Transgender pregnancy is the gestation of one or moreembryos orfetuses bytransgender people. This is possible for those born withfemale reproductive systems. However,transition-related treatments may impact fertility. Transgender men andnonbinary people who are or wish to become pregnant face social, medical, legal, and psychological concerns. Asuterus transplantations are currently experimental, and none have successfully been performed ontrans women, they cannot become pregnant.
Pregnancy is possible fortransgender men who retain functioningovaries and auterus, such as in the case ofThomas Beatie.[1] Regardless of priorhormone replacement therapy (HRT) treatments, the progression of pregnancy and birthing procedures are typically the same as those ofcisgender women. Delivery options include conventional methods such asvaginal delivery andcesarean 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 offollicular function oroocyte 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 (includingbilateral salpingo-oophorectomy and/or totalhysterectomy).
Continuous testosterone use iscontraindicated (not medically recommended) at the same time a trans man is attempting to conceive, pregnant, or while breastfeeding.[4][5] This is because exposing a fetus to high levels of exogenous testosteronemay damage an embryo or fetus, especially the urogenital system of a female fetus.[4] This is particularly important in thefirst trimester when many pregnancies have not been discovered yet.[6] Previous studies of pregnancies in women suggest that high levels of endogenousandrogens 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 byoophyte banking, but the process may increase gender dysphoria or may not be accessible due to lack of insurance coverage.[7]
Additionally, patients experiencingamenorrhea (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.[6] 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.[6] Many trans men who had planned pregnancies were able to conceive within six months of stopping testosterone.[7] 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 theovarian cycle anduterine cycle, which would otherwise causeoocyte maturation,ovulation, andmenstruation every month. Testosterone therapy also causesatrophy of the vagina and uterus.[8] Testosterone use in trans men and other transmasculine individuals affects the ovaries, leading to an increased amount ofovarian cysts, which is also seen in cisgender women withPCOS. Individuals studied also displayedfollicular atresia, overgrowth of thestroma, and the replacement of ovarian tissue withcollagen. Theuterine 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 availablegametes (eggs/sex cells).[9]
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 discussfertility preservation options with trans male clients before prescribing HRT.[10]
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][11] Trans men may experienceunintended pregnancy,[7][10] especially if they miss doses.[7]
Another important postpartum consideration for trans men is whether to resume testosterone therapy. There is currently no evidence that testosterone entersbreast milk in a significant quantity.[12] However, elevated testosterone levels may suppresslactation and healthcare guidelines have previously recommended that trans men do not undergo testosterone therapy while chestfeeding (breastfeeding).[13] Trans men who undergo chest reconstruction surgery may maintain the ability to chestfeed.[14]
Chestfeeding is possible for many trans men who medically transition, but it is rarely discussed by doctors who prescribetestosterone or completechest 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.[15]
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.[16] 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 affectglandular tissue and chestfeeding ability, and binding during a chestfeeding period is not recommended, as it can causemastitis.[17]
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.[18][19] 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 prefermidwifery services rather than experience labor and delivery in a hospital.
Some individuals reported havinggender 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.[20] Some state feelingdisconnected 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.[21][22]
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.[23] Unwanted pregnancy can cause severe gender dysphoria andsuicidal ideation in trans people. One nonbinary person who performed aself-induced abortion stated,[24]
[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.[19] This may be attributed to factors such as lack of social support, discrimination, and lack of adequate healthcare practitioner training.[19]
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 experienceminority 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.[25]
Some trans men who carry pregnancies are subjected todiscrimination, 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.[20] Inaccessibility to these services may lead to difficulty in finding comfortable and supportive services concerningprenatal care, as well as an increased risk for unsafe or unhealthy practices.
The prevalence and experiences of transgender, gender expansive, andnon-binary people with abortion is understudied.[26] Unintended pregnancies can result in transgender men or nonbinary people considering or attemptingself-induced abortion. Many transgender men report attempting a self-induced abortion because of lack of safe, effective abortion methods.[24] Studies differ on abortion rates in trans men. Different studies report that between 12%[10] and 21% of trans people's pregnancies end in abortions. Some trans people report choosing between abortion andsuicide because pregnancy causes them intolerablegender dysphoria.[24]
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.[27]
Pregnancy is not yet possible fortransgender women who lack a uterus capable of supporting gestation. As of 2019,uterus transplantation has not been successfully performed in transgender women.[28] The Danish transgender painterLili Elbe died in 1931 from immune rejection following a uterus transplant operation. Modern uterus transplants, typically require the patient to take anti-reaction medication until gestation is complete.
Uterine transplantation, or UTx, is in its infancy and is not yet publicly available. As of 2019,[update] in cisgender women, more than 42 UTx procedures had been performed, with 12live 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, inTransplant International.[31] Under these criteria, and because no research has been conducted inkaryotypically male individuals, only karyotypically female individuals were considered to be a transplant recipient. The exclusion of trans women from candidacy was 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 inBioethics with an ethical framework for consideration of karyotypic XY individuals' eligibility for uterine transplants.[33] Additionally, there have been several cases of XY individuals with Swyer syndrome who have successfully hosted pregnancies[34][35][36][37]. There have also been successful uterus transplants in male rats.[38]
Some trans women caninduce lactation, enabling them to breastfeed babies they did not birth. Practices such as medical lactation induction can simulate the changes of breasts during pregnancy and begin lactation with the assistance of medication.[39]
Non-binary people with a functioning female reproductive system can give birth.[40]
Nonbinary people taking testosterone totransition must interruptHRT in order to carry the pregnancy, as testosterone is ateratogen.[4] Unintended pregnancies by non-binary people on testosterone therapy may be more common if they are on a low dose of testosterone.[7] Nonbinary parents choose whether to be called "mom," "dad," or newly coined gender-neutral or nonbinary titles.[41]
Non-binary people who have written or been profiled about their experiences of pregnancy include Rory Mickelson,[42] Braiden Schirtzinger,[43] and Mariah MacCarthy.[44]
In 2021,Unicode approved the "pregnant man" and "pregnant person"emojis in version 14.0, and added to Emoji 14.0.[45] Additionally, these emojis are used in a humorous sense to refer to the feeling of being very full after a large meal.[45]
Most participants were not afraid of pregnancy (n=130, 69.5%)
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 aprima 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.
