If a man can become pregnant, is he still a man?

Thomas Beatie became famous when his first pregnancy became a medical emergency—and “the pregnant man” became the talk of his small, conservative Oregon town. Thomas later made his family’s story public, when he wrote about his experiences and appeared with his wife, Nancy, and their children on talk shows. On Oprah’s talk show Beatie said, “I feel it’s not a male or female desire to want to have a child, it’s a human desire. I’m a person and I have the right to have my own biological child,” a sentiment many people, trans or not, can relate to. But an Arizona judge is claiming that Thomas is actually a woman because of these pregnancies. Now Beatie’s fighting for the right to exercise his reproductive rights, and still be legally recognized as a man.

It wasn’t so long ago that trans people and the health care providers who served them believed trans people had to trade reproductive health for psychological health. The authors of a new guide specifically for transmen’s health care providers write, “Some transgender patients (and their physicians) have historically felt that sterility is the ‘price to pay’ for transition. However, it is important for providers to inform patients that transsexualism is not mutually exclusive with retaining reproductive potential,” information that may come as news even to some in the transgender community.

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Yet Beatie, famous for being the first pregnant trans man, wasn’t the first, or the last, transgender man to choose to become pregnant after transition. When Andy Inkster sought medical help to conceive from a Massachusetts infertility clinic in 2009, he was turned down—by a provider with a stated non-discrimination policy toward transgender patients. Inkster’s case, which has not yet been settled, could have far reaching implications, forcing health care providers to educate themselves on the needs of this small, stigmatized community.

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Trans men and women on the cusp of transition from one gender to the other face dramatically different decision trees regarding their future reproductive lives. While trans women contemplating hormone therapy can have sperm frozen for future use, making future genetic offspring possible, if potentially costly, trans men about to begin testosterone—and who want to preserve their chances of someday becoming a biological parent—must undergo expensive, time consuming, and risky procedures. The least invasive option, egg harvesting, requires weeks of self-injected hormones to induce ovulation, and sedation for the retrieval process; of the others, at least one, ovarian tissue banking, is experimental. The most successful technique, embryo freezing, requires choosing not only to have a baby in the future, but with whose sperm: a decision few who are just beginning to transition are ready to make.

Belgian infertility specialist Paul De Sutter wrote in 2001, “transsexual people should be offered the same options as any person that risks losing their germ cells because of treatment for a malignant disease.”

Yet it “may be possible to stop hormones long enough for natal hormones to recover” and restore fertility, according to a medical guide published by Lyon-Martin Women’s Health Services in San Francisco. Anecdotally, those most successful at becoming pregnant after transition take testosterone for as short a period as is effective in developing a masculine appearance—a few months or a year or two will work—then stop hormone treatment and wait—and pray—for menstruation to resume. Ovulation is most likely to recur, upon cessation of hormone therapy, if the trans man is young and fertile before he starts testosterone, and stops relatively quickly. No studies have yet been undertaken to determine the fertility window; nonetheless, it remains a popular strategy among trans men who want to become parents.

Belgian infertility specialist Paul De Sutter wrote in 2001, “transsexual people should be offered the same options as any person that risks losing their germ cells because of treatment for a malignant disease.” This approach to trans patients’ reproductive health is reflected in the current World Professional Association for Transgender Health (WPATH) standards of care for trans people, now in their seventh version, which state that “Transsexual, transgender, and gender-nonconforming people should not be refused reproductive options for any reason.”

The WPATH confirms that transgender men can evidently—though not always—take the risk that a few months, or years, of testosterone therapy will not permanently damage fertility. This is how Andy Inkster planned to become pregnant. When he wasn’t able to conceive after months of attempts, he sought infertility treatment from Baystate Reproductive Medicine, “one of the few clinics in the country with an anti-discrimination policy for gender identity,” according to The New York Times. “And yet, it refused to treat him, arguing that it didn’t have enough expertise to treat transgender patients.”

“From instances of humiliation and degradation to outright refusals to provide care, many institutions—consciously or not—have made it very difficult for transgender people to receive respectful, knowledgeable treatment,” says Lambda Legal, in their guide to creating Transgender Affirming Hospital Policies. Ironically, biases in how trans people are presumed to organize their lives and priorities mean that while needle exchanges and condom usage are often covered by transgender health guides, reproductive health for transgender patients includes only contraception and disease prevention, not fertility tracking or prenatal care. Lambda Legal’s hospital guide on providing trans-aware care doesn’t mention trans fertility; neither do the National Coalition for Transgender Advocacy, the American Medical Student Association, and the Vanderbilt School of Medicine Program for LGBTI Health guides to transgender health concerns.

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Thomas’ marriage was as a man to Nancy, a woman. Because Thomas has since had children, a judge has ruled that Thomas is no longer a man, and therefore his marriage is invalid.

According to court documents, Andy Inkster was denied infertility treatment after failing to comply with a request that his current therapist confirm Andy was “emotionally ready to handle pregnancy and parenting. Mr. Inkster argued that nontransgender patients weren’t asked to do the same.” Beatie writes in Labor of Love: The Story of One Man’s Extraordinary Pregnancy of being turned away by infertility clinics in 2006 and 2007 in Portland, Oregon. Like Inkster, Beatie was ultimately successful in conceiving: he gave birth to his first child in 2008, and his second and third children were born in 2009 and 2010.

Nancy and Thomas Beatie have filed for divorce in Arizona, where Thomas now lives with their three children. However, the divorce has not yet been granted, on the grounds that the courts do not have jurisdiction, saying that Thomas must be a woman, because he stopped taking testosterone and gave birth. Beatie says the courts have set a new precedent by refusing to recognize Thomas’ legal gender, despite all documentation to the contrary. Beatie’s appeal could go to the Supreme Court, setting federal precedent on the Constitutional right to exercise reproductive freedom, regardless of gender identity.

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The facts about transgender bodies, and what constitutes “sex change surgery,” are as clouded by mythology within the trans community as without, with both sides being invested in the notion of a singular transgender narrative, in which trans people leap the divide between genders quickly and cleanly. By always telling this version of trans people’s lives, the idea is reinforced that there are only two biological and social genders, and that they are distinct and easily discernible. The reality is that it takes time and technology to change bodies from female to male or male to female, that thousands of people live part or all of their lives somewhere in between the two extremes of the gender spectrum, and that surgical procedures to create new genitalia are far from perfection. In 2014, we can make good looking body parts (NOTE: this link is NSFW) that sometimes function well and retain sensation. We cannot make working ovaries out of testicles, or vice versa. No trans woman has yet borne a child with a transplanted uterus, nor a trans man ever become a biological father through the wonders of medicine. With current technology, our reproductive choices remain limited to those possible in our natal sex, no matter our gender, appearance, or documented sex.

For many reasons, cost and function both being high on the list, the great majority of transgender people never have genital surgery. According to one source, “only one in five MtF (male to female) and one in twenty FtM (female to male) people will complete full sexual reassignment.” This language, with its presumptions of completion, however uncommon it remains, is how most medical publications continue to describe genital surgery in transgender people. Some states in the US require “sex change surgery” for legal gender reassignment, but are not specific about what that is. Hysterectomy (removal of the uterus), oophorectomy (removal of ovaries), vaginectomy (removal of the vaginal opening), and phalloplasty (creation of a penis) are all separate procedures, and no one of them requires any other to be performed—the ovaries can be removed while leaving the uterus; a penis and testes can even be constructed from the clitoris—already enlarged by testosterone—and labia, while the vaginal opening is unchanged. Recently, Thomas underwent genital surgery with Dr. Marci Bowers, a procedure they discuss on a documentary program, “The Doctors.” Beatie could still have more children, should he choose, and he says that if his fiancee, Amber, is unable to conceive, he would consider stepping up again for his family.

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Rules like “real men don’t get pregnant” seek to prioritize deeply subjective, private desires.

There is no universal agreement on what makes someone legally male or female. Medically speaking, transgenderism is diagnosed by the presence of gender dsyphoria, a psychiatric condition; treatment includes social, hormonal, and/or surgical transition to the opposite sex. The social aspect of transition can include everything from a change of wardrobe to the change of legal documentation of one’s gender. Whether a jurisdiction requires sterilization or “sex change surgery” to legally change the gender on a birth certificate varies. Thomas Beatie was born in Hawaii, which since 1993 has not specifically required sterilization to complete a legal “sex change operation.” According to filed briefs, Beatie underwent all required procedures and legally changed his sex before marrying Nancy in Hawaii in 2003. Thomas’ marriage was as a man to Nancy, a woman. Because Thomas has since had children, a judge has ruled that Thomas is no longer a man, and therefore his marriage is invalid in Arizona, which does not recognize same-sex marriages. For this reason, the court will not adjudicate their divorce, leaving Thomas and Nancy in a legal limbo.

It’s not only activist judges in Arizona who think real men don’t have babies. In Edwards’ NYT op-ed Jamison Green, a leader of the transmasculine community, describes an ongoing debate among trans men, one that reopens every time a Beatie or an Inkster hits the headlines, whether the reproductive parts we were born with should be used at all. Every one of us must live with a body that is less than ideal, but for trans people it’s categorically wrong—a kind of wrong that causes deep pain at the juncture of body and soul. Yet one trans person can still say to another, “How could you say that anything is worse than this?” These questions boil down to, “How could you cope with what I feel is unbearable?” or “How could you make a different choice than I did?” To come out as transgender is to feel a pain that, very often, no one around you has felt. Rules like “real men don’t get pregnant” seek to prioritize deeply subjective, private desires in an Oppression Olympics that nobody wins.

Thomas Beatie is a tae kwon do instructor, a former model and competitive bodybuilder: the kind of athlete who always knows his weight and body fat percentage, as well as his most recent bench press, and for whom body modification is a professional requirement. He was keenly aware of the changes pregnancy wrought on his body. Yet being pregnant, he told interviewers, did not adversely affect his self image as a man. “It was like putting on a pink shirt,” he says of his five years off testosterone to have children. “Wouldn’t any man do this for his wife, if he were able?” What does not come on and off so easily are Beatie’s identity, physical appearance, and social status as a man. Being pregnant did not change Thomas’ identity as a man. He identifies himself as his children’s father, and Nancy is their mother.

But laws do not yet support the legal concept of a father who gives birth. When Thomas’ children were born, he could only be listed as the mother on their birth certificates. In order for Nancy to be listed as mother and Thomas as father, Beatie had to legally adopt his own children. When Andy Inkster gave birth in 2010, his daughter Elise became the first child born in Massachusetts with no legal father or mother, just one legal “parent.”

As men who fight for the right to bear children, the greatest legacy of Inkster and Beatie may leave is the challenge they represent to our ideas of manhood.

Based on the lack of attention paid to fertility in transgender advocacy, it would seem that the transgender community agrees with Sarah Elizabeth Richards’ view that “All these paths toward creating transgender families deserve careful study. Yet these issues aren’t likely to get the attention they deserve until transgender people succeed in getting basic health care first.” Violence, including domestic abuse, hate crimes, suicide, and murder, particularly victimizing trans women, remain the most pressing health concerns of the trans community, along with substance abuse, poverty, and depression. But this characterization of the trans community belies its diversity.

Beyond the realm of infertility treatments, the transgender community has multiple challenges in its pursuit of equal health care for all. The National Coalition for Transgender Advocacy has identified more than a dozen needed changes in American policy and law. One is the recognition of trans people as a population marked by health disparities, particularly regarding substance abuse and mental health. By counting our numbers and recording our challenges, we can replace medical decision-making based on the most visible trans myths with evidence-based medicine.

Another change to get behind is the rescinding of laws that permit health care providers to refuse treatment. This change would mean that no patient could be turned away by doctors made uncomfortable by difference. Of course, relieving trans people of the burdens of discrimination in housing, employment, public accommodations, and in all walks of life, including health care and insurance coverage, would go a long way toward providing trans people with the discrimination-free health care—and overall quality of life—that every human has the right to receive.

So would more support among trans people for one another’s rights, even to make nonconformist choices. Transgender health advocates should respond with positive concern for the Massachusetts Commission’s decision in Andy Inkster’s discrimination case, not fall prey to zero-sum or binary thinking regarding gender identity and health care. If Inkster hadn’t pursued the discrimination complaint, only he would know how Baystate Reproductive Medicine had failed to live up to its own stated objectives for services to transgender patients. Instead, Baystate, a large regional health care organization is forced to reconsider the biases with which they serve their patients, not only in reproductive health, but in all areas of care. The scope of impact is likely to extend much farther, as neighboring organizations follow suit.

As men who fight for the right to bear children, the greatest legacy of Inkster and Beatie may leave is the challenge they represent to our ideas of manhood. As medical science progresses, the day will surely come when a cisgender man is able to experience the miracle of pregnancy and childbirth. For some, this will be a miracle: the ability to have a child where before they could not. Will those men also be told that having a baby turns them into women? How we treat future pregnant men will depend, in some degree, on how we respond to the ones in the world today. Which one will people choose to believe in: the idea of a pregnant man, or the idea of a “Man Card”?

Read more:

Manning Up: Transsexual Men on Finding Family, Brotherhood, and Themselves [Book Review]

Trans 101: What is the Process to Change One’s Sex?

Behold the Pregnant Man

Photo credit: Simon Daniel Photography/Flickr