103. Use of a Hospital Ethics Committee in Offering Total Hysterectomy in a Transgender Adolescent Population: A Case Series

• Published in: Journal of pediatric & adolescent gynecology 2023-04, Vol.36 (2), p.217-217
• Main Authors: Batchelor, Jourdin, Vasquez, Peter
• Format: Article
• Language: English
• ISSN: 1083-3188; 1873-4332
• DOI: 10.1016/j.jpag.2023.01.246

The vast majority of transgender males experience gender dysphoria, with many adult patients choosing hysterectomy as one option for therapeutic gender affirmation. For transgender male adolescents, there are limited recommendations for surgical management of gender dysphoria related to natal female anatomy given ethical and legal concerns regarding permanent sterilization in minors. Here we present two adolescent patients with transgender male identity who underwent total hysterectomy prior to age eighteen. IRB approval was not required. Two transgender male adolescent patients presented for desired total hysterectomy for gender affirmation. Case 1 (age 16) presented with a longstanding history of pelvic pain, abnormal uterine bleeding, and a biopsy confirmed diagnosis of endometriosis. His symptoms were refractory to medical management despite progestin therapy, testosterone, and laparoscopic ablation of visible endometriotic implants. Case 2 (age 16) presented with debilitating gender dysphoria, unable to complete daily activities of living. He had normal menses that were adequately suppressed while on testosterone therapy. He had undergone bilateral mastectomy prior to presentation. Both cases were reviewed by the hospital ethics committee prior to offering and ultimately proceeding with surgical management. Based on the ethical principles of autonomy, beneficence, and non-maleficence, hysterectomy was felt to be the appropriate intervention for both patients. Both cases declined options for fertility preservation including retention of ovaries, and oocyte and embryo cryopreservation. Both patients underwent an uncomplicated laparoscopic assisted vaginal hysterectomy, bilateral salpingoophorectomy, and cystoscopy. These cases showcase the possible spectrum of indications for total hysterectomy in adolescent transgender males. They also demonstrate the utility of integrating ethical models for management of complex issues for patients under the age of eighteen. Case 1 highlights hysterectomy as treatment for both refractory endometriosis and concurrent gender dysphoria. However, resolution of severe gender dysphoria (Case 2) is a compelling argument to offer hysterectomy without menstrual dysfunction in certain patients. Current recommendations for menstrual manipulation for other specialized adolescent populations, such as those with mental or physical disabilities, propose that hysterectomy may be considered after other management strategies have been