Journal of Midwifery & Women’s Health www.jmwh.

org
Original Research

Conception, Pregnancy, and Birth Experiences of Male

and Gender Variant Gestational Parents: It’s How We Could
Have a Family
Simon Adriane Ellis, CNM, MSN, Danuta M. Wojnar, PhD, RN, MED, IBCLC, Maria Pettinato, RN, PhD

Introduction: Like members of any other population, transgender and gender variant people - individuals whose gender identity varies from the
traditional norm or from the sex they were assigned at birth - often seek parenthood. Little is known about the decision making and experiences of
these individuals, including male-identified and gender-variant natal females who wish to achieve parenthood by carrying a pregnancy. This pilot
qualitative study used grounded theory methodology to explore the conception, pregnancy, and birth experiences of this population of parents.
Methods: A grounded theory methodology was used to guide data collection and analysis. Eight male-identified or gender-variant gestational
parents participated in the study. Data collection included individual 60-minute to 90-minute interviews conducted by recorded online video
calls, as well as a self-administered online demographic survey. Data were collected from September 2011 through May 2012. Data saturation was
achieved at 6 interviews, after which 2 more interviews were conducted. The interviews were transcribed verbatim, and a constant comparative
method was used to analyze the interview transcripts.
Results: Loneliness was the overarching theme that permeated participants’ experiences, social interactions, and emotional responses during
every stage of achieving biologic parenthood. Within this context of loneliness, participants described complex internal and external processes
of navigating identity. Navigating identity encapsulated 2 subthemes: undergoing internal struggles and engaging with the external world. The
preconception period was identified as participants’ time of greatest distress and least involvement with health care.
Discussion: The findings of this study suggest that culturally-sensitive preconception counseling could be beneficial for transgender and gender-
variant individuals. The grounded theory produced by this pilot investigation also provides insights that will be useful to health care providers
and others working with male-identified and gender-variant prospective parents.
J Midwifery Womens Health 2015;60:62–69  c 2014 by the American College of Nurse-Midwives.

Keywords: cultural competency, gender identity, parenting, preconception care, testosterone, transgender, vulnerable populations

INTRODUCTION The current study sought to begin filling the gap in knowl-
Conservative estimates suggest that between 2% and 6% of edge by investigating the conception, pregnancy, and child-
the US population are transgender or gender variant,1 mean- birth perspectives of male and gender-variant gestational par-
ing their gender identity varies from the traditional norm ents who have undergone social or medical gender transition
(see Table 1 for definitions of gender-related terms). All prior to pregnancy.
gender-variant individuals face multiple barriers to access-
ing equitable health care,2–5 particularly in the area of repro- METHODS
ductive health.6–10 While limited research has demonstrated Grounded theory methodology as described by Glaser guided
that transgender and gender-variant individuals often de- the investigation.16 This is an inductive research approach that
sire parenthood, and can and do undertake pregnancy,11,12 requires openness of the researchers for data to inductively
published guidelines specific to gender-variant health con- emerge from the participants’ narratives.17 This approach is
tain very limited information on conception, pregnancy, and considered ideal for exploring social relationships and behav-
parenting.13,14 iors of groups when there has been little exploration of the
To date, no research has been published on physiologic contextual factors that affect individuals’ lives.18 The goal of
aspects of pregnancy after undergoing testosterone hormone our investigation was to explore social relationships and be-
therapy (HT) for masculinizing gender affirmation. Scarce havior patterns of male and gender-variant gestational parents
and conflicting information exists as to whether androgenic to guide clinical interventions.19
agents such as testosterone increase the risk of virilization Ethical approval for the protection of human subjects was
of the female fetus during pregnancy.15 No research has ad- obtained from the institutional review board at Seattle Uni-
dressed the medical or emotional consequences of HT discon- versity prior to participant recruitment. Participants were in-
tinuation or the feasibility and safety of pregnancy following formed of risks and benefits of participation, confidentiality
HT discontinuation. procedures, and their right to withdraw from the research.
Each signed consent forms prior to participating.
Address correspondence to Simon Adriane Ellis, CNM, MSN, Cedar Inclusion criteria were: 1) natal female sex; 2) lack of cur-
River Clinics, 263 Rainier Ave South, Suite 200, Renton, WA 98057. rent pregnancy at time of interview; 3) history of carrying
E-mail: [email protected] a pregnancy within the past 5 years that did not result in

62 1526-9523/09/$36.00 doi:10.1111/jmwh.12213 
c 2014 by the American College of Nurse-Midwives
 ✦ People whose gender identity varies from the traditional normal or from the sex they were assigned at birth can and do
achieve parenthood through pregnancy.
✦ Persistent loneliness and navigating identity formed a constant and significant backdrop of daily life for all participants,
requiring a considerable investment of energy and attention.
✦ Emotional responses to the process of achieving gestational parenthood ranged from joy to intense distress, with highest
levels of distress during the preconception period.
✦ Culturally sensitive preconception counseling could be beneficial for this population. Health care providers need to better
understand and support male and gender-variant individuals undertaking pregnancy.

pregnancy loss; 4) self-identification as male or gender vari- participants who reported multiple gender identities, 4 iden-
ant at the time of conception and throughout pregnancy and tified as male, 4 as transgender, 3 as genderqueer, 3 as female-
birth; 5) disclosure of gender identity to at least some health to-male, 2 as gender variant, one as two-spirit, and one as
care providers during conception, pregnancy, and birth; 6) androgynous. Six participants reported their sexual orienta-
having given birth in the United States; and 7) fluency in tion as gay, one as bisexual, and one did not disclose sexual
English. Study participants were recruited directly by health orientation.
care and social service providers using text provided by the Six study participants had legally changed their names
authors. Additionally, several participants self-initiated re- whereas 2 had not. Six had undergone testosterone HT
cruitment efforts within their community networks. Data col- whereas 2 had not. Seven study participants had undergone
lection took place from September 2011 through May 2012. gender affirming surgery whereas one had not. Six partici-
Saturation of the data occurred at 6 interviews, after which 2 pants had a male gender marker on their legal identification,
more were conducted. whereas 2 had a female gender marker. Methods of concep-
Data collection included individual 60-minute to 90- tion, birth setting, and health care providers varied among
minute interviews conducted by recorded online video calls, participants, with the majority (n = 5) conceiving or attempt-
as well as a self-administered online demographic survey. All ing to conceive via sexual intercourse, and 6 giving birth in
interviews were conducted by the primary author, and data a hospital setting with an obstetrician-gynecologist or fam-
analysis included all authors. All transcripts were initially ily physician (see Table 2). Several participants used multi-
coded using line-by-line gerund coding to protect against ple methods of conception as a result of difficulties conceiv-
premature theory formation.20,21 Focused coding was subse- ing. For example, participants who were partnered with natal
quently used to interpret larger fragments of data through the males attempted to conceive first via sexual intercourse and
lens of frequently occurring codes, and analysis was a nonlin- then sought fertility treatment as needed.
ear process of memo writing and constant comparison guided Loneliness was the overarching theme that permeated all
by the emerging data.20 This analytical process resulted in participants’ experiences, social interactions, and emotional
the creation of a schematic representation of grounded the- responses through every stage of achieving gestational par-
ory that reflected participants’ experiences. Continued memo enthood. Within this context of loneliness, which surfaces re-
writing, review of the data, conversations with experts, and peatedly throughout participant narratives, participants de-
member checking interviews with 7 out of 8 participants fur- scribed complex internal and external processes of navigating
ther contributed to the development and affirmation of the identity. A schematic representation of the grounded theory
emerging grounded theory. that emerged from the participants’ narratives is depicted in
Figure 1.
RESULTS
In total, 15 individuals requested to participate in the study.
Navigating Identity
Of these, 12 met all participation criteria. Four were lost to
follow-up prior to interview. The final sample was 8 individ- Navigating identity encapsulated 2 subthemes and their
uals. There was no participant dropout. related social processes. The first, undergoing internal strug-
All participants self-identified as white, and they reported gles, refers to participants’ wrestling with their own sense of
a wide range of spiritual/religious affiliations. Participants also self, thinking about the most feasible method of achieving
reported a broad spectrum of gender identities and sexual ori- parenthood, and decision making about disclosure. The sec-
entations for themselves and their partners, as well as many ond, engaging with the external world, refers to participants’
levels of gender transition and gender identity disclosure (see social interactions and use of disclosure or nondisclosure to
Table 2 for additional participant demographic information). best protect self and the future child. These themes and related
Six participants reported more than one gender identity, and processes constituted an integral part of participants’ daily
the other 2 participants identified solely as male. Of the 6 lives that infused most decisions, actions, and interactions.

Journal of Midwifery & Women’s Health r www.jmwh.org 63

 Table 1. Terminology Related to Gender Identity and Sexual Orientation
Androgynous Someone whose gender identity is both male and female, or neither male nor female.29
Bisexual A person emotionally, romantically, sexually, and relationally attracted to both men and
women, although not necessarily simultaneously.30
Female-to-male, FTM, transman Someone who was assigned as female at birth but who identifies and portrays his gender
as male.29
Gay A person who is emotionally, romantically, sexually, and relationally attracted to
members of the same sex.30
Gender expression The external manifestation of a person’s gender identity, expressed through carriage
(movement), dress, grooming, hairstyles, jewelry, mannerisms, physical
characteristics, social interactions, and speech patterns (voice).29
Gender identity A person’s innate, deeply felt psychological identification as a man, woman, or
something else, which may or may not correspond to the person’s external body or
assigned sex at birth.29
Gender transition or gender The process that people go through as they change their gender expression and/or
affirmation physical appearance to align with their gender identity.29
Gender variant or genderqueer Umbrella terms that include all people whose gender identity varies from the traditional
norm; also used to describe a subset of individuals who feel their gender identity is
neither female nor male.29
Hormone therapy (HT) The use of exogenous hormones for the purpose of gender transition or gender
affirmation.
Natal sex Male or female designation assigned at birth based on a person’s anatomy (genitalia
and/or reproductive organs) and/or biology (chromosomes and/or hormones).29 A
natal female is a person who was assigned female at birth.
Passing When people are perceived as the gender they are presenting in (eg, a transwoman who
is perceived by others as female, or a transman who is perceived as a man).29
Queer Often used interchangeably with lesbian, gay, bisexual, and transgender. The term may
have negative or derogatory connotations for some people; however, many are
comfortable using it.30
Sexual orientation A person’s enduring physical, romantic, emotional, and/or spiritual attraction to another
person. Sexual orientation is distinct from sex, gender identity, and gender
expression.29
Two-spirit Someone who displays characteristics of both male and female genders; sometimes
referred to as a third gender. The term is derived from the traditions of some native
North American cultures.29
Transgender An umbrella term for people whose gender identity and/or gender expression differs
from their assigned sex at birth.29

Undergoing Internal Struggles could be congruent with their gender identity; for others,
it was a means to achieving parenthood that was markedly
For each study participant, some degree of conflict ex-
incongruent with their identity. One participant stated that he
isted between the internal sense of self and dominant
had always wanted to be pregnant; another did not think about
social norms that define a pregnant person as woman and
the possibility until he was partnered—and then thought it
a gestational parent as mother. This conflict informed par-
would be “a really cool thing to do.” Other participants were
ticipants’ experience of achieving parenthood in the form
not interested in pregnancy itself, but stated a strong desire to
of internal struggles throughout each stage of becoming a
be a part of creating a new life:
parent.
Pregnancy Planning and the Preconception Period
Becoming pregnant started with a deliberate decision for all Even though I really hated the idea that I had to be seen
participants. For some, pregnancy was a desired state that as a woman in some places by some people to be pregnant,

64 Volume 60, No. 1, January/February 2015

 Table 2. Participant Demographics, Methods of Conception, entering the unknown. Most participants experienced this
Birth Settings, and Health Care Providers (N = 8) as a particularly lonely and overwhelming time. The major-
Characteristic Value ity of participants were unable to locate relevant resources
Age at time of interview, mean (range), y 33 (29-41) on conception and pregnancy, and few knew others who had
gone through the same experience. Participants described
Home community, n (%)
creating coping strategies for managing their feelings of ex-
Rural 4 (50) citement and turmoil. Reflecting his uncertainty and loneli-
Urban 4 (50) ness during the preconception period, one participant stated
Educational attainment, n (%) that he wished he had been able to know that he “wasn’t
the only one . . . that there were other people [like me] out
Doctoral degree 1 (12.5)
there.”
Master’s degree 1 (12.5) Most participants found the preconception stage to be a
Bachelor’s degree 4 (50) critical point of internal struggle and reported varying degrees
Some college 1 (12.5) of distress and curiosity during this time. For several, it was a
High school or GED 1 (12.5) point of crisis. For participants who experienced conception
difficulties, this crisis lasted for a period of years. Emotional
Relationship status, n (%)
processes that participants described during the preconcep-
Partnered 7 (87.5) tion period included exploration and loss. Exploratory experi-
Single 1 (12.5) ences focused on gender identity in the context of pregnancy.
Family size, n (%) One participant described experimenting with gender expres-
One child 5 (62.5)
sion, going to another city dressed as a girl to see if “passing”
as a woman would be acceptable during pregnancy. Although
2 children 3 (37.5)
this participant and the majority of other participants main-
Method of conception, n (%)a tained a stable gender identity throughout pregnancy, several
Sexual intercourse 5 (62.5) mentioned a fear of returning to being female when they be-
Home insemination 2 (25) gan trying to conceive or discontinued the testosterone HT
they had taken as part of their gender transition.
Clinic insemination 2 (25)
Physiologic and emotional responses to the discontinua-
Fertility medications (no IVF) 1 (12.5) tion of HT evoked loss for many participants. Participants de-
IVF 1 (12.5) scribed physical feminization, with changes in weight distri-
Care providers, n (%) b bution, facial shape, and physical strength. They consistently
Licensed midwife 3 (37.5) described significant emotional changes as well; some referred
to these changes as “girl feelings” and an “emotional roller
Certified nurse-midwife/Certified midwife 1 (12.5)
coaster.” One participant, who had worried that his physical
Family physician 1 (12.5) appearance would return to how it was prior to undergoing
Obstetrician-gynecologist 7 (87.5) HT, experienced less dramatic feminizing changes than antic-
Birth setting, n (%) ipated. Although this was a welcome surprise, it caused un-
expected grief: “I realized . . . that the person that I was pre-
Home 2 (25)
testosterone . . . doesn’t exist anymore . . . she was dead now.”
Birth center 0 (0) Some participants articulated a loss of control over their
Hospital 6 (75) body as they attempted to conceive. One stated, “[i]t really
made me realize that . . . I really didn’t have control over my
Abbreviations: GED, general educational development; IVF, in vitro fertilization.
a
Methods of conception were marked “select all that apply.” Several participants body whether or not I was putting testosterone into it.” Others
used multiple methods of conception as a result of difficulties conceiving.
b
Care providers were marked “select all that apply.” Some participants saw described “not feeling right” or “no longer feeling manly.”
multiples types of providers during the course of their care. Another form of loss participants described was preg-
nancy loss. Half of participants (n = 4) experienced at
I really liked the idea of bringing life into this world and least one miscarriage. All described miscarriage as emotion-
being a part of that. And I couldn’t do it any other way. ally devastating, although responses to the experience varied
significantly:
For most participants, pregnancy represented the most
viable way to achieve parenthood. Participants cited social
and financial barriers to other routes of becoming a parent. The hardest part for me was when I was trying to use my
One participant feared being discriminated against if he and body . . . the way it was supposed to work, and it wasn’t
his male partner attempted surrogacy or adoption, stating, working. . . . I felt betrayed—like, I was supposed to be fe-
“Who’s gonna choose us?” Two participants made the state- male and females are supposed to have babies, and here I
ment, “I was my own surrogate,” highlighting the emotional was trying to have a baby and we would get pregnant and
complexity of their experience. then I would have a miscarriage.
Following the decision to pursue gestational parenthood,
and prior to achieving a successful pregnancy, participants Coping strategies participants began to use during
entered a time of ambiguity that can aptly be described as the preconception period focused on holding onto some

Journal of Midwifery & Women’s Health r www.jmwh.org 65

 PLANNING PRECONCEPTION PREGNANCY/BIRTH PARENTING

Undergoing Internal Struggles

Exploration - Losing and Gaining - Connection and Disconnection

Loneliness
Loneliness

Engaging with the External World

Active Disclosure - Passive Disclosure - Active Non-Disclosure

Choosing Gestational Entering the Unknown Using Coping Strategies Creating a Unique
Parenthood Family Narrative

Engaged in Perinatal Care

Figure 1. Male and Gender-variant Pregnancy: Navigating Identity Through the Stages of Achieving Gestational Parenthood

consistent aspect of one’s identity, usually related to gender I really went through the pregnancies in a fog. . . . I just
expression. pushed it aside. . . . I knew there was something growing
inside me but I wasn’t connecting with it as a baby. It was
Pregnancy
more of a thing, an organism, a parasite, anything. . . . I
Most participants felt a sense of relief from gaining the
wasn’t thinking of myself as a mother who’s pregnant at all.
concrete “mission” and timeline that pregnancy afforded;
nonetheless, the theme of navigating identity continued to Birth
dominate everyday life and to present pleasant surprises as Most participants described strong feelings about the birth
well as challenges. process. Some desired connection with the process, whereas
Some participants shared that they felt physically attrac- others desired disconnection from the physiologic reality of
tive or that their partner found them particularly attractive birth. For some, the idea of having a vaginal birth, with
during pregnancy, and others described a sense of embodi- their genitals exposed for extended periods of time, was emo-
ment, peace, access to self, and connection with the develop- tionally unsettling. Thus, some described a preference for
ing fetus. One participant stated: “I really liked it . . . I felt a cesarean:
really strong connection to my babies. And I don’t know if
that would make me less of a man, but I enjoyed it.” Another I want[ed] the c-section. . . . I think that emotionally it was
described gaining a sense of wholeness during pregnancy: a better choice than having to push a baby out. . . . I had
This whole process has made me more, I guess at peace with just made it so that it was—this was how we were having a
my own body and even with how I was born. . . . I’m more family, and the thought of that part of my body being . . . on
accepting of the trans part of myself, or the female part of display . . . was just a little too much for me. I didn’t want a
myself. . . . The whole pregnancy and birth has made me natural delivery.
more whole and more comfortable in my own skin, more
comfortable with myself and my past. Others strongly preferred a physiologic vaginal birth, and
described birth as a physically painful but emotionally mean-
For others, pregnancy was marked by a deep sense of dis- ingful experience. Participants who gave birth vaginally noted
connection; these participants experienced disembodiment, a lack of inhibition during labor and birth that transcended
lack of access to self, and lack of connection to the developing their usual concerns about gender identity and revealing their
fetus. One participant stated that he “hated being pregnant,” bodies to others.
and described profound loneliness about this feeling both dur-
Transition to Parenthood
ing preconception and pregnancy:
In the postpartum period, navigation of identity extended be-
I think it felt really lonely. . . . I was like am I the only one yond the immediate self and moved into the realm of the
that feels like this? Like it super sucks, like it’s scary and it’s, family unit. The process of creating a unique family narra-
um, lonely and, you know my boyfriend’s [a natal male] and tive began with developing an internal parental identity. For
he wasn’t going through it so he didn’t understand what I some participants a singular, paternal role was a comfortable
was feeling. fit; others described fulfilling dual parental roles. One partici-
pant said, “I’m serving 2 roles. I’m going to be their father, but
Another participant, who also experienced loneliness and I’m also being my own surrogate so I’m . . . the birth mother
emotional discomfort throughout pregnancy, reported: at the same time.” Another participant reflected:

66 Volume 60, No. 1, January/February 2015

In a sense I’m his mommy, you know, and that’s okay, that is stated, “[t]hey were all surprisingly excellent; really, across the
the role I have, and I’m the only mommy that he has. But I board my experience with people was excellent. I was shocked
guess I feel more dad-like now, and I don’t even know what by that.”
that means. When accessing community resources for expectant fam-
ilies, several participants described feeling “alienated,” ig-
Some participants easily fell into paternal kinship names, nored, and misunderstood by both social service providers
whereas others, particularly those who identified as gen- and other expectant parents. In social settings, many par-
derqueer or who had not undergone HT, struggled with ticipants described acts of active and passive nondisclosure
finding an appropriate term. Naming one’s parenthood role throughout pregnancy as a coping strategy. Participants de-
brought together both internal and external aspects of scribed a variety of strategies to pass or hide their pregnancies
parental identity and was challenging to these participants. to avoid judgment from others. Some wore beards; one was
careful to limit his weight gain. The use of items of clothing
Engaging with the External World such as large jackets and sweaters allowed many participants
to hide their pregnancies:
Throughout the process of achieving gestational parent-
hood, managing others’ perceptions and either communi- I bought this like big puff y sleeveless jacket, and I wore
cating or hiding one’s gender identity or gestational parent- that, like, everyday. And that managed to hide it really well.
hood was a constant and pervasive experience. Participants . . . Genuinely, people didn’t know I was pregnant . . . and
described protecting self by choosing from a “menu” of dis- then I’d unzip it and they’d be like “holy crap, you’re totally
closure choices, including: active nondisclosure (hiding), pas- pregnant!”
sive nondisclosure (passing, allowing assumptions), or active
self-disclosure (telling, being open). Some participants nearly Study participants also discussed passive nondisclosure
consistently chose either disclosure or nondisclosure, whereas by exploiting social norms and expectations. One participant
others moved between disclosure choices based on context. stated, “[w]hen you’re not out as trans to begin with there’s no
Choice of disclosure behaviors was not always based on par- way someone’s gonna think of this as something that’s in the
ticipant preference; for example, those who had a history of realm of possibility.” Participants who had not undergone HT
HT were required to disclose their natal sex to their prenatal also stated they were rarely perceived as pregnant in public
care provider as well as their work supervisors. settings. However, concealment did become more challeng-
ing for all participants in late pregnancy. Some restricted their
Pregnancy Planning and the Preconception Period activities to avoid unwanted attention, whereas others contin-
Like most expectant parents, study participants faced choices ued with all aspects of their daily lives. One participant stated,
about when and how to disclose their intention of starting a “Sometimes I’d be like ‘oh, I just don’t want to get stared at to-
family. One decision faced by all families is whether or not to day.’ . . . It was a lot of negative attention. . . . Some days . . . I
use nondisclosure as a means of maintaining privacy for the just stayed in.” Others noted that the discomforts of late preg-
fledgling idea of parenthood and establishing emotional self- nancy were significant enough to supersede their concerns
protection in case of pregnancy loss or infertility.22 This held about others’ perceptions.
true for the participants of this research, and the loneliness of For participants who had undergone HT, disclosing preg-
this time period was further complicated by participants’ gen- nancy always involved disclosing gender identity to people
der identities. One participant described a loss of community who were not aware they were a natal female, including col-
as he entered the preconception period: leagues, supervisors, and partners’ family members. This dis-
I was really feeling alone. . . . I distanced myself from . . . closure caused a significant loss of anonymity and comfort for
a group of FTMs that I used to hang out with a lot when I these participants. One said, “[my partner] ended up having
decided to get pregnant. . . . I felt like I was, uh, kinda doing to tell [his family] that I was trans and that we were pregnant
something that shouldn’t be done. Even though I know that and having a baby at the same time. . . . It was a lot.”
it’s done, I still felt like—eehh, you know . . . some of the Transition to Parenthood
older guys in the group would say “oh you don’t want to Participants varied in their approach to crafting a unique fam-
[get pregnant], there could be problems.” ily narrative. Some used active nondisclosure of their ges-
Pregnancy
tational parenthood. One stated: “I just say that we had a
None of the participants received perinatal care from a surrogate. . . . In a lot of ways it was true because I was
provider who had experience working with transgender or my own surrogate.” Others described passive nondisclosure
gender-variant patients. A few reported negative experiences strategies, such as not correcting people’s assumptions. This
with health care providers: strategy was described as “just let[ting] people draw their own
conclusions.” In contrast, other participants preferred active
[She] was referring to my boxers as panties, which I found disclosure of their biologic parenthood. One described his
totally weird. . . . I just kind of went under the radar with desire for disclosure as a source of social discomfort and
her because I didn’t like her. . . . I just kind of dealt with isolation:
her. . . . There was never any room for me to be anything
other than, like, a lady with panties. I’ll tell any gay dad . . . but like when it’s, you know, a
75-year-old woman at the salad bar at Whole Foods—you
Most participants, however, expressed surprise that their know you just kinda want to not say it. But I also don’t want
interactions with health care providers were positive. One to be like “yeah, we adopted our kid,” like I . . . hate that, I

Journal of Midwifery & Women’s Health r www.jmwh.org 67

 Table 3. Common Points of Tension in Perinatal Health Care Settings
Building rapport with providers Fear of negative interactions based on past health care experiences and hearing others’
experiences; desire to establish trust prior to any physical examination
Phone calls and e-mails from staff Uncomfortable interactions with staff who are unaware of the patient’s gender identity,
preferred name, and preferred pronouns
Waiting rooms Discomfort waiting in areas where patients are expected to be female, fear of judgment
from other patients, being called back by nonpreferred name
Concerns about privacy Fear that providers will have inappropriate discussions about the patient, fear that
sensitive information will be overheard by other patients
Arrival in labor Discomfort waiting in areas where patients are expected to be female, fear of judgment
from other patients, fear of inability to self-advocate while in labor
Housing on the L&D and Discomfort being housed in areas where patients are expected to be female, fear of
postpartum units judgment from other patients, fear of uncomfortable interactions with staff
Accessing services and resources Discomfort accessing resources in group settings, discomfort utilizing gender-restricted
for expectant parents assistance programs such as WIC
Referrals to outside providers Discomfort interacting with new providers who do not know the patient’s gender
identity, preferred name, or preferred pronouns

Abbreviations: L&D, labor and delivery; WIC, Women, Infants, and Children.

mean he’s my kid, I had him. . . . So you know, you wanna racial, ethnic, and socioeconomic diversity; however, efforts
be fair about that too. to increase the accessibility of the study were not successful
and must be improved upon in the future. Further research
is needed to explore the experiences of gender-variant indi-
viduals from diverse racial and socioeconomic backgrounds,
DISCUSSION as well as the experiences of those who do not wish to un-
In this study, the stages leading to achieving gestational par- dergo physical transition and those who choose to breast-
enthood were consistent with that of heterosexual and les- feed. Rigorous scientific research is needed to explore the
bian parenthood.23–26 However, the journey to parenthood physiologic relationships between HT and fertility and allow
had unique features not typical for other populations of par- for evidence-based preconception and perinatal care for this
ents. The unique finding of this study was that participants ex- population.
perienced significant and persistent loneliness on their paths Despite these limitations, this research makes important
to parenthood and that, within this context of loneliness, the contributions to the limited knowledge base on transgender
process of navigating identity formed a constant backdrop and gender-variant parenting. Although the findings of this
of daily life that required considerable energy and attention. pilot study must be applied with caution related to its small
With a lack of clear models of what a positive, well-integrated, sample size, foundational knowledge contributed by this work
gender-variant parental role might look like, navigating iden- includes the identification of the preconception period as the
tity extended into parenthood as well. time of greatest distress and least involvement with health
Similar to lesbian, gay, and bisexual parents,24,27 some par- care—a finding that has bearing on the creation of culturally
ticipants felt comfortable with themselves as gestational par- responsive models of health care for this population and casts
ents, whereas others felt quite constrained by external factors new light on current standards of preconception care.
and loneliness. Also consistent with prior reports,28 partici- The experiences of participants suggest that culturally
pants articulated expectations of strained or negative expe- sensitive preconception counseling could be beneficial for this
riences with their health care providers. Although nearly all population. Simple interventions such as asking, “[A]re you
participants stated that they were “surprised” by the compas- interested in becoming a parent someday?” and if so, “[H]ave
sion and professionalism of their health care providers, the 2 you thought about how you would like to become a parent?”
participants who had not undergone HT found that their neg- may provide an entry point to health care by positioning the
ative expectations were confirmed by at least one health care provider as an informed and nonjudgmental resource. The
provider. This research also revealed that key points of ten- grounded theory produced by this pilot investigation also pro-
sion in health care settings were not limited to direct provider- vides insights that will be useful to health care providers and
to-patient interactions (see Table 3). In social contexts, others working with male and gender-variant prospective ges-
participants were acutely aware they were transgressing ex- tational parents.
pectations that male and gender-variant people will not use Key strategies for patient advocacy and addressing points
their bodies to bear children. This led to feelings of loneliness of tension in perinatal health care settings emerged from par-
and marginalization. ticipant narratives (see Supporting Information Appendices
As with any research, this study has several limitations. A and B). These strategies included: providing training to all
The intended sample for this study aimed to include greater staff, documenting preferred name and pronouns clearly in

68 Volume 60, No. 1, January/February 2015

the patient chart, offering scheduling accommodations or al- 7.Dutton LL. Gynecologic care of the female-to-male transgender man.
ternate waiting areas, proactively discussing privacy issues, J Midwifery Womens Health. 2008;53:331-337.
planning ahead of time to coordinate a smooth labor arrival 8.Fugate SR. Gender reassignment surgery and the gynecological pa-
tient. Prim Care Update Ob Gyns. 2001;8:22-24.
and housing process based on patient needs, offering private
9.Perrone AM, Cerpolini S, Maria Salfi NC, et al. Effect of long-term
information sessions and tours as appropriate, maintaining testosterone administration on the endometrium of female-to-male
continuity of health care, and calling ahead to any outside (FtM) transsexuals. J Sex Med. 2009;6:3193-3200.
providers to which patients must be referred. 10.van Trotsenburg MAA. Gynecological aspects of transgender health-
care. Int J Transgenderism. 2009;11:238-246.
AUTHORS 11.More SD. The pregnant man: an oxymoron? J Gender Studies.
1998;7:319-328.
Simon Adriane Ellis, CNM, MSN, is in clinical practice at 12.Wierckx K, Van Caenegem E, Pennings G, et al. Reproductive wish in
Cedar River Clinics in Renton, Tacoma, and Seattle, Washing- transsexual men. Hum Reprod. 2012;27:483-487.
ton, where he provides well-woman care, abortion care, and 13.Feldman JL, Goldberg J. Transgender primary medical care: sug-
LGBTQ wellness services. gested guidelines for clinicians in British Columbia. 2006. Transcend
Transgender Support & Education Society, Vancouver Coastal Health.
Danuta M. Wojnar, PhD, RN, MED, IBCLC, FAAN, is Asso- http://transhealth.vch.ca/resources/library/tcpdocs/guidelines-
ciate Professor and Chair of Maternal/Child and Family Nurs- prim-care.pdf.
14.Coleman E, Bockting W, Botzer M, et al. Standards of care for the
ing at Seattle University in Seattle, Washington.
health of transsexual, transgender, and gender-nonconforming peo-
Maria Pettinato, RN, PhD, is Associate Professor in the Col- ple, version 7. Int J Transgenderism. 2011;13:165-232.
lege of Nursing at Seattle University in Seattle, Washington. 15.Sir-Petermann T, Maliqueo M, Angel B, Lara HE, Perez-Bravo
F, Recabarren SE. Maternal serum androgens in pregnant
women with polycystic ovary syndrome: Possible implications
CONFLICT OF INTEREST in prenatal androgenization. Hum Reprod. 2002;17(10):2573-
The authors have no conflicts of interest to disclose. 2579.
16.Glaser, BG. The Grounded Theory Perspective: Conceptualization
Contrasted with Description. Mill Valley, CA: Sociology Press; 2001.
ACKNOWLEDGMENTS 17.Charmaz K. Grounded theory. In: Smith JA, ed. Qualitative Psychol-
ogy: A Practical Guide to Research Methods. Los Angeles, CA: Sage
The authors offer deep gratitude to the participants of this Publications; 2008:81-110.
study for their selfless sharing and to Stephanie Brill of Gen- 18.Crooks DL. The importance of symbolic interaction in grounded the-
der Spectrum and Kristin Kali, LM, CPM, of Maia Midwifery ory research on women’s health. Health Care Women Int. 2001;22:
for their support with the recruitment process. 11-27.
This research is dedicated with love and hope to those 19.Glaser BG. Theoretical Sensitivity. Mill Valley, CA: The Sociology
Press; 1978.
who still stand on the painful precipice of their desire for
20.Charmaz, K. Constructing Grounded Theory: A Practical Guide
parenthood. Through Qualitative Analysis. Thousand Oaks, CA: Sage Publica-
tions; 2006.
SUPPORTING INFORMATION 21.Glaser BG. Basics of Grounded Theory Analysis Emergence vs. Forc-
ing. Mill Valley, CA: The Sociology Press; 1992.
Additional Supporting Information may be found in the on- 22.Modh C, Lundgren I, Bergbom I. First time pregnant women’s ex-
line version of this article at the publisher’s Web site: periences in early pregnancy. Int J Qual Stud Health Well-Being.
2011;6.
Appendix S1: Advocacy in Healthcare Settings. 23.Lampic C, Svanberg AS, Karlstroom P, Tyden T. Fertility awareness,
Appendix S2: Addressing Points of Tension in Healthcare intentions concerning childbearing, and attitudes towards parent-
Settings. hood among female and male academics. Hum Reprod. 2006;21:558-
564.
24.Wojnar D. Miscarriage experiences of lesbian couples. J Midwifery
REFERENCES
Womens Health. 2007;52:479-485.
1.Richard D. Trans behind bars: officials, activists struggle with options. 25.McCartney K, Philips D, Bornstein MH, Sawyer J. Family systems. In:
Contemp Sexuality. 2001;34:1. McCartney K, Phillips D, eds. Handbook of Early Child Develop-
2.Lombardi E. Enhancing transgender health care. Am J Public Health. ment. Oxford, UK: Blackwell Publishing Ltd; 2008.
2001;91:869-872. 26.Dahl B, Fylkesnes AM, Sorlie V, Malterud, K. Lesbian women’s ex-
3.Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Lan- periences with healthcare providers in the birthing context: a meta-
ders S. Sexual and gender minority health: what we know and what ethnography. Midwifery. 2013;29:674-681.
needs to be done. Am J Public Health. 2008;98:989-995. 27.Peel E. Pregnancy loss in lesbian and bisexual women: an online survey
4.National Gay and Lesbian Task Force. Injustice at every turn: a re- of experiences. Hum Reprod. 2010;25:721-727.
port of the National Transgender Discrimination Survey. National 28. Lamba Legal. When health care isn’t caring: Lambda Legal’s sur-
Gay and Lesbian Task Force. 2011. http://www.thetaskforce.org/ vey on discrimination against LGBT people and people living with
downloads/reports/reports/ntds full.pdf HIV. 2010. Lambda Legal. http://data.lambdalegal.org/publications/
5.Vanderleest JG, Galper CQ. Improving the health of transgender peo- downloads/whcic-report when-health-care-isnt-caring.pdf
ple: transgender medical education in Arizona. J Assoc Nurses AIDS 29. Fenway Health. Glossary of Gender and Transgender Terms.
Care. 2009;20:411-416. 2010. http://www.fenwayhealth.org/site/DocServer/Handout˙7-C
6.Baba T, Endo T, Honnma H, et al. Association between polycys- Glossary of Gender and Transgender Terms fi.pdf?docID = 7081
tic ovary syndrome and female-to-male transsexuality. Hum Reprod. 30.Human Rights Campaing. Glossary of Terms. 2014. http://www,hrc.
2007;22:1011-1016. org/resources/entry/glossary-of-terms

Journal of Midwifery & Women’s Health r www.jmwh.org 69