Sexual health, fertility and pregnancy

Young people spoke about their experiences of accessing sexual health services. Sexual health services on the NHS provide free sexual health screening (tests), treatment, contraception and advice as well as some other services (dependent on location) such as vaccines (for Hepatitis A/B, HPV), sexual assault support, HIV care, and cervical screening. Read more about young people’s experiences of sexuality and relationships.

Some medical treatments that trans and gender diverse people might have, including hormone therapy and surgery, may impact fertility. Oestrogen or testosterone hormone therapy can impact fertility in combination with other factors. However, research and understanding in this area is growing.

Fertility preservation refers to procedures that allow gametes (sperm, eggs or embryos) to be harvested, frozen and stored for later use in fertility treatment (Human Fertilisation & Embryology Authority, 2020).

The young people we spoke to talked about sexual health and fertility in the following ways:

  • Accessing sexual health services and information
  • STIs and HIV testing and cervical screening (smear tests)
  • Sexual health and inclusive language
  • Deciding about fertility preservation
  • Experiences of fertility preservation and pregnancy

Accessing sexual health services and information

The young people we spoke to talked about where and how they accessed sexual health information and services. Participants also talked about their experience of sex education.

Our participants had positive experiences with services specifically for and by the trans and gender diverse community, in particular services such as CliniQ in London. Patrick said, ‘I mainly access sexual health care through CliniQ – the trans sexual health service in London because it’s super accessible for me.’ He said he likes knowing that ‘the people… treating me or supporting me with my sexual health get it, they are specifically trained [and] they’re either trans themselves or they really get what the interplay of trans issues are with sexual health.’ Summer said, ‘CliniQ… will test you for everything and they’re very respectful with non-gendered language.’

Charke talks about the value of LGBTQ+ youth groups when discussing sexual health.

Age at interview 17

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Young people spoke about other services that are specific LGBT clinics and services run through local LGBTQ+ centres. Sophie said, ‘There was a specific clinic which I go to which is for LGBT run by NHS, but an LGBT clinic, which is very good, very helpful and very nice. Everyone has been very nice and very friendly.’ Noelle was aware of a ‘local LGBT+ centre [that] does [HIV and STI] testing’. Jaz said, ‘We need more trans positive services. It feels really alarming that there are only so few and they’re located in major cities quite far away from each other’. She said that trans people who use sexual health service need to ‘feel comfortable that the [staff] there… are not going to fuck up or say something offensive’.

Erion talks about a local trans friendly healthcare service which is an amazing resource’ dealing with HIV, STI testing, sexual assault and unwanted pregnancies.

Age at interview 22

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Some participants talked about uncomfortable experiences in mainstream sexual health clinics that relied on binary-gendered spaces and waiting rooms. Tyra said, ‘From my own personal experience accessing sexual healthcare was an issue as a trans person.’ She said, ‘you’d be put into the male room because of your anatomy, and not because of how you identify, and this was an issue for me. I remember raising it with the lead people at the hospital, and they sat down and listened to me, and took on board all of my concerns.’

M talks about their experience of sexual health screening and assumptions being made according to how they were presenting. Now they only go to a sexual health clinic specifically for trans people.

Age at interview 25

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Eel wishes there was more information available about sexual health for queer people.

Age at interview 17

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STIs and HIV testing and cervical screening (smear tests)

Young people talked about experiences of testing for sexually transmitted infections (STIs) and HIV. Anderson said, ‘Trans friendly testing is really important. I think anything to do with [the] sort of stuff that’s sensitive should just be handled by somebody who is sensitive. Cos it’s awkward already. I don’t need help with you being confused to make it extra awkward for me’. Patrick said, ‘I like [to] self-test at home, do the sexual health testing at home because that’s really easy for me to do and a lot less stressful.’

Jack talks about his experience of HIV and STI screenings and being asked questions based on genitals and being sent a non-gendered healthcare kit.

Age at interview 22

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The sexual health clinic Shash attended was really good. She talks about the assumptions made and how she and the healthcare team dealt with it.

Age at interview 23

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Cervical screening appointments were a particular concern for participants with vaginas. Ari said, ‘If you are someone who’s assigned female at birth, who gets your gender marker changed on the NHS. You do have to remember to organise your own pap smears and stuff, because [the GP surgery] won’t send those reminders for you. So it’s just something to keep an eye on.’ Max said, ‘Because I’m at the age and I’ve changed my gender in the GP [surgery], I’m not gonna get the letter calling for a pap smear… even though I actually should do… I haven’t set up that appointment yet.’

Henry said having smear tests ‘terrifies me… just having the interaction with the doctor… [the] smear test was just generally awful, but it needs to happen.’ He added, ‘I think there are barriers to trans people accessing it, and I know what they feel like, but at the same time, for me, yeah it, it’s something that is, is very important… as excruciating as it is. I see it like it’s a job, it has to be done, you have to make sure that you’re sexually as healthy as possible’. Reuben said, ‘I have been to [a] check-up with the gynaecologist, like smears and swabs and stuff. But I’ve always just shut my eyes when it happened’. N said cervical smears ‘can be mortifying for trans people, healthcare professionals can be confused.’

Bay talks about making a smear test appointment with their GP reception and the difficulties with this.

Age at interview 28

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Sexual health and inclusive language

Our participants talked about the importance of non-gendered language in sexual, genital health and reproductive settings. Cassie said, ‘most trans people that I know… like binary trans people at least, have an ambivalent at best relationship with their genitals. So going to the sexual health clinic is not fun, ever for anyone.’ She felt that services and sexual healthcare professionals should ‘normalise and explain the decisions that [are being] made and why things are structured the way they are structured… Is it too much to be asking that non-gendered language be used?’

Cassie wants to see sexual healthcare services for trans people to use more inclusive language.

Age at interview 23

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A says the resources at most sexual health clinics are really cisnormative and heteronormative.

Age at interview 21

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Anderson says there’s a lot of internal transphobia within [sexual health] servicesthey could do better.

Age at interview 26

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Safia says I’ve actually been really impressed’ with their sexual health clinic’s attention to trying to be more inclusive for trans people.

Age at interview 27

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Cassie was impressed with the language used by her local sexual healthcare provider. She said ‘the websites and stuff… are well designed and basically…it gives you options for… “What’s your gender identity?” And then saying, “What’s your genital configuration?” …explaining the reason we have to do this is because different tests require depending on genital configuration. If you want further information call this helpline.’

At a sexual health clinic appointment, June had to correct a health professional on the language he was using.

Age at interview 29

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Beth says having the right information and actually listening to trans peopleshouldn’t be a big hurdle but for some reason [it] is’ for some healthcare professionals and services.

Age at interview 23

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Deciding about fertility preservation

The people we interviewed talked about having children in the future, their thoughts on fertility preservation and what was important to them. For some young people, having children was not part of their future plans. Sally said, ‘I was very much of the opinion that I want to be sterile… I never accessed… reproductive services.’ She said, ‘partly it was that… I don’t want anything to hold me up getting on the hormones so I was really against it.’

Cassie said, ‘I didn’t freeze sperm, I wasn’t particularly interested in it. I’ve never really wanted children for a variety of reasons. I think part of me feels like if I was to have biological children, I would want to have biological children.’ Shash said, ‘It’s like every other moment, even in my private life people are still going, “Are you sure that’s your choice? Are you sure that you don’t wanna store anything? I’m like, “Yeah, I’m sure …I’m content in my decision not to have kids, respect my decision”.

PJ says he’s known since he was very young that he doesn’t want kids in the future.

Age at interview 21

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Some young people were keen to have children in the future and considered the possibility of adoption. Patrick said, ‘I personally don’t want to have biological children so I don’t plan on freezing my genetic material and I don’t plan on carrying my own child. But I am very keen on the idea of adopting if either I get to a place where I’m comfortable doing that independently or I find a partner who I want to raise a child with.’ He added that it was ‘really exciting’ to see the development of ‘options for trans people in terms of pregnancy and having children’.

M is glad to have taken the opportunity of gamete storage.

Age at interview 25

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Jay said, ‘Me and my girlfriend definitely want to have kids at some point. I think she wants to adopt, but I know that’s gonna be really hard and long process.’ He continued ‘I would never want to physically have kids myself. The thought of it makes my skin crawl to be honest. It’s not something I wanna do at all.’ Bay says, ‘I’ve always been quite clear that if they’re not biologically mine that doesn’t really matter to me. You know there are still options, there are still ways of having children that I would be perfectly happy with going forward.’

Other options such as surrogacy were mentioned. Jacob talked about a combination of IVF and surrogacy and said, ‘there were options if we wanted a biological child.” Tom said, ‘I’ve actually had a conversation with my older sibling who is bi, and she was like, “I’d happily carry a child for you”. It was, ‘just like different ways and different options really.’

Henry talks about the distinction between physically carrying a child and wanting to have children which is something he’s always wanted.

Age at interview 25

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Getting information on fertility preservation

Participants mentioned the lack of information and resources on fertility preservation, as well as cost of it. G said that they didn’t know how to directly access any fertility preservation services, ‘I’ve been given a thing that takes me to get my sperm levels checked and then my GP can forward me to a clinic from there’, and also had concerns about the costs: ‘It costs £400 If you wanna do it normally and then you have to pay £100 every year.’

Declan said, ‘since I was 14, I’ve always said, “I don’t want to carry my own [children] and I don’t want to save my eggs or anything”. He shared ‘I’ve heard other trans men who’ve tried to preserve their fertility are having real issues with it because the ways that they do it are quite invasive.’ He had heard ‘you have to take oestrogen and other hormones before and it’s quite dysphoria inducing…I don’t want to go through that process. I’ve looked into it. If I want children, I can adopt.’

Evelyn talks about the emphasis placed on fertility preservation by GIDS before starting blockers and her experience of this.

Age at interview 14

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People talked about how it was often brought up in conversations with health professionals. Some young people felt there was a mismatch in what the health professionals thought was important to them. Bay said that fertility preservation ‘was something I was encouraged to think about prior to starting testosterone.’ They said ‘at that time… it kind of felt like other people saw that as one of the biggest decisions I needed to make around it and for me it really wasn’t a big thing at all. I have never had any desire to have children, I certainly never pictured myself carrying a child.’

Ari said, ‘The doctor I saw at my first [gender] appointment pushed it quite hard and said some stuff about how people often feel [they don’t want children] when they’re my age and then tends to change when they grow older and then they regret not being able to do it’ which I found intensely frustrating, because I never wanted children.’

At the same time, some young people were happy to be given the option. Bailey said, ‘I’d rather have my eggs frozen just in case I do want kids. But at the minute I don’t really know. I just sort of live in the moment.’

H says he was desperate’ to start hormones and did not choose fertility preservation but looking at it now I wish I did just sort it out.

Age at interview 28

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One participant had regrets that they did not take the fertility preservation option when offered to them. H said, ‘My advice to people who haven’t yet started their transition, I know it’s horrible having to wait that extra bit of time [to begin hormone therapy] which seems like a lifetime… but just take that extra couple of months to sort out your fertility options’. He said, ‘I was only 23 when I said [no]… now I’m 28 I’m like, “Oh, shit,” …it would’ve been nice to know that within the next few years it is a possible thing.’

Fertility preservation and pregnancy

Some young people we talked to had experience of undergoing fertility preservation. For some the experience was positive. Kat said the gender specialist she saw ‘recommended fertility preservation if you’re not 100% sure you don’t ever want kids.’ She said the process was ‘really easy… the people at the clinic were very nice’. She said, ‘I think I need to change my name on their forms when I get it legally changed but other than that it’s some money a year to keep gametes frozen.’

Jessica talks about her experience of fertility preservation and her hopes of having children in the future.

Age at interview 17

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Summer talks about her experiences of fertility preservation.

Age at interview 25

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Other young people spoke about disappointing experiences with being misgendered or it being unsuccessful. Henry said, ‘When I went to the ‘women’s’ hospital to have my eggs frozen… the surgeon who was involved in that process [used] the wrong pronouns… I think quite a few people in that space used the wrong pronouns.’ He said, ‘I remember feeling very small and invalidated and just generally a bit nauseous about going into a women’s hospital and waiting in a women’s waiting room’.

Evelyn shared, ‘we [Evelyn and her mother] had to wait one or two months after seeing the therapist and then we went and did the whole sperm [storage] thing… but there was no sperm present. It failed basically. And it was just an extra one or two months not on blockers pretty much, ‘cos we had to not go on blockers to do it, so it was just a pointless extension.’

One of our participants talked about their pregnancy, labour and birth. Beth talked about having to ‘stand up for myself as a non-binary person when I was pregnant.’ They asked midwives and doctors to ‘use they/them pronouns,” or [asked] “Can you not call me a mother”. Beth said, ‘They would kind of take it on board for that conversation and then forget about it, or just ignore it completely, or not really understand what I was talking about.’

Beth talks about being a non-binary parent, the importance of inclusive language and useful resources.

Age at interview 23

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For more information about pregnancy and inclusive language see Brighton and Sussex University Hospitals website

and research on trans pregnancy at University of Leeds.

See also:

Trans and gender diverse young people’s experiences of sexuality and relationships 

Trans and gender diverse young peoples’ views on LGBTQ+ education

Trans and gender diverse young people’s experience of GP surgeries

Trans and gender diverse young people’s views on improving healthcare

Sexuality and relationships

Young people described their experiences of diverse sexualities in different ways. Those with experiences of sex and relationships shared what sexuality and gender identity meant...