Trans parenthood

Choice of words

In texts about trans and parenthood we use medical terms about body parts that have to do with fertility and reproduction: about the ability to make someone pregnant and the ability to become pregnant and about pregnancy, delivery and breastfeeding.

In some parts of this text we might use words that can be perceived as gendered, but it is because we want to convey information without it being lost in euphemisms.

Introduction

The demand for sterilisation for trans people who wanted to change their legal gender was abolished in 2013. That means that since then, trans people have greater opportunities to become parents by using their own gem cells or becoming pregnant.

The term parent can have many meanings, especially in rainbow families. A parent can be the genetic, biological and/or legal parent to one or more children. You can be all these things at the same time, but you can also be a parent in one or two of these aspects.

A genetic parent is the one who has contributed with gem cells (eggs or sperm) in order to produce a child. A person who has donated sperm also counts as genetic parent to the child/children that are produced by their sperm. A person can also give birth to a child without being the genetic parent, if donated eggs have been used. The person who gives birth to a child always counts as the child’s biological parent. A legal parent is the one who is registered as the child’s parent in the population register. In Sweden, only two people can be legal parents.

A fourth, and very important, aspect of parenthood is the social parenthood. That you take responsibility for a child, satisfy the child’s needs and guard its rights. To also be legal parent means increased safety for the child. You can also be an important person in a child’s life and shoulder much of parenthood without calling oneself or seeing oneself as a parent to the child.

Saving eggs/sperm

Previously, in order to change legal gender, you had to be unable to reproduce.  That meant that many trans people were sterilised through surgical intervention, whether you wanted to or not. In addition, you were not allowed to save gem cells.

After the forced sterilisations were abolished in 2013 there are no legal obstacles for keeping inner reproductive organs (testicles, uterus, fallopian tubes, ovaries) after changing legal gender. There are no obstacles for you as a trans person to save gem cells (eggs or sperm) if you want to, either. But there is still no obligation for general healthcare to offer trans people the opportunity of saving gem cells, the possibilities vary depending on where in the country you live.

Gender affirming care can offer you to save eggs/sperms

According to the Swedish National Board of Health and Welfare, the person receiving gender affirming care should be informed about healthcare’s possibility of helping you to conceive with your own gem cells. Healthcare should give information about fertility preserving measures and about how different gender affirming treatments can affect your fertility. If you are under 18 healthcare should also offer you to save gem cells or tissue from ovaries or testicles.

Today, all gender assessment teams in Sweden offer people with the diagnosis transsexualism the opportunity to save gem cells, also people over 18. If you get a different gender dysphoria diagnosis than transsexualism it may differ depending on what team does your assessment. If you are over 18 it may happen that the county council where you live doesn’t want to pay the cost for you to save your gem cells. That means that many trans people still lack the opportunity to become parents with their own gem cells, even though the requirement of sterilisation has been removed.

Best to save eggs/sperm before hormone treatment

If you are undergoing gender affirming hormone treatment with puberty blockers, testosterone or estrogen and/or testosterone blockers you will be temporarily sterile or your fertility decreases. Taking hormones and/or blocking the body’s own hormones means that you no longer produce mature eggs or sperm or that you don’t produce that many gem cells.

This kind of sterility or decreased fertility is often just temporary. If you stop hormone treatment or treatment with hormone blockers the body’s production of mature gem cells starts up again and you become fully or partly fertile again. There is no guarantee that you can become fertile again after gender affirming hormone treatment or to what degree you become fertile or how long it takes. The safest way is to save gem cells before starting gender affirming hormone treatment if you have the opportunity. Then you retain the best possibilities to conceive with your own gem cells in the future.

Some gender affirming genital surgery leads to sterility. That includes vaginoplasty, orchidectomy (removal of the testicles) and salpio-oophorectomy (removal of the fallopian tubes and ovaries). If you undergo hysterectomy (removal of the uterus) and vaginectomy (removal of the vagina) you can no longer carry and give birth to a child. If you are to undergo one or some of these surgeries and want to save gem cells you need to harvest them before surgery. These surgeries are irreversible. 

If you remove the uterus and vagina you can no longer carry a child or give birth. Your possibilities of becoming a parent with your own gem cells (eggs) are very limited in Sweden today. There is more information in the chapter “Legal opportunities to use saved gem cells”.

This is how it works

If you are to save eggs or sperm you need to do it before you have genital surgery. If you are to undergo gender affirming hormone treatment it is advisable to save gem cells before treatment is initiated. If you have already started gender affirming hormone treatment or are self medicating, you need to stop hormone treatment temporarily for the production of mature gem cells to start. For people with a uterus, that means the re-starting of menstruation. How long it takes varies.

You will go through an assessment to see how fertile you are. If you have testicles that usually means giving a semen sample. If you have ovaries you need to undergo a gynecological examination to establish if you have eggs in your body.

You have to make an appointment at a fertility clinic to save sperm. There you will get access to a room where you masturbate and collect the semen in a test tube or jar given to you by the staff at the clinic. If you want to, you may take someone you know with you into the room.

If you are to freeze eggs you need to undergo a hormonal treatment which stimulates the ovaries so that many eggs mature at the same time. The first part of the treatment consists of injections that you either administer yourself in the subcutaneous fat on the stomach or receive help doing. The injections are taken every day for about ten days. An ultrasound will be made in the vagina to see how many eggs are starting to mature and when they have grown enough. After that you will be given an injection to make the eggs mature at the same time. You may receive medication that makes sure that only the ovaries are affected by the hormone stimulation. The eggs are harvested during surgery at a fertility clinic or a gynecological clinic. The doctor inserts an instrument into the vagina and harvests the eggs with it. During and after the procedure you will be given pain relievers and you may get a sedative if you need it.

If you have a partner or someone else who contributes with sperm you can choose to freeze embryos, that is eggs that are fertilised.

One option if your body hasn’t started to produce mature gem cells is to freeze tissue from ovaries or testicles. If you want to conceive with your own gem cells later you need to reattach the tissue to the body where it can start producing mature gem cells, given that you haven’t undergone genital surgery.

Legal opportunities to use saved gem cells

If you save sperm you can use it for assisted fertilisation or for insemination at home with the egg of a partner or co-parent who carries the child.

If you save eggs you can use them to become pregnant through assisted fertilisation (IVF or insemination with donated sperm or a partner or co-parent’s sperm). You can choose to become pregnant as a single parent and be helped by healthcare with assisted fertilisation. The same legislation about assisted fertilisation applies to single people regardless of legal gender.

Many are curious about methods like double donation, simultaneous egg and sperm donation; that one partner becomes pregnant with your egg (can be called reciprocal IVF or R-IVF) or surrogacy. That a partner becomes pregnant with your egg means that you give an egg to a partner who is to carry and give birth to the child, and that donated sperm is used to fertilise the egg. Simultaneous egg and sperm donation, or double donation, means that you receive both donated eggs and donated sperm. Surrogacy means that you give sperm to a person who is to carry and give birth to the child, but who is not going to be a co-parent. It’s not legal in Sweden to get help with surrogate pregnancy from healthcare. Simultaneous egg and sperm donation is legal since January 1 2019. Currently, very few clinics have started such treatment and it’s still unclear what criteria should apply for someone being allowed to carry a partner’s egg. The clinics are waiting for guidance from the National Board of Health and Welfare, who works with producing recommendations but isn’t finished yet. Gender assessment teams should be able to give information about what legal opportunities there are to become a parent, for example about assisted fertilisation and adoption.

There might be a possibility to use R-IVF (that a partner becomes pregnant with your egg) or surrogacy abroad.

If you want to become pregnant

Trans people with a uterus can become pregnant and give birth. A person who is legally male who gives birth is automatically registered as the child’s father, and a person who is legally female who has contributed with sperm should be registered as mother. Trans people can also become parents by sharing parenthood with two or more parents.

Regardless of gender affiliation a person can have a strong desire to have a child. This desire may have complicated the thoughts about wanting/needing to undergo gender affirming care, and you might choose to have a child before you start your assessment. This doesn’t make you “less” trans. You may never have identified as a girl/woman, but may have lived as a man for a long time. It’s not the body that makes a person man or woman. 

Gender affirming care

If you have had gender affirming treatment you may have undergone parts of the care that is offered. Hormone treatment is often the first step. A trans person assigned female at birth may receive testosterone, which makes the body change and produces male attributes such as increased body hair, darker voice, “masculine” features in the face, a change in body fat distribution and the cessation of menstruation. 

Many trans people describe that gender affirming treatment in the form of surgery or hormone treatment has been necessary in order to make the decision to carry a child. It may have been necessary to have a less feminine gender expression in order to “face” a pregnancy and risk being seen as a woman because of norms. Research shows that for some people it’s easier to accept the changes during pregnancy if they have come further in the process with gender affirming care. 

Gender dysphoria and pregnancy

Gender dysphoria means that you feel that the body doesn’t match your gender identity. For some, gender dysphoria leads to mental ill-health with depression and anxiety. Trans men ans non-binary people who go through a pregnancy may have a complicated relationship with their body. Furthermore, norms make pregnancy strongly connected to identifying as a woman, which increases the risk that a pregnant man or non-binary person is misgendered. As a pregnant person you may experience that strangers comment on or even touch your body. Gender dysphoria can increase during pregnancy as the body goes through changes that make the body be perceived as more feminine.  

Some trans people express a strong worry during early pregnancy about how you can feel when the changes in the body become more apparent, with increased body fat around the hips, stomach and bum, breast tissue that increases and a growing belly. 

Becoming pregnant

As a trans person with a uterus you need sperm that fertilises an egg. Maybe you live with a person that produces sperm, in which case you can get pregnant without the help of healthcare, either through intercourse or home insemination. 

If you want to be a single parent you need to get in the county councils queue for singles to receive help from healthcare. They have some requirements, for example that you have to be under 39 years old and have a BMI under 30. The requirements and the waiting times vary in the different regions in the country. You may seek private care or go to a clinic abroad. There, the waiting times are shorter. If you go abroad there are some things to think about if you live together with someone who is legally female who wishes to be the child’s second parent. One thing that simplifies the legal process in Sweden with second parent adoption is if you use an open donor, as Swedish law requires that a child that has come of age should be able to find out who the donor is. 

Temporarily cease testosterone treatment

If you’re on testosterone and plan to get pregnant, you and your endocrinologist will plan for a controlled break in the treatment. After the break it may take between a few weeks to a year before you begin to menstruate and ovulate. Testosterone is toxic to fetuses and therefore you need to cease testosterone treatment six months before undergoing assisted fertilisation. 

There’s a lack of research about the effects of testosterone on long term fertility, but we know that it’s possible to regain fertility even after many years of treatment. The bodily changes resulting from testosterone treatment (for example an increase in body hair) will not go away. During that time some experience increased gender dysphoria, as some of the effects of testosterone wear off. Many of the changes from testosterone are irreversible, that is to say they won’t go away when treatment is paused, such as the increase in body hair and the more masculine features of the face. 

Assisted fertility treatment

If you seek help from healthcare to get pregnant you will find that fertility care is relatively standardised across the country. Before you start care it can be good to undergo a fertility assessment, but it’s not always a requirement. You can do it at the gynecologist’s. In order to gain an image of your preconditions to get pregnant an examination with an ultrasound is made to inspect the uterus and ovaries. You may also do blood tests to check your hormone levels. 

You will also undergo an assessment where you meet a physician, midwife and counsellor who together will decide if you qualify for help with assisted fertilisation. Some are most nervous about the meeting with a counsellor, as trans people may have less trust in healthcare and counsellors. The counsellors job is to find out if you understand what it means to become a parent and if you have good preconditions for being a parent. You will talk about your economy, your mental health and what kind of social network you have. When you have been approved you will primarily be offered assisted fertilisation through insemination. You will then use donated sperm that is inseminated when you ovulate. In order to find out when that is you will pee on sticks at home, and when the test is positive, you will go to the clinic which will inseminate you. You will then be lying in a gynecological chair, which can be uncomfortable. You may need to remind yourself of the goal and think about when the baby comes to get through the process. The procedure is often very quick, and thereafter you can get back to your everyday life. 

For some insemination doesn’t work, and you may need to move on to IVF, which means taking one of your eggs and donated sperm and fertilising the egg outside of your body. When the egg and sperm meet and the cell division has started you insert the clump of cells directly into the uterus and hope that it will take. 

To undergo assisted fertilisation can be taxing on many levels and for some it’s an emotional rollercoaster to try to get pregnant. Some have miscarriages, but that doesn’t mean that you won’t get pregnant. Find support in those around you, talk about your feelings and experiences with someone you want to take with you on the journey to parenthood.  

Parenthood assessments can be emotional

Before you can be approved for national or international adoption you need to undergo an assessment where it is assessed if you are suitable as parent and if you have what it takes to care for a child. Not least if you are a trans person, such an assessment can be difficult and emotional. There’s a long history of questioning trans people’s ability to be parents in Sweden. Until 2013, the gender recognition act requested that trans people should be sterilised or lack reproductive ability in order to change legal gender. When the law was instated in 1972, the “interest of order in family relationships” was an argument for requesting sterilisation and it was questioned that people who wanted to become pregnant or make someone pregnant met the requirements to change legal gender. Requirements that the applicant wanting to change legal gender shouldn’t be allowed to have existing children were discussed but abandoned.

Being pregnant

Are you a pregnant trans man or non-binary person? You’re not alone. Many trans people have had children before you and there are role models to look up to.

The decision to carry a child, and the thoughts and feelings around it, of course differs between people. If you have gender dysphoria, that may change by pregnancy. It could get worse, with worry about how the environment will view you and with an increased risk of being misgendered. Maybe it gets better. With pregnancy the body has a purpose, creating a new life, and you’ll experience that it’s working as it should. It’s a nest for your growing child. The body undergoes big changes during a short time in pregnancy. It’s a special and limited time of your life. Remember that the changes the body undergoes are temporary. 

You decide how open you want to be about your pregnancy. Find stable people who can support you during this time. It’s important to be able to contemplate and share thoughts and feelings with others who understand you.

Healthcare staff should have the knowledge and competency to be able to treat you based on who you are, but not all caregivers have knowledge about trans and norms, even though we would wish them to. You as a patient are not responsible for educating healthcare staff in gender affirming care or assisted fertilisation. It’s their responsibility to procure information if they don’t know. You can tip healthcare staff to read the material we have produced, Hbtq-kompetens, that can be downloaded here. They can also contact us at RFSL if they have questions. 

How can you prepare for meeting the health care?

Seek knowledge about what happens in the body during pregnancy and how delivery works. 1177.se has a few texts about giving birth that are based on facts and is written in an easily accessible way. If it feels uncomfortable with written information that often has a cis normative approach, you can ask your midwife to go through the changes verbally. Maybe you can watch pictures if you don’t want to use certain words. Knowledge makes it easier to understand how you want your baby to be delivered. Tell your midwife about what your feelings about giving birth are, so that you can plan for you feeling good about delivery. 

Many people want to use different terms than the medical to name their own body, and you have the right to use the words you are comfortable with. When you meet healthcare staff they should be attentive to what words you want to use and if there are words you don’t want to be used about you and your body. That goes for the terms you use about the relationship you have with your children, like “mom”, “dad” and “parent”. Be clear with healthcare staff about the words you are comfortable with and if there are words you want them to avoid.

How does pregnancy care work in Sweden?

As soon as you have a positive pregnancy test you can contact the maternity care center you want to go to during pregnancy. Some LGBTQI people prefer to go to maternity care centers that are LGBTQI competent, but you should be able to get the same care regardless of what caregiver you choose. 

At registration the midwife will ask you about previous illnesses, if you’re on any medication and you also get the chance to talk about your social situation, if you live with one or more partners or if you live alone. You will also get to fill out forms about the use of alcohol, tobacco and narcotics. They will ask you about your mental health and your eating and exercise habits.

Already at registration it can be valuable to tell the midwife about your trans background so that they know what pronoun to use and what support you need during pregnancy. 

If you’re healthy and have a normal pregnancy you will see your midwife 11-12 times during pregnancy at check ups. They will check your blood pressure, your iron, your blood sugar and listen to the baby’s heartbeat and measure your stomach to see that the child is growing normally. About week 17-20 you will have an ultrasound where they look at the baby to see that it’s developing normally. Then you get to see your baby. The ultrasound is done with a probe on your stomach. 

Gendered and gender neutral terms

It’s healthcare’s responsibility to use an inclusive language. Currently there are only two genders, which means that for example non-binary people are misgendered in their social security numbers. Trans people have always had children, regardless of personal identity number, but as of 2013, males can give birth. That requires an evolution of language for healthcare staff, which is more difficult for some than others. 

Sometimes it’s hard to work around a gendered language. If you are to explain what happens in the body during delivery it can be hard to avoid certain words and it can become confusing for you as a patient. Try to be lenient towards them and let them know if you feel uncomfortable or want the midwife to use other words.

Fear of childbirth

Midwives in maternity care need knowledge about how LGBTQ and minority stress affects fear of childbirth. If you have a strong desire to give birth through a planned C-section will meet a midwife and a doctor to talk about this. You can influence what your delivery will be like, but healthcare has to make sure that patients understand what the different options entail. 

Some are ambivalent about a C-section, but at the same time have a lot of anxiety connected to minority stress, the risk of being treated negatively during delivery or to gender dysphoria about the body and delivery. In order to get support, it’s a good idea to talk to your midwife about this. Then they can help you and arrange counselling.

In our contact with trans people who want a C-section it has become clear that it’s been a great relief to be approved for a C-section early on, and that it has lessened the stress around body, gender dysphoria and pregnancy. Trans people may lack positive role models, but research shows that trans people who have chosen to give birth vaginally may have a very positive experience of delivery.

All who fear childbirth don’t necessarily have to get counselling. If you’re comfortable with the midwife you’ve got, they can make a birth plan with you based on the thoughts and fears you might have. Often, continuity in the care chain, a continuous support and knowledge about that the staff are LGBTQ competent can be important keys. 

Before the birth

At the end of your pregnancy, the midwife writes a summary. It can be a good tool for you to try and reduce possible minority stress and anxiety about childbirth. It’s the first thing that is read at delivery, both over the telephone and at arrival, and all possibilities to facilitate the staff getting to know how you want to be received are a good way of reducing the risk of something going wrong. 

When you give birth you should be surrounded by people who can give you the best support possible. Remember that there are many people who think your wellbeing is important. Dare to ask for help and support. Ask to change care staff if things aren’t working. All care is on your terms. You can also ask the staff to minimise the number of physical examinations. Your body, your child, your decision. But not alone.

Being naked

To healthcare staff, bodies and nudity is something they encounter every day. All people can be more or less uncomfortable with being naked in front of others. For some, this is connected to gender dysphoria, for others, it can be about having had traumatic experiences. If you feel uncomfortable getting undressed or being examined, tell the staff. Ask not to have to be undressed in a challenging situation longer than necessary. Ask to have a sheet placed over you when the midwife or doctor examines you. You can also ask to minimise examination as much as possible. 

Birth plan/birth letter

Some find it a good idea to write a letter to the staff at the hospital. Here, you can write about your thoughts about delivery. Are there any fears? How does the gender dysphoria manifest itself? Is there something that it’s important to know about you, like your pronoun, your words for parents or what words you don’t want the staff to use about your body? What are your preferences about pain relief, and do you want the child to lie on your chest as soon as it’s born? Write down what is important to you. You can also write down thoughts about how you want your child to be fed or thoughts about nursing or bottle feeding. 

At the labour ward

When you come to delivery you will be received by the staff responsible for your delivery. Often, the team is a midwife and a nurse. They read your delivery letter to get an idea about what support you need during delivery. They check your blood pressure, pulse and temperature. Then the midwife feels your stomach to see how the child is positioned and how far down the head is. Thereafter, you are connected to a CTG registration. That is done through putting a box on the stomach by the baby’s back to listen to the baby’s heartbeat, and one box a the tip of the uterus that registers your contractions. The boxes are there for 20-30 minutes and are disconnected if everything looks good. Through the CTG registration the midwife can gain an image of how often you have contractions and how the baby is feeling and if the baby reacts to the contractions. After that, the midwife does an internal examination through the vagina and feels the cervix to see if it’s started to shorten and if it’s started to open. Then they speak of degrees of dilation that can indicate how far into labour you are. If the midwife believes that you are in active labour you are admitted for delivery. The midwife admits you in the medical records and is there as support to help you through delivery. If you want pain medication they will help you. 

At the hospital you work in three shifts; one that starts at 7 in the morning, one at 14 and a night shift between 21-07. You will probably meet more than one team during delivery, but they give each other reports and make sure that the new midwife knows how far along you are. 

During labour it’s good to change positions and move to help the baby to descend into the pelvis and to facilitate contractions. You are often examined every other hour to check that labour is moving forward. You can switch between more upright positions and lying and resting in bed, and in the bed too you can change positions. Think about drinking and trying to eat something during labour. 

When the cervix is fully dilated and the baby’s head is fixed there is often a strong impulse to push. You feel a great pressure downwards, towards the bottom and it’s hard not to push during a contraction. Some feel that the final contractions are easier to handle, maybe because you are doing something “active” when the contractions come. You choose in what position you want to deliver in. Some want to give birth on a stool, others want to stand, some want to lie on their side while others rather kneel. The midwife is there as support and to guide you if needed. When the baby is on its way out, the midwife presses warmth towards your vagina (is you’re OK with that) to lessen the risk of taring. The midwife also halts the birthing process for the same reason. They do it by holding a hand on the baby’s head and one hand in perineum to alleviate and steer how the head is born. Don’t forget that all care should be given with your consent and that you have the right to speak up if something feels wrong. 

As patient, you have the right to change midwives if you feel uncomfortable. All care is on your terms, with the aim that you and the child are well.

Becoming a family

There are strong norms about what a family looks like, but rainbow families may have a different view on family. It can be anything from who can be pregnant, how you can get pregnant and how many parents a child can have. To have a network with other rainbow families can be strengthening. There, you can talk about the thoughts that come up during pregnancy about stereotypical gender roles and what it means to be mother or father. And what words do families use when one or more parents aren’t mother or father. 

Being a good parent has nothing to do with gender identity. There are other trans people and non-binary parents that have found other ways of starting a family. Some people make up their own words for parents. Play with the thought about what words you want to use. 

In rainbow families equality is often important with more than one parent, and there might be conflicts. It’s not odd if that happens, talk to each other about your expectations, fears and hopes before the baby is born and try to solve conflicts immediately when they occur. Care about each other and your relationship.   

Useful links

At rfsl.se there are links and resources for support groups online with the possibility of experience exchange in carrying and giving birth to a child, and also a collection of texts that help you feed your child, if you wish. There’s also a preparatory lecture on delivery with a less gendered language than the lectures provided by maternity care.