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Although some off-label medication use is justified, the use of testosterone for nonspecific symptoms of aging is not. Using testosterone to treat older men with decreased energy, decreased strength, low libido, erectile dysfunction, mood disorders, sleep disorders, or poor memory is inappropriate because symptoms do not correlate with testosterone levels, testosterone supplementation is unimpressive in clinical trials, and inappropriate testosterone therapy is not safe.

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W hen the call came, my brother was at work in the open office in Cambridge, Mass. The phone came up blocked, so he knew it must be the doctor. He stood up, unsteady on his feet.

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Was he a little nauseous? Or was that just adrenaline? He ducked into the hallway in search of quiet. My brother Evan, 35, is a stocky guy of medium height with a trimmed, fuzzy blond beard and two gem studs in each earlobe.

But on that September afternoon, both of his hands were clutching his phone, the right one cupping the left for privacy. The identification was unnecessary.

Ania Kowalik is a reproductive endocrinologist at a clinic called Fertility Solutions in Dedham, Mass. Evan, who was born female, had wanted to be a parent since he was very young, when he played with dolls just a bit longer than the other .

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Evan knew he should feel excited. But instead, he felt a chill of anxiety and anticipation. She was brief: Evan was pregnant. Kowalik told him he had low levels of progesterone, a hormone that helps maintain a healthy pregnancy, and prescribed some pills for him to start taking right away.

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People from other offices brushed by him, caught up in their work. He called his partner, and her gasp was loud enough that Evan held the phone away from his ear momentarily.

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He pulled up a calculator to figure out his due date. Transgender Americans have gained greater visibility and acceptance as stars like Caitlyn Jenner and Laverne Cox have trained a pop-culture spotlight on trans issues. Corporate leaders across the Fortune have moved to protect their transgender employees.

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And in May, the Obama Administration declared that all public schools must treat students equally regardless of their gender identity, classifying inner feelings of maleness and femaleness as protected by the government. We have come to the point where the President of the United States can candidly and comfortably discuss gender fluidity. We have also come to the point where the backlash against these rapid changes has manifested in sometimes surreal fashion, as it did earlier this year during the so-called battle of the bathroom, when about half of all states ed lawsuits against the Obama Administration.

There have been reports of increased violence directed at transgender people. Americans are just starting to open up to the idea that you may be born into a female body, but believe that you are really a man. But what if you are born into a female body, know you are a man and still want to participate in the traditionally exclusive rite of womanhood?

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What kind of man are you then? This question can bother people.

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It can make them uncomfortable. I thought about what strangers might say to my bearded, big-bellied little brother when he was nine months along. And I wondered, Would he be safe? I am six years older than Evan.

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We also have a middle sister, Katje. Once, when Evan was in college at Oberlin and I was in grad school at the University of California, Berkeley, he flew across the country to visit me. When he got off the plane, we were both wearing the same thing: puffy down vests over long-sleeved ultimate-frisbee T-shirts and baseball caps worn backward. He called me to say that when he came for my graduation, I should call him Evan.

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Over the next few months, I watched his body change. He started binding his chest with a thick bandage wrap. His hair began to thin. His hips disappeared and were replaced by thick muscles around his chest. But To all the hot men at american family, I remember his hands. We both have the same small hands, the same indelicate, stubby fingers.

I watched the hair grow thick over his knuckles, which were my knuckles. The transition was messy. Our parents were supportive but distracted. They were in a protracted divorce after my father had, at 50, come out as gay. Looking back, I regret these jokes. They were a crass way to cover the pain of knowing that the childhood we all shared—the one in which we were three round-faced, pigtailed girls in matching dresses—had been a charade for my brother. I said the wrong things all the time.

That first year Evan looked strange to me, like a butch lady or a girly man. And in an attempt to sound interested and supportive, I asked him invasive and personal questions, often in mixed company. Once, during a brunch with our extended family, I asked him about whether he planned to alter his genitals. Physically, he is transformed.

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Before his pregnancy, he injected hormones into his thigh once weekly to lower his estrogen while boosting his testosterone. He elected not to have top surgery, the double mastectomy that many trans men undergo, because he is allergic to most antibiotics. Also, he knew he might one day want to nurse a baby. So he wears two compression-tank binds made by a company called Underworks beneath his shirt.

Physiology of testosterone and causes of hypogonadism in males

His transformation is as much social as it is physical. For nearly a dozen years, the world has responded to him as a guy.

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Inwhen Evan made an appointment with his primary-care physician at the Boston LGBT health center Fenway Health, he was the first prospective birth father his doctor had seen. Several years earlier, a few trans men who, like my brother, had undergone hormone treatment but kept their reproductive organs, had begun consulting physicians about pregnancy and speaking openly about wanting to give birth. InThomas Beatie posed for People magazine, bare-chested with a rotund belly, and went on Oprah to talk about his pregnancy.

Benefits of testosterone replacement therapy

Trans men began to trickle into fertility clinics more frequently. The case settled a few years later; Inkster sought out another clinic and later gave birth to a daughter. What happened to Inkster is not uncommon.

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Medical care of all kinds is complicated for trans Americans. Roughly 1 in 5 have been turned away by a medical professional at some point, according to the National Transgender Discrimination Survey. There is very little research about trans pregnancies. Harvey Makadon. They noted that, in form and function, getting pregnant as a trans man is not that different than getting pregnant as a woman.

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Most of the time, trans men stop taking testosterone, and their bodies begin ovulating again. Some trans men may have unintentional pregnancies while taking it. If their partner is biologically male, trans men may try to conceive without medical intervention. My brother has a female partner, so he inseminated using donor sperm. It took a while. The first time Evan tried, five years ago, he was unsuccessful. He took a break before starting again three years ago. If the physical process of getting pregnant is fairly straightforward, transgender birth parents often face more challenges when it comes to mental health.

Obedin-Maliver and Makadon referred to two recent studies that highlighted psychological issues involved with trans pregnancies. In both cases, the sample sizes were too small to be statistically relevant, but ificant themes emerged. For one, the birth parents were often lonely. And they reported complex feelings about their gender identity. I spoke to another trans dad who had given birth to his son at age He said the pregnancy catapulted him into depression.