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Transgender Sterilization: Sweden and Beyond

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The day I sat in my doctor's office, quietly placing an "X" next to boxes on a paper checklist, he sat placidly across the small room, eyes unfocusedly pointed towards the floor. I felt gratified at this attempt to give me privacy, but I didn't need any more time to think. I had put unquantifiable amounts of physical, mental, and spiritual energy into reaching this moment, into actualizing an inner self within the social realm via bodily transformation.

So I was not anticipating, as perhaps my doctor did, that I would be blindsided by my first biological reason to grieve. About halfway down the page, I paused. Filling out this Informed Consent waiver to access testosterone, I was unexpectedly confronted with the possibility of becoming sterile.

_X_ I understand that it is not known exactly what the effects of testosterone are on fertility. I have been informed that if I stop testosterone, I may not be able to become pregnant in the future. I have been advised to undergo gamete (egg) banking if this is a concern of mine.

Today, my mind returns to this buried moment of my early transition days, in light of a current ongoing lawsuit in Sweden. In the wake of their overturned forced sterilization law -- a mandate that required that trans citizens become infertile (and unmarried) to gain legal gender recognition -- last year, trans Swedes are currently suing the state for compensation and an apology.

A year ago, the final paperwork hurdle to accessing hormone treatment instructed me to bank my eggs if I ever imagined I would desire biological children -- an option I instantly found meaningless. Even if I wanted to undergo this invasive procedure, it's prohibitively expensive for all but the most class-privileged. And it's inconceivable to put off my medical transition for the years that it would take to decide whether or not I wish to give birth. How many people know as a young adult when and how many children they will someday have?

"Do you have any questions?" my provider asked me as I signed off with little fanfare, save the flourish I still excitedly gave to writing my newly legalized name.

After a silently loaded moment, he kindly offered to explain the discrepancy that stands out to anyone familiar with trans male communities: men giving birth after being on testosterone. For the most part, trans men are not jumping to bank their eggs, to the point that my doctor and I both joylessly chuckled at the preposterous financial demand. We both knew that men who do not opt for hysterectomies can choose to temporarily cease hormone therapy should they desire to bear a biological child. And it should go without saying that there are trans men and trans women who desire to have biological offspring. I include myself among this group.

Before this moment, testosterone had, at least to me, never represented an either/or choice between becoming male-bodied and reproducing, just as pregnancy does not represent an either/or choice between being a woman or a man. What was this mutual exclusion suddenly staring me in the face?

My provider succinctly explained that without a study explicitly finding that testosterone doesn't cause infertility, trans men legally must be informed of the possibility that it might. He then reminded me to access a health-care institution open to halting and restarting my hormone therapy should I ever express the desire to become pregnant -- a practice that many non-trans-inclusive practices might erroneously consider "going back" or being "uncommitted" to gender transition. Cue the withholding of trans health care based on a patient being deemed not "trans enough."

Now solidly enmeshed within medical transition, I find myself eagerly imagining a future where I could give birth, should I so choose (and should my phantom polycystic ovary syndrome not thwart me). On the other hand, transgender women's hormone regimens result in infertility, yet the option of indefinitely banking sperm is unrealistically costly for many in this historically low-income community.

It's time to turn our eyes to Sweden. Citizens suing their government over forced sterilization usefully places medical realities alongside the demands of legal transition. In the United States most, if not all, states require a record of "sex reassignment" surgery in order to change the gender marker on one's birth certificate. Some states accept vague references to any transitional surgery; others specifically require genital reconstruction, sometimes with and sometimes without explicit sterilization requirements.

Clearly, state logic generally glosses over the reality that not all trans people opt for surgical intervention, and that there are numerous procedures that affirm gender. Those who require medical transition often find that altering the chest, face, and voice impact daily socializing and policing more regularly and may opt for these surgeries long before the doubly-to-triply expensive genital alignments. Furthermore, altering genitalia is contingent upon previous regular hormone use, which, of course, requires medical access. The hoops go on.

While most trans people cannot afford surgery, we continue to live our true genders daily because being ourselves simply cannot wait for the system to catch up. In the meantime, lacking legal documents that reflect lived experience opens us, particularly trans women of color, to excessive scrutiny and, at times, outright violence.

For those who can access surgery, the pressure to change one's documents and avoid potentially dangerous social stigma can be understandably immense. Legal gender recognition helps mitigate not just to the immediate dangers of violence and self-harm but the slow fatality of chronic unemployment, which influences access to health care, shelter, education, and the need to engage in illegal practices that increase chances of incarceration and HIV/AIDS.

When a state, such as Sweden, offers the option to alter gender on legal documents at the expense of fertility, it is unavoidable that underprivileged trans people will be placed between a rock and a hard place: obtaining what they need now to survive and flourish by foregoing a future biological parenthood they may not even reach if they succumb to transphobic social harms in the meanwhile.

This coercive non-choice constitutes forced sterilization. When a trans woman knows she needs hormone therapy to survive yet is priced out of banking her sperm for a desired future motherhood, this is forced sterilization, "forced" because it is within the power of the state to not exact such demands, but historical prejudices against a marginalized population bias decision making. This resonates with the forced sterilization of other oppressed groups, including low-income African-American, Latino, and American Indian cisgender women in the United States.

The specter of sterilization hangs around trans people in the EU, the United States, and numerous other states, with especially dire consequences for trans women and those at multiply oppressed intersections of race, class, age, language, and ability. When governments offer trans citizens the carrot of altering legal gender markers -- thereby showing support for gender self-determination -- yet maintain a system that requires proof of sterility and fails to support reasonably priced gamete banking practices, they place inhumane caveats on trans people's full life potentials.

We've learned from the emergence of fertility medicine that recognition of gender is not contingent on reproductive capacity, so why is this unrelated ability brought to bear on trans people's legal gender legitimacy? Ultimately, this is about what sterilization has always been about: purifying a state by punishing "others," rendering nonconformist lives undesirable, stripping away the agency and dignity of oppressed peoples, and sacrificing reproductive freedoms for basic rights.