A new study from Amsterdam UMC and Murdoch Children’s Research Institute in Australia shows that transgender women can retain the ability to produce viable sperm if they interrupt hormone replacement therapy after years of use, turning upside down a major argument against such concern.
As part of the study, published Jan. 17 in Cell reports medicine, clinicians from both research institutions observed the effects of hormone therapy for nine transfeminine women who were in transition. Norah van Mello, one of the authors of the new study, told The Daily Beast that the women in this cohort had been on hormone replacement therapy for an average of about 58 months, or nearly five years.
The participants came from the Netherlands and Australia, with the youngest member of the cohort starting hormone therapy at age 18 and the oldest at age 33.
Traditionally, when starting hormone replacement therapy (HRT), transfemale people undergo a regimen of anti-androgen medication along with estrogen. The goal of anti-androgen medication is to suppress testosterone production, which causes the testicles to shrink and, in most cases, stops sperm production.
Within 10 months of stopping HRT, eight of the nine study participants produced viable sperm samples, with one patient producing viable samples from a testicular biopsy 17 months after stopping. Four of the patients tried to conceive naturally with their partners after stopping HRT, three of whom were successful.
The new findings could have major implications for transfemale people as they consider family planning options and decide when to begin medical transition. For some, the cost of storing sperm in a cryogenic bank is too prohibitive to justify when family planning may not even be something they’re considering. Preserving genetic material can cost hundreds of dollars a year and is rarely covered by medical insurance.
“Until now, the assumption was that after the start of feminizing hormones and testosterone blockers, trans women would become infertile, so the results were surprisingly positive,” Van Mello said.
“I think this shows that hormone therapy can play a role in gender affirmation as well as having the flexibility to allow transfemale people and transmale people to make choices about family planning in the future.”
— Kellan Baker, Whitman-Walker Institute
Transfemale people who no longer wish to undergo surgery can postpone sperm storage until after hormone therapy has started – with the caveat that they will have to interrupt treatment to produce viable sperm again. Otherwise, van Mello said, the best time for transfemale people to conserve their sperm is before starting hormone therapy.
The new study challenges the idea that medical transition leads to permanent infertility for trans women, and could lead to changes in both transgender medicine and policymakers considering public health legislation that impacts the trans community, Kellan Baker, the executive director of the Whitman-Walker Institute, an LGBTQ-centered health clinic, told The Daily Beast.
“I think this shows that hormone therapy can play a role in both gender affirmation and has the flexibility to make it possible for transfemale people and transmale people to make choices about family planning in the future,” Baker said.
For some patients in the cohort, stopping HRT to try to conceive was a different life path from when they first sought gender-affirming care. The results of the study show that there may be more family planning options available to transfemale individuals than previously thought, many of whom are told they will be infertile after starting HRT.
So far, four states have issued bans on providing gender-affirming care to minors, including hormone replacement therapy. In Arkansas, the first state to pass such a ban, the law is currently being challenged in court by the ACLU. In addition, Texas and Florida have used executive orders from Republican governors to prevent transgender minors from receiving gender-affirming care.
Some states have gone even further by introducing laws that would ban any form of gender-affirming care for adults up to age 25. In many of these cases, legislators or other government officials have repeatedly stated that such care may cause “permanent infertility” when justifying health care. prohibits. However, there is robust evidence showing that transmasculine individuals who discontinue hormone therapy have comparable egg yields to cisgender women.
It is not only policymakers who have become involved in the scientific debate on gender-affirming care. As the World Professional Association for Transgender Health (WPATH) has released its “Standards of Care” best practices for medical professionals, many media outlets have begun to focus on transgender health care practices, largely from a cisgender-driven perspective. This has led to the emergence of columnists decrying the lack of science surrounding better access to gender-affirming care.
These columns have been criticized for focusing largely on healthcare practices, without putting doctors or patients at the center of a debate about their care. In a rare move, WPATH released a multi-page release that attempted to provide more context on how reporting on transgender minors falls short of understanding the science it seeks to question.
This kind of perspective, Baker said, is an example of what cisgender people think is important to transgender people — in contrast to the new study from Amsterdam UMC and the Murdoch Children’s Research Institute.
“There are plenty of examples of research asking questions that aren’t really that important to transgender people’s lived experiences,” he added. “And it’s nice to see that this research is asking something that’s important to many transgender people, something as basic as forming a family.”
“It’s nice to see that this research is asking something that is important to many transgender people, something as basic as forming a family.”
— Kellan Baker, Whitman-Walker Institute
For years, trans-female people have shared anecdotes about the withdrawal of hormone therapy to produce viable sperm and affirm that through research, this is a step toward a better understanding of the health care needs of the trans community. Given the variety of diversity within the trans community, it’s so important to have as many options as possible and better understand family planning needs and wants, Baker added.
More research will be needed before definitive conclusions can be made about stopping hormone therapy and sperm production, van Mello warned. The youngest participant in this study started hormone therapy at age 18, meaning it’s unclear if those who start earlier can achieve similar results. It’s also unclear if any of the participants were on puberty-blocking drugs before starting hormone therapy. The researchers could not identify a specific timing of when sperm production resumed after sex-confirming hormone therapy was stopped. And finally, the sample size of nine participants is quite small for a clinical trial, and follow-up studies will be needed to strengthen the findings.
Current guidelines from WPATH suggest starting puberty blocking after puberty to prevent future infertility, and an overwhelming number of patients who start puberty blocking undergo hormone therapy. Continued research into their future will be important as advances in transgender medicine continue.
Van Mello says she hopes more studies are done to learn more about the quality of “more insight into the process of recovery” of sperm production after stopping hormone therapy.