Original Report
Fertility Desires of Adolescent Females: Decreased Desire for Children in Those Identifying as Transgender/Gender Diverse and in Depressed Adolescents

The findings of this study were presented, in part, at the North American Society of Pediatric and Adolescent Gynecology Annual Meeting, June 2020 (virtually due to COVID-19 restrictions) and accepted for presentation at the Pediatric Academic Societies Annual Meeting scheduled for May 2020 that was canceled due to the pandemic.
https://doi.org/10.1016/j.jpag.2020.09.001Get rights and content

Abstract

Study Objective

We aimed to describe fertility desires in healthy adolescent females and to explore associations of fertility desire with conditions and therapies potentially compromising fertility.

Design

This was a cross-sectional, anonymous survey.

Setting and Participants

A total of 323 female adolescents aged 13-19 years were recruited from clinic waiting areas at a children's hospital. We oversampled on days when clinics serving adolescents with potential fertility compromise were scheduled.

Main Outcome Measures

We measured fertility desire by agreement with the statement “I want to have children someday.” To measure compromised fertility we asked “In the past year, has a doctor, nurse or other medical professional ever talked to you about the possibility that you may have decreased fertility and may not be able to have your own biological child someday?” To measure depression severity, we used a validated scale, the PHQ-9, scores were dichotomized into no/mild and moderate/severe depression.

Results

Mean age was 16.06 ± 1.87 years. Of the 323 participants, 57% identified as Hispanic, 24% as Black, 93.5% as cisgender, 6.5% as transgender/gender diverse, 70% as heterosexual, and 30% as sexual minority. A total of 35% had moderate/severe depression, and 12% had compromised fertility. Overall, 89% wanted children. Fewer transgender/gender diverse than cisgender participants wanted children (67% vs 93%, P < .001), as did fewer with moderate/severe versus no/mild depression (83% vs 93%, P < .05), whereas those with compromised fertility versus those without and heterosexual versus sexual minority participants had similar fertility desires. Transgender/gender diverse identity (odds ratio, 0.33; 95% confidence interval, 0.11-0.97; P < .05) and moderate/severe depression (odds ratio, 0.45; 95% confidence interval, 0.22-0.93; P < .05) were independently associated with lower fertility desire.

Conclusions

We found a high overall proportion of female adolescents desiring future children, and only 2 independent predictors of decreased fertility desire, namely, transgender/gender diverse identity and moderate/severe depression.

Introduction

The past 2 decades have seen considerable interest in fertility preservation methods for adolescents who are facing medical treatments that may compromise their fertility, such as chemotherapy and radiation.1,2 More recently, with the increase in provision of gender-affirming care for transgender and gender diverse adolescents, practice guidelines have been developed recommending counseling about options for fertility preservation prior to initiating such therapy, as it may have irreversible adverse effects on fertility.3,4 Cryopreservation of sperm is relatively straightforward, but the options to preserve ovarian tissue or oocytes is invasive, time consuming, costly, and not guaranteed to result in a fertilized embryo in the future.5 It is not surprising that adolescents assigned female at birth undergoing fertility-compromising therapy often refuse fertility preservation measures.6, 7, 8 We do not know, however, whether refusal of fertility preservation is based on a lack of desire for children or on other factors. A 2009 systematic review of fertility desires and intentions among adults with human immunodeficiency virus /acquired immune deficiency syndrome noted that fertility desires are influenced by many cultural, demographic, health, stigma-associated, and psychosocial factors, and we expect that the influences are similar for adolescents.9

Little is known about the fertility desires of healthy female adolescents, making it difficult to interpret the choices made by those with potential fertility compromise. Investigations of fertility desires over the life course in a prospective study of a British birth cohort found that for female adolescents interviewed at age 16 years, few respondents wanted no children or only 1 child, and increased academic ability was associated with the desire to remain childless.10 A 2006 study of 12- to 17-year-old adolescents recruited from a predominately low-income, African American neighborhood in San Francisco found that 80% of the 166 female participants reported that having children in the future was important to them.11 A qualitative study designed to assess female adolescents’ attitudes toward fertility and cancer conducted focus groups using hypothetical scenarios with 25 primarily white and Asian, healthy, 12- to 18-year-old girls in Florida.1 All except one of the girls indicated that they would like to have a baby in the future and would be “sad,” “disappointed,” and “upset” if they found out that they could not have children because of cancer treatment.

In contrast, studies show that when fertility counseling is routinely provided to transgender youth prior to initiation of hormonal therapy, few use the fertility preservation services available; this is particularly true of those in the transmasculine spectrum (assigned female at birth).7,8 In a chart review study of 73 youths aged 9-18 years at initiation of gender-affirming therapy, accessing care through the gender management program at Nationwide Children's Hospital, 98% received fertility counseling, but only 2 transgender females opted to preserve their sperm.8 This study found that 16% of the transgender males refused fertility preservation because they stated that they never wanted to have children.

To our knowledge, a direct comparison of fertility desires of adolescent females with no fertility compromise to those with potential fertility compromise related to health conditions as well as medical treatments has not been done. In this study, we aimed to describe fertility desires in female adolescents without known fertility compromise, and to explore associations of fertility desires with conditions and treatments potentially compromising fertility as well as with sociodemographic, behavioral, and mental health variables.

Section snippets

Procedure and Participants

From August 2019 through February 2020, trained research assistants approached all individuals who appeared to be female adolescents in the emergency room waiting area and the common waiting rooms for subspecialty clinics affiliated with an academic children's hospital located in Bronx County, New York, a dense, low-resource urban area. The research assistants read a brief script to those individuals who acknowledged that they were 13-19 years of age to invite them to complete an anonymous,

Participant Characteristics and Fertility Desires

Of 323 participants, the mean age was 16.06 ± 1.87 years (Table 1). Most participants self-identified as either Hispanic or Black and were enrolled in middle or high school. More than 90% of participants reported their gender identity as female, and 6.5% (n = 21) reported their gender identity as transgender, nonbinary, gender queer, or something else. In this sample of adolescents assigned female at birth, 70% identified their sexual orientation as heterosexual, whereas 30% identified as

Discussion

To our knowledge, this is the first study to directly compare desire for future children in a large sample of more than 300 female adolescents 13-19 years of age, with and without potential fertility-compromising conditions or therapies. We found, as have others, that the large majority (89%) of the teens whom we surveyed wanted to have children someday. Our finding is nearly identical to that reported in a study of fertility desires and intentions of US women using data from the 2011-2013

References (24)

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MDL, EJS, NAD, and SMC have no conflicts to disclose. HJT discloses that she is an Associate Editor of the Journal of Pediatric and Adolescent Gynecology.

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