Emerging evidence indicates that transgender youth are ineffectively counseled on fertility preservation prior to beginning cross-sex hormone therapy. As transgender individuals grow into adulthood, many are unable to conceive a biological child, which is associated with psychological distress. The paradox of conserving reproductive sex hormones that do not align with an individual’s affirmed gender is an additional source of stress on transgender youth navigating the decision to preserve their fertility.
Nahata et al. conducted a retrospective review of electronic medical records of adolescent youth experiencing gender dysphoria, who were referred to pediatric endocrinology. They found that 72 out of 73 adolescents in the sample were made aware of their option for fertility preservation and given the option to pursue it in concordance with cross-sex hormone therapy. Only two participants pursued the option, despite receiving information for either sperm banking or a referral to a reproductive endocrinologist.
Participants reported being interested in adoption over having biological children (38.1% of transgender females; 50% of transgender males) among their reasons for not wanting to attempt fertility preservation. Other reasons included discomfort in producing a semen sample through masturbation, or concern that attempting fertility preservation would further delay cross-sex hormone therapy.
The pressure of deciding to transition, coupled with the prospect of preserving the very sex hormones that do not align with one’s perceived gender is one reason that fertility preservation is currently underutilized.
While results from this study indicate that transgender adolescents may not be interested in fertility preservation, other studies have highlighted that interest in conceiving biological children increases in adulthood. One study found that, out of a sample of 121 individuals from the United States and Europe, 51% of transgender females would have considered sperm banking if given the option. Another study found that, out of a sample of 50 transgender males, 54% reported a desire for biological children, while 37.5% would have considered freezing their eggs. The results from studies like these are difficult to infer generalizability to the US transgender population as a whole.
Many studies on transgender populations are small in sample size and/or conducted cross-sectionally at a single site. Additionally, transgender individuals fall along a spectrum throughout the transition process, making it difficult to capture perceptions associated with transgender status. Individuals sampled in the De Sutter et al. study expressed increased interest in fertility preservation if they had also undergone gender re-assignment surgery, and were under 40 years of age, compared to individuals who identified as trans, but had not undergone surgery.
It seems that, as transgender adolescents develop into adults, their perceptions surrounding fertility preservation may change as well. Healthcare providers are introducing the topic at a sensitive time, when transgender youth are still considering cross-hormone therapy. The pressure of deciding to transition, coupled with the prospect of preserving the very sex hormones that do not align with one’s perceived gender is one reason that fertility preservation is currently underutilized. As transgender individuals mature in adulthood, the potential for having biological children can become a challenge, as years of undergoing cross-sex hormone therapy can compromise an individual’s sexual reproductive organs, particularly in trans men.
Healthcare practitioners within reproductive endocrinology are making strides to incorporate fertility preservation as part of the continuum of care for transgender individuals. It is important, however, for those providing care to trans patients to become educated on guiding them through the transition process, while also making youth aware of fertility preservation options in a sensitive manner.
Further research on this topic is necessary to illuminate the complexities of reproductive health needs among the transgender population.
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