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
Conservative estimates suggest that between 2% and 6% of
the US population are transgender or gender variant,1 mean-
ing their gender identity varies from the traditional norm
(see Table 1 for definitions of gender-related terms). All
gender-variant individuals face multiple barriers to access-
ing equitable health care,2–5 particularly in the area of repro-
ductive health.6–10 While limited research has demonstrated
that transgender and gender-variant individuals often de-
sire parenthood, and can and do undertake pregnancy,11,12
published guidelines specific to gender-variant health con-
tain very limited information on conception, pregnancy, and
parenting.13,14
To date, no research has been published on physiologic
aspects of pregnancy after undergoing testosterone hormone
therapy (HT) for masculinizing gender affirmation. Scarce
and conflicting information exists as to whether androgenic
agents such as testosterone increase the risk of virilization
of the female fetus during pregnancy.15 No research has ad-
dressed the medical or emotional consequences of HT discon-
tinuation or the feasibility and safety of pregnancy following
HT discontinuation.
Address correspondence to Simon Adriane Ellis, CNM, MSN, Cedar
River Clinics, 263 Rainier Ave South, Suite 200, Renton, WA 98057.
E-mail: simonsays13@gmail.com
The current study sought to begin filling the gap in knowl-
edge by investigating the conception, pregnancy, and child-
birth perspectives of male and gender-variant gestational par-
ents who have undergone social or medical gender transition
prior to pregnancy.
METHODS
Grounded theory methodology as described by Glaser guided
the investigation.16 This is an inductive research approach that
requires openness of the researchers for data to inductively
emerge from the participants’ narratives.17 This approach is
considered ideal for exploring social relationships and behav-
iors of groups when there has been little exploration of the
contextual factors that affect individuals’ lives.18 The goal of
our investigation was to explore social relationships and be-
havior patterns of male and gender-variant gestational parents
to guide clinical interventions.19
Ethical approval for the protection of human subjects was
obtained from the institutional review board at Seattle Uni-
versity prior to participant recruitment. Participants were in-
formed of risks and benefits of participation, confidentiality
procedures, and their right to withdraw from the research.
Each signed consent forms prior to participating.
Inclusion criteria were: 1) natal female sex; 2) lack of cur-
rent pregnancy at time of interview; 3) history of carrying
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-
ant at the time of conception and throughout pregnancy and
birth; 5) disclosure of gender identity to at least some health
care providers during conception, pregnancy, and birth; 6)
having given birth in the United States; and 7) fluency in
English. Study participants were recruited directly by health
care and social service providers using text provided by the
authors. Additionally, several participants self-initiated re-
cruitment efforts within their community networks. Data col-
lection took place from September 2011 through May 2012.
Saturation of the data occurred at 6 interviews, after which 2
more were conducted.
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. All
interviews were conducted by the primary author, and data
analysis included all authors. All transcripts were initially
coded using line-by-line gerund coding to protect against
premature theory formation.20,21 Focused coding was subse-
quently used to interpret larger fragments of data through the
lens of frequently occurring codes, and analysis was a nonlin-
ear process of memo writing and constant comparison guided
by the emerging data.20 This analytical process resulted in
the creation of a schematic representation of grounded the-
ory that reflected participants’ experiences. Continued memo
writing, review of the data, conversations with experts, and
member checking interviews with 7 out of 8 participants fur-
ther contributed to the development and affirmation of the
emerging grounded theory.
RESULTS
In total, 15 individuals requested to participate in the study.
Of these, 12 met all participation criteria. Four were lost to
follow-up prior to interview. The final sample was 8 individ-
uals. There was no participant dropout.
All participants self-identified as white, and they reported
a wide range of spiritual/religious affiliations. Participants also
reported a broad spectrum of gender identities and sexual ori-
entations for themselves and their partners, as well as many
levels of gender transition and gender identity disclosure (see
Table 2 for additional participant demographic information).
Six participants reported more than one gender identity, and
the other 2 participants identified solely as male. Of the 6
Journal of Midwifery & Women’s Health r www.jmwh.org
participants who reported multiple gender identities, 4 iden-
tified as male, 4 as transgender, 3 as genderqueer, 3 as female-
to-male, 2 as gender variant, one as two-spirit, and one as
androgynous. Six participants reported their sexual orienta-
tion as gay, one as bisexual, and one did not disclose sexual
orientation.
Six study participants had legally changed their names
whereas 2 had not. Six had undergone testosterone HT
whereas 2 had not. Seven study participants had undergone
gender affirming surgery whereas one had not. Six partici-
pants had a male gender marker on their legal identification,
whereas 2 had a female gender marker. Methods of concep-
tion, birth setting, and health care providers varied among
participants, with the majority (n = 5) conceiving or attempt-
ing to conceive via sexual intercourse, and 6 giving birth in
a hospital setting with an obstetrician-gynecologist or fam-
ily physician (see Table 2). Several participants used multi-
ple methods of conception as a result of difficulties conceiv-
ing. For example, participants who were partnered with natal
males attempted to conceive first via sexual intercourse and
then sought fertility treatment as needed.
Loneliness was the overarching theme that permeated all
participants’ experiences, social interactions, and emotional
responses through every stage of achieving gestational par-
enthood. Within this context of loneliness, which surfaces re-
peatedly throughout participant narratives, participants de-
scribed complex internal and external processes of navigating
identity. A schematic representation of the grounded theory
that emerged from the participants’ narratives is depicted in
Figure 1.
Navigating Identity
Navigating identity encapsulated 2 subthemes and their
related social processes. The first, undergoing internal strug-
gles, refers to participants’ wrestling with their own sense of
self, thinking about the most feasible method of achieving
parenthood, and decision making about disclosure. The sec-
ond, engaging with the external world, refers to participants’
social interactions and use of disclosure or nondisclosure to
best protect self and the future child. These themes and related
processes constituted an integral part of participants’ daily
lives that infused most decisions, actions, and interactions.
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
Undergoing Internal Struggles
Exploration - Losing and Gaining - Connection and Disconnection
Loneliness
Engaging with the External World
Active Disclosure - Passive Disclosure - Active Non-Disclosure
Choosing Gestational Entering the Unknown
Parenthood
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
expression.
Pregnancy
Most participants felt a sense of relief from gaining the
concrete “mission” and timeline that pregnancy afforded;
nonetheless, the theme of navigating identity continued to
dominate everyday life and to present pleasant surprises as
well as challenges.
Some participants shared that they felt physically attrac-
tive or that their partner found them particularly attractive
during pregnancy, and others described a sense of embodi-
ment, peace, access to self, and connection with the develop-
ing fetus. One participant stated: “I really liked it . . . I felt a
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
described gaining a sense of wholeness during pregnancy:
This whole process has made me more, I guess at peace with
my own body and even with how I was born. . . . I’m more
accepting of the trans part of myself, or the female part of
myself. . . . The whole pregnancy and birth has made me
more whole and more comfortable in my own skin, more
comfortable with myself and my past.
For others, pregnancy was marked by a deep sense of dis-
connection; these participants experienced disembodiment,
lack of access to self, and lack of connection to the developing
fetus. One participant stated that he “hated being pregnant,”
and described profound loneliness about this feeling both dur-
ing preconception and pregnancy:
I think it felt really lonely. . . . I was like am I the only one
that feels like this? Like it super sucks, like it’s scary and it’s,
um, lonely and, you know my boyfriend’s [a natal male] and
he wasn’t going through it so he didn’t understand what I
was feeling.
Another participant, who also experienced loneliness and
emotional discomfort throughout pregnancy, reported:
66
PREGNANCY/BIRTH PARENTING
Loneliness
Using Coping Strategies Creating a Unique
Family Narrative
Engaged in Perinatal Care
I really went through the pregnancies in a fog. . . . I just
pushed it aside. . . . I knew there was something growing
inside me but I wasn’t connecting with it as a baby. It was
more of a thing, an organism, a parasite, anything. . . . I
wasn’t thinking of myself as a mother who’s pregnant at all.
Birth
Most participants described strong feelings about the birth
process. Some desired connection with the process, whereas
others desired disconnection from the physiologic reality of
birth. For some, the idea of having a vaginal birth, with
their genitals exposed for extended periods of time, was emo-
tionally unsettling. Thus, some described a preference for
cesarean:
I want[ed] the c-section. . . . I think that emotionally it was
a better choice than having to push a baby out. . . . I had
just made it so that it was—this was how we were having a
family, and the thought of that part of my body being . . . on
display . . . was just a little too much for me. I didn’t want a
natural delivery.
Others strongly preferred a physiologic vaginal birth, and
described birth as a physically painful but emotionally mean-
ingful experience. Participants who gave birth vaginally noted
a lack of inhibition during labor and birth that transcended
their usual concerns about gender identity and revealing their
bodies to others.
Transition to Parenthood
In the postpartum period, navigation of identity extended be-
yond the immediate self and moved into the realm of the
family unit. The process of creating a unique family narra-
tive began with developing an internal parental identity. For
some participants a singular, paternal role was a comfortable
fit; others described fulfilling dual parental roles. One partici-
pant said, “I’m serving 2 roles. I’m going to be their father, but
I’m also being my own surrogate so I’m . . . the birth mother
at the same time.” Another participant reflected:
Volume 60, No. 1, January/February 2015
In a sense I’m his mommy, you know, and that’s okay, that is
the role I have, and I’m the only mommy that he has. But I
guess I feel more dad-like now, and I don’t even know what
that means.
Some participants easily fell into paternal kinship names,
whereas others, particularly those who identified as gen-
derqueer or who had not undergone HT, struggled with
finding an appropriate term. Naming one’s parenthood role
brought together both internal and external aspects of
parental identity and was challenging to these participants.
Engaging with the External World
Throughout the process of achieving gestational parent-
hood, managing others’ perceptions and either communi-
cating or hiding one’s gender identity or gestational parent-
hood was a constant and pervasive experience. Participants
described protecting self by choosing from a “menu” of dis-
closure choices, including: active nondisclosure (hiding), pas-
sive nondisclosure (passing, allowing assumptions), or active
self-disclosure (telling, being open). Some participants nearly
consistently chose either disclosure or nondisclosure, whereas
others moved between disclosure choices based on context.
Choice of disclosure behaviors was not always based on par-
ticipant preference; for example, those who had a history of
HT were required to disclose their natal sex to their prenatal
care provider as well as their work supervisors.
Pregnancy Planning and the Preconception Period
Like most expectant parents, study participants faced choices
about when and how to disclose their intention of starting a
family. One decision faced by all families is whether or not to
use nondisclosure as a means of maintaining privacy for the
fledgling idea of parenthood and establishing emotional self-
protection in case of pregnancy loss or infertility.22 This held
true for the participants of this research, and the loneliness of
this time period was further complicated by participants’ gen-
der identities. One participant described a loss of community
as he entered the preconception period:
I was really feeling alone. . . . I distanced myself from . . .
a group of FTMs that I used to hang out with a lot when I
decided to get pregnant. . . . I felt like I was, uh, kinda doing
something that shouldn’t be done. Even though I know that
it’s done, I still felt like—eehh, you know . . . some of the
older guys in the group would say “oh you don’t want to
[get pregnant], there could be problems.”
Pregnancy
None of the participants received perinatal care from a
provider who had experience working with transgender or
gender-variant patients. A few reported negative experiences
with health care providers:
[She] was referring to my boxers as panties, which I found
totally weird. . . . I just kind of went under the radar with
her because I didn’t like her. . . . I just kind of dealt with
her. . . . There was never any room for me to be anything
other than, like, a lady with panties.
Most participants, however, expressed surprise that their
interactions with health care providers were positive. One
Journal of Midwifery & Women’s Health r www.jmwh.org
stated, “[t]hey were all surprisingly excellent; really, across the
board my experience with people was excellent. I was shocked
by that.”
When accessing community resources for expectant fam-
ilies, several participants described feeling “alienated,” ig-
nored, and misunderstood by both social service providers
and other expectant parents. In social settings, many par-
ticipants described acts of active and passive nondisclosure
throughout pregnancy as a coping strategy. Participants de-
scribed a variety of strategies to pass or hide their pregnancies
to avoid judgment from others. Some wore beards; one was
careful to limit his weight gain. The use of items of clothing
such as large jackets and sweaters allowed many participants
to hide their pregnancies:
I bought this like big puff y sleeveless jacket, and I wore
that, like, everyday. And that managed to hide it really well.
. . . Genuinely, people didn’t know I was pregnant . . . and
then I’d unzip it and they’d be like “holy crap, you’re totally
pregnant!”
Study participants also discussed passive nondisclosure
by exploiting social norms and expectations. One participant
stated, “[w]hen you’re not out as trans to begin with there’s no
way someone’s gonna think of this as something that’s in the
realm of possibility.” Participants who had not undergone HT
also stated they were rarely perceived as pregnant in public
settings. However, concealment did become more challeng-
ing for all participants in late pregnancy. Some restricted their
activities to avoid unwanted attention, whereas others contin-
ued with all aspects of their daily lives. One participant stated,
“Sometimes I’d be like ‘oh, I just don’t want to get stared at to-
day.’ . . . It was a lot of negative attention. . . . Some days . . . I
just stayed in.” Others noted that the discomforts of late preg-
nancy were significant enough to supersede their concerns
about others’ perceptions.
For participants who had undergone HT, disclosing preg-
nancy always involved disclosing gender identity to people
who were not aware they were a natal female, including col-
leagues, supervisors, and partners’ family members. This dis-
closure caused a significant loss of anonymity and comfort for
these participants. One said, “[my partner] ended up having
to tell [his family] that I was trans and that we were pregnant
and having a baby at the same time. . . . It was a lot.”
Transition to Parenthood
Participants varied in their approach to crafting a unique fam-
ily narrative. Some used active nondisclosure of their ges-
tational parenthood. One stated: “I just say that we had a
surrogate. . . . In a lot of ways it was true because I was
my own surrogate.” Others described passive nondisclosure
strategies, such as not correcting people’s assumptions. This
strategy was described as “just let[ting] people draw their own
conclusions.” In contrast, other participants preferred active
disclosure of their biologic parenthood. One described his
desire for disclosure as a source of social discomfort and
isolation:
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
know you just kinda want to not say it. But I also don’t want
to be like “yeah, we adopted our kid,” like I . . . hate that, I
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
be fair about that too.
DISCUSSION
In this study, the stages leading to achieving gestational par-
enthood were consistent with that of heterosexual and les-
bian parenthood.23–26 However, the journey to parenthood
had unique features not typical for other populations of par-
ents. The unique finding of this study was that participants ex-
perienced significant and persistent loneliness on their paths
to parenthood and that, within this context of loneliness, the
process of navigating identity formed a constant backdrop
of daily life that required considerable energy and attention.
With a lack of clear models of what a positive, well-integrated,
gender-variant parental role might look like, navigating iden-
tity extended into parenthood as well.
Similar to lesbian, gay, and bisexual parents,24,27 some par-
ticipants felt comfortable with themselves as gestational par-
ents, whereas others felt quite constrained by external factors
and loneliness. Also consistent with prior reports,28 partici-
pants articulated expectations of strained or negative expe-
riences with their health care providers. Although nearly all
participants stated that they were “surprised” by the compas-
sion and professionalism of their health care providers, the 2
participants who had not undergone HT found that their neg-
ative expectations were confirmed by at least one health care
provider. This research also revealed that key points of ten-
sion in health care settings were not limited to direct provider-
to-patient interactions (see Table 3). In social contexts,
participants were acutely aware they were transgressing ex-
pectations that male and gender-variant people will not use
their bodies to bear children. This led to feelings of loneliness
and marginalization.
As with any research, this study has several limitations.
The intended sample for this study aimed to include greater
racial, ethnic, and socioeconomic diversity; however, efforts
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,
as well as the experiences of those who do not wish to un-
dergo physical transition and those who choose to breast-
feed. Rigorous scientific research is needed to explore the
physiologic relationships between HT and fertility and allow
for evidence-based preconception and perinatal care for this
population.
Despite these limitations, this research makes important
contributions to the limited knowledge base on transgender
and gender-variant parenting. Although the findings of this
pilot study must be applied with caution related to its small
sample size, foundational knowledge contributed by this work
includes the identification of the preconception period as the
time of greatest distress and least involvement with health
care—a finding that has bearing on the creation of culturally
responsive models of health care for this population and casts
new light on current standards of preconception care.
The experiences of participants suggest that culturally
sensitive preconception counseling could be beneficial for this
population. Simple interventions such as asking, “[A]re you
interested in becoming a parent someday?” and if so, “[H]ave
you thought about how you would like to become a parent?”
may provide an entry point to health care by positioning the
provider as an informed and nonjudgmental resource. The
grounded theory produced by this pilot investigation also pro-
vides insights that will be useful to health care providers and
others working with male and gender-variant prospective ges-
tational parents.
Key strategies for patient advocacy and addressing points
of tension in perinatal health care settings emerged from par-
ticipant narratives (see Supporting Information Appendices
A and B). These strategies included: providing training to all
staff, documenting preferred name and pronouns clearly in

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

the patient chart, offering scheduling accommodations or al-
ternate waiting areas, proactively discussing privacy issues,
planning ahead of time to coordinate a smooth labor arrival
and housing process based on patient needs, offering private
information sessions and tours as appropriate, maintaining
continuity of health care, and calling ahead to any outside
providers to which patients must be referred.
AUTHORS
Simon Adriane Ellis, CNM, MSN, is in clinical practice at
Cedar River Clinics in Renton, Tacoma, and Seattle, Washing-
ton, where he provides well-woman care, abortion care, and
LGBTQ wellness services.
Danuta M. Wojnar, PhD, RN, MED, IBCLC, FAAN, is Asso-
ciate Professor and Chair of Maternal/Child and Family Nurs-
ing at Seattle University in Seattle, Washington.
Maria Pettinato, RN, PhD, is Associate Professor in the Col-
lege of Nursing at Seattle University in Seattle, Washington.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
The authors offer deep gratitude to the participants of this
study for their selfless sharing and to Stephanie Brill of Gen-
der Spectrum and Kristin Kali, LM, CPM, of Maia Midwifery
for their support with the recruitment process.
This research is dedicated with love and hope to those
who still stand on the painful precipice of their desire for
parenthood.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the on-
line version of this article at the publisher’s Web site:
Appendix S1: Advocacy in Healthcare Settings.
Appendix S2: Addressing Points of Tension in Healthcare
Settings.
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