ORIGINAL RESEARCH

TRANSGENDER HEALTH

Desire to Have Children Among Transgender People in Germany:

A Cross-Sectional Multi-Center Study
Matthias K. Auer, MD,1,2,* Johannes Fuss, MD,3,* Timo O. Nieder, PhD,3 Peer Briken, MD,3
Sarah V. Biedermann, MD,4 Günter K. Stalla, MD,1 Matthias W. Beckmann, MD,5 and Thomas Hildebrandt, MD5

ABSTRACT

Background: Many trans individuals undergo medical interventions that result in irreversible loss of fertility.
Little is known about their desire to have children and attitudes toward fertility preservation options.
Aim: To study how the desire for children and the use of fertility preservation options varies among trans women
and trans men in different transitioning stages in Germany.
Methods: In this cross-sectional multi-center study, N ¼ 99 trans women and N ¼ 90 trans men were included.
Of these, 26 of each sex were just about to start medical treatment.
Outcomes: Outcome parameter were the prevalence and determinants of a desire to have children in trans persons.
Results: Before treatment, a desire for children was significantly higher in trans men compared to trans women
(P ¼ .016). In contrast, in those who had already started treatment, a current desire to have children was equally
present in about one fourth of participants of both genders while the interest in having children in the future was
significantly higher in trans women (69.9%) than in trans men (46.9%; P ¼ .034). Although 76.1% of trans
women and 76.6% of trans men indicated that they had at least thought about preserving germ cells before
starting medical transition, only 9.6% of trans women and 3.1% of trans men had put this idea into practice.
Most trans men in both groups indicated that insemination of a female partner with sperm from an unrelated
donor was a suitable option to fulfill their child wish, potentially explaining their low interest in preserving their
own germ cells. Finally, a logistic regression analysis accounting for potential confounders revealed that overall
trans women were more than twice as likely to have a current desire to have children (odds ratio 2.58), and this
wish was on average 5.3% lower with each year of increasing age.
Clinical Translation: A low level of fertility preservation among trans persons is contrasted by a high level of
desire for children. This highlights the importance of counseling trans individuals regarding fertility preservation
options.
Conclusions: To our knowledge, this is the first study that addresses desire to have children in a clinical sample
of trans women. It is also the first that investigates this issue among trans men who have not started medical
treatment, and the first comparison of both genders. A limitation for the generalization of our results is the
special legal context in Germany that forbids oocyte donation for reciprocal in vitro fertilization. Reproductive
desire is high among trans individuals, but the use of reproductive options is surprisingly low. Auer MK, Fuss J,
Nieder TO, et al. Desire to Have Children Among Transgender People in Germany: A Cross-Sectional
Multi-Center Study. J Sex Med 2018;15:757e767.
Copyright
2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Transgender; Gender Dysphoria; Fertility; Children; Reproduction; Preservation

Received July 13, 2017. Accepted March 27, 2018.
1
Research Group Clinical Neuroendocrinology, Max Planck Institute of Psy-
chiatry, Munich, Germany;
2
Medizinische Klinik und Poliklinik IV, Klinikum der Universität München,
Munich, Germany;
3
Human Behavior Laboratory and Interdisciplinary Transgender Health Care
Center, Institute for Sex Research and Forensic Psychiatry, University
Medical Center Hamburg-Eppendorf, Hamburg, Germany;
4
Department of Psychiatry and Psychotherapy, Center for Psychosocial
Medicine, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany;
5
Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen,
Erlangen, Germany
*These authors contributed equally to this article.
Copyright ª 2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2018.03.083

J Sex Med 2018;15:757e767 757

758
INTRODUCTION
Individuals diagnosed with gender dysphoria (GD) (Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition1) or
transsexualism (International Statistical Classification of Diseases,
10th Revision2) often receive hormonal treatment to alter sex-typical
bodily features (ie, gender-affirming hormone treatment [GAHT]).
Trans women usually receive estrogens in combination with anti-
androgens such as cyproterone acetate or spironolactone, while
trans men use testosterone. On the one hand, these medications
induce the intended development of secondary sex characteristics of
the identified gender; on the other hand, they significantly impair
the fertility of trans persons.3 Although this seems to be potentially
reversible,3 it cannot be predicted if and when gamete maturation
will return to normal if hormone treatment is discontinued.4,5 After
the initiation of GAHT, some individuals also strive for gender-
affirming surgery. In trans women, the male genitals are reshaped
to appear as female genitalia and testicles are removed.6 In trans
men, in addition to mastectomy, hysterectomy and bilateral
salpingo-oophorectomy are usually included in gender-affirming
surgery.6 In both groups, these surgical interventions irreversibly
lead to sterility. Until the highest German court declared its non-
conformity to the constitution in 2011,7 infertility and being
divorced were mandatory prerequisites for trans persons to change
civil sex to match it with the identified gender. This having changed,
in addition to the fact that not all trans persons seek both GAHT
and gender-affirming surgery, opens new possibilities to fulfilling a
reproductive wish in this population.
Importantly, the current desire to have children seems to in-
crease with age in the general German population from adoles-
cence until the age of 40 years.8 Since a substantial number of
trans persons begin medical transition in adolescence and early
adulthood, it is possible that some will develop a desire to have
children only after starting medical transition with its reversible
or irreversible fertility sequelae.3 This side effect of medical
transition may become even more problematic as the number of
adolescents referred to gender clinics seems to be increasing in
the Western world.9,10 To reduce the risk that individuals regret
medical transition because they are unable to have a genetically
related child afterward, the International Standards of Care of the
World Professional Association for Transgender Health recom-
mends informing patients about future reproductive options
before starting endocrine treatment.11 These options include
long-term cryo-preservation of sperm in trans women,12 while in
some countries trans men can choose among oocyte banking,
embryo banking, and banking of ovarian tissue.13 Individual
reproductive choices may depend on sexual orientation. Impor-
tantly, trans men with female partners can choose to use sperm
from a donor while trans women with male partners depend on a
surrogate mother to bear a genetically related child. Of note,
however, some trans individuals report a change of their sexual
orientation during or after transition.14
Earlier studies investigating the desire to have children and the
use of reproductive options in trans people studied Belgian
Auer et al
populations12,15 or online populations from various countries.16
Importantly, however, the legal situation concerning reproductive
options differs significantly between countries. While some such as
Belgium, the Czech Republic, or the Netherlands allow oocyte
donation for reciprocal in vitro fertilization (IVF) (ie, the use of
oocytes from one partner, fertilized with donor sperm and placed
into the other partner’s uterus), it is considered egg donation and
therefore is illegal in others such as Germany, Switzerland, and
Austria where only sperm and embryo donation and banking of
ovarian tissue for auto-transplantation are allowed.13
Here, we were interested in the reproductive desires and
behavior of trans persons from a German multi-center study
(TRANSIT) that was designed to investigate a wide range of
metabolic and psychological outcomes in these individuals.17
We were particularly interested if and how these wishes differ
between patients who had already transitioned medically and
those who were yet to start hormone treatment.
These 2 groups were expected to not only differ in terms of
treatment progress but also in terms of general characteristics
such as age and already having children. As these factors may
affect desire and motivation for fertility-related wishes and
efforts, we wanted to identify the most key factors influencing
current desires to have children. Moreover, we were interested if
these factors are intrinsic (eg, sexual orientation) or extrinsic and
therefore potentially modifiable.
Earlier studies suggested that pre-transition psychosocial
burden is particularly high27 and may therefore interfere with
long-term decision making28 and a positive perception of the
future.29 Both factors seem to be important modulators for
future desire for children. Notably, it has been repeatedly re-
ported that depressive symptoms are significantly improving
during medical treatment18 and may therefore result in changing
views on parenting. Thus, we were also interested if depressive
symptoms affect desire for children in our sample.
Earlier studies also indicate that there are differences in desire
for having children, respectively interest in fertility-preserving
options between trans men15 and trans women.16 Those
studies suggest that desire for children seems to be generally
higher in trans women than in trans men,15,16 but may also be
affected by a variety of interfering factors such as age or the
higher rate of already having biological children. Rare cases such
as the one of Thomas Beatie24 who became famous due to wide
media coverage as he became pregnant by insemination after
initiation of GAHT may also have obscured the view on the
reality of trans men’s parenting wishes. For most trans men,
getting pregnant and giving birth is a highly feminine if not the
most feminine act, which should be expected to conflict with a
trans male self-concept.
We therefore hypothesized that a desire to have children is
higher in trans women compared to trans men and that a desire
for having children might be higher after medical transition in
both sexes when accounting for potential confounders.
J Sex Med 2018;15:757e767
Desire to Have Children Among Transgender People in Germany
METHODS
Participants and Procedures
A total of 189 trans individuals (99 trans women, 90 trans
men) were included in this study, of which 221 participants had
been initially approached, translating into a response rate of
85.9%. All participants were part of an observational multi-
center study in Germany to assess the effects of medical in-
terventions on psychological and metabolic outcomes of
transition-related health care. This study reports on data
collected between November 2013 and October 2016 at 4
different centers: the Department of Endocrinology at the Max
Planck Institute of Psychiatry, Munich, in conjunction with the
“Hormon- und Stoffwechselzentrum München,” Munich; the
Gynecological Department at the University Hospital of Erlan-
gen; and the Interdisciplinary Transgender Health Care Center
with the Institute for Sex Research and Forensic Psychiatry at the
University Medical Center Hamburg-Eppendorf. All patients
were treated according to the 7th version of the Standards of
Care published by the World Professional Association for
Transgender Health11 and treatment was accordingly individu-
alized according to the person’s needs.18 According to the
patient’s preferences, trans men were either treated with trans-
dermal testosterone gel containing 25e50 mg testosterone,
testosterone-undecanoate 1000-mg injections every 12e14
weeks, or testosterone enanthate 250 mg every 2e3 weeks,
aiming for testosterone levels in the mid-range age-adapted
reference ranges right before the next injection. Trans women
were receiving either gel containing 1.2e3.6 mg 17b-estradiol or
2e8 mg estradiol valerate orally and cyproterone acetate 5e50 mg,
aiming for normal or suppressed luteinizing/follicle-stimulating
hormone levels (if they had not yet undergone gonadectomy),
with estradiol levels in the mid-follicular range about 2e4 hours
after application, respectively, and with intake and testosterone
levels in the female reference range.
Those eligible for inclusion in the study were all patients with
a diagnosis of GD (Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition,1 302.85) or transsexualism (International
Statistical Classification of Diseases, 10th Revision,2 F64.0) who
visited one of the study clinics between November 2013 and
October 2016.
Every eligible subject was asked to participate during a routine
visit at the corresponding center. Individuals treated at the
Interdisciplinary Transgender Health Care Center associated
with the Institute for Sex Research in Hamburg were mostly
included right before referral for GAHT, while participants from
other centers were included before and after initiation of GAHT
or gender-affirming surgery.
The study was approved by the local ethics committees and
was conducted in accordance with the ethical standards in the
Declaration of Helsinki. All participants gave written informed
consent. This study is registered at clinicaltrials.gov (identifier:
NCT02185274).
J Sex Med 2018;15:757e767
759
Data Acquisition
The following variables were acquired by a self-constructed,
self-report questionnaire designed for the purpose of this study
and verified with data available in the individual’s clinical re-
cords: age, sex, age of onset of GD (before 12 years of age or 12
years and after), educational level (having left school without a
degree, low, intermediate, or high education and holding a
university degree), being employed or unemployed, self-
estimation of the financial situation (good, average, bad),
relationship status (single vs in a relationship), sexual orienta-
tion (exclusively oriented toward women, ie, gynephilic;
exclusively oriented toward men, ie, androphilic; to some extent
to both sexes, ie, bisexual; not having any sexual feelings, ie,
asexual; or oriented toward other trans people), the current use
of GAHT, and having undergone 1 or more gender-affirming
surgeries.
Items concerning age, relationship status, and sexual orienta-
tion were taken from an adjusted version of the Dutch
Biographic Questionnaire on Transsexualism, which the partic-
ipants completed on their own.19 For sexual orientation, a
modified 0e6 Kinsey scale was used.20 For a complete transcript
of the questions provided please see Supplement S1. For the
purpose of this study, some more detailed answer options were
subsumed into broader categories to allow them to be added into
our statistical model.
According to a chart file review, participants classified as
having undergone any genital surgery had, per our definition,
undergone orchiectomy, penectomy, and vaginoplasty if they
were transitioning from a male to a female physical appearance,
and ovariectomy and hysterectomy with or without phalloplasty
if they were transitioning from a female to a male physical
appearance. Additionally, we report on the frequency of per-
formed mastectomies and breast augmentation surgeries.
Moreover, participants were provided with a questionnaire
designed for the present study concerning relationships and
reproduction (Supplement S1). The questionnaire included
questions on whether or not they had children and how they
were conceived, their desire to have (more) children, consider-
ations about freezing of germ cells during transition at the time
of starting hormone treatment, and considerations of freezing
germ cells during transition if the technique had been available,
potential reasons for not freezing germ cells before transition, and
acceptable options to have children independent of any current
desire to have children, etc (Figure 1). Participants were also
encouraged to comment on other aspects of having children that
had not been inquired about in the standardized question part,
but which were important to them.
The Beck Depression Inventory (BDI)-II was used to measure
symptoms of depression. It comprises 21 questions about how
the patient has been feeling in the last 2 weeks. A total score of
0e9 indicates minimal, a score of 10e18 mild, a score of 19e29
moderate, and a score of 30e63 severe depression.21
760
Figure 1. Attitudes about fertility-preserving options. Adoption
and insemination of a female partner with sperm from an unrelated
donor were the most accepted options to have children in our
sample. Both were more accepted among trans men than trans
women. NA ¼ Not applicable. *Significant difference. Figure 1 is
available online at www.jsm.jsexmed.org.
Statistical Analysis
Statistical analysis was performed using PASW Statistics
(formerly SPSS; IBM, New York, NY, USA) Version 22.0 for
Windows. The following groups were compared with each other:
trans women vs trans men before medical transition, trans
women vs trans men already receiving treatment, as well as trans
women and trans men before transitioning with their counter-
parts already receiving treatment.
Sample characteristics between groups were compared using
c2 tests and Fisher exact test for categorical variables (gender,
relationship status, age of onset of GD, parenthood, sexual
orientation, employment status, financial situation, all
reproduction-related questions) and the Mann-Whitney U test
for ordinal and nominal variables (age, age at start of endocrine
treatment, time since start of hormone treatment, BDI-II score).
Auer et al
A logistic regression analysis using the entry method was
performed in order to identify the most important factors
influencing current desires to have children, and if these were
intrinsic such as sexual orientation or extrinsic factors such as
current financial situation. The following independent variables
were entered: age (years), gender (trans men/trans women),
being androphilic (yes/no), being gynephilic (yes/no) age of
onset of GD (before or at age of 12 years/after), receiving GAHT
(yes/no), having undergone gender-affirming surgery (yes/no),
having children (yes/no), being unemployed (yes/no), living
alone (yes/no), and BDI (score points).
A 2-sided P value of <.05 was considered statistically
significant.
RESULTS
General Characteristics
At the time of evaluation, in line with earlier research,22 trans
women before and undergoing treatment were significantly older
than trans men. More information on the sample, eg, self-
reported age of onset of GD, relationship status, start of hor-
monal treatment and sexual orientation can be found in Table 1.
Desire for Children Before Gender-Affirming
Treatment
6 Trans women who were just about to start treatment indicated
that they already had their own biological children, while no trans
man reported this (P ¼ .009) (Figure 2A). About half of trans men
(46.2%) at this stage indicated that having children was currently
important for them, while it was only important for 15.4% of trans
women (P ¼ .016). However, 53% of trans men and 65.4% of
trans women in this group indicated that they could imagine
having children in the future (P ¼ not significant) (Figure 2B).
About one third of both genders indicated that they had
thought about preserving germ cells before gender-affirming
treatment but had not proceeded due to technical reasons.
More than half of trans women and trans men indicated that
they could imagine having (more) children in the future. 3 Trans
women and 2 trans men had preserved germ cells in this group.
Of those reporting preserving germ cells, 2 trans women and all
trans men indicated that they had postponed gender-affirming
treatment to preserve their fertility. However, so far none had
used their preserved cells to beget children.
Desire to Have Children Under Gender-Affirming
Treatment
In accordance with their higher age, significantly more trans
women (31.5%) at this treatment stage already had children at
the time of evaluation. All children had been conceived before
starting gender-affirming treatment. Fewer trans men (10.9%)
reported having children (P ¼ .004) (Figure 2A). In this
group, only about one fourth of patients in both genders
declared that having children was currently important to them
J Sex Med 2018;15:757e767
 Table 1. 4-Group comparison of general characteristics between transgender persons of both sexes at different transition stages
J Sex Med 2018;15:757e767

Desire to Have Children Among Transgender People in Germany

Under treatment Before treatment

Trans women Trans men Trans women Trans men

73 64 26 26

N Median (IQR) % Median (IQR) % P* Median (IQR) % Median (IQR) % P* P† P‡

Age, y 41 (31e51) 33 (24.75e37) .001§ 41 (26.25e47.75) 25 (20e32.5) .001§ .709 .005§

Age at initiation of endocrine treatment, y 36.5 (23.75e52) 28 (21e39) .001§ 42 (28e41) 25 (19e32.5) .005§ .366 .121
Time since start of hormone treatment, mo 26 (13.5e42.5) 20 (10e36) .131 NA NA NA
BDI-II 7 (3e14) 4 (1.25e11.5) .104 5 (3e16) 8.5 (5e16.25) .220§ .709§ .022§
N % N % N % N %
Age of onset of GD, y
Early 58 79.5 54 87.1 .239 18 69.2 20 76.9 .532 .290 .230
Late 15 20.5 8 12.9 8 30.8 6 23.1
Relationship status
In a relationship 44 60.3 38 59.4 .629 21 80.8 16 61.5 .126 .160 .850
Single 28 38.4 26 40.6 5 19.2 10 38.5
Not answered 1 1.4 0 0.0
Sexual orientation
Androphilic 6 8.2 7 10.9 .186 5 19.2 3 11.5 .04§ .360
Gynephilic 35 47.9 26 40.6 7 26.9 12 46.2
Bisexual 20 27.4 22 34.4 12 46.2 9 34.6
Asexual 5 6.8 0 0.0 0 0.0 1 3.8
Not answered 7 9.6 9 14.1 1 3.8 1 3.8
Transsexual 0 0.0 0 0.0 1 3.8 0 0.0
Estimation of
financial status
Good/very good 36 49.3 33 52.4 .762 12 46.2 10 43.5 .847 .81 .72
Average 14 19.2 10 15.9 4 15.4 5 21.7
Bad or very bad 22 30.1 20 31.7 10 38.5 8 34.8
Not answered 1 1.4 0 0.0
Surgeries
Any genital surgery Yes 26 35.6 20 31.3 NA NA NA NA
No 47 64.4 44 68.8 .589 NA NA NA NA NA NA NA
Mastectomy Yes NA NA 30 46.9 NA NA NA NA
No NA NA 34 53.1 NA NA NA NA NA NA NA NA
Breast augmentation Yes 16 21.9 NA NA NA NA NA NA
No 57 78.1 NA NA NA NA NA NA NA NA NA NA
c or Fischer exact test.
2

BDI ¼ Beck Depression Inventory; GD ¼ gender dysphoria; IQR ¼ interquartile range; NA ¼ not applicable.
*Between trans women and trans men.
†
Between trans women before and trans women under treatment.
‡
Between trans men before and trans men under treatment.
§
Significant differences.

761
762 Auer et al

Figure 2. Desire for children. Trans women were significantly more likely to have their own children compared to trans men before and
after gender-affirming treatment (A). Having children was particularly important for trans men before gender-affirming treatment (B).
About half of the sample indicated that they could imagine having children in the future (C). *Significant difference. Figure 2 is available
online at www.jsm.jsexmed.org.

(21.9% trans women, 25.0% trans men) (Figure 2B), but a
majority recalled that having children had been important
before starting hormone treatment (69.9% trans women,
68.8% trans men) and 69.9% of trans women and 46.9% of
trans men indicated that they could still imagine having (more)
children in the future (P ¼ .034). Desire for children was
significantly higher for trans men before, compared to after,
initiation of gender-affirming treatment (P ¼ .049). Among
trans women the desire for children was comparably high
between both groups.
Sperm freezing before initiating GAHT was performed by 9.6%
of trans women, but no trans man had cryo-preserved eggs for
fertility-preserving purposes (P ¼ .011) (Table 2). However,
76.1% of trans women and 76.6% of trans men indicated that they
had at least thought about preserving germ cells before tran-
sitioning. Of those trans women who had actually frozen sperm
before treatment, the majority reported that they had postponed
transition to perform this step. Only a minority indicated that not
having been informed about fertility-preserving options was the
major reason for not proceeding with any of these options.
Most participants of both genders indicated that the treating
physician should inform patients about the available options for
preserving fertility before initiating GAHT.
Attitudes About Fertility-Preserving Options
An equal number of trans women and trans men already
receiving treatment stated that adoption would be an acceptable
option to fulfill their future desire to have children (46.6% vs
64.1%; P ¼ not significant). However, the number was higher
for trans men than for trans women in the pre-treatment group
(73.1% vs 38.5%; P ¼ .012).
Oocyte cryo-preservation was considered an acceptable option
for preserving fertility by 12.5% of trans men (15.4%, pre-
treatment) although oocyte donation is illegal in Germany.
Only 1 trans man indicated that insemination with donor
sperm would be an option to become pregnant. In contrast,
insemination of a female partner was regarded as an acceptable
option for 40.6% (26.9% pre-treatment; P ¼ not significant)
of trans men. This was also true for 9.6% (3.8% pre-treatment;

J Sex Med 2018;15:757e767

Desire to Have Children Among Transgender People in Germany
P ¼ not significant) of trans women (P < .001 vs trans men).
Insemination of a female partner with their own sperm was
considered an acceptable fertility option for 11.0% (11.5% pre-
treatment; P ¼ not significant) of trans women. In addition,
23.3% (19.2% pre-treatment; P ¼ not significant) of trans
women declared that they would be interested in the theoretical
option to undergo uterine transplantation surgery in the future,
even if this was associated with complications of a mandatory
immune suppression such as increased infection risk.
2 Trans women and 3 trans men had used options to have a
child after transition. 1 Trans woman had adopted a child while
the other one did not state how she had a child. 1 Trans man had
also used adoption and another used insemination of a female
partner with the sperm of an unrelated donor. 1 Participant in
this group did not answer the question.
Regression Analysis
The regression analysis (Table 3) showed that the whole
model was significant [c2 (10) ¼ 25.23; P ¼ .008]. The only
independent significant predictors of a current desire to have
children were being a trans woman (ß ¼ 0.948; P ¼ .016) and
higher age (ß ¼ 0.055; P ¼ .006). This translated into trans
women being more than twice as likely to have a current desire to
have children (odds ratio 2.58), while every additional year of age
translated into a 5.3% less probability across all groups.
DISCUSSION
To our knowledge, this is the first study that has addressed the
desire to have children in a clinical sample of trans women. It is
also the first of its kind that investigates this issue in trans men
who had not yet started medical treatment, and the first com-
parison in this regard of both genders.
General Desire to Have Children
We could show that having children is generally important for
trans individuals independent of medical transition stage. Never-
theless, only a minority had so far proceeded with putting this idea
into practice after medical transition. The percentages of those
expressing a current or future desire to have children were in
accordance with those reported in studies by Wierckx et al15 and de
Sutter et al.16 In these studies, having children was still important
for half of those trans men who had already undergone gender-
affirming surgery and in a similar proportion of trans women.
In line with our hypothesis, after beginning medical transition
trans women indicated more often than trans men that they
could still imagine having (more) children in the future. This was
interesting, as one third of them already had children that had
been conceived before transition. Importantly, already having
children did not negatively impact a current desire to have
children, in line with earlier reports.15,16 This finding is in
contrast to the general German population. People with 1 or
more children have a lower desire for children compared to
childless people from the general population.8 Moreover, the
J Sex Med 2018;15:757e767
763
desire for children in the general population seems to be com-
parable between male and female subjects, which contrasts with
trans people in the present study.8
In line with earlier studies, half of those with a desire to have
children reported a preference for having genetically related
children.
Factors Affecting a Current Desire to Have Children
After correcting for potential confounders, such as a higher age,
being a trans woman was the strongest predictor for a current desire
to have children independent of treatment progress in our study. It
has been discussed before that for trans women the desire to parent
children may be driven by a desire to experience biological
motherhood. Indeed, about one fourth of trans women from our
sample expressed a wish to receive a donor uterus to give birth to a
child, while also acknowledging the severe side effects that might
accompany such a procedure. This underscores the importance of
achieving complete bodily transition including female reproduc-
tive functions as a fundamental feature of femininity for some trans
women. Of note, if the desire for children is primarily driven by a
wish for complete transition and less by an actual desire for chil-
dren, children’s rights need to be respected. The right of every
child to have an opportunity to appropriate care and nurture must
be considered.30,31 This said, the highly theoretical option of
childbearing by trans women raises not only thorny ethical issues
but also medical problems given the potential side effects of
immune-suppressive medication.
Having genetically related children using their own (male)
reproductive organs was important only for a small subgroup of
trans women. Only 10% of trans women had chosen to preserve
their germ cells for later use before initiation of GAHT. In line
with this finding, other clinics report a comparably low rate of
sperm cell freezing among trans women.18 Financial issues were
rarely reported as a major reason for not having proceeded with
sperm freezing. Some patients, however, expressed the wish that
germ cell preservation and fertility procedures should be covered
by public health insurance.
In addition, only a minority of participants explained that
their decision was based on their treating physician providing
either insufficient or no information about fertility preservation
options. This contrasts with an earlier study where 51% of trans
women indicated that they would have considered sperm
freezing, or would have chosen to do so, if it had been offered to
them.16 This may be attributable to changing guidelines, as the
earlier study was performed in 2002. In the meantime, the need
to address fertility issues has been recognized and implemented
in the consensus guidelines of the Endocrine Society from 20093
and the Standards of Care.11 This might have increased aware-
ness among patients and their treating physicians.
No trans man in the treatment group and only 2 who had yet
to begin treatment had preserved egg cells. Most treated trans
men indicated having thought about preserving egg cells before
 764
Table 2. Use of and attitudes toward fertility options in transgender persons at different transition stages
Under treatment Before treatment

Trans Trans
women Trans men women Trans men

N 73 64 P* 26 26 P* P† P‡
Used fertility-preserving options N % N % N % N %
Yes 7 9.6 0 0.0 .011§ 3 11.5 2 7.7 .638 .077 .025§
No 66 90.4 64 100.0 23 88.5 24 92.3
Would have postponed GAHT to preserve fertility
Yes 4 57.1 0 0.0 NA 2 66.7 2 100.0 .361 .778 NA
No 3 42.9 0 0.0 1 33.3 0 0.0
Thought about germ cell preservation before GAHT
Yes, but I did not proceed due to technical reasons 48 67.6 38 59.4 .465 10 38.5 10 38.5 .790 .022§ .067
Yes, but I did not proceed due to financial reasons 3 4.2 4 6.3 2 7.7 4 15.4
Yes, but the treating physician did not inform me about 3 4.2 7 10.9 1 3.8 2 7.
these options
Yes (total) 76.1 76.6 50.0 61.5
No 16 22.5 15 23.4 9 34.6 8 30.8
Not answered 1 1.4 0 0.0 4 15.4 2 7.7
Used any option to have a child
Yes 2 2.7 3 4.7 .223 NA NA NA NA NA .391 .262
No 68 93.2 61 95.3 NA NA NA NA
Not answered 3 4.1 0 0.0 NA NA NA NA
Which option
Adoption 1 1.4 1 1.6 .567 NA NA NA NA NA NA NA
Insemination of partner with sperm from an unrelated donor 0 0.0 1 1.6 NA NA NA NA
Not answered 1 1.4 1 1.6 NA NA NA NA
c2 or Fischer exact test.
GAHT ¼ gender-affirming hormone treatment; NA ¼ not applicable.
J Sex Med 2018;15:757e767

*Between trans women and trans men.

†
Between trans women before and trans women under treatment.
‡
Between trans men before and trans men under treatment.
§
Significant differences.

Auer et al
Desire to Have Children Among Transgender People in Germany 765

Table 3. Logistic regression of potential predictors for a current child-wish

95% CI for Exp(B)§

B* SE† Exp(B)‡ Lower Upper P value

Age 0.055 0.020 0.947 0.911 0.984 .006k

Being a trans woman 0.948 0.395 2.580 1.191 5.590 .016k
Being androphilic 0.152 0.603 1.164 0.357 3.794 .801
Being gynephilic 0.306 0.433 0.736 0.315 1.719 .479
Late onset of GD 0.467 0.522 0.627 0.226 1.742 .371
Receiving GAHT 0.389 0.471 1.475 0.586 3.713 .409
Having undergone GAS 0.538 0.507 1.713 0.634 4.630 .289
Having children 0.111 0.636 1.117 0.321 3.882 .862
Being unemployed 0.190 0.592 1.209 0.379 3.861 .748
Living alone 0.099 0.432 1.104 0.473 2.573 .819
BDI-II 0.036 0.025 0.965 0.918 1.014 .156
BDI ¼ Beck Depression Inventory; GAHT ¼ gender-affirming hormone treatment; GAS ¼ gender-affirming surgery; GD ¼ gender dysphoria.
*Unstandardized regression coefficients.
†
Of unstandardized coefficients.
‡
Odds ratios for the predictors.
§
Odds ratios of the predictor.
k
Significance.

GAHT, while only about one third of trans men who had not yet
started GAHT indicated having thought about it. This contrasts
with the study of Wierckx et al,15 where only 20% of partici-
pants indicated having considered germ cell preservation but had
never confronted a health professional with these thoughts.
It must be kept in mind that egg donation for surrogacy, even if
the surrogate mother is the female spouse, is not allowed in Ger-
many, and if a person wants to perform this procedure, they must
seek help at a medical institution abroad such as the Czech Republic,
Belgium, or the Netherlands. Medical professionals in Germany are
also not allowed to advise their patients about such options and
would be liable to prosecution if doing so. This also implies that the
process of egg preservation is associated with much more effort and
financial burden compared to sperm freezing in trans women.
Trans men seem to be generally less interested in germ cell
preservation independent of the legal context.15,23 This may be
due to various reasons. Firstly, as already mentioned above, egg
cell cryo-preservation is more costly and complex than sperm
retrieval. Secondly, according to their predominant gynephilic
sexual orientation, almost half of trans men indicated that
insemination of a female partner with sperm from an unrelated
donor was regarded a suitable option for having children, indi-
cating that a genetic relationship to their potential children was
of minor importance.
In contrast, despite recent reports in the media about trans
men such as Thomas Beatie,24 who became pregnant by
insemination after initiation of GAHT, only 1 trans man in our
study cohort regarded this as an acceptable way to have children.
Although ovarian tissue preservation is legal in Germany and
would be easily feasible during gender-affirming surgery, so far,
no trans man was interested in this option. This is probably
because retrieved tissue, so far, is only suitable for later auto-
transplantation. To date, very few successful pregnancies
worldwide have been from ovarian tissue,25,26 although there
is potential for future in vitro maturation of oocytes from
cryo-preserved ovarian tissue for use in IVF.
Strengths and Limitations
To our knowledge, this is the first study that addresses the
desire to have children in a clinical sample of trans women. It is
also the first of its kind that investigates this issue among trans
men who have not yet started medical treatment, and the first
comparison in this regard of both genders. A limitation is the
special legal context in Germany that forbids oocyte donation for
reciprocal IVF, as is the case in other Western countries, and may
therefore potentially limit the generalizability of the results.
Future studies should also investigate in a longitudinal design
how desire to have children evolves during transition to help to
identify those who might regret not having undertaking fertility
preservation measures in the long run.
CONCLUSION
We conclude that a reproductive desire is high among trans
individuals and particularly in trans women, but the use of
reproductive options is surprisingly low. According to their
predominant gynephilic sexual orientation, most trans men in
both groups indicated that insemination of a female partner with
sperm from an unrelated donor was a suitable option to fulfill
their child wish, potentially explaining their low interest in
preserving their own germ cells. It is worth noting that missing
information regarding fertility options from the treating physi-
cians was not the major problem in this regard.

J Sex Med 2018;15:757e767

766
Corresponding Author: Matthias K. Auer, MD, RG Clinical
Neuroendocrinology, Max Planck Institute of Psychiatry,
Kraepelinstr. 10, Munich 80804, Germany. Tel:
þ498930622270; Fax: þ4989306227460; E-mail: Matthias.
Auer@med.uni-muenchen.de
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Matthias K. Auer; Thomas Hildebrandt
(b) Acquisition of Data
Matthias K. Auer; Johannes Fuss; Timo O. Nieder; Peer Briken;
Günter K. Stalla; Matthias W. Beckmann; Thomas Hildebrandt
(c) Analysis and Interpretation of Data
Matthias K. Auer; Johannes Fuss; Sarah V. Biedermann;
Thomas Hildebrandt
Category 2
(a) Drafting the Article
Matthias K. Auer; Johannes Fuss
(b) Revising It for Intellectual Content
Matthias K. Auer; Johannes Fuss; Timo O. Nieder; Peer Briken;
Sarah V. Biedermann; Günter K. Stalla; Matthias W. Beckmann;
Thomas Hildebrandt
Category 3
(a) Final Approval of the Completed Article
Matthias K. Auer; Johannes Fuss; Timo O. Nieder; Peer Briken;
Sarah V. Biedermann; Günter K. Stalla; Matthias W. Beckmann;
Thomas Hildebrandt
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SUPPLEMENTARY DATA
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jsxm.2018.03.083.