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International Review of Psychiatry

ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20

Fertility options in transgender people

Chloë De Roo, Kelly Tilleman, Guy T’Sjoen & Petra De Sutter

To cite this article: Chloë De Roo, Kelly Tilleman, Guy T’Sjoen & Petra De Sutter (2016)
Fertility options in transgender people, International Review of Psychiatry, 28:1, 112-119, DOI:
10.3109/09540261.2015.1084275

To link to this article: http://dx.doi.org/10.3109/09540261.2015.1084275

Published online: 19 Nov 2015.

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INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
VOL. 28, NO. 1, 112–119
http://dx.doi.org/10.3109/09540261.2015.1084275

REVIEW ARTICLE

Fertility options in transgender people


Chloë De Rooa, Kelly Tillemana, Guy T’Sjoenb and Petra De Suttera
a
Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium; bDepartment of Endocrinology and Centre for
Sexology and Gender, Ghent University Hospital, Ghent, Belgium

ABSTRACT ARTICLE HISTORY


Hormonal and surgical treatments for transgender people have a devastating effect on the Received 25 June 2015
possibility for these patients to reproduce. Additionally, transgender people tend to start sex Revised 12 August 2015
reassignment treatment at a young age, when reproductive wishes are not yet clearly defined nor Accepted 13 August 2015
fulfilled. The most recent Standards of Care of the World Professional Association for Transgender Published online
Health recommend clearly informing patients regarding their future reproductive options prior to 18 November 2015
initiation of treatment. This review gives an overview of the current knowledge and state-of-the-art KEYWORDS
techniques in the field of fertility preservation for transgender people. Where genital reconstructive Cryopreservation, fertility,
surgery definitely results in sterility, hormone therapy on the other hand also has an important, but transgender, reproductive
partially reversible impact on fertility. The current fertility preservation options for trans men are wish
embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. For trans
women, sperm cryopreservation, surgical sperm extraction and testicular tissue cryopreservation
are possible. Although certain fertility preservation techniques could be applicable in a
standardized manner based on clear biological criteria, the technique that eventually will be
performed should be the preferred choice of the patient after extended explanation of all possible
options.

Introduction transgender people without children (Wierckx et al.,


2012b). In transgender women, parenting was even
Gender dysphoria refers to distress or discomfort caused
identified as a suicide protective factor (Hamada et al.,
by the incongruence between a person’s sex assigned at
2014). Apart from an apparent child wish, a small
birth and the gender a person identifies him or herself
majority of transgender men and transgender women
with (Coleman et al., 2012). Treatment options to
would actually have cryopreserved their gametes, or
facilitate the social gender role transition and to live in
would have seriously considered doing it, if the tech-
accordance with the gender experienced comprises both
nique had been available (Wierckx et al., 2012b).
hormone therapy and/or surgical interventions
Especially lesbian and bisexual transgender women
(Coleman et al., 2012). Unfortunately, both these options were interested in using their own cryopreserved sperm
have a negative effect on fertility (Coleman et al., 2012; to fulfil a future child wish (Wierckx et al., 2012b).
T’Sjoen et al., 2013). Health care professionals should Regardless of their personal desire, the majority of
address the consequences for future fertility with their transgender people clearly expressed the opinion that
patients before treatments have started. fertility preservation techniques should be discussed and
Although there are only few studies that have offered (De Sutter et al., 2002). On the other hand it is
investigated the desire of transgender people to have striking that some transgender people are willing to
children, they all conclude that approximately half of sacrifice their fertility, since fertility preservation was
trans women (male to female transgender persons) and considered not important enough to postpone their
half of trans men (female to male transgender persons) transition process (De Sutter et al., 2002) as most of
wish to have children (De Sutter et al., 2002; Wierckx transgender people are in favour of a fast transition
et al., 2012a; Wierckx et al., 2012b). (Wierckx et al., 2012a).
The relevance of this topic is also reflected in the fact The World Professional Association for Transgender
that transgender people with children score significantly Health (WPATH) Standards of Care recommend in their
higher on mental health and vitality scores than seventh version to discuss fertility options with patients

CONTACT Chloë De Roo, MD chloe.deroo@ugent.be Department of Reproductive Medicine, University Hospital Ghent, De Pintelaan 185, 9000 Ghent,
Belgium
ß 2015 Taylor & Francis
INTERNATIONAL REVIEW OF PSYCHIATRY 113

prior to any treatment or medical intervention, especially (Hamada et al., 2014; Lubbert et al., 1992). If semen
before genital reconstructive surgery (Coleman et al., samples of such poor quality are used, assisted repro-
2012). The impact of each treatment on fertility as well duction techniques, such as in vitro fertilization (IVF) or
as a possible fertility preservation option to maintain the intracytoplasmic sperm injection (ICSI) are needed
possibility of having future genetically related children (Ettner et al., 2007).
should be addressed. As fertility preservation and Payer et al. (1979) described the histological effects on
transgender healthcare are rapidly evolving fields, this Leydig cells of treatment with oestrogens alone or with
review gives an overview of the current state-of-the-art of medroxyprogesterone acetate in transgender women.
fertility preservation options for transgender people. Three morphologies were distinguished: Leydig cells very
Clustered around questions, this manuscript provides similar to untreated Leydig cells (type 1), the absence of
the most recent insights on the effects of therapy on Leydig cells in the presence of cells with increased
fertility, fertility preservation options, success rates, microfilaments and abundant smooth endoplasmic
future use of stored gametes, and transgender parenting. reticulum and lipid drops (type 2) and complete absence
This review is of interest for all healthcare professionals of any cell type but with varying amounts of microfila-
working with transgender people and could be used as a ments and pigmentation (type 3) (Payer et al., 1979). The
tool in order to correctly inform their patients on the persisting spermatogonia show the typical features of the
possible fertility preservation options they have. so-called pale type-A spermatogonia (Schulze, 1988).
Because of the low mitotic rate of these cells, the pale
Methods type-A spermatogonia survive disturbances of the endo-
crine balance, as well as other noxious stimuli such as
Relevant literature on fertility and fertility preservation
radio- and chemotherapy (Schulze, 1988). Therefore,
in transgender was searched on PubMed. The time
these cells are regarded as the stem cells of the human
period ranged from an unlimited start date to 1 May
testis (Schulze, 1988).
2015. To identify appropriate studies, the following
These histological findings explain why feminizing
terms were used (listed alphabetically): assisted repro-
hormonal therapy induces hypo spermatogenesis, ultim-
duction, cryopreservation, donor, ethics, fertility, freez-
ately leading to azoospermia (De Sutter, 2001). The
ing, gender dysphoria, oocyte, ovary, preservation,
impact is – to a certain extent – heterogeneous possibly
reproduction, sperm, transgender, transgender men,
due to different types of cross-sex hormone therapy
transsexual, transgender women. Abstracts were used
(Schneider et al., 2015) and is reversible upon cessation
to select key articles. Of the identified literature, the
of oestrogen therapy based on the presence of the
reference and citation lists were screened to find other
spermatogonial stem cells (Schulze, 1988).
related and important articles.

What is the effect of sex reassignment therapy Genital reconstructive surgery in


on fertility? transgender men
Genital reconstructive surgery in transgender Hysterectomy with bilateral oophorectomy leads to
women irreversible sterility (De Sutter, 2001; Wierckx et al.,
2012b).
Penectomy and orchidectomy in transgender women
leads to irreversible sterility.
Cross-sex hormone treatment in transgender men
Cross-sex hormone treatment in transgender
Masculinizing hormonal therapy will in most cases lead
women
to a reversible amenorrhea but ovarian follicles are not
Clinically, prolonged oestrogen treatment results in depleted from the tissue (De Roo et al., 2014; Van Den
reduction of the testicular volume (Payer et al., 1979). Broecke et al., 2001b). Increased androgen levels may
Additionally, oestrogens have a suppressive effect on however adversely affect follicle growth, mostly affecting
sperm motility and density in a (cumulative) dose- the more matured follicle stages as these follicles are
dependent manner (Payer et al., 1979). Hamada et al. surrounded by an androgen sensitive theca cell layer
(2014) clearly demonstrated a poor semen quality in (Caanen et al., 2015; De Roo et al., 2014; Pache et al.,
transgender women following feminizing therapy. Their 1991). Apparently, primordial follicles in cryopreserved
results show a high incidence of oligozoospermia, and xenotransplanted ovarian cortical tissue do not lose
asthenozoospermia and teratozoospermia, related to their potential to resume growth and maturation (Van
cross-sex hormone treatment in transgender women den Broecke et al., 2001a).
114 DE ROO ET AL.

Table 1. Fertility preservation options in transgender men prior to a hysterectomy and bilateral oophorectomy procedure.
Technique Description Considerations Future use
Embryo cryopreservation Controlled ovarian stimulation for Established method Male partner:
oocyte retrieval and fertilization to Controlled ovarian stimulation Use of partner’s sperm prior to cryo-
obtain embryos for Vaginal procedure preservation, needs a surrogate
cryopreservation Post-pubertal mother
Partner or donor sperm Female partner:
Fertilization by donor sperm prior to
cryopreservation, implantation into
the partner’s uterus
Oocyte cryopreservation Controlled ovarian stimulation to Established method Male partner:
obtain oocytes for cryopreservation Controlled ovarian stimulation Use of partner’s sperm, needs a
Vaginal procedure recipient uterus (surrogate mother)
Post-pubertal Female partner:
No partner required Fertilization by donor sperm,
implantation into the partner’s
uterus
Ovarian tissue cryopreservation Surgical excision of ovarian tissue for Experimental Male partner:
cryopreservation Pre- or post-pubertal In vitro maturation and use of part-
No controlled ovarian stimulation ner’s sperm, need of a recipient
Possible at moment of genital uterus (surrogate mother) (not
reconstructive surgery possible at this stage)
No partner required Female partner:
In vitro maturation, fertilization by
donor sperm, implantation into the
partner’s uterus (not possible at
this stage)

A current debate is still ongoing whether or not considerations in favour of and against the technique,
masculinizing therapy induces polycystic ovarian syn- and the potential future use in the case of a male or a
drome (PCOS) (Caanen et al., 2015; Grynberg et al., 2010; female partner. These options are based on the known
Pache et al., 1991). Descriptive histology by Pache et al. fertility preservation options for patients undergoing
(1991) showed some evidence for altered morphology gonadotoxic treatment (such as chemotherapy) trans-
induced by testosterone treatment comprising of enlarged posed to the specific needs of transgender patients. It is
ovaries, collagenized ovarian cortex, theca interna hyper- preferable to bank gametes before commencing cross-sex
plasia and stromal hyperplasia (Pache et al., 1991; Spinder hormone treatment. For transgender men and trans-
et al., 1989). The idea that androgens induce high anti- gender women already using cross-sex hormone treat-
Müllerian hormone levels, which is a particular feature of ment, an interruption of hormone treatment is
PCOS is, however, questionable (Caanen et al., 2015). recommended for 3 months to restore possible ther-
On the other hand, one must realize that hormonal apy-induced effects.
interventions for transitioning do not exclude possible
pregnancy in transgender men (Light et al., 2014; T’Sjoen
Embryo cryopreservation
et al., 2013). This implies that exogenous testosterone is
not an adequate means of birth control. Testosterone has The embryo cryopreservation technique consists of
teratogen effects on the fetus, therefore transgender men hormonal stimulation and oocyte aspiration for IVF/
should avoid pregnancy while on testosterone therapy. In ICSI techniques to create embryos that are subsequently
cases of non-surgery, contraception should be discussed. cryopreserved for future embryo transfer (Ettner et al.,
Evidence regarding the choice of the correct contracep- 2007; Wallace et al., 2014). This is an appropriate option
tive is currently lacking. We suggest progesterone-only for post-pubertal transgender men with a male partner
medication, a progesterone-releasing intra-uterine device and offers the possibility of a genetically related child.
or barrier methods of birth control in order to avoid the However, if desired, a sperm donor can also be used to
use of oestrogen treatment. create embryos (Wallace et al., 2014). This fertility
preservation method requires a controlled ovarian
stimulation and thus female hormone exposure
What are the current fertility preservation
(Wallace et al., 2014). Additionally, frequent vaginal
options for transgender men?
ultrasound monitoring is needed during the ovarian
Current fertility preservation options include cryo- stimulation phase and a transvaginal surgical procedure
preservation of embryos, oocytes or ovarian tissue. is performed for oocyte aspiration (De Sutter, 2001;
The theoretical options are presented in Table 1, Wallace et al., 2014). This can be a physical and
including a short description of every technique, psychological burden for many transgender men,
INTERNATIONAL REVIEW OF PSYCHIATRY 115

thereby limiting their future reproductive options The technique requires a surgical procedure but does not
(Wierckx et al., 2012b). Although technically possible, include an ovarian stimulation. Since cross-sex hormone
genital exams in transgender men may need to be treatment does not deplete the ovary, resection of the
postponed until a trusted doctor-patient relationship is tissue can be performed at the time of genital recon-
established (Steever, 2014). structive surgery (Van Den Broecke et al., 2001). At the
Nowadays embryo freezing is a routine procedure in moment it is a promising but experimental procedure
the field of assisted reproduction. In the case of an embryo (Wallace et al., 2014).
transfer, a recipient uterus (surrogacy mother) is required, Future use of the frozen tissue can be either transplant-
especially when the uterus has been removed upon genital ation of thawed tissue or in vitro maturation of primordial
reconstructive surgery in transgender men (De Sutter, follicles. Transplantation of ovarian cortical strips can,
2001; Ettner et al., 2007). In the case of a female partner, however, include unwanted side effects by restoring female
partner donation – where an oocyte of the transgender hormone activity. It makes natural conception theoretic-
man is inseminated with donor sperm and subsequently ally possible in cases where the uterus was not removed or
transferred to the female partner – is a possibility. if this transplanted ovarian tissue is stimulated in order
to obtain mature oocytes for IVF/ICSI techniques. In vitro
Oocyte cryopreservation maturation of primordial follicles (the abundant fol-
licle stage in ovarian cortex) would prevent the recovery
Oocyte cryopreservation includes hormonal stimulation of female hormone activity after transplantation, but
and oocyte retrieval for oocyte vitrification (Wallace in vitro maturation starting from these immature follicles
et al., 2014). Therefore the same considerations as for is not yet possible (Dewailly et al., 2014; Ettner et al., 2007;
controlled ovarian stimulation for embryo cryopreserva- Wierckx et al., 2012b). Like oocyte cryopreservation,
tion have to be taken into account. Cryopreservation of once a mature oocyte is obtained, the use of partner
oocytes does not require fertilization before cryopreser- sperm or donor sperm and a recipient uterus upon
vation. Therefore there is no need for a partner or for the thawing of the oocytes for future use (female partner or
use of donor sperm at the moment of the fertility surrogate mother) enables fertility treatment.
preservation procedure. Again it is an established
technique and future use of the cryopreserved oocytes
requires the use of partner sperm or donor sperm and a What are the current fertility preservation
recipient uterus which can be the female partner or a options for transgender women?
surrogate if a male partner is present (De Sutter, 2001).
The fertility preservation options for transgender women
include cryopreservation of sperm collected through
Ovarian tissue cryopreservation
ejaculation or direct testicular extraction and cryopreser-
Ovarian tissue cryopreservation is the resection and vation of immature testicular tissue. An overview is
cryopreservation of the ovary (Wallace et al., 2014). provided in Table 2.

Table 2. Fertility preservation options in transgender women.


Technique Description Considerations Future use
Sperm cryopreservation Cryopreservation of ejaculated sperm Established technique Male partner:
through masturbation or vibratory Masturbation Needs a donor oocyte and surrogate
stimulation Post-pubertal mother
Female partner:
Intra-uterine insemination or IVF/ICSI
depending on sperm quality followed
by embryo transfer in partner
Surgical sperm extraction Percutaneous aspiration of sperm Established technique Male partner:
from testis or epididymis No masturbation Needs a donor oocyte and surrogate
Surgical procedure mother
Post-pubertal Female partner:
IVF/ICSI treatment followed by embryo
transfer in partner
Immature testicular Surgical biopsy of testicular tissue Experimental Male partner:
tissue cryopreservation Pre- or post-pubertal In vitro maturation and need of a donor
Possible at moment of genital oocyte and surrogate mother (not
reconstructive surgery possible at this stage)
Female partner:
In vitro maturation and IVF/ICSI followed
by embryo transfer in partner (not
possible at this stage)
IVF, in vitro fertilization; ICSI, intracytoplasmic sperm injection.
116 DE ROO ET AL.

Sperm cryopreservation What would be the future fertility preservation


options for transgender patients?
The cryopreservation of ejaculated sperm (through
masturbation or vibratory stimulation) is the simplest Current research focuses on optimizing the in vitro
and most reliable method of male fertility preservation maturation of immature oocytes and spermatogonial
(Wallace et al., 2014). Transgender women may find it stem cells. An optimized culture model would allow the
difficult to masturbate in order to produce a semen use of the currently banked ovarian or testicular tissue
sample for preservation. Even the fact that they have without the need for transplantation. This would solve
semen samples stored would remind them of their male the unwanted side effect of endocrine restoration by the
past and would therefore not make them feel as a transplanted tissue.
complete woman (De Sutter et al., 2002; Wierckx et al., For transgender men, the in vitro maturation of
2012a). Depending on the sperm quality, the cryopre- cumulus-enclosed oocytes collected during ovarian tissue
served spermatozoa can be used for future intrauterine processing may be possible in the future. These oocytes
insemination or to perform IVF/ICSI in the case of a originate most probably from antral follicles punctured
female partner (De Sutter, 2001). The need for IVF/ICSI, through manipulation of the tissue during the cryo-
however, creates the necessity to start controlled ovarian preservation procedure. In combination with freezing of
stimulation in the female partner, followed by oocyte the ovarian cortex, cryopreservation of in vitro matured
aspiration. The embryo obtained can subsequently be oocytes might further broaden the reproductive perspec-
transferred into the partner’s uterus. In the case of a male tives for transgender men.
partner, a donor oocyte and a surrogate mother are both Apart from a testicular biopsy in transgender women
necessary. to obtain spermatogonial stem cells, research to obtain
artificial gametes through stem cells is ongoing
(Duggal et al., 2014; Ettner et al., 2007). This would be
Surgical sperm extraction
a possibility for those patients who cannot or have not
In cases of surgical sperm extraction, a percutaneous stored their own gametes and currently need oocyte or
aspiration of sperm from the testis or the epididymis is sperm donation to fulfil their future genetically related
performed (Wallace et al., 2014). Again, this is an child wish (T’Sjoen et al., 2013).
established method in daily IVF practice. Although a
solution for transgender women for whom masturbation
After fertility preservation, what is the
is a burden, one must not forget that this is a surgical
possibility for transgender gestation?
procedure (Wallace et al., 2014). The obtained spermato-
zoa can be used for future IVF or ICSI procedures in the In the USA, unlike in many European countries,
case of a female partner. Again, in the case of a male hysterectomy with oophorectomy are not necessary for
partner, an oocyte donor and surrogate mother are both legal sex reassignment (T’Sjoen et al., 2013). Also, in
necessary in order to fulfil their child wish (Ettner et al., Sweden, the requirement of sterilization for sex reassign-
2007). ment legalization was ruled unconstitutional in court in
2013. These changes affect clinical practice (Rodriguez-
Wallberg et al., 2014). In cases where transgender men
Testicular tissue cryopreservation decide to retain their ovaries and uterus, they may regain
For cryopreservation of immature testicular sperm, a fertility after discontinuing androgen therapy. It is a fact
surgical biopsy of testicular tissue from pre- or post- that transgender men are becoming pregnant and are
pubertal transgender women is performed (Wallace having babies, regardless of prior testosterone use (Light
et al., 2014). This option overcomes the need for et al., 2014). This also emphasizes the need for
masturbation and is possible in pre-pubertal boys specialized obstetric care, addressing the specific needs
(Wallace et al., 2014). It is a surgical procedure that of pregnant transgender men.
can be combined with the genital reconstructive surgery. In transgender women, being pregnant and giving
Compared to the other two options, this is an experi- birth is still impossible. The Swedish research unit of
mental method. For future use, an in vitro maturation Brännström and his colleagues conducted a series of
procedure or transplantation is necessary followed by uterus transplants and reported a first live birth in 2014
assisted reproduction techniques. Transplantation (Brännström et al., 2015). This opens the possibility for
can, however, restore the male endocrine environment, assisted gestation for transgender women (Murphy,
which clearly is an undesired effect for transgender 2014). However, there are important medical concerns
women. regarding uterus transplantation if introduced to
INTERNATIONAL REVIEW OF PSYCHIATRY 117

transgender people (Hamada et al., 2014; T’Sjoen et al., Discuss ferlity and
refer to a
2013). A difficult surgical procedure would be needed in specialized centre
order to change the anatomy of the male pelvis with the
intention to perform a successful uterus transplantation. Assessment and Hormonal Sex reassignment
Moreover, immunosuppressive therapy would be neces- diagnosis treatment surgery
sary and is possibly contra-indicated during a pregnancy
(T’Sjoen et al., 2013), but that by itself would not be any Discuss ferlity and
refer to a
different from a uterus transplantation in a cisgender specialized centre
(being a non-trans) female patient.
Figure 1. Therapeutic approach.
What is known about transgender parenting
and children? Discussion and conclusion

The above mentioned options clearly show the oppor- Fertility and fertility preservation are important topics to
tunities (and limits) for transgender patients with a discuss before planning any treatment to facilitate a
present or future genetically related child wish. All these transgender person to live according to the gender they
possibilities, however, are strictly regulated by national identify themselves with. An overview of when to
legislations. Apart from legislation, some healthcare address fertility in the approach of transgender people
professionals still need to be convinced about the is given in Figure 1. A patient should be clearly informed
necessity and the ethical acceptability to preserve fertility upon diagnosis, before starting hormonal treatment or
in this patient group (De Sutter, 2001). The underlying genital reconstructive surgery. The first information on
question is whether transgender parenting has a negative fertility preservation should be given by healthcare
influence on the gender identity and the sexual orien- professionals at the gender identity clinic service. Next,
tation of a child (T’Sjoen et al., 2013; White & Ettner, the patient should be referred to a specialized fertility
2004). Few studies have addressed this question and centre to discuss in more detail his or her options.
conclusive evidence is scarce. Although the results from Information on success rates of each technique especially
these studies are reassuring, long-term follow-up studies is highly patient-specific. In cases of sperm cryopreser-
are undoubtedly needed. None of the studies published vation or surgical sperm extraction, success rates are
so far showed that children suffer to such an extent that similar to preservation in non-trans patients. However,
would warrant a prohibition of transgender parenting reproductive techniques (intrauterine insemination or
(Murphy, 2012). Transgenderism as a reason to interrupt ICSI) as well as pregnancy results depend on the age and
contact between the transgender parent and his or her fertility-related medical history of the partner. In cases of
children, as is the case in some countries, is documented embryo or oocyte cryopreservation, the age of the trans
to be harmful for the children (Green, 1978; T’Sjoen men at the moment of cryopreservation is very import-
et al., 2013). It is shown that a child having a transgender ant. All the other aforementioned techniques are still
parent may experience more transient and mild harass- experimental, therefore referring a patient to a specia-
ment than those who do not have a transgender parent lized fertility centre in order to have correct and nuanced
(Green, 1978; T’Sjoen et al., 2013). information is highly recommended.
Children who were younger at the time of their The current available options for fertility preservation
parent’s transitioning, showed better adaptation and are very promising. One must, however, realize that the
maintained healthier relationships with both the transi- banking of gametes cannot guarantee future treatment. If
tioning and the other parent in a study by White and a trans person has a wish for a genetically related child
Ettner (2007). A less conflicted relationship between (individually or as a couple) pre- or post-transitioning,
child and parents is also predicted by a positive they should undergo the screening procedure according
relationship between the two parents (White & Ettner, to the protocol of the centres for assisted reproduction.
2004, 2007). In cases of transitioning of the transgender Furthermore, not all theoretical reproductive options are
parent before the birth of a child, it is important to possible at this time and not all forms of medically
disclose the transgender identity of the parent early in assisted reproduction are available in every country.
childhood, rather than later in the life of the child. The Additionally, medically assisted reproduction, although
possibility that certain specific circumstances concerning considered to be safe, is not without health risks and it is
the birth of the child are disclosed by someone else than often expensive.
the parents should be avoided as this can be tremen- The use of the cryopreserved gametes will there-
dously traumatic for the child (Chiland et al., 2013) fore depend on their quality, success rate of the
118 DE ROO ET AL.

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Grynberg, M., Fanchin, R., Dubost, G., Colau, J. C., Brémont-
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Education Society (GIRES) foundation for their support in our
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