allow the couple to have their own genetic child.

Embryo banking

Embryo banking requires hormonal stimulation and oocyte retrieval (as for oocyte banking or IVF) and it also requires spermatozoa from a male partner (or donor) with subsequent freezing of the embryos. Embryo freezing is now a routine procedure in IVF and yields reasonably good results. Of course it also would require a recipient uterus (female partner or surrogate mother).

Ovarian tissue banking

Ovarian tissue banking probably has the most potential for the future and is already being used for women who undergo chemo- or radiotherapy for a malignant disease. Ovarian tissue banking requires no hormonal stimulation nor IVF, and is technically as easy as sperm freezing. Through means of a laparoscopy ovarian tissue can be removed, and the ovaries retain usable follicles even after hormonal therapy (Van den Broecke et al., 2000), which implies that removal of ovarian tissue can well be performed at the time of oophorectomy.

Ovarian tissue banking would also require donor spermatozoa and a recipient uterus of a future female partner or a surrogate mother in case of a male partner. The problem of ovarian tissue banking is not the freezing but the question of what to do with the tissue after thawing. One has the option to graft the ovarian tissue into the patient himself (Shaw et al., 2000) (of course this is not an option for transsexual men), in another patient (leading to possible problems of immune rejection) or in another animal (such as the mouse, but here may arise some serious ethical objections). In these three scenarios follicular growth and ovulation should still be induced (Oktay and Karlikaya, 2000) and IVF would be needed to obtain fertilization and pregnancy. As another possibility, in-vitro culture of the tissue fragments, with follicular growth and oocyte maturation in vitro still seems to lead to poor results so far (Smitz and Cortvrindt, 1999) and intermediate approaches are being explored, combining grafting and in-vitro maturation (Liu et al., 2000). So, although ovarian tissue banking seems to be the option to choose, much research will still be needed to bring this in practice for transsexual men.

The future

In the future there may be other asexual ways of procreation awaiting us. Since the birth of Dolly it has been shown to be possible to obtain an individual starting from an adult cell (Bryan, 1998; Solter, 1998; Wolf et al., 1998). Many other animal species have already been cloned and theoretically the human species will probably not be difficult to clone either. Although cloning may offer great potential to medicine in general and may have many useful applications, reproductive cloning (reproducing a copy of a given individual) probably does not seem of interest (Jones and Cohen, 1999). Indeed, no two clones would be really identical and at best one could obtain similarities such as the ones that exist between monozygotic twins raised at different times and in different places. Although a remote possible application of reproductive cloning would theoretically be the creation of chimeras from two different cloned embryos, so that an individual arises consisting of the genetic make-up of two different individuals (Boediono et al., 1999), it is not to be expected that such a strategy will readily be admissible to society.

Conclusion

In conclusion, several reproductive options to help transsexual people fulfil their desire for a child are already technically feasible, or will soon be available The medical world, legislation and society at large will need time to accept the concept of transsexual reproduction and allow treatment. We think, however, that sperm and ovarian tissue-banking should now be discussed and offered to transsexual people undergoing gender reassignment therapy, so that future treatment may be possible if wanted. Experience with lesbian couples shows that when new techniques are available, new treatment options are sought and offered (Hodgen, 1988), and there is no reason why transsexual people should be refused these new possibilities.

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The Pentagon will pay for a transgender soldier's gender reassignment surgery. It's the first time such surgery has been provided for a member of the military.

The director of the Defense Intelligence Agency approved a waiver for the surgery because the service member had already begun treatment, and the treating doctor deemed the surgery medically necessary, the Defense Department said.

In a statement emailed to CBN News, Major Dave Eastburn said, "This afternoon, an active-duty military member received a sex-reassignment surgery," the Pentagon said in a statement, adding that the surgery was performed in a private hospital because military hospitals do not have the "surgical expertise" needed to perform the operation.

Funding for service members' gender reassignment surgeries has become a hot-button issue in American politics, with some arguing that the cost would be a burden on the military.

President Donald Trump said this is why he announced a ban on transgender troops in July.

"Our military must be focused on decisive and overwhelming victory and cannot be burdened with the tremendous medical costs and disruption that transgenders in the military would entail," the President tweeted at the time.

A 2016 study commissioned by the military found that allowing transgender troops to serve would "have minimal impact on readiness and health care costs" for the Defense Department. Health care costs would increase by an estimated $2.4m – a 0.04 to 0.13 percent increase in spending.

President Trump issued a formal memo in August, officially banning all new transgender recruits and giving Defense Secretary James Mattis the power to decide what would happen to active transgender service members.

The memo also ordered the Pentagon to stop paying for all transgender-related medical expenses, "except to the extent necessary to protect the health of an individual who has already begun a course of treatment to reassign his or her sex."

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