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Translated by Florence Bois-Villeneuve.

“Since [finding out I’m pregnant], I’ve watched a lot of videos about pregnancy and parenthood, and most of them start with something like ‘Hey, moms-to-be!’ I quickly realized that, even today, the whole pregnancy experience is far from being inclusive.”
— Jessy, non-binary person  

Like everything else care related, pregnancy is strongly regarded as an experience reserved for cis women. But women aren’t the only ones who can get pregnant! According to the latest Canadian census, there are 16,225 (0.23%) trans and/or non-binary people (TNBP) over the age of 15 living in Quebec (Statistics Canada, 2022). Unfortunately, there are no data on the number of TNBP who have experienced one or more pregnancies, but one thing is certain: They do exist. 

As part of my midwifery studies, I am doing an internship with Les 3 sex* to raise awareness of the realities of trans and/or non-binary people who have been pregnant or experienced parenthood. I chose to collect testimonials using a form that I shared on social media. I also conducted short interviews with some people who preferred to tell their stories in person. After hearing these stories, I asked myself: How does gender identity influence the pregnancy experience? But also, how is gender identity affected by this experience?

“I had a lot of conversations about gender stereotypes with the father of my child, and the roles associated with certain genders, the mental load, and the fact I felt like I was honestly taking on more in terms of the logistics, housework, childcare, and breastfeeding. I was really expected to deal with it all, and I felt like parenthood was pigeonholing us even more into those gender stereotypes that I’d tried so long to reject—and that I’m still actively rejecting. I think we really expect a lot from ‘mothers.”
— 

Laure, non-binary, genderfluid¹ person

There are very few representations in popular culture of gender non-conforming² people who are pregnant. This invisibility plays a role in marginalizing their realities and perpetuating prejudices and stereotypes about them. Since society associates pregnancy with femininity, trans and/or non-binary people who are pregnant can feel isolated and unable to picture themselves in a parenting role, even more so if they are carrying the child in their womb (Ellis et al., 2015). This feeling may be reinforced by the medical staff these people encounter throughout their pregnancy, who may misgender them, treat them with hostility, or even deny them care (Light et al., 2014).

And so we find ourselves in a vicious cycle that leads to more ignorance and discrimination against trans and/or non-binary people experiencing pregnancy. This ignorance can be even more dangerous when it spills over into the health setting, resulting in a lack of resources and accessibility for these populations. This can result in ill-informed staff, inadequate services, denial of care, or inadequate systems (Ellis et al., 2015; Fischer et al., 2021; Hoffkling et al., 2017; Light et al., 2014; MacDonald et al., 2016; Obedin-Maliver et al., 2016).

“I feel stressed each time I have to go to the hospital. It starts when I’m standing in front of the secretary and pull out my [health insurance] card; that’s when the stress starts. When you’re in the waiting room and the name that’s called doesn’t match your clothes or your style, the other patients tend to look at you funny.”
— Shine, trans man, in the article Accoucher à l’hôpital quand on est un homme trans, by Quentin Dufranne, February 25, 2023.

Many trans and/or non-binary people have a complex relationship with the medical profession. Difficult experiences are common for these people, ranging from embarrassment and discomfort to transphobia or even medical violence. It’s no wonder many TNBP avoid hospitals, clinics, and anything related to the medical field. Mental health instabilities can also make a person more likely to avoid primary care (Tami et al., 2022). This behaviour is understandable, especially given the medical profession’s history of attempts to normalize bodies. For example, we need only think of the multiple gender-normalizing surgeries performed on many intersex people to make their genitals match their gender assignment. This topic is addressed in an article by Édith Paré-Roy. Although perhaps more subtle, gynecology is no exception to this trend. “Gynecology is practically seen as the institution that defines ‘womanhood’ because it sets the criteria for its patient base: The women it treats must menstruate and have heterosexual penetrative sex. Anyone who does not fit into these categories is excluded from this discipline and from this ‘rite of passage’ that makes them so-called women.” (Gelly, 2018: (139). 

Negative interactions with the health system can also make people decide not to discuss their gender identity with staff.

“When I was on the phone [with the abortion providers], it was obvious the lady was used to working with girls because she was saying things like ‘the girls who go through this are okay afterwards’ or ‘the girls say’... They insist on gendering the whole thing, so I didn’t even bother wasting my time with it [gender identity]. It’s pointless. It’s bad enough they don’t listen to my medical needs, do you really think they’re going to gender me properly?”

— Amélie, non-binary person

When it comes to prenatal care, clinics and hospitals are used to seeing a patient base made up of cis women. So, when a trans and/or non-binary person needs care, they know they’ll have to educate the medical staff. That places them in the dual role of service user and service provider. In that situation, being yourself and speaking your truth is no easy task. Obtaining medical care becomes a political action of sorts. They have to be willing to step into a teaching role, which they often do out of consideration for the people who will come after them. 

“If I’m going to do it [tubal ligation], I’m going to document everything from A to Z. All my interactions, every step I take, all my feelings and reactions in meetings with health professionals. I figure if I document everything, [...] it could really help a lot of other people later on.” 
— Amélie, non-binary person

“It sounds silly, but it’s super important to create that awareness [about sex assigned at birth] and education during pregnancy and at the beginning of a child’s life, because that’s really when gender socialization starts. [...] I think people are ridiculously obsessed with knowing a baby’s sex. That’s always the question you get when you’re pregnant: ‘Penis or vagina?’ But really, who gives a damn about a baby’s genitals? They might not even represent the person that baby will eventually become. So, I think we need to have that super important conversation, take the focus off that and help the health system be a little more openminded about non-binary people.”
— Laure, non-binary, genderfluid person

Whenever trans and/or non-binary people have to deal with the medical system, they are almost always confronted with their sex assigned at birth, whether or not their legal transition is complete. What’s more, the gender “X” designation, now an option in Quebec, is not recognized everywhere. For example, only the M or F designation can appear on the health insurance card. Feel free to visit the Éducaloi website for more information about changing official documents. But when even official documents have been changed, there can still be confusion among staff members. According to most medical professionals, there are only two sexes: male and female. And those sexes predispose people to certain conditions, risk factors, symptoms and complications. In this medicalized world, women have a vagina and a uterus, and they alone are capable of becoming pregnant and giving birth. 

In an online report about trans parenthood by Ici Radio-Canada published in 2021, Maxime, a trans man who gave birth to his children, talked about how the system could not fathom the idea of a man giving birth. In fact, he was even denied access to a labour and delivery room because he was listed as male on his health insurance card. The staff had to create a fake card number to help him get around this obstacle. 

In all cases, trans and/or non-binary people have to deal with the rigid mentality of healthcare institutions that don’t recognize their gender identity, whether or not they are “out.” 

“Looking back, I realize the pride I felt watching my body change [during pregnancy] wasn’t related to an inner sense of euphoria, but rather to outside forces. Having bigger breasts validated the way others looked at my body, my femininity, my gender performativity. While I’ve always been terrible at putting on that performance, being pregnant was the validation that my body was ‘female enough’ in the eyes of society. Getting pregnant again is out of the question for me: It’s not something I want to repeat, and I wouldn’t be able to stand the scrutiny.”
— Manu (fictitious name), non-binary person

“I feel like being pregnant is the ultimate feminizing experience. And it’s often seen as a milestone in a woman’s life. Pregnancy really puts you in touch with your femininity, and it got on my nerves [...]. Because I was like, ‘But why are they assuming this is my story?’”
—Laure, non-binary, genderfluid person

When it comes to non-binarity and transness, respecting a person’s chosen pronouns is one of the first topics that springs to mind. Asking people for their pronouns and stating theirs in return isn’t exactly a habit yet for most people—nor for most medical institutions. Language is difficult to change, but it also has far-reaching consequences. Beyond pronouns, the terms used to talk about oneself and one’s body are just as important. For example, some people use very specific words to refer to their genitals or their chest, because the words used generally carry a gendered load or can bring up previous trauma or trigger feelings of dysphoria. Pregnancy is so closely associated with the female experience that we refer to it as “maternity” (from the Latin mater, meaning “mother”), and the branch of medicine that studies it is called “gynecology” (from the Greek gyne-, meaning “woman”). Speaking of, in their memoir Une gynécologie au masculin? De l’accessibilité des soins en gynécologie pour les hommes trans à Montréal (2018), Morgane Gelly considers what the discipline might look like if it were conceived differently, particularly with regard to gender. It is the only medical discipline defined according to sex.

“[The most difficult thing about pregnancy is] the body dysphoria caused by all the hormone changes, especially the fact my breasts got bigger; and being constantly misgendered by the health system and by my family and friends, who automatically associate pregnancy with femininity.”
—Jessy, non-binary person 

“I didn’t understand my gender identity at the time, but I understand now that it was extremely distressing to go through something [an abortion] that is considered the exclusive domain of women, when I’m not a woman.”
— Lou (fictitious name), non-binary person

Dysphoria is a very common feeling among trans and/or non-binary people, although not all trans people experience dysphoria. It is often heightened by pregnancy (Hoffkling, 2017), due to the highly gendered perception of this experience. Pregnancy also changes a body: breasts become larger and more sensitive, and curves become rounder due to weight gain. When confronted with these changes, onlookers are most likely to conclude the pregnant person they are looking at is a woman. Some people do not feel uncomfortable with their bodies per se, but rather with the way it is perceived by others (Fischer, 2021). When that is the case, being misgendered becomes a major source of dysphoria. For others, certain gender-specific bodily functions can lead to a dysphoric relationship with their body (MacDonald, 2016). For example, menstruation, breastfeeding, and even pregnancy can cause varying degrees of discomfort, up to and including dissociation. 

“Everything I’ve experienced surrounding sexuality, pregnancy, and all the rest, has only confirmed that gender has done me more harm than good, so I just try to dissociate myself from it as much as possible.”
— Amélie, non-binary person

Some trans and/or non-binary people undergo gender-affirming hormone therapy. People who are AFAB (assigned female at birth) sometimes take testosterone, which has a “masculinizing” effect on the body. For example, it can increase muscle mass and body hair, and make the voice deeper. It can also affect the menstrual cycle and fertility. Anyone who wants to get pregnant should stop taking testosterone before trying to conceive, to make sure they are ovulating regularly and to minimize the potential effects on the fetus. Few studies have been conducted on perinatal testosterone exposure. Some evidence suggests that taking synthetic testosterone could influence the genital development of female fetuses, causing hypertrophy among other things. We also know that testosterone can suppress lactation (Obedin-Maliver et al., 2016).

In closing, I would like to quote sociologist Aimé Cloutier, author of “Suivi périnatal pour homme trans, pourquoi pas avec une sage-femme?” : échos d’un gars trans sociologue et parent d’un bambin né avec une sage-femme (2018), who writes: “Trans people and transparent families are just like everyone else, yet also very different from everyone else.” He also reminds us to refrain from placing all trans people into one homogeneous category. Each person has specific needs, especially people at the intersection with other systems of oppression (racism, classism, ableism, etc.). To achieve this, medical professionals must demonstrate openness and humility, not to mention challenge their own beliefs and continue learning—always with the goal of providing better care for people in need, whatever their gender. 

Notes

¹ Genderfluid refers to a person whose gender or gender expression changes or shifts along the gender spectrum (Translation Bureau, 2019)

² Gender non-conforming: In a given society, that differs from what is culturally associated with a person's gender (Translation Bureau, 2019).

³ Transness: There is a lot of debate about the right terms to use to describe the fact of being a transgender person, but there is no real consensus. In France, the term “transidentity” is commonly used, although it strongly questioned in Quebec, since it implies that being trans is necessarily an identity, whereas for some people it is more of a state, or a stage (Gelly, 2018).

⁴ Gender dysphoria: A condition where a person experiences persistent discomfort or distress because of a mismatch between their gender and the sex they were assigned at birth (Translation Bureau, 2019).