204. Factors Impacting Fertility Preservation Decision-Making Among Transgender Adolescents And Young Adults

Abstract

Transgender adolescents and young adults (AYA) increasingly seek treatment with gender-affirming hormones (GAH) (testosterone and estrogen). While effective in reducing gender dysphoria (GD), long-term GAH use may impair reproductive functioning. Thus, clinical guidelines by the World Professional Association for Transgender Health, the Endocrine Society, and the American Society of Reproductive Medicine recommend fertility counseling involving discussion about fertility preservation (FP) for transgender AYA prior to starting GAH. Despite these recommendations, FP utilization is low among transgender AYA, with fewer than 5% completing FP across two studies (Chen et al., 2017; Nahata et al., 2017). Reasons for low utilization are unclear; recent studies suggest that some transgender AYA (24-36%) desire biological parenthood (Chen et al., 2018; Strang et al., 2018). This study aims to examine factors impacting FP decision-making in transgender AYA purposively sampled to include varying personal experiences with FP counseling and procedures and for non-white and assigned male participants to diversify respondent characteristics. Participants completed an in-person, semi-structured interview to inform improvements in fertility counseling and the development of a fertility decision-aid targeted for transgender youth. Interviews included open-ended questions within the following domains: (1) gender-affirming medical care received, (2) understanding of GAH effects on fertility, (3) knowledge of FP options, and (4) information needs and preferences regarding fertility and FP. Interviews were analyzed thematically (Braun & Clarke, 2006) to identify factors impacting FP decision-making. Eighteen transgender AYA (ages 15 to 24) participated (60% participation rate). Most were assigned female at birth (67%). Half received specialized fertility counseling (50%). Few pursued FP (33%). Themes regarding FP decision-making were identified in four domains: individual factors, family factors, provider factors, and contextual factors. Three key themes characterized individual factors influencing decision-making: AYA’s anticipated future parenthood ideals, AYA’s desires for biological parenthood, and impact of FP on GD. Two key themes characterized family factors influencing decision-making: parent/family values of biological parenthood, and parents’ roles in decision-making. Four key themes characterized provider factors influencing decision-making: clinicians provide accurate information and answer questions effectively, clinicians do not provide complete information, desires for further discussion about FP, and clinicians support independent decision-making. Four key themes characterized contextual factors influencing decision-making: societal views on transgender parenthood, medical aspects of FP, technology limitations, and costs. Transgender AYA consider myriad factors in weighing whether to pursue FP. While individual desires for biological parenthood and family values influenced whether AYA pursued FP counseling, contextual factors such as costs and expectation of GD exacerbation in the context of FP were barriers to completing FP. AYA also identified shortcomings in fertility counseling with providers, highlighting the need to establish standardized counseling protocols and develop patient decision-aids.