Having Children When Transgender

Transgender man with daughter explaining how to do homework
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Individuals are considered to be transgender if their gender identity does not align with the sex they were assigned at birth. Many transgender individuals choose to socially or medically transition so that their gender presentation aligns with their gender identity—socially transitioning usually involves dressing and presenting in a way that fits with the person's gender identity, while medically transitioning can involve taking cross-sex hormones, surgery, or both.

Not all individuals choose to medically or surgically transition. However, those who do may face a dilemma: what do they do if they want to have children later in life? Both hormone treatments and surgery can impact fertility. Some surgeries, such as the removal of the ovaries or testes, will leave someone permanently infertile.

Research has shown that around half of transgender adults regret their inability to have children after they transition. This has led to the recommendation that providers discuss fertility issues with all transgender people before they start to transition. However, that doesn't always happen. In addition, even when it does, the need to transition can be overwhelming enough to make other concerns seem unimportant. That's particularly true for concerns such as fertility that may not be relevant until later in life.

For some people, the inability to have their own genetic children is not an issue—they may not be interested in having a family or they may want a family but not care about whether their children are biologically related to them. For others, however, the ability to have biological children is important to their long-term happiness.

That's where fertility preservation comes into play.

For Transgender Men

Transgender men who transition after puberty have several options for fertility preservation. Specifically, individuals can undergo egg stimulation and harvesting—similar to that for an IVF procedure. However, for many transgender men, this option can increase their dysphoria—their discomfort in their bodies. They may not feel comfortable taking large numbers of female hormones to stimulate their ovaries. In such cases, there is the possibility of ovarian tissue harvesting. However, it is less effective than ovarian stimulation.

It is worth noting that transgender men who do not have bottom surgery can get pregnant. If they keep their ovaries and uterus, it is possible for them to experience a healthy pregnancy. However, in order to do so, they need to stop taking testosterone for the duration of the pregnancy. They also need access to either sperm or a fertilized ovum.

For Transgender Women

Fertility preservation for transgender women is easy if it is done before they start taking estrogen. Sperm banking is relatively simple and affordable. However, for some women, the need to masturbate and ejaculate can be too dysphoric. For these women, it's possible to either stimulate ejaculation electrically or to use surgery to harvest sperm directly from the testicles.

For Transgender Adolescents

When transgender adolescents are identified before puberty, it can be an incredibly positive thing for them. The standard of care has become using puberty blockers to halt puberty until teenagers and their families are ready. Then either the teenager can start using cross-sex hormones or stop taking blockers to resume the puberty associated with the sex they were assigned at birth. Either way, the teenager only has to go through puberty once. They don't have to go through a puberty that may be upsetting or painful. They also are more likely to be able to conform to visible gender expectations as an adult.

Unfortunately, the downside of puberty blockers is that transgender adolescents who take them have reproductive tracts that do not fully mature. That means that young transgender women can't provide sperm and young transgender men can't provide eggs. In order to do so, they would need to go further through the puberty that blockers are designed to prevent.

There are some experimental options that have been pioneered in young cancer patients whose fertility is also often affected by medical treatment. Ovarian or testicular tissue can be harvested and frozen. Then, at a later date, it may be possible to use hormones to mature that tissue and provide viable eggs and sperm.

The efficacy of these techniques is not something that young people can count on. However, it may be a worthwhile option for adolescents who think they might want to have children and can afford the procedures.

Transgender People as Parents

A significant number of transgender people have children before they transition, particularly when they transition later in life. As a whole, their children are as happy and healthy as children of cisgender couples. That's true for couples who divorce as well as couples who stay together.

One of the biggest factors in children's adjustment is whether their parents continue to have a good relationship. It is also often easier for children to adjust to a parent's transition earlier in their life.

No matter when a parent transitions, their whole family will likely benefit from support. It's a big change for the transgender parent's life, but also for the lives of those who love them. Seeking out resources such as family therapy with a transgender-affirming therapist, or transgender parenting support groups, can be incredibly helpful both in person or online. 

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