A Pilot Study to Assess Attitudes Toward Future Fertility and Parenthood in Transgender and Gender Expansive Adolescents
Abstract
Purpose: In this pilot study, we sought to characterize the knowledge about fertility and attitudes about future parenthood in a sample of transgender and gender expansive (TGE) youth attending an academic, university-affiliated adolescent gender program.
Methods: A 22-item cross-sectional survey assessing knowledge of fertility issues and attitudes toward future parenthood was administered to 23 transgender adolescents, 12–22 years of age, who reported gender identity incongruent with birth-assigned sex, and who were seen at our university-affiliated clinic during an 11-month period between October 2016 and August 2017. Knowledge scores and ranked responses on selected topics in fertility and reproduction were evaluated.
Results: Participants were well informed overall about fertility topics related to their gender care (mean score of 3.8±0.8 out of 5), but over half of participants lacked specific knowledge regarding basic fertility principles and overestimated the ability of physicians to predict the effects of gender-affirming hormone therapy on fertility. The majority of participants (15/23) preferred nonbiological parenthood in the form of adoption. Participants who ranked future parenthood as unimportant had the greatest concern about becoming a parent (p<0.05), and over one-third were also concerned about interrupting their gender-affirming hormone therapy to preserve fertility.
Conclusion: TGE youth would benefit from fertility-related counseling that both assesses baseline understanding of reproduction and also acknowledges the limitations of current data on gender-affirming hormones and future fertility. Counseling should also be comprehensive and explore both biological and nonbiological forms of parenthood.
Introduction
In the United States, an estimated 150,000 adolescents, or 0.7% of youth 13–17 years of age, identify as transgender or gender expansive (TGE).1 Adolescents who identify as transgender in early puberty are likely to continue to identify as transgender in adulthood2,3 and will often seek medical treatment to alleviate their gender dysphoria: the pervasive and persistent sense of distress from the incongruence between their birth-assigned sex and their gender identity.4–6 Medical treatment includes either pubertal blockade with gonadotropin-releasing hormone agonists to suppress the hypothalamic-pituitary axis or the administration of gender-affirming hormones, such as masculinizing testosterone or feminizing estrogen, to achieve secondary sex characteristics consistent with affirmed gender. Ideally, such treatment is begun before or during puberty, before the irreversible development of unwanted secondary sexual characteristics.7
Although treatment with gender-affirming hormones markedly improves quality of life of transgender individuals,3,8,9 current, but sparse evidence suggests that long-term exposure may compromise fertility by decreasing sperm quality in individuals with testes10,11 and by reducing the rate of ovulation in individuals with ovaries.12,13 Guidelines from the World Professional Association for Transgender Health and the Endocrine Society therefore strongly recommend that TGE individuals be counseled about and offered fertility preservation before starting gender-related care.7,14 Despite these recommendations and the expanding availability of fertility preservation services, only 12% of 105 transgender adolescents in one study sought consultation from a reproductive endocrinology and infertility specialist,15 and fewer than 5% completed fertility preservation.15,16
Previous studies have suggested that few TGE adolescents express desire to have their own biological child.17 These studies have come from a handful of institutions with a small sample size. Given the surge in interest surrounding TGE-related care and limited evidence available, studies from additional institutions and populations are needed to better characterize the needs of the adolescent TGE population. We sought to add to this growing body of literature and better understand the fertility-related experiences of TGE adolescents by conducting a pilot study to determine knowledge of fertility principles and attitudes toward future parenthood in a sample of transgender youth seen at our institution.
Materials and Methods
Participants
A written cross-sectional survey was administered to a convenience sample of patients seen at the Yale Pediatric Gender Program over an 11-month period between October 2016 and August 2017, as part of a larger database study. We included patients between 12 and 22 years of age, who identified with a gender different from their birth-assigned sex and were able to read English. Patients whose gender identity aligned with their birth-assigned sex (i.e., cis-gender), were younger than 12 or older than 22 years, or who declined to participate were excluded. The lower age limit of 12 years (or grade 6) was the age at which the majority of schools in the state reported teaching students about sexual education,18 while 22 years of age was considered the upper limit of late adolescence.19
Study investigators approached prospective participants (and their parent[s] or guardians, if minors) about participation in the study during routine medical or mental health visits at the Gender Program. Face-to-face meetings were held with investigators to address questions about the study rationale, procedures, risks, and benefits. Adult participants who wished to participate were provided with the Adult Consent Form, and minor participants were given Child or Adolescent Assent Forms, depending on their age (7 to <13 years or 13 to <18 years). Parents/guardians of minor subjects were given the Parent Permission Form to read, and the appropriate consent/assent forms were signed by participants/parents and investigators. Participants' general sociodemographic data, including birth-assigned sex, age, race/ethnicity, insurance status, and treatment-related data, including the use of puberty blockers or gender-affirming hormones, were obtained from consenting participants' electronic medical records. The study was approved by the Human Investigations Committee at Yale University (HIC 1605017811).
Survey design
A multidisciplinary group of specialists from pediatric and adolescent gynecology, reproductive endocrinology and infertility, and child psychiatry developed the 22-item survey to determine knowledge about fertility and attitudes toward future parenthood (Appendix A1). All survey questions were adapted from validated questionnaires in the young adult oncofertility literature20–23 to be relevant and developmentally appropriate to the TGE population.
For the knowledge items, participants answered five true-false-unsure statements. Each correctly answered item contributed one point to the total score, with no points awarded for incorrect or unsure responses. A total knowledge score from 0 to 5 was generated for each participant. To assess attitudes, participants answered 17 multiple-choice, true-false, or Likert-scale response questions. Likert-scale responses were rated on a 5-point scale of agreement, where 1 was “strongly disagree” and 5 was “strongly agree.” For descriptive purposes, we combined “strongly disagree” and “disagree” into one category. Similarly, we grouped “strongly agree” and “agree” responses.
Survey analysis
Statistical analyses were conducted using GraphPad Prism statistical software (version 7.0c; GraphPad Software, La Jolla, CA). Categorical variables were reported as frequency data and analyzed using Fisher's exact test. Continuous variables were assessed for normality by the D'Agostino and Pearson test and expressed as mean (standard deviation, or SD) or median (interquartile range) to reflect parametric and nonparametric data, respectively. Subgroups for analyses included birth-assigned sex, race/ethnicity, age, the importance of future parenthood (important, unimportant, and unsure), and medical treatment for gender dysphoria. All p-values were two sided with a statistical significance level of 0.05.
Results
Participant characteristics
Of the 38 eligible patients seen during the study period, 23 (61%) completed the survey, which we considered adequate, given the young age of participants and the potentially sensitive content of the survey. Eligible participants did not differ from nonparticipants in sociodemographic characteristics, suggesting that individuals who completed the survey are representative of the larger group of eligible individuals seen in our program (Table 1). The mean (SD) participant age was 16.2 (Table 2). Most participants were birth-assigned females (17/23), white (18/23), and privately insured (15/23), and received puberty blockers or gender-affirming hormones (18/23) (Table 2). Participants who were birth-assigned female and birth-assigned male did not differ significantly by sociodemographic or treatment-related variables (Table 2).
| Participant group | Participants (n=23) | Nonparticipants (n=15) | p |
|---|---|---|---|
| Age (years), mean±SD | 16.2±2.5 | 16.3±2.8 | 0.91 |
| Birth-assigned sex, n (%) | |||
| Female | 17 (74) | 12 (80) | 1.0 |
| Male | 6 (26) | 3 (20) | |
| Gender identity, n (%) | |||
| Transgender male | 15 (65) | 11 (73) | 0.59 |
| Transgender female | 6 (26) | 2 (13) | |
| Gender nonconforming | 2 (9) | 2 (13) | |
| Race/ethnicity, n (%) | |||
| White/Caucasian | 18 (78) | 8 (53) | 0.27a |
| Black/African-American | 2 (9) | 3 (20) | |
| Hispanic or Latino | 2 (9) | 2 (13) | |
| Asian | 1 (4) | 1 (7) | |
| Insurance, n (%) | |||
| Public | 8 (35) | 5 (33) | 1.0 |
| Private | 15 (65) | 10 (67) | |
Sociodemographic variables were extracted from patient medical records and compared between participants and nonparticipants using an unpaired t-test for continuous variables and Fisher's exact test for categorical variables.
a
Caucasian versus Non-Caucasian.
SD, standard deviation.
| Participant characteristic | Total (N=23) | Birth-assigned sex | p | |
|---|---|---|---|---|
| Female (n=17) | Male (n=6) | |||
| Age (years), mean±SD | 16.2±2.5 | 16.2±2.3 | 16.2±3.1 | 0.99 |
| Race/ethnicity, n (%) | 0.99a | |||
| White/Caucasian | 18 (78) | 13 (76) | 5 (83) | |
| Black/African-American | 2 (9) | 2 (12) | 0 (0) | |
| Hispanic or Latino | 2 (9) | 1 (6) | 1 (17) | |
| Asian | 1 (4) | 1 (6) | 0 (0) | |
| Insurance, n (%) | 0.99 | |||
| Public | 8 (35) | 6 (35) | 2 (33) | |
| Private | 15 (65) | 11 (65) | 4 (66) | |
| Use of puberty blockers or gender-affirming hormones, n (%) | 0.58 | |||
| Yes | 18 (78) | 14 (82) | 4 (66) | |
| No | 5 (22) | 3 (18) | 2 (33) | |
Sociodemographic and medical data were extracted from patient medical records and compared between birth-assigned females and males using the unpaired t-test for continuous variables and Fisher's exact test for categorical variables.
a
Caucasian versus Non-Caucasian.
Knowledge of fertility principles
The mean (SD) knowledge score for participants was 3.8 (0.8), with a maximum possible score of 5. Most participants knew that hormone therapy could affect future fertility and that options exist to preserve fertility (Table 3). Of concern, only a slight majority of participants (14/23) knew basic fertilization principles (“An egg and a sperm are needed to make a baby”), and more than half (13/23) erroneously perceived that physicians could accurately predict the effect of gender-affirming hormone therapy on fertility.
| Question | Correct answer | n (%) correct |
|---|---|---|
| Q1. All people who want to become birth parents are able to | False | 21 (91) |
| Q2. Hormones may affect a person's ability to have a child in the future | True | 22 (96) |
| Q3. A doctor can accurately predict the effect that hormones will have on a person's ability to have a child in the future | False | 10 (44) |
| Q4. An egg from a person born female and a sperm from a person born male are needed to make a baby | True | 14 (61) |
| Q5. Storing eggs or sperm is one way to preserve the ability to have a child in the future | True | 20 (87) |
Participants were asked a series of five true/false/unsure questions to establish baseline knowledge about reproductive health and fertility. % correct indicates the percentage of the 23 total participants who answered each question correctly.
Attitudes toward future parenthood
Participants indicated at similar rates that future parenthood was important (7/23) and unimportant (9/23); the remaining sample (7/23) was undecided (Fig. 1). When asked about their interest in types of parenthood, most participants preferred adoption (16/23). Fostering was the second preferred source of parenthood (10/23), followed by having a biologically related child (5/23). Surrogacy was the least common preference overall (4/23). Preferences did not vary significantly by age, race, or use of puberty blockers or gender-affirming hormones (all p>0.05).
We also asked participants to rank their concerns regarding fertility and future parenthood. More than half the participants (12/23) reported that thinking about trying to have a child one day was stressful, and many (7/23) worried that trying to have a child would take too much time and effort. Over one-third of participants (8/23) were concerned about delaying or stopping their transition process to seek fertility preservation. Of note, participants who indicated that future parenthood was unimportant were significantly more likely to express concern about becoming a parent than were participants who indicated that future parenthood was important or who were unsure (p<0.05).
Sources of information and information gaps
Most participants (15/23) reported discussing fertility topics and issues of future parenthood with a physician. Other common sources of information were friends and family (12/23), followed by online resources (9/23). Slightly more than half of participants (13/23) felt they were sufficiently informed about reproductive health and fertility issues at the time of survey completion. Of the 10 participants who requested additional information, a majority requested information about options for preserving fertility potential (7/10) and the risks and benefits of delaying gender-affirming hormones to undergo fertility preservation (6/10). Most preferred to get this additional information from an online website (7/10) than from a physician (4/10) or an informational handout (4/10).
Discussion
In this pilot study of TGE adolescents, we demonstrate that many of these adolescents lack detailed baseline knowledge of reproduction. Fewer than half of our participants understood that an egg and a sperm are both needed for reproduction to occur. We also show that underlying reproductive concerns in transgender adolescents may manifest as disinterest in future parenthood, and these adolescents place a high amount of trust in medical providers' abilities to predict the effects of gender-affirming hormone therapy on fertility, despite the fact that rigorous studies in this field are limited. Thus, physicians caring for the TGE adolescent should assess and reassess patients' baseline knowledge to ensure that decisions about fertility and future parenthood are fully informed, and continue to discuss patients' reproductive desires and goals as more data become available. Ensuring adequate information and understanding is crucial in preventing future reproductive regret.
High-quality data from randomized controlled trials regarding the effects of gender affirming hormone therapy on fertility are lacking, and long-term follow-up data are limited. A benefit of the use of gonadotropin-releasing hormone analogues in early adolescence (the “Dutch model” of care3) is the ability to achieve pubertal delay in younger transgender youth, avoiding the use of potentially irreversible gender-affirming treatments until the long-term developmental course and patient treatment preferences are clear and can be made with more mature assent and/or consent. Because most gender-affirming hormone therapy occur after consultation with a multidisciplinary team of specialists,5,7,24 TGE adolescents have multiple points of contact during this time period to obtain information about their reproductive health. Our finding that most TGE adolescents have received fertility-related information from a physician suggests that calls from professional organizations7,14,25 to counsel TGE adolescents about effects of gender-affirming hormone therapy on fertility have been well received and implemented. Current guidelines do not specify under whose purview fertility-related counseling should fall; therefore, clinics providing gender-affirming hormone therapy should establish practice-specific guidelines delineating this responsibility to ensure that all patients receive timely counseling.
TGE adolescents in our study were more likely to report an interest in nonbiological forms of parenthood. Our results suggest that this preference may be linked to the concern about stopping gender-affirming hormone therapy to pursue biological parenthood. These findings are consistent with other studies in transgender adolescents demonstrating a strong interest of TGE individuals in alternative family formation and prioritization of gender-affirming care over fertility.16,17,26 These results also affirm that reproductive counseling for TGE adolescents should include the full spectrum of reproductive options, including adoption. We found that many pilot participants reported feeling stressed about the process of becoming a parent. In previous literature, TGE birth-assigned females report transvaginal egg retrieval for assisted reproduction as uncomfortably invasive15,27 and worry that pregnancy may mean a return to their female identity.28,29 Similarly, TGE birth-assigned males report feeling that masturbation for sperm retrieval is gender incongruent16 and conception by insertive sexual intercourse is an unwanted experience.29,30 Therefore, a desire for nonbiological parenthood may stem from both a desire to continue gender-affirming medical therapy and to avoid procedures associated with biological parenthood, which may be incongruent with their gender identity.
Importantly, transgender adolescents in our study, who reported future parenthood as unimportant, were also the most likely to be concerned about the time, stress, and effort of having a child. These data suggest that reproductive concerns in transgender adolescents may manifest as disinterest in future parenthood. Transgender adolescents acknowledge the possibility that their attitudes toward parenthood may change in adulthood.17 Studies reporting planned pregnancy in many transgender adults after transitioning have indicated that many sought medical intervention to become pregnant.28,31 These changing attitudes highlight the importance of reassessing reproductive values over time, even in adolescents who express an initial disinterest in future parenthood.
A strength of our pilot study is its contribution to the literature surrounding reproductive decision making in TGE youth. If TGE adolescents receiving fertility preservation counseling do not understand basic reproductive principles, true “informed consent” when accepting or declining treatment options (such as oocyte or sperm cryopreservation) may not be present. It is also essential that practitioners understand that TGE adolescents may express their underlying reproductive concerns as disinterest, which could lead to a decision to decline fertility preservation in a patient who might otherwise pursue such options. Finally, our study shows that adolescents overestimate the ability of physicians to predict the effects of gender-affirming hormone therapy on fertility. Equally important in counseling TGE adolescents about their reproductive options is acknowledging the current limitations of available data regarding the effects of gender-related care on fertility. Specifically, no randomized controlled trials or studies with long-term follow-up have demonstrated the effects of gender-affirming hormone therapy on fertility and other risks and benefits of such treatment. For the substantial number of patients who continue to desire nonbiological forms of parenthood, counseling should also include alternative routes to parenthood.
Limitations
There are limitations to our study. As a pilot study, our work is based on a small sample size; these results will guide larger future studies, but given that the majority of the sample population in our study is Caucasian, care must be taken when generalizing our results to the larger TGE adolescent population. Moreover, while our survey questions were adapted from validated questionnaires in the young adult oncofertility literature to be relevant and developmentally appropriate to the TGE population, psychometric parameters such as reliability, sensitivity, and specificity are not available. The survey has been incorporated into a larger battery of clinical evaluations which will be used to provide robust validation for future studies. As patients continue to attend our clinic for gender-related care, we plan to readminister this survey to stratify resulting data by age group and determine whether there are age-related differences in knowledge or concerns about fertility relevant to consent for gender-affirming hormone treatment. This will also allow us to identify differences in reproductive regret in adolescents who do or do not pursue fertility preservation, and employ comprehensive qualitative interviews with youth and their families.
Finally, cross-sectional studies are by nature limited in their ability to explore additional details about survey responses or to follow longitudinal changes in participant knowledge and attitudes. Future studies may further this area of research by exploring the change in fertility-related attitudes over time and the role of regret in transgender adolescents who decline fertility preservation. Ultimately, because the effects on fertility and other risks and benefits of such treatments are lacking from randomized controlled trials and long-term follow-up, conversations with TGE adolescents must be guided by informed consent/assent discussions. Data such as those presented in this study are needed to gauge baseline knowledge and reproductive wishes to better guide these nuanced discussions.
Conclusion
In summary, in our study of TGE adolescents, we demonstrate that many of these adolescents possess limited baseline knowledge of reproduction, and that underlying reproductive concerns in transgender adolescents may manifest as disinterest in future parenthood. Providers caring for these individuals should carefully evaluate patients' baseline knowledge, engage in discussions regarding currently available data, and keep abreast of developments in our knowledge of fertility preservation options and limitations. These considerations will help ensure that decisions about fertility and future parenthood are fully informed and prevent future reproductive regret in this vulnerable population.
Abbreviations Used
- SD
- standard deviation
- TGE
- transgender or gender expansive
Acknowledgments
We thank Dr. Anisha Patel, Dr. Susan Boulware, Dr. Stuart Weinzimer, Faria Kamal, Wendy Bamatter, Naomi Libby, and Rachel Lawton of the Yale Gender Program for their contribution to the development and implementation of this survey.
References
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8. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol. 2010;72:214–231.
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10. Lubbert H, Leo-Rossberg I, Hammerstein J. Effects of ethinyl estradiol on semen quality and various hormonal parameters in a eugonadal male. Fertil Steril. 1992;58:603–608.
11. Schulze C. Response of the human testis to long-term estrogen treatment: morphology of Sertoli cells, Leydig cells and spermatogonial stem cells. Cell Tissue Res. 1988;251:31–43.
12. Ikeda K, Baba T, Noguchi H, et al. Excessive androgen exposure in female-to-male transsexual persons of reproductive age induces hyperplasia of the ovarian cortex and stroma but not polycystic ovary morphology. Hum Reprod. 2013;28:453–461.
13. Futterweit W, Deligdisch L. Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals. J Clin Endocrinol Metab. 1986;62:16–21.
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15. Chen D, Simons L, Johnson EK, et al. Fertility preservation for transgender adolescents. J Adolesc Heal. 2017;61:120–123.
16. Nahata L, Tishelman AC, Caltabellotta NM, Quinn GP. Low fertility preservation utilization among transgender youth. J Adolesc Heal. 2017;61:40–44.
17. Strang JF, Jarin J, Call D, et al. Transgender youth fertility attitudes questionnaire: measure development in nonautistic and autistic transgender youth and their parents. J Adolesc Heal. 2018;62:128–135.
18. Centers for Disease Control and Prevention. Connecticut School Health Profiles Data, 2015. Available at https://nccd.cdc.gov/youthonline/App/Default.aspx Accessed January 28, 2018.
19. Hamburg BA. Psychosocial development. In: Comprehensive Adolescent Health Care. (Friedman S, Schonberg S, Alderman E; eds). St. Louis, MO: Mosby, 1998. pp. 38–49.
20. Kim J, Deal AM, Balthazar U, et al. Fertility preservation consultation for women with cancer: are we helping patients make high-quality decisions? Reprod Biomed Online. 2013;27:96–103.
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Cite this article as: Morrison A, Olezeski C, Cron J, Kallen AN (2020) A pilot study to assess attitudes toward future fertility and parenthood in transgender and gender expansive adolescents, Transgender Health 5:2, 129–137, DOI: 10.1089/trgh.2019.0075.
Appendix
Appendix A1. Yale Gender Program Reproductive Knowledge and Experiences Survey
The questions below are related to your current thoughts about your plans and expectations, if any, for having a child in the future. Please check the box that best describes your current thoughts. There are no right or wrong answers, and we understand that your thoughts may change over time. Your answers will not affect your care at the Yale Gender Center and will not be shared with your parent without your prior permission.
Section 1
For each of the following statements, please check the box that best describes your current thoughts about having a child in the future.
1.1 It is important to me to have a child one day. □Yes □No □ Unsure
1.2 Which of the following are of interest to you? (check all that apply)
□ Having my own biological child
□ Having a surrogate birth a child
□ Having my partner bear a child
□ Adoption
□ Fostering
□ None of the above
| Strongly Disagree | Disagree | Neither Agree nor Disagree | Agree | Strongly Agree | |
|---|---|---|---|---|---|
| 1.3 I worry about my ability to have a child one day | |||||
| 1.4 I worry about telling my potential partner that I may not be able to have a child | |||||
| 1.5 I wonder whether my future child would have a high chance of being transgender | |||||
| 1.6 It is okay if I am not able to have a child one day | |||||
| 1.7 I worry that trying to have a child will take too much time and effort | |||||
| 1.8 It is stressful to think about trying to have a child one day | |||||
| 1.9 I am concerned about delaying my transition for 1 month or more to preserve my eggs/sperm |
Section 2
Please answer the following questions to the best of your ability. The word “hormones” means estrogen or testosterone, the medicine someone would take to change their physical appearance to female or male.
| True | False | Not sure | |
|---|---|---|---|
| 2.1 All people who want to become birth parents are able to | |||
| 2.2 Hormones may affect a person's ability to have a child in the future | |||
| 2.3 A doctor can accurately predict the effect that hormones will have on a person's ability to have a child in the future | |||
| 2.4 An egg from a person born female and a sperm from a person born male are needed to make a baby | |||
| 2.5 Storing eggs or sperm is one way to preserve the ability to have a biological child in the future |
Section 3
3.1 Before today's visit, has anyone talked to you about hormones and the ability to have a child in the future?
□ Yes □ No
If yes, whom have you spoken to? ___________________________________
3.2 Do you feel like you have as much information as you would like about the following topics:
| Yes | No | |
|---|---|---|
| a. The possible effects of taking hormones on a person's ability to have a child in the future | ||
| b. The risks and benefits of waiting to take hormones to preserve eggs/sperm | ||
| c. Whom to talk to about my own ability to have a child in the future | ||
| d. Options to increase my chance of becoming a birth parent in the future | ||
| e. Alternatives to having biological children one day (for example, adoption, or egg/sperm donation) |
3.3 If you knew anything about the above topics (a–e) before today's visit, how did you receive this information? (check all that apply)
□ Discussion with a doctor
□ Handout with written information from a doctor
□ Discussion with family or friends
□ Researched online on my own—please describe: ____________________
□ Other—please describe: ________________________________________
□ I did not know about any of the above topics before today's visit
3.4 If you answered “No” to the above topics (a-e) and would like more information, what resources would be most helpful to you? (check all that apply)
□ Discussion with a doctor
□ Handout with written information from a doctor
□ Research online
□ Other—please describe: ________________________________________
Information & Authors
Information
Published In
Transgender Health
Volume 5 • Issue Number 2 • June 2020
Pages: 129 - 137
Copyright
Copyright 2020, Mary Ann Liebert, Inc., publishers.
History
Published online: 8 June 2020
Published in print: June 2020
Published ahead of print: 25 February 2020
Topics
Authors
Author Disclosure Statement
No competing financial interests exist.
Funding Information
Yale University School of Medicine Research Fellowship provided funding for this research.
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