Myths About Testosterone and Fertility, Told Through Three Perspectives

Title- Testosterone and Fertility. Images of three faces, labeled, “Me, hoping to be pregnant soon,” “Kayden X Coleman, Black trans advocate was pregnant and birthed his two daughters,” “Roman Ruddick, started the Transgender Cancer Patient Project. Never wanted to be pregnant.” What do we know? What were we told? What do we still need? Testosterone impacts many body systems including our reproductive system. Testosterone can pause menstruation and ovulation (it’s not birth control though!) But there is lots of misinformation, questions, and harm being done. Image of a person with ovaries and a uterus drawn on.

I’ve heard so many different things about testosterone and fertility. From the news… and from my doctors. Image of a spiral with me overwhelmed at the center. Around me are faces saying, “You’ll be infertile,” “Your ovaries atrophy,” “You’ll be able to get pregnant when you’re ready,” “You should freeze eggs,” and “We don’t have enough data.” Quotations from the news say, “Because testosterone can reduce fertility in trans men over time… - NBC News 2019.” and “We don’t yet know much about the complex hormonal relationships going on within the bodies of AFAB people on testosterone - Clue, period tracker app.”

Titled Roman’s Story. The story begins when I was diagnosed with ovarian cancer. I said, “I would like a full hysterectomy. My periods are painful, I don’t want kids, and I’m afraid of cancer returning.” The doctor said, “No. We’re going to do a fertility sparing surgery. You may change your mind about kids.” 3 years later I said, “I’m trans and would like to start testosterone.” A different doctor said, “You’ll need to sign this to say you understand you’re likely giving up your chance to have biological children. And you might want to get a hysterectomy to get it all out.” What had felt like doctors coercing me to have children turned on a dime to them convincing me that I would be better off having anything related to reproduction removed. Images are of Roman conversing with two different doctors.

Roman’s Story continued. I was told I was giving up something because of my transness with no consideration for my disinterest in having children. 4 months after starting testosterone I said, “I need a hysterectomy because of endometriosis related pain.” A different doctor said, “It will be easier to justify to your insurance as medically necessary if we say it’s because you’re trans.” Because I was trans I had to do almost no convincing to get it approved by my gynecologist, endocrinologist, oncologist, and insurance company. I experienced extreme contrasting reactions to the topic of fertility related to ovarian cancer and being trans. I wish doctors would let go of their transphobia to consider how all people (including cis people) have fluctuating hormones. We all have different wants and needs and those should be treated on an individual basis. Images of Roman talking to a doctor.

Titled: So what do we actually know about testosterone and fertility? Lots of people who have taken testosterone have become pregnant and birthed babies. There is no evidence testosterone impacts fertility long term. Image of me and Kayden Coleman. I say, “I didn’t have a period for 4 years and got it back a month after stopping testosterone.” Kayden says, “I got pregnant just a few weeks after stopping testosterone. I never even menstruated.” This leaves me with more questions. What science/research does exist? Where are most doctors getting information?

Titled: Kayden’s Story. Image of Kayden holding his daughter. He says, “I found out I was pregnant five and a half months in. I’ve been offered more abortions than I’ve been offered information about fertility. There’s a history of trying to keep trans people from having kids.”

I am talking with Dr Resetkova. I say, “If the research suggests testosterone just pauses things, why do so many doctors think it makes us infertile?” Dr Resetkova says, “Since testosterone can stop ovulation, they may be extrapolating. But other hormonal things that can affect ovulation, like PCOS and birth control, have been shown they don’t cause permanent infertility. If someone stops testosterone and can’t get pregnant that may be due to ovarian aging or other factors. There’s no evidence it’s the testosterone. But we don’t know yet.” I say, “So where do doctors get information about trans health?” and point to The World Professional Association for Transgender Health (WPATH)

From WPATH’s Standards of Care, “Many transgender, transsexual, and gender nonconforming people will want to have children. Because… masculinizing hormone therapy limits fertility (Darney, 2008, Zhang, Gu, Wang, Cui, & Bremner, 1999), it is desirable for patients to make decisions concerning fertility before starting hormone therapy.” Pointing to both the articles that are cited, I say, “Both of these articles are about temporary hormonal birth control for cisgender people! One article is about estrogen and progestin birth control pills for cis women and the other is about testosterone limiting sperm in cis men. Hormones do impact fertility, that’s how hormonal birth control works. But it’s misleading. Reading this, a doctor or anyone else might think there is evidence of long term impacts of testosterone on fertility. There isn’t!”

Title: My Story. Testosterone is a life saving medication for me. But sometimes I avoid my shot. Why? A pie chart that is mostly black and a tiny sliver white. The black part is labelled, “Testosterone fertility anxiety” and the white part labeled, “ow!” From my first appointment I’ve been encouraged to freeze my eggs. For many, egg freezing is dysphoric (You have to stop testosterone and be very aware of your ovaries, I don’t experience this kind of dysphoria but lots of people do!) and expensive ( $10,000-$50,000 I have never had insurance that would cover it). If testosterone doesn’t har fertility, then I have no reason to freeze my eggs. Please don’t just focus on freezing eggs, research the long term effects of testosterone.

I am saying, “I wish there were a clear study that showed if long term testosterone use had any impact on fertility. In the mean time, the false assumption that T causes permanent infertility is harming our community.” Images of different people saying, “No one believes I’m pregnant.” “I get misgendered at all my appointments,” “I didn’t know I needed to use birth control,” “Everything I need as a pregnant person is designed only for pregnant women.” Listening to stories of people in our trans community is crucial to understanding the complexities of this issue and what we need.

Titled: Our Community Also Has Solutions. Image of people from the previous page all smiling together. We are healthcare workers, researchers, designers, educators… and we all have wisdom from our experiences. Articles! Data! Stories! Advice! Resources! Expertise! Answers! Support! Community! Check out the Facebook group ‘Birthing and Breast or Chestfeeding Trans People and Allies.’ This is one of many resources!

Titled: Kayden’s Story. Kayden says, “Here’s one example of what I experienced when I was pregnant this year. My doctor had called the clinic to tell them I was coming and that my pronouns are he/him…” Image of Kayden at a reception desk holding a piece of paper. Kayden says, “I have an appointment at two.” The receptionist says, “Where’s you’re wife?” Kayden says, “I’m here for an appointment at two. The receptionist says, “For a blood test?” Kayden says, “No… I’m here for an appointment at two.” The receptionist says, “This clinic is only for women.”

Kayden’s story continued. Image of Kayden holding his daughter. He says, “I started testosterone over 10 years ago. I was told there’s a high chance you’re infertile and the chance you’re pregnant is next to none. So I found out I was pregnant five and a half months in. I’ve been offered more abortions than I’ve been offered information about fertility. There’s a history of trying to keep trans people from having kids.”

Doctors suggesting unnecessary hysterectomies and telling trans people we’re infertile is one way of stopping trans people from having kids. But also, fourteen U.S. states still require trans people to be sterilized in order to change our gender on our license and/or birth certificate. Map of US with the states WI, MI, WY, NE, MO, KY, NC, GA, AL, AR, LA, OK, AZ, and TX filled in. In TX, individual judges can decide the requirements for gender changes. There may be even more, because some states are unclear about requirements to change gender on identification. In 2017 the European court of Human Rights struck down required sterilization for trans people. Some trans Germans who were sterilized are currently fighting for reparations.

Titled: So, What do we need? Access to information! Understanding how racism and transphobia intersect (and then taking action!) Image of Kayden Coleman saying, “A Black trans man’s experience differs tremendously from that of a white trans man.” Education! Take Kayden’s workshop on trans fertility and read Roman’s work with the Transgender Cancer Patient Project. Get rid of forced sterilization policies! Change the laws! Universal health care. More trans doctors! Research & Studies to provide trans people with information. Change Language! Pregnant Women to Pregnant People. Breastfeeding Mothers to Chestfeeding or Lactating People. No more Women’s Health or Feminine Hygiene. Listen to Trans People! Add Your own needs regarding trans fertility!

Sources: Interviews with Kayden X Coleman, Roman Ruddic, and Nina Resetkova. Conversations with JB Brown and Miles Harris. Thank you. WPATH Standards of Care 2011 “A Mouse Model to Investigate the Impact of Testosterone Therapy on Reproduction in Transgender Men” Human Reproduction 2019 “Assisted Reproductive Technology Outcomes in Female-to-Male Transgender Patients Compared with Cisgender Patients: A New Frontier in Reproductive Medicine” Fertility and Sterility 2019 “Proper Care of Transgender and Gender Diverse Persons In The Setting of Proposed Discrimination: A Policy Perspective” The Journal of Clinical Endocrinology & Metabolism 2020 “Evidence for Preserved Ovarian Reserve in Transgender Men Receiving Testosterone Therapy: Anti-Mullerian Hormone Serum Levels Decrease Modestly After One Year of Treatment” Journal of the Endocrine Society 2019 “Reproducing Eugenics, Reproducing While Trans: The State Sterilization of Trans People” Journal of GLBT Family Studies 2018 “Transgender Men Who Experienced Pregnancy After Female-To-Male Gender Transitioning” Obstetrics & Gynecology 2014 “Transgender Men and Pregnancy” Obstetric Medicine 2016 “Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers” 2005 National Center For Transgender Equality ID Documents Center “Transgender Men, Eager to Have Biological Kids, Are Freezing Their Eggs” NBC News 2019 “Informed Consent for Testosterone Therapy” Fenway Health

Correction: The map indicating states that require sterilizing surgeries vary depending on whether an individual is obtaining a gender change on a driver’s license or a birth certificate.

For driver’s licenses, eight states require proof of surgery (but not necessarily sterilizing surgeries), court order, or an amended birth certificate: Texas, Oklahoma, Louisiana, Georgia, South Carolina, Kentucky, Tennessee, South Carolina, and Iowa.

For birth certificates, fourteen states require a sterilizing surgery in order to change the gender marker: Arizona, Montana, North Dakota, Nebraska, Iowa, Wisconsin, Missouri, Arkansas, Louisiana, Alabama, Georgia, North Carolina, Kentucky, and New Hampshire.

You can learn more about identification documents requirements from the Movement Advancement Project.

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Will Betke-Brunswick is a trans and nonbinary cartoonist. They make diary comics, informational comics, and funny comics. Their graphic memoir is coming out in 2022!

Will has written 2 articles for us.

13 Comments

  1. I love your work. This was so accessible and informative!

    Can you do one for trans women and fertility? :) I would be happy to chat about my experience if it’s helpful.

    I had to donate sperm this year, bc I am prepping for bottom surgery. It was weird. Luckily, as of 2021, my insurance (Kaiser) covers it! But I am pretty sure that’s not the norm.

  2. This is so good! Also way more informative and thorough than the scientific research we read through. We gave up on the idea of reciprocal IVF in part due to a doctor’s outright dismissal of the idea of using my testosterone-taking partner’s eggs. Even though we knew better, it’s exhausting fighting the medical system constantly

  3. This was so informative! It would also be interesting to hear about people’s experiences of going through this single vs partnered.

    Also, can I just say, after having done IVF for 3+ years, and knowing a lot of people who’ve gone through it, I have never heard of anyone getting 14 eggs from a cycle, let alone 18! Geez. Although I have read lots of times that 12-15 is a normal amount.

  4. Great resource, it should be put on the wall at health centers/community centers. It really seems like cis doctors are just making assumptions based on how they *feel* about how testosterone should work.

  5. I loved this illustration style. I asked doctors about sterilisation for 15 years now, and it’s only now I’m transitioning that anyone is taking me seriously. It really pisses me off.

  6. FYI – my surgeon referred to my top surgery as “an irreversible FTM gender reassignment surgery” in her letter and I was able to change the sex marker on both my driver’s license and my birth certificate in North Carolina with no problems. It doesn’t solve the problem of requiring *a* surgery, but I figure it’s worth asking your surgeon for similar phrasing if you live in a state listed as requiring sterilization.

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