Transgender men's experiences of fertility preservation: a qualitative study.

STUDY QUESTION: How do transgender men experience fertility preservation (FP) by cryopreservation of oocytes?

SUMMARY ANSWER: The procedures required prior to oocyte cryopreservation, such as hormonal ovarian stimulation and transvaginal ultrasound (TVS), have a negative impact on gender dysphoria as they are closely linked to the men's female assigned sex at birth, which is incompatible with their current status.

WHAT IS KNOWN ALREADY: Transgender persons often have high dissatisfaction with assigned sex-specific body features, such as the genital organs and androgen/oestrogen-responsive features. Thus, undergoing FP that requires genital-specific examinations, aimed at obtaining oocytes to cryopreserve, could be distressing. As no previous studies have investigated transgender men's experiences of FP involving cryopreservation of oocytes, little is known about their experience of the procedures.

STUDY DESIGN, SIZE, DURATION: This is a prospective study among adult transgender men referred for FP between March 2014 and December 2015. Individual in-depth qualitative interviews were conducted shortly after FP treatment. The interviews lasted between 62 and 111 min (mean 81 min) and were digitally recorded and transcribed verbatim.

PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were recruited on their first visit to the assisted reproduction clinic for reproductive counseling. There were 15 men, scheduled for FP, who chose to participate in the study (age 19-35); none had given birth and eight had a partner. Data were analyzed by thematic content analysis.

MAIN RESULTS AND THE ROLE OF CHANCE: The analysis resulted in three main categories: the journey to FP, reactions to the FP proceedings and strategies for coping. The referral for FP was an important part of the assessment and diagnosis and sometimes lined with frustrating waits and doubts. The reaction to the FP proceedings revealed that the genital examinations and the physical changes associated with discontinuation of testosterone or hormonal stimulation treatment triggered gender incongruence and dysphoria. However, for some, the negative expectations were not met. The participants used several coping strategies in order to manage the procedure, such as focusing on their reasons for undergoing FP, reaching out to friends and family for support and the cognitive approaches of not hating their body or using non-gendered names for their body parts. The results demonstrate the importance of contextual sensitivity during FP procedures.

LIMITATIONS, REASONS FOR CAUTION: The authors have strived to be reflective about their pre-understanding of the phenomenon. The majority of the participants resided in large urban areas; it is possible that transgender men living in rural areas have different experiences.

WIDER IMPLICATIONS OF THE FINDINGS: As the results are based on qualitative data from 15 transgender men, the results cannot readily be generalized to larger populations. However, the results are suggested to be applicable to other transgender men who want to undergo FP by cryopreservation of oocytes. The results show that transgender men's experience of FP places may elicit gender incongruence and gender dysphoria. However, health care personnel can alleviate distress by using a gender-neutral language and the preferred pronoun. Also, reassuringly, the men also have coping strategies of how to handle the situation. This knowledge is important to ensure adequate professional support for patients with gender dysphoria during FP.

STUDY FUNDING/COMPETING INTERESTS: Swedish Society of Medicine, Stockholm County Council and Karolinska Institutet (to K.A.R.-W.).

TRIAL REGISTRATION NUMBER: N/A.