When Jay Thomas, 33, decided he wanted to get pregnant in 2016, he spoke to his physician.
Thomas, a cook who lives in Louisville, Kentucky, explained to his doctor that he and his wife, Jamie Brewster, 33, a bank employee, are both transgender, and that he had been on testosterone for more than two years. The physician said Thomas had likely gone through early menopause, and that if they were able to conceive at all, he would have to go off the hormone for at least 18 months.
But none of that turned out to be true, according to Thomas, who gave birth to the couple’s son Dorian, 2, less than a year after that doctor’s appointment.
“We got pregnant in three months,” Thomas said.
One of the most persistent myths transgender men and nonbinary people hear from doctors is that testosterone has sterilized them, experts say. While testosterone generally blocks ovulation, trans men can get pregnant while taking it, particularly if they are not taking it regularly.
It’s just one example of the misinformation and discouragement transgender men say they face from the medical establishment when they decide to get pregnant — a problem advocates and experts blame on a lack of training and research around transgender health care, as well as doctors’ biases.
There is no data on how many transgender men and nonbinary people give birth in the United States each year, because medical systems track them as female, but experts believe the numbers are likely higher than many would expect. The number of people who identify as transgender is growing: A 2016 study from the Williams Institute found that 1.4 million adults in the U.S identify as transgender, which was double the estimate based on data from a decade earlier.
In Australia, where government agencies began tracking both sex and gender in official records in 2013, 54 transgender men gave birth in 2014, according to statistics from the country’s universal health care system. And a Dutch study published in the journal Human Reproduction in 2011 found that a majority of trans men reported wanting families.
But doctors, nurses and medical office staff are still adjusting to the idea that those who are pregnant may not identify as women. Transgender and nonbinary people describe gaps in medical professionals’ understanding ranging from an ultrasound technician calling them by the wrong name to doctors who tell them hormone therapy probably ruined their fertility. The consequences can be dire. A recently published case study described a transgender man who went to an emergency room with severe abdominal pain — but doctors were slow to realize that he was pregnant and in danger. The man delivered a stillborn baby several hours later.
The issue extends to all types of medical care for transgender and nonbinary people, not only to prenatal care, said Dr. Alex Keuroghlian, director of the National LGBT Health Education Center at Fenway Health, which educates health care organizations on how to care for lesbian, gay, bisexual, transgender and queer people.
A 2017 report by the Center for American Progress, a liberal policy institute, found that 29 percent of trans people reported that a medical provider had refused to see them because of their sexual orientation or gender identity in the previous year, and 21 percent of trans respondents said a provider had used harsh or abusive language when they sought medical care.
“It’s not a standard part of medical education, it’s not a standard part of nursing education, or training of mental health clinicians,” Keuroghlian, who is a psychiatrist at Massachusetts General Hospital, said of health care for transgender and nonbinary people. “So many health care professionals are playing catch-up after the fact and learning how to accommodate the range of experiences that gender minority people have in health care.”
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That lack of awareness can cause trans people to avoid doctors. According to a 2016 report in the journal Medical Care, about 30 percent of trans people reported delaying or not seeking care due to discrimination.
“It really is a matter of life and death for transgender and nonbinary people to be seen, valued, and supported by their medical providers,” said Trystan Reese, who is the director of family formation for the Family Equality Council, a national nonprofit that advocates for LGBTQ families, “whether in a fertility setting or going in for a broken arm or diabetes or any other health issue they might have.”
‘The whole process is difficult’
The need for trans people to constantly explain themselves to doctors and other medical staff can be draining.
Ethan Clift, 36, and his wife Allison Clift-Jennings, 41, who are both transgender, decided in 2017 that they wanted biological children. Clift, a lobbyist, also wanted to begin taking testosterone as part of his transition. Because testosterone blocks ovulation, the couple, who live in Reno, Nevada, decided to freeze their embryos before Clift transitioned.
Clift said doctors and nurses at the fertility clinic in Reno where he had his eggs harvested were well intentioned but struggled to get his pronouns right. He tried to correct them, he said, but it became too exhausting, so he gave up.
“The whole process is difficult — it really is tailored for women, essentially, in the language and everything about it,” Clift said.
Keuroghlian said this is a common experience of transgender men in medical settings.
“There’s a tremendous amount of stigma related to having a gender minority identity, and most people weren’t raised to have an awareness of gender diversity, including an awareness of the fact that people of many genders need OB-GYN services and may experience pregnancy and have children,” Keuroghlian said.
Whether the mistreatment is intentional or not, Keuroghlian said trans and nonbinary people who are made to feel uncomfortable usually don’t return and are more likely to avoid doctors in the future.
Some choose to give birth outside of hospitals instead.
According to a small 2014 study published by the American College of Obstetricians and Gynecologists, 22 percent of trans and nonbinary people said they chose to give birth at home with the assistance of a midwife or doula. Overall, just 1.36 percent of births in the U.S. were outside of hospitals in 2012, according to the Centers for Disease Control and Prevention.
Jasper Moon, a midwife in Portland, Oregon, who is nonbinary and uses “they” and “them” pronouns, is four months pregnant and plans to give birth at home with the assistance of midwives. “They know me really well, I know them really well, I trust them, and everything goes appropriately because I don’t have random newcomers like I would at a hospital birth,” Moon said.
Many trans and nonbinary people also look online for information about getting pregnant and giving birth.
A private Facebook group for trans men, which contains more than 200 members, serves as a network for those looking for advice on how to plan families.
Clift said he and his wife use Reddit and Instagram to find and share information with other trans and nonbinary people who are going through transition or pregnancy. On Instagram, Clift said there aren’t many trans men who are pregnant, but he can find them through hashtags and ask them questions in the comments.
“There’s very little knowledge, and there’s often an opening for misinformation."
“I feel like transgender health is a form of biohacking because there aren’t a ton of studies out there — legitimate studies — and there aren’t a ton of doctors that really know it inside and out,” Clift said.
While it’s good that people are informing themselves and each other, Dr. Juno Obedin-Maliver, a gynecologist and an assistant professor at Stanford University School of Medicine, said some of her trans and nonbinary patients have misconceptions based on what they’ve read online.
For example, some trans men think they need to undergo hysterectomies because they have read that testosterone will cause uterine cancer, but there is no rigorous research supporting that, said Obedin-Maliver, who co-authored the Pride Study, the first nationwide report on the physical, mental and social health of LGBTQ people.
“There’s very little knowledge, and there’s often an opening for misinformation,” Obedin-Maliver said. “The answer to that is rigorous comprehensive data that fills in those answers and comprehensive medical education for clinicians so that we can meet what is a real need for people to take care of themselves.”
More health care centers are getting trained
Since 2011, the National LGBT Health Education Center has trained more than 1,000 health care organizations on how to care for LGBTQ patients.
Dr. Rupal Yu, a family physician for Piedmont Health Services, which implemented training in all 12 of its North Carolina centers, recalled a young trans man who came to her for care prior to the training. She said she was surprised at how little she understood about trans patients, both socially and medically.
Yu’s center in Carrboro, North Carolina, made several changes starting in 2014, including developing gender-inclusive patient intake forms and documenting patients’ gender identity and sex assigned at birth in both physical and electronic records. Staff were trained on how to ask and consistently use a patient’s preferred name and gender from “the front door until they exit,” she added.
“I have more experience now simply being comfortable with talking to and taking care of non-cisgender people, getting comfortable with the idea that a man can have a vagina or a woman can have a penis, that the identity was in the brain, and not our biological parts.”
Keuroghlian, of the National LGBT Health Education Center, suggested that hospitals change the name of their maternity wards to “labor and delivery,” so everyone feels welcome.
But providers who strive to be more inclusive can face criticism from non-transgender clients, including on social media, said Maya Scott-Chung, program director for SprOUT Family, a nonprofit that supports LGBTQ people through the family building process. She said some clinics create separate marketing materials for their LGBTQ clientele.
Scott-Chung has worked with clinics that “have done that to avoid the pushback from more conservative, heterosexual clients,” she said.
‘You can be a man and have a baby’
Pregnant trans men and nonbinary people also fight battles within their own bodies.
Thomas said pregnancy reignited his dysphoria, the sense of disconnect transgender people experience between their bodies and their gender identity. The surgeon who had done his mastectomy neglected to remove all of the glands in his chest, he said, which caused some of the tissue to return as the pregnancy progressed.
“A lot of things had changed for those few months and it was rough — it was really hard,” Thomas said.
After giving birth, Thomas experienced postpartum depression, but he began to feel better over time after going back on testosterone.
Reese — a transgender man who gave birth to a son in 2017 in Portland, Oregon, and who has provided guidance for hundreds of trans men who have given birth around the world — said it’s common for them to experience dysphoria and postpartum depression. He said it’s another area where research is needed.
“All we have is anecdotal evidence,” Reese said, “and anecdotally, it does seem as though transgender and nonbinary people are more susceptible to things like postpartum anxiety and postpartum depression.”
But he believes it’s a good thing that more trans men and nonbinary people are beginning to see that pregnancy is a possibility for them, whether they want to experience it or view it simply as a means to an end.
“You can be a man and have a baby,” Reese said, “and they are starting to see that that is possible and that hasn’t always been the case.”
Thomas said nothing about having a child — even his dysphoria — changed how he saw himself as a man.
“I think that’s the definition of a father — you give up everything for your child,” Thomas said.