Choosing Sex: Trans Folks and Embryo Selection
“Do you want to know the gender of your baby?”
It’s a question that is dreaded by many trans people going through family-building processes. Most of us are uniquely attuned to the problematic nature of this question. We know that chromosomes (XX, XY, or any of the other variations that exist) don’t determine one’s internal knowing of gender. Neither does anatomy (or the medical definitions of “male” and “female,” in addition to the variations that exist here, too). So in this moment, when a provider asks us if we wish to know the “gender” of a potential future human, we are forced to make many decision, often in a split second.
Will we try to educate this professional on how their language could be more inclusive?
Do we want to know what chromosomes or visible sex organs our potential future baby might have?
If so, what information will that actually tell us?
Will our “trans cards” be pulled if we want to know? Are we missing out on something important if we don’t want to know?
…and so on.
This question is further complicated when we are being asked to make a decision not about whether to know the chromosomal or anatomical sex of a developing fetus but instead about an embryo—the tiny collection of cells created during IVF. If we have two or more available embryos to attempt implantation with, we have to make a decision about which to proceed with first.
Should the genetic “sex” of these embryos make a difference?
For many cis people going through IVF, it does. They have a vision of what a happy family might look like: one boy child and one girl child, or a family full of girls (or boys). They might want to “even things out” based on their current configuration or start off on a certain gendered foot. Regardless of our feelings about this, it’s simply true that lots of people going through IVF choose to know the chromosomal configuration of their embryos, and weigh that information heavily when choosing which to implant first.
But what about trans people? How do we feel when placed in that scenario? A recent study asked that exact question, and we spoke with one of the study’s co-authors, Madison Chilian, to learn more.
Madison and her co-authors interviewed trans, nonbinary, and gender diverse people directly to learn more about their thoughts on non-medical sex selection, and gathered some fascinating data on the topic. She is a genetic counselor and a member of the LGBTQ+ community, and has presented these findings at the National Society of Genetic Counselors conference.
About the Study
The research team interviewed thirteen trans, nonbinary, and gender diverse adults, most of whom had some personal or close experience with pregnancy or fertility treatment. What they found was not surprising: most of the interview subjects were uncomfortable with non-medical sex selection.
First, study subjects expressed concern that choosing an embryo based on chromosomes reinforces the cisnormative idea that sex chromosomes, anatomical configurations (aka “biological sex”), and gender are the same thing. When, in fact, having XX, XY, or something else doesn't always tell you what that person's body will look like, and it definitely doesn't tell you who that person will grow up to be.
Second, participants worried about what selecting for a sex actually signals about a parent's expectations. If you feel strongly enough about wanting "a girl" that you'd choose an embryo for it, what happens if that kid grows up and isn't the girl you pictured? Participants shared their worries about the rigidity behind this decision, and what that rigidity might mean for a future child who doesn't fit the mold.
However, study respondents felt differently depending on when the selection happened. Some said it made no real difference whether the choice was made among embryos in a lab or during pregnancy (for example, if someone is carrying twins and is medically advised to terminate one pregnancy because of health and safety reasons). Others felt more at ease with an embryo decision, since it's happening while the embryo is still in a petri dish. One participant felt more comfortable with a prenatal decision, reasoning that it affects one pregnancy, while an embryo decision could shape the fate of several embryos at once.
What was most fascinating to me is this: even the participants who felt genuinely uneasy about nonmedical sex selection still defended people's right to do it. Over and over, the research team heard some version of: I don't love this, but it's not my place to take that choice away from someone else. A couple of participants felt outright positive about the ability to make the decision at all, grounding their view in reproductive autonomy. That juxtaposition, personal discomfort sitting right next to a fierce belief in bodily autonomy, is very familiar territory for our community. We know exactly what happens when other people start legislating what someone can and can't do with their own fertility journey… we're usually first in line to lose that right.
Some caveats about the study: this was a small examination of 13 perspectives, and the group ended up mostly white and mostly nonbinary. Madison was candid with me about wanting more data, especially across race and culture, before anyone builds recommendations that assume these 13 trans experiences speak for all of them.
If you're facing this decision
The study participants who had faced this decision shared that many of them had no idea this would even be a choice they'd be asked to make until they were already in it! So be prepared: if you go through IVF and do pre-implantation genetic testing, there's a real chance someone is going to hand you the option to select for sex. And because not all providers have been through advanced trans inclusion training, sometimes they might offer you the choice as a binary: boy or girl.
Knowing this ahead of time will hopefully mean that you’ll get to decide how you feel about it on your own timeline, not theirs.
So, if you think this question will come up, talk it through with your partner or partners, or with other people you trust, well before your embryos come back with chromosomal results. If you're building your family solo, sit with these questions yourself first. Ask yourself honestly what you're hoping for and why, and what you'd do with those feelings if your future kid didn't match the picture in your head. You're also allowed to bring this up first, without waiting to be asked. If sex selection isn't something you want to consider, you can say so before anyone offers it to you.
A Note for Providers
If you're a genetic counselor, OB-GYN, embryologist, or anyone else in the fertility space, the participants in this study gave specific, useful recommendations for you.
Don't assume that patients or colleagues already understand that sex chromosomes, anatomy, and gender are three separate things. Say it plainly every time this topic comes up. Normalize the existence of intersex and transgender people as part of that conversation, rather than treating them as an edge case you'll address if it comes up.
When a patient raises nonmedical sex selection, ask open questions: why does this matter to you, what are you hoping for, how would you respond if your child doesn't meet that expectation. Use the same nondirective, values-centered counseling genetic counselors are already trained to do, just applied here too.
If this genuinely isn't your area of comfort or training, invest in your own learning while building a referral pathway to someone who can hold it well, such as a colleague, a genetic counselor, or a gender-inclusive mental health counselor.
This study is one of the first real data points we have on how trans people actually feel about this, instead of guessing on their behalf. That's what moves a field forward: trans people telling the truth about their own experiences. We definitely need more of this!!!
