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Trans and nonbinary parents push birth industry to rethink care

on December 15, 2019

Eli Wise told his mom the news on Christmas morning, sitting beside the tree. He was pregnant.

“Sorry?” his mom asked, still holding a present. “I’m very confused but very happy.”

Wise told her it was okay to be confused. “There’s this general perception that having a child equals female,” said Wise, who is a transgender man. “So I think both my parents were like, ‘Is this possible?’”

Five years ago, most doctors would’ve said no. Until recently, a dearth of medical research on fertility options for trans men led to a prevailing belief that taking any dose of testosterone would negate the possibility of pregnancy. Wise had been taking low-dose, weekly shots of the hormone since 2006.

But only three months after stopping testosterone, Wise became pregnant. He conceived his daughter Kestral with his partner, Stephen, the way most heterosexual couples do—sperm fertilizing an egg.

Wise is among a growing network of trans and nonbinary parents gradually pushing the birth industry to be more gender inclusive about who can carry a baby—from a shift in the language of hospital intake forms to the naming of body parts to how and where babies are delivered.

Wise always knew he wanted to be a parent, ideally to a child who was biologically his. And when he fell in love with Stephen it actually seemed possible. (Stephen is cisgender, which means his gender identity matches his gender assigned at birth.)

“Then I was like, ‘Maybe we should adopt,’” Wise said. The idea of actually growing a baby inside of him just seemed too risky. For years, he kept it between him and his therapist.

What scared Wise the most was that, in order to regain ovarian function, he would have to stop taking testosterone. For nearly 16 years, he’d lived in a body that aligned with the gender identity he considers fundamental to his being. His chest was flat from top surgery, a double mastectomy. He’d grown a light beard. His voice had a low nasal tone to it. “Biology aside, I consider myself a male human. Nothing mixed about it,” Wise said.  

He feared stopping his hormone shots would throw it all into jeopardy. But Wise decided to go for it. “I just really wanted to feel a small life,” Wise said. Under supervision of his OB-GYN at Kaiser, he experimented with taking a few weeks off his testosterone shots at a time. Two months later, he was visiting his father for the holidays and found himself sneaking out to the drugstore to buy a pregnancy test. “I had a moment I never had in high school,” Wise said. He called Stephen. They were elated.

But if conceiving had been relatively easy, now Wise had different challenges. First were the mood swings. Testosterone had made him feel even. Without it, his emotions were all over the place. His menstrual cycle returned—something he acknowledged can be unpleasant for any female-identifying person. “But if you’re not comfortable in a female gender, all of that just feels like a reinforcement of who you aren’t,” he said.

*****

For Dr. Sara Reid, a reproductive endocrinologist and infertility specialist at the Reproductive Science Center in Foster City, figuring out how and when to transition her transmasculine patients off testosterone is one of the biggest challenges.

In Reid’s practice, the majority of these patients are in relationships with female partners and want to contribute to the pregnancy by providing their eggs, rather than carrying the child themself. But some are trans men like Wise, who want to carry the pregnancy. When it comes to fertility treatments, the risks and processes for them are largely the same as they are for Reid’s other patients. As long as someone has a functioning uterus and ovaries, they can carry a child. The biggest question is how to handle the hormone adjustment, to allow for conception but to avoid changes that are too abrupt and may cause problems for the patients.

Reid said stopping testosterone can make her transmasculine patients feel uncomfortable in their own skin. They can lose facial and body hair. Their voices become softer and higher in pitch. Muscle mass can decrease, and places where the body holds fat may start to soften. “And those changes can be really distressing,” she said.

Eli Wise holds his daughter in his living room. Photo by Katie Bernstein.

“For our transmasculine patients, one of the first things we have to think about is what’s been the hormone environment and for how long,” Reid said. “Fortunately, now a lot of people are taking these medications prescribed by an endocrinologist or an internal medicine physician who is prescribing and monitoring. A lot of people were buying stuff from questionable sources before.”

So she tries to minimize the time her patients are off testosterone. For her clients who are retrieving their eggs but not carrying, she has been experimenting with medications that lower their estrogen levels to lessen the withdrawal effects.

There are still large gaps in the research about the long term effects of testosterone on fertility. “Until recently, we haven’t had much research on fertility or pregnancy outcomes for trans men who have taken testosterone” said Reid. The limited data on the subject primarily dealt with cis men who had used testosterone supplements, concluding that supplemental testosterone often reduces sperm count, sometimes irreversibly.

The first major study to debunk the idea that testosterone causes infertility in trans men was published in 2014 by Alexis Light and Juno Obedin-Mavelier in Obstetrics and Gynecology. In a group of 41 transgender men who became pregnant after transitioning, 25 had previously taken testosterone, and five of them actually conceived while on the hormone. “This is very reassuring,” Reid said, “that fertility remains an option for many trans men whether or not they have taken testosterone.”

In addition to guiding her patients off and on testosterone, Reid has been taking steps to make her office feel more welcoming. She edited the language on her website and intake forms, which she says can be “super heteronormative and binary.” Questions about periods and sperm counts often assume that a female patient will arrive with a male partner, both of whom identify with the sex they were assigned at birth. “It’s challenging enough for trans patients to come out for help in this regard. But if you do so and then the paperwork doesn’t match you or doesn’t fit your story, that’s just another barrier,” she said.

Reid’s forms have gone through many iterations. Five years ago, an industry-wide shift was to change the categories from “husband and wife” or “boyfriend and girlfriend” to “patient and partner.” These days, Reid is trying to assume less and be more open. She’s done away with binary gender checkboxes and asks broader questions. Who are you? What’s your story? Is there a partner involved and what’s their story? What sex organs do you have?

Reid credits these changes to Trystan Reese, an Oregonian trans man and public advocate for all things related to building trans families. He travels around the country leading workshops for healthcare practitioners on what he calls “cultural competency.” As a baseline, he pushes providers, especially those in private practices without institutional barriers, to use inclusive language on their websites and learn how to use they/them pronouns fluently. “If not, you’re probably not someone that is going to be safe for me to go to,” Reese said.

He also provides special training for doulas and midwives. “Much of the industry is really rooted in the idea that giving birth and creating a life is a sacred act that belongs to women,” Reese said. He said this can sometimes lead to an unhealthy emphasis on what is perceived to be natural, such as breastfeeding, which isn’t always an option for trans men who’ve had top surgery.

In 2016, Reese conceived his son Leo with his cisgender male partner, Biff. While pregnant, he volunteered to share his story with the parenting podcast The Longest, Shortest Time. Weeks later, he was launched into the spotlight, approached by reporters from Cosmopolitan, The Washington Post, CNN, NBC.com, and Vice News.

Reese felt obligated to tell his story responsibly, in a way that would help dispel common myths about trans pregnancy and reduce backlash. “There’s an idea out there that all LGBTQ people—trans people specifically—are trying to become parents as some kind of political statement or experiment,” Reese said. “Or that we don’t have parents who love and support us.” Whenever he does an interview or speaking event, Reese emphasizes how seriously he takes parenting and how close he is to his own parents.

Online, Reese serves as a fact-checker. He moderates his own private Facebook group for aspiring transmasculine parents, weeding out a wide amount of misinformation that troubles him, and directing people towards a massive Google Drive folder of scientific articles he’s annotated for clarity. Just because your primary care tells you one thing doesn’t mean it’s true, Reese often tells his followers. 

Through his joint Instagram with his partner, @BiffAndI, he serves as a personal confidant for his 35,600 followers. “Basically every spare minute I have, I’m answering questions on [trans fertility] through Instagram direct messages,” he said. Every day, he finds himself telling young trans men that taking testosterone won’t prevent them from having babies in the future.

Reese said he wants to see a more diverse representation of pregnancy in the media— to have as many trans parents in the public eye as there are now gay couples with children. “Whether that’s through adoption or surrogacy or biological children or blended families, nontraditional family structures, I want to imagine all the possible futures for ourselves,” he said.

*****

On a wide suburban street in Sacramento, Jessie Ewing and their partner Rachel, live in a single-level, mid-century house with their son Lenny, a rowdy 2-year old with a persistent runny nose. Ewing’s mother, a retired delivery nurse, rakes leaves into a compost heap. 

“It’s funny,” said Ewing, who uses they/them pronouns and identifies as nonbinary. “I think a lot of people would expect Rachel to carry the baby.” Ewing feels like they exist somewhere between male and female, though they present more masculine.

Jessie, Lenny, and Rachel Ewing in their backyard in Sacramento. Photo by Katie Bernstein

But from an early age, Ewing dreamed of being a parent. They wanted 10 kids. Having been adopted, they had no known biological relatives. “For me was a big thing of like, ‘What does it really mean to have somebody who’s related to you by blood?” said Ewing.

Pregnancy meant navigating medical spaces Ewing had repeatedly felt uncomfortable in. First was the supposedly “queer friendly” Bay Area clinic that provided the donor sperm for fertilization. Though their name preference—Jessie over Jessica—was noted on their forms, only their OB-GYN at Kaiser respected it. “Nobody really checks what your pronouns are,” Ewing said, “or what you call different parts of your body or how comfortable you are with people touching your body.”

And once Ewing conceived and their body started changing, misgendering happened more frequently. “Everyone saw me as this divine feminine, which was just not me,” Ewing said. They hated having to wear tighter shirts and maternity pants that rode up to their belly button, and how their chest grew two sizes. “No matter how hard I try to strap it down, everyone still assumes I’m a she,” Ewing said. “I don’t want to be called ‘sir,’ but I also don’t want to be called ‘ma’am.’”

So Ewing was relieved to find a doula and midwife, both of whom knew how to use a nonbinary person’s pronouns fluently and always asked before touching Ewing’s body. They started referring to lactation as “chest feeding,” a way to acknowledge that it’s not something that can only be done by people who identify as female. “I’d never heard that before. It felt like such a huge shift,” Ewing said.

“It’s like, if medicine were safe, like that’s kind of what [a midwife] is,” Ewing continued. “And then my doula was more about creating the birth experience.”

Ewing decided on a homebirth. They didn’t feel like hospitals could ever feel like a safe space. “There’s so much history behind people of color’s pain being diminished,” said Ewing, who is Black. “And then you add on top of it being masculine, being queer, being in an interracial relationship.”

At the time, they were living in the unincorporated community of Canyon, which borders Oakland on the east side of Redwood Regional Park. So Ewing gave birth to Lenny at home, laboring outside in a birthing tub under a tent beneath the tall trees, their doula supporting them with massages and cold towels on the forehead. The doula reminded them to breathe, to try a new position, to relax their jaw.

The midwife worked in tandem with Ewing’s mom, monitoring the baby’s heart rate and their energy level. The only people there were the ones Ewing invited in. Labor waxed and waned for hours, with no interruptions by medical staff, bright lights or shift changes.

“I really got to have my own experience and a hospital birth would not have been that at all,” Ewing said. “I got to be at home for it. I got to be surrounded by my people.”

Though pregnancy was difficult —the misgendering, the unwanted public touching—they are hoping to get pregnant again before the year ends. Ewing underwent an insemination in early December, and if all goes well, they’ll be welcoming a new baby next fall.

“I think the second time around, I feel much more confident that I’m going to be able to deal with the gender and body stuff so much better,” they said. “So many people have no idea what it’s like to have to face all the stigma that goes with that. There’s so much that you have to experience to go through this. Nonbinary and trans folks who are pregnant, I’m just like, you’re incredible.”

*****

Judah Joslyn’s walls are filled with encouragement. On the bathroom mirror, he’s written in white marker: “You are enough.” And: “breathe.” Above the kitchen table, next to a large trans flag, he affixed a decal of a black family tree, each branch leading to a different photo from the same shoot. In the photos, he’s wearing a bowtie, smiling wide with his two kids.

Joslyn realized he was trans nearly a year ago, only two months after his second child was born. Growing up in Sacramento in the 1990s, he had no exposure to trans men. He thought if you were transgender, you were a trans woman. “It just hit me like a ton of bricks,” he said. “All of a sudden you see who you are and the world just kind of opens up and becomes possible.”

Judah Joslyn came out as trans a year ago soon after his second child was born. Photo by Katie Bernstein.

He started making changes immediately. “Once you identify who you are, it changes everything,” he said. “You can’t put the genie back in the bottle.” 

He started asking people at his work, a family resource center in South Sacramento, to use he/him pronouns, which confused people because at the time, because he was also nursing his newborn. He wanted to wear a binder but it hurt too much. “Here I am, trying to establish to the world I am a man and having to go to work and pumping every couple of hours,” he said.

He asked his 7-year-old daughter, Mykha, to start calling him dad, rather than mom. “It was terrifying,” Joslyn said, “navigating her traditional, anti-gay Catholic school.” His family was already fractured—he was in the middle of getting a divorce with his second husband.

“It just took being slow and deliberate,” he said. He started exposing his daughter to drag culture through YouTube videos. They watched makeup tutorials of drag queens, practice putting full faces on each other. He read her the children’s book Neither, about a creature that’s not quite a bird and not quite a bunny.

In September, Joslyn emceed the first annual Trans Family Day the LGBTQ center in Sacramento. They had a bounce house and art corner where the kids could draw portraits of their queer families. “It was really good for my daughter to see me in a place of power,” he said.

But still, it was isolating. So Joslyn created a Facebook group, FTM Dads, to create a sense of community. And it worked. There are now 330 members. “Most of the posts are cute pictures of their kids,” he said. But it’s also a space to talk about real issues. Like last June, when he was about to start testosterone, he wrote: “I have no idea how to talk to [my daughter] about this? Do I even talk to her about it? Or do I just let it all happen and answer questions if and when she has them?” One member offered gently that Joslyn’s daughter was probably not struggling as much with the transition as much as with the sheer amount of change. And that she’d recommend letting her call him mom for a little while.

He hopes his transition can be a good lesson for his kids. He says he’s just trying to be proud of who he is. “No, I’m her dad. Like, this is this is our family,” he said. “No, we’re not perverted. We’re normal, just like everybody else.”

*****

For Eli Wise, pregnancy was hard. “I felt cheerful, but I also felt miserable. Not for gender reasons, just because I was basically sick for like seven months,” he said.

Wise decided to tell only his close friends that he was pregnant. He could hide it by wearing baggy clothes and clipping extenders to his pants. “I think I always pretty much just looked like I had a bit of a beer belly,” he said. 

“I think the benefit of being a somewhat private transgender man who’s pregnant is nobody knows—nobody’s going to come up to you and try to touch you,” Wise said. “But the downside is also: Nobody knows.” Like the time when he felt nauseous in the grocery store line but didn’t think he could ask to cut to the front, or the time when he was on an airplane and hurt himself lifting his suitcase into the overhead bin. “And then I just started crying. It was like, I hurt. I should have asked for help. But I couldn’t ask,” he said.

Like Jessie Ewing, for delivery Eli chose a midwife to assist with the birth and help support him and the baby postpartum. “I think having that consistency of care is really important, because otherwise you don’t know who’s going to be delivering your baby and you don’t know who’s going to be your primary support person,” Wise said.

He chose Marea Goodman, a midwife who supports women, queer and trans patients through pre-natal care, homebirths, and after the baby is born. Goodman says in the 10 years she’s been a birthworker, she’s seen a big uptick in LGBTQ people having babies in the Bay Area. Nearly all of her clients this year have been queer or trans. “There’s a lot more resources now than there were even just a year and a half ago,” she said.

For Goodman, every birth is a unique experience. She thinks hospitals tend to rely on a singular idea of what birth should look like, which is often medicated and on a tight schedule. “What’s great about homebirth, especially for queer and trans people, is just that individualization,” she said. “I’m interested in the personal care aspect, in helping people feel safe and seen and comfortable,” she said. 

Goodman, who is queer herself, also took a training with Trystan Reese. “It’s not perfect,” she said. “The word midwife means ‘with women,’ you know, and not all my clients identify as women.

Wise gave birth to Kestral in September. The birth was arduous and slow. He and Stephen named the baby after the smallest bird in the hawk family, who can hover in one place for prolonged periods of time. “That whole thing, it’s wild,” said Wise. “The actual moment of birth, where suddenly there is a child in your arms. Because you know that there’s a child living inside you, but it still seems kind of imaginary. It’s just amazing.”

Today, Kestral is three months old and napping. As she sleeps, her feet twitch and tap the air in her red-footed pajamas. Wise folds her laundry.

When the baby wakes up, she starts to cry and Wise darts off to fetch her a bottle of donated breast milk. He lifts her from the crib and gently cradles her to his body as she nurses from the bottle, her eyes half-closed, gurgling gratefully. As she drinks, her small chubby finger grabs hold of his hand.

It’s an unseasonably warm fall day, so Wise takes Kestral and his guitar outside onto the back porch. He sets her down in a bungee seat, bouncing her with his foot as he sings a song he wrote when he was still pregnant.

“I’ve transformed myself, in this life.
From girl to man, to man carrying life.
There’s no discrepancy,
there is pure beauty.”

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