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Fertility preservation for young trans and gender-diverse people

We asked parents and carers we talked to if they have thought about and discussed fertility preservation options with their children. We also asked whether fertility preservation was some-thing health professionals discussed with the young person. Here you can read and see what parents said about:
  • Discussing fertility preservation with the young person;
  • Discussing fertility preservation with health professionals; and
  • Their views of fertility preservation.

Oonagh talked about how as a parent you think about the long-term impact of hormone treatment and about discussing fertility with her daughter

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You think about all these things, because obviously that’s one of the things that you do worry about. You know, if you were gonna go down the route of puberty blockers, cross sex hormones and things, you’re gonna go down that route then the child needs to know that that is gonna effect their fertility. And Ive, we, I have talked, I have said to her about it. Ive talked to her. Weve talked around the subject of puberty blockers, already. And I said, What about children? What if you cant have children? What would you do? She said, ‘shed adopt. I mean I know she cant really know for sure how she’s gonna feel now as she would when she’s older. You cant, as a child, you don’t really know the consequence, the full consequence of it, do you? But I don’t know a lot about the actual process for fertility preservation. But I do know that if the earlier that you go on puberty blockers and sex hormones then it’s harder to be able to preserve fertility, I think, because of the hormones just affect so much.

Some medical treatments that trans and gender diverse people might have, including hormone therapy and surgery, can impact fertility. Oestrogen or testosterone hormone therapy are considered to impact on fertility in combination with other factors. However, science's understanding of this area is rapidly changing.
Fertility preservation refers to procedures that allow sperm, eggs or embryos to be harvested, frozen and stored for later use in fertility treatment (Human Fertilisation & Embryology Authority, 2020).

Discussing fertility preservation with the young person

Parents and carers we spoke to felt that discussing fertility and fertility preservation with their children was important. They had carefully researched the available options and spent time preparing their children for the different choices available. At times, parents felt that they had to work hard to find reliable information and that they also needed to preempt any difficulties, as Leigh put it to be '2,3,4,5 steps ahead' of everyone else.
Parents and carers who wanted to discuss fertility preservation with the young person found it could be challenging. Mel said that these were some 'really big conversations' that her and her partner wanted to have with her stepdaughter, who was at a cusp of puberty, and about to start on hormone blockers.

Mel said her stepdaughter wanted to have children and that they have discussed fertility preservation as a family and with the Gender Identity Development Services.

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We had some really big conversations around, you know, she wants to get married. She wants to have children. And started in the process of how that might work and you know, part of the hormone blockers and waiting for as long as waiting for the, you know, for the sperm to be produced and then they could extract it. These are massive conversations to be having when you are eleven. She gets it. We get it. But it’s huge. I never thought in a million years we’d be having those kinds of conversations and they can be really challenging, at times. Because the person you are at eleven is not the person that you are, you know, when you’re 21 or 31 or whatever. But, yeah.

So, the fertility preservation is that something that was discussed at the GIDS or is there something that you discussed as a family?

Oh yeah, both, all the way through, yeah they’ve spoken about it and so that’s something she really, really wants. She really wants having children.

Some young people, whose parents we talked to, were not interested in preserving their eggs, or sperm. Josie said that her daughter was asked about it in the Gender Identity Development Services appointment, but did not think it was relevant to her. Andrew's daughter was certain she did not want to explore fertility preservation options. He said: 'She didn't want to do anything about it. I think she probably thought it was a bit invasive.'
Children of some people we spoke to talked about alternative ways of having a family in the fu-ture. Kate's son told her that he was sure he did not want children, but when she asked him about the possibility of changing his mind in the future, he said he 'won't mind if the child was biologically his or not'. The possibility of adopting a child in the future was also something that Ross's child considered: 'If, in the future at any point they do decide, they want a family then theres millions of children that need adopting and they would adopt a child.'

Kate said her son did not want children, but was open to having a child that was ‘not biologically his’, if he changed his mind in the future.

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He doesn’t want to. He has always been he’s never ever wanted children, ever. My nephew had a baby a few years ago, he’s five now. So, that would have made my son 11 and they are very close. And at that point, that’s the only point in his life where he has ever been like, maybe I would have a baby. But that lasted for a couple of weeks. And so we did talk about it. And he is adamant that he doesn’t want, he doesn’t want that. I said, Well, what if you change your mind in the future?’ His view is that, if he does, he won’t mind whether that child is biologically his or not. He’s really not at all, doesn’t just, it isn’t an issue for him. it’s not something he wants to think more about.

Discussing fertility preservation with health professionals

For some young people, whose parents we spoke to, fertility preservation was discussed in relation to starting on puberty blockers, or hormone therapy. For Richard's daughter this discussion took place when his daughter saw the endocrinology specialist about getting puberty blockers.

Richard talked about his daughter being offered fertility preservation options by the endocrinologist.

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Have you discussed fertility preservation options with your daughter?

Yeah. it’s something which they basically they offered for her. They explained that it was something that she could do with the aid of something, or the more traditional technique, which she was obviously quite embarrassed about, but most children would be, sat in a room with adults talking about producing sperm. So, I think it’s something which she would like to do in the sense that she would like the option of being a parent when she was older. But she’s talked about adopting or something like that. I remember when she was very young she was saying that she would like to meet a girl who wanted to be a boy, the opposite of her and they could, they could fall in love together and get married and have a baby together because they would have the right physical body parts to make a baby.

When you say, they discussed fertility preservation options with your daughter, who is they?

The hospital. The doctor.

Okay.

I don’t remember [Gender Identity Development Service] ever discussing or describing that.

Richard talked about his daughter being offered fertility preservation options by the endocrinologist.

Discussions around fertility preservation need to be handled with care as they often relate to parts of the body, about which young people feel sensitive (see also Managing body dysphoria and puberty related pressures). Ross, for example, described how 'they didnt want the in-vasion of egg harvesting, because its an area of the body that they dont want looking at, playing with, touching, talking about, they dont even wanna think about that area of their body'. Another parent said their child was embarrassed 'as most children would be sat in a room with adults talking about producing sperm'.
Lesley's son was clear they did not want their eggs harvested, yet during an unrelated hospital stay, CAMHS professionals wrongly decided to take him off testosterone because they judged this decision to be best in light of fertility preservation. Lesley felt there was a lot of judgement and not enough deliberation.

Ross said his child felt fertility preservation was a stalling tactic to stop them starting testosterone.

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We discussed it, it came up at the first [name] GIDS meeting and sadly, because my child didnt have the confidence to say, Absolutely not. I definitely don’t want it. They thought that to please the person that was asking they should say that they would look into it. And then we had a barrage of appointments offered at various fertility treatment places and my child then thought that that was a stalling tactic, because you cant harvest eggs if you’re on testosterone. So they thought it was just a stalling tactic to stop them starting testosterone. But theyve always been pretty adamant that they personally don’t want to have any children. They didnt want the invasion of egg harvesting, because it’s an area of the body that they don’t want looking at, playing with, touching, talking about, they don’t even wanna think about that area of their body. So they were absolutely anti harvesting

Some parents we spoke to felt that fertility preservation for trans young people was treated with less care than in other situations, for example, cancer, when young person's fertility might be impacted by medical treatment.
Fertility preservation discussions can make the young person feel they are being prevented from accessing medication they urgently need. Ross talked about his child feeling they needed to go along with the suggestion to explore fertility preservation options, despite being against it and not wanting the 'the invasion of egg harvesting.'

Leigh talked about making sure her foster son has a choice regarding fertility preservation and how access to it was uneven across local authorities in England.

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Well weve got a year to get to the next step. However, I’m already working towards making sure that the next step is easier. So we are having conversations, right now and for the last six, twelve months about preserving his eggs or you know, birth children before he starts cross sex hormones. If that’s his choice if that’s what he wants to do, you know, we have to kind of pre-empt what the [Gender Identity Development Services] and what the judges and what the local authorities are going to say he needs to do. So it, it is continual working and being that two, three, four, five steps ahead of everybody else.

And how did you find out about the fertility preservation option?

Google [laughs]. Yeah, just Google. There’s not much out there. I did have to contact the CCG myself. I sent them an email, the Clinical Commissioning Group. So I did contact them myself and asked them what their policy was for trans youth if they was accessing fertility to be told that this local authority doesnt prejudice against trans, trans young people. So it would just be a case of the GP referring if that’s what he wanted to do. And then looking at him going through the process, whereas many, many, many, many other local authorities don’t support trans young people in fertility whatsoever. You then need to pay privately. Bearing in mind, eggs are only viable for about ten years. So if a 13 year old, 14 year old, 15 year old is looking at preserving their eggs, you know, they have to have had children by 23, 25, 26. You know, most people arent starting families until their 30s. Why are our kids having to think about it at 15, 16. It’s a big conversation to be having.

Parents and carers' views of fertility preservation

Some parents we spoke to respected their child's decisions regarding fertility preservation and some talked about alternative ways of becoming a parent, such as adoption. There was recognition that the age of their child was influential in thinking about these issues. Some parents felt the need to safeguard their child's future ability to become a biological parent. Lisa felt it was important for young trans people to have the option to preserve fertility:
For Leigh, who is a foster carer, safeguarding her foster son's future meant taking the necessary legal steps with the local authorities. She felt there was not enough information about fertility preservation options for young trans people, their parents and carers. Leigh also spoke about the unequal support for fertility preservation for young trans people from the local authorities compared to non-trans young people that meant that for some people the only option was to pay for it privately.