Transgender pregnancy

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Transgender pregnancy is the gestation of one or more embryos or fetuses by transgender people. As of 2024, 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.

Contents

Trans men

Pregnant trans man Zack Elias and his transgender wife, Diane Rodriguez. Diane Rodriguez y Su esposo Zack Elias en alta resolucion.jpg
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 embryo or fetus, 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 cisgender 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]

Chestfeeding

Chestfeeding is not off the table for many trans men who medically transition, but it is rarely discussed by doctors who prescribe testosterone or complete chest masculinization surgeries. While chestfeeding can be a dysphoric activity for some trans men and nonbinary people, some find it fulfilling and a practice that connects them to their baby. [14]

Some chest masculinization surgeries prohibit people from chestfeeding at all, but some surgeries maintain the mammary glands and just remove breast tissue. With these surgeries, the baby can have trouble latching and milk supply may be diminished. [15] This can be bypassed with medication and support from doctors.

For people that are attempting chestfeeding without chest masculinization surgery, Chest binding has an effect on milk supply. Binding for years or binding unsafely for long periods of time prior to pregnancy can negatively affect glandular tissue and chestfeeding ability, and binding during a chestfeeding period is not recommended, as it can cause mastitis. [16]

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. [17] [18] 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. [19] 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. [20] [21]

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. [22] Unwanted pregnancy can cause severe gender dysphoria and suicidal ideation in trans people. One nonbinary person who performed a self-induced abortion stated, [23]

[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. [18] This may be attributed to factors such as lack of social support, discrimination, and lack of adequate healthcare practitioner training. [18]

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. [24]

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. [19] 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. [23] 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 them intolerable gender dysphoria. [23]

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. [25]

Trans women

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

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. [26] 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. [27] The International Society of Uterine Transplantation (ISUTx) was established internationally in 2016, with 70 clinical doctors and scientists, and currently has 140 intercontinental delegates. [28]

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. [29] 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. [30] 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. [31]

Chestfeeding

Some trans women can induce lactation, allowing them to breastfeed babies they did not biologically birth. Practices such as medical lactation induction can simulate the changes of breasts during pregnancy and begin lactation with the assistance of medication. [32]

Non-binary people

Non-binary people with a functioning female reproductive system can give birth. [33]

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. [34]

Non-binary people who have written or been profiled about their experiences of pregnancy include Rory Mickelson, [35] Braiden Schirtzinger, [36] and Mariah MacCarthy. [37]

Society and culture

In 1583, an intersex person that had masculine gender expression reportedly became pregnant in Beaumaris, Wales. [38]

Noto Emoji v2.034 1fac3.svg
Noto Emoji v2.034 1fac4.svg
"Pregnant man" and "pregnant person" emojis displayed in Noto Color Emoji

In 2021, Unicode approved the "pregnant man" and "pregnant person" emojis in version 14.0, and added to Emoji 14.0. [39]

See also

Related Research Articles

Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their gender identity—their personal sense of their own gender—and their sex assigned at birth. The term replaced the previous diagnostic label of gender identity disorder (GID) in 2013 with the release of the diagnostic manual DSM-5. The condition was renamed to remove the stigma associated with the term disorder. The International Classification of Diseases uses the term gender incongruence instead of gender dysphoria, defined as a marked and persistent mismatch between gender identity and assigned gender, regardless of distress or impairment.

<span class="mw-page-title-main">In vitro fertilisation</span> Assisted reproductive technology procedure

In vitro fertilisation (IVF) is a process of fertilisation in which an egg is combined with sperm in vitro. The process involves monitoring and stimulating a woman's ovulatory process, then removing an ovum or ova from her ovaries and enabling a man's sperm to fertilise them in a culture medium in a laboratory. After a fertilised egg (zygote) undergoes embryo culture for 2–6 days, it is transferred by catheter into the uterus, with the intention of establishing a successful pregnancy.

Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, though many such treatments are also pursued by cisgender and non-intersex persons. It is also known as sex reassignment surgery (SRS), gender confirmation surgery (GCS), and several other names.

<span class="mw-page-title-main">Family planning</span> Planning if or when to have children

Family planning is the consideration of the number of children a person wishes to have, including the choice to have no children, and the age at which they wish to have them. Things that may play a role on family planning decisions include marital situation, career or work considerations, financial situations. If sexually active, family planning may involve the use of contraception and other techniques to control the timing of reproduction.

<span class="mw-page-title-main">Trans man</span> Man assigned female at birth

A trans man is a man who was assigned female at birth. Trans men have a male gender identity, and many trans men undergo medical and social transition to alter their appearance in a way that aligns with their gender identity or alleviates gender dysphoria.

Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

Gender transition is the process of affirming and expressing one's internal sense of gender, rather than the gender assigned to them at birth. It is the recommended course of treatment for individuals struggling with gender dysphoria, providing improved mental health outcomes in the majority of people.

<span class="mw-page-title-main">Male pregnancy</span> Pregnancy in males

Male pregnancy is the incubation of one or more embryos or fetuses by organisms of the male sex in some species. Most species that reproduce by sexual reproduction are heterogamous—females producing larger gametes (ova) and males producing smaller gametes (sperm). In nearly all animal species, offspring are carried by the female until birth, but in fish of the family Syngnathidae, males perform that function.

Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for distress caused by incongruence between assigned sex and gender identity in some pre-pubescent transgender and gender diverse children.

Gender incongruence is the state of having a gender identity that does not correspond to one's sex assigned at birth. This is experienced by people who identify as transgender or transsexual, and often results in gender dysphoria. The causes of gender incongruence have been studied for decades.

A uterine transplant is a surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased. As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile. This phenomenon is known as absolute uterine factor infertility (AUFI). Uterine transplant is a potential treatment for this form of infertility.

Masculinizing hormone therapy, also known as transmasculine hormone therapy, is a form of hormone therapy and gender affirming therapy which is used to change the secondary sexual characteristics of transgender people from feminine or androgynous to masculine. It is a common type of transgender hormone therapy, and is predominantly used to treat transgender men and other transmasculine individuals who were assigned female at birth. Some intersex people also receive this form of therapy, either starting in childhood to confirm the assigned sex or later if the assignment proves to be incorrect.

Feminizing hormone therapy, also known as transfeminine hormone therapy, is hormone therapy and sex reassignment therapy to change the secondary sex characteristics of transgender people from masculine or androgynous to feminine. It is a common type of transgender hormone therapy and is used to treat transgender women and non-binary transfeminine individuals. Some, in particular intersex people, but also some non-transgender people, take this form of therapy according to their personal needs and preferences.

Puberty blockers are medicines used to postpone puberty in children. The most commonly used puberty blockers are gonadotropin-releasing hormone (GnRH) agonists, which suppress the natural production of sex hormones, such as androgens and estrogens. Puberty blockers are used to delay puberty in children with precocious puberty. Since the 1990s, they are also used to delay the development of unwanted secondary sex characteristics in transgender children, so as to allow transgender youth more time to explore their gender identity under what became known as the "Dutch Protocol". They have been shown to reduce depression and suicidality in transgender and nonbinary youth. The same drugs are also used in fertility medicine and to treat some hormone-sensitive cancers in adults.

Gender-affirming hormone therapy (GAHT), also called hormone replacement therapy (HRT) or transgender hormone therapy, is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender nonconforming individuals for the purpose of more closely aligning their secondary sexual characteristics with their gender identity. This form of hormone therapy is given as one of two types, based on whether the goal of treatment is masculinization or feminization:

Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions for transgender individuals. A major component of transgender health care is gender-affirming care, the medical aspect of gender transition. Questions implicated in transgender health care include gender variance, sex reassignment therapy, health risks, and access to healthcare for trans people in different countries around the world. Gender affirming health care can include psychological, medical, physical, and social behavioral care. The purpose of gender affirming care is to help a transgender individual conform to their desired gender identity.

<span class="mw-page-title-main">Trevor Kirczenow</span> Canadian politician

Trevor Kirczenow is a transgender health researcher and diabetes healthcare advocate. He is an author and community organizer in the field of LGBTQ lactation and infant feeding. He has run twice as a candidate for the Liberal Party of Canada.

Menstrual suppression refers to the practice of using hormonal management to stop or reduce menstrual bleeding. In contrast to surgical options for this purpose, such as hysterectomy or endometrial ablation, hormonal methods to manipulate menstruation are reversible.

<span class="mw-page-title-main">Use of assisted reproductive technology by LGBT people</span>

Lesbian, gay, bisexual, and transgender people people wishing to have children may use assisted reproductive technology. In recent decades, developmental biologists have been researching and developing techniques to facilitate same-sex reproduction.

Discrimination against transgender men and transmasculine individuals is sometimes referred to as transandrophobia, anti-transmasculinity, or transmisandry.

References

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  2. 1 2 3 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. 1 2 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.
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  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.
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  29. ↑ 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.
  30. ↑ 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.
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