A Qualitative Study Examining Transgender People’s Attitudes Toward The Desire to Have Biological Children and Pursue Fertility Treatments in Greece

Background: Biomedical technologies advances permit transgender individuals not only to achieve gender transition but also experience parenthood. Little is known about it in Greece, a traditionally conservative country, which however, is changing at legal level towards greater recognition of transgender people’s rights. This study aimed to investigate transgender people’s attitudes toward the desire to have biological children and pursue fertility treatments in Greece. Methods: This is a prospective study among adult individuals who identied as transgender men or transgender women between April 2019 and March 2020. Individual in-depth qualitative interviews were conducted with twelve participants. The interviews were conducted in person and were digitally recorded and transcribed verbatim. The authors performed an inductive analysis of data. Results: The inductive analysis of the study ndings resulted in the following themes that represent key barriers to pursuing FP or ART: lack of fertility counseling, fears of discrimination and bullying, high costs, concerns related to the child’s welfare, less than perfect legal framework, and gender transition. Not all participants expressed strong desire to have offspring. A number of sub-themes were grouped under the base themes. Concerns related to the child’s welfare due to factors related to context or transgender people themselves. Fertility treatment may the or the of The strength of the desire for fertility treatment is Various reasons behind the transgender people’s desire for parenthood were identied. Transgender individuals (especially those in social transition) showed striking adherence to patterns of the dominant culture when it comes to having children. Conclusion: The results demonstrate the importance of contextual factors (stigma,


Background
An increasing number of young transgender people today are using medical procedures such as gendera rming hormonal or surgical therapies to achieve gender transition 1 [1,2]. Gender transitioning is 'the process of changing one's gender presentation and/or sex characteristics to accord with their internal sense of gender identity' [3]. Importantly, transgender young people never before than today were seeking medical (i.e. hormone) therapy as part of the transition process at earlier stages of development [1]. While research has shown that gender transitioning people experience a psychological bene t [4], the multifaceted process of gender transitioning with hormones or sex reassignment surgery may introduce a higher risk of signi cant long-term implications, including temporary or permanent loss of fertility [5,6]. Notwithstanding, recent advances in biomedical technologies not only have enabled gender transition but have also made it feasible for transgender individuals to experience parenthood. At present, fertility preservation (FP) techniques include sperm banking for transgender women and oocyte, embryo, or ovarian tissue banking for transgender males, while new FP techniques may appear in the future. For instance, uterus transplantation may become available in the coming (although not presently foreseeable) future for transgender women.
As a consequence, transgender people face complex and tough decisions about whether to freeze sperm or eggs or undergo assisted reproductive technologies (ART) [6]. The introduction of alternative means of achieving biological parenthood through medical advances has, therefore, created new forms of families including (at least) one transgender person. However, 'the uptake of this option to date has been low' [7] and very little is known 'about how transgender people create their families and the issues involved in these decisions' [8]. More speci cally, 'little is known about their desire to have children and attitudes toward fertility preservation options' [9]. As yet so little is known about the complex topic 'medically assisted reproduction in transgenders', and hence, it needs some more clari cation [10].
This manuscript attempts to expand what is known about transgender adults' attitudes and desires as related to family formation and FP in Greece, where further empirical research is needed to provide a more nuanced exploration of transgender people's rights, including the right to equal access to healthcare services [11].
As yet, in Greece there is a lack of empirical evidence to support an understanding of what it is like for transgender people to make a decision on whether to pursue FP or ART. Greek society is traditionally conservative. However, within the recently changing legal framework that gave a major boost to transgender rights by allowing citizens to choose to legally change their gender identity, more transgender people are expected to be at fertility clinics. If this is the case fertility clinics will face an entirely new patient group (transgender people) "whose reproductive futures were previously considered either impossible or undesirable are now 'anticipating infertility' and engaging in 'family planning" as central parts of their lifecourse and medical engagements' as Payne and Erbenius (2018) wrote in respect to Sweden [12].

The legal context of transgenderism in Greece
In Greece, transgender people are protected from discrimination, bullying, and harassment under the current legal framework. Since 2013 the Greek Criminal Code has punished gender identity discrimination and violence. This legal protection has been enhanced by the anti-racism Law n.4285/2014. Nevertheless, over the past recent years Greece adopted extreme austerity measures that led to the rise of the far-right parties. As a consequence homophobic and transphobic violence and rhetoric have substantially increased [13,14]. More recently, the Law n. 4491/2017 allows citizens to choose to legally change their gender identity (from the age of 15). Importantly, this law actually improves transgender people's right to change their o cial gender registration according to their own understanding of their gender identity without requiring a medical treatment. Under the new law young people (between the age of 15 and 17) can apply for legal change of their gender identity after having obtained a certi cate issued by a medical council (in Athens Children Hospital). The law brings the Greek legislation in line with the legislation of most EU countries [15]. Transgender Europe (2017) welcomed this law [16]. Undoubtedly, the law is an important step to improving transgender people's autonomy. As the new law allows citizens to choose to legally change their gender identity without requiring a medical treatment, it is paving the way for transgender parenthood. However, certain needs of transgender people remain unaddressed, as the autonomy of transgender people to choose their gender identity remains quite limited. First, a legal change of gender identity is granted to the applicant after their appearance before a court. Second, transgender people must be single (perhaps against their will) to apply for a legal change of their gender identity. Third, transgender people who Methodological Aspects Instrument The present work has been a prospective qualitative research study centered on exploring the social reality and the description of the lived experiences and attitudes of individuals who identify as transgender toward having biological offspring. Data were collected through semi-structured in-depth interviews conducted in person with 12 individuals who identi ed as transgender men or transgender women between April 2019 and March 2020. .

Research questions
The grand tour question that delineates the focus of this study is the following: What is the attitude of adult transgender women and transgender men toward the desire to have biological children and pursue fertility treatments in Greece?
The secondary research questions are: 1. What are the factors (if any) affecting transgender individuals' fertility decisions?
2. What are the challenges (if any) that transgender people face in accessing fertility treatment or pregnancy and birth services?
Participants: Sampling criteria and recruitment already have children and apply for a legal change of their gender identity are presented in the registry certi cates of their children with their old gender identity (sex assigned at birth). This may affect the relationships between transgender people and their children.
Unsurprisingly, legal amendments can hardly alter culture-rooted issues [14]. The Orthodox Church of Greece has been for a long time profoundly shaping Greek people's moral and social attitudes. The Orthodox Church of Greece stated that the law was 'a satanic deed' that leads to 'the destruction of social cohesion and the spiritual necrosis of man' [15].
Greek cultural values place considerable emphasis on heterosexual coupledom, promoting the view that it is a prerequisite for one's personal ful llment [17]. Religion is a major factor that strongly in uences Greek culture, particularly regarding sexuality and marriage. The potentially selected respondents of this study (N=12) were transgender men and women in different transitioning stages, diverse in terms of age, gender identity, transition phase or type, place of residence, sexual orientation, and educational backgrounds. The age of the participants ranged from 23 to 60 years, with the majority between 27 and 45. The mean (standard deviation, SD) age of participants was 40 (11) years.
Participants were recruited through incentivized snowball sampling, community outreach and the interviewer's personal contacts. Potential participants were contacted by telephone to schedule an interview.
All participants were adults and had been Greek citizens for at least the last 10 years. All participants resided in urban areas. Participant characteristics are presented analytically in Table 1.

Data collection and analysis
The interviews conducted one on one. The interview guide development was guided by a review of the relevant literature. The guide was slightly re ned after the initial results from a few interviews, in order for participants to be allowed to get better understanding of the speci c issues being questioned. Last, we developed an informal grouping of topics and questions that the interviewer could ask in different ways for different participants. The interview guide comprised a number of topics to capture a wide range of participants' lived experience. These topics were related to a) making fertility decisions, b) accessing fertility treatment, and c) accessing pregnancy and birth services. The participants were encouraged to expand upon the examined topics.
All interviews were conducted by a researcher experienced in carrying out qualitative interviews, which lasted from 38 minutes to 55 minutes each (mean 44 min). All interviews were held in quiet places (mostly private rooms) where the environment was comfortable. As phenomenological researchers we were interested in describing participants' experiences while being in a natural (normal, unre ective and effortless) attitude. Interviews were digitally audio-recorded and transcribed verbatim to preserve authenticity. In addition, eld notes were used for recording non-verbal behavior patterns. The data obtained from interviewees were thematically categorized and analysed. In addition, eld notes were used for recording non-verbal behavior patterns, as well as procedural and contextual aspects of the interviews, which enabled deeper and contextual critical re ection on data collected. The research data were gathered through combining conversational interviewing and structured-question interviewing to help produce a set of insightful ndings. Re exive thinking was used throughout the research process to reduce unwitting personal bias. The authors strived to use re ection for increasing awareness of their pre-understanding of the study phenomenon. To ensure trustworthiness in the study, the interviewer spent time beforehand to gain participants' trust. For this reason, in all the interviews the initial part was devoted to the apprehension phase of the interview process that follows the phase of building rapport [18]. This phase was largely devoted to topics not directly concerning the matter of this research, such as gender dysphoria, social stigma and discrimination, or gender transitioning process. Interestingly, this part of interviews has been proved to be useful for the purpose of conducting a better data interpretation in the process of thematic analysis. Interviews were assigned to a bioethicist (CV) who conducted thematic analysis of data.
Each one of us engaged with other researchers to limit research bias.
Qualitative analysis used thematic content analysis [19]. As transgender men's experiences of barriers in making fertility decisions or in accessing fertility treatment or pregnancy and birth services had not been previously explored in the context of Greece, the authors considered themselves as not being already aware of probable participants' responses. Therefore, they selected to use 'the actual data itself to derive the structure of analysis a data-driven analysis' (namely, the inductive approach), which is less bias and more comprehensive and exible (though time-consuming) than the deductive approach that involves analyzing data with 'predetermined theory, structure or framework' [19].
A verbatim transcription of the auto-recorded narratives was performed. The researchers followed Gibbs' (2007) [20] advice on how to demonstrate qualitative reliability. Using this perspective, they carefully examined, veri ed and read repeatedly the transcripts to get a good sense of the participants' narratives [19]. They constantly compared data (as described by Patton, 2002) [21] to ensure the codes were used consistently. Open coding used to identify quotations related to our research questions. After having summarized these quotations in notes, the researchers grouped phrases re ecting the same context to form categories and subcategories that might represent starting points for the results of the study. Then, transcripts were reread in constant comparison with the list of categories and subcategories to identify further phrases in transcripts that might serve the purpose of our research goal. Thereby, the researchers strived to capture and investigate in depth all aspects of participants' narratives related to our research goal. Moreover, the researchers coordinated communication, and shared analysis among the researchers. Finally, a data management software program (NVIVO, 2015) was used to secure and further re ne the systematic character of the analysis.

Ethical considerations
The interviews were conducted in neutral places of the participant's choice, thereby ensuring privacy and con dentiality and minimizing environmental impact. Prior to participating in this study, the participants were given adequate information on the aim, procedure, nature and con dentiality of the study, and oral consent to participation was obtained. The ethical principles of anonymity, voluntary participation and con dentiality were considered. Anonymity and con dentiality have been maintained throughout the study. In order to preserve their anonymity, numbers (e.g. T 1) are used in this paper. The interviews were registered and stored in a strictly con dential fashion. The study and consent procedure was approved by ethics committee a liated to Aristotle University of Thessaloniki, Faculty of Health Sciences, Department of Medicine (No: 2.128 / 27-02-2019).

Results
The inductive analysis of the study ndings resulted in the following themes that represent key barriers to pursuing FP or ART: lack of fertility counseling, fears of discrimination and bullying, high costs, concerns related to the child's welfare, less than perfect legal framework, and gender transition. Not all participants expressed strong desire to have offspring. A number of sub-themes were grouped under the base themes. Concerns related to the child's welfare due to factors related to context or transgender people themselves. Fertility treatment may be a challenge for the process of transition or the result of it. The strength of the desire for fertility treatment is crucial. Various reasons behind the transgender people's desire for parenthood were identi ed. Transgender individuals (especially those in social transition) showed striking adherence to patterns of the dominant culture when it comes to having children.

Lack of fertility counseling
None of the participants reported having received adequate FP counseling before starting their transition, while six out of twelve participants indicated that they had not been given adequate information about their FP options.
The participants Τ1 (51-year-old transwoman in complete transition), Τ5 (28- what are the potential implications of their decisions as well as what they will be wanting many years later, due to the fact that they were minors or young adults. Transitioning transgender adolescents may not feel ready to make such an important, lifelong decision at their age. However, they are forced to consider whether to preserve their sperm or eggs. The participant T6, a 27-year-old transman in incomplete transition, stated that he was not provided with fertility counseling before starting gender transition because, in the healthcare context, he came across as being uninterested in having children. Re ecting on his experience, he said, "They did not talk about this; it was not their priority for any reason... in the health system.. .They knew that this matter did not concern me…" 2. Fears of discrimination, bullying, and harassment as barriers to transgender parenthood a) Discrimination, bullying, and harassment during pregnancy Participants expressed fears of discrimination ranging from subtle forms (such as social disapproval) to physical violence.
The fact that the phrase 'transgender parent' gives other people a bad impression was reported as discouraging to transgender people with regard to considering FP and assisted reproduction options. Participant Τ9, a 29-yearold transman in complete transition, said, "... it sounds bad... when you say 'trans-parent', they immediately think, as soon as they hear it, that it is very strange..." The participant T3, a 23-year-old transwoman in late transition, stated, "Imagine a trans-man pregnant walking in the town square... to start with, it is dangerous for the person themselves, for their physical integrity…" The participant T12, a 52-year-old transwoman in incomplete transition, believed that a transgender parent may be at high risk of being bullied by other people as long as she remains visible as a transgender person. However, the participant expressed fears of another form of bullying that may occur among transgender parents even though a transgender parent remains invisible as a transgender person. This form of bullying (forced removal or separation of children from their parents) comes from a transgender parent's family context or close relatives.
The participant stated, "Now, look! If you see a trans person in public who shows they are trans, if they go out with the child, they may be taunted, they may have to face many things, I believe. If it does not show, I believe they will not face any particular problem, unless there is a problem in their environment, their closer, family circle... the [family members] may set procedures in motion to take the child themselves or send it to an institution or something. All that matters is that the child should not be with the trans individual, which is the worst thing for them..."

b) Bullying by health providers in birth settings
A transman who goes into hospital or a midwifery unit to give birth may commonly be the subject of bullying by health professionals. The participant T2, a 60-year-old transman in complete transition, bisexual, expressed his fears: "The only problem is society, when you go to a maternity clinic with a beard... You will have to be able to go for pre-natal birthing classes; you need to receive treatment in an atmosphere of understanding at the hospital, not to be abused." In the same vein, the participant T3, a 23-year-old transwoman in late transition, said: "... and how would they be treated during delivery? Does such a person, in other words, have to be rich and go to a private clinic and pay so they are treated with dignity? This does not mean that there are not people in the public health system who do not treat you with dignity [she relates her experience]." Unfortunately, health professionals are reported to be the originators of bullying behavior not only within reproductive healthcare contexts, but also within other healthcare contexts. Two participants described negative experiences with health providers that re ected de cits in their providers' willingness to offer appropriate healthcare to transgender patients. More speci cally, they described instances in which health professionals demonstrated subtle (verbal and 'low intense') bullying-related behavior or at least a lack of empathy for the issues faced. Note, however, that this view may result from mechanisms such as ex-post realization or the over-generalization of hard-wired perceptions due to low self-esteem (which, in turn, may be due to internalized anti-trans prejudice).
Further studies are needed to assess whether internalized anti-trans prejudice is associated with a weak desire for having biological children or an unwillingness to have children. In conclusion, the analysis of our ndings revealed that transgender people are most likely to have the same basic reproductive needs as cis-people. Some transgender individuals place great weight on the value of genetic relatedness.

Skipping fertility health care due to high costs
In this study, economic factors such as the cost of the FP procedure and the storage of gametes were reported as major barriers to transgender parenthood. More particularly, the participants T3 (a 23-year-old transwoman in late transition) and T7 (a 36-year-old transman in late transition) highlighted that the costs of long-term cryopreservation of sperm and oocytes (respectively) are so high that many transgender people skip fertility preservation, provided that these procedures of storage are not covered by health insurance (private or public). Furthermore, the costs of the mere assisted reproductive technology procedures were found to be high by the participant Τ5 (a 28-year-old transman in incomplete transition, pansexual). Moreover, the participant T8, a 50- year-old transwoman in social transition said that transgender people have to be rich ('bourgeois') to raise children! 6. Concerns related to the child's welfare as barriers to fertility preservation and assisted reproduction a) Transgender people fear that their children will be bullied The participant Τ3, a 23-year-old transwoman in late transition, highlighted the social prejudice and discrimination faced by children with transgender parents, and stated, "…In the local community [reference to the name of the person's village of origin], even an adopted child is at times pointed to and called a bastard." Interestingly, from the inductive analysis of the study ndings, fear of social prejudice did not emerge as the main barrier to transgender parenthood related to a child's welfare.
Surprisingly, the participant Τ1, a 51-year-old transwoman in complete transition, took a clear stance against same-sex parenthood while being in favor of transgender parenthood, and said: "…I don't think that we are ready, as a society, let's say... children are very cruel at such ages and say to another child: 'I have a daddy and a mummy and you don't; you have two daddies or two mummies'..." b) Concerns related to the role of the parent Several participants had positive perceptions regarding transgender parenthood.
The participant T10, a 38-year-old transman in incomplete transition, said: "Whatever love is given, eh,... by a straight couple, is the same as the love that can be given by a trans person; in essence, eh, love or one's conduct does not change because of one's gender identity." In the same vein, the participant Τ2, a 60-year-old transman in complete transition, bisexual, said: "…gender identity has nothing to do with wanting to have a child." In In conclusion, several of the aforementioned ndings in this section (6) of the paper suggest that some transgender people have very low expectations about what parents they could become. Moreover, it is worth noting that we identi ed several sub-themes grouped under the base theme 'concerns related to child's welfare'.
In our opinion, this re ects the assumption that transgender parenthood is a complex, complicated, and multidimensional issue.

Legal framework thought of as being less than perfect
The participant T1, a 51-year-old transwoman in complete transition, and the participant T3, a 23-year-old transwoman in late transition, focused on the fact that it is not possible under the current Greek legal framework for children birth certi cate to be changed to include transgender parent's revised name or legal gender. As a consequence, the current legal framework 'prevents' transgender parents from applying for legal change of their gender identity.

Discussion
Lack of adequate fertility counseling One of the problems often facing transgender people about fertility preservation or assisted reproduction is lack of information. Consistent with past literature, it was emerged from our study ndings that a signi cant barrier to pursue fertility preservation or/and assisted reproduction techniques was providers' not counseling about fertility preservation options. As is anticipated above one of the participants reported having received adequate FP counseling before starting their transition, while six out of twelve participants indicated that they had not been given adequate information about their FP options.
Participants T3, T7 and T9 expressed regret about missed opportunities for fertility preservation.
Over the last decade many authors have highlighted the need for the vulnerable population of transgender adolescents and young adults to be provided with fertility counseling prior to initiation of medical transition process [7,10,22]. Already in 2012, Wierckx et al. had remarked that transgender people's fertility issues were not adequately addressed [23]. This still applies in the present day. Chen et al. (2019) found shortcomings in fertility counseling and providers who highlighted the need for standardized counseling protocols [24]. Interestingly, their ndings indicated that transgender people may later regret not pursuing fertility preservation despite having previously received FP counseling. Fertility counseling should be highly prioritized as ethical, interdisciplinary practice [25,26]. Murphy (2012) argued that there is nothing objectionable that would justify closing off parenting options to transgender people [27]. The American Society for Reproductive Medicine (ASRM, 2015) stated that "transgender persons have the same interests as other persons in having children," and "providers should offer fertility preservation options to individuals before gender transition" [28]. The Ethics Committee of the American Society for Reproductive Medicine stated that transgender people's gender identity cannot be grounds for unequal treatment and that professional autonomy is not a su ciently strong countervailing reason to justify an exemption. Despite multiple papers being written about the need for this issue to be addressed, all of the participants in this study felt that fertility preservation had not been offered.
Transgender people should be provided with 'enough information, support and opportunity to make an informed decision about fertility preservation' and the discussion should include 'a consideration of interweaving factors, particularly costs…' [7]. 'Detailed information about every option in the absence of any form of coercion and with ample time is essential for a person to make complex, life-changing decisions'. [26]. The importance of genetic relatedness is said it might be used as a 'heuristic through which to provide fertility counseling to transgender people' [29]. In the perspective of transgender people's fertility counseling it is highlighted health professionals communication with transgender people about desires related to reproduction [8]. Furthermore, transgender people should be informed that 'FP methods do not guarantee future access to medically assisted reproduction (due to the best evidence then available i.e. concerning the child's welfare) or successful reproduction' [10].
In addition, it should be highlighted that some children/pubertal children/adolescents/young adults may not yet be mature and competent enough to evaluate, on their own, whether to pursue fertility preservation [25]. Therefore, questions may arise regarding decision-making authority [10].

Desire to have biological children
Involuntary childlessness is associated with serious negative psychological effects: serious anxiety and stress, feelings of grief, social isolation, low self-esteem, and sexual dysfunction [30][31][32] Furthermore, in light of the holistic-positive concept of health involuntary childlessness can be regarded as unhealthy situation.
Reproductive desire was high among the majority of the participants in the present study. Prior studies suggest that reproductive desire is as high among transgender people as it is in the general population [23,28,33]. However, among transgender adolescents, utilization rates of fertility preservation and reproductive options are presently impressively low [9,34] though steadily rising [10,23]. In 2012 it was argued that 'research on transgender adults suggests that about half desire biological children…, and over a third would have considered FP had such technologies been available at the time of their transition' [23]. In our small sample this percentage was much greater. Lack of adequate FP counseling may partly explain these low rates [9].
Nevertheless, this topic seems to be much more complex. A U.S. study found that only two out of 72 transgender young people receiving fertility counseling prior to endocrine transition attempted fertility preservation [34], while a recent study with a Dutch cohort of transgirls found a much greater percentage attempting fertility preservation [35]. Persky et al. (2020) found that the majority of transgender youth were not willing to delay their hormonal transition for fertility preservation as they 'did not nd having biological offspring important' [36]. Chiniara et al. (2019) arguably hypothesized that fertility may be a low life-priority for young transgender people. 'The majority wish to become parents but are open to alternative strategies for building a family' [37]. However, under the rstorder desire to remain childless there may be the second-order desire to not delay gender transition Participants T1, T5 and T6 were of the opinion that delaying gender transition to facilitate fertility preservation could have negative impact on gender dysphoria and hence it could be distressing. Chen and Simons (2018) put it best in saying 'Transgender adolescents pursuing hormones may be at particularly high risk for prioritizing short-versus long-term outcomes, putting them in jeopardy for later experiencing regret' [6]. At any rate, Nahata et al., 2017 arguably stated that 'more research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood' [34].

Barriers related to dysphoria
Transgender adolescents face several obstacles that get in the way of fertility decision making [24,25] including invasiveness of procedures, individual experiences of gender dysphoria, and desire not to delay medical transition [24,38]. De Sutter et al. (2002) found that while the vast majority of respondents were of the belief that fertility preservation should be offered to transgender women, 90% of respondents were of the belief that loss of fertility was not a strong reason to delay their transition [33]. This is in consistency with the aforementioned statement of Chiniara et al. (2019) [37].
In consistency with past literature, we found that among transgender people there are unique barriers to fertility preservation related to gender dysphoria. This was a signi cant theme that emerged from our data analysis because of the fact that there was a large number of comments provided in this category. Importantly, fertility preservation methods 'might reinforce transgenders' old sex or make them feel it does not t with their new gender identity' [10]. Indeed, procedures required for obtaining fertility preservation (i.e. hormonal ovarian stimulation and transvaginal ultrasound that is a genitalia-speci c procedure) may be experienced by transmen as having a negative impact on their gender dysphoria [39]. These procedures may heighten feelings of dysphoria, thus challenging the break up with the transgender people's old gender identity.
However, this is not always the case. Some transgender people may use several coping strategies, 'such as focusing on the reasons for undergoing fertility preservation, reaching out to friends and family for support and the cognitive approaches of not hating their body or using non-gendered names for their body parts.' [39]. Note, however, that the negative psychological effects of FP for transgender individuals may be caused by several reasons. Armuand et al. (2020) found that health care professionals 'experienced important challenges to their professionalism when their preconceived opinions and values about gender and transgender were confronted' [40]. This may establish an unsafe environment for transgender people undergoing FP through various procedures, which may heighten their distress. Furthermore, the break up with the transgender people's old gender identity may be challenged by the fact that it cannot be ruled out that future child will be informed about its parent(s)' state of being transgender person [10]. At any rate, it is crucial to bear in mind that 'presently little is known about the psychological effects of fertility preservation for transsexuals' [10] and the number of the relative studies is still limited.
Barriers related to economic instability Four (T3,T5,T7,T8) out of 12 participants in the present study believed that economic factors are major barriers to transgender parenthood. This is not unreasonable. The costs of fertility preservation are signi cant barriers because these procedures are typically not covered by insurance companies [25] Transgender people are particularly vulnerable to economic instability due to the high unemployment rate related to the mere fact of being transgender.

Barriers related to discrimination and bullying
This was one of the frequent themes and encompassed the sub-themes bullying during pregnancy and bullying by health professionals in birth settings. Five (T1, T3, T7, T9, T12) out of the twelve participants in our study expressed intense fear of discrimination and bullying in case of transgender parenthood. Across the globe, transgender people are extremely vulnerable population to physical and sexual violence and experience epidemic levels of stigma, discrimination, harassment and social rejection in almost every aspect of their daily life, including access to health care services. In Europe the European Union Agency for Fundamental Rights (2014) reported that around 20% of all trans respondents who accessed healthcare services or social services reported that had experienced discrimination for the same reason [41]. In Australia, despite the fact that in 2013 the Sex Discrimination Act was amended transgender individuals still experience discrimination and barriers to access to health care services [42]. Much of the same holds for Asia [43] as well as for Latin America and the Caribbean [44].
Canadian interview study found that transgender men face considerable discrimination throughout their pregnancy [45]. Riggs (2013) has found that transgender men who go through a pregnancy negotiate complex intersections between their masculinity and child bearing with their pregnant bodies being regarded by health care providers as female [29]. Giannou (2017) stated that in Greece transgender people often experience discrimination by healthcare providers when accessing healthcare services, ranging from disrespect or transphobic insults to outright denial of service [14]. This can be seen as a public health issue. It was emerged from our inductive analysis of study ndings that stigma against pregnant transmen can be enacted in hospitals or midwifery units where pregnant transman have to go into to give birth. Importantly, this prejudice was going 'underground' and was expressed in more subtle, indirect, ways. This is not surprising, given the truth of the assumption that anti-homosexual prejudice is no longer exercised in the traditional, 'old-fashioned' form (openly related to the adherence to 'naturalness'), but rather in the modern subtle, 'non-discriminative' form [46]. The ndings related to discrimination or bullying by health professionals call for efforts on the part of the health service system to provide equal access to fertility and reproductive health services for transgender people. For instance, Armuand et al. (2017) argue that health professionals may 'alleviate distress by using a gender neutral language and the preferred pronoun' [39].
Furthermore, transgender people's children are vulnerable to discrimination and bullying. Although best evidence currently available does not support inherent risks for the welfare of the child of a transgender person, there may be external risks for the welfare of the child based on social discrimination and stigma [10]. Having children is strongly related to the stereotype of heteronormativity.
Barriers related to parenting and child's welfare This was a frequently recurring theme in our interview data analysis. Among several participants in our study there were barriers to having children related to children's welfare. The reported barriers were of various types and can be t into the following three sub-themes: a) Barriers related to social environment (Prejudice against children) Although the best evidence currently available does not support the notion that there are inherent risks to the welfare of the child of a transgender person, there may be external risks to the welfare of the child based on social discrimination and stigma [10], as having children is strongly related to the stereotype of heteronormativity. b) Barriers related to transgender parents themselves (Transgender people feel incapable of being good parents or potentially harmful to their offspring) The majority of participants in our study felt incapable of meeting the standards of good enough parenting or they were perceiving themselves as potentially harmful to their children. From the analysis of their statements and their relative non-verbal behavior patterns we got a sense that they drew unfair conclusions about their parental capacity based on low self-esteem. Internalized transphobia may negatively impact on self-esteem [47] and hence, limit transgender people's (reproductive) autonomy [48]. This may be the real reason behind the unwillingness of transgender people to become parents. Transgender individuals' parental role is a complex According to the ndings of the present study, transgender individuals may have not only new but also old understandings of patterns related to parenthood, as biological relatedness and parenting gures. This nding is consistent with past literature related to issues of LGBT parenthood [50].

Transmen: Cryopreservation of oocytes
Transmen participants in our study touched upon some aspect of oocyte cryopreservation. It is of great importance that little is known about transgender men's experience of fertility preservation procedures such as cryopreservation of oocytes due to lack of previous empirical research on the particular topic [39]. Note, however, that transmen use contraception and can experience pregnancy, even after having socially, medically, or both transitioned [51]. Importantly, Insogna, Ginsburg and Srouji (2020) state that 'adolescent transgender males who choose to undergo oocyte cryopreservation tolerate the process well' [52].
Transwomen: Envisioning the perspective of uterus transplantation The participant T1 (transwoman) said that a uterus transplant at a younger age would make him/her feel 100% woman. Robertson (2017) argues that procreative liberty only supports a right to gestate when sought for genetic reproduction, and hence, the claim of a transgender woman desiring a uterus transplant for having the woman-speci c experience of gestation is not strong enough to undergird a positive right [53]. Notwithstanding, Alghrani (2018) argued that procreative liberty does extend to a right to gestate [54].

Rigorous psychological evaluation is required
A careful, in-depth psychological evaluation would contribute important information to the understanding of the operant reason behind a transgender individual's attitude towards fertility matters. The participant T9 in our study, a 29 year-old transman in complete transition, in the short time frame of an interview reported four reasons for his/her unwillingness to consider fertility preservation options or assisted reproduction techniques.
The participant gave ground for assuming that these reasons (mentioned elsewhere in this paper) were considered equally strong. For instance, the participant's attitude might result from mechanisms as ex-post realization or over-generalization of hard-wired perceptions.

Strengths and limitations
This research is signi cant in that to our knowledge it is the rst to directly examine the transgender people's attitudes towards the use of fertility preservation options or assisted reproduction techniques.
However, our study has two primary limitations: First, our ndings cannot readily be generalized to larger populations because of the small number of our participants. However, the ndings of this study might be applicable to other transgender people. Second, the participants in this study were re ecting on their past experiences, which, for some, occurred more than 10 years prior to being interviewed. Recall bias, may have distorted the recollections of their experiences of considering fertility preservation options or assisted reproduction techniques.

Implications for research and practice
The results emerged from our inductive analysis of study ndings may have implications for both research and clinical practice. These results might provide guidance for professionals handling of transgender people's applications for medically assisted reproduction and fertility preservation. At any rate, our ndings might heighten awareness and stimulate debates over ethical topics related to our research questions.
Already, some research hypotheses are formulated in this paper, as follows: The statement of the participant T4 (mentioned above in 3c, under the subheading 'Type of transition and desire to pursue FP and ART) gives us the opportunity to create the following hypothesis for further research. While transmen are not willing to get pregnant, this is probably not the case for those in social transition. Further, we hypothesize that those transgender individuals considering or going through social transition and hence, not placing considerable emphasis on the value of gender-related bodily features, are much more willing to pursue FP or ART than those considering or going through medical transition. In our opinion, this hypothesis is supported by the aforementioned participant T9 (a transman) who was unwilling to disclose the storage of his/her oocytes to his/her partner while being in complete medical transition. The truth of the above presented hypothesis that emphasizes the association between the type of transition and the willingness to get involved in creating a child remains to be tested.
The statement of the participant T12 (mentioned above in 4., under the heading 'Reasons behind the desire for biological parenthood' raises the question as to whether transgender people should be classi ed as a separate group of the LGBT community and whether the data related to transgender individuals should be analyzed separately. The statements of the participant T8 (mentioned above in 4., under the heading 'Reasons behind the desire for biological parenthood') allows us to formulate the following hypothesis for further research: Transgender individuals who are in social transition show a greater adherence to the dominant culture than those in medical transition, at least in the context of reproduction.
Finally, we stress the need for further empirical research into transgender men's experience of fertility preservation procedures such as cryopreservation of oocytes

Conclusion
The results demonstrate the importance of a) contextual factors (stigma, economic instability, law), b) factors related to transgender people themselves (gender dysphoria, desire to become parents, self-trust), as well as c) the preferred type of gender transition in considering or pursuing FP or ART. The results allow us for hypothesizing that transgender individuals in social transition are much more willing to pursue FP or ART (or get pregnant when it comes to transmen) than those in medical transition. Transgender people's attitude towards having children is a complex topic in need for further investigation. We stress the need for training health professionals to establish a safe environment for transgender people who want to undergo fertility treatments, go through pregnancy and give birth.
The ndings of this study call for efforts on the part of the fertility and reproductive health service system to support and provide equal access to fertility and reproduction-related services for transgender people. Addressing the barriers to transgender parenthood that are documented in this article will require policy initiatives and a social justice approach toward transgender individuals' health and human rights. Health providers can play a crucial role in this process. Therefore, the need is highlighted to establish standardized protocols and provide necessary training to physicians.

Declarations
Footnotes 1 The term 'transition' will be used to refer to all types of medical (endocrine or surgical) transition. The term 'social transition' is used to re ect the speci c type of gender transition. The participants in 'social transition' selected not to undergo medical treatment, believing that a change in gender role or behavior would be of itself, su cient. 2 In terms of 'complete' and 'incomplete' transition we mean participants perception of their transition completion. At the time of the interview, participants mentioned as being in 'incomplete transition' were reported to be on the road towards what they considered full transition.

Ethics approval and consent to participate
The study and consent procedure was approved by ethics committee a liated to Aristotle University of Thessaloniki, Faculty of Health Sciences, Department of Medicine (No: 2.128 / 27-02-2019).

Consent to publish
Not applicable.

Availability of data and materials
Transcripts of the full interviews collected and qualitatively analysed in the current study are not available due to the ease with which study participants could be identi ed. Redacted transcripts can be made available upon request.

Competing interests
The authors declare that they do not have any con icts of interest to disclose.

Funding
This study received no speci c grant from any funding agency in the public, commercial or not-for-pro t sectors.
Author's Contributions PV was responsible for the study conception, data analyses, ethical analysis of ndings, writing the paper and report of the study. C-EZ was responsible for the data collection. All authors were involved in the data analysis and revisions of the paper. All authors have read and approved the nal manuscript.