The challenges of infertility in the transgender community

By Lamia Choudhury

In between driving for Lyft, finding a fulltime job and applying to graduate school, 23-year-old Jaylin Culkin doesn’t always have time to think about the future long term. Unlike most young adults his age, Culkin, a Centereach native, has already made a solid plan on starting a family.

Fertility in the transgender community can be an especially sensitive topic. Individuals who take puberty- suppressing medications and then go straight to hormone therapy may be left infertile completely, Courtney Finlayson, a pediatric endocrinologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago said.

“When an individual goes through puberty, the germ cells—what becomes eggs or sperm—mature,” Finlayson said. “You have to have puberty for those cells to mature. So if we prevent puberty from occurring, the germ cells in those gonads are not going to mature. In that situation, those individuals who have never gone through a natural puberty in their body are not going to have germ cells to use.”

Transgender individuals must think far ahead before starting hormone therapy. It is a tough subject to think about and probably the last one on their minds, Juno Obedin-Maliver, a founding member of the Stanford Lesbian, Gay, Bisexual and Transgender Medical Education Research Group (LGBT MERG), said.

She recommends freezing eggs or sperm whenever possible before starting any kind of medical transition process.

“There are cases where a transgender man has been on testosterone for years but then gets pregnant, but that’s not a surefire bet and I would never tell a patient to count on that,” Obedin-Maliver said. “Long term hormone therapy affects every individual and their reproductive system differently, so it’s difficult to draw conclusive data.”

It is important for transgender individuals to use protection and engage in safe sex for this very reason, Obedin-Maliver said.

“My doctor warned me about those things before I started testosterone,” Culkin, who has been on the hormone for two years, said.

“He recommended freezing my eggs but I was only 19 when we had that conversation and I didn’t have the money to do that,” he said. “It costs thousands of dollars and it’s not like a one time thing. You have to keep paying for the freezing until you’re ready to use them. And then there’s the price of in vitro.”

Culkin has previously struggled with dysphoria, a condition that affects a majority of the transgender community. It is the mental and emotional distress that comes from the disconnect of being assigned a different gender at birth and can often lead to physical self-harm.

“It can be framed as an ethical issue‘how do you let a child decide whether or not they want to be fertile later on in life,’ but the other part of it is, if you don’t give them the tools to transition, will that child even make it to adulthood?” Wendy Stark, executive director of Callen- Lorde Community Health Center said.

Culkin was not able to wait any longer and began taking testosterone at the age of 21. He takes solace in hoping to one day adopt a child.

“Ideally, I’d like to start a family at 25 but, realistically, it looks like I’ll be about 30. And that’s only because of how much it costs to adopt a child.” 

The cost of having a biological child is one of the biggest reasons why many transgender individuals forego the option entirely. A single vial of sperm is $500, each round of in vitro fertilization costs around $15,000 and opting for a surrogacy can cost between $50,000 and $100,000, according to Endocrine Web,

“These numbers are hard to swallow,” Dane Menkin, a family nurse practitioner at Mazzoni Family and Community Medicine in Philadelphia, said. He has performed over 50 intrauterine inseminations for transgender individuals.

The unemployment rate in the transgender community is three times higher than the national average of five percent, making them an especially economically vulnerable population. 16 percent of those that are employed reported being fired for expressing their gender expression.

“There is an enormous cost for transgender individuals that the cisgender community as a whole doesn’t have to think about,” Menkin said.

On top of cost, transgender individuals are not always welcome at fertility clinics. Trellis Health is dedicated to helping women freeze their eggs. They refused to comment on whether they help transgender men do the same.

Women & Infants, a Rhode Island based hospital, offers resources for transgender individuals looking to freeze their eggs or sperm, but they are highly limited when compared to their other services.

There is an enormous mental toll that comes with trying to conceive for transgender individuals and Joanne Spataro and her girlfriend Lara learned that the hard way.

“We encountered a lot of confusion and transphobia at sperm banks,” Spataro said. “Lara was off HRT for about a year. We had a doctor tell us that this isn’t something trans people do. They come off the hormone for a few weeks or maybe months at most but not a whole year.”

It was hard for Spataro to watch Lara be off her hormones and lose who she is. Fortunately, the couple was able to bank some sperm and are hoping to have a child within the next two years.

“I don’t feel like a trailblazer. I just feel like someone who is trying to have a baby with the person I love. I am glad to have the chance to do this.”

Lara is back on HRT and the pair are “getting to know each other again.”

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