The inductive analysis of the study findings resulted in the following themes that represent key barriers to pursuing FP or ART: lack of fertility counseling, fears of discrimination and bullying, high costs, concerns related to the child’s welfare, less than perfect legal framework, and gender transition. Not all participants expressed strong desire to have offspring. A number of sub-themes were grouped under the base themes. Concerns related to the child’s welfare due to factors related to context or transgender people themselves. Fertility treatment may be a challenge for the process of transition or the result of it. The strength of the desire for fertility treatment is crucial. Various reasons behind the transgender people’s desire for parenthood were identified. Transgender individuals (especially those in social transition) showed striking adherence to patterns of the dominant culture when it comes to having children.
1. Lack of fertility counseling
None of the participants reported having received adequate FP counseling before starting their transition, while six out of twelve participants indicated that they had not been given adequate information about their FP options.
The participants Τ1 (51-year-old transwoman in complete transition), Τ5 (28-year-old transman in incomplete transition2), and T6 (27-year-old transman in incomplete transition) did not express regret about missed opportunity for receiving further information from their psychologist/psychiatrist or endocrinologist about FP. However, participants T3 (23-year-old transwoman in late transition), T7 (36-year-old transman in late transition), and Τ9 (29-year-old transman in complete transition) stated clear complaints about being deprived of the opportunity to make fertility decisions, namely, to have a choice about having children genetically related to them. Hence, some participants described a point at which they should have receive information about fertility preservation options, although at the time some transgender persons may not have been able to fully understand what are the potential implications of their decisions as well as what they will be wanting many years later, due to the fact that they were minors or young adults. Transitioning transgender adolescents may not feel ready to make such an important, lifelong decision at their age. However, they are forced to consider whether to preserve their sperm or eggs.
The participant T3 (23-year-old transwoman in late transition) stated,
"…A health scientist should have informed me about it... and I went as early as 16... this is what I tell other youngsters, that, 'OK, you may not be interested in becoming a parent now, but you never know what might happen ten years from now'... no information is given to us..."
In the same vein, the participant T7 (36-year-old transman in late transition) said,
"...if I had known when I was 20 [about cryopreservation], I don't know what I might have done. Some people did not make this choice because they did not know about such an option, and they might have wanted to make such a choice later on…"
The participant T6, a 27-year-old transman in incomplete transition, stated that he was not provided with fertility counseling before starting gender transition because, in the healthcare context, he came across as being uninterested in having children. Reflecting on his experience, he said,
"They did not talk about this; it was not their priority for any reason... in the health system.. .They knew that this matter did not concern me…"
2. Fears of discrimination, bullying, and harassment as barriers to transgender parenthood
a) Discrimination, bullying, and harassment during pregnancy
Participants expressed fears of discrimination ranging from subtle forms (such as social disapproval) to physical violence.
The fact that the phrase ‘transgender parent’ gives other people a bad impression was reported as discouraging to transgender people with regard to considering FP and assisted reproduction options. Participant Τ9, a 29-year-old transman in complete transition, said,
"... it sounds bad... when you say 'trans-parent', they immediately think, as soon as they hear it, that it is very strange..."
The participant T3, a 23-year-old transwoman in late transition, stated,
"Imagine a trans-man pregnant walking in the town square... to start with, it is dangerous for the person themselves, for their physical integrity…"
The participant T12, a 52-year-old transwoman in incomplete transition, believed that a transgender parent may be at high risk of being bullied by other people as long as she remains visible as a transgender person. However, the participant expressed fears of another form of bullying that may occur among transgender parents even though a transgender parent remains invisible as a transgender person. This form of bullying (forced removal or separation of children from their parents) comes from a transgender parent’s family context or close relatives. The participant stated,
"Now, look! If you see a trans person in public who shows they are trans, if they go out with the child, they may be taunted, they may have to face many things, I believe. If it does not show, I believe they will not face any particular problem, unless there is a problem in their environment, their closer, family circle... the [family members] may set procedures in motion to take the child themselves or send it to an institution or something. All that matters is that the child should not be with the trans individual, which is the worst thing for them..."
b) Bullying by health providers in birth settings
A transman who goes into hospital or a midwifery unit to give birth may commonly be the subject of bullying by health professionals. The participant T2, a 60-year-old transman in complete transition, bisexual, expressed his fears:
"The only problem is society, when you go to a maternity clinic with a beard... You will have to be able to go for pre-natal birthing classes; you need to receive treatment in an atmosphere of understanding at the hospital, not to be abused."
In the same vein, the participant T3, a 23-year-old transwoman in late transition, said:
"... and how would they be treated during delivery? Does such a person, in other words, have to be rich and go to a private clinic and pay so they are treated with dignity? This does not mean that there are not people in the public health system who do not treat you with dignity [she relates her experience]."
Unfortunately, health professionals are reported to be the originators of bullying behavior not only within reproductive healthcare contexts, but also within other healthcare contexts. Two participants described negative experiences with health providers that reflected deficits in their providers’ willingness to offer appropriate healthcare to transgender patients. More specifically, they described instances in which health professionals demonstrated subtle (verbal and ‘low intense’) bullying-related behavior or at least a lack of empathy for the issues faced.
The participant T3, a 23-year-old transwoman in late transition, recalled:
"… When I visited a plastic surgeon for the breasts, he had forgotten my problem; he was, like, 'Is a psychiatrist attending to you? Are you seeing any doctor? What kind of hormones have you taken? What other operations?' I felt, in a way, [that] I was being abused. Because there were other people present..."
In a similar vein, the participant T7, a 36-year-old transman in late transition, detailed his experience:
"… access to the health sector is very difficult for us... and an unpleasant experience, right? How can you go to the hospital and hear them ask you: 'Now, what are you?' 'What is it that you've got under your knickers?'..."
… [the health professional] hardly looked at my health booklet, although I had explained that I was a transexual person... He took one look at the injection and he went: 'Ah... testosterone... why are you having this shot?' , in front of other people; and I go: 'I am going to tell you'..."
3. The process of transition as a barrier to fertility preservation and assisted reproduction
This was a significant theme. We got the sense that transgender people who are willing to become parents have a close brush with a dilemma that may occur because of equally (or almost equally) compelling reasons both for and against pursuing fertility treatment. Achieving a successful gender transition as soon as possible is a compelling reason against pursuing fertility treatment. Nevertheless, we recognized that participants were almost always clear about their choices.
a) Fertility preservation as a challenge for the break-up with the old gender
The procedures required for fertility preservation (such as hormonal ovarian stimulation) as well as sperm or oocyte storage may challenge the break-up with the transgender person’s old gender identity.
The participant T1, a 51-year-old transwoman in complete transition, was highly concerned that sperm storage would strongly challenge the (highly desired) break-up with his/her old gender identity. She explicitly declared that it would be distressing (for reasons related to gender dysphoria) to pursue fertility preservation and stated,
"... there was no such suggestion by anyone; even if there had been such a discussion, I would not even stand to hear about it; I wanted to erase any trait left... It is out of the question that I would give my sperm for a biological child... I think this is because it would reduce my female substance (!)… I don't even remember myself... It's as if a roller shutter has come down, a curtain, and I cannot see the past... I try to remember me and I cannot remember me..."
However, the participant said that if she had the opportunity to undergo uterus transplantation at a younger age, it would have significantly contributed to the success of her transition. The participant stated,
"… in other words, it would be continuing on the way to a sense of completion... 100%; I would have felt completed, but, OK, this did not take place when it should have..."
In a similar vein, the participant T5, a 28-year-old transman in incomplete transition, pansexual, expressed strong concerns about worsening gender dysphoria by completing invasive fertility preservation (at least without strong countervailing reasons). He believed that going through the FP procedure (i.e.,including hormonal stimulation and egg retrieval) could be quite invasive, and stated,
"… I am not going to subject my body [to this] and risk my mental health and serenity, if it is not absolutely necessary... I don't know how it might affect my emotions, because I am trying to break free from that gender; I would not like to go back to such symptoms..."
The participant T6, a 27-year-old transman in incomplete transition, made it clear that it could be distressing (as having a negative impact on gender dysphoria) to delay gender transition to facilitate fertility preservation or to undergo invasive FP procedures while having to wait for (medical) gender transition to start.
"I was thinking about doing this before I started the transition, but the procedure was truly difficult even before the transition, because of the hormonal disorders... No way could I have had the physical or mental strength to put up with this; that's why I am looking forward to my hysterectomy, to be done with this matter once and for all."
Furthermore, mere oocyte storage may challenge the break-up with the transgender individual’s old gender identity, although the particular individual is in complete transition. The participant T9, a 29-year-old transman in complete transition stated,
"... I think it's difficult to communicate this to the other person... to sit and tell him, 'You know, I have some stored [i.e.,ova]... and we can do it this way'... I don't know how easy that might be."
b) Fertility preservation (or fertility treatment) as a challenge for the medical transition process
The participant T3, a 23-year-old transwoman in late (endocrine) transition, discussed her worry that treatment with testosterone to improve sperm quality would significantly challenge her process of (medical) transition and, hence, that the effort would not be worth it, as the success rate is very low, which means that there would be no strong reasons for doing it. She stated,
‘A child of my own? I don't think this is possible anymore... because I have no intention to reverse my hormone treatment, so I am telling you, wittingly, THIS possibility is out of the question for me, i.e., to become a biological parent; I do NOT exclude becoming a parent, but I DO exclude the biological aspect of it. Because I would have to reverse the hormonal treatment, which I am not going to do... why should I give testosterone to my body? Whatever for? For something that is very unlikely to be successful? Because the chances they give you that my sperm will be OK are very low... This would take me way back in time, for my appearance as well..."
c) Type of transition and desire to pursue FP or ART
The participant T4, a 45-year-old transman in social transition, was much more willing to donate gametes (oocytes) than many other participants. Strikingly, he states that he cannot understand why many transmen are not willing to get pregnant as well as that the desire for parenthood may be stronger than the desire for gender transition.
"Yes, absolutely, yes, yes, yes, [I would like to donate an ovum]... this is why, if I am going to receive hormones, I will discuss it a lot with my doctor... after their transition, trans persons do not want to have children as... hmmm... using their body. If you ask me about it, I would say that they would like their boyfriend or girlfriend to do it with another person or to adopt... the question is what [do] you want more: to be a trans person or to be a father? To be a trans person or to be a mother?..."
d) The unwillingness of transmen to get pregnant is very strong
This is also an opportunity to formulate another hypothesis for further research. The participant T10, a 38-year-old transman in incomplete transition, declared his unwillingness to get pregnant although he had a strong desire to have children and a family. However, he was willing to pursue FP and donate oocytes.
" …I am all for having a family and children. Hmmm, ... if my girl wants to get pregnant, if that is her intention [she is in a wheelchair]; I don't want to. I want to proceed with the removal, so this will never happen. Any kind of surgery to freeze my ova so that they may be fertilised, if this is possible..."
4. Reasons behind the desire for biological parenthood
We remarked differences in responses and attitudes towards fertility desire and about having children. Participants were not always clear about the reasons behind a transgender individual’s willingness or unwillingness to have biological children and the interviewer often needed to ask directly.
Participants in the present study indicated that the desire to have biological children has a deeper meaning than a legitimate wish. While rationalizing transgender people’s desire to have biological children, participants discussed several reasons for this desire. For example, the participant T9, a 29-year-old transman in complete transition, placed considerable emphasis on the value of genetic relatedness and biological resemblance between parents and children as the reason behind the desire for biological parenthood, and stated,
"Simply because of the reasons anyone has: that they want to feel it is their own child, made with their own material... to see some features in this child... biological ones."
In a similar vein, the participant T12, a 52-year-old transwoman in incomplete transition, believed that a transgender person’s desire to have children is based on the innate human need for having children, and stated,
"Someone who is a trans individual does not stop wishing they had a child... Just like with cis… I believe that [the wish to have a child] emerges purely for the biological need each individual has."
However, the participant considers that it is the strong desire for parenthood that motivates a transgender person to pursue FP techniques and ART, and stated,
"Now, I don't know if a transwoman would undergo the procedure to have a biological child… only if she truly wants it…" "…I believe things are completely different for homosexuals…"
In a similar vein, the participant T8, a 50-year-old transwoman in social transition, strikingly underscored the role of the so-called ‘biological clock’ in shaping a desire for biological parenthood, and stated,
"Whether you are a trans-sexual or a bisexual or a heterosexual, aren't you going to have a kid? Therefore, don't you want to have a family and a home for this child?… You are beautiful yourself, why adopt? [Having a child] is a blessing from nature... For better or worse, when the biological clock ticks, everyone wants a child..."
The aforementioned participant T8 strongly stood in favor of the natural way of conceiving a baby. She strongly rejected the use of medically assisted reproduction techniques, and said,
"Artificial insemination/cryopreservation? I really don't want any of all this, dear girl! In other words, I prefer more traditional things. Even a lesbian who wants to have a child, could find a one-night stand and have a child… Frozen sperm? Yuck! Not for me!"
Surprisingly, the participant remained strikingly steadfast in adherence to patterns of the dominant culture (based on naturalness/biology and heteronormativity), at least in the context of reproduction.
It is worth mentioning that the participant T9, a 29-year-old transman in complete transition, highlighted the genetic relatedness between parents and children, and conveyed the impression that if he had ‘excellent DNA’ it would constitute a strong reason for making him willing to pursue FP and donate oocytes to his partner. He stated,
"…Personally, I couldn't care less if the child is mine; ha, ha, OK [to donate, e.g.ova to his girlfriend to get pregnant], I don't even believe that my DNA is anything special... so, this is what I believe."
Note, however, that this view may result from mechanisms such as ex-post realization or the over-generalization of hard-wired perceptions due to low self-esteem (which, in turn, may be due to internalized anti-trans prejudice). Further studies are needed to assess whether internalized anti-trans prejudice is associated with a weak desire for having biological children or an unwillingness to have children.
The participant T3, a 23-year-old transwoman in late transition highlighted that the desire for biological parenthood is egoistically motivated, and stated,
"[I would like a child] for the same selfish reasons any cis person does; I don't believe [there is] some biological clock... eh, the feeling has to do with selfishness..."
This view deviated from the dominant culture that highlights essentialism (biology, naturalness). However, on the other hand, the above-mentioned participant took a clear stance in favor of biological ties between parents and children. The participant T3 missed the opportunity to have her own children (due to a lack of information about FP options before starting her transition), and stated,
"... what I expect for the future is for my partner to have a child... it would be our child... because this would be my first thought before adoption..."
Not surprisingly, the participant T11, a 38-year-old transman in late (almost complete) transition, did not emphasize the biological ties between parents and children. Strikingly, he believed that genetic and social parenthood should be thought of as having equal value, while placing considerable emphasis on values such as love and affection between parents and children. This view clearly deviated from the essentialist reasoning about parenthood that highlights nature (biology), which is strictly associated with the dominant culture and ideology. The participant stated,
"Sharing ova [giving one of hers to her partner]? Hm, no... what I mean is, won't it be my child if I raise it? Is it necessary for the child to have my ova so that it is mine? The point is, if you have a child, whether biological or not, you have to love it. In other words, if it is not your biological child, you are not going to love it?"
In conclusion, the analysis of our findings revealed that transgender people are most likely to have the same basic reproductive needs as cis-people. Some transgender individuals place great weight on the value of genetic relatedness.
5. Skipping fertility health care due to high costs
In this study, economic factors such as the cost of the FP procedure and the storage of gametes were reported as major barriers to transgender parenthood. More particularly, the participants T3 (a 23-year-old transwoman in late transition) and T7 (a 36-year-old transman in late transition) highlighted that the costs of long-term cryopreservation of sperm and oocytes (respectively) are so high that many transgender people skip fertility preservation, provided that these procedures of storage are not covered by health insurance (private or public). Furthermore, the costs of the mere assisted reproductive technology procedures were found to be high by the participant Τ5 (a 28-year-old transman in incomplete transition, pansexual). Moreover, the participant T8, a 50-year-old transwoman in social transition said that transgender people have to be rich (‘bourgeois’) to raise children!
6. Concerns related to the child’s welfare as barriers to fertility preservation and assisted reproduction
a) Transgender people fear that their children will be bullied
The participant Τ3, a 23-year-old transwoman in late transition, highlighted the social prejudice and discrimination faced by children with transgender parents, and stated,
"…In the local community [reference to the name of the person's village of origin], even an adopted child is at times pointed to and called a bastard."
Interestingly, from the inductive analysis of the study findings, fear of social prejudice did not emerge as the main barrier to transgender parenthood related to a child’s welfare.
Surprisingly, the participant Τ1, a 51-year-old transwoman in complete transition, took a clear stance against same-sex parenthood while being in favor of transgender parenthood, and said:
"…I don't think that we are ready, as a society, let's say... children are very cruel at such ages and say to another child: 'I have a daddy and a mummy and you don't; you have two daddies or two mummies'..."
b) Concerns related to the role of the parent
Several participants had positive perceptions regarding transgender parenthood.
The participant T10, a 38-year-old transman in incomplete transition, said:
"Whatever love is given, eh,... by a straight couple, is the same as the love that can be given by a trans person; in essence, eh, love or one's conduct does not change because of one's gender identity."
In the same vein, the participant Τ2, a 60-year-old transman in complete transition, bisexual, said:
"…gender identity has nothing to do with wanting to have a child."
In the same vein, the participant T7, a 36-year old transman in late transition, said:
"...Everyone is entitled to becom[e] a parent; what is necessary is for relevant legislation to be in place, as we said; what is necessary is to study the situation so some things are done correctly..."
Similarly, the participant T1, a 51-year-old transwoman in complete transition, said,
"This has nothing to do with gender; [both trans and cis] should have [a child], why not? They have love to offer, and many other things that everyone can give..."
c) The responsibility of raising a child
The participant Τ5, a 28-year-old transman in incomplete transition, pansexual, said,
"…It's a very big responsibility to be responsible for someone else..."
Moreover, the participant Τ9, a 29-year-old transman in complete transition, said,
"...[I would like], if something goes wrong, for example, that the child should be more my girlfriend's... but I think I generally prefer adoption."
d) The fears of themselves becoming harmful to their children (due to heredity or use of hormones)
Participants were of the belief that even if they had children, it is likely that they would blame themselves for how their children’s lives might turn out due to heredity or even the use of hormone replacement therapy. The participant Τ5, a 28-year-old transman in incomplete transition as a pansexual stated,
"..I am bipolar, OK? I don't know if it is passed down, if it is hereditary..."
"... but, if my child told my 'Dad, I am trans',... I would not like the child to be subjected to the procedure I have been through..."
While the participant T12, a 52-year-old transwoman in incomplete transition was of the belief that a child raised by LGBT parents would receive only so much love and affection, she was afraid of the fact that the parent’s hormone replacement therapy might negatively affect the health of the child.
"If you have taken hormones, then the child may be born with problems, which means it would have been better not to have had it... why bring a child with problems into the world, to suffer?"
e) The perceived need for clear (trans) parental identity seen through others’ eyes
The participant T4, a 45-year-old transman in social transition was of the belief that a transgender individual should gain unambiguous social acceptance of his new gender identity before becoming a parent. The participant stated,
"[in the past] I did not think of becoming a father, because… there were people who could not accept [my male name], and I had to fight... I believe that trans-parents are also parents, but I think that for [a trans person] to start [the process of becoming a parent], everyone must have accepted this... trans person first."
In a similar vein, the participant T2, a 60-year-old transman bisexual stated,
"… First of all, you need to feel OK with who you are, to know who you are and where you are going and then [have a child]…They say that I should have completed the transition and then have children... And now, sometimes, they call me 'mamo'; my daughter [tells] her fiance:'my mother is not like others, she is a trans-man; this is how we live..."
f) The transgender people’s capacity to meet the needs of their children
The participant T6, a 27-year-old transman in incomplete transition focused on his chronic depression and stated,
"…I don't believe that I will ever reach the psychological stage of my life when I am going to want and be capable of raising a child (psychologically); I suffer from chronic depression and I don't know how this may affect a child's life."
The participant T1, a 51-year-old transwoman in complete transition focused on her characteristics, and stated,
"…I think I would be overprotective and possibly authoritarian; I might not be able to fully control and fully manage that..."
g) Adherence to heteronormative patterns of parenting (parent figures)
Participants perceived their adherence to heteronormative patterns of parenting as their motivations for rejecting same-sex and transgender parenthood. The participant T1, a 51-year-old transwoman in complete transition expressed her strong intuition-based prejudice against same-sex parenthood, and stated,
"…I cannot fully ratify this; I may be wrong - should I call myself a racist? I don't know why, but there is something I don't like about it; I cannot fully decipher it... I don't know exactly what it is. Is it being old school?..."
The participant T8, a 50-year-old transwoman in social transition placed considerable emphasis on naturalness, and stated,
"The child is going to see me as I am. What can I tell you? If I were in the child's place, I would like to have a mum and a dad!... Why should I do this? Isn't it selfish? ...It is a sacred thing, Christina!!! It is not only a social issue, but also a matter of nature! How can I explain this to you? To your eyes, what is nicer? A photo with mum, dad, grandpa and grandma or a photo with two transvestites? What can I tell you? What seems nicer to you??"
In conclusion, several of the aforementioned findings in this section (6) of the paper suggest that some transgender people have very low expectations about what parents they could become. Moreover, it is worth noting that we identified several sub-themes grouped under the base theme ‘concerns related to child’s welfare’. In our opinion, this reflects the assumption that transgender parenthood is a complex, complicated, and multidimensional issue.
4. Legal framework thought of as being less than perfect
The participant T1, a 51-year-old transwoman in complete transition, and the participant T3, a 23-year-old transwoman in late transition, focused on the fact that it is not possible under the current Greek legal framework for children birth certificate to be changed to include transgender parent’s revised name or legal gender. As a consequence, the current legal framework ‘prevents’ transgender parents from applying for legal change of their gender identity.