Thoughts and opinions about fertility preservation and family building from the transgender community—an interview-based approach

Abstract

Background

When considering the significant prevalence of transgender and gender nonconforming individuals, it is imperative that physicians work to understand the unique needs of this population including paths to family building and fertility preservation.

Objective

To understand the thoughts and opinions about fertility preservation and family building within the transgender community.

Study design

Survey-based study and qualitative study at a single, large hospital-affiliated fertility center. A 16-question survey followed by a 30-minute virtual interview was utilized. Forty-three participants completed the survey and were used for quantitative analysis, and 40 audio files were used for qualitative analysis.

Results

The average age of participants was 27.0±7.3 years old. The majority of participants were assigned female at birth (70.7%); however, most participants’ gender identities were transgender (54.8%) or nonbinary (47.6%). The average age at which participants realized they were transgender and disclosed their identity to a friend, or partner, was 16.2±7.0 (range 3–30) and 20.1±5.6 (range 11–33), respectively. The average age that participants disclosed their gender identity to their parents, siblings, or other family was 22.4±5.9 (range 12–35). Five categories were utilized to summarize the experiences and opinions of the participants: family building and parenthood goals, influences of family background/partner on parenthood goals, awareness and knowledge about fertility preservation, barrier to family building, and recommended healthcare provider communication and education. Sixteen participants (40.0%, n/N=16/40) were interested in having children in the future, 18 (45.0%, n/N=18/40) were unsure/dependent on their partner, and 6 (15.0%, n/N=6/40) were not interested in having children. Of those interested in having children (n/N=16/40), the majority wished to utilize adoption to build their family (68.8%, n/N=11/16). Nine participants (22.5%, n/N=9/40) reported that fertility preservation was never discussed. Most participants agreed that gender dysphoria, cost, inadequate counseling, and improvements in healthcare knowledge about transgender individuals were key influences on their opinions about pursuing fertility preservation or parenthood.

Conclusion

Transgender individuals want to build families, and the majority consider adoption the preferred method. There are still transgender individuals who are not counseled about fertility preservation. It is imperative the healthcare system continues to improve the education of healthcare providers about management and care of transgender individuals to provide the best care for this vulnerable population.

AJOG Global Reports at a Glance.

Why was this study conducted?

This study was conducted to assess transgender individuals’ wish for parenthood or fertility preservation.

Key findings

Most transgender individuals agree that gender dysphoria, cost, inadequate counseling, and improvements in healthcare knowledge about transgender individuals were key influences on their opinions about pursuing fertility preservation or parenthood.

What does this add to what is known?

Most transgender individuals surveyed wish to pursue adoption for family building.

Introduction

There are currently 1.6 million people in the United States over the age of 13 that identify as transgender or gender nonconforming.¹ It is important that physicians work to understand the unique needs of this population including paths to family building and fertility preservation (FP).

Fertility preservation prior to initiating gender affirming hormone treatment (GAHT) is one option for transgender individuals seeking to have biological children. This path towards family building has been the focus of numerous studies. However, there are significant barriers to FP which impact the utilization of FP, including inadequate counseling by providers, concerns of gender dysphoria, discomfort with masturbation, and cost.² When exploring other methods of family building, transgender adolescents expressed a clear desire for counseling on all options with a preference for adoption.³

Studies have evaluated future family-building goals and perceived barriers; however, overarching thoughts and opinions on family-building of transgender individuals at different stages of transition are poorly understood. WPATH recommends providers counsel patients on their FP options and offer a formal referral to reproductive endocrinology prior to starting GAHT. However, utilization of FP is low in adolescents seeking gender affirming care with only 11.1% of AMAB participants and 0.01% of AFAB participants undergoing FP prior to starting GAHT.⁴ In another study, similarly low rates of FP were reported with more than a third of participants reporting mild to severe regret of not undergoing FP.⁵ Overall, decision regret has been shown to be lower in those who underwent FP; however, when comparing to cisgender women considering FP for various medical conditions, the rates of decision regret were not statistically different.⁶

Prior studies have been limited by small sample sizes and survey-based data lacking subjective reasoning from participants to better understand patients’ mindsets surrounding FP when initiating gender affirming care. The goal of this study is to understand thoughts about FP and family-building within the transgender community by utilizing quantitative analysis of a preinterview demographic survey and qualitative analysis of semistructured interviews.

Methods

Study participants

Participants were recruited to participate in the study by flyers posted at Fenway Health, an LGBTQIA+ focused primary care clinic, in Boston, Massachusetts from 4/1/2022–3/1/2024. Additionally, participants were recruited by snowball sampling through referrals from other participants to reach a wider audience of transgender individuals that may not have received care directly at Fenway Health. We do not believe this introduced a selection bias as less than 5 participants were recruited this way. Participants had to identify as transgender or noncisgender and be ≥18 years old to meet eligibility. No participants who met inclusion criteria were excluded. Participants were sent a 16-question survey (Appendix A) to complete prior to their individual 30-minute Zoom interviews. A qualitative semistructured interview was conducted utilizing a constructivist ontology approach given the personal nature of the topic and its previous use in prior studies investigating fertility decisions.⁷

Interviews were audio recorded using Voice Recorder (Tapmedia Ltd.) and transcribed using Microsoft Word® dictation software. Transcribed responses were edited by ZW and KM to ensure correctness. Responses were reviewed by ZW for common answers among responses. A $30 gift card for completion of the survey and virtual interview was provided.

Survey design

The preinterview survey consisted of 16 questions that obtained demographic information (age, gender assigned at birth, gender identity, sexual orientation, and preferred pronouns), realization and disclosure of gender identity, social history, use of gender affirming hormones, and history of gender affirming surgery (GAS). Participants were instructed that responses were voluntary, as certain questions could be triggering or induce dysphoria. All participants completed the preinterview survey.

Statistical analysis

The initial study sample size was 30 due to initial funding by the Massachusetts Medical Society LGBTQ Health Disparities Grant, which paid participants’ renumeration. The sample size was increased in 10/2023 with acquisition of additional funds from an internal sundry account. Three participants had corrupted audio files, which could not be transcribed for qualitative analysis; however, their responses were included in the analysis of the preinterview survey. Descriptive statistics were used to summarize patient demographics. Chi-squared and Fisher's exact tests were used for categorical variables. Kruskal–Wallis test was used for continuous variables. Data reported in this study reflected statistical significance when P<.05. All analyses were performed using online statistical calculators (https://www.socscistatistics.com/tests/ and https://astatsa.com/FisherTest/). This study was approved by the Institutional Review Board (Protocol #2021P002755).

Results

Study population

A total of 43 participants were included. The average age of participants was 27.0±7.3 years. The majority were assigned female at birth (70.7%) and most participants’ identified as transgender (54.8%) or nonbinary (47.6%) (Table 1). The average age that participants realized they were transgender and disclosed their identity to a friend, or partner, was 16.2±7.0 years (range 3–30) and 20.1±5.6 (range 11–33), respectively (Table 2). Most participants used contraception (54.8%), most commonly condoms (40.5%) (Table 3). Additionally, 73.8% of participants were on GAHT (Table 4). Last, 35.7% (n=15) of participants previously underwent GAS, and most remaining participants (66.7%, n/N=18/27) wished to in the future.

Table 1.

Baseline demographics

Characteristic	N=43 (%)
Agea	27.0±7.3
Gender assigned at birth
Male	12 (29.3)
Female	29 (70.7)
Missing	1
Gender identity (select all that apply)
Male	13 (31.0)
Female	7 (16.7)
Transgender	23 (54.8)
Trans	14 (33.3)
Nonbinary	21 (50.0)
Genderqueer	7 (16.7)
Gender diverse	1 (2.4)
Gender nonconforming	8 (19.0)
Agender	1 (2.4)
Intersex	0 (0)
Something else	4 (9.5)
History of puberty blockers	1 (2.3)
Sexual orientation (select all that apply)
Straight	3 (7.1)
Gay	6 (14.3)
Lesbian	5 (11.9)
Bisexual	14 (33.3)
Pansexual	9 (21.4)
Asexual	2 (4.8)
Queer	21 (50.0)
Still figuring it out	1 (2.4)
Other	3 (7.1)
Pronouns (select all that apply)
He/him	18 (42.9)
She/her	11 (26.2)
They/them	22 (52.4)
E	0 (0)
Ze	0 (0)
Other	1 (2.4)
None	0 (0)

^aValues are given as mean±SD.

Walker. Transgender population and family building. Am J Obstet Gynecol MFM 2024.

Table 2.

Age at time of realization and disclosure

Question	Responsea (N=43)
What age did you first start to realize you were transgender, gender diverse, or gender nonconforming?	16.2±7.0 (3–30)
What age did you tell a friend or partner?	20.1±5.6 (11–33)
What age did you tell your parents, siblings, or other family members?	22.4±5.9 (12–35)
What age did you disclose to a therapist?	21.1±5.4 (11–31)

^aValues are given as mean±SD (range).

Walker. Transgender population and family building. Am J Obstet Gynecol MFM 2024.

Table 3.

Social life

Question	N=43 (%)
Who do you live with (select all that apply)?
Parents	4 (9.5)
Friend(s)/roommate(s)	24 (57.1)
Romantic partner(s)	13 (31.0)
Live alone	7 (16.7)
Other	1 (2.4)
Relationship status
Single and not dating or hooking up	10 (23.3)
Single but causally dating or hooking up	9 (20.9)
Nonexclusive romantic relationship	9 (20.9)
Exclusive romantic relationship not legally recognized	11 (25.6)
Legally recognized romantic relationship (with one or more partners)	2 (4.7)
Other	2 (4.7)
Do you use contraception?
Yes	23 (53.5)
No	16 (37.2)
Sometimes	4 (9.3)
What type of contraception do you use (select all that apply)?
Condoms	17 (40.5)
Birth control pills	5 (11.9)
IUD	11 (26.2)
Nexplanon	1 (2.4)
Vaginal ring	0 (0)
Other	0 (0)
If not using contraception, has a health care provider discussed option for contraception with you? (n=20)
Yes	8 (53.3)
No	5 (33.3)
Not sure	2 (13.3)
Missing	5
Would you like more information about contraception?
Yes	7 (21.2)
No	22 (66.7)
Not sure	4 (12.1)
Missing	10
Have you conceived a spontaneous pregnancy with a sexual partner?
Yes	0 (0)
No	41 (95.3)
Not sure	2 (4.7)

Walker. Transgender population and family building. Am J Obstet Gynecol MFM 2024.

Table 4.

Hormone use

Question	N=43 (%)
Are you currently taking hormones?
Yes	31 (72.1)
No	12 (27.9)
What hormones are you taking? (n=31)
Estrogen alone	3 (9.7)
Testosterone alone	19 (61.3)
More than one	9 (29.0)
Do you use any other hormones (e.g., spironolactone, finasteride, etc.)?
Yes	7 (77.8)
No	2 (22.2)
Does a health care provider help manage the dose and schedule of your hormones? (n=31)
Yes	30 (100)
Sometimes	0 (0)
No	0 (0)
Missing	1
What type of provider manages your hormone? (n=31)
Primary care	22 (73.3)
Endocrinologist	6 (20.0)
Pediatrician	0 (0)
Gynecologist	0 (0)
Other	2 (6.7)
Missing	1
How long have you been on hormones? (n=31)
Less than 6 months	4 (13.3)
6–12 months	4 (13.3)
More than 12 months	22 (73.3)
Missing	1
Have you currently stopped hormone after being on them in the past?
Yes	4 (12.1)
No	29 (87.9)
Missing	10

Walker. Transgender population and family building. Am J Obstet Gynecol MFM 2024.

Family building and parenthood goals

All participants (N=43) underwent a virtual interview. Three had corrupted audio files and their responses were excluded. Sixteen participants (40.0%) were interested in having children in the future, 18 (45.0%) were unsure/dependent on their partner's wishes, and 6 (15.0%) were not interested. Of those interested (n=16), the majority desired adoption for family-building (68.8%, n/N=11/16).

When asked how their current viewpoints on parenthood corresponded to their childhood viewpoints, 18 participants reported that they desired to have a family in the future (interested->interested, n/N=11/40 [27.5%]; indifferent->interested, n/N=2/40 [5.0%]; not interested->interested, n/N=5/40 [12.5%]) (Table 5). Nine participants who were interested in parenthood as a child became indifferent (n/N=5/20, 25%) or not interested (n/N=4/20, 20%) as adults. Only four participants (n/N=4/18, 22.2%) expressed interest in having a biological child. When comparing those who were interested, indifferent, and not interested in family building, we found that there was a significant difference between groups pertaining to the time they revealed their gender identity to a friend or partner (P=.02) (Supplemental Table 1).

Table 5.

Change in viewpoint of parenthood from childhood to adulthood

Childhood views->adulthood views	N=40 (%)
Interested
interested->interested	11 (27.5)
interested->indifferent	5 (12.5)
interested->not interested	4 (10.0)
Indifferent
indifferent->interested	2 (5.0)
indifferent->indifferent	3 (7.5)
indifferent->not interested	1 (2.5)
Not interested
not interested->interested	5 (12.5)
not interested->indifferent	4 (10.0)
not interested->not interested	3 (7.5)
Could not remember	2 (5.0)

Walker. Transgender population and family building. Am J Obstet Gynecol MFM 2024.

Influences of family background/partner on parenthood goals

Several participants expressed being positively (n/N=13/40, 32.5%) or negatively (n/N=15/40, 37.5%) influenced to pursue family building based on experiences with their or their partner's families. Examples of negative influences included: “bad genetics,” history of abuse, unsupportive home environment, parents being divorced, and feelings of worry about having offspring in the current state of world.

• •“Yeah, so my father had some pretty serious mental illnesses, so that sort of scared me with parenting. I was worried about them potentially being genetic and passing them down and things like that.”
• •“I think the state of the world right now, it's interesting thinking about raising a child or bringing a new child into the world. Thinking about their futures and stuff, that's a big contributing factor.”
• •“I had really abusive parents. The idea of having little offshoots of my DNA doesn't seem like an appealing idea because I didn't want to make any of the same mistakes my parents made.”

In contrast, some participants who originally had a negative perspective on family-building were later positively influenced by their or their partner's families to pursue parenthood.

• •“…I want to make sure that I give my children an open space that I didn't necessarily get when I was a child.”
• •“I think that that's a really big thing because so many of us haven't had good family situations, so seeing that [my partner] would be responsible and how they interact with kids...”

Last, some stated they were interested in building a family; however, they struggled with finding open-minded partners who were similarly interested. Some mentioned that being transgender placed greater emphasis on their being intentional about how they chose to build a family.

• •“First, I need to find possible potential partners, but I know not so many people are open minded, even though they recognize there are certain amount of LGBTQ+ people.”
• •“It's one of those things whereas a trans person, it's not as easy for me. I'm going to have to be intentional about whatever I do.”

Awareness and knowledge about fertility preservation

Nine participants (n/N=9/40, 22.5%) reported that FP was never discussed. Some participants perceived the possibility that GAHT could be withheld, or refused, if they expressed interest in preserving fertility. Participants reported varying healthcare experiences and a negative connotation about divulging their truth with providers.

• •“I don't even think I've ever been asked about [fertility preservation or family building]. My PCP at home has grown up with me, and to him I'm just this little straight girl.”
• •“Well at that time I thought if I take testosterone, I'm not going to have kids so subsequently at times I used it as my only form of birth control.”
• •“If I were to preserve sperm, that would almost be a sense of dysphoria because I don't want to have sperm.”
• •“I know places, or I know people who've gone to places where, if they're not saying, “I'm a transwoman or transman” then there's an issue getting HRT.”

For those who received counseling (n/N=31/40, 77.5%), many felt it was inadequate or misleading, lacking discussion about cost, insurance coverage, service locations, or how GAHT may affect future fertility.

• •“My insurance actually did cover egg banking and had I known that I actually probably would've done that before starting testosterone.”
• •“I know I delayed starting testosterone for almost like 7-8 years because I thought it would cause permanent infertility…”
• •“…the wait list for the cryogenic banking was so long and the cost is just too high. I was like, never mind I'm good, let's move on.”

Some transgender female participants wished to carry a pregnancy and were waiting for the medical community to develop techniques to enable this (e.g., uterine transplant). Transgender male participants desired to donate their reproductive organs but did not wish to undergo invasive procedures for this.

• •“I haven't done the preservation thing. I'm more interested in waiting for science to advance. I'd be interested on waiting until they are able to put it inside of me, like a uterine transplant.”
• •“Honestly one of the reasons I've been holding on to mine besides being scared of surgery is because maybe someone can use this.”

Participants who previously underwent GAS with a hysterectomy, metodioplasty (aka bottom surgery), or orchiectomy (n/N=5/6, 83.3%) reported that their surgeon discussed future family planning before surgery.

Barriers to family building

The majority of participants (n/N=34/40, 85.0%) either desired or were unsure about future parenthood. Discussions about barriers to family building elicited numerous problems, including cost, medical providers’ inexperience with counseling transgender patients, and anticipated difficulty with the adoption process. Most (n/N=30/40, 75%) felt the adoption process would be difficult based on their gender identity or sexual orientation.

• •“Part of me also fears providers again, like are they going to be comfortable and knowledgeable?”
• •“It's definitely going to play a factor but if it came to a point in the world where nobody can be transgender, I'm fortunate because I pass very well [as a female]. So, if it came to it, I would just not say anything.”
• •“I think there is still bias in the adoption world that transgender individuals aren't suitable parents.”

Participants had varying experiences with adoption. Some were adopted themselves while others had friends or family that were adopted. Even those with no personal adoption experience preferred to adopt due to lack of desire to carry a pregnancy, altruism for LGBTQIA+ children looking to be adopted, and desire to foster.

• •“It seems to me like the big issue in Massachusetts right now is finding foster parents who will still care for a child if they come out as gay or trans regardless of their gender identity. So, I feel like for Massachusetts DCF, it could be like, a positive thing.”
• •“Even before I knew I was trans I was interested in adoption.”

Some felt the adoption process was unethical and felt like a business transaction. Others had special situations influencing their path towards family-building. For example, one participant carried a BRCA mutation which placed pressure on their decision-making timeline for family-building.

Recommended healthcare provider communication and education

Participants verbalized recommendations for how providers can improve education about FP, family-building, and access to care. Reoccurring responses included discussions about cost, insurance coverage, inclusive language, and avoiding making assumptions about family-building goals.

• •“It'd be helpful to have some good quick simple information about the cost.”
• •“What happens when you start and stop hormones with your fertility?”
• •“As the patient coming to the experts, I would hope that even if we don't deep dive into every single option, I would still be made aware.”

Additionally, participants requested that clinics increase representation of nontraditional families and to counsel patients on nontraditional family-building.

• •“I feel like the stigma with trans men getting pregnant is so dense because even there are trans men that are like, why would you ever do that? So, I feel like it's coming from both sides. I feel like representation of normalizing something like [being pregnant] would make a lot more people comfortable to the idea of actually doing that.”

Last, participants discussed experiences about seeking GAHT at younger ages and how providers may not recognize the stress and pressure that patients face from parents.

• •“Being aware of not only what it is like [as a patient] with your parents at the doctor, but what it is like on the car ride there.”
• •“Until I got into college, I didn't have my own money and also I was sure that my parents would not allow me to go see a doctor.”

Discussion

Primary findings

Our study found that transgender individuals are interested in family-building and would primarily pursue this by adoption. Most participants realized their gender identity before adulthood (<18 years old) and disclosed their gender identity to friends and/or partners before family. Most participants wished to undergo GAS if not previously done. This highlights that pediatricians, surgeons, and other healthcare professionals are responsible for counseling patients about these opportunities. Our study showed that most surgeons performing GAS counsel patients about FP. Additionally, our qualitative study found several reoccurring responses: gender dysphoria with pregnancy, fear of passing “bad” genetics to offspring, strong influence by family and/or partner's family, cost of family building and FP, lack of insurance coverage, and lack of adequate FP counseling.

Results in the context of what is known

Our findings are similar to studies investigating transgender individuals’ wish to family build.^8,9 Strang et al. found that one-third to two-thirds of transgender individuals desired children and only 24% expressed interest in having biological child(ren). This is similar to our findings which showed that 40% of participants desired to have children in the future and only 22% desired a biological child.

Studies have shown that transgender individuals who desire to build a family preferred adoption which was related to concerns about passing along “bad” genes, not prioritizing having a biological child, or planning adoption preferentially.¹⁰ Conversely, fears about discrimination from adoption agencies are apparent.¹¹ Our study supports these findings with common responses of preference for adoption, concern of passing along “bad” genes, preferentially planning adoption, and fear of the adoption process. There is little heterogeneity within the results of our study and other recent studies, highlighting the importance of our findings, and emphasizes the need for additional support for transgender individuals seeking family-building.

Fertility preservation counseling is inconsistent among the transgender community.¹² This may be due to their preference to forego FP and start hormonal treatment as soon as possible, gender dysphoria with banking unwanted gametes, or lack of communication from healthcare providers. The need to discontinue testosterone for transgender men prior to FP and/or the impact of testosterone on long-term fertility continues to be debated. Study participants who received counseling on GAHT reported that discussion of long-term effects of testosterone on fertility were lacking. Several studies have reported lack of discussion of potential negative impacts of GAHT on fertility.^10,13,14 One study reported that only 22.7% of participants discussed FP with a provider.¹⁰ This is contrary to our study, which revealed that 77.5% discussed FP; however, the depth of conversation varied. This is an important area of focus as transgender men may not pursue FP due to lack of desire to stop testosterone and fear of experiencing gender dysphoria during the FP process. Albar et al. found no association between duration of testosterone therapy or timing of testosterone cessation with number of mature oocytes obtained in transgender men undergoing FP.¹⁵ Case reports of patients who completed FP while on testosterone demonstrated overall good success with retrieval of mature oocytes.16, 17, 18, 19 Providers counseling transgender individuals should be transparent about the limited knowledge on the potential effects of testosterone, but discuss that completion of FP without cessation of treatment to date has shown good outcomes.16, 17, 18

Our study revealed the desire for transgender women to carry a pregnancy and for transgender men to donate reproductive organs. Studies have shown that transgender men may be a potential source for uterine donation at the time of GAS. A study by Carbonnel et al. among transgender men who underwent GAS found that 88.3% (n/N=83/94) would donate their uterus for transplantation.²⁰ As increasing research and efforts are placed into uterine transplantation, the transgender community should be included in discussions as a potential source and recipient of this procedure to ensure inclusivity and access.

Clinical implications

Access to care is lacking within the transgender community.^21,22 Finding providers who are well-versed in transgender healthcare is challenging. This study highlights gaps in educating transgender individuals on FP and family-building. The goals for family-building and FP are diverse among the transgender community, and counseling should be tailored towards individuals’ goals. Counseling efforts should focus on cost, insurance coverage, effects of GAHT on fertility, locations for FP, and the adoptive process. This expansive amount of counseling may require a multidisciplinary approach or close follow-up visits to aid in efficiency of care while also reducing barriers for those interested in these services. All transgender individuals should be offered counseling but have the option to opt-out.

Strengths and limitations

Strengths of our study include use of a mixed-methods study design within a targeted population that allowed for better understanding, improved analysis of data collection, and insight to possible clinical applications that will improve FP and family-building counseling for transgender individuals. All participants volunteered, which demonstrated true interest in the study, lends confidence in the accuracy of responses, and minimizes biases. Our study has limitations. Corrupted audio data for 3 participants may have influenced our qualitative analysis. We only recruited patients from a single site (Fenway Health, Boston); however, this site is well-known as a leading center for transgender care, and participants were recruited by snowball effect to increase the catchment area for participation. Last, there may be recall bias in some answers given the survey and interview discussed information that occurred >5 years ago for most participants.

Conclusion

Transgender individuals want to build families and consider adoption their preferred method. Some transgender individuals are still not counseled about FP. It is important that the healthcare system continues to improve education of healthcare providers about treatment for transgender individuals to provide the best care for this vulnerable population.

CRediT authorship contribution statement

Zachary W. Walker: Writing – review & editing, Writing – original draft, Project administration, Investigation, Formal analysis, Data curation. Katelin McDilda: Writing – original draft, Project administration, Investigation. Andrea Lanes: Writing – review & editing, Methodology. Randi Goldman: Writing – review & editing, Validation. Elizabeth S. Ginsburg: Writing – review & editing, Validation. Iris Insogna: Writing – review & editing, Funding acquisition, Conceptualization.