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Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey

  • Amy C. TishelmanEmail author
  • Megan E. Sutter
  • Diane Chen
  • Amani Sampson
  • Leena Nahata
  • Victoria D. Kolbuck
  • Gwendolyn P. Quinn
Fertility Preservation

Abstract

Purpose

To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients.

Methods

Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August–November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes.

Results

Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health.

Conclusion(s)

This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.

Keywords

Transgender Fertility preservation Fertility counseling Gender-affirming hormones Reproductive health Qualitative research 

Notes

Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

This study was deemed exempt.

References

  1. 1.
    Oktay K, et al. Fertility preservation in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol. 2018;2018:78 1914.Google Scholar
  2. 2.
    Hirshfeld-Cytron J, Gracia C, Woodruff TK. Nonmalignant diseases and treatments associated with primary ovarian failure: an expanded role for fertility preservation. J Women's Health. 2011;20(10):1467–77.CrossRefGoogle Scholar
  3. 3.
    Nahata L, Quinn GP, Tishelman AC. Counseling in pediatric populations at risk for infertility and/or sexual function concerns. Pediatrics. 2018;142(2):e20181435.CrossRefGoogle Scholar
  4. 4.
    Wallace SA, Blough KL, Kondapalli LA. Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer. Gynecol Endocrinol. 2014;30(12):868–871.Google Scholar
  5. 5.
    Leavy M, Trottmann M, Liedl B, Reese S, Stief C, Freitag B, et al. Effects of elevated β-estradiol levels on the functional morphology of the testis - new insights. Sci Rep. 2017;7:39931.Google Scholar
  6. 6.
    Jindarak S, Nilprapha K, Atikankul T, Angspatt A, Pungrasmi P, Iamphongsai S, et al. Spermatogenesis abnormalities following hormonal therapy in transwomen. Biomed Res Int. 2018;2018:15.Google Scholar
  7. 7.
    Schneider F, Neuhaus N, Wistuba J, Zitzmann M, Heß J, Mahler D, et al. Testicular functions and clinical characterization of patients with gender dysphoria (GD) undergoing sex reassignment surgery (SRS). J Sex Med. 2015;12(11):2190–200.Google Scholar
  8. 8.
    Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120–7.CrossRefGoogle Scholar
  9. 9.
    Baba T, Endo T, Honnma H, Kitajima Y, Hayashi T, Ikeda H, et al. Association between polycystic ovary syndrome and female-to-male transsexuality. Hum Reprod. 2007;22(4):1011–6.Google Scholar
  10. 10.
    Caanen MR, Soleman RS, Kuijper EAM, Kreukels BPC, de Roo C, Tilleman K, et al. Antimullerian hormone levels decrease in female-to-male transsexuals using testosterone as cross-sex therapy. Fertil Steril. 2015;103(5):1340–5.Google Scholar
  11. 11.
    Schneider F, Kliesch S, Schlatt S, Neuhaus N. Andrology of male-to-female transsexuals: influence of cross-sex hormone therapy on testicular function. Andrology. 2017;5(5):873–80.CrossRefGoogle Scholar
  12. 12.
    Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.Google Scholar
  13. 13.
    ASRM. Access to fertility services by transgender persons: an ethics committee opinion. Fertil Steril. 2015;104(5):1111–5.CrossRefGoogle Scholar
  14. 14.
    Colebunders B, De Cuypere G, Monstrey S. New criteria for sex reassignment surgery: WPATH standards of care, version 7, Revisited. Inte J Transgenderism. 2015;16(4):222–33.CrossRefGoogle Scholar
  15. 15.
    Wierckx K, van Caenegem E, Pennings G, Elaut E, Dedecker D, van de Peer F, et al. Reproductive wish in transsexual men. Hum Reprod. 2011;27(2):483–7.Google Scholar
  16. 16.
    Tornello SL, Bos H. Parenting intentions among transgender individuals. LGBT Health. 2017;4(2):115–20.CrossRefGoogle Scholar
  17. 17.
    Auer MK, Fuss J, Nieder TO, Briken P, Biedermann SV, Stalla GK, et al. Desire to have children among transgender people in Germany: a cross-sectional multi-center study. J Sex Med. 2018;15(5):757–67.Google Scholar
  18. 18.
    Maxwell S, Noyes N, Keefe D, Berkeley AS, Goldman KN. Pregnancy outcomes after fertility preservation in transgender men. Obstet Gynecol. 2017;129(6):1031–4.CrossRefGoogle Scholar
  19. 19.
    Wierckx K, Stuyver I, Weyers S, Hamada A, Agarwal A, de Sutter P, et al. Sperm freezing in transsexual women. Arch Sex Behav. 2012;41(5):1069–71.Google Scholar
  20. 20.
    Nahata L, Tishelman AC, Caltabellotta NM, Quinn GP. Low fertility preservation utilization among transgender youth. J Adolesc Health. 2017;61(1):40–4.CrossRefGoogle Scholar
  21. 21.
    Chen D, Simons L, Johnson EK, Lockart BA, Finlayson C. Fertility preservation for transgender adolescents. J Adolesc Health. 2017;61(1):120–3.CrossRefGoogle Scholar
  22. 22.
    Pfäfflin F, et al. The desire to have children and the preservation of fertility in transsexual women: a survey. Inte J Transgenderism. 2002;6(3):97–03.Google Scholar
  23. 23.
    Schelble AP, Fisher AR, Jungheim E, Lewis C, Omurtag K. Fertility preservation (FP) referral and follow-up in male-to-female (MTF) and female-to-male (FTM) transgender patients. Fertil Steril. 2017;108(3):e115–6.CrossRefGoogle Scholar
  24. 24.
    Flink DM, Sheeder J, Kondapalli LA. A review of the oncology patient’s challenges for utilizing fertility preservation services. J Adolesc Young Adult Oncol. 2017;6(1):31–44.CrossRefGoogle Scholar
  25. 25.
    Klosky JL, Anderson LE, Russell KM, Huang L, Zhang H, Schover LR, et al. Provider influences on sperm banking outcomes among adolescent males newly diagnosed with cancer. J Adolesc Health. 2017;60(3):277–83.Google Scholar
  26. 26.
    Shnorhavorian M, Kroon L, Jeffries H, Johnson R. Creating a standardized process to offer the standard of care: continuous process improvement methodology is associated with increased rates of sperm cryopreservation among adolescent and young adult males with cancer. J Pediatr Hematol Oncol. 2012;34(8):e315–9.CrossRefGoogle Scholar
  27. 27.
    Chen D, Kolbuck VD, Sutter ME, Tishelman AC, Quinn GP, Nahata L. Knowledge, practice behaviors, and perceived barriers to fertility care among providers of transgender healthcare. J Adolesc Health. 2018;0(0).Google Scholar
  28. 28.
    Glaser BG. The constant comparative method of qualitative analysis. Soc Probl. 1965;12(4):436–45.CrossRefGoogle Scholar
  29. 29.
    Levitt HM, Bamberg M, Creswell JW, Frost DM, Josselson R, Suárez-Orozco C. Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: the APA publications and communications board task force report. Am Psychol. 2018;73(1):26–46.CrossRefGoogle Scholar
  30. 30.
    Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.CrossRefGoogle Scholar
  31. 31.
    Wu YP, Thompson D, Aroian KJ, McQuaid EL, Deatrick JA. Commentary: writing and evaluating qualitative research reports. J Pediatr Psychol. 2016;41(5):493–505.CrossRefGoogle Scholar
  32. 32.
    Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.CrossRefGoogle Scholar
  33. 33.
    Hallgren KA. Computing inter-rater reliability for observational data: an overview and tutorial. Tutor Quant Methods Psychol. 2012;8(1):23–34.CrossRefGoogle Scholar
  34. 34.
    James-Abra S, Tarasoff LA, green, Epstein R, Anderson S, Marvel S, et al. Trans people’s experiences with assisted reproduction services: a qualitative study. Hum Reprod. 2015;30(6):1365–74.Google Scholar
  35. 35.
    Mitu K. Transgender reproductive choice and fertility preservation. AMA J Ethics. 2016;18(11):1120.Google Scholar
  36. 36.
    Armuand G, Dhejne C, Olofsson JI, Rodriguez-Wallberg KA. Transgender men’s experiences of fertility preservation: a qualitative study. Hum Reprod. 2017;32(2):383–90.CrossRefGoogle Scholar
  37. 37.
    Jones CA, Reiter L, Greenblatt E. Fertility preservation in transgender patients. Inte J Transgenderism. 2016;17(2):76–82.CrossRefGoogle Scholar
  38. 38.
    Abern L, Maguire K, Diego D, Wong A. Contraceptive use and fertility preservation among transgender individuals: are we doing enough? Fertil Steril. 2017;108(3):e115.CrossRefGoogle Scholar
  39. 39.
    Patterson P, McDonald FEJ, Zebrack B, Medlow S. Emerging issues among adolescent and young adult cancer survivors. Semin Oncol Nurs. 2015;31(1):53–59.Google Scholar
  40. 40.
    Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of transsexual, transgender, and gender-nonconforming people, version 7. Inte J Transgenderism. 2012;13(4):165–232.Google Scholar
  41. 41.
    O’Connor, A., D. Stacey, and M. Jacobsen, Ottawa decision support tutorial: improving practitioners’ decision support skills Ottawa Hospital Research Institute: patient decision aids; 2011. Disponible en ligne: https://decisionaid.ohri.ca/ODST/pdfs/ODST pdf, 2014.
  42. 42.
    Chen D, Simons L. Ethical considerations in fertility preservation for transgender youth: a case illustration. Clinical Pract Pediatric Psychol. 2018;6(1):93–100.CrossRefGoogle Scholar
  43. 43.
    Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374–80.CrossRefGoogle Scholar
  44. 44.
    Grossman AH, D'augelli AR. Transgender youth and life-threatening behaviors. Suicide Life Threat Behav. 2007;37(5):527–37.CrossRefGoogle Scholar
  45. 45.
    Nahata L, Quinn GP, Caltabellotta NM, Tishelman AC. Mental health concerns and insurance denials among transgender adolescents. LGBT Health. 2017;4(3):188–93.CrossRefGoogle Scholar
  46. 46.
    Testa RJ, Michaels MS, Bliss W, Rogers ML, Balsam KF, Joiner T. Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. J Abnorm Psychol. 2017;126(1):125–36.CrossRefGoogle Scholar
  47. 47.
    De Vries AL, et al. Autism spectrum disorders in gender dysphoric children and adolescents. J Autism Dev Disord. 2010;40(8):930–6.CrossRefGoogle Scholar
  48. 48.
    Shumer DE, Reisner SL, Edwards-Leeper L, Tishelman A. Evaluation of Asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health. 2016;3(5):387–90.CrossRefGoogle Scholar
  49. 49.
    Turban JL, van Schalkwyk GI. “Gender dysphoria” and autism spectrum disorder: is the link real? J Am Acad Child Adolesc Psychiatry. 2018;57(1):8–9 e2.CrossRefGoogle Scholar
  50. 50.
    Strang JF, Janssen A, Tishelman A, Leibowitz SF, Kenworthy L, McGuire JK, et al. Revisiting the link: evidence of the rates of autism in studies of gender diverse individuals. J Am Acad Child Adolesc Psychiatry. 2018;57(11):885–7.Google Scholar
  51. 51.
    Strang JF, Meagher H, Kenworthy L, de Vries ALC, Menvielle E, Leibowitz S, et al. Initial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in adolescents. J Clin Child Adolesc Psychol. 2018;47(1):105–15.Google Scholar
  52. 52.
    Imam B, Chulani VL. Consent and assent in adolescents with gender dysphoria and developmental disabilities. J Pediatr Adolesc Gynecol. 2018;31(2):180–2.CrossRefGoogle Scholar
  53. 53.
    Shumer DE, Tishelman AC. The role of assent in the treatment of transgender adolescents. Inte J Transgenderism. 2015;16(2):97–102.CrossRefGoogle Scholar
  54. 54.
    Snelgrove, J.W., et al., “Completely out-at-sea” with “two-gender medicine”: a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research, 2012. 12(1): p. 110.Google Scholar
  55. 55.
    Vance SR Jr, Halpern-Felsher BL, Rosenthal SM. Health care providers’ comfort with and barriers to care of transgender youth. J Adolesc Health. 2015;56(2):251–3.CrossRefGoogle Scholar
  56. 56.
    Wingo E, Ingraham N, Roberts SCM. Reproductive health care priorities and barriers to effective care for LGBTQ people assigned female at birth: a qualitative study. Womens Health Issues. 2018;28(4):350–7.CrossRefGoogle Scholar
  57. 57.
    De Roo C, et al. Fertility options in transgender people. Int Rev Psychiatry. 2016;28(1):112–9.CrossRefGoogle Scholar
  58. 58.
    Mattawanon N, Spencer JB, Schirmer DA, Tangpricha V. Fertility preservation options in transgender people: a review. Rev Endocr Metab Disord. 2018;19(3):231–42.CrossRefGoogle Scholar
  59. 59.
    Nahata L, Chen D, Moravek MB, Quinn GP, Sutter ME, Taylor J, et al. Understudied and under-reported: fertility issues in transgender youth—a narrative review. J Pediatr. 2018.  https://doi.org/10.1016/j.jpeds.2018.09.009.
  60. 60.
    Shnorhavorian M, Harlan LC, Smith AW, Keegan THM, Lynch CF, Prasad PK, et al. Fertility preservation knowledge, counseling, and actions among adolescent and young adult patients with cancer: a population-based study. Cancer. 2015;121(19):3499–506.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Departments of Endocrinology and PsychiatryBoston Children’s HospitalBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA
  3. 3.Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaUSA
  4. 4.Division of Adolescent MedicineAnn and Robert H. Lurie Children’s Hospital of ChicagoChicagoUSA
  5. 5.Department of Child and Adolescent PsychiatryAnn and Robert H. Lurie Children’s Hospital of ChicagoChicagoUSA
  6. 6.Departments of Psychiatry and Behavioral Sciences, and PediatricsNorthwestern University Feinberg School of MedicineChicagoUSA
  7. 7.Departments of OB-GYN and Population HealthNew York University School of MedicineNew YorkUSA
  8. 8.Division of Endocrinology and Center for Biobehavioral HealthNationwide Children’s HospitalColumbusUSA
  9. 9.The Ohio State University College of MedicineColumbusUSA

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