A 2018 study found that 35% of trans women wanted to have children in the future, but only 9% had frozen their sperm. With such a disparity in these figures, why are trans women not freezing their sperm? What are the barriers they are facing? This article discusses some of the financial, social, and emotional obstacles to transgender sperm freezing.
Key takeaways
- The best time for trans women to freeze their sperm is prior to starting gender-affirming hormone therapy.
- Many trans women aren’t able to, or ultimately don’t freeze their sperm due to barriers such as the cost of sperm freezing and transition overall, not receiving adequate counseling as to the fertility impact of therapy, or having conflicted feelings about masturbation, sperm, or parenthood.
- Seeking a gender-affirming therapist to discuss future parenthood and exploring at-home sperm freezing options are two ways to make the fertility preservation process less stressful and more accessible.
When should trans women freeze their sperm?
Gender-affirming hormone therapy (GAHT) — like estrogen and testosterone-blockers — is likely to impact sperm parameters. Therefore, transgender sperm freezing before beginning medical transition usually offers the best results. As soon as a person hits puberty and can produce a semen sample, sperm freezing can be considered.
However, there are options if you are considering freezing your sperm after starting hormone therapy. The best starting point is a semen analysis, to see if the hormones have affected your fertility. If they have, you may need up to 6 months off of gender-affirming hormone therapy to allow sperm quality to improve.
Stopping GAHT is likely to result in a reversal of some of the feminization that estrogen therapy has offered. This can trigger distress physically, socially, and emotionally, so getting support through this time is advised.
Sperm freezing can be expensive
The cost of gender transition costs vary wildly; for some, it can spiral into six figures, and it’s not always covered by health insurance. Health insurance companies brand surgery as “cosmetic.” But although it may be cosmetic for a cis person, it might be essential for someone transgender in transition.
Plus, many people transition in their early 20s when they don’t have many additional funds. Therefore, cost can be a barrier to transgender sperm freezing.
Sperm freezing costs an average of $1,000, plus $300–$500 or more per year for ongoing cryogenic storage, depending on where you live. If you are lucky enough to live in a state where it’s covered by your insurance plan, this might be achievable. But if it’s not, it could be unaffordable.
Legacy’s aims to increase the accessibility of fertility care and fertility preservation, lowering sperm freezing costs and providing more affordable sperm freezing storage plans.
There’s a lot to think about during transition
Lisa Schuman, LCSW, a fertility-focused social worker and director of The Center for Family Building, highlighted that the discussion about transgender freezing sperm could come at a very overwhelming time for trans women. There are many steps to transition, each with their own challenges. Even if you are a trans person in a community that accepts you, where you can come out and embrace who you are, the process can feel daunting — as much as it feels exciting.
And much like cisgender young people, trans youths may not be emotionally ready to think about what a future family might look like.
“There’s research where trans youths have been interviewed and asked, ‘Would you freeze your gametes before you transition?’ And so many of them say… ‘I’ve got too much on my plate, I can’t think about that now.’ And so they don’t want to think about it,” begins Schuman. “And, of course, it’s hard for young people to plan life in general, right? No teenager will usually be thinking about whether or not to freeze their sperm,” she added. “It’s a lot for a teenager to think about.”
However, we know that — when interviewed at later ages — many trans people do want children, and wish they’d taken steps to preserve fertility earlier. Schuman stresses that counseling and discussions around fertility and family building are vital during the transition process.
“Having those discussions and being given the option of at least finding out that sperm freezing is available is such an important conversation to have,” she emphasizes. Other experts agree — fertility preservation counseling is recommended by the World Professional Association of Transgender Health (WPATH), the American Society of Reproductive Medicine (ASRM), and the Endocrine Society.
Trans women don’t always know the impact of hormone therapy on fertility
As we’ve discussed above, gender-affirming hormone therapy, also known as hormone replacement therapy (HRT), can significantly affect a person’s fertility and ability to produce healthy sperm.
Testosterone is essential to the production of sperm, but the goal of hormone therapy for transgender women is to decrease testosterone and increase estrogen levels. Testosterone levels under 264 ng/mL are associated with poorer semen parameters, and the use of estrogen and androgen-blockers is linked to poor sperm quality and lower sperm count.
Learn more about how male-to-female gender transition affects fertility.
In many cases, fertility can be recovered. One study found that about ⅔ of trans women were able to restart sperm production after up to 6 months off hormone therapy. However, that means that a final third of women may not ever be able to recover fertility after GAHT.
Unfortunately, not every trans patient is given information about HRT and sperm count prior to transition. In one study of pediatric patients, 54% of trans girls had no documented fertility preservation counseling upon chart review.
And today, many trans people are receiving care from digital health platforms, where they can be prescribed and order hormone medication remotely. This is a huge step forward for transgender care, since so many people live in areas where they can’t access experienced, affirming providers. But it also may increase the likelihood that people aren’t getting adequate counseling about HRT and fertility before starting therapy.
Trans women need to be given all the details to ensure they can make an informed decision about whether or not to preserve their fertility. Speaking to a gender-affirming counselor or therapist can be particularly helpful in navigating these decisions.
The sperm freezing process can be more uncomfortable for gender non-conforming people
Sperm freezing can involve various levels of personal and societal discomfort, or even feeling unsafe. This can be especially true in communities that are less accepting of transgender identities, or for folks who have difficulty thinking about their genitals or sperm due to gender dysphoria.
Personal discomfort and dysphoria
Sperm banking involves masturbation to produce a sample. Some trans people experience gender dysphoria — a mismatch between their biological sex and gender identity that causes unease and distress. This can lead to being uncomfortable with their genitals or masturbation. Research shows that trans women have greater difficulty masturbating due to genital dysphoria or lower libido, when compared to trans men.
It doesn’t help that many fertility clinics are built primarily for cisgender, heterosexual couples who are trying to have children right now. This focus, which can be obvious from the clinic’s website to its waiting room, can make young trans people feel like they aren’t welcome.
Plus, as mentioned, depending on where you are in the transition process, you may have to temporarily stop your hormones in order to be able to give a healthy and viable sperm sample.
From her experience as a fertility counselor, Schuman has heard people say that they feel upset stopping their hormones because they don’t want to suddenly start growing body or facial hair again. They don’t want to feel masculine again. They finally feel like the person they want to be, and now they have to stop their hormones which is a huge deal.
Discrimination
If you do decide to freeze your sperm, there is then the concern of having to visit a fertility clinic. Depending on the area where you live, you may experience discrimination, misgendering, or a care team that isn’t equipped to support a trans people.
Gigi Gorgeous’ viral video in 2018 describes her very real experience of going to a sperm bank as a trans woman. She had to face the difficulty of explaining several times to the staff that she was a trans woman there to bank sperm, as there was a severe lack of understanding.
While, in 2022, increasing numbers of fertility specialists are trained in transgender care, there will inevitably still be many experiences of medical discrimination that can make trans patients feel uncomfortable or unsafe.
Trans women may feel confused about future parenthood
As they’re figuring out their gender identity and relationship to their bodies, trans women may not yet have clarity on how they feel about having a biological child — especially as they won’t be able to play the same biological role that cis women typically play in childbearing.
“I’ve heard some people say… “What if I start to do this and my kids understand that I use my sperm? Are they going to call me Dad instead of Mom, and is that going to be really hard for me?’” describes Schuman.
It can be extremely beneficial to talk to an affirming, understanding therapist about any conflicted feelings around parenthood. Of course, not every person — cis or trans — will want to have children. But if you think you may want a family, and you just don’t know how that fits into your gender identity, counseling can help.
“Every stage can be a struggle, and I think trans people benefit from counseling to support them through each step,” says Schuman.
Making fertility preservation easier for trans women
If you’re a trans woman considering sperm freezing — or the parent or loved one of someone who’s transitioning — here are some tips for making the process easier.
- Talk directly to your provider about the fertility risks associated with gender therapy. You deserve the full spectrum of information about how your hormone therapy protocol may impact your fertility. Talk to your provider about the effects of GAHT, and your options for having a family in the future. If your provider is unwilling or unable to discuss fertility with you, we recommend seeking out a fertility specialist who can have this conversation with you prior to transition.
- Seek professional and/or social support while making decisions about your transition and future fertility. It may feel totally overwhelming to be making decisions about your future family plans while you’re still in your teens or early 20s, or while you’re preoccupied with your transition. That’s normal! It’s something that many cis people don’t have to think about for years.
If possible, we recommend talking to a gender-affirming therapist about your feelings around fertility and parenthood. If you can’t access or afford 1:1 therapy, a support group can be valuable instead (or in addition), and most are free to attend.
- Explore your insurance coverage and payment options. In some states, gender transition is considered a condition that mandates insurance coverage for sperm banking. Plus, some employers offer supplementary fertility benefits plans, such as Carrot or Progyny, that are typically more inclusive, covering fertility preservation for everyone regardless of gender identity.
Some community organizations may offer discounted access to fertility preservation for trans folks. And finally, many services offer payment plans that allow you to break the cost of sperm freezing into smaller monthly installments. Research your options before writing off fertility preservation as too expensive for you.
- Consider at-home sperm freezing. Producing a sample at home can be much more comfortable for many people, especially trans women who may not feel at home in traditional medical settings. Plus, it can be significantly more affordable. Legacy offers different sperm freezing storage plans, depending on your needs, with options for annual, 5-year, or lifetime cryostorage. Learn more.