When Kayden Coleman was pregnant with his now 10-month-old daughter, no one held the door for him, fussed over his growing belly or made him feel special in the way that pregnant women are sometimes treated.
In a way, he feels as though he missed out on "the perks" of pregnancy, he said. In another, he's relieved no one knew the truth. As a transgender man, he felt safer that way.
"I didn't have to walk around in fear, worrying that people wanted to inflict violence on me," Coleman, who lives in Houston, said. "They thought I had a beer belly."
Coleman, who also has a 7-year-old daughter, is one of a growing number of advocates trying to educate the public — and the medical community — about what it is like to navigate pregnancy, childbirth and the postpartum experience as a trans person. He also wants to dispel stereotypes about trans people that he said even health care workers believe.
Trans people already face high rates of violence, discrimination and harassment; in the world of pregnancy and childbirth, their struggles are only magnified, according to Coleman. The 34-year-old called both of his pregnancies "very tumultuous."
"There was a lot of trauma," he said. "Most of that came from inside the birthing world, with medical professionals. There was a lot of questioning about my identity, a lot of misgendering. Being told I shouldn't be in spaces I was seeking care from because they were considered women's spaces. I was offered an abortion a ridiculous amount of times."
Birth workers say the current medical system isn't set up to support pregnant transgender people.
"Pregnancy literature is geared towards white, heterosexual, cisgender people," said Ray Rachlin, a certified professional midwife and founder of Refuge Midwifery in Philadelphia. "That's who all the images are geared towards and the resources geared towards. From the get-go, they're having to hack a system that wasn't set up for their needs."
For starters, the female-oriented language around pregnancy and childbirth can be hurtful and triggering to someone who doesn’t identify as a woman. Rachlin and others suggest people consider saying perinatal care instead of maternity care, chestfeeding instead of breastfeeding, birthing people instead of mothers, for example.
“It really is a big paradigm shift in how we think about birth and postpartum,” she said.
Rachlin admits there can be a learning curve.
"When I started off, even though I was queer, I didn't use inclusive language,” she said. “Gender is really ingrained in how we see pregnancy, birth and parenthood. I had to do a lot of learning and unlearning to take a step back. One of the most common things is calling someone ‘mom’ or ‘mama’ instead of their name. When I called someone 'mama,' I was trying to create connection, but I was taking away their autonomy."
Davis Chandler, 38, a parent of two who identifies as trans and nonbinary (meaning their gender identity is neither exclusively male nor female), said the language around pregnancy adds to the alienation of the experience for a trans person.
"I downloaded some of those silly apps to see how big the baby is growing and all of them assume that the person who's the gestational parent is a woman who identifies as a mother," Chandler, a licensed therapist in Northampton, Massachusetts, said. "My partner, who's a queer-identifying person, also didn't feel the mirror and reflection of where she fit in. She's not a daddy."
Many aspects of the typical pregnancy experience don’t work for trans people. Seeing multiple providers, as is common with many obstetrics practices, can be uncomfortable for transgender patients if their providers are unable to offer them culturally competent care.
Nearly 1 in 5 transgender people reported being refused care in a health care setting due to their gender identity, according to the 2011 National Transgender Discrimination Survey. Transgender or gender-nonconforming people are also more likely than the general population to postpone medical care when they need it, either due to fear of discrimination or because they cannot afford it, according to the survey.
“A trans person is at risk of harm any time they enter a health care setting,” said Rachlin, who does home births. “Midwives like myself are in this unique situation — our model of care is already better set up to care for trans people. I don’t have a front desk receptionist or a waiting room where people might stare at them. I draw labs in my office instead of sending someone to a laboratory.”
This is likely why trans people are turning to home births at a much greater number than their cisgender counterparts. According to one small 2014 study, 22 percent of transgender and nonbinary people chose home births over hospital births, while home births only account for 1 percent of total births among the U.S. population as a whole.
That said, hospital births are still by far the most common, and for many trans people, they offer at least one clear incentive: the opportunity to have a scheduled cesarean section.
"The experience of labor and delivery is so ... there's just so much invasion of people's bodies. For myself, the amount of intensive, invasive contact people would have had to have with my body in order to labor and deliver just felt like way too much for me," said Chandler, who uses gender-neutral pronouns.
Yet some trans people say their providers push back when they express their desire for a cesarean section over a vaginal delivery. That happened with Chandler, so they shopped around for a new obstetrician.
"The provider I ultimately worked with said, 'People have scheduled c-sections all the time. I support them for a huge variety of reasons, and gender is as valid a reason as any other,'" Chandler said. "I wound up having a really beautiful experience, being able to walk into the operating room and have everything happen in a predictable sort of way. I had a little bit more autonomy and control over the experience."
In the case of c-sections upon request, the American College of Obstetricians and Gynecologists tells doctors to explore the "reasons behind the patient's request" and discuss the "risks and benefits," but a committee opinion updated in January 2019 does not mention gender specifically.
Dr. Alson Burke, an OB-GYN at the University of Washington in Seattle, who cares for trans pregnant patients, said the decision of how to give birth may depend on multiple factors, including whether the patient has had gender-affirming surgery or whether a vaginal delivery would create extreme gender dysphoria for the patient.
"The way I practice is that it's a conversation of shared decision-making, and I feel like the guidelines of ACOG really support that," Burke said.
In her practice, she takes many steps to make patients feel safe, she said. She allows them to insert the speculum themselves in the case of a vaginal exam, opt for an abdominal ultrasound instead of a vaginal one when possible, and she makes sure their care team knows what pronouns to use ahead of time. Burke believes these are easy ways providers can offer more inclusive care — for all patients.
Finding the right provider is only half the battle, according to transgender advocates, who note that trans people have a long history of facing discrimination in the medical world. "Transexualism," for example, wasn't removed from the World Health Organization's diseases manual until 2018.
"It takes decades for culture to shift, and the medical system is really a reflection of that culture," Jenna “JB” Brown, a doula in Austin, Texas, said. “Treating trans people in medical settings isn’t taught in medical school or midwifery school.”
That means that trans patients are usually the ones educating their doctors about their needs, Brown and Rachlin said. Fifty percent of transgender people surveyed said they’ve had to teach their medical providers about transgender care.
This lack of education and awareness at a high level can have even more dire consequences on a personal level: Trans people themselves are sometimes misinformed about their own bodies.
Brown said that when trans people go on gender-affirming hormone therapy, they’re required to sign something that acknowledges that they may not be able to have children in the future. And yet, it is possible for trans men to have kids, he said. Say someone lapses while taking testosterone and their period returns; they could get pregnant, perhaps unintentionally. On the flip side, trans people who have undergone hormone therapy and do want to have children may be under the impression that they can’t.
“There are many options,” Brown said. “We need more providers who are aware of these options and providing true information.”
Brown equates the misinformation to “cultural eugenics.”
“When people think you shouldn’t have children because you’re queer, that affects you,” he said. “It becomes something you’re socialized to believe.”
Inspired by his own struggles with pregnancy and childbirth, Coleman teaches trans fertility and birth workshops to birth workers.
People like him, Brown and Rachlin are trying to teach the public that the only necessary ingredients to make a baby are sperm, an egg and a uterus — that’s all. How the pregnancy gets into the uterus? Well, there are many options. By educating the public, they hope society will eventually start to disassociate reproduction and parenthood with gender identity — a goal they say will benefit everyone, not just trans people.
“The desire to have children is not attached to gender,” Rachlin said. “Plenty of people who were assigned male at birth want to parent and plenty of people who were assigned female at birth want to parent.”
"The more we can move gender away from birth and treat people as individuals, the better outcomes we're going to have for everyone," she added. "Misogyny is at the root of transphobia. It is also the root of the sexism that many cisgender women face. We have the same enemy."
Yet, the crusade is not an easy one. Rachlin said she’s lost clients due to being vocal about supporting trans people. The inclusive language alone that she and others use can be seen as inflammatory by some.
“There’s a large community of people who feel that expanding our language to include trans and nonbinary people is taking birth away from mothers,” she said.
As Coleman sees it, personal beliefs shouldn’t have anything to do with the care he and other trans people receive.
“It’s not about whether or not you quote-unquote agree with us,” he said. “We don’t care about your acceptance or agreement. We just want equity and safe, inclusive care.”