Illustration by Eleanor Doughty

For Trans Men, Reproductive Health Is Yet Another Obstacle to Overcome

The stigma against trans men's health, coupled with misinformation, makes attaining adequate care incredibly difficult. We talked to trans guys and leading health experts to unpack the status of this under-researched issue.

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Oct 21 2016, 6:30pm

Illustration by Eleanor Doughty

In honor of Planned Parenthood's 100-year anniversary, we're taking an in-depth look at the history and future of reproductive rights. Read more of our coverage here.

Six days before Javier was scheduled to have a hysterectomy, his insurance provider contacted him to say that an issue had come up: They wouldn't be able to cover the surgery unless he could obtain a second letter of support from a mental health provider within 24 hours.

The call was unexpected; according to Javier, his insurance company had already approved coverage, along with the letter he'd already been given by his therapist. He took off work the following day, trying desperately to get a second letter from a therapist, but ultimately was unsuccessful given the incredibly short timeframe. His hysterectomy had to be rescheduled.

Hysterectomy is just another step in transition for many transgender men, and since trans people are required to obtain letters of endorsement from mental health providers when undergoing many gender related surgical procedures, their reproductive health is weirdly bound to the psychiatric field. The oddness of this is sometimes reflected in the way that mental health providers speak about transgender people; even those who are technically supportive may use language that no trans person would ever use. Javier rummaged through a stack of papers to find a letter one therapist had written about him in support of surgery. "He has had an unwavering goal of transgendering," Javier read aloud, scoffing at the absurdity of it: "He will not technically become male until after his planned surgery."

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All of this can feel ridiculous, but also humiliating and frustrating. "I had to prove that I had no desire to give birth to children," Javier said. "You need a mental health professional to tell you what to do with your reproductive organs." It was especially frustrating for Javier to have to prove that he would not one day wish to become pregnant, because it was his capacity to become pregnant that made him so uncomfortable with his body. "The idea of pregnancy in general was an extremely dysphoric idea for me," Javier said.

Dr. Asa Radix is an expert in the field of transgender medicine at Callen-Lorde, where he helps to treat more than 3,500 trans patients. In an interview with Broadly, Radix explained that some trans men feel dysphoric as a result of their internal sex organs, and that hysterectomy can alleviate that dysphoria.

But that doesn't mean the procedure is standard. There is no data suggesting that hysterectomies ought to be routinely performed, Radix explained, but many trans men, like Javier, do choose to undergo the procedure, and there are many different reasons that people make that decision. For instance, "there are guys who prefer to have a hysterectomy because they are very uncomfortable having pelvic exams and pap smears, which are necessary when you have a cervix," Radix said. Research shows that many trans men avoid getting pap smears because of discomfort associated with their bodies, which could account for the higher instances of cervical cancer identified in trans male populations.

Javier says his aversion to pap smears contributed to his reasoning when he decided to have a hysterectomy. Though he could tolerate a pap smear in the interest of his long-term health, he knew that he could avoid them by having his cervix removed. For Javier, the benefits of this procedure are many. "I can never have a period again even if I stop taking testosterone," he said excitedly.

While men like Javier have hysterectomies because they want to, and Radix says that insurance companies are rightfully obligated to pay for them, the history of surgical gender transition is grievous, and trans people are still navigating the aftermath of decades of injustice that shaped the choices—or lack of choices—they had about their medical care.

I can never have a period again even if I stop taking testosterone.

There have long been institutional barriers between transgender people and medical gender transition. From psychiatrists to insurance companies, there's a significant history of protocols that transgender people have to comply with and submit to in order to receive treatment. Historically, institutional gatekeepers have effectively controlled gender transitions, often bending people to conform to social standards of gendered appearance and behavior and thus postponing—or even preventing—their transition altogether. This can feel alarming to patients who are dependent upon transition in order to survive. "Why did I need a letter from a therapist who doesn't know me to tell me I'm trans, and then to charge me $200 to write me a letter?" Javier asked.

Radix pointed out that transgender people used to be required to have reconstructive genital surgery in order to legally alter their sex identification, which amounts to sterilization through the excision of reproductive organs. "Hysterectomies were therefore done for legal reasons," Radix said, adding that this practice has increasingly been identified as a violation of human rights. However, "despite changes to laws, there are still 23 European countries and many states that still mandate this."

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Transgender health care remains woefully under-researched, and, according to Radix, trans men's reproductive health is even more poorly studied. The existing studies on transgender medicine generally they center trans women's mental and sexual health, Radix explained. This is partially due to a lack of funding, but also because trans men are intentionally "excluded from research (especially in HIV/STI prevention research)."

People often assume that transgender men are exclusively attracted to cisgender women, which Radix describes as a "misconception." Like cisgender people, trans individuals are sexually diverse. Radix noted that researchers may still exclude gay trans men from their studies because of false beliefs, such as the notion that gay trans guys aren't going to "use their vaginas for sex." This is personally relevant to Javier, who says that his sexuality includes people of all genders and body types.

In Javier's experience, there's a widespread belief that trans men only want to have sex with women. "People want us to fit into that box," Javier explained, adding that these attitudes are informed by the false assumption that trans people only transition in order to have heterosexual sex.

These societal norms have negative consequences on trans men's reproductive health; some trans men may feel too ashamed to be honest with their doctor about the kind of sex that they're having, and subsequently remain uninformed about the sexual healthcare they ought to be receiving. If your provider doesn't know that you're having sex with a cisgender guy, then "your provider can't tell you about your pregnancy risk and can't tell you about birth control," Javier said.

It's particularly important that providers counsel trans men about these topics, according to Javier, because many trans men incorrectly believe that they cannot become pregnant since they stopped having periods after they went on testosterone. Unfortunately, the idea that trans men on testosterone cannot become pregnant "is bullshit," Javier said. "It's scary how many people think that."

Most trans men don't realize that there are birth control options that are not as invasive as they might think.

According to Javier, another issue is the fact that some trans guys struggle to find a form of contraception that doesn't make them feel badly about their body. "Most trans men don't realize that there are birth control options that are not as invasive as they might think," he said.

Trans guys who are having sex with cisgender men have multiple options of birth control available, including an IUD or the tri-monthly injectable DepoProvera. The traditional birth control pill wouldn't be advisable for trans men who are hormonally transitioning, because it is generally comprised of a cocktail of drugs that include estrogen, but for guys who aren't taking Hormone Replacement Therapy (HRT), the standard pill works just fine.

"Fortunately, providers are becoming much more aware of the diversity of sexual behaviors and identities of transmasculine people," Radix explained, citing "important research" being put out by Dr. Sari Reisner of Boston's leading transgender health provider, Fenway Health, and the work of Dr. Juno Obedin-Maliver of the University California San Francisco. These researchers are "highlighting that trans men have specific reproductive health and education needs, especially those who identify as gay."

As Javier sees it, the specific problems trans men face in accessing crucial health care can be curbed through an increase in visibility of transgender men and the specific issues they're dealing with, alongside an expansion in society's understanding of gender and sexual diversity. But it is also critical to have providers who understand trans medicine.

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There are staggering rates of discrimination against transgender men by healthcare professionals. One study found that 42 percent of transgender men "reported verbal harassment, physical assault, or denial of equal treatment in a doctor's office or hospital." One story from 2015 illustrates this: a transgender man in Minnesota alleged that he was subjected to a litany of abuses while being treated at a local healthcare facility. Javier isn't surprised by these stories or statistics; he knows that medical environments are often unsafe for transgender men.

But while there are so many obstacles to care, there are also places that are going out of their way to provide compassionate treatment to trans patients--places like Callen Lorde, where Radix works, as well as Planned Parenthood, where Javier works, which offers transgender hormone therapy at 26 out of 57 local affiliates. They don't use labels like "gay" or "straight" at his office, and they're proactive about identifying and using the correct pronouns for patients and employees alike.

Because trans people confront injustice throughout their lives every day, and discrimination in doctor's offices is so prevalent, Javier believes that having compassionate physicians is useful to helping trans people feel comfortable enough to receive the care they need. Given that reproductive healthcare is deeply personal, it makes sense that responsible providers would want to do everything in their power to make their patient comfortable. "Say you pass as a guy," Javier said. "Going into a clinic and being like, 'I need an abortion?' I can't imagine how that would feel."