A new study from Amsterdam UMC and the Murdoch Children’s Research Institute in Australia shows that transgender women can retain the ability to produce viable sperm if they pause hormone replacement therapy after years of use—upending a major talking point against such care.
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 transitioning. 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 around 58 months, or nearly five years.
Participants were drawn from The Netherlands and Australia, with the youngest member of the cohort starting hormone therapy at the age of 18, and the oldest starting at age 33.
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Traditionally, when starting hormone replacement therapy (HRT), transfeminine people undergo a regimen of anti-androgen medication along with estrogen. The purpose of anti-androgen medication is to suppress testosterone production, which reduces the size of testicles and in most instances stops the production of sperm.
Within 10 months of ceasing HRT, eight out of the nine study participants produced viable sperm samples, with one patient producing viable samples from a testicular biopsy 17 months after cessation. Four of the patients attempted to conceive naturally with their partners after stopping HRT, of which three were successfully able to do so.
The new findings could have major implications for transfeminine people who are contemplating family-planning options and deciding when to begin medical transitioning. For some, the cost of preserving sperm in a cryogenic bank is too prohibitive to justify when family planning may not even be something they are considering. Preserving genetic material can cost hundreds of dollars a year and is rarely covered by medical insurance.
“Thus far, the assumption was that after the start of feminizing hormones and testosterone blockers transwomen would become infertile, therefore the results were surprisingly positive,” van Mello said.
Transfeminine people who no longer want to undergo surgery can delay preserving their sperm until after starting hormone therapy—with the caveat of having to pause treatment in order to produce viable sperm again. Otherwise, van Mello said, the best time for transfeminine people to preserve their sperm is before beginning hormone therapy.
The new study challenges that notion that medical transition leads to permanent infertility for transfeminine people, and may inform changes in both transgender medicine and as well as policymakers who are contemplating public health legislation affecting the trans community, Kellan Baker the executive director at the Whitman-Walker Institute, an LGBTQ-centered health clinic, told The Daily Beast.
“I think that this shows that hormone therapy can play a role both in gender affirmation and has the flexibility to make it possible for trans feminine people and trans masculine people to be able to make choices in the future about family planning,” Baker said.
For some of the patients in the cohort, going off HRT to try and conceive was a different life path than they had when first seeking out gender affirming care. The results of the study show that more options with family planning could be available to transfeminine individuals than previously thought, many of whome are told they will be infertile after starting HRT.
So far, four states have passed bans on providing gender affirming care for minors, which includes 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 actions from Republican governors to prevent transgender minors from receiving gender affirming care.
Some states have even gone further introducing laws that would ban any sort of gender affirming care for adults up to age 25. In many of these cases, lawmakers or other state officials have repeatedly stated that such care can cause “permanent infertility” in justifying healthcare bans. However, there has been robust evidence that shows that transmasculine individuals who stop hormone therapy have similar egg yields to cisgender women.
It’s not just policy makers that have waded into the scientific debate about gender affirming care. While the World Professional Association for Transgender Health (WPATH) has put out its “Standards of Care” best practices for medical professionals, many media outlets have begun focusing on transgender healthcare practices largely from a cisgender-led perspective. This has led to the rise of columnists decrying the lack of science surrounding greater access to gender affirming care.
These columns have been criticized for largely focusing on healthcare practices, without centering doctors or patients who are at the center of a debate over their care. In a rare-step, WPATH issued a multi-page release that attempted to provide more context on how reporting on transgender minors falls short in understanding the science it tries to question.
This type 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 that is asking questions that really aren’t that important to the lived experiences of trans people,” he added. “And it’s nice to see that this research is asking something that's important for a lot of trans people, something as fundamental as forming a family.”
For years, transfeminine people have shared anecdotes about going off hormone therapy to produce viable sperm and confirming this via research is a step towards better understanding the healthcare needs of the trans community. Given the range of diversity within the trans community, having as many options as possible and having more understanding about family planning needs and wants is so important, Baker added.
More research will be needed before any definitive conclusions can be drawn linking the cessation of hormone therapy and the production of sperm, van Mello cautioned. The youngest participant in this study began hormone therapy at the age of 18, meaning it is unclear about whether those who start earlier can achieve similar results. It is also unclear if any of the participants underwent puberty blocking drugs before starting hormone therapy. The researchers couldn’t identify any specific timing of for when sperm production resumed after gender-affirming hormone therapy was stopped. And lastly, the sample size of nine participants is quite small for a clinical study, and follow-up studies will be necessary to strengthen the findings.
WPATH’s current guidelines suggest beginning puberty blocking drugs after puberty to prevent future infertility, and an overwhelming number of patients that begin puberty blocking drugs go on to undergo hormone therapy. Continuing research into their futures will be important as advancement in transgender medicine continues.
Van Mello says that she hopes that more studies are done to learn more about the quality “more insight in the process of restoration” of sperm production following the cessation of hormone therapy.
