The inductive analysis of the study findings resulted in the identification of the following themes that represent key barriers to pursuing FP or ART: lack of adequate information and fertility counseling, worsening gender dysphoria (fertility treatment may be a challenge to the transition process or a result of it, with the strength of the desire for fertility treatment being crucial), increased discrimination against transgender people due to the rise of extreme far-right populism, low parental self-efficacy, high costs, and the less than perfect legal framework. Not all participants expressed a strong desire to have offspring. Various reasons behind transgender people’s desire for parenthood were identified. A number of subthemes were grouped under the base themes, such as the symbolic value of the uterus and pregnancy, the relationship between the type of gender transition and willingness to pursue FP and IVF, and transgender people’s (especially those in social transition) striking adherence to heteronormative patterns in the context of reproduction.
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 Jessie (a 51-year-old trans woman who had completed the transition process 3), Luis (a 28-year-old trans man still in transition), and Jonathan (a 27-year-old trans man still in transition) did not express regret about the missed opportunity for receiving further information from their psychologist/psychiatrist or endocrinologist about FP. However, the participants Fabiola (a 23-year-old trans woman at an advanced stage of the transition process), Edward (a 36-year-old trans man at an advanced stage of the transition process), and Patrick (a 29-year-old trans man who had completed the transition process) made clear complaints about being deprived of the opportunity to make fertility decisions, namely, to have a choice about having children genetically related to them. Furthermore, the participants noted that when they were adolescents in the gender transition, they did not feel ready to make important and lifelong reproductive decisions at their age. However, they were forced to consider whether to preserve their sperm or eggs.
Fabiola (a 23-year-old trans woman at an advanced stage of the transition process) 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, Edward (36-year-old trans man at an advanced stage of the transition process) 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…"
Jonathan, a 27-year-old trans man still in 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…"
Fears of discrimination, bullying, and harassment as barriers to transgender parenthood
a) Bullying by the general population: Discrimination, bullying, and harassment during pregnancy
The 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 negative impression was reported as discouraging to transgender people with regard to considering FP and assisted reproduction options. Patrick, a 29-year-old trans man who had completed the transition process, said,
"... it sounds bad... when you say 'trans-parent', they immediately think, as soon as they hear it, that it is very strange..."
Fabiola, a 23-year-old trans woman at an advanced stage of the transition process, 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…"
Fay, a 52-year-old trans woman still in 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 if a transgender parent remains invisible as a transgender person. This form of bullying (the forced removal or separation of children from their parents) occurs in a transgender parent’s family context or is instigated by close relatives. Fay 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 him/her [the child] 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..."
The aforementioned participants expressed their fear of aggressive behaviors against them, highlighting the rising extreme far-right populism in the urban areas where they were living.
b) Bullying by health providers in birth settings
A trans man who goes to the hospital or a midwifery unit to give birth may commonly be the subject of bullying by health professionals. George, a 60-year-old trans man who had completed the transition process and was 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 prenatal birthing classes; you need to receive treatment in an atmosphere of understanding at the hospital, not to be abused."
In the same vein, Fabiola, a 23-year-old trans woman at an advanced stage of the transition process, 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 were 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 their providers’ lack of willingness to offer appropriate healthcare to transgender patients. More specifically, they described instances in which health professionals demonstrated subtle (verbal and ‘low-intensity’) bullying-related behavior or at least a lack of empathy for the issues faced.
Fabiola, a 23-year-old trans woman at an advanced stage of the transition process, recalled,
"… When I visited a plastic surgeon for 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, Edward, a 36-year-old trans man at an advanced stage of the transition process, 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'..."
The transition process as a barrier to FP and assisted reproduction
a) FP as a challenge for the break with one’s old gender
Jessie, a 51-year-old trans woman who had completed the transition process, was highly concerned that sperm storage would strongly challenge the (highly desired) break with her old gender identity. She explicitly declared that it would be distressing (for reasons related to gender dysphoria) to pursue FP and explained,
"... there was no such suggestion by anyone; even if there had been such a discussion, I would not have even stood 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 had the opportunity to undergo uterus transplantation at a younger age, it would have significantly contributed to the success of her transition. As the topic of uterus transplantation was not part covered in the interview guide questions, this mention of uterus transplantation came up as an emergent theme. 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, Luis, a 28-year-old trans man still transition and was pansexual, expressed strong concerns about worsening his gender dysphoria by completing invasive FP (at least without strong countervailing reasons). He believed that going through the FP procedure (i.e., hormonal stimulation and egg retrieval) could be quite invasive and noted,
"… 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..."
Jonathan, a 27-year-old trans man still in transition, made it clear that it could be distressing (having a negative impact on gender dysphoria) to delay gender transition to facilitate FP or to undergo invasive FP procedures while having to wait for the (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, oocyte storage may challenge the break with the transgender individual’s old gender identity, even if the individual has completed the transition process. Patrick, a 29-year-old trans man who had completed the transition process, stated,
"... I think it is difficult to communicate this to the other person... to sit and tell him, 'You know, I have some [ova] stored ... and we can do it this way'... I don't know how easy that might be."
Fabiola, a 23-year-old trans woman at an advanced stage of the (endocrine) transition process, 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 and there is therefore no strong reason for doing it. She explained,
‘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..."
b) The highly symbolic value of pregnancy (considered strictly related to femininity) as a barrier to FP and assisted reproduction for individuals undergoing female-to-male medical gender transition
We found that trans men may be very unwilling to become pregnant, whereas they may be willing to become genetic parents.
Antonio, a 38-year-old trans man still in transition, reported his unwillingness to become pregnant, but he had a strong desire to have children and a family. 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 fertilized, if this is possible..."
Nevertheless, John, a 45-year-old trans man in social transition, was much more willing to donate gametes (oocytes) than many other participants. Strikingly, he noted that he could not understand why many trans men are not willing to become pregnant, as 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?..."
Notably, however, some trans men believed that a trans man might get pregnant and give birth after the gender transition. George said, ‘They say that I should have completed the transition and then had children… [If you get pregnant]… the only problem is society, when you go to a maternity clinic…not to be abused’.
A range of reasons for transgender peoples’ willingness (or unwillingness) to become biological parents
The participants reported several reasons for their willingness (or unwillingness) to become biological parents. We remarked on the differences in responses and attitudes related to fertility desire and in those related to having children during the interviews. The 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.
The participants in the present study indicated that the desire to have biological children has a deeper meaning than just a wish. While rationalizing transgender people’s desire to have biological children, the participants discussed several reasons for this desire. For example, Patrick, a 29-year-old trans man who had completed the transition process, 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, Fay, a 52-year-old trans woman still in transition, believed that a transgender person’s desire to have children is based on the innate human need for having children and noted,
"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 from the biological need each individual has."
However, this participant thought that the strong desire for parenthood motivates a transgender person to pursue FP techniques and ART, and stated,
"Now, I don't know if a trans woman 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, Jenny, a 50-year-old trans woman in social transition, strikingly underscored the role of the so-called ‘biological clock’ in shaping the 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, Jenny, was strongly in favor of the natural way of conceiving a baby. She strongly rejected the use of medically assisted reproductive 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 her 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 Patrick, a 29-year-old trans man who had completed the transition process, 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."
Notably, however, this view may been a result of mechanisms such as ex post realization or the overgeneralization 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.
Fabiola, a 23-year-old trans woman at an advanced stage of the transition process, 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 and naturalness). However, on the other hand, the abovementioned participant took a clear stance in favor of biological ties between parents and children. Fabiola 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, Richard, a 38-year-old trans man in the final (almost complete) stage of the transition process, did not emphasize the biological ties between parents and children. Interestingly, he believed that genetic and social parenthood should be thought of as having equal value while considerable emphasis should be placed on values such as love and affection between parents and children. This view clearly deviated from the essentialist reasoning regarding 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 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.
Concerns related to transgender parenting and children’s welfare as barriers
a) Transgender people’s fears that their children will be affected by bullying
Fabiola, a 23-year-old trans woman at an advanced stage of the transition process, 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, in the inductive data analysis, fear of social prejudice did not emerge as the main barrier to transgender parenthood related to a child’s welfare.
Surprisingly, Jessie, a 51-year-old trans woman who had completed the transition process, 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 transgender parent (low parental self-efficacy)
Several participants showed positive attitudes towards transgender parenthood.
Antonio, a 38-year-old trans man still in 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, George, a 60-year-old trans man who had completed the transition process and was bisexual, said,
"…gender identity has nothing to do with wanting to have a child."
In the same vein, Edward, a 36-year-old trans man at an advanced stage of the transition process, noted,
"...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, Jessie, a 51-year-old trans woman who had completed the transition process, 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..."
However, some participants believed that they would not be able to perform parenting tasks successfully. They were afraid of taking responsibility because they were extra cautious about being responsible for someone else and doing things properly.
Luis, a 28-year-old trans man still in transition and was pansexual, said,
"…It's a very big responsibility to be responsible for someone else..."
Moreover, Patrick, a 29-year-old trans man who had completed the transition process, 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."
Other participants explicitly expressed their belief that they did not have the qualifications to be a good parent.
Jonathan, a 27-year-old trans man still in 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 to 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."
Jessie, a 51-year-old trans woman who had completed the transition process, 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..."
Interestingly, some participants were afraid of becoming parents because they were extra cautious about potential dangers to their children (i.e., due to heredity or the toxicity of the use of hormones to embryos or fetuses)
The participants believed that even if they had children, it was 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. Luis, a 28-year-old trans man still in 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 Fay, a 52-year-old trans woman who was in the transition process, believed that a child raised by LGBT parents would receive ample love and affection, she feared 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?"
c) Concerns about children’s welfare related to a well-established transgender identity
Some participants considered that gaining a clear gender identity implicitly accepted by others is a prerequisite for becoming a transgender parent.
John, a 45-year-old trans man in social transition, believed 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, George, a 60-year-old trans man bisexual noted,
"… 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 fiancé, 'My mother is not like others, she is a trans-man; this is how we live'..."
d) Concerns about children’s welfare related to the fact that transgender parenthood diverges from heteronormativity (dominant sexual and gender norms)
Importantly (though not surprisingly), the participants perceived their adherence to heteronormative patterns of parenting (traditional parent figures) as their motivation for rejecting same-sex and transgender parenthood. Jessie, a 51-year-old trans woman who had completed the transition process, 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?..."
Jenny, a 50-year-old trans woman in social transition, placed considerable emphasis on naturalness and explained,
"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?"
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 specifically, the participants Fabiola (a 23-year-old trans woman at an advanced stage of the transition process) and Edward (a 36-year-old trans man at an advanced stage of the transition process) highlighted that the costs of long-term cryopreservation of sperm and oocytes are so high that many transgender people choose not to pursue FP, provided that these storage procedures are not covered by health insurance (private or public). Furthermore, the costs of assisted reproductive technology procedures were found to be high by Luis (a 28-year-old trans man still in transition and pansexual). Moreover, Jenny, a 50-year-old trans woman in social transition, said,
transgender people have to be rich (‘bourgeois’) to raise children!
Legal framework perceived as less than perfect
Jessie, a 51-year-old trans woman who had completed the transition process, and Fabiola, a 23-year-old trans woman at an advanced stage of the transition process, focused on the fact that it is not possible under the current Greek legal framework for a child’s birth certificate to be changed to include the transgender parent’s revised name or legal gender. As a consequence, the current legal framework ‘prevents’ transgender parents from applying for legal changes to their gender identity.