Transgender youth are increasingly able to access gender-affirming healthcare. Because gender-affirming care such as hormone therapy is clinically shown to reduce gender dysphoria and ease physical and social transition, every major U.S. medical association recognizes that gender-affirming healthcare is medically necessary for the treatment of dysphoria. However, an important dimension of gender-affirming care remains under-insured and overpriced: fertility preservation (FP). Several studies indicate that hormone therapies and certain gender-affirming surgeries can have negative, long-term impacts on future fertility. Although these impacts can be mitigated through approved FP methods such as sperm cryopreservation and oocyte cryopreservation, such methods are rarely affordable for those who need them.

These cost barriers largely exist because fertility care (including FP) remains excluded from most public and private insurance plans. Even though states have the regulatory authority to remedy this, only seventeen have taken steps to do so. This paper will demonstrate how the failure to provide coverage for fertility care forces young people into cruel dilemmas. Because gender-affirming care is, itself, expensive, paying additional out-of-pocket fees for FP is often not in the cards for many young people. Section I will delve into the landscape of FP coverage in the U.S. and the barriers that prevent people from accessing FP services. Section IV will then connect the lack of insurance coverage to a broader pattern of state efforts to withhold and eliminate child-bearing capacity, either directly or indirectly, from marginalized communities. Finally, Section III will offer legal and policy recommendations that could disrupt this history of reproductive oppression, and secure greater access to bodily autonomy for trans youth.