Stop Excluding Transgender Families From Maternal Health Conversations

Too many healthcare settings continue to operate under heteronormative assumptions that fundamentally exclude queer, trans, and gender-expansive Black people from the important conversation around perinatal health. Specifically, Black transgender and nonbinary/gender-expansive people who are pregnant or seeking to become parents run into shock and surprise from providers who are ill-equipped to provide them care. In some cases, they run into outright discrimination and refusal of care. 

The core issue is that gestational healthcare systems were built exclusively around cisgender women’s experiences, leaving transgender and non-binary pregnant people to navigate systems that range from unwelcoming to actively hostile. Providers must be thoroughly educated on considerations for pregnant people who are transgender and nonbinary in order to create an affirming environment for perinatal care. Creating truly inclusive maternal and gestational healthcare requires fundamentally reimagining how these services are structured and delivered. 

Gestational healthcare is saturated with terms like mother, women’s health, and she, which can be deeply dysphoric for transgender men and nonbinary people. These experiences include being repeatedly referred to with incorrect pronouns by providers and staff and being required to sign documentation that lacks language or options that accurately represent their identities. This forces the group to receive perinatal care in non-affirming environments, which can impact the efficacy of the care. 

Most OB-GYNs, midwives, and doulas receive little to no education or training about transgender or non-binary pregnancy. As a result, many providers express shock that a transgender man can become pregnant, leading some to refuse care outright, respond with hostility, or display judgmental attitudes. For providers who do continue with care, their lack of training can lead to unrelated and invasive questions about gender history and the use of a patient’s birth name (or dead name) despite legal name changes, which creates a stressful environment for the pregnant person. This can impact the well-being of not just the pregnant person, but the fetus as well. 

The dysphoric experiences of pregnant trans and nonbinary/gender-expansive people may not only come up in a provider’s attitude, education, and training, but also in the anatomy of the pregnant person themselves. There are often considerations for trans men or nonbinary people who have been on testosterone, specifically its implications for fertility and pregnancy. 

Too many providers do not know about lactation for those who have had top surgery. Transgender pregnant people who have had top surgery–where their breasts are amputated to allow for a more masculine look in line with their gender identity–may face lactation complications or impossibility. These patients may also experience dysphoria related to chest-focused care discussions and pregnancy-related bodily changes, including breast development, body shape changes, and fetal movement. 

Additionally, prior genital, or “bottom,” surgeries may affect delivery planning. Insufficient provider education can increase the risk of gestational health complications. The cumulative burden of discrimination and marginalization can significantly affect mental health, increasing the risk of anxiety and depression. These barriers can result in delayed or avoided prenatal care, substandard monitoring and support, increased risk of complications, and healthcare experiences that cause lasting psychological harm for transgender people. 

Improving perinatal healthcare for transgender and non-binary/gender-expansive people requires a patient-centered approach that incorporates gender-neutral language and inclusive terminology. Rather than defaulting to gendered terms such as “mother-to-be,” clinicians should ask patients how they identify and how they prefer to be addressed throughout their care. During health, physical, and biopsychosocial assessments, clinicians should ask open-ended questions to identify patients’ preferred pronouns and the terminology they use to describe their bodies and body parts. 

When discussing pregnancy and parenthood, terms such as “pregnant person” or “parent” may provide more inclusive alternatives to gendered language when consistent with the patient’s preferences. Similarly, in conversations about infant nutrition and lactation, the term “chestfeeding” may be more affirming and accessible than “breastfeeding” for some patients who use lactation as their baby’s primary source of nutrition. Clinicians should also assess for past or current hormone use as these factors may have implications for delivery planning, pregnancy management, and other aspects of perinatal care. 

Ultimately, inclusive care should not rely on assumptions about the terminology, bodies, or healthcare needs of transgender and non-binary/gender-expansive people. As with pronouns and gender identity, terminology preferences vary across individuals. Thus, no one-size-fits-all model exists for providing inclusive perinatal healthcare. Rather, the most affirming approach centers the individual patient, respects their self-identified language and preferences, and addresses their unique healthcare needs.  

Individual providers cannot carry the responsibility for inclusion alone. Healthcare systems must also change. Provider training in transgender health and trauma-informed care, inclusive intake forms, electronic medical record systems, and policies that explicitly protect patients from discrimination are necessary to create healthcare environments where transgender and non-binary/gender expansive people can access care without having to educate or defend themselves at every turn. More holistic research on transgender pregnancy and birth outcomes is also necessary so that clinical guidelines, policies, and interventions work for all of us. Inclusivity is care, and everyone who chooses to bring life into the world deserves it. 

Ashley N. Brevil, PhD, LCSW, is a researcher and clinician whose work focuses on Black perinatal mental health, pregnancy loss, and health equity. Grounded in reproductive justice and Black feminist thought, her research, advocacy, and clinical practice center the experiences of communities that have experienced systemic marginalization and advance more equitable, compassionate care.