Abstract
Objective
To assess pathways to parenthood, pregnancy outcomes, future pregnancy desire, and fertility counseling experiences among a cross-sectional sample of transgender men and gender diverse individuals assigned female or intersex at birth in the United States
Methods
Participants were recruited from The Population Research in Identity and Disparities for Equality (PRIDE) Study and the general public. Eligible participants for this analysis were able to read and understand English, assigned female or intersex at birth, US residents, 18+ years old, and identified as transgender, nonbinary, or gender diverse. We analyzed responses to close-ended survey questions, overall and stratified by gender identity, race/ethnicity, and testosterone use. We also qualitatively assessed open-text responses on fertility counseling.
Results
Among the 1694 participants, median age was 27 years (range: 18–72), 12% had ever been pregnant, and 12% were parents. Carrying a pregnancy where the individual was the egg source (36%) was the most common pathway to parenthood. Individuals with an exclusively binary gender identity (ie, transgender man or man) more often reported becoming parents through adoption than individuals with gender diverse identities (19% vs 12%). A third of individuals did not receive fertility counseling prior to initiating testosterone; individuals who exclusively reported nonbinary identities were recommended to investigate fertility preservation options less often (36%) compared to transgender men (50%).
Conclusion
Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption. Clinicians should avoid making assumptions about reproductive desires in these populations based on gender identities or testosterone use and should provide consistent fertility counseling prior to and after hormone initiation.
Key words: family building, fertility counseling, non-binary persons, parenthood, pregnancy, reproduction, sexual and gender minorities, sexual health, transgender persons
AJOG Global Reports at a Glance.
Why was this study conducted?
Data on the pathways to parenthood for TMGD individuals, particularly regarding pregnancy, are needed to support evidence-based, culturally-competent reproductive healthcare.
Key findings
Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption. A third of individuals did not receive fertility counseling prior to initiating testosterone. Individuals who exclusively reported nonbinary identities were recommended to investigate fertility preservation options less often compared to transgender men.
What does this add to what is known?
Transgender men and gender diverse individuals often become parents through diverse means and can desire to become pregnant in the future. There is a need for additional transgender-specific research and patient resources on conception after testosterone therapy.
Introduction
Varied pathways to parenthood exist for lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) individuals, including through adoption or fostering, medically assisted reproduction supported pregnancy, and sexual activity leading to pregnancy.1,2 While research examining aspects of LGBTQIA+ parenthood and family life exists, there is limited information on how transgender men and gender diverse (TMGD) people assigned female or intersex at birth specifically build their families.1,3 Many TMGD individuals who were assigned female or intersex at birth have a uterus, and some choose to carry pregnancies.4,5 Understanding the pathways to parenthood is increasingly important given that TMGD people have unique birthing experiences and face substantial barriers within legal and healthcare systems, rooted in institutional erasure and structural cisnormativity and heteronormativity.6, 7, 8, 9, 10, 11, 12, 13, 14 Rich qualitative and mixed-methods work provides a foundation for understanding the complex and nuanced journeys of TMGD people pursuing parenthood, but there is a paucity of descriptive and quantitative work on this topic.4,8,15, 16, 17, 18
Data on the pathways to parenthood for TMGD individuals, particularly regarding pregnancy, are needed to support evidence-based, culturally-competent reproductive healthcare. To address this gap and contribute to the epidemiological evidence base, we conducted a descriptive, quantitative analysis of data from a cross-sectional national survey among a large sample of TMGD individuals in the United States (US) who were assigned female or intersex at birth.
Methods
Study population
We recruited participants from two sources: (1) The Population Research in Identity and Disparities for Equality (PRIDE) Study, a longitudinal cohort study of LGBTQIA+ adults (18+ years) in the US19 and (2) from the general public. Between May and September 2019, The PRIDE Study participants could opt into a self-administered cross-sectional online survey within their participant dashboard. We additionally recruited TMGD individuals aged 18 to 45 via social media posts, email distribution lists, word of mouth, and flyers at academic conferences and community events (details elsewhere9). This age range was targeted to recruit individuals most likely to be of reproductive ages and per original grant/funding materials. For these participants recruited from the general public, the survey could be accessed anonymously online via a standalone website distinct from The PRIDE Study. All eligible participants could read and understand English, were assigned female or intersex at birth, resided in the US, and identified as LGBTQIA+ (The PRIDE Study), or more specifically identified as transgender or gender diverse (general public). Upon survey completion, participants could opt into a raffle to receive one of 100 $50 electronic gift cards. We used a validated two-step approach, augmented with write-in gender identity responses, to identify TMGD participants (Appendix B).20 Results from cisgender sexual minority women from this sample are described elsewhere.21
Data collection
The online survey on sexual and reproductive health needs and experiences of LGBTQIA+ individuals is described elsewhere.9 To maximize comfort, participants could customize up to nine medical words and phrases regarding reproductive anatomy and processes (eg, “vagina,” “period,” “pregnant,” etc.) that were propagated throughout the survey (described elsewhere9,22). The survey included the following topics: current gender identity, sex assigned at birth, current sexual orientation, gender affirmation process history, sexual activity, contraceptive use and preferences, pregnancy history and desires, abortion history, and preferences, priorities for sexual and reproductive health care, and family building experiences.22
Study measures
Primary outcomes included pathways to parenthood and pregnancy outcomes, assessed using structured questions. Given that not all individuals build their families through pregnancy, we examined whether participants were parents or if they had ever been pregnant. We assessed if participants were ever pregnant or currently pregnant, their number of previous pregnancies, pregnancy outcomes (miscarriage, ectopic pregnancy, abortion, stillbirth, live birth, and cesarean birth), and prospective pregnancy intentions. We derived testosterone use as a dichotomous ‘ever used’ versus ‘never used’ variable, and assessed whether and when participants received fertility counseling associated with the receipt of gender affirming hormones, puberty blockers, and surgery. Relevant survey items are presented in Appendix B and a prior publication.9
We created three exclusive analytic categories for gender: (1) individuals who only endorsed man or transgender man; (2) individuals who only endorsed a gender diverse identity (ie, agender, genderqueer, nonbinary, Two-spirit, additional write-in gender); and (3) individuals who endorsed man or transgender man along with any gender diverse identities. For brevity, we subsequently refer to these groups as “binary gender identity only,” “gender diverse identity only,” and “both binary and gender diverse identity,” respectively. We excluded participants who only endorsed one or more of the following: woman, transgender woman, or cisgender woman. We assessed racial and ethnic identity as a social category. Additional self-reported characteristics at the time of survey completion included age, sexual orientation, annual household income, relationship status, marital status, education, health insurance coverage, percent of healthcare providers aware of gender identity, and US census region (created by assigning zip codes to states and US census regions).
Analyses
We analyzed close-ended multiple-choice and open-ended survey questions. Frequencies, percentages, and medians were calculated for participant characteristics, overall and stratified by whether the participant was a parent or had ever been pregnant. Additionally, frequencies were calculated for pathways to parenthood, pregnancy experiences, pregnancy intentions, and fertility counseling received by individuals who ever used testosterone in the overall sample as well as stratified using the three analytic gender categories described above and race/ethnicity. We also assessed pregnancy intentions stratified by testosterone use.
When queried about fertility counseling experiences while initiating gender affirming hormones, participants could provide further context through an open-ended response field (Appendix B). As an exploratory analysis, a rapid qualitative analysis (an alternative to thematic analysis) of these responses was conducted to identify key themes and exemplary quotations.23
This study was reviewed and approved by the Institutional Review Boards (IRB) of Stanford University and the University of California, San Francisco, and is now included in continuing review by WCG IRB. Additionally, The PRIDE Study Research Advisory Committee and The PRIDE Study Participant Advisory Committee (pridestudy.org/pridenet) reviewed and approved the study. All analyses were performed in SAS 9.4 (Cary, NC).
Results
Participant characteristics
Of the 1,694 individuals who identified as TMGD, 99.4% were assigned female at birth (0.4% selected “Not listed”; wrote-in responses included “intersex,” “intersex female,” “both male and female,” “was not assigned a sex,” and others). A total of 322 individuals endorsed at least one racial/ethnic identity other than Non-Latinx White (19%; Table 1). Participants often selected multiple sexual orientations (60%) and multiple gender identities (61%). Commonly endorsed sexual orientations included queer (68%) and bisexual (34%) and commonly endorsed gender identities included nonbinary (51%) and transgender man (39%). In the sample, 12% (n=210) of individuals had ever been pregnant, and 12% (n=200) were parents; 57% (n=113) of parents had ever been pregnant.
Table 1.
Participant characteristics of a sample of transgender men and gender diverse individuals assigned female or intersex at birth, overall and stratified by status as a parent and by pregnancy history (N=1694)
| Overall (N=1694) | Is a parenta |
Has ever been pregnantb |
|||
|---|---|---|---|---|---|
| Yes (N=200, 11.8%) | No (N=1420, 83.8%) | Yes (N=210, 12.4%) | No (N = 1455, 85.9%) | ||
| Age in years, Median (IQR) | 27.1 (17.1, 37.1) | 39 (25.1, 52.9) | 26.1 (17.6, 34.7) | 34.9 (21.8, 48) | 26.3 (17.1, 35.5) |
| N (%) | N (%) | N (%) | N (%) | N (%) | |
| Racec | |||||
| American Indian or Alaska Native | 42 (2.5) | 7 (3.5) | 35 (2.5) | 9 (4.3) | 33 (2.3) |
| Asiand | 77 (4.6) | 4 (2) | 73 (5.1) | 12 (5.7) | 65 (4.5) |
| Black or African American | 67 (4) | 6 (3) | 61 (4.3) | 8 (3.8) | 59 (4.1) |
| Hispanic or Latinx | 101 (6) | 10 (5) | 91 (6.4) | 13 (6.2) | 88 (6.1) |
| Middle Eastern or North African | 24 (1.4) | 3 (1.5) | 21 (1.5) | 5 (2.4) | 19 (1.3) |
| Native Hawaiian or Pacific Islander | 5 (0.3) | 0 (0) | 5 (0.4) | 0 (0) | 5 (0.3) |
| White | 1472 (86.9) | 183 (91.5) | 1289 (90.8) | 190 (90.5) | 1280 (88) |
| None of these | 57 (3.4) | 6 (3) | 51 (3.6) | 11 (5.2) | 46 (3.2) |
| Another/Unknown | 4 (0.2) | 2 (1) | 2 (0.1) | 2 (1) | 2 (0.1) |
| Multiple racial identities | 202 (11.9) | 16 (8) | 186 (13.1) | 34 (16.2) | 168 (11.6) |
| Missing | 96 (5.7) | 2 (1) | 20 (1.4) | 8 (3.8) | 61 (4.2) |
| Sexual orientationc | |||||
| Asexual | 252 (14.9) | 15 (7.5) | 232 (16.3) | 20 (9.5) | 232 (16) |
| Gay | 348 (20.5) | 25 (12.5) | 317 (22.3) | 47 (22.4) | 301 (20.7) |
| Bisexual | 571 (33.7) | 54 (27) | 506 (35.6) | 68 (32.4) | 499 (34.3) |
| Lesbian | 218 (12.9) | 36 (18) | 178 (12.5) | 26 (12.4) | 191 (13.1) |
| Pansexual | 418 (24.7) | 56 (28) | 346 (24.4) | 74 (35.2) | 339 (23.3) |
| Queer | 1150 (67.9) | 134 (67) | 984 (69.3) | 142 (67.6) | 1000 (68.7) |
| Same-gender loving | 111 (6.6) | 18 (9) | 91 (6.4) | 17 (8.1) | 94 (6.5) |
| Straight | 61 (3.6) | 16 (8) | 43 (3) | 4 (1.9) | 57 (3.9) |
| Questioning | 69 (4.1) | 3 (1.5) | 65 (4.6) | 7 (3.3) | 61 (4.2) |
| Another sexual orientation | 129 (7.6) | 15 (7.5) | 105 (7.4) | 17 (8.1) | 112 (7.7) |
| Multiple sexual orientations | 1010 (59.6) | 101 (50.5) | 885 (62.3) | 126 (60) | 879 (60.4) |
| Missing | 75 (4.4) | 14 (7) | 38 (2.7) | 2 (1) | 53 (3.6) |
| Gender Identityc | |||||
| Agender | 226 (13.3) | 19 (9.5) | 197 (13.9) | 34 (16.2) | 189 (13) |
| Cisgender Woman | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Genderqueer | 655 (38.7) | 82 (41) | 559 (39.4) | 95 (45.2) | 554 (38.1) |
| Man | 293 (17.3) | 33 (16.5) | 245 (17.3) | 19 (9.1) | 269 (18.5) |
| Nonbinary | 868 (51.2) | 87 (43.5) | 751 (52.9) | 110 (52.4) | 745 (51.2) |
| Prefer not to say | 2 (0.1) | 1 (0.5) | 1 (0.1) | 1 (0.5) | 1 (0.1) |
| Transgender man | 662 (39.1) | 85 (42.5) | 542 (38.2) | 70 (33.3) | 579 (39.8) |
| Transgender woman | 4 (0.2) | 1 (0.5) | 1 (0.1) | 1 (0.5) | 2 (0.1) |
| Two-spirit | 26 (1.5) | 9 (4.5) | 15 (1.1) | 9 (4.3) | 16 (1.1) |
| Woman | 204 (12) | 21 (10.5) | 176 (12.4) | 20 (9.5) | 181 (12.4) |
| Multiple gender identities | 1036 (61.2) | 113 (56.5) | 887 (62.5) | 118 (56.2) | 901 (61.9) |
| Another gender identity | 197 (11.6) | 18 (9) | 174 (12.3) | 24 (11.4) | 171 (11.8) |
| Missing | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Relationship status | |||||
| Not in a relationship | 570 (33.7) | 25 (12.5) | 545 (38.4) | 48 (22.9) | 522 (35.9) |
| 1 partner, not living with partner | 268 (15.8) | 16 (8) | 252 (17.8) | 21 (10) | 247 (17) |
| 1 partner, living with partner | 580 (34.2) | 127 (63.5) | 453 (31.9) | 96 (45.7) | 483 (33.2) |
| >1 partner, not living with partner(s) | 79 (4.7) | 12 (6) | 67 (4.7) | 22 (10.5) | 56 (3.9) |
| >1 partner, living with partner(s) | 105 (6.2) | 20 (10) | 85 (6) | 19 (9.1) | 85 (5.8) |
| Another type of relationship | 57 (3.4) | 9 (4.5) | 48 (3.4) | 7 (3.3) | 50 (3.4) |
| Missing | 76 (4.5) | 0 (0) | 2 (0.1) | 5 (2.4) | 44 (3) |
| Legal marital status | |||||
| Single, never married | 1113 (65.7) | 29 (14.5) | 1084 (76.3) | 71 (33.8) | 1041 (71.6) |
| Married | 342 (20.2) | 122 (61) | 220 (15.5) | 85 (40.5) | 256 (17.6) |
| Legally recognized civil union | 3 (0.2) | 1 (0.5) | 2 (0.1) | 0 (0) | 3 (0.2) |
| Registered domestic partnership | 7 (0.4) | 0 (0) | 7 (0.5) | 1 (0.5) | 6 (0.4) |
| Separated | 21 (1.2) | 13 (6.5) | 8 (0.6) | 13 (6.2) | 8 (0.6) |
| Divorced | 84 (5) | 28 (14) | 56 (3.9) | 32 (15.2) | 52 (3.6) |
| Widowed | 3 (0.2) | 2 (1) | 1 (0.1) | 1 (0.5) | 2 (0.1) |
| Not listed | 46 (2.7) | 4 (2) | 42 (3) | 2 (1) | 44 (3) |
| Missing | 75 (4.4) | 1 (0.5) | 0 (0) | 5 (2.4) | 43 (3) |
| Annual household income | |||||
| <$15,000 | 624 (36.8) | 33 (16.5) | 517 (36.4) | 51 (24.3) | 546 (37.5) |
| $15-<30,000 | 162 (9.6) | 10 (5) | 152 (10.7) | 19 (9.1) | 143 (9.8) |
| $30-<50,000 | 265 (15.6) | 27 (13.5) | 238 (16.8) | 38 (18.1) | 227 (15.6) |
| $50-<75,000 | 218 (12.9) | 30 (15) | 188 (13.2) | 31 (14.8) | 185 (12.7) |
| $75-<100,000 | 152 (9) | 32 (16) | 120 (8.5) | 23 (11) | 129 (8.9) |
| $100-<150,000 | 151 (8.9) | 38 (19) | 113 (8) | 31 (14.8) | 120 (8.3) |
| ≥$150,000 | 122 (7.2) | 30 (15) | 92 (6.5) | 17 (8.1) | 105 (7.2) |
| Health insurance coverage | |||||
| Yes | 1512 (89.3) | 187 (93.5) | 1325 (93.3) | 190 (90.5) | 1320 (90.7) |
| No | 92 (5.4) | 11 (5.5) | 81 (5.7) | 12 (5.7) | 80 (5.5) |
| Don't Know | 10 (0.6) | 1 (0.5) | 9 (0.6) | 1 (0.5) | 9 (0.6) |
| Missing | 80 (4.7) | 1 (0.5) | 5 (0.4) | 7 (3.3) | 46 (3.2) |
| Percent of healthcare providers aware of gender identity | |||||
| 0% | 340 (20.1) | 39 (19.5) | 300 (21.1) | 293 (20.1) | 46 (21.9) |
| 1-50% | 482 (28.5) | 58 (29) | 421 (29.7) | 414 (28.5) | 67 (31.9) |
| 51-90% | 340 (20.1) | 29 (14.5) | 310 (21.8) | 311 (21.4) | 29 (13.8) |
| >90% | 357 (21.1) | 58 (29) | 298 (21) | 305 (21) | 52 (24.8) |
| I don't know | 94 (5.6) | 15 (7.5) | 79 (5.6) | 84 (5.8) | 10 (4.8) |
| Missing | 81 (4.8) | 1 (0.5) | 12 (0.9) | 48 (3.3) | 6 (2.9) |
| US Census Region | |||||
| Midwest | 304 (18) | 37 (18.5) | 267 (18.8) | 34 (16.2) | 269 (18.5) |
| Northeast | 411 (24.3) | 44 (22) | 367 (25.9) | 45 (21.4) | 366 (25.2) |
| South | 326 (19.2) | 38 (19) | 288 (20.3) | 44 (21) | 281 (19.3) |
| West | 468 (27.6) | 66 (33) | 402 (28.3) | 66 (31.4) | 402 (27.6) |
| Missing | 185 (10.9) | 15 (7.5) | 96 (6.8) | 21 (10) | 137 (9.4) |
Abbreviations: IQR, interquartile range, US United States.
Observations with missing status as a parent, N=74
Observations with missing pregnancy history, N=29
Categories presented are overlapping and are not mutually exclusive, since participants could endorse multiple categories
Asian category was collapsed from Central Asian, East Asian, South Asian, and Southeast Asian due to sample size.
Bane. Pathways to parenthood among transgender men and gender diverse people. Am J Obstet Gynecol Glob Rep 2024.
Pathways to parenthood
Among parents (n=200), carrying a pregnancy as the egg source (36%) was the most common pathway to parenthood (94% of these individuals co-selected sexual activity leading to pregnancy; Table 2). In addition, participants became parents through stepparenting (25.5%), adoption (13.5%), and fostering (5.5%). Individuals with binary gender identity only (ie, transgender man or man) were equally likely to become parents through carrying a pregnancy as the egg source (29%) or stepparenting (29%); adoption (19%) were also common. In contrast, individuals with gender diverse identity only were more likely to become parents through carrying a pregnancy as the egg source (38%) or use sexual activity to get pregnant (41%); we observed similar results for individuals with both binary and gender diverse identity (42% for both carrying a pregnancy as the egg source and using sexual activity to get pregnant). Anonymous donor sperm for pregnancy was more often used by individuals with binary gender identity only (19%), compared to individuals with gender diverse identity only (11%) or those who endorsed both gender diverse and binary identities (8%). Data on pathways to parenthood, pregnancy intentions, and hormone use stratified by race/ethnicity can be found in the supplementary materials (Table A.1, A.2 and A.4).
Table 2.
Pathways to parenthood among a sample of transgender men and gender diverse individuals assigned female or intersex at birth, by gender identity categories (N=1694)
| Overall |
Binary Identity: Man/transgender man (only)a |
Endorsed both gender diverse and man/transgender manb |
Gender diverse identity (only)c |
|||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| N | 1694 | 100 | 466 | 100 | 232 | 100 | 966 | 100 |
| Is a parent | 200 | 11.8 | 62 | 13.3 | 26 | 11.2 | 110 | 11.4 |
| Pathways to parenthood ever usedd | ||||||||
| Pregnancy, respondent carried pregnancy | ||||||||
| Sexual activity leading to pregnancy with another parent of the child | 68 | 34.0 | 11 | 17.7 | 11 | 42.3 | 45 | 40.9 |
| Carried pregnancy and was egg source | 72 | 36.0 | 18 | 29.0 | 11 | 42.3 | 42 | 38.2 |
| Carried pregnancy but was not egg source | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Pregnancy, respondent did not carry pregnancy | ||||||||
| Provided egg that a partner carried | 4 | 2.0 | 3 | 4.8 | 0 | 0 | 1 | 0.9 |
| Surrogacy | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Second parent adoption of partner's genetic childe | 14 | 7.0 | 3 | 4.8 | 1 | 3.8 | 10 | 9.1 |
| Pathways not involving respondent or partner's pregnancy | P | |||||||
| Adoption | 27 | 13.5 | 12 | 19.4 | 2 | 7.7 | 13 | 11.8 |
| Stepparent | 51 | 25.5 | 18 | 29.0 | 4 | 15.4 | 29 | 26.4 |
| Foster parent | 11 | 5.5 | 4 | 6.5 | 1 | 3.8 | 6 | 5.5 |
| Ever used gamete donorsd | ||||||||
| Nonidentified donor sperm | 26 | 13.0 | 12 | 19.4 | 2 | 7.7 | 12 | 10.9 |
| Identified donor sperm | 10 | 5.0 | 4 | 6.5 | 1 | 3.8 | 5 | 4.5 |
| Egg donor | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Includes individuals who only endorsed man or transgender man as their gender
Endorsed man or transgender man along with any gender diverse identities (agender, genderqueer, nonbinary, Two-spirit, additional gender); if woman or cisgender woman was endorsed, the record was excluded from this category
Did not endorse man or transgender man and endorsed any gender identity (agender, genderqueer, nonbinary, Two-spirit, additional gender)
Denominator is among parents.
This is process in which parents who are not otherwise related to a child can adopt their partner's child without terminating the first legal parent's right.
Bane. Pathways to parenthood among transgender men and gender diverse people. Am J Obstet Gynecol Glob Rep 2024.
Pregnancy experiences and intentions
Among participants who had ever been pregnant (n=210), there were 433 pregnancies (Table 3). Gender groups had similar history of live birth: 44% of individuals with a binary identity only, 39% of gender diverse individuals, and 41% who endorsed both binary and gender diverse identity. Miscarriage was more common among individuals with gender diverse identity only (38%), while individuals who endorsed binary gender only or individuals who endorsed both binary and gender diverse identity more commonly had abortions (27% and 29%, respectively, compared to 19% among gender diverse identity only). Pregnancy outcomes stratified by race/ethnicity are reported elsewhere.19
Table 3.
Pregnancy experiences among a sample of transgender men and gender diverse individuals assigned female or intersex at birth, by gender identity categories (N=1694)
| Overall |
Binary Identity: Man/transgender man (only)a |
Endorsed both gender diverse and man/transgender manb |
Gender diverse identity (only)c |
|||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | |
| N | 1694 | 100 | 466 | 100 | 232 | 100 | 966 | 100 |
| Ever pregnant | 210 | 12.4 | 41 | 8.8 | 29 | 12.5 | 135 | 14.0 |
| Currently pregnant | 7 | 0.4 | 1 | 0.2 | 0 | 0 | 5 | 0.5 |
| Number of pregnanciesd | ||||||||
| 1 | 115 | 54.8 | 23 | 56.1 | 12 | 41.4 | 78 | 57.8 |
| 2 | 47 | 22.4 | 7 | 17.1 | 10 | 34.5 | 28 | 20.7 |
| 3+ | 48 | 22.9 | 11 | 26.8 | 7 | 24.1 | 29 | 21.5 |
| Total pregnancies | 433 | 100 | 82 | 100 | 62 | 100 | 281 | 100 |
| Pregnancy outcomese | ||||||||
| Still pregnant | 7 | 1.7 | 1 | 1.2 | 0 | 0 | 5 | 1.8 |
| Miscarriage | 142 | 33.7 | 20 | 24.4 | 16 | 27.1 | 104 | 38.0 |
| Ectopic pregnancy | 2 | 0.5 | 0 | 0 | 1 | 1.7 | 1 | 0.4 |
| Abortion | 92 | 21.9 | 22 | 26.8 | 17 | 28.8 | 53 | 19.3 |
| Stillbirth | 2 | 0.5 | 1 | 1.2 | 0 | 0 | 1 | 0.4 |
| Live birth | 169 | 40.1 | 36 | 43.9 | 24 | 40.7 | 106 | 38.7 |
| Cesarean birthf | 39 | 23.1 | 9 | 25.0 | 1 | 4.2 | 27 | 25.5 |
Includes individuals who only endorsed man or transgender man as their gender
Endorsed man or transgender man along with any gender diverse identities (agender, genderqueer, nonbinary, Two-spirit, additional gender); if woman or cisgender woman was endorsed, the record was excluded from this category
Did not endorse man or transgender man and endorsed any gender identity (agender, genderqueer, nonbinary, Two-spirit, additional gender)
Denominator is among those ever pregnant
Denominator is among all births with an outcome provided (N=421 in overall sample)
Denominator is among all live births (N=169 in overall sample).
Bane. Pathways to parenthood among transgender men and gender diverse people. Am J Obstet Gynecol Glob Rep 2024.
Individuals with binary gender identity were more likely to have ever used testosterone (87% for binary only, 81% for both binary and gender diverse), compared to those with a gender diverse identity only (22%; Table 5). A higher proportion of individuals who had ever used testosterone desired a future pregnancy (15%) compared to never users (7%; Table 4). Gender diverse individuals more often desired a future pregnancy (15%) compared with individuals with a binary gender only (6%) and those who endorsed both binary and gender diverse identity (5%).
Table 5.
Fertility counseling with gender affirming hormone use among a sample of transgender men and gender diverse individuals assigned female or intersex at birth, by gender identity categories (N=1694)
| Overall |
Binary Identity: Man/transgender man (only)a |
Endorsed both gender diverse and man/transgender manb |
Gender diverse identity (only)c |
|||||
|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | N | % | |
| Received Hormones | 807 | 47.6 | 404 | 86.7 | 187 | 80.6 | 213 | 22.1 |
| Received fertility counseling prior to hormone use | 571 | 70.8 | 281 | 69.6 | 144 | 77.0 | 143 | 67.1 |
| Was told would be capable of pregnancy afterd | 267 | 46.8 | 135 | 48.0 | 63 | 43.8 | 69 | 48.3 |
| Was told would not be capable of pregnancy afterd | 51 | 8.9 | 25 | 8.9 | 12 | 8.3 | 14 | 9.8 |
| Was told provider was unsure of pregnancy capabilities afterd | 214 | 37.5 | 91 | 32.4 | 57 | 39.6 | 63 | 44.1 |
| Recommended to investigate fertility preservation optionsd | 265 | 46.4 | 138 | 49.1 | 74 | 51.4 | 51 | 35.7 |
| Received fertility counseling after hormone use | 260 | 32.2 | 144 | 35.6 | 53 | 28.3 | 62 | 29.1 |
Includes individuals who only endorsed man or transgender man as their gender
Endorsed man or transgender man along with any gender diverse identities (agender, genderqueer, nonbinary, Two-spirit, additional gender); if woman or cisgender woman was endorsed, the record was excluded from this category
Did not endorse man or transgender man and endorsed any gender identity (agender, genderqueer, nonbinary, Two-spirit, additional gender)
Denominator is among those who received fertility counseling prior to hormone use.
Bane. Pathways to parenthood among transgender men and gender diverse people. Am J Obstet Gynecol Glob Rep 2024.
Table 4.
Future pregnancy desire among a sample of transgender men and gender diverse individuals assigned female or intersex at birth, by testosterone use and gender identity categories (N=1694)
| Overall |
Testosterone Use |
Gender |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Ever Use |
Never Use |
Binary Identity: Man/transgender man (only)a |
Endorsed both gender diverse and man/transgender manb |
Gender diverse identity (only)c |
||||||||
| n | % | n | % | n | % | n | % | n | % | n | % | |
| Would like to be pregnant at some point | 186 | 11.0 | 131 | 14.5 | 55 | 7.0 | 26 | 5.6 | 11 | 4.7 | 141 | 14.6 |
| Within next yeard | 31 | 16.7 | 21 | 16.0 | 10 | 18.2 | 2 | 7.7 | 2 | 18.2 | 27 | 19.2 |
| Within next 5 yearsd | 60 | 32.3 | 42 | 32.1 | 18 | 32.7 | 11 | 42.3 | 2 | 18.2 | 45 | 31.9 |
| Within 6-10 yearsd | 57 | 30.7 | 43 | 32.8 | 14 | 25.5 | 5 | 19.2 | 5 | 45.5 | 45 | 31.9 |
| More than 10 yearsd | 4 | 2.2 | 3 | 2.3 | 1 | 1.8 | 1 | 3.9 | 1 | 9.1 | 2 | 1.4 |
Includes individuals who only endorsed man or transgender man as their gender
Endorsed man or transgender man along with any gender diverse identities (agender, genderqueer, nonbinary, Two-spirit, additional gender); if woman or cisgender woman was endorsed, the record was excluded from this category
Did not endorse man or transgender man and endorsed any gender identity (agender, genderqueer, nonbinary, Two-spirit, additional gender).
Denominator is among those who would like to be pregnant at some point.
Bane. Pathways to parenthood among transgender men and gender diverse people. Am J Obstet Gynecol Glob Rep 2024.
Fertility counseling as part of gender affirming care
Overall, 48% of participants had ever used testosterone (n=807; Table 5). Among those individuals, 71% received fertility counseling prior to initiating testosterone and 32% received fertility counseling after initiating testosterone. Individuals with a gender diverse identity only (44%) and individuals with both binary and gender diverse identities (40%) were more frequently told that their provider was unsure of their pregnancy capability after initiating testosterone compared to those with binary gender identity only (32%). Gender diverse individuals were recommended to investigate fertility preservation options less often (36%) than individuals with binary gender only (49%) or individuals with both binary and gender diverse identity (51%). Data for puberty blocker use (n=17) and gender affirming surgeries (n=115) are presented in Table A.3.
Among the 87 write-in responses regarding fertility counseling conversations with providers, multiple themes emerged (Table 6). Participants reported a wide range of experiences, including information from providers that was contradictory, vague, or inaccurate. Several participants noted that their providers emphasized that pregnancy was possible while on testosterone but also cautioned about the potential of infertility with prolonged hormone usage: “[I was told] I would have a very low probability of getting pregnant initially and that would approach zero over time.” In contrast, a single participant noted: “[When] I asked about capability to get pregnant in the context of strongly not wanting to be, they said I "would probably not have to worry about it" while on hormones.” Some participants were informed that the impact of hormones on fertility was unknown. Others were counseled about the possibility of pregnancy if hormones were stopped and that they would need to cease hormones if they desired to continue the pregnancy or risk complications.
Table 6.
Key themes and supporting quotes from write-in fields for fertility counseling received with gender affirming hormone use among a sample of transgender men and gender diverse individuals assigned female or intersex at birth (N=87)
| Theme/Content | Quotes |
|---|---|
| Testosterone is not a form of birth control |
|
| Increasing potential for infertility with hormone usage |
|
| Lack of information on risk of infertility |
|
| Possibility for future pregnancies |
|
| Risks for future pregnancies while on hormones |
|
| Ambivalence towards Fertility Preservation |
|
Abbreviations: HRT hormone replacement therapy, T testosterone.
Bane. Pathways to parenthood among transgender men and gender diverse people. Am J Obstet Gynecol Glob Rep 2024.
Discussion
Summary of Key Findings
In a large study of TMGD individuals assigned female or intersex at birth from across the US, we explored pathways to parenthood, pregnancy outcomes, and fertility counseling experiences. A third of TMGD participants grew their family by carrying pregnancies achieved through sexual activity, and pathways to parenthood differed by gender identity. Transgender men were more likely to adopt compared to gender diverse individuals, who more commonly relied on sexual activity that led to a pregnancy. A desire for future pregnancy was more often reported by individuals who had ever used testosterone compared to those who had never used testosterone. Although participants across gender identities indicated a desire for future pregnancy, nearly one third of participants who had ever used testosterone did not receive fertility counseling prior to initiating hormones. Among those who did receive fertility counseling, the advice received was mixed.
Findings in context of prior work
Prior studies have demonstrated that transgender men build their families using pregnancy.4,16 Relatedly, in this sample, sexual activity that led to pregnancy was the most common pathway to parenthood, alongside other methods of family building (including stepparenting, adoption, and fostering). Notably, a very low proportion of individuals used surrogacy and reciprocal in vitro fertilization (IVF; ie, provided an egg that a partner carried or vice versa). Although we did not directly ask about medically assisted reproductive technologies use, 18% of parents reported using identified or non-identified donor gametes for pregnancy. TMGD individuals experience financial and other barriers to medically assisted reproduction, which is expensive and rarely covered by insurance.24,25 In light of this, and the fact that 11% of the sample desired future pregnancy, further investigation of how these barriers specifically impact pathways to parenthood among TMGD populations is warranted. The pathways to parenthood reported in this study do not tell us about preferences for family building. The most commonly used pathways in this study may simply be the pathways that were practical and accessible to TMGD individuals but are not necessarily the most desired or preferred, due to legal, logistical, social, and financial barriers.6, 7, 8, 9, 10, 11, 12
We observed differences in pathways to parenthood by gender. Transgender men in our sample were less likely to pursue pregnancy and more likely to adopt than gender diverse individuals. Gender diverse individuals most commonly expressed a desire to be pregnant in the future. Tornello et al.26 reported similar results from a survey of 311 TMGD individuals. Higher proportions of transgender men became parents through adoption or foster parenting compared to gender diverse individuals, and higher proportions of gender diverse individuals were genetically related to their children compared to transgender men.
Across the gender identity categories assessed there was a similar prevalence of live births, supporting that TMGD individuals can and do give birth. Gender diverse individuals were more likely to experience miscarriages and less likely to get an abortion than transgender men. It is known that gender diverse individuals experience structural limitations to optimal health and health care, such as increased psychological stress, lack of access to care, lower socioeconomic position.27, 28, 29 Further in depth investigation is warranted to understand whether these factors differ between transgender and gender diverse individuals Alternatively, it is possible that this difference is a data artifact due to small sample size.30 The higher rates of abortion among transgender men may contribute to the lower miscarriage rates (eg, through the elective termination of complicated or undesired pregnancies). Prior work using this sample has demonstrated that unintended pregnancies were slightly more likely to end in miscarriage as compared to intended pregnancies.10 Given small sample sizes and these data are self-reported, the findings may not be broadly generalizable. Prior studies using this sample showed that participants more commonly sought procedural (61%) over medication abortions (34%), although they preferred medication abortions for a future abortion. Among participants who attempted a self-managed abortion, the majority used unsafe methods (eg, physical trauma) or methods of unknown safety (eg, herbs) due to privacy concerns and lack of access.31,32 Existing evidence comparing perinatal outcomes among transgender men33 or birthing fathers34 shows similar prevalence of perinatal outcomes including cesarean birth, postpartum hemorrhage, and severe morbidity compared to the overall population, although more work with prospective collection of gender identity is needed.33,34
Implications for clinical practice and research
In this study, approximately 1 in 10 participants desired a future pregnancy. Individuals who had ever used testosterone were more likely to desire a future pregnancy than those who had never used testosterone. This implies that initiating testosterone for masculinization does not preclude TMGD individuals from later desiring a pregnancy. Concerningly, approximately one-third of participants did not receive fertility counseling prior to hormone use, and 9% were incorrectly informed that they would be incapable of pregnancy after initiating hormones. These statistics are underscored by the exploratory qualitative analysis, in which participants shared how they received contradictory, vague, and incorrect counseling with concerning their fertility prospects. Although there are limited data on the effect of gender affirming hormone therapy on fertility and fecundity, after initiation of exogenous testosterone and desires for pregnancy can change after initiating testosterone.4,35,36 Given the cross-sectional nature of these data, rate of fertility counseling and the specific natures of counseling may have improved by the present time. Regardless, these data support the need for ongoing fertility counseling not only before testosterone use but also as an ongoing practice by clinicians.37 Crucially, given that desires for parenthood can change over time, fertility counseling should be a routine and ongoing practice by clinicians. Write-in responses indicated that participants received inconsistent and contradictory fertility counseling. Clinicians who discuss fertility preservation options with their patients, prior to and after gender affirming surgery or hormone use, should base their recommendations on patients’ desires for pregnancy and/or children of their own genetic material regardless of patient gender identity.37,38 Fertility preservation, when desired, may not be accessible or affordable to TMGD patients, who are disproportionately likely to experience economic disenfranchisement and live in poverty.39 It is imperative that fertility preservation is covered by health insurance to meet the family building needs of TMGD people.
Our findings underscore the importance of evidence-based and culturally competent reproductive healthcare, particularly with regard to hormone use and fertility preservation, if desired. Clinicians and researchers cannot make assumptions about an individual's desire for pregnancy or parenthood based on their gender identity or hormone use history. Differences exist among pathways to parenthood by gender identity among TMGD individuals. While the focus of our study was quantitative and descriptive in nature, our numerical findings on fertility preservation were supported by our exploratory rapid qualitative analysis of open-text responses to questions on fertility preservation. Given that the majority of research on this topic is qualitative, future research should consider mixed methods and quantitative designs for such research questions with appropriate rigor.
Strengths and Limitations
This study's strengths included a relatively large sample of TMGD individuals who were assigned female or intersex at birth with diversity in gender identity, sexual orientation, and geography. Prior foundational work examined smaller study samples, typically from clinical settings.4,8,15, 16, 17 The study instrument was designed using a community-engaged approach and was tailored to the needs and lived experiences of TMGD individuals. Our findings add critical information and nuance to how this underserved and under-researched population builds their families. This study is not without limitations. First, the survey instrument was cross-sectional and used convenience sampling, limiting our ability to address temporal or causal questions. Notably, the cross-sectional nature of these data cannot capture how perspectives on family building could change across the life course; future work could access life course differences in desires for pregnancy and pathways to parenthood among TMGD individuals. Second, this study sample might not represent the diversity of the TMGD population in the US. For example, 87% (n=1,472) of participants endorsed Non-Latinx White as their race/ethnicity (12% of whom also endorsed other racial/ethnic categories). Additionally, a part of our recruitment strategy applied an upper age limit of 45 years; we acknowledge that individuals older than 45 years can be capable of pregnancy or pursue other pathways to parenthood. Future work should sample for racial/ethnic diversity and wider age ranges. Third, we cannot distinguish whether the observed pathways to parenthood for TMGD individuals represent their most desired paths. The data we observed could be impacted by access and affordability (eg, fewer individuals in this study used medically assisted reproductive technologies or surrogacy). Additionally, we did not directly ask about medically assisted reproductive therapy use directly or the sex, gender, or available gametes of partners at the time that participants become parents, all of which could impact the pathways to parenthood chosen. Fourth, we considered testosterone use as a dichotomous variable, which does not capture variation between past vs current use and timing of testosterone initiation. Only 11 individuals who desired a future pregnancy had prior (but not current) testosterone use. Future studies with larger sample sizes should examine testosterone use in greater detail. Lastly, we did not collect comprehensive on the timing of all pregnancies (just the most recent pregnancy) and hence cannot appropriately assess the role of age during pregnancy for pregnancy outcomes.
Conclusions
We descriptively assessed the pathways by which TMGD individuals who were assigned female or intersex at birth become parents. We observed that TMGD individuals often become parents through pregnancy (in addition to stepparenting or adoption) and can desire to become pregnant in the future. While we showed that TMGD individuals are succeeding in building families, we highlighted gaps in the reproductive healthcare they receive. Despite being most likely to desire future pregnancies, TMGD participants who had ever used testosterone often did not receive fertility counseling prior to initiating hormones. Given the dearth of information available for fertility and pregnancy after testosterone, there is a need for additional transgender-specific research and patient resources on conception after testosterone therapy. These findings provide clinicians with context from which to counsel their TMGD patients, underscoring the importance of consistent, evidence-based, and inclusive reproductive healthcare.
Patient consent statement
Patient consent is not required because no personal information or details are included.
Tweetable statement
Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption.
CRediT authorship contribution statement
Shalmali Sunil Bane: Writing – review & editing, Writing – original draft, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Juno Obedin-Maliver: Writing – review & editing, Resources, Project administration, Investigation, Funding acquisition, Data curation, Conceptualization. Sachiko Ragosta: Writing – review & editing, Validation, Software, Investigation, Data curation. Jen Hastings: Writing – review & editing, Methodology, Investigation, Funding acquisition. Mitchell R. Lunn: Writing – review & editing, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Data curation. Annesa Flentje: Writing – review & editing, Resources, Methodology, Investigation. Matthew R. Capriotti: Writing – review & editing, Methodology, Investigation. Micah E. Lubensky: Writing – review & editing, Methodology, Investigation. Diana M. Tordoff: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization. Heidi Moseson: Writing – review & editing, Writing – original draft, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization.
Acknowledgments
We are grateful to Lyndon Cudlitz, Mary Durden, Laura Fix, Eli Goldberg, Anna Katz, Avery Lesser-Lee, Laz Letcher, Anei Reyes, and Arami Stoeffler for their support in developing the survey and interpreting results. We are grateful to Sydney Reese for their support in reviewing analyses. We acknowledge the courage and dedication of all participants, including The PRIDE Study participants, for sharing their stories; the careful attention of PRIDEnet Participant Advisory Committee (PAC) members for reviewing and improving every study application; and the enthusiastic engagement of PRIDEnet Ambassadors and Community Partners for bringing thoughtful perspectives as well as promoting enrollment and disseminating findings. For more information, please visit https://pridestudy.org/pridenet.
Footnotes
MRL has received consulting fees from Hims, Folx Health, and Otsuka Pharmaceutical Development & Commercialization, Inc. for work unrelated to this manuscript. JOM has received consulting fees from Hims, Inc.; Folx Health, Inc.; and Sage Therapeutics for work unrelated to the study described here. The other authors report no conflicts of interest.
This study was funded by the Society of Family Planning Research Fund (SFPRF11-II1) to HM; SR, HM, JH, and JOM received partial support in the form of salaries, stipends, or consulting fees from funds provided by the Society of Family Planning grant, but the Society of Family Planning did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Research in this article was partially supported by Patient-Centered Outcomes Research Institute (PCORI) Award (PPRN-1501-26848) to MRL. JOM was partially supported by grant K12DK111028 from the National Institute of Diabetes, Digestive, and Kidney Disorders. MRL and JOM were partially supported by Stanford University School of Medicine. AF was supported by the National Institute on Drug AbuseK23DA039800. The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of Patient‐Centered Outcomes Research Institute, its Board of Governors or Methodology Committee, or the National Institutes of Health, or the Society of Family Planning Research Fund. None of the funders had a role in the study design, in the collection, analysis, or interpretation of data, in the writing of this manuscript, or in the decision to submit the article for publication.
Cite this article as: Bane SS, Obedin-Maliver J, Ragosta S, et al. Pathways to parenthood among transgender men and gender diverse people assigned female or intersex at birth in the United States: analysis of a Cross-Sectional 2019 Survey. Am J Obstet Gynecol Glob Rep 2024;4:100381.
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.xagr.2024.100381.
Appendix. Supplementary materials
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