Last week, within the span of 24 hours, I had conversations with two different cisgender patients regarding fertility and procreation: a thirty-year-old married man unsure if now is the right time to start a family; and a menopausal gay woman feeling confused about why she is grieving her loss of fertility given that she never wanted to have children.
In juxtaposition, yesterday I spoke with the mother of a trans teen wondering about fertility preservation options even though her child has been on hormones for about a year. The mother reported to me that there was inadequate discussion of the topic prior to medical intervention. She wanted to know if it was too late to explore options.
Fertility Preservation (FP) for trans people was superficially addressed in WPATH SOC 7 but current consensus is that it is vital to discuss this topic at length, especially with trans youth and their parents.
Ideally, talking about fertility preservation should begin as early as possible and long before discussing medical intervention. This is the only way to allow time for adequate consideration. Options for FP do exist even for prepubertal children – though they remain experimental. Difficult discussions about the option of delaying medical intervention until adolescence must be undertaken to obtain truly informed consent for puberty blockade. For these children, the topic of FP must also be revisited before moving on to cross-gender hormones.
For teens who have already experienced puberty, having the discussion before starting hormones is crucial because hormones may have a negative impact on later fertility options. Of course, having these discussions with trans teens is challenging for multiple reasons.
One challenge is the fact that teens likely do not have a clear opinion about parenthood. As the two patient interactions above demonstrate, thoughts and feelings about fertility and procreation evolve over a lifespan.
Another complicating factor is that many teens want to start medical intervention as soon as possible and will resist discussing FP based on the idea that it will slow down medical intervention. If the discussion happens well in advance of starting medical treatment that will not be the case.
We have evidence to suggest that if the conversation about FP happens once the endocrinology appointment has already been scheduled, many teens will decline FP options and report a plan to adopt children. In fact, about 40% of transgender youth in a recent retrospective study reported a plan to adopt in the future as a reason for declining FP.
The cost and invasiveness of procedures of FP are often given as a reasons teen and parents decline FP options. Yet the adoption process is lengthy, intrusive in its own way, and more expensive than FP (average cost of about $30,000). Adoption can also be discriminatory in cases where agencies or birth parents can influence the decision when choosing among several potential adoptive families.
Discussions with trans youth and their parents about FP should occur with both medical and mental health providers. Discussions should take place with youth and parents, separately and together. Topics to address include parenthood goals, fluidity of sexuality, different family constellations, logistics of sperm banking and oocyte cryopreservation, and potential benefits and barriers.
I urge all therapist to start addressing FP early and suggest that every informed consent form for medical intervention make parents explicitly endorse that adequate discussion has taken place. Parents can also begin discussions with all their children about family planning including FP for trans kids.
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Antonia Caretto, Ph.D. is a fully licensed Clinical Psychologist and a graduate of the University of Michigan and the Alliant International University California School of Professional Psychology. Dr. Caretto’s 1991 doctoral dissertation research was on “Familial Homosexuality Among Women and It’s Relationship to Childhood Gender Role Non-Conformity and Adult Sex Role.”
Dr. Caretto has a solo private practice in Farmington Hills, MI, and gender identity development continues to the focus of much of her work.