I dreamed of having children from a young age — so much so that I assumed I had to be a cisgender woman. Society had taught me that only a cisgender woman would want so badly to carry and birth a child, so I suppressed any feelings that suggested I might not be a cisgender woman. I did not realize I was transgender until well after I had my children.
Now, I wish I could have experienced pregnancy and childbirth while living openly as a nonbinary transgender man.
I’m not the only one. Many transgender and gender diverse (TGD) people who are able to become pregnant and give birth decide to do so. But birthing TGD people are largely excluded from the important conversations about access to high-quality, compassionate prenatal care.
Many are skeptical about these conversations — particularly when it comes to using inclusive language about “birthing people” instead of “pregnant women” or “chest feeding” instead of “breast feeding” — because they believe that very few TGD people give birth or want to. Why change long-standing language practices for what is assumed to be a tiny group?
But the fact is that we do not know how many birthing TGD people there are, due to both data blind spots and social challenges.
In almost all cases, maternal health data reporting assumes that, well, the birthing person is maternal. It does not include gender information. Even if a birth certificate lists the birthing person as male, as is possible in Massachusetts, the Office of Vital Records and Statistics does not differentiate between female and male birthing people in the state’s Annual Birth Report.
These problems also happen when receiving care. Birthing TGD people have reported in research articles and on social media that doctors have refused to provide prenatal care, saying they are unable to meet the patients’ needs.
Many birthing TGD people are also denied insurance coverage for prenatal and postpartum care. According to many insurance schemes, only cisgender women can be pregnant. So pregnancy-related claims from anyone other than cisgender women are denied. In a similar vein, electronic medical record systems require patients to be identified as female or male and may automatically prevent care based on a patient’s gender. In one research article, a birthing TGD person shared that they were denied an epidural during labor because the hospital’s electronic medical record system prevented them from receiving the fetal monitoring required with an epidural. Another birthing TGD person said they had to bring physical copies of their records to appointments because the clinic’s electronic medical record system was unable to create a patient profile for a pregnant man. This limits the efficacy of built-in safety mechanisms, increasing the pregnant person’s risk for trauma and injury.
Electronic medical record systems may even prevent an accurate recording of a person’s medical history, such as a transgender man’s obstetric history. They may also inaccurately report lab results because normal levels may be different for cisgender people, something I have experienced several times. These systems need to be updated or replaced. The cost of not doing so could be patient lives.
Many birthing TGD people choose to pass as cisgender women or hide their pregnancies to limit their exposure to transphobic discrimination and violence. In a study published in the International Journal of Transgender Health, researchers found that patients reported experiencing prejudicial treatment, physical and social isolation, loss of choice and control during labor, and poor care leading to preventable baby loss. These are serious risk factors for traumatic birth. But again, we don’t know how common these experiences are, due to data blind spots.
Imagine attempting to navigate these challenges while experiencing miscarriage, infertility treatments, and high-risk pregnancies. How can you navigate such difficult and highly vulnerable experiences while being made to feel invisible?
Many birthing TGD people report involvement with social services before their child is even born. I have seen this both in research and from birthing TGD people seeking community and support on social media. The common theme is that health care providers report birthing TGD people to social services solely due to their gender, arguing that they were unsure how the pregnant person would react to having a child.
Choosing to pass as a cisgender woman and hiding their gender identity during pregnancy prevents birthing TGD people from receiving critical gender-affirming care throughout the pre-pregnancy, pregnancy, childbirth, and postpartum periods. Gender-affirming care is more than access to hormones — it includes social affirmation, such as using the correct name and pronouns and wearing clothing that affirms their gender identity. This means providers should ask their patients about their gender identity, rather than assume their pregnant and birthing patients must be cisgender women. They should also use the self-reported gender of their pregnant and birthing patients when reporting maternal health data.
Anti-trans legislation and the ongoing restriction of reproductive rights in many states is creating an especially precarious situation for people who are already made to feel invisible. This year is the fifth consecutive record-breaking year for anti-trans legislation, with more than 630 bills under consideration across the country as of late July. Legislation is needed to protect TGD people and their reproductive rights.
Massachusetts is one state making strides towards better supporting diverse families that others can emulate. State-issued birth certificates list “parents” rather than “mother” and “father.” State-issued birth certificates also now include a X option, in addition to female and male. The Massachusetts Parentage Act makes the state parentage law equitable for all families, and its text refers to “person who gave birth” instead of “mother.” Massachusetts is also among only 14 states that include a question about the birthing person’s gender on the Pregnancy Risk Assessment Monitoring System survey from the CDC.
Now, those policies need to become nationwide. Perhaps that is unlikely to happen in the near future, but that doesn’t mean we can’t work toward it. This starts with including TGD birthing people in maternal health data reporting. The desire for children should not prevent a person from being able to explore their gender identity. And experiencing pregnancy should not prevent a TGD person from receiving high-quality, compassionate prenatal care.
Gavin Fraser is a graduate research assistant pursuing a master of social work at Boston University School of Social Work.