29.1 Introduction

Many men of transgender experience have female reproductive organs and are capable of getting pregnant and carrying out a pregnancy. While the prevalence of pregnancy among transgender men is uncertain, it is likely that the number of pregnancies in this population is increasing and will continue to rise with greater social acceptance, visibility, and healthcare support.

When caring for transgender men who are considering pregnancy and who are pregnant, it is essential for healthcare professionals to promote gender affirmation and support their patients’ gender identities, including male, genderqueer, agender, and other identities. Creating healthcare systems that promote these values – in the midwifery and obstetrics and gynecology office, hospital labor and delivery and birth center, and the postpartum settings – is essential to strengthen the patient–healthcare professional relationship to achieve optimal health outcomes.

In this chapter, we describe obstetrical care for transgender men and people with diverse gender identities. We review important considerations during the preconception, perinatal, and postpartum periods, including the impact of stopping gender-affirming hormone therapy, monitoring for perinatal depression, labor and delivery care, and chest feeding. We conclude with a discussion about research gaps and suggest areas for future research. There is a dearth of high-level evidence on this topic; therefore, our discussion is primarily informed by the results of cross-sectional surveys and expert opinion.

29.2 Background

Transgender people experience poor health outcomes at higher rates than cisgender people. Factors unique to the healthcare system contribute to healthcare disparities, such as lack of healthcare professional exposure to transgender people in medical school and in clinical practice [Reference Hoffkling, Obedin-Maliver and Sevelius1–Reference Grant and Tanis3] and limited insurance coverage for universal and gender-affirming (also called “transition”)-related services. Studies suggest that transgender people often have to teach their doctors about transgender issues in order to receive adequate care [Reference James, Rankin, Keisling, Mottet and Anafi2]. Manifestations of stress from living in a society that promotes binary notions of gender also contribute. Transgender people report increased rates of psychological stress, suicidal ideation, and substance use disorder compared to the general population [Reference James, Rankin, Keisling, Mottet and Anafi2]. Transgender people may not seek medical care due to fear of mistreatment or prior experiences with discrimination in the healthcare system, such as verbal harassment or refusal of medical treatment [Reference James, Rankin, Keisling, Mottet and Anafi2]. As a result of these and other factors, transgender people are less likely to be up-to-date on healthcare maintenance screening or seek specialized services, such as family planning counseling and contraception care, compared to cisgender people. When they seek medical attention, transgender people may require treatment at advanced stages of disease.

A useful framework guides the provision of obstetrical care for transgender men, as well as medical care for peoples with diverse gender identities. This framework suggests that transgender men and other gender minority people, compared to cisgender women, are the same, different, and unique [Reference Light4]. The supposition that transgender men are the same means that transgender men have some needs that are the same as cisgender women, which is a consequence of biology and anatomy. Providers should be aware of the limits of classification (i.e. seeing patients through binary “lenses”) as this could lead to delayed recognition of medical complications [Reference Stroumsa, Roberts, Kinnear and Harris5]. For example, transgender men with female reproductive organs are at risk for gynecologic emergencies, such as ectopic pregnancy, and obstetric emergencies, such as umbilical cord prolapse, just like cisgender women [Reference Stroumsa, Roberts, Kinnear and Harris5]. Transgender men are different reflects the notion that transgender people are at increased risk for healthcare disparities, compared to cisgender women, that lead to disproportionate health outcomes. The third component of this framework reminds healthcare professionals that each person – whether transgender, cisgender, or with other gender identities – is defined by unique experiences, risk factors, and resiliencies driven by personal privileges and disadvantages that contribute to one’s world view, one’s likelihood for health or illness, and one’s interaction with the healthcare system.

Gender affirmation in the provision of care is extremely important in the healthcare system. To achieve a gender-affirming healthcare environment, training and education should be provided for all staff, including physicians and midwives as well as nurses, clerical staff, security, nutrition, social work, and laboratory technicians, among others [Reference Adams6]. Strategies that promote gender affirmation include informing receptionists and other office staff that patients of all sexual orientations and gender identities are welcome, modifying office registration forms and questionnaires to be inclusive of all gender identities, and having a nondiscrimination policy for the office posted in the reception area [7]. Staff should use inclusive language that strives to be the least gendered as possible with all patients: this includes asking and using individuals’ correct name and pronouns, employing the use of neutral terms for body parts and processes (e.g. “internal reproductive organs” versus womb and “underwear” versus panties), sexual behaviors (e.g. “penis-in-vagina sex” versus intercourse), and relationship structures (e.g. “partner” or “spouse” versus husband or boyfriend) [Reference Potter, Peitzmeier and Bernstein8], and being a resource for health information about sexual orientation and gender issues [7].

Providers may not have experiences with transgender people or be familiar with the tenets described above. Especially in obstetrics, it is imperative that the healthcare team learn about these principles to create supportive care environments [Reference Light4]. Figure 29.1 highlights some available resources (from an US perspective) for providers seeking to learn more about this population and how to deliver gender-affirming care.

Figure 29.1 Resources for healthcare professionals (from an US perspective) taking care of pregnant transgender men and people with diverse gender identities.

29.3 Epidemiology

Despite substantial media attention highlighting pregnancies among some transgender men [Reference Trebay9–Reference Noble11], the demographic breakdown, including age, ethnicity, and socioeconomic factors, is understudied [Reference Brandt, Patel, Marshall and Bachmann12]. The 2015 US Trans Survey, which was commissioned by the National Center for Transgender Equality to better understand the demographics, health, and experiences of transgender people in the US, did not include questions about pregnancy [Reference James, Rankin, Keisling, Mottet and Anafi2]. A recent cross-sectional survey-based study of 1,694 transgender and gender expansive people assigned female sex at birth in the US reported 12% of the sample with a past pregnancy and a resultant 16.8 per 1,000 pregnancy rate among transgender and gender expansive people with a uterus [Reference Moseson, Fix and Hastings13]. Although population-based figures are lacking, expert opinion suggests that the number of pregnancies among transgender men is increasing and will continue to rise in the future.

29.4 Preconception Care

Transgender people may choose to engage with none, some, or many gender-affirming processes and procedures which include social affirmation (e.g. using affirmed name and pronouns), legal affirmation (e.g. changing identity documents), medical affirmation (e.g. using gender-affirming hormones like testosterone), and surgical affirmation. Approximately 8–20% of transgender men are reported to have undergone a hysterectomy in the US, and about half of these individuals will undergo a bilateral salpingo-oophorectomy [Reference Hahn, Sheran, Weber, Cohan and Obedin-Maliver14,Reference Bretschneider, Sheyn, Pollard and Ferrando15]. In Europe and other continents, estimations are much higher, as removal of internal reproductive organs was a prerequisite for legal gender recognition until recently. Still, many transgender men keep the reproductive organs in situ and retain their capacity to become pregnant.

The reproductive desires of transgender men appear to be similar to the reproductive desires of cisgender women [Reference Hoffkling, Obedin-Maliver and Sevelius1]. Although unintended pregnancies were common (32–54%) in two studies, particularly for those who were not taking testosterone therapy, many transgender men have desired and planned pregnancies [Reference Moseson, Fix and Hastings13,Reference Light, Obedin-Maliver, Sevelius and Kerns16]. One study suggested that a planned conception occurs in two-thirds of pregnancies among transgender people [Reference Light, Obedin-Maliver, Sevelius and Kerns16]. Another found that 11% of transgender and gender expansive people assigned female sex at birth desired a pregnancy in the future, while 16% were unsure [Reference Moseson, Fix and Hastings13]. This suggests that there is a healthcare opportunity for preconception counseling for many transgender men to address transgender health and obstetrical care before pregnancy occurs. The key components of the preconception visit are highlighted in Figure 29.2.

Figure 29.2 Key components of preconception care for transgender men and people with diverse gender identities.

The World Professional Association for Transgender Health (WPATH) guidelines encourage providers to begin the discussion about family-building goals and fertility preservation options with patients prior to the initiation of gender-affirming hormone therapy [Reference Brandt, Patel, Marshall and Bachmann12]. Discussions about fertility preservation, an important component of the preconception consultation, are addressed in Chapter 24.

A second important preconception issue relates to the impact of gender-affirming hormone therapy, including its potential impact on fecundity as well as its impact on quality of life. A recent cross-sectional survey suggested that 61% of transgender men reported using testosterone therapy prior to pregnancy and 20% became pregnant while taking this therapy [Reference Light, Obedin-Maliver, Sevelius and Kerns16]. In another larger cross-sectional survey, 10% of transgender and gender expansive people assigned female sex at birth and who had prior pregnancies reported prior testosterone use [Reference Moseson, Fix and Hastings13]. As testosterone is potentially teratogenic, especially in the first 14 weeks of pregnancy, this medication should be discontinued as soon as pregnancy is identified, although it is preferable to stop it before a planned pregnancy.

Testosterone has a significant positive impact on quality of life [Reference Murad, Elamin and Garcia17]. The desired effects of testosterone include amenorrhea, ovulation diminishment or cessation, deepening of the voice, and phenotypic changes such as decreased breast tissue, increased facial hair growth, and fat redistribution from the hips to abdomen [Reference Steinle18–Reference Garcia-Acosta, San Juan-Valdivia, Fernandez-Martinez, Lorenzo-Rocha and Castro-Peraza20] (see also Chapters 31 and 32). In a meta-analysis of 28 studies that included 1,833 transgender people, the impact of hormone treatment was dramatic, with improvements in gender dysphoria, quality of life, and sexual function [Reference Murad, Elamin and Garcia17]. In light of its positive impact, discontinuation of testosterone therapy plus confrontation with society’s gendered notions of pregnancy and the physical changes of pregnancy may be challenging for some transgender men during pregnancy. The potential for inciting or exacerbating gender dysphoria, a mental health diagnosis describing the conflict between one’s gender identity and one’s sex assigned at birth that some transgender people experience [Reference Ellis, Wojnar and Pettinato21], should be addressed with transgender men in the preconception context and throughout the perinatal period [Reference Safer and Tangpricha22]. An emotional support plan should be developed should mood symptoms worsen during pregnancy and the postpartum period [Reference Martinez, Klein and Obedin-Maliver23].

The long-term impact of testosterone on the hypothalamic-pituitary-adrenal axis is uncertain, but the short-term impact is better elucidated. Return of menses typically occurs within 3 to 6 months after cessation of testosterone, with some studies suggesting that it takes around 8 to 12 months to resume ovulation [Reference Light, Obedin-Maliver, Sevelius and Kerns16,Reference Garcia-Acosta, San Juan-Valdivia, Fernandez-Martinez, Lorenzo-Rocha and Castro-Peraza20]. However, there are reports of conception occurring prior to the resumption of menses, and ovulation can occur despite amenorrhea or oligomenorrhea [Reference Light, Obedin-Maliver, Sevelius and Kerns16]. Thus, while the use of testosterone therapy is thought to reduce the chance of spontaneous pregnancy, there is a chance of ovulation and conception while on therapy.

Limited human data guides our understanding about potential risks of testosterone exposure in pregnancy. Animal models suggest an androgenizing effect on fetal development and abnormal differentiation of female external genitalia associated with first trimester androgen exposure [Reference Grumbach and Ducharme24–Reference McCoy and Shirley26]. It is unclear whether testosterone exposure to the human embryo alters neuroendocrine or psychosexual development. Testosterone may have an impact on fetal growth. A small study that measured endogenous testosterone levels during pregnancy of 147 cisgender women found that increased testosterone levels were associated with decreased birthweight [Reference Carlsen, Jacobsen and Romundstad27]. More specifically, an increase in testosterone levels from the 25th to 75th percentile at 17 weeks’ gestation led to a decrease in birthweight of 160 g; when the same difference was seen at 33 weeks’ gestation, a decrease of 115 g was observed. Although these results warrant further study, it remains uncertain whether prenatal exposure to androgens, especially exogenous testosterone, has a causal association with fetal growth restriction. Due to limited safety data and the potential risks, the use of testosterone is not recommended in pregnancy [Reference Gorton and Spade28]. If testosterone use is stopped prior to conception, the available limited evidence suggests that pregnancy, delivery, and birth outcomes are not negatively impacted [Reference Light, Obedin-Maliver, Sevelius and Kerns16].

Importantly, the preconception visit should also address routine topics, including folic acid supplementation to reduce the risk of open neural tube defects, an assessment of current vaccination status, the availability of genetic carrier screening for autosomal recessive conditions, as well as discussions about prenatal diagnosis for copy number variants and aneuploidy [Reference Brandt, Patel, Marshall and Bachmann12,29]. It is especially important to address health maintenance screening for transgender men to ensure age-appropriate screening is up-to-date. Health maintenance considerations may include cervical, breast/chest, and colorectal cancer screening, as indicated by age and patient history [Reference Brandt, Patel, Marshall and Bachmann12,30]. Due to the gendered nature of many of these screening tests and barriers to accessing care in general, transgender people are less likely than cisgender people to be up-to-date on preventative health maintenance [30].

In patients who are >35 years old, counseling about specific age-related risks is also required, though most risk occurs after age 40 or 45 [Reference Brandt, Patel, Marshall and Bachmann12,Reference Carolan, Davey, Biro and Kealy31,Reference Dildy, Jackson and Fowers32]. These risks include miscarriage, infertility, aneuploidy, preeclampsia, gestational diabetes, intrauterine fetal demise, and preterm delivery [Reference Carolan, Davey, Biro and Kealy31,Reference Dildy, Jackson and Fowers32]. It is not known whether rates of these risks in transgender men differ from cisgender women of the same age group [Reference Brandt, Patel, Marshall and Bachmann12]. Parental ages are highly correlated, and there has been recent attention to the reproductive risks associated when people providing sperm are >40 years old [Reference Brandt, Cruz Ithier, Rosen and Ashkinadze33]. When indicated, patients should be counseled about these reproductive risks during the preconception consultation, such as de novo autosomal dominant conditions, birth defects, poor neurodevelopmental outcomes, and childhood cancer [Reference Brandt, Cruz Ithier, Rosen and Ashkinadze33].

29.5 Antepartum Care

Surveys of transgender men suggest that most will seek care with obstetricians, but the literature shows that transgender men are more likely than the general population to pursue prenatal care with certified nurse midwives, lay midwives, and family practice physicians [Reference Light, Obedin-Maliver, Sevelius and Kerns16]. Nearly half of transgender men had midwifery care according to one survey [Reference Obedin-Maliver and Makadon34]. In contrast, 9.4% of the general population in the US were delivered by nurse midwives in 2018 [Reference Martin, Hamilton, Osterman and Driscoll35]. The reason for this difference is uncertain, but may be related to prior negative experiences with the traditional healthcare system. An overview of prenatal care is illustrated in Figure 29.3.

Figure 29.3 Overview of prenatal care for pregnant transgender men and people with diverse gender identities.

Legend: *with additional testing as guided by obstetric or parental indications.

Much of prenatal care for transgender and cisgender people is the same. This includes counseling about physiologic adaptations of pregnancy, preterm labor precautions, fetal kick count monitoring, and surveillance for the development of complications such as preeclampsia, and assessing for social support and changes. Based on current evidence, there is no reason to deviate from current prenatal care guidelines based on a patient’s gender identity or prior use of testosterone [Reference Obedin-Maliver and Makadon34]. Some evaluations, such as group B streptococcus screening or digital cervical exams at the beginning and end of pregnancy, may require lower genitalia examination. Some transgender men may be uncomfortable with these evaluations [Reference Hoffkling, Obedin-Maliver and Sevelius1]. When these exams are indicated, the rationale should be explained to patients and a support person may be utilized. In some circumstances, self-swab sampling should be considered as an alternative, as this has been performed for sexually transmitted infection testing and cervical cancer screening with reassuring outcomes [Reference Reisner, Deutsch and Peitzmeier36,Reference Reisner, Deutsch and Peitzmeier37].

A recurring theme in several cross-sectional surveys of transgender men is self-reported increased feelings of isolation, loneliness, and gender dysphoria during pregnancy [Reference Light, Obedin-Maliver, Sevelius and Kerns16,Reference Ellis, Wojnar and Pettinato21]. Screening for perinatal depression is important in all pregnancies [38], but transgender men may be at increased risk. Professional societies encourage healthcare professionals to screen for perinatal depression using a standardized, validated tool at least once during pregnancy and again in the postpartum period [38]. The Edinburgh Postnatal Depression Scale (EPDS) is the most frequently used tool [38]. No specific and validated surveys are available for transgender men in pregnancy, but some providers [Reference Brandt, Patel, Marshall and Bachmann12] use this tool at the first prenatal visit, at 28 weeks of gestation, and again at all postpartum visits. A more frequent assessment of subjective mood symptoms and shorter intervals between prenatal care visits may also be considered.

The coronavirus disease 2019 (COVID-19) pandemic may put transgender men and other sexual and gender minority patients at higher risk for worsening feelings of depression, anxiety, or loneliness [Reference Flentje, Obedin-Maliver and Lubensky39]. In a recent study that evaluated changes in self-reported depressive and anxiety symptoms of 2,288 participants in The PRIDE Study, including 12.2% transgender men, researchers found increases in both anxiety and depression coinciding with the onset of the COVID-19 pandemic [Reference Flentje, Obedin-Maliver and Lubensky39]. Healthcare professionals must be aware that additional mood symptom screening may be necessary during times of pandemic.