Iris de Nie

30 C H A P T E R 2 DISCUSSION This is the first follow-up study reporting on reflections of transgender adults of reproductive age, who started their medical treatment as adolescents, on the consequences of gender-affirming treatment for their fertility and the possibilities of starting a family. Since all participants initiated medical treatment before 2014, at that time laws requiring sterilization for legal gender recognition were still in place. Many participants reported they did not receive proper fertility counseling and none of them pursued fertility preservation. In addition, almost all participants underwent gonadectomy and thus became permanently infertile. Approximately 1 out of 4 participants found becoming infertile troublesome, and stated that theywere not able to make decisions regarding fertility and future family building during adolescence. Moreover, 1 out of 6 would, in retrospect, rather not have undergone gonadectomy and more than one third of the study population would have chosen to pursue fertility preservation. The percentage of participants with a (future) desire for children changed from 34% at start of medical treatment to 56% at time of this study, and 23% had already started a family.These results implicate that views and desires regarding fertility and family building may change over time, which may be related with improved body satisfaction and mental health, matured intellectual and emotional cognitions, social status, and coming of reproductive age when starting a family becomes a topical theme. Although some studies have been conducted on reproductivewishes and parenting intentions in transgender youth and adolescents, none of these studies focused on how people reflect on these topics years later, when they actually reached adult reproductive age. What these studies did show however, is that the rates of transgender adolescents expressing a desire for parenthood are much higher than the rates of people pursuing fertility preservation. Whereas, 48 to 80% expresses an interest in having children someday. 55-57,60 , reported fertility preservation rates differ from 0 to 7% in trans masculine adolescents and 9 to 62% in trans feminine adolescents. 54,61-64 In line with these findings, 34% of the people in our study cohort reported that they had a desire for children when they initiated medical treatment in adolescence but nobody pursued fertility preservation. It must be noted however, that in the period that our participants started medical treatment, options for fertility preservation were not widely available and only 1 out of 3 people received information about these options. Therefore, it is essential that all transgender adolescents receive proper fertility counseling prior to initiation of medical treatment, regardless of their age, and that the topic is discussed recurrently prior to subsequent steps in the medical transition. Furthermore, it may be valuable to involve caregivers in fertility counseling, especially in young adolescents. Other reported reasons for not pursuing fertility preservation were the costs of the procedure, not wanting to masturbate or undergo medical procedures, and a conflict between their gender identity and their biological gametes. These barriers are similar to what was reported in other study populations. 56,65 For example, Persky et al. found that 58% of transgender youth stated that the idea of having children with their biological gametes conflicted with their affirmed gender, and that for 47% financial considerations played a role in not pursuing fertility preservation. 66 For health care providers it is important to carefully assess potential barriers for fertility preservation in each individual, and tailor