Mental Health 101: Trans Men Who Give Birth
Gender dysphoria, discrimination, and other considerations for the reproductive experiences of trans men
Mental Health 101 is an ongoing series where I discuss a mental health concern that is common throughout pregnancy or early parenthood. I’ve previously written about “the baby blues,” the global prevalence of postpartum depression, intrusive thoughts, postpartum psychosis, and abortion access.
This week I’m discussing what we know about the experiences of trans men who get pregnant and give birth.
I usually start these posts with some sort of personal anecdote, relating my experiences to what I’m going to write about. As a cisgender, straight, femme woman writing about trans men who give birth, that tactic feels disingenuous. In all honesty, I wanted to write about this topic because of the Texas Attorney General Ken Paxton’s heinous attempt to treat parents who seek gender-affirming care for their trans children as child abuse, something that the American Psychological Association’s president has condemned as unethical. There are a lot of things in the world to be angry about, and as a newly licensed clinical psychologist, this is one that has been on my mind a lot recently. Trans and nonbinary young adults, especially people of color, are at increased risk of transphobic violence and mental health concerns, with the Trevor Project’s 2020 national survey of LGBTQ youth reporting that over half of trans and nonbinary young adults seriously contemplated suicide that year. Gender-affirming care is in the best interests of the mental health needs of trans young adults, as it lowers the likelihood of them experiencing depression and suicide.
Pregnancy and giving birth are so closely tied to conventional ideas of being a woman. The gender binary is EVERYWHERE when you’re pregnant: friends asking, “Is it a boy or a girl?”, or family making well-meaning comments about your future child’s favorite color or sport or clothing preferences, all based on their genitalia and the social constructions of what it means to have those genitalia. It’s… a lot. The existence of pregnant men threaten these notions of womanhood and gender. Thus, pregnant men are often portrayed in media as aberrations or jokes, if they are portrayed at all.
The research on the experiences of trans and gender diverse individuals who experience pregnancy and/or give birth is scarce. The first study on assistive reproductive technology in trans men was published in 2019. The National Institute of Health only recently recognized transgender and gender non-conforming populations as health disparity populations in 2016.
A recent review by Bess, Lampe, and Mann (2020) titled, “Experiences with achieving pregnancy and giving birth among transgender men: A narrative literature review” summarizes themes present in 14 studies (from 2012-2019) that attempted to examine these experiences. The majority of these studies were qualitative studies, or studies where researchers analyze non-numerical data (e.g., verbal information from extensive interviews), that assessed patterns in the ways that transgender or transmasculine people discuss their beliefs, fears, or experiences related to their reproductive health.
Trans men experience a variety difficulties throughout their pregnancy journeys. This can include the necessity of medical interventions to achieve pregnancy for many (e.g., in vitro fertilization), though not for everyone (e.g., achieving pregnancy through penile-vagina intercourse). The medical system often explicitly and implicitly “otherizes” trans men during their reproductive journeys or acts as if they don’t exist (e.g., when an OB/GYN’s office is called a “women’s center”). Many men discussed the invalidation they feel when they work with practitioners who make it known that they have never worked with a pregnant man before, or who make transphobic or ignorant comments (“How can you be trans if you want a baby?”)
One of the major themes this review discussed is the heightened experience of gender dysphoria that pregnant men or men who give birth experience. Gender dysphoria is the clinically significant distress or impairment one can experience when their gender identity differs from their sex assigned at birth or their sex-related physical characteristics. Many men discussed how uncomfortable they felt with "routine” medical exams, such as cervical checks or transvaginal ultrasounds, or when their bodies presented as more feminine (e.g., enlarged breasts during pregnancy). As the authors state:
Pregnancy removes some bodily autonomy and a transgender man may feel unable to control the bodily changes that pregnancy brings. This can adversely impact their perception of their gender identity and their pregnancy experience. (p. 524)
Specifically, that feeling of having no control over one’s body is something anyone who has been pregnant can relate to, though obviously this feeling is unique for trans men. Many men discussed how vulnerable they felt during childbirth, experiencing hypervigilance (i.e., constantly assessing whether there is a threat in one’s environment) during the process. Fear of childbirth and satisfaction with medical staff during delivery have been shown to be predictors of postpartum posttraumatic stress in cis women, and I imagine this would be the same (if not more prevalent) for trans men. Unfortunately, this fear appears to be warranted, as gender diverse people experience high rates of discrimination in medical settings. One study that assessed over 1,110 gender diverse individuals across five European countries found that one in four respondents (including trans men) reported feeling personally discriminated against by a healthcare provider within the past year.
However, Bess and colleagues (2020) also discuss the strategies men use to take back control of their bodies in adaptive ways. For example, men differed in their decisions about disclosing their pregnancy to others. Some men reported how being pregnant and presenting as a man could lead to a lower quality of prenatal care and/or increased risk of discrimination and transphobic violence, so they decided to not disclose their pregnancy at all, hiding it as a “fat male belly.” Others decided to present as a woman during pregnancy, something they felt would be deemed as more socially acceptable. Still, others embraced their gender and their pregnancy status by being out as both pregnant and visibly masculine. Additionally, many men discussed seeking out nurse midwives for delivery rather than physicians, mostly from fear of discrimination in more medicalized settings. Many chose home births and/or worked with doulas to help them feel more in control of the birthing process. Because the research is so limited, it’s unclear which of these choices may have led to better mental health outcomes for these men. My speculation is that whatever helps someone feel more in control of their choices and their bodies, as well as more supported and safe, is the best option for them.
Reading about these experiences highlighted the privileges my gender presentation afforded me when I sought prenatal care. Pelvic exams were uncomfortable, but I did not experience gender dysphoria during them. I did not feel like I had to hide my pregnancy status or my gender expression for fear of discriminatory violence. I did not need medical intervention to get pregnant (a privilege that is not just about my status as a cis woman). While, as a woman, I’m used to people assuming that my body is for public comment and consumption, I understand how much worse it often is for trans and gender diverse individuals.
At the same time, in reading about these men’s pregnancy and birth experiences, I was struck by familiar fears and emotions. Feeling like you had a parasite growing inside of you, changing you in ways that you weren’t always comfortable with. Getting to know your body in a totally different way than any other time in your life. That total lack of control over one’s body during delivery. The comfort of a supportive doula (in my case, as the only other person of color in the delivery room). The disassociation from one’s body that can happen as a means of coping with the physical trauma of birth. Childbirth and parenthood, regardless of your gender, make you extraordinarily vulnerable in a multitude of ways.
I’ll end this piece the same way that Besse and colleagues (2020) ended their review:
[…] all people should have the right to bodily autonomy and be able to decide if and when to have children […] All people, regardless of gender identity, should be able to have safe and positive pregnancy and birth experiences […] Advancing the research on the experiences of transgender men becoming pregnant, being pregnant, and achieving childbirth is integral to realizing the principles of reproductive justice in policy and practice. (p. 527)
If you want to read more, the Trans Pregnancy Project, led by Professor Sally Hines at the University of Leeds, is the first international study of the reproductive practices of trans people (including trans men, transmasculine people, and non-binary individuals) who become pregnant and/or give birth after transitioning. They have a list of resources and publications on their website.
If you want to support LGBTQ+ parents and children in the US, here are some organizations doing important work: