Attitudes Toward Fertility and Reproductive Health Among Transgender and Gender-Nonconforming Adolescents.

As part of a larger study, 20 – 22 participants were recruited for an online survey on adolescent sexual health and HIV prevention research with the following eligibility criteria: ages 14–17; identifies as a sexual minority and/or TGNC; romantically/sexually interested in cisgender males; lives in the United States (US); 8 th grade English reading level; and HIV-negative or naïve to HIV testing. The analytic sample for this study consisted of participants who identified as TGNC. All procedures were approved by the Northwestern University and Fordham University Institutional Review Boards. A waiver of parental permission was granted and a Certificate of Confidentiality was issued from the National Institutes of Health. Participants were recruited through paid advertisements on Facebook from September-October 2016, which targeted adolescents in the US who were romantically interested in people of the same or both genders and/or listed interests relevant to sexual and gender minority (SGM) youth. Clicking on advertisements linked to an online eligibility survey. Eligible participants were presented with an online consent form, then automatically directed to the survey after agreeing to participate. Participants whose data passed the study’s validation protocol received a $30 electronic Visa gift card. Participants completed items assessing age, state of residence, race and ethnicity, assigned sex at birth, gender identity and sexual orientation, and disclosure of sexual orientation and gender identity to parents. Responses to a closed-ended item assessing gender identity were dichotomized into transgender (woman, man, transgender man, transgender woman) and GNC (genderqueer, gender-nonconforming) groups for comparison. For analyses, race and ethnicity were combined into one variable reflecting two groups: White non-Hispanic/Latino youth and youth of color (e.g., Hispanic/Latino, Black or African American, Asian, Multiracial/Other). The larger survey included items examining SGM youth’s experiences with affirming healthcare. Only items specific to TGNC youth and fertility were included in the present analysis. Yes/no questions assessed whether participants had ever received pubertal suppression treatment or GAH and whether participants had ever discussed these therapies with a healthcare provider. Fifteen items (13 closed-ended; 2 open-ended) assessed participants’ thoughts about fertility/biological parenthood and family formation (the former defined as using their own eggs or sperm to have children), including the degree to which they have discussed fertility and family formation with others and comfort having these discussions, and preferred methods of obtaining information about fertility and family formation. Open-ended questions specifically asked respondents to describe reasons for discomfort discussing fertility and any other thoughts they may have about fertility and family formation. Descriptive statistics were computed for all relevant variables. Pearson Chi-Square tests were used to assess sociodemographic group differences (i.e., age, race/ethnicity, assigned sex at birth, gender identity) in participants’ thoughts about and discussion of fertility and family formation; Fisher’s exact test is reported when expected cell counts were less than five. Qualitative data were imported into Dedoose, an Internet-based qualitative data analysis package, and were analyzed thematically. 23 Two root codes reflecting each open-ended item were applied to each transcript: Other thoughts about fertility and family formation and Reasons for discomfort with answering questions about fertility and family formation. Next, open coding was performed to identify themes within responses to each open-ended item. Codes were created based on whether themes emerged as a meaningful pattern in the data and/or emerged frequently. Themes were not required to emerge from a minimum number of participants to be considered meaningful. One coder (second author) reviewed excerpts, generated a list of potential themes and noted any significant patterns of topics in the data. A second coder (first author) then reviewed and identified additional emergent themes. These codes were refined via comparison, discussion and consensus. The codes were applied to the excerpts, and coders continued to iteratively refine codes and definitions. An auditor (third author) reviewed the final codes, then the second coder performed reliability testing on a subset of the excerpts. The pooled kappas were 0.94 for other thoughts about fertility and family formation codes (25 excerpts) and 1.00 for reasons for discomfort with answering questions about fertility and family formation codes (6 excerpts), indicating excellent inter-coder reliability. 24

The analytic sample included 156 participants ( M age =16.1 years, SD =0.97) drawn from 42 of the 50 states, and 58.3% identified as youth of color. Few participants had received puberty blocking treatment ( n =3) or GAH ( n =6). See Table 1 for additional details. Table 2 displays responses to closed-ended items assessing thoughts about fertility and family formation. Almost half of the participants indicated interest in having children someday. More participants expressed interest in adoption (70.5%) than biological parenthood (35.9%), with a significantly greater proportion of FAAB participants (74.4%) expressing interest in adoption than MAAB participants (53.8%), χ 2 = 4.445, p < 0.05. FAAB participants (77.5%) also thought about having children through adoption more frequently than MAAB participants (53.8%), χ 2 = 6.233, p < 0.05. More GNC youth (43.8%) expressed interest in biological parenthood than transgender youth (25.8%), χ 2 = 5.358, p < 0.05. In addition, a significantly greater proportion of youth of color (42.2%) expressed interest in biological parenthood than White non-Hispanic/Latino youth (26.6%), χ 2 = 3.995, p < 0.05. Figure 1 shows participants’ preferences for obtaining information about fertility and family formation options. Although 60.9% were interested in learning more about their options, most had “never” discussed fertility or family formation with a healthcare provider (79.5%), parent/guardian (64.7%), or SGM peer (50%). Only 13.5% of participants indicated a healthcare provider discussed how GAH can affect fertility. Among the 19.2% of our sample who had spoken to a healthcare provider about GAH, only 53.3% reported their healthcare provider discussed the impact of hormones on fertility. Fisher’s exact test revealed a significantly greater proportion of participants who were out to their parents (17.1%) discussed how GAH can affect fertility with their healthcare provider than participants who were not out (0.0%; p < 0.05). There were no other sociodemographic differences in responses to the closed-ended items. Table 3 summarizes the qualitative codes, definitions, and frequency of code application. A total of 80 participants responded to the open-ended item on thoughts about fertility and family formation. A subset ( n =17) reported they had nothing else to say and for several participants, comments were too vague to be coded ( n =3). Participants varied in their expressed interest in having children, with some indicating no interest ( n =14) and others ( n =9) referencing uncertainty about their desires for parenthood. In addition, three participants who expressed no interest in having children discussed social norms and expectations surrounding biological parenthood. For instance, a 17-year-old gender-nonconforming FAAB participant said, “I don’t want to have children, I wish my doctor didn’t talk to me assuming that I do. It’s misogynistic to do so, I have no ‘maternal instinct’ and women, gay, straight or otherwise, shouldn’t be made to justify that.” Participants also discussed interest in specific family formation options such as adoption ( n =13) or biological parenthood ( n =9). Among youth providing reasons for interest in adoption, five commented that pregnancy was undesired as it could exacerbate gender dysphoria and two wanted to “save one of the kids from orphanages” and “give them a chance.” Many noted they were currently unsure whether they wanted to have children in the future, but several indicated they would adopt if they changed their mind. Two excerpts referenced interest in both adoption and biological parenthood as potential family formation options. For example, one 17-year-old gender-nonconforming FAAB participant said, “I’d like to have a mix of my own children and adopted children.” The most frequently cited concern related to fertility and family formation was stigma toward SGM parenting (n=7). One 15-year-old transgender girl described how she and her partner had contemplated how stigma associated with biological parenthood may be a barrier to family formation: “My partner and I have discussed and are unsure about having children in the future. We both have concerns about the implications of pregnancy that go with our gender identities.” Additionally, a 16-year-old transgender man shared concern that knowledge of his gender identity might negatively impact his chances of parenthood: “I’ve always wanted to adopt. I’m just scared that if I’m transgender and people notice they won’t let me adopt a child.” Participants ( n=6 ) also expressed concerns regarding the effect of GAH on fertility. Within this axial code, participants who had not spoken with a healthcare provider about medical interventions referenced desires for GAH but worried about whether treatment might impact fertility. On the other hand, participants who had discussed medical interventions with a provider demonstrated awareness of GAH effects on fertility and the need to consider this potential impact. Two of these responses explicitly referenced a desire to have biological children. For example, a 17-year-old transgender man said, “I’ve wanted to transition but I’ve also wanted to carry my own child.” Another 15-year-old transgender man described concerns about the cost of assisted reproductive technologies in relation to his desire to have a biological child: “I would like to be able to have a kid using my eggs (no giving birth), but because it is too expensive, I might end up starting HRT before I can freeze them. It makes me very sad but I will deal with it.” Some concerns related to gender dysphoria or discomfort emerged ( n =6), whereby participants expressed personal discomfort with, no desire for, or an aversion to pregnancy, giving birth to a child, or using ones’ own eggs or sperm to create biological children due to their gender identity. For example, a 16-year-old transgender man explicitly described feelings of gender dysphoria in response to the idea of giving birth to a child saying, “I will never have a child come out of my own body … it’d give me horrible dysphoria and I don’t want to do it.” Another 16-year-old transgender man shared, “I want to have kids in the future, I really want to be a father one day. I absolutely refuse to carry a child of my own or use my eggs in anyway.” Finally, youth had several general concerns about pregnancy and parenting ( n =13) that were not explicitly related to one’s gender identity. For example, youth expressed concerns about the prospect of discomfort or pain during pregnancy and childbirth, worries about being able to financially support children, and concerns about fertility related to pre-existing health conditions (e.g., endometriosis). Several excerpts indicated that participants need more information ( n =18) about fertility or family formation. Comments included questions pertaining to fertility and family formation (e.g., “If I’m trans, and my partner is trans, can we have children?” –17-year-old transgender man) and identified topics SGM youth should be exposed to through discussion, education, or research (e.g., “I feel that for transgender people starting HRT at a younger age, egg/sperm harvesting and saving should be more encouraged” –17-year-old transgender man). One participant who had spoken to a healthcare provider about GAH commented on a need for more research examining the impact of GAH on fertility. Other comments reflected a lack of knowledge or suggested misunderstanding of reproductive biology (e.g., “I’m really interested in bone marrow to have a baby, but I’m scared it’s painful and expensive and has risks” – 17-year-old gender-nonconforming FAAB participant), pointing to a need for increased education about fertility and family formation, particularly among those who had not spoken to a healthcare provider about medical treatment. The vast majority of participants were comfortable answering questions about fertility. Only 16.0% expressed discomfort. A significantly larger proportion of Hispanic/Latino participants (25.0%) felt uncomfortable answering questions about fertility than non-Hispanic/Latino participants (12.0%), χ 2 (2, N = 155) = 9.269, p < 0.05. Of those who were uncomfortable answering fertility-related questions, 17 participants provided codeable responses describing reasons for discomfort. The majority of responses ( n =10) reflected general discomfort with answering questions about fertility (e.g., “It’s very invasive” –16-year-old transgender man). Three referenced gender dysphoria as a reason for discomfort; however, a 15-year-old transgender man also acknowledged the importance of doing research with SGM youth on these topics: “I get dysphoric answering questions in regards to fertility because it emphasizes the part of being born with a girl’s body that I hate addressing. However, I don’t think that this should stop you from answering these questions because they are important when understanding how LGBTQ teens’ sexual health is.” Other infrequently endorsed reasons for discomfort reflected similar themes from the open-ended question on participants’ other thoughts about fertility and having children (e.g., uncertainty about having children, social norms surrounding biological parenthood, stigma of SGM parenthood, and concerns about the effect of pre-existing health conditions on fertility).

Historically, TGNC people seeking gender-affirming medical interventions accepted the loss of biological fertility as the “price to pay” for transition. 25 Recent advances in FP and assisted reproductive technologies now provide TGNC people the option of biological parenthood. 26 , 27 While FP in TGNC youth has been documented in case studies, 28 utilization rates are low. 16 , 17 Studies of TGNC youth seeking medical treatment identified barriers to FP, including hypothesized differences between transgender and cisgender youth regarding family formation desires. 17 However, this is the first study, to our knowledge, that explores attitudes toward fertility and family formation in a diverse, online-recruited sample of TGNC adolescents who may not necessarily desire medical transition. Overall, findings suggest variability among TGNC adolescents regarding attitudes toward fertility and desires for parenthood. About half of our sample expressed a desire to parent in the future, just over a quarter were not interested in parenting, and the remainder was uncertain about parenthood. Our findings on parenting desires are relatively consistent with a recent report by Strang and colleagues 29 which found that slightly more than half of their sample of transgender adolescents wished to have children and almost one-third expressing uncertainly about future parenthood. Moreover, it is notable that a similar percentage of our sample was not interested in parenting compared to a previous study of transgender adolescents presenting for medical intervention 17 because it is uncommon for cisgender adolescents to explicitly report no interest in having children someday. 17 In fact, research on cisgender teen girls suggest strong desires for biological parenthood even during adolescence. 19 Thus, our study provides further evidence for possible differences in parenthood desires between TGNC and cisgender youth. Despite variability with regard to fertility and parenthood desires, over one-third of our sample wanted biological children, with more GNC youth (43.8%) than transgender youth (25.8%) expressing interest in biological fertility. While this is not surprising given that transgender youth are more likely to experience gender and body dysphoria than GNC youth, it does bring up an important point regarding clinical care. Discussions about fertility and reproductive options by pediatric and adolescent providers are grossly lacking, 30 and when discussions do occur with TGNC youth, it is most likely in the context of informed consent for fertility-compromising transition-related treatments. Because GNC youth are less likely than transgender youth to seek GAH, they may have fewer opportunities to discuss parenthood options with healthcare providers. Therefore, primary care practitioners also need to be prepared to have discussions about reproductive health with TGNC youth. While many youth-identified concerns impacting their family formation desires overlapped with those previously identified as barriers to FP (e.g., unwilling to delay hormone treatment, gender dysphoria), 16 , 17 the most commonly cited concern was stigma related to SGM parenting. Several participants cited societal perceptions of SGM individuals being “bad parents” potentially impacting their ability to adopt or maintain custody of children. One youth expressed concern about the stigma a future child would face having a transgender parent as impacting their desires for parenthood. Thus, not only are TGNC youth’s fertility and parenting desires impacted by internal factors such as gender dysphoria and desires for medical transition, minority stress 31 also appears to be playing a role in TGNC youth’s desires (or lack thereof) for parenthood. The majority of our sample expressed interest in learning more about options for family formation with over half expressing preference for online sources. Thus, there is a need to develop and disseminate reputable information about fertility and family formation options so that TGNC youth may access accurate information. Additionally, almost half our participants expressed preference for information about fertility and reproductive health to be delivered by a healthcare provider. This is particularly notable because fertility and family formation was almost never discussed with healthcare providers, and deficits in knowledge about fertility and family formation options were identified and explicit need for more information expressed by our study participants. Indeed, about half of the youth who were considering medical transition did not have all the information necessary to provide informed consent. Thus, identifying and addressing barriers to counseling on fertility and reproductive options is necessary to improve knowledge in this population. It may be helpful for providers to know that the vast majority of youth (84%) were not uncomfortable answering questions about fertility. Moreover, among youth expressing discomfort, it was noted that discomfort should not prevent fertility-related questions from being asked as they are important for understanding SGM sexual and reproductive health needs. Providers may find the newly validated Transgender Youth Fertility Attitudes Questionnaire helpful in facilitating these discussions. 29 This study has several strengths. First, it extends what is known about fertility and family formation desires among transgender youth to: (1) GNC/non-binary adolescents, and (2) TGNC youth who are not explicitly seeking transition-related medical care. Second, our online recruitment strategy yielded a sample of TGNC adolescents with geographic diversity thus expanding generalizability of findings. Last, utilizing a mixed-methods approach enriched our understanding TGNC youth’s attitudes toward fertility and family formation. There are also limitations to acknowledge. First, youth were recruited for a larger study on HIV risk; eligibility criteria included romantic/sexual interest in cisgender male partners. Therefore, findings may not generalize to TGNC youth who are romantically/sexually attracted to cisgender women. Also, our sample included very few MAAB youth, which may further limit generalizability. Additionally, qualitative data were provided by only half of the analytic sample and in response to open-ended online survey questions. Thus, future research on attitudes toward fertility and family formation desires should incorporate key informant interviews or focus groups that would allow for probing to elicit more nuanced data. Direct comparison with an age- and gender-matched cisgender control group also would expand understanding. In conclusion, TGNC adolescents varied in their desires for parenthood, expressed interest in multiple family formation options, and identified a need for more information about their options. It is imperative that clinicians working with adolescents are aware of the unique fertility and reproductive health needs of TGNC youth.