Iris de Nie

31 REFLECTING ON THE IMPORTANCE OF FAMILY BUILDING AND FERTILITY PRESERVATION 2 the provided counseling and offered procedures to their specific needs and abilities (e.g. cryopreservation of surgically obtained spermatozoa to avoid masturbation, or an ovum pick up procedure under general anesthesia). Many transgender adolescents with a desire for children do not find it important to have biological children; Kerman et al. reported that of participants who wanted a family, 84% were excited by the idea of adopting children. 56 While it was previously found that trans masculine people consider adoption more frequently than trans feminine people (78% vs 54%), we observed the opposite (20% vs 39%). 60 On the other hand, using a sperm donor to fulfill a desire for children was only considered by trans masculine people in our study cohort. In addition, only trans masculine people started a family, of whom 95% did not have biological children. These observations might be explained by the fact that the majority of participants reported to have a heterosexual sexual orientation, meaning that partners of trans masculine people are most likely able to become pregnant, whereas partners of trans feminine people are not. Another reason for the low rate of fertility preservation among transgender adolescents might be due to an inability to oversee the importance of future fertility. Adolescents often experience severe distress of pubertal development due to their gender dysphoria, and may therefore be preoccupied with starting puberty suppression as soon as possible. 67 Especially in trans feminine adolescents, the equipoise of commencing medical treatment to avoid progression of puberty, and delaying treatment to enable semen cryopreservation as only option for biological children may be stressful, as puberty is accompanied by irreversible and often unwanted physical changes such as a lowering of the voice and facial hair growth. In our study cohort, many participants stated that they felt that medical treatment for gender dysphoria was more important than staying fertile. These findings are in line with the results of a study by Chiniara et al. , which reported that 58% of trans masculine and 64% of trans feminine people ranked having children as their least important priority, while their highest life priorities were being in good health, do well in school/work and have close friends. When asked to envision what their ranking of these same priorities would be 10 years from now, having children was still the lowest ranked priority. 55 However, other studies found that up to 48% of transgender adolescents acknowledged that their views regarding parenthood might change over time, and they referenced their age and self-assessed maturity as they discussed future fertility decisions. 56,57 This was confirmed by participants in the current study, who felt that they were in retrospect too young to make decisions about fertility, who started to find it troublesome to have become infertile over the years, and who developed a desire for children although they did not expect to do so. Therefore, health care providers should warn adolescents that views on future family building might change over time and create a safe environment in which adolescents are able to change their mind regarding pursuing fertility preservation. Since this study reports on the first transgender adults who started medical treatment during adolescence worldwide, the major strengths of this study are the unique study cohort and, consequently, the obtained insights on how transgender adults of reproductive age look back on choices made regarding fertility during adolescence approximately