How Transmasc Parents Navigate Testosterone After Pregnancy
9:56 AM EDT on August 18, 2023
Histories Of Transition is a series spotlighting the experiences of trans people as they've worked to exist within structures that don't want them to.
The first time I went on testosterone, in 2016, I’d waffled for years, only filling a prescription after about a decade of thinking it was probably right for me. The second time, in March 2023, I was re-initiating T after over two years off to conceive and birth my daughter, who was born in November 2022.
I had been on hormones about five years when I stopped my shots because I was thinking about conceiving a baby (my second gestational kid; I birthed my son Samson in 2013, before medical transition). Plainly, testosterone had been a boon for me. I liked my body and the way my mind worked better on hormones. But, ultimately, my family wanted one more child, and for a variety of reasons, I opted to carry her.
My plan: Spend a few months off testosterone to make sure I could “make it” emotionally without it, get pregnant, have the baby, and go back on hormones.
The problem is that guidance and reasoning for how to do this is scant. For around 10 years, I’ve been in a Facebook group for birthing and nursing trans people and their allies, mostly folks working in the birth and lactation worlds. The group has over 7,600 members and has inspired a number of offshoots, which I’m also a part of, for increasingly narrow subsets of trans birthing people.
Here’s some of what I’ve observed in years of waxing and waning participation in this group: Testosterone suppresses fertility while you take it (hence the lack of menstrual cycle most folks on testosterone experience), but many trans people can get pregnant after taking it; it usually takes a few months for an observable, “normal,” ovulation pattern to commence; and plenty of trans guys and nonbinary people who’ve taken testosterone get pregnant after months or years or even over a decade on T, though, just like with cis women, some need fertility treatment.
The few research studies concerning transmasculine fertility, birthing, and breastfeeding are enthusiastically passed around—this 2014 study of healthcare experiences of 41 trans men who had given birth, or this small 2017 qualitative study of 10 trans men’s experiences gestating children. Reading these studies, which were published in the long interval between my pregnancies, gave me hope for the healthcare I might get during a second time around.
When I switched my prenatal care to one of Philadelphia’s trans midwives midway through my pregnancy, it wasn’t because I was getting hostile or transphobic care. The vibes were just off at my first few visits with another provider, and I figured that, given its availability, I ought to invest in care with a trans provider that would be, in ways I could not quite conceptualize until I was in its arms, better.
And it was. My midwife didn’t behave like someone who was interacting with a trans person after reading about how to do it in a manual or learning in an online seminar. They talked to me in a calm, matter-of-fact voice, laid their hands on me to take my blood pressure and measure my fundus in a way that made my body feel what it was to me—something to be cared for, not defensively coddled. In their office, and in my home when I birthed my daughter, I was what I want to be in any medicalized setting: deserving and regular.
In one of those visits, my midwife asked what my plans were for going back on testosterone. The question, so simple, set me back. They listened as I stumbled through the early phases of planning what would be the ultimate form of postpartum self-care. This conversation planted the seed in me that I should steer the decision to go back on hormones, that it was mine to control.
After my second birth, I was depressed and anxious. I felt like I was watching my daughter develop through a blurred lens. When, one night in the dark, facing another night of breastfeeding and doomspiraling, I asked my partner if she thought I should try medication for my behavioral health, she wanly came back at me with, Yes. Testosterone.
So I did. My baby was two months old when I messaged my primary care physician to tell her I was thinking of weaning around six months. I nursed my first for way longer, I wrote, but really miss being on hormones so starting in late April/early May seems like a good compromise. She messaged back quickly, letting me know that in her opinion breastfeeding on testosterone was safe. Testosterone can get into your milk, she wrote, but based on the (somewhat limited) data we have, it is unlikely that it gets absorbed by the baby in any significant amount.
A case study from 2021 backs up this advice. The participant went back on testosterone at 13 months postpartum and bloodwork showed that, when his testosterone reached therapeutic levels, it was detected in his milk, but was not in his infant’s blood serum monitoring. This is because testosterone doesn’t have great oral bioavailability (the NIH’s database of medications and breastfeeding agrees). This study mirrors evidence that some Facebook group members have been sharing for years about monitoring they underwent while nursing on T.
With this guidance in hand, I re-initiated T when my daughter was five months old. I started right back on the dose and delivery method that had worked well for me before, and overall it’s been great. I am still exclusively breastfeeding four months later, with no change to my milk supply, which has always been robust.
I was interested in seeing if other postpartum trans people’s experiences mirrored or differed from mine, so I connected with a number of transmasculine birthing parents. Although I know firsthand how incredible it is to start hormones for the first time, I was specifically interested in how people with prior knowledge about HRT and their bodies–what doses and delivery methods work for them, how the medication makes them feel–navigated going back on testosterone. Most of the people I spoke to responded to a post I made in the Facebook group I mentioned above, and the ones who responded to my Instagram story asking to talk revealed to me that they were also in the group.
Each of the five people I spoke with at length had become a gestational parent intentionally, ceasing hormone therapy before trying to conceive (in addition to suppressing one’s cycle, testosterone is teratogenic, which means it may cause fetal harm). They had been on testosterone for periods between 18 months and 10 years before going off hormones to try to conceive a child. The length of time they waited to re-initiate hormones varied greatly, as well, from one month after birth to eight years after birth.
Like the transmasculine people included in some of the research on pregnancy experiences, the people I spoke with described difficulty finding providers who had clear guidance to offer. Some described overt harm and erasure, while others’ experiences fell more in the realm of personal anxiety and doubt about where to seek care and support.
Sauce, whose child is four-and-a-half years old, was on testosterone for about a decade before conceiving. Sauce got information about conceiving a baby when, at what was formerly the Trans Health Conference, he attended a midwife’s workshop on trans fertility. He ended up hiring them as his midwife.
When asked about whether he talked to his providers about going off testosterone to conceive, Sauce said, “I really just consulted [my midwife], I didn’t really consult anybody else, because there was so little out there. I felt like all of my questions were answered by, ‘Well, there haven’t been any trials, nobody really knows, everybody’s making it up as they go along.’”
Sauce’s goal was to get back on T as soon as possible, because he found going off to be difficult. He went back on testosterone somewhere in the four-to-six week postpartum range. For him, going back on hormones was “great, with no bumps in the road. It was kind of as if I was never off.”
Like me, Sauce relied on a queer midwife for guidance. Sauce’s midwife emphasized that, just like he would notice cues his body was ready to start trying to conceive, his body would also give him cues to resume hormone therapy. Sauce noted that his years on hormones have included interactions with doctors who “do things in a ridiculously cautious manner,” and that trans people should be prepared to make their own decisions about hormones.
“I feel like a lot of people are just trained to need to have permission from somebody,” he said. “You don’t need permission to do any of this. You just do what feels right to you, and it’s probably the right thing.”
Noah, who gave birth in March 2020, resumed testosterone therapy when his child was six months old. For Noah, who went on testosterone eight years before conceiving, a body that had been altered by testosterone was key for him to feel ready to gestate.
When it came to going back on testosterone, in the postpartum period, Noah struggled with “discriminatory viewpoints that all the people around me had taken in about it.” Noah expressed difficult feelings about resuming hormone therapy. “I felt a lot of grief that I had waited that long,” he says, “and that I had robbed myself of feeling like myself needlessly.” And finally, after he was back on T, “I felt relief.”
Noah described an evolving relationship with his primary care physician, who works in an LGBT clinic. As he has read more about trans healthcare over the years, his relationship with his doctor has become more collaborative.
“The question for the providers is: Do they know what they don’t know? Just getting that acknowledged shifts power and is closer to the truth.”
Although Noah stressed that living in a major metro area gives him access to a wider variety of providers than others might have, there is still a clear takeaway: “Even if your doctor says no, our community knowledge, again and again, is that the medical establishment has not caught up with our reality. Period.”
Niko, who has a four-year-old and is currently pregnant, described resuming hormone therapy after birth as “a real relief” which “helped me get back into who I was.” Niko took testosterone for about 18 months before their first pregnancy and resumed testosterone at about 18 months postpartum. “My brain is just better on the right hormones for me,” Niko said, “so going back on testosterone was really, really important for my mental health.”
The step-by-step of getting back on T after giving birth was fraught. The early pandemic made visiting doctors and pharmacies difficult, and Niko also felt hesitancy about approaching their primary care physician to resume testosterone. “I had been seeing [my doctor] for years, and she’s treated a million trans patients,” Niko said. “I just had this feeling she wasn’t going to be amenable to me still nursing and going back on T, so my midwife prescribed it because I was just too nervous to consult with my doctor.” Niko felt comfortable with less monitoring through their midwife because they had experience taking testosterone. Niko continues to nurse their baby while on hormones.
After their current pregnancy, Niko hopes to resume therapy “as soon as four or five months. And I plan to nurse longer than that … But I’ll have to find a provider who is willing to work with me, and I have no plans on how to do that.” Navigating fertility care and finding a midwife comfortable with a home birth after cesarean has taken Niko’s energy away from their plans to get back on testosterone, where they worry that “this stuff is so niche” that it will be hard to find a doctor they feel comfortable seeing.
Stephen, whose daughter is nine years old, was on testosterone for about a decade before going off to conceive. He stayed off testosterone longer term after birth, both because he was thinking about having another child and because he wasn’t sure long-term testosterone therapy was right for him after carrying a child: “My body’s been through a lot … Maybe now that I’ve seen I can go through a pregnancy and I still can keep my beard and my voice isn’t going to change, maybe that’s good enough.”
But over time, with the help of a therapist, Stephen decided that “maybe progesterone and estrogen are not right for my body or my brain chemistry, and that, for whatever reason, testosterone is what works for me.” He started hormones eight years postpartum. He has been satisfied with the results: “I can feel the comfort come back. I have more energy.”
Stephen was surprised at how simple the process was for resuming therapy compared to when he had initially started 18 years prior. “I didn’t need a letter. It was a very different experience than when I originally went on.” He recalled his early experiences, in which he and a small group of local trans friends struggled to find family doctors who would accept them as patients. Stephen said that this time, “It really was like: You want testosterone? You seem to know what you’re doing. You’re a 40-year-old man.”
Like me, Stephen has been involved in online communities for trans birthing people for years. Although he didn’t express regret at his own timeline or journey, he did note that hormones play a key role in mitigating postpartum depression and anxiety. “I think about some of the guys who are in our pregnancy group,” he said. “The ones who went back on T sooner seem to have had a better experience.”
My conversation with Aakash stressed the importance of trans healthcare that is cognizant and mindful of the diversity of experiences pregnant and postpartum people face. Before birthing his living child in December, Aakash had a stillbirth. This loss, as well as the fact that Aakash is a trans person of color, shaped his difficulties accessing adequate, trans-competent care.
Aakash was on hormones for about a decade before going off to get pregnant. Because he was pregnant twice, he was off hormones for two-and-a-half years before resuming therapy when his living child was five months old. One of the reasons for resuming hormones was that he is “still struggling,” and that as a trans person of color who has experienced significant grief and loss, finding mental health support and healthcare has been difficult.
“It’s been really challenging to find support to meet me where I’m at,” Aakash said. “The hope was for maybe some leveling out. I’d lost so much of myself and maybe there was some peace, some foothold, in T, that I might be able to access.”
They expressed frustration that trans healthcare providers have a narrow definition of trans healthcare that does not include visibility or awareness of the needs of trans people who are pregnant and postpartum. They knew there was a lack of clear evidence that would provide a specific time for going back on T, and their attempt to decide for themself when to do so was hurt by their inability to find a sounding board who could have an informed conversation about it. Although they found significant support from their midwife, she was not an expert in trans healthcare and not the provider who would be prescribing testosterone.
Aakash has some ambivalence about starting T again. “My pregnancies were not what I planned or expected,” he said. “I experienced so much loss through both of them.” Resuming hormone therapy is the end of a period of his life that has been marked by resoluteness in the face of erasure: “I carried our children. I birthed our children. Who I am is fundamentally changed in ways I don’t even know I can fully articulate … I felt like I fought and fought my way through to have a living child.” When he went back on testosterone, “The symbolism of it was a little like closing that chapter, and that felt really hard.”
The issues in postpartum trans care reflect wider issues in postpartum care. While the American College of Obstetricians and Gynecologists (ACOG) released recommendations in 2016 for more comprehensive postpartum care, few people I know personally have more than a six-week check-up. Pregnancy is marked, for many of us, by a stark increase in our contact with the medical field, especially in the biweekly and then weekly third trimester visits. But the actual act of giving birth is followed by a sharp drop-off in care.
It seems vital to theorize a better way. Imagine trans birth care that was coordinated with or even integrated into primary care practices, in which midwives and OB/GYNs could collaborate with the nurse practitioners and physicians most likely to prescribe hormone therapy. Even though I had already given birth when I began testosterone initially in 2015, none of the four primary care providers who prescribed my testosterone asked me robust questions about my plans for birth control, gave me information about what pregnancy would look like after hormone therapy, or talked about what I would likely experience physically or emotionally if I chose to suspend, and then resume, my therapy. I have relied, instead, on informal networks of information and support. The knowledge there is robust in its own way, with men and other trans people sharing their experiences of accessing hormone therapy after pregnancy and during breast/chestfeeding. But it’s past time to formalize that knowledge with research that can be shared widely with any healthcare practitioners who will care for us at all points on our reproductive journeys.
Krys Malcolm Belc is the author of The Natural Mother of the Child: A Memoir of Nonbinary Parenthood (Counterpoint) and the flash nonfiction chapbook In Transit (The Cupboard Pamphlet). He is the memoir editor of Split Lip Magazine. Krys is the current Edelstein-Keller Writer-in-Residence at the University of Minnesota and lives in St. Paul with his partner and their four young children.