Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians

The attitudes of transgender and gender-diverse adolescents and their parents regarding fertility, parenthood, and fertility preservation before the start of puberty suppression or gender-affirming hormone therapy

BACKGROUND

Gender-affirming treatment for transgender and gender-diverse (TGD) adolescents can consist of puberty suppression (PS) and gender-affirming hormone treatment (GAHT), which may affect fertility.

AIM

This study aims to evaluate the attitudes and decision-making regarding parenthood and fertility preservation from TGD adolescents and their parents and analyze the fertility preservation use and outcome before the start of treatment.

METHODS

Adolescents under 18 starting PS or GAHT between November 2021 and March 2024 were enrolled in a multicenter prospective cohort study "ENIGI adolescents," conducted at Amsterdam University Medical Centre, Ghent University Hospital, and Florence University Hospital. Adolescents and parents were asked to complete the "Transgender Youth Fertility Attitudes Questionnaire" and the "Decision Conflict Scale." Information about fertility preservation use and outcomes was extracted from electronic patient files.

OUTCOMES

Attitudes from TGD adolescents and their parents regarding desire for children, fertility preservation use, outcomes, and decision-making.

RESULTS

A total of 316 adolescents were counseled about fertility options; 100 (49%) registered female at birth (RFAB) and 50 (48%) registered male at birth (RMAB) adolescents expressed a future desire for children. More than 1/3 had interest in or are still undecided about having a genetic offspring. None of the RFAB TGD adolescents underwent fertility preservation. In total, 20 (22%) RMAB adolescents pursued fertility preservation, 14 before PS and 6 before GAHT. Before PS, three performed testicular sperm extraction (TESE). All others performed semen cryopreservation. The post-thawed semen quality was low. The testicular volume and Tanner stage in the semen cryopreservation group were significantly higher compared to TESE, P = .013 and P = .021, respectively. There was no significant difference in age between those groups.Adolescents experience moderate to high decisional conflict about their fertility choices. RFAB adolescents experience a significantly higher conflict in decision-making compared to RMAB adolescents (40/100 vs 34/100 95% CI [2.1-9.4]). Younger RFAB adolescents experienced more decisional conflict (B =-1,25, 95% CI [-2,25, -0.25]). In RMAB this was not significant.

CLINICAL IMPLICATIONS

This study helps to further understand TGD adolescents' needs and can further improve the development of tailored fertility counseling.

STRENGTHS AND LIMITATIONS

This is the first European collaborative study on transgender healthcare in adolescents. A limitation of our study is the relatively low response rate to the questionnaires, which varied between 25% and 62%.

CONCLUSION

Many TGD adolescents express a desire for future parenthood yet experience decisional conflict about their reproductive options, even after receiving comprehensive fertility counseling prior to PS or GAHT.

The experience of transfeminine adolescents and their parents regarding fertility preservation via testicular sperm extraction (TESE): a qualitative study

STUDY QUESTION

How do transfeminine adolescents and their parents experience fertility preservation via testicular sperm extraction (TESE)?

SUMMARY ANSWER

Participants experienced the TESE process positively when provided with appropriate guidance to navigate the decisional dilemma between preserving future biological parenthood and the pressure to start puberty suppression early.

WHAT IS KNOWN ALREADY

Sperm banking through ejaculation is not feasible for all transfeminine adolescents due to genital dysphoria and early puberty; for this group, TESE is the only alternative. However, during early puberty, they must postpone or pause puberty suppression until spermatogenesis is fully developed.

STUDY DESIGN, SIZE, DURATION

All consecutive TESE patients in our centre and their parents were invited to participate. Between December 2022 and May 2023, we included 6 adolescents and 10 parents. We used a qualitative approach based on semi-structured interviews to study the experience of the transfeminine adolescents and their parents.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Transfeminine adolescents diagnosed with gender dysphoria in early puberty (Tanner stage ≥2) who underwent TESE before the start of puberty suppression or gender-affirming hormones participated in this study. The interviews were recorded, manually transcribed and analysed using reflective thematic analysis focusing on understanding the participants' experiences of puberty and fertility preservation and the various factors and social processes influencing their decision to undergo TESE.

MAIN RESULTS AND THE ROLE OF CHANCE

Transfeminine adolescents decide to undergo invasive fertility preservation because of a possible, future desire for parenthood. Parents stressed the importance of preventing future decisional regret. They both saw masturbation to obtain a semen sample as unreachable. Even though TESE is a surgical procedure with possible complications and pain afterwards, this alternative seemed less dysphoric to them.Adolescents had to postpone the start of puberty suppression, waiting for spermatogenesis to complete. Given the unpredictable development of puberty, they felt a lot of stress and anxiety during this period and were primarily concerned about the lowering of their voice. Because of this puberty-related stress, they were constantly balancing their motivations for fertility preservation against the early start of puberty suppression to prevent unwanted irreversible pubertal body changes. To support this decisional dilemma, adolescents and their parents need adequate communication with each other and their healthcare providers to reflect on their stress for pubertal change. Furthermore, close, continuous surveillance of their current mental state by their parents, together with their psychologist and pubertal development by their physicians, is needed. Despite the challenging decision and postponement of puberty suppression, they retrospectively experienced it positively without any regret.

LIMITATIONS, REASONS FOR CAUTION

All adolescents successfully underwent TESE, with viable spermatozoa obtained and without complications. This may result in a more positive reflective experience regarding fertility preservation. Furthermore, the perspectives of adolescents with the intention of TESE but who already started with puberty suppression before the preservation were not included.

WIDER IMPLICATIONS OF THE FINDINGS

This study helps healthcare providers improve their counselling and guidance of transfeminine adolescents who consider postponing puberty suppression for fertility preservation via TESE. The adolescents and their parents know more clearly what to expect during fertility preservation. Specific peer-support programs may facilitate the decision process for upcoming adolescents.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. None of the authors have any conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Capacity to consent: a scoping review of youth decision-making capacity for gender-affirming care

BACKGROUND

Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments.

METHODS

Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed.

RESULTS

Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning).

CONCLUSIONS

For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice

OBJECTIVE

To examine the treatment of gender dysphoria described in Bell v Tavistock (UK 2020). Bell documents the treatment and sequelae of a 16-year-old adolescent referred to the Tavistock with gender dysphoria. Her case highlights contrasts between gender affirming care and comprehensive care.

CONCLUSIONS

Consistent with other western centres, in the 2010s, the Tavistock began treating patients with gender dysphoria under the 'Dutch protocol' for gender affirming care. Bell reveals concerning lapses of clinical governance influenced by activists and linked to patient harm. The recent suspension of a senior child psychiatrist from an Australian public hospital service after questioning the evidence base and ethical foundation of gender affirming care underlines the need to resolve these uncertainties to address the crisis in the treatment of gender dysphoria.

Challenges in Pediatric Endocrinology

As the Section Editor-in-Chief, it is my pleasure to introduce the new section of Children devoted to pediatric endocrinology [...].

Patient Empowerment Among Transgender and Gender Diverse Youth

Purpose: Patient empowerment is becoming increasingly important as health care moves toward more collaborative models of care. The goal of this study was to evaluate and characterize patient empowerment in a sample of transgender/gender-diverse/nonbinary (TGDNB) youth aged 14-24 who have had at least one conversation with a medical health care provider about gender-affirming care. Methods: We adapted a health care empowerment scale for use with TGDNB young people and collected patient empowerment and sociodemographic data among TGDNB youth in the United States over an 8-week period in the spring of 2022. Overall and domain-specific empowerment (including knowledge and understanding, control, identity, decision-making, and supporting others) were assessed on a four-point scale from a low of 1 to a high of 4. Results: A total of 177 youth completed the survey. Mean age was 18.4 ± 3.0 years, the sample was 39.5% gender-diverse/nonbinary, 16.4% transfemme, 44.1% transmasc, and 81.9% White. Average empowerment was 0.22 points higher in youth with supportive caregivers than those without (99% confidence interval [CI] 0.05-0.38, p < 0.001) and 0.20 points higher in youth who sought gender-affirming mental health support (99% CI 0.04-0.36, p = 0.001). Caregiver support increased youths' sense of control over their health/health care (estimated increase 0.29, 99% CI 0.09-0.50, p < 0.001), and mental health support increased youths' decision-making agency by 0.30 points (99% CI 0.06-0.53, p = 0.001). Conclusions: This is the first study to assess patient empowerment in TGDNB youth. Several sociodemographic factors were significantly associated with overall and domain-level empowerment. Further work in this area, both longitudinal and in larger samples, is warranted.

Transition Regret and Detransition: Meanings and Uncertainties

Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.