Iris de Nie

32 C H A P T E R 2 15 years ago. Hereby, we were able to explore how views on family building and the importance of biological parenthood might change over time. However, the design of this study has some limitations. Since people reflect on a period in which fertility counseling was not offered on a structural basis, results of this study are not directly translatable to current practice. Nowadays, a general consensus exists on the need to inform all people initiating medical treatment for gender dysphoria about its effect on fertility, and to offer fertility preservation options. 68 In our gender identity clinic, at present all transgender adolescents are therefore counseled by a fertility specialist prior to the start with puberty suppression as well as before initiation of GAHT. To assess how this affects decisional conflict and regret we will need to repeat this study in 10 to 15 years, although in the meantime clinical practice might have changed again. Another factor that has to be taken into account when interpreting the responses of participants is the influence of choice-supportive bias, which is the tendency to retroactively ascribe positive attributes to an option one has selected and to demote the forgone options. 69 This may be a useful coping strategy to be at peace with decisions made in the past and to avoid feelings of regret. Because of this, the percentage of people reporting to find it difficult to have become infertile, and to would have want to pursue fertility preservation or keep their gonads, might be lower. Conversely, the percentage of people recommending transgender adolescents to pursue fertility preservation might be relatively high due to a lack of knowledge about what to options for fertility preservation exactly entail and how invasive they can be. Furthermore, participants were asked to reflect on feelings and choices they made more than 10 years ago. Therefore, it may be possible that not all aspects were accurately remembered. For future studies, it would be worthwhile to explore this topic more in-depth using semi- structured interviews and to longitudinally assess feelings about fertility with validated questionnaires. CONCLUSION Overall, this study provides valuable insights on transgender people’s experiences with starting gender-affirming treatment as adolescent and their feelings regarding fertility and family building. Since the participants started medical treatment in a period when sterilization was required for legal gender recognition, the vast majority (96%) became permanently infertile due to this treatment. Although many report to be at peace with this and to have found other ways to start a family, a substantial part does experience their infertility as troublesome and reports that, with today’s knowledge, they would have chosen fertility preservation or keep their reproductive organs. Moreover, the majority of participants developed a desire to have children, of whom more than 30% would have preferred to use their own gametes to fulfill this desire.