The Impact of Autism and Mental Health on Fertility Preservation among Transgender and Gender Diverse Adolescents

Research question What factors are associated with the decision to pursue fertility preservation (FP) counseling and utilization among transgender and gender-diverse (TGD) adolescents? Design This retrospective study included 217 TGD adolescents (129 assigned female at birth [AFAB]/88 assigned male at birth [AMAB]) from a single tertiary referral gender clinic who initiated GnRH analog (GnRHa) and/or gender-affirming hormones (GAH) between 2013 and 2023. The mean age at initiation of GnRHa and GAH treatment was 16.1±1.6 and 16.5±1.4 years, respectively. All were offered FP counseling prior to treatment. Sociodemographic, clinical, and mental health data were collected and analyzed for associations with completing FP counseling and subsequently undergoing FP utilization. Results A total of 111 participants (53.9%) completed FP counseling. Adolescents with autism spectrum disorder were more likely to complete FP counseling ( p = .04). FP was pursued by 31.3%, with significantly higher rates among AMAB compared to AFAB (59.1% vs. 12.4%, respectively, p < .001). A history of self-harm or suicidal attempts was overall negatively associated with FP ( p = .017 and p = .025, respectively). The absence of suicidal attempts significantly predicted FP completion (multivariable analysis, odds ratio (OR) = 8.85, p = .044). Conclusion The utilization rates of FP in this cohort of TGD adolescents were among the highest reported in the literature. Decisions to undergo FP were influenced by cultural factors, the availability of specialized counseling, and socioeconomic status. Mental health factors appear to play a significant role in fertility decision-making. These findings delineate the needs unique to TGD adolescents that should be considered when they seek counseling for FP.