Family planning desires and barriers to fertility preservation for transgender and gender-diverse military service members in the United States

Purpose: Fertility preservation is recommended prior to initiation of gender-affirming hormone therapy. However, barriers have been described in providing appropriate counseling and pursuing fertility preservation. We hypothesized transgender and gender diverse (TGD) people serving in the United States military would face their own unique barriers to fertility preservation given the historic undulating policies with respect to their ability to openly serve. We aimed to evaluate barriers that transgender and gender diverse (TGD) individuals face when pursuing fertility preservation in the United States Military Health System (MHS). Methods: We developed a mixed-methods study using an explanatory sequential design. Data collection occurred between February and April 2024. We created and distributed a survey to all individuals presenting for an initial surgical consultation for gender-affirming genital reconstructive surgery at our institution and posted it on a social media page for TGD military service members. This survey assessed family-building desires, barriers to family-building, and satisfaction with prior fertility preservation counseling. In the survey, participants had the option to request a follow-up interview. We report descriptive statistics from both the survey and interviews. Results: We received 26 responses from self-identified transgender men (n = 9), transgender women (n = 14), and nonbinary (n = 3) individuals aged 21 to 49. Most respondents were married (61.5%) and desired at least one child (76.9%). The majority of respondents did not feel supported in building their families during their military service (61.5%). Twenty respondents agreed to participate in a follow-up interview, and ten interviews were conducted. Five barriers emerged from coding interviews: heterogeneity in counseling, limited resources and support, systemic barriers, providers’ implicit bias and insurance policy. Conclusion: Numerous family planning and fertility preservation barriers exist for TGD people within the Military Health System. Although many individuals stated they received fertility preservation counseling, many felt it was a formality and lacked individualization. This research highlights the need to standardize fertility preservation counseling, train US military providers on fertility preservation counseling for TGD service members and pursue policy reform to decrease barriers to accessing this care.