A central finding was the wide variation within the population of transgender men giving birth, along many axes of difference, including identity, reproductive intent, fecundity and gamete source, need for affirmation of identity and pregnancy, social support, degree of outness, and priorities and sequencing of transition and reproduction.
Inclusion criteria for this study required patients to identify as male at the time of their pregnancy. Participants in this study described themselves, variously, as ‘male,’ ‘man,’ ‘female-to-male,’ ‘transman,’ ‘trans man,’ ‘transgender man,’ ‘transmasculine,’ ‘nonbinary,’ and ‘on the transmasculine spectrum.’ Some participants had a clear preference, and others were comfortable with a variety of terms.
Participants described their pregnancies as, variously, strongly desired, necessary to build a family, or unintended. Some unintended pregnancies occurred after male identification but prior to any medical or surgical transition, “I first started questioning my gender at about age 19… when I was 20 I talked to a doctor about [testosterone], and was waiting to get that started [when] I accidentally got pregnant.” Some chose pregnancy as a tolerable means to become a parent, “but if I want to reproduce, that is the only way I can do it. So I agreed this - if I could do it another way, I would maybe do it another way, but I don’t have the option,” while some enthusiastically desired pregnancy, “I always knew that I wanted to have kids, and that I would be giving birth to my own kids.” No participants reported serious consideration of terminating their pregnancy or of seeking healthcare related to elective termination.
Fecundity and gamete sources
There was variable fecundity; participants had had one to four pregnancies, with one to three live births. Participants conceived using sperm from committed partners, sexual partners with whom they had no intent to have a long-term relationship, known donors, and anonymous donors. All participants conceived using their own oocytes.
Access to social support
Participants’ social support ranged from robust to minimal and tenuous. For some, their pregnancy was a very isolating experience: “I just lost everybody.” While others found abundant support and affirmation from family, friends, and strangers:
“In the queer community and the leather community… I had an overwhelmingly positive reaction… When it was really obvious that I was a pregnant tranny, I actually received a lot of positive love and affection from queer strangers…and I actually had strangers stop and ask if they could hug me and thought that it was beautiful.”
Some participants directly cited their supportive communities as a source of resilience against the challenges they faced,
“If I hadn’t had positive reactions [from family] in the very beginning of my transition… I would have been far more self-questioning, and less strong in standing up to [others] who wanted to tell me something that wasn’t true.”
A particular source of support for several participants was the Facebook group “Birthing and Breastfeeding Trans People and Allies” (https://www.facebook.com/groups/449750635045499/ accessed April 2015). Several participants reported that pregnancy and parenting support organizations for gay, lesbian, and bisexual people were ill-equipped to support transgender parents.
Need for identity and pregnancy affirmation
Need for affirmation of gender identity was also highly variable. For some, being seen and treated as male – with consistent use of male names and pronouns – was critical to their sense of emotional safety and wellbeing. Others were minimally bothered by being misgendered. Similarly, for some, it was important that they be seen as pregnant. Others did not want their pregnancy known or acknowledged by anyone other than their close loved ones and medical providers.
“I just didn’t like leaving the house at all because I knew that I was going to be read as pregnant female, and it just ugh. After I’d worked so hard the past couple of years to get [people to see me as male].”
“[I wanted] support from my community… so I told my coworkers and my synagogue [that I was pregnant]. I wrote an email… and it was really nice, how ridiculously excited they were for me.”
Degree of outness
Visibility and ‘outness’ had to be considered in two domains. The choice of whether and how to be ‘out’, or visible as pregnant and/or transgender, played out in complex ways for the participants. Participants described a mix of strategies in navigating degree of outness, and most of the participants employed several of these strategies, varying by setting, whom they were with, and time during the pregnancy. The three most common strategies were (1) passing as a cisgender woman (i.e., one who identifies as a woman and was assigned female sex), (2) going stealth, and (3) being out and visible.
Strategy 1, passing as a cisgender woman (acting so as to incline others to think one is a cisgender woman), increased external affirmation of the pregnancy, but decreased external affirmation of male gender, as reported in the original online survey preceding these interviews . This strategy increased some participants’ feelings of safety, and decreased their exposure to transphobic violence,
“[I was] intentionally trying to be inconspicuous and fly below the radar. I wanted to be able to present as male, but I made that decision [to present as female] at that time because I was afraid.”
At times it appeared that this strategy came at the expense of increasing dysphoria due to passing as a gender that does not align with their sense of self.
Strategy 2, going stealth (acting so as to incline others to think one is a cisgender male), increased external affirmation of gender and decreased exposure to transphobic violence, but also decreased external affirmation of the pregnancy. By not being visible as pregnant, some benefits were missed, including social support, physical assistance, and external affirmation. Those who pass as cisgender male report being consistently “perceived as a fat man and never as a pregnant woman.” It sometimes surprised participants how invisible their pregnancies were:
“People could not process my masculine appearance with pregnancy… How can [this cashier] think that I’m male when I’m eight-and-a-half months pregnant? This is really crazy. But I look around and I’m like, oh, because I look exactly like all these other fat guys with beer bellies who were at this plant show, like middle-aged fat guys. That’s what we look like.”
“I was really pleasantly surprised by how easily people saw me as a fat man – I thought I would be really struggling to be read as male, and I wasn’t, at all.”
Strategy 3, being out and visible (acting so as to incline others to see one as transgender), may increase internal affirmation,
“I find that when I try and normalize myself or act normal or be more normal than I am, I become really uncomfortable and unhappy. And it doesn't help anyone. So, yeah, just sort of doing it my own way and knowing that I was doing it my own way was a really helpful strategy.”
Being visible as trans men allowed for affirmation on three axes, namely of their gender as male, as trans, and of their pregnancy. However, some participants worried that it would expose them to more transphobic violence and discrimination, which was the main reason for employing strategy 1.
Prioritizing transition or pregnancy?
Among many participants, there was a tension between pursuing their reproductive goals and their transition goals. One participant deferred initiating testosterone therapy for over a decade until after child bearing because of uncertainty regarding testosterone and potential impairment of high priority reproductive prospects “If they can’t give me better information about having babies, then I'm not going to start testosterone. So, in that way, it [the decision to delay hormone therapy] was easy to make, but it was difficult to accept.” Another participant knew from childhood that he wanted to bear children, but held medical transition as a higher priority, so he initiated testosterone as soon as possible, despite believing it might impair future conception and pregnancy, stating, “I still had a desire to have children one day, I just started testosterone because I felt it was necessary for me to socially transition that way. Having children was an issue for the future.”
Some participants felt confident, based upon knowing the stories of other men who had given birth, that testosterone would not impair their ability to get pregnant, “I had read [about another trans man] who had gotten pregnant after years on testosterone… So I was never really afraid I wouldn’t be able to.” They chose their timing of testosterone and pregnancy independently, when they were ready for each. Some participants only began considering pregnancy after having already initiated testosterone.
Sequencing of transition relative to pregnancy
There was a diversity in how participants sequenced pregnancy and transition.
Some become pregnant before transitioning socially, some while they were living part-time as male, and some had been living as male for over a decade before becoming pregnant.
Some participants became pregnant without having previously taken testosterone, and some had been taking testosterone and stopped taking it in order to become pregnant. Of those who had not taken testosterone before pregnancy, some had started to take it afterward, some intended to start but had not yet, and some did not intent to start.
None of the participants had genital surgery prior to their pregnancies. Some had genital or reproductive organ surgery (metoidioplasty, phalloplasty, and hysterectomy) after pregnancy.
Some participants had had no chest surgery prior to their pregnancies. Others had had chest reduction, with a mix of surgical techniques. Of those without prior chest surgery, some chose to nurse their child “I fed both my kids mammal-style until they were one,” and some did not. Of those with prior chest surgery, some produced sufficient milk and fed their child for over 6 months, some swelled but did not lactate, and some experienced no swelling or lactation.
Structural barriers, erasure, and transphobia
Participants described myriad challenges and barriers to care throughout their process of reproductive planning, conception, pregnancy, delivery, and the postpartum period. Most of these barriers can be attributed to erasure and/or transphobia.
‘Pregnant man’ as unintelligible
One pervasive way erasure functioned to disempower participants was to produce a discourse in which the notion of a pregnant man was unintelligible. “They could not make sense of the concept at that time of being male and pregnant.” For participants themselves, the absence of any models of transgender men choosing pregnancy was profoundly disempowering, “that was the thing that I most wanted, was to be aware that some other people were doing it.” Those with even one example cited it as immensely affirming of their choices and experiences. “I had seen a documentary where a trans guy was pregnant… so that helped me roll with it when I did get pregnant… by accident.”
Lack of biomedical information and provider training
There is a dearth of biomedical research and education on the lives and issues of concern to transgender people in general. This applies even more so to issues of reproduction. Participants described frustration with the lack of information on the short-term and long-term effects of testosterone on reproductive organs, ease of conception, pregnancy outcomes, mental health, and lactation. These pervasive questions directly disempowered patients through limiting information useful in informed decision-making. For example, the above participant delayed childbearing for a decade while waiting for information about the effects of testosterone. This lack of information was experienced as coming from paltry research and/or inadequate provider training. One participant articulated the importance of providers “differentiat[ing] between ‘I don’t know’ and ‘science doesn’t know’.”
Per participant perceptions, this lack of information also interacts with individual providers values. Some participants perceived women’s health providers as unwilling to treat transgender male patients.
“I had heard many times over that [providers] felt uncomfortable with me. And just as a blank statement, I can only read into what that means. But they also said that they didn’t have anything to refer to. [A transgender male patient seeking pregnancy] was too new and too different for them, and they didn’t have studies to look at. They didn’t know if this was safe, none of that. So I think that they were afraid of helping, and getting it wrong, in addition to feeling uncomfortable.”
This participant perceived the provider’s decision (choosing not to provide care) as the consequence of both inadequate information and personal discomfort, where neither alone would necessarily have led to that decision.
Lack of cultural competency
Participants reported a long list of ways that providers and medical staff demonstrated a lack of cultural competence in their interactions. Prime examples of mistreating patients due to lack of cultural competency included:
Addressing the patient with the wrong title or pronoun, “this one [clinic], it was always ‘miss’ this and ‘her’ that.”
Calling the patient by their legal name rather than the name they use, “she called me by my legal name, which is not the name I use.”
Presuming to know the shape of a patient’s genitals by their name or face,
Ignoring intake forms that ask patients’ gender, “they even asked gender and preferred name on their intake form, but the person who called me back, and the doctor, never looked at it.”
Presuming that a patient has, or should have, a given relationship with their body “This midwife… forced me to reach inside and touch my babies head, even though I clearly didn’t want to.”
And discussing gender identity as though it is sexual orientation.
Participants described comments that were probably intended to be affirming or positive, but had the effect of tokenizing or objectifying them, “many people said ‘Oh, you’re so amazing…’ [they] were really trying to be kind and reach out to me. I just felt kind of tokenized.” An example is being told, “you should be on Oprah,” by a nurse in the middle of an intimate procedure.
Participants describe “getting laughed at” by providers and nurses, having providers “make references…to bad fiction… about trans women,” and nurses refusing to see them. One patient described a fertility specialist who “just thought I was too masculine to get pregnant.” Another was denied lactation coaching in the hospital.
Participants described such events as “transphobic.” Recounted experiences centered around rudeness, which was more or less overt. Consider this description of a physician conveying a new diagnosis of a medically urgent ectopic pregnancy and the subsequent treatment steps:
“It’s in the way he talks to you. It’s in the things that he says. It’s in the things that he doesn’t say. And I could tell that this physician was creeped out by me. He didn’t need to say it.”
In addition to rudeness, participants experienced a pathologization of being transgender. For participants, this came across when being transgender was seen as a problem. Several participants reported social services threatening or attempting to remove their children from their care, even before the birth and in one case lasting years afterward.
“Social Services [said] ‘we’re deeming you as a risk to your child, and we’re going to try and get a court order to take her off you on the basis of neglect’.”
Inappropriate medical care
Patients reported that some providers performed seemingly unnecessary physical exams – especially pelvic exams – and asked questions that felt prurient, exotifying, voyeuristic, and superfluous to the patient’s care. “The doctor asked me some weird questions that didn’t have to do with the [reason I was there], but with my [genitals].”
One participant described an example of how the specter of transphobia can act as a barrier to appropriate care:
“I had a wound on my finger that did not heal for 6 months, while I was breastfeeding… The first doctor I told that I was trans, and that I was breastfeeding, and that I could not take any medicine that would harm the child. Then he asked me some weird questions that didn’t have to do with the wound, but with my being trans and breastfeeding a baby. So I went to another doctor. I did not tell I him was trans, so I did not tell [him] that I breastfed… I got some medicine, which evidently goes into the milk and would harm the baby. So I tried to take these medicines. The baby got sick. I stopped taking the medicines, and I decided to go to a third doctor… [In all,] I went to see five different [doctors]. This is why I hardly ever go to see a doctor now.”
In this case we see a patient receiving what they see as inappropriate medical care due to provider unfamiliarity with the patient’s obstetric history and current breastfeeding. In attempting to access appropriate and comfortable care, the patient incurred an extra burden in time and resources. Moreover, the patient’s repeated experiences with care that they perceived to be culturally inappropriate served as a deterrent to the patient seeking further care.
Another participant said, “I never really wanted to do a home birth… I was only going to have a home birth just out of fear of how the hospital wouldn’t be able to deal with me.” Here, we see a patient avoiding the hospital and changing care potentially for less support, during a medically intense time – labor – out of fear of transphobia, discrimination, and invasive experiences.
Some participants were denied reproductive care because of provider attitudes about their gender,
“I went to this doctor… to sign the form to get donor sperm…and he made me see the clinic psychologist to gauge whether or not I’d be fit as a parent. And so she saw me and [my spouse]. And then after that it went to their ethics board, and the ethics board said that they weren’t going to treat us. So [the doctor] turned us away.”
Other participants who live their lives as ‘out’ men discussed how they pretended to be women in order to avoid such barriers at sperm banks and clinics. As a private service, sperm banks are allowed to determine whether or not to provide sperm to any given client, based upon that bank’s judgment and many require prior medical approval from a physician . These participants perceived, through personal experience, ‘word of mouth,’ or general caution that sperm banks are likely to deny sperm to a client who does not meet their norms for prospective parents. Some clients opted to reduce their risk by “let[ting] them think I was female” and “I didn’t want to risk a problem, when I could avoid it, and the stakes were my ability to get pregnant…”
Some transgender men even experienced barriers to care from providers who provide gender-affirming care (i.e., hormones and surgery), stating that they had to conceal their reproductive goals in order to receive appropriate gender-related care. One participant noted: “Then they would definitely think you are not really trans if you still want to have a baby, [and] so they would not [give you hormones].” Here, participants perceived that providers’ norms (i.e., that only women choose to become pregnant) would lead providers to deny care to transgender men because of their reproductive intent.
“But mostly just don’t make assumptions. That’s the main thing, if you would just not make assumptions. And I guess that sounds kind of weird to probably a lot of people who treat pregnant women. Because they’re like, what do you mean? If someone’s pregnant, then they must be a woman. I’m like, no, that’s actually not true. So I think like if you could get people to grasp that, then you’d have made a lot of progress.”
Many OB/GYN spaces “feel like they only cater to women giving birth…and that made me feel alienated.” This was true in the physical space and decoration as well as education materials with mottos, pamphlets, posters, etc. Many participants noted that they had challenges even with physical space wherein clinics only had restrooms for women. This is in keeping with other literature on the topic [3, 16, 17].
Participants described information systems that did not have the capacity to account for a man needing services traditionally ascribed to female-only patients, in several ways. First, men who needed obstetrical (e.g., prenatal or post-partum care) or gynecological services (e.g., pap smears, cervical sexually transmitted infection testing) often faced challenges with booking or billing for those services, because of how computer and filing systems were managed. Second, many record systems did not have the capacity to differentiate between a patient’s legal name and the name they should be called. Third, although some clinics had intake forms on which patients could accurately report their gender, participants reported that many providers did not refer to these forms during visits. Finally, most men in this study reported that it was difficult or impossible to be listed as ‘father’ on their child’s birth certificate, despite this being their parental identity. Some had to undertake a legal battle, or even adopt their own children, in order to be legally recognized as a father. Overall, participants felt that these combined conditions conveyed the message that their lives could not exist within the system, and their identities did not matter.
Positive experiences with healthcare providers
While many participants experienced mistreatment throughout the healthcare system, many also reported having positive healthcare experiences. Positive experiences were characterized both by the presence of positive features in clinical encounters (e.g., privacy, gender affirmation, and normalization) and by the absence of aversive features (e.g., misgendering, invasive questions, or exotification).
Participants consistently described the use of their appropriate name and pronouns as fundamental to feeling safe. A few patients described whole healthcare teams who were consistently good about this,
“And they were, like, super-conscientious about it. Like we were off on the side where people wouldn't be barging in. And they were consulting me before anybody came in the room. And they were using the right pronouns. And they were not weird about it. They didn't ask me any weird questions. It was just unbelievable. I was just kind of blown away at how good they were about it.”
This participant perceived their treatment to be exceptional and described this in direct contrast to their more common experiences with care that was much less gender affirming.
Naming and normalizing the patient’s gender can be valuable, if it can be done genuinely:
“I walked in and the doctor who I saw, like, the very first one, she was, like, ‘Look, you're not the first pregnant guy we've had. So don't worry about that…’ I just really prefer if healthcare providers can act as though it's not exceptional or weird to be trans.”
Additional safety seemed to come from explicitly not identifying transgender experiences as exotic or medically unique, as one participant noted:
“I … really dislike it when people are like, ‘So, that must be so interesting to be trans’.”
Participants spoke highly of providers who responded well to being outside familiar territory, either medically or culturally, “She took it upon herself to educate herself, … and learned what she could before my next visit.” They appreciated when providers did not expect their patients to teach them, but listened and learned when the patient did teach. Providers built trust by differentiating between what they themselves did not know and what medicine in general did not know. When providers could not find satisfying evidence-based guidance – such as whether it is safe to start taking testosterone while still breastfeeding – some providers were good at discussing the uncertainty with their patient, and jointly evaluating risks. This is in contrast to other providers whose style of approach seemed to be that of reflexively ruling out any approach that had a hypothetical risk.
One participant observed a common feature of providers with whom he had good interactions. “[They are] appreciative of the fact that their regular day-to-day routine is shaken up a little bit. As opposed to freaked out.”
Many reported having had one provider (often a primary care provider or obstetrician) with whom they had a good relationship. These same participants continued to note difficulty with other providers, such that having a good provider did not attenuate other experiences but did delineate between some positive and negative patterns of interactions in the ways they were treated.
A common theme was the participants’ difficulty in identifying in advance a provider with whom they could have a positive relationship. Some successfully found good providers through community networks or health organizations specifically serving the lesbian, gay, bisexual, and transgender communities. Some happened upon a provider who was initially not well informed, but who was able to build a good relationship and pursue guidance on how to provide medically and culturally appropriate care. However, some struggled to ever find providers with whom they felt safe. On the whole, although participants wanted their providers to be able to answer all their biomedical questions about transgender-specific situations, what they cared about more was being accepted and respected for who they were.
Anticipatory guidance throughout the family planning process
Participants described a number of ways in which they were surprised by their experience, and frequently offered advice or information they wish they had received early in their process. One common theme was that, when patients are seeking care for transition (hormones or surgery), their providers should initiate discussions about reproductive options. Participants wished they had had better information about fertility preservation (e.g., egg cryopreservation or embryo preservation) early in their decision-making. They also wanted information on the impact of gender-affirming procedures (both medical and surgical) on future reproductive health and function (e.g., the effects of chest reconstruction on lactation, the effects of testosterone on future fertility, and the ability to carry a pregnancy). Patients wanted a general description of options and known and unknown impact of these procedures but also wanted to understand the specific logistics around fertility preservation procedures. They also stressed that this information should not only come from reproductive health providers but from those who were initiating and/or facilitating gender-affirming procedures. For example, “The egg freezing, the embryo freezing, it has to come from the transition providers.” “I wish they had talked to me about what to do if I wanted to get pregnant, when they gave me T [testosterone].”
Another common theme was unanticipated emotional experiences associated with stopping testosterone, being pregnant, and/or the postpartum period. For some, these shifts in emotions were entirely unanticipated, and others still found them challenging even if they suspected they might occur. Many participants experienced a stable mood throughout the processes of discontinuing testosterone, being pregnant, and the postpartum period. Some described a very positive experience, “being pregnant… I just felt great.” Some of the participants who had been on testosterone reported struggling with emotional changes after stopping testosterone, while pregnant, and/or in the postpartum period.
“Healthcare professionals need to know that postpartum depression needs to be talked about more, and it really needs to be talked about with trans men who plan on having babies and plan on breastfeeding, meaning that they won’t be getting back on testosterone to level out the hormones. Because that roller coaster was an insanity you cannot describe.”
These participants wished that someone had advised them that such moods might happen. They also expressed a desire for normalization and contextualizing these moods as part of rapid hormonal changes and not a sign of some other medically concerning problem.
“I hated being pregnant. It was just awful… The thing that helped the most… is my friend saying ‘it’s okay to hate being pregnant, it doesn’t mean you’re a bad parent….’ It helped me be okay with it…”
While this may be true for any pregnant patient, many participants linked their prior testosterone use and their tenor of emotional experience surrounding pregnancy. Many participants had no memory of being advised about postpartum depression before giving birth, or of having discussed it with providers afterward, and felt ill-equipped to differentiate depression from less concerning mood swings.
“By then I had seen a lot of providers, and no one had discussed postpartum [depression] with me. I thought it was normal until [my family member] told me I was sick and needed to see someone.”
Participants perceived a recent rapid increase in the incidence of transgender men getting pregnant. This increasing visibility was often tied to optimism and hope, insofar as increasing familiarity with the topic among providers would make it easier for other transgender men in future pregnancies.
“I think today it’s better because there are more people coming forward giving birth, and it’s not such a mind blower like it was when my pregnancy came up. Now that it’s out there, it’s like, yeah, we’ve seen this before. And more people are supportive.”
“Times are changing, and there are a lot of gay [transgender men] out there, some of whom are getting pregnant.”
“Ten years ago I probably would have been sent to a psych ward to have my baby taken away. But ten years from now I hope that things will be even better than [they were for me]. This really [will] become normalized.”