Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey
To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients.
Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August–November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes.
Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health.
This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.
KeywordsTransgender Fertility preservation Fertility counseling Gender-affirming hormones Reproductive health Qualitative research
Compliance with ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
This study was deemed exempt.
- 1.Oktay K, et al. Fertility preservation in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol. 2018;2018:78 1914.Google Scholar
- 4.Wallace SA, Blough KL, Kondapalli LA. Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer. Gynecol Endocrinol. 2014;30(12):868–871.Google Scholar
- 5.Leavy M, Trottmann M, Liedl B, Reese S, Stief C, Freitag B, et al. Effects of elevated β-estradiol levels on the functional morphology of the testis - new insights. Sci Rep. 2017;7:39931.Google Scholar
- 6.Jindarak S, Nilprapha K, Atikankul T, Angspatt A, Pungrasmi P, Iamphongsai S, et al. Spermatogenesis abnormalities following hormonal therapy in transwomen. Biomed Res Int. 2018;2018:1–5.Google Scholar
- 7.Schneider F, Neuhaus N, Wistuba J, Zitzmann M, Heß J, Mahler D, et al. Testicular functions and clinical characterization of patients with gender dysphoria (GD) undergoing sex reassignment surgery (SRS). J Sex Med. 2015;12(11):2190–200.Google Scholar
- 9.Baba T, Endo T, Honnma H, Kitajima Y, Hayashi T, Ikeda H, et al. Association between polycystic ovary syndrome and female-to-male transsexuality. Hum Reprod. 2007;22(4):1011–6.Google Scholar
- 10.Caanen MR, Soleman RS, Kuijper EAM, Kreukels BPC, de Roo C, Tilleman K, et al. Antimullerian hormone levels decrease in female-to-male transsexuals using testosterone as cross-sex therapy. Fertil Steril. 2015;103(5):1340–5.Google Scholar
- 12.Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.Google Scholar
- 15.Wierckx K, van Caenegem E, Pennings G, Elaut E, Dedecker D, van de Peer F, et al. Reproductive wish in transsexual men. Hum Reprod. 2011;27(2):483–7.Google Scholar
- 17.Auer MK, Fuss J, Nieder TO, Briken P, Biedermann SV, Stalla GK, et al. Desire to have children among transgender people in Germany: a cross-sectional multi-center study. J Sex Med. 2018;15(5):757–67.Google Scholar
- 19.Wierckx K, Stuyver I, Weyers S, Hamada A, Agarwal A, de Sutter P, et al. Sperm freezing in transsexual women. Arch Sex Behav. 2012;41(5):1069–71.Google Scholar
- 22.Pfäfflin F, et al. The desire to have children and the preservation of fertility in transsexual women: a survey. Inte J Transgenderism. 2002;6(3):97–03.Google Scholar
- 25.Klosky JL, Anderson LE, Russell KM, Huang L, Zhang H, Schover LR, et al. Provider influences on sperm banking outcomes among adolescent males newly diagnosed with cancer. J Adolesc Health. 2017;60(3):277–83.Google Scholar
- 26.Shnorhavorian M, Kroon L, Jeffries H, Johnson R. Creating a standardized process to offer the standard of care: continuous process improvement methodology is associated with increased rates of sperm cryopreservation among adolescent and young adult males with cancer. J Pediatr Hematol Oncol. 2012;34(8):e315–9.CrossRefGoogle Scholar
- 27.Chen D, Kolbuck VD, Sutter ME, Tishelman AC, Quinn GP, Nahata L. Knowledge, practice behaviors, and perceived barriers to fertility care among providers of transgender healthcare. J Adolesc Health. 2018;0(0).Google Scholar
- 29.Levitt HM, Bamberg M, Creswell JW, Frost DM, Josselson R, Suárez-Orozco C. Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: the APA publications and communications board task force report. Am Psychol. 2018;73(1):26–46.CrossRefGoogle Scholar
- 34.James-Abra S, Tarasoff LA, green, Epstein R, Anderson S, Marvel S, et al. Trans people’s experiences with assisted reproduction services: a qualitative study. Hum Reprod. 2015;30(6):1365–74.Google Scholar
- 35.Mitu K. Transgender reproductive choice and fertility preservation. AMA J Ethics. 2016;18(11):1120.Google Scholar
- 39.Patterson P, McDonald FEJ, Zebrack B, Medlow S. Emerging issues among adolescent and young adult cancer survivors. Semin Oncol Nurs. 2015;31(1):53–59.Google Scholar
- 40.Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of transsexual, transgender, and gender-nonconforming people, version 7. Inte J Transgenderism. 2012;13(4):165–232.Google Scholar
- 41.O’Connor, A., D. Stacey, and M. Jacobsen, Ottawa decision support tutorial: improving practitioners’ decision support skills Ottawa Hospital Research Institute: patient decision aids; 2011. Disponible en ligne: https://decisionaid.ohri.ca/ODST/pdfs/ODST pdf, 2014.
- 50.Strang JF, Janssen A, Tishelman A, Leibowitz SF, Kenworthy L, McGuire JK, et al. Revisiting the link: evidence of the rates of autism in studies of gender diverse individuals. J Am Acad Child Adolesc Psychiatry. 2018;57(11):885–7.Google Scholar
- 51.Strang JF, Meagher H, Kenworthy L, de Vries ALC, Menvielle E, Leibowitz S, et al. Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol. 2018;47(1):105–15.Google Scholar
- 54.Snelgrove, J.W., et al., “Completely out-at-sea” with “two-gender medicine”: a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 2012. 12(1): p. 110.Google Scholar
- 59.Nahata L, Chen D, Moravek MB, Quinn GP, Sutter ME, Taylor J, et al. Understudied and under-reported: fertility issues in transgender youth—a narrative review. J Pediatr. 2018. https://doi.org/10.1016/j.jpeds.2018.09.009.
- 60.Shnorhavorian M, Harlan LC, Smith AW, Keegan THM, Lynch CF, Prasad PK, et al. Fertility preservation knowledge, counseling, and actions among adolescent and young adult patients with cancer: a population-based study. Cancer. 2015;121(19):3499–506.Google Scholar