Transgender pregnancy

Transgender pregnancy is the gestation of one or more embryos or fetuses by transgender people. As of 2023, the possibility is restricted to those born with female reproductive systems. However, transition-related treatments may impact fertility. Transgender men and nonbinary people who are or wish to become pregnant face social, medical, legal, and psychological concerns. As uterus transplantations are currently experimental, and none have successfully been performed on trans women, they cannot become pregnant.

Trans men

 

Pregnant trans man Zack Elías and his transgender wife, Diane Rodríguez.

Pregnancy is possible for transgender men who retain functioning ovaries and a uterus, such as in the case of Thomas Beatie.^[1] Regardless of prior hormone replacement therapy (HRT) treatments, the progression of pregnancy and birthing procedures are typically the same as those of cisgender women. Delivery options include conventional methods such as vaginal delivery and cesarean section, and patient preference should be taken into consideration in order to reduce gender dysphoric feelings associated with certain physical changes and sensations.^[2] It has been shown that historical HRT use may not negatively impact ovarian stimulation outcomes, with no significant differences in the markers of follicular function or oocyte maturity between transgender men with and without a history of testosterone use.^[3]

Among the wide array of transgender-related therapies available, including surgical and medical interventions, some offer the option of preserving fertility while others may compromise one's ability to become pregnant (including bilateral salpingo-oophorectomy and/or total hysterectomy).

Effect of masculinizing hormone therapy

Exposing a fetus to high levels of exogenous testosterone may damage an unborn child, especially the urogenital system of a female fetus.^[4] This is particularly important in the first trimester when many pregnancies have not been discovered yet.^[5] Previous studies of pregnancies in women suggest that high levels of endogenous androgens are associated with reduced birth weight, although it is unclear how prior testosterone in a childbearing trans person may affect birth weight.^[2] Future pregnancies can be achieved by oophyte banking, but the process may increase gender dysphoria or may not be accessible due to lack of insurance coverage.^[6]

Additionally, patients experiencing amenorrhea (a common side effect of HRT) may experience additional challenges in identifying early pregnancies due to the lack of regular menstrual cycling that could indicate a pregnancy if missed, for example.^[5] For this reason, it is important for patients and healthcare practitioners to comprehensively discuss fertility goals, family planning and contraceptive options during gender-affirming care.^[5] Many trans men who had planned pregnancies were able to conceive within six months of stopping testosterone.^[6] Testosterone-induced changes to the reproductive tract may be partly or completely reversed after stopping HRT.

HRT for trans men eventually decreases fertility. Continued use of testosterone suppresses the ovarian cycle and uterine cycle, which would otherwise cause oocyte maturation, ovulation, and menstruation every month. Testosterone therapy also causes atrophy of the vagina and uterus.^[7] Testosterone use in trans men and other transmasculine individuals affects the ovaries, leading to an increased amount of ovarian cysts, which is also seen in cis women with PCOS. Individuals studied also displayed follicular atresia, overgrowth of the stroma, and the replacement of ovarian tissue with collagen. The uterine tubes of many trans men studied were also closed or partially closed; normally, the uterine tubes are clear, allowing for fertilized oocytes to move to the uterus. However, observation of trans men and studies on lab mice reveal that testosterone treatment does not affect the number of available gametes (eggs/sex cells).^[8]

In a study of American trans men, 28.3% reported that they were afraid of not being able to become pregnant because of hormone therapy. Because some trans men want to carry children, it is important for providers to discuss fertility preservation options with trans male clients before prescribing HRT.^[9]

Despite its effects on fertility, testosterone therapy is not an effective contraceptive. Trans men and nonbinary people who take testosterone may still become pregnant even if their periods have stopped.^[2][10] Trans men may experience unintended pregnancy,^[6][9] especially if they miss doses.^[6]

Another important postpartum consideration for trans men is whether to resume testosterone therapy. There is currently no evidence that testosterone enters breast milk in a significant quantity.^[11] However, elevated testosterone levels may suppress lactation and healthcare guidelines have previously recommended that trans men do not undergo testosterone therapy while chestfeeding (breastfeeding).^[12] Trans men who undergo chest reconstruction surgery may maintain the ability to chestfeed.^[13]

Mental health

Special consideration of the mental health of transgender people during pregnancy is important. It has previously been shown that transgender individuals often experience higher rates of suicidality than cisgender people and lesser degrees of social support from their environment and familial relationships.^[14][15] Relatedly, many transgender individuals experiencing pregnancy reported that choices of healthcare providers were substantially impacted by the views of the healthcare worker, and many transgender people prefer midwifery services rather than experience labor and delivery in a hospital.

Some individuals reported having gender dysphoria and feelings of isolation due to the public reception of their gender identity and drastic changes in appearance which occur during pregnancy, such as enlarged breasts.^[16] Some state feeling disconnected or alienated from their pregnant bodies. Both social gender dysphoria (related to perception by others) and physical gender dysphoria (perception of one's own body) can occur while a trans person is pregnant.^[17][18]

Unintended pregnancy can also be dangerous to a trans person's mental health. According to a study of American transgender men between the ages of 18 and 45, 30.5% reported being afraid of pregnancy.^[19] Unwanted pregnancy can cause severe gender dysphoria and suicidal ideation in trans people. One nonbinary person who performed a self-induced abortion stated,^[20]

[I used] blunt force to [my] abdomen. Considered drinking poison, as my insurance did not cover an abortion. Luckily, I was able to get on state insurance which did cover the procedure, so it did not come to that. I 100% would have done it. Dying was a better alternative to forced pregnancy.

According to the National Transgender Discrimination Survey, postpartum rates of suicide and depression in trans individuals has been found to be higher than the adult average.^[15] This may be attributed to factors such as lack of social support, discrimination, and lack of adequate healthcare practitioner training.^[15]

Sociocultural factors

Transgender people, including trans men and nonbinary people, are more likely than the general population to experience homelessness, food insecurity, intimate partner violence, and adverse child experiences. All of these can impact pregnancy outcomes. Additionally, trans people experience minority stress and may be at higher risk of substance use than the general population. Some also report avoiding medical care or mistrusting medical professionals because of discrimination.^[21]

Medical discrimination

Some trans men who carry pregnancies are subjected to discrimination, which can include a variety of negative social, emotional, and medical experiences, as pregnancy is regarded as an exclusively feminine or female activity. Several studies indicate a lack of awareness, services, and medical assistance available to pregnant trans men.^[16] Inaccessibility to these services may lead to difficulty in finding comfortable and supportive services concerning prenatal care, as well as an increased risk for unsafe or unhealthy practices.

Abortion

Unintended pregnancies can result in transgender men or nonbinary people considering or attempting self-induced abortion. Many transgender men report attempting a self-induced abortion because of lack of safe, effective abortion methods.^[20] Studies differ on abortion rates in trans men. Different studies report that between 12%^[9] and 21% of trans people's pregnancies end in abortions. Some trans people report choosing between abortion and suicide because pregnancy causes terrible gender dysphoria.^[20]

Statistics

According to figures compiled by Medicare for Australia, one of the few national surveys as of 2020, 75 male-identified people gave birth naturally or via C-section in the country in 2016, and 40 in 2017.^[22]

Non-binary people

Non-binary people with a functioning female reproductive system can give birth.^[23]

Nonbinary people taking testosterone to transition must interrupt HRT in order to carry the pregnancy, as testosterone is a teratogen.^[4] Unintended pregnancies by non-binary people on testosterone therapy may be more common if they are on a low dose of testosterone.^[6] Nonbinary parents choose whether to be called "mom," "dad," or newly coined gender-neutral or nonbinary titles.^[24]

Non-binary people who have written or been profiled about their experiences of pregnancy include Rory Mickelson,^[25] Braiden Schirtzinger,^[26] and Mariah MacCarthy.^[27]

Trans women

 

Lili Elbe in October 1930, a year before her death from a rejected uterus transplant

Further information: Uterus transplantation

Pregnancy is not possible for transgender women as they lack a female reproductive system. As of 2019, uterus transplantation has not been successfully performed in transgender women.^[28] The Danish transgender painter Lili Elbe died in 1931 from surgical complications following an attempt at such an operation.

Uterine transplantation, or UTx, is in its infancy and is not yet publicly available. As of 2019, in cisgender women, more than 42 UTx procedures had been performed, with 12 live births resulting from the transplanted uteri as of publication.^[29] The International Society of Uterine Transplantation (ISUTx) was established internationally in 2016, with 70 clinical doctors and scientists, and currently has 140 intercontinental delegates.^[30]

In 2012, McGill University published the "Montreal Criteria for the Ethical Feasibility of Uterine Transplantation", a proposed set of criteria for carrying out uterine transplants, in Transplant International.^[31] Under these criteria, and because no research has been conducted in genetic males, only a genetic female could ethically be considered a transplant recipient. The exclusion of trans women from candidacy is justified by the lack of research to determine how to conduct the surgery, rather than an inherent bar.^[32] In 2021, authors of the Montreal Criteria published a revised set of criteria in Bioethics with an ethical framework for consideration of genetic males' (and other genetic XY individuals') eligibility for uterine transplants.^[33]

In 2020, Mikey Chanel, an intersex trans woman, allegedly managed to achieve pregnancy after being artificially fertilized following a diagnosis of persistent Müllerian duct syndrome. She was assigned male with XY chromosomes and external male reproductive organs, but discovered she had internal female reproductive organs after an X-ray, which diagnosed her with PMDS.^[34][35][36] No further information was released. Since Chanel's announcement, many have suspected it to be a hoax, citing Chanel's inaccuracies of describing PMDS symptoms and her history of sensationalism and radical attempts at social media popularity. Chanel has since taken down her social media pages.

Society and culture

In 1583, an intersex person that had masculine gender expression reportedly became pregnant in Beaumaris, Wales.^[37]

Unicode introduced "pregnant man" and "pregnant person" emojis in version 14.0, approved September 2021.^[38] However, this came with some controversy, as some viewed it to be absurd.^[39]

See also

• Transgender rights
• LGBT parenting
• LGBT reproduction
• Male pregnancy
• Engineered uterus

References

1. Beatie, Thomas (April 8, 2008). "Labor of Love: Is society ready for this pregnant husband?". The Advocate. p. 24.
2. Obedin-Maliver, Juno; Makadon, Harvey J (2016). "Transgender men and pregnancy". Obstetric Medicine. 9 (1): 4–8. doi:10.1177/1753495X15612658. PMC 4790470. PMID 27030799.
3. Adeleye, Amanda J.; Cedars, Marcelle I.; Smith, James; Mok-Lin, Evelyn (October 2019). "Ovarian stimulation for fertility preservation or family building in a cohort of transgender men". Journal of Assisted Reproduction and Genetics. 36 (10): 2155–2161. doi:10.1007/s10815-019-01558-y. PMC 6823342. PMID 31435820.
4. Thornton, Kimberly G.S.; Mattatall, Fiona (August 23, 2021). "Pregnancy in Transgender Men". Canadian Medical Association Journal. 193 (33): E1303. doi:10.1503/cmaj.210013. PMC 8412429. PMID 34426447.
5. Krempasky, Chance; Harris, Miles; Abern, Lauren; Grimstad, Frances (February 2020). "Contraception across the transmasculine spectrum". American Journal of Obstetrics and Gynecology. 222 (2): 134–143. doi:10.1016/j.ajog.2019.07.043. PMID 31394072. S2CID 199504002.
6. Berger, Anthony P; Potter, Elizabeth M; Shutters, Christina M; Imborek, Katherine L. (24 August 2015). "Pregnant transmen and barriers to high quality healthcare". Proceedings in Obstetrics and Gynecology. 5 (2): 1–12. doi:10.17077/2154-4751.1285.
7. Hembree, Wylie C.; Cohen-Kettenis, Peggy; Delemarre-van de Waal, Henriette A.; Gooren, Louis J.; Meyer, Walter J.; Spack, Norman P.; Tangpricha, Vin; Montori, Victor M. (September 1, 2009). "Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline". Journal of Clinical Endocrinology and Metabolism. 94 (9): 3132–3154. doi:10.1210/jc.2009-0345. PMID 19509099. S2CID 20486653.
8. Kinnear, Hadrian M.; Moravek, Molly B. (February 2023). "Effects of Masculinizing Therapy on Reproductive Capacity". In Moravek, Molly B.; de Haan, Gene (eds.). Reproduction in Transgender and Nonbinary Individuals. Springer Publishing. pp. 33–47. doi:10.1007/978-3-031-14933-7. ISBN 9783031149337.
9. Light, Alexis; Wang, Lin-Fan; Zeymo, Alexander; Gomez-Lobo, Veronica (October 2018). "Family planning and contraception use in transgender men". Contraception. 98 (4): 266–269. doi:10.1016/j.contraception.2018.06.006. PMID 29944875. S2CID 49434157.
10. Bonnington, Adam; Dianat, Shokoufeh; Kerns, Jennifer; Hastings, Jen; Hawkins, Mitzi; De Haan, Gene; Obedin-Maliver, Juno (August 2020). "Society of Family Planning clinical recommendations: Contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth". Contraception. 102 (2): 70–82. doi:10.1016/j.contraception.2020.04.001. PMID 32304766. S2CID 215819218.
11. Glaser, Rebecca L.; Newman, Mark; Parsons, Melanie; Zava, David; Glaser-Garbrick, Daniel (2009). "Safety of maternal testosterone therapy during breast feeding". International Journal of Pharmaceutical Compounding. 13 (4): 314–317. PMID 23966521.
12. Gorton, Nick; Buth, Jamie; Spade, Dean. Medical therapy and health maintenance for transgender men: a guide for health care providers. Lyon-Martin Women's Health Services. ISBN 0977325008. from the original on 2022-08-17. Retrieved 2021-09-29.
13. "Tips for Transgender Breastfeeders and Their Lactation Educators". from the original on 2021-09-04. Retrieved 2021-09-20.
14. Obedin-Maliver, Juno; Makadon, Harvey J (March 2016). "Transgender men and pregnancy". Obstetric Medicine. 9 (1): 4–8. doi:10.1177/1753495X15612658. PMC 4790470. PMID 27030799.
15. "Injustice at Every Turn: A Report of the National Transgender Discrimination Survey" (PDF). (PDF) from the original on 2022-12-15. Retrieved 2021-09-20.
16. Light, Alexis D.; Obedin-Maliver, Juno; Sevelius, Jae M.; Kerns, Jennifer L. (December 2014). "Transgender Men Who Experienced Pregnancy After Female-to-Male Gender Transitioning". Obstetrics & Gynecology. 124 (6): 1120–1127. doi:10.1097/AOG.0000000000000540. PMID 25415163. S2CID 36023275.
17. Greenfield, Mari; Darwin, Zoe (2020). "Trans and non-binary pregnancy, traumatic birth, and perinatal mental health: a scoping review". International Journal of Transgender Health. 22 (1–2). Taylor & Francis: 203–216. doi:10.1080/26895269.2020.1841057. PMC 8040683. PMID 34806082.
18. Verbanas, Patti (August 15, 2019). "Pregnant Transgender Men at Risk for Depression and Lack of Care, Rutgers Study Finds". Rutgers Today. Rutgers University.
19. Light, Alexis; Wang, Lin-Fan; Zeymo, Alexander; Gomez-Lobo, Veronica (October 2018). "Family planning and contraception use in transgender men". Contraception. 98 (4): 266–269. doi:10.1016/j.contraception.2018.06.006. PMID 29944875. S2CID 49434157. Most participants were not afraid of pregnancy (n=130, 69.5%)
20. Moseson, Heidi; Fix, Laura; Gerdts, Caitlin; Ragosta, Sachiko; Hastings, Jen; Stoeffler, Ari; Goldberg, Eli A; Lunn, Mitchell R; Flentje, Annesa; Capriotti, Matthew R; Lubensky, Micah E; Obedin-Maliver, Juno (January 2022). "Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States". BMJ Sexual & Reproductive Health. 48 (e1): e22–e30. doi:10.1136/bmjsrh-2020-200966. PMC 8685648. PMID 33674348.
21. Indig, Gnendy; Ramos, Sebastian; Stroumsa, Daphne (February 2023). "Obstetric, Antenatal, and Postpartum Care for Transgender and Nonbinary People". In Moravek, Molly B.; de Haan, Gene (eds.). Reproduction in Transgender and Nonbinary Individuals. Springer Publishing. pp. 75–96. doi:10.1007/978-3-031-14933-7. ISBN 9783031149337.
22. Hattenstone, Simon (April 20, 2019). "The dad who gave birth: 'Being pregnant doesn't change me being a trans man'". The Guardian. from the original on February 13, 2023. Retrieved April 3, 2023 – via www.theguardian.com.
23. Toze, Michael (May 2018). (PDF). Feminism & Psychology. 28 (2): 194–211. doi:10.1177/0959353517747007. S2CID 149082977. Archived from the original (PDF) on 2023-08-08. Retrieved 2023-07-02.
24. King-Miller, Lindsay (March 13, 2020). "Not All Parents Are "Mom" Or "Dad"". Ravishly. from the original on June 5, 2020. Retrieved June 4, 2020.
25. "I'm Pregnant, But I'm Not a Woman". www.advocate.com. 2018-11-13. from the original on 2019-12-12. Retrieved 2020-03-10.
26. "Non-binary, pregnant and navigating the most gendered role of all: Motherhood". Washington Post. from the original on 2019-09-14. Retrieved 2020-03-10.
27. "I'm Nonbinary. I Loved Being Pregnant. It's Complicated". Narratively. 2018-09-03. from the original on 2020-04-23. Retrieved 2020-03-10.
28. Cheng, Philip J.; Pastuszak, Alexander W.; Myers, Jeremy B.; Goodwin, Isak A.; Hotaling, James M. (June 2019). "Fertility concerns of the transgender patient". Translational Andrology and Urology. 8 (3): 209–218. doi:10.21037/tau.2019.05.09. PMC 6626312. PMID 31380227.
29. Jones, Bp; Williams, Nj; Saso, S; Thum, M-Y; Quiroga, I; Yazbek, J; Wilkinson, S; Ghaem-Maghami, S; Thomas, P; Smith, Jr (January 2019). "Uterine transplantation in transgender women". BJOG. 126 (2): 152–156. doi:10.1111/1471-0528.15438. PMC 6492192. PMID 30125449. S2CID 52046974.
30. . Archived from the original on 2021-11-23. Retrieved 2020-05-11.
31. Lefkowitz, Ariel; Edwards, Marcel; Balayla, Jacques (2012). "The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation". Transplant International. 25 (4): 439–47. doi:10.1111/j.1432-2277.2012.01438.x. PMID 22356169. S2CID 39516819.
32. Lefkowitz, Ariel; Edwards, Marcel; Balayla, Jacques (October 2013). "Ethical considerations in the era of the uterine transplant: an update of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation". Fertility and Sterility. 100 (4): 924–926. doi:10.1016/j.fertnstert.2013.05.026. PMID 23768985. in the absence of sufficient research demonstrating safety and efficacy, uterine transplant in men and trans individuals fails to meet the first stipulation of Moore's Criteria for Surgical Innovation, which requires that novel surgical procedures have an adequate research background. It is on this basis that the Montreal Criteria exclude nongenetic female recipients. However, it certainly bears mentioning that there does not seem to be a prima facie ethical reason to reject the idea of performing uterine transplant on a male or trans patient. A male or trans patient wishing to gestate a child does not have a lesser claim to that desire than their female counterparts.
33. Balayla J.; Pounds P.; Lasry A.; Volodarsky-Perel A.; Gil A. (2021). "The Montreal Criteria and uterine transplants in transgender women". Bioethics. 35 (4): 326–330. doi:10.1111/bioe.12832. PMID 33550647. S2CID 231862917.
34. Cliff, Martha (November 17, 2020). "Teenager raised as a boy announces pregnancy after discovery of female reproductive organs".
35. Agrawal, Saumya (November 18, 2020). "Trans teen who was raised as a boy is four months pregnant after finding she has ovaries and womb". Times Now News.
36. "A teen who was born with male genitalia has become pregnant after finding out that she also has working ovaries, a uterus, cervix and fallopian tubes". Yahoo News. November 16, 2020.
37. Hume, M.A.S. (2013). Calendar of Letters and State Papers Relating to English Affairs: Volume 3: Preserved Principally in the Archives of Simancas. Cambridge Library Collection - British and Irish History, 15. Cambridge University Press. p. 475. ISBN 978-1-108-06189-6. from the original on 2022-10-25. Retrieved 2022-10-25.
38. "Why is There a Pregnant Man Emoji?". 15 September 2021. from the original on 28 January 2022. Retrieved 29 January 2022.
39. "The pregnant man emoji and other absurdities". The Spectator Australia. May 12, 2022.