Men, trans/masculine, and non-binary people negotiating conception: Normative resistance and inventive pragmatism

Abstract

Background

Growing numbers of men, trans/masculine, and non-binary people are undertaking pregnancies, yet relatively little is known about the experiences of this diverse population in regard to conception.

Aims

This study sought to examine men’s, trans/masculine, and non-binary people’s experiences of pregnancy, including conception.

Methods

Interviews were conducted with 51 men, trans/masculine, and non-binary people who were gestational parents living in Australia, Canada, the European Union (including the United Kingdom), and the United States. Thematic analysis was undertaken, focusing on accounts of conception. Pfeffer’s conceptual frameworks of normative resistance and inventive pragmatism were used as an analytic tool.

Results

Themes developed focused on: 1) choosing a clinic donor, 2) kinship with donors, 3) conceiving via intercourse with a partner, 4) negotiating receipt of donor sperm, 5) challenges associated with known donors, 6) challenges associated with fertility clinics, and 7) experiences of conception.

Discussion

The forms of normative resistance and inventive pragmatism identified suggest that men, trans/masculine, and non-binary people who are gestational parents seek to normalize their experiences of conception, while also acknowledging the specific challenges they face.

Introduction

Considerable numbers of men, trans/masculine, and non-binary people are considering and undertaking pregnancies (Obedin-Maliver & Makadon, 2016; Tornello & Bos, 2017). In this paper, we use the term “men, trans/masculine, and non-binary people” to refer to those who were coercively assigned female at birth, but report their identity as, for example, male, man, trans, masculine, transmasculine, non-binary, genderqueer, or agender. This paper explores their experiences of conception.

Historically across the globe, and presently in 16 countries in Europe and Central Asia, men, trans/masculine, and non-binary people have been required to undergo sterilization to change their gender markers and/or to receive gender affirming medical treatment (Transgender Europe, 2019), a requirement that continues to affect their reproductive decisions (Lowik, 2018). With growing awareness of their reproductive options, accompanied by changes to legislation and medical practice in many countries, increasing numbers of men, trans/masculine, and non-binary people appear to now be pursuing pregnancy during or following a sex/gender transition (Obedin-Maliver & Makadon, 2016). This may involve: fertilization via intercourse, at-home or clinical insemination techniques; pausing testosterone treatment and undertaking egg retrieval and subsequent fertilization by a partner’s or donor’s sperm; the use of one’s own eggs stored prior to the commencement of hormone therapy that are fertilized by a partner’s or donor’s sperm; or the use of a partner’s or donor’s eggs that are fertilized by a partner’s or donor’s sperm. Of course, it is also possible to unintentionally become pregnant, either while or while not taking testosterone, following intercourse or rape.

Despite the growing visibility of pregnant men, trans/masculine, and non-binary people (Lampe et al., 2019), only a small body of academic research (e.g., Charter et al., 2018; James-Abra et al., 2015; Light et al., 2014) and first-person accounts (e.g., Beatie, 2009; MacDonald, 2016; Ware, 2015), have investigated pathways to conception among this diverse group after coming out and/or beginning a transition. Further, to date there has been little theorizing about how we might understand their conception-related experiences and negotiations. With this in mind, the present paper utilizes a conceptual framework developed by Pfeffer (2012), derived from research on cisgender women partnered with transgender men. Pfeffer identified two distinct ways in which these women managed assumptions about their relationships, and accessed services in the face of cisgenderism (i.e., the ideology that delegitimizes people’s own understanding of their bodies and gender: Ansara & Hegarty, 2014). Pfeffer refers to these strategies as normative resistance and inventive pragmatism. The former refers to “strategies and actions for making life choices distinct from those considered most socially expected, celebrated, and sanctioned”; the latter to “strategies and actions that might be considered clever manipulations of an existing social structure in order to access social and material resources” (p. 578, emphasis in original).

The present paper utilizes Pfeffer’s (2012) conceptual framework as a lens through which to view the experiences of an international sample of 51 men, trans/masculine, and non-binary people who were interviewed about their experiences of pregnancy. It reports on a thematic analysis of the interview data focused on conception and uses Pfeffer’s framework as a conceptual overlay through which to examine more closely the contents of the themes developed. Pfeffer’s framework is useful to the present paper as it offers a robust approach to examining the effects of cisgenderism and (un)intelligibility upon the imagined futures of men, trans/masculine, and non-binary people who are gestational parents. More specifically, this paper focuses on negotiations and experiences connected to conception that are not limited solely to the biological joining of two gametes, but also accessing gametes in order to conceive, and diverse pathways to conception.

Materials and methods

Researcher reflexivity

We are a team of researchers who, over the past decade, have undertaken research with transgender and non-binary people and/or their family members. Our focal areas include but are not limited to family formation, parenting, intimate relationships, and healthcare. As a team we are comprised of cisgender, transgender, and non-binary people, of a diversity of genders and sexualities, one of whom has conceived and carried a pregnancy. All of us are white. In another paper (under review, available by request to the lead author), we offer a detailed and critical analysis of the role of whiteness in shaping our research and research process. We are also mindful that we currently occupy a privileged social location as academics.

Study design

The study involved a cross-sectional in-depth interview design, specifically the collection of qualitative interviews with 51 men, trans/masculine, and non-binary people. Inclusion criteria were (i) identifying as a man, trans/masculine, or non-binary, (ii) having undertaken at least one pregnancy, (iii) living in Australia, the European Union (including the United Kingdom), the United States, or Canada, (iv) being at least 18 years of age, and (v) having conceived after coming out or beginning a social and/or medical transition. A purposive sampling technique was employed to obtain participants using social media and social network recruitment, including targeted recruitment distributed to groups comprised of men, trans/masculine, and non-binary people of color. Research informational and recruitment flyers were posted to social media accounts (e.g. private Facebook groups), shared at community conferences and events, and circulated via researcher and participant networks.

Ethics approval

Ethics approval for the study was granted by the University of Leeds Research Ethics Committee, Flinders University Social and Behavioral Research Ethics Committee, and the University of South Carolina Institutional Review Board. Upon contacting the research team, potential participants were provided with a full information sheet about the project, detailing the focus of the project, what was requested of them in terms of time, and contacts should they need support following participation. Consent or assent was obtained for all participants (depending upon research site and requirements of each ethics review board) and consent was explicitly continuous, able to be withdrawn by participants at any point in the research process.

Participants in the U.S. and Canada were paid $25–$50 to participate; participants of color were compensated at a higher rate due to targeted recruitment aims for the study and to reflect structural constraints to participation (e.g., U.S. history of racist research exploitation and increased requests for participation) faced by participants of color. Participants in the European Union and Australia were not compensated for their participation. This reflected research norms at the institutions where ethical approval was granted; compensation for participation in social research is often understood as a form of potential coercion.

Data collection

Semi-structured interviews were undertaken either in person or via tele- and/or video conference facilitated by Skype, Whereby, or Zoom, by a research associate of the first author (for Australian interviews), by the second author (for interviews in the United States and Canada), or by the third author (for interviews in the European Union). Interviews were undertaken between June 2018 and October 2019. In terms of interview questions specific to the present paper, a general question was asked about experiences of undertaking a pregnancy, with a specific follow-up probe asking: "How did you become pregnant?” Interviews ranged from less than sixty minutes to over three hours, with an average length of 100 minutes. Interviews were transcribed by a professional service, and participants either chose their own pseudonym, or were allocated a pseudonym if they did not opt to choose their own. Participants were also asked about pronouns, with most using either he/him or they/them.

Analytic approach

For the purposes of the present paper, responses to the probe question: “How did you become pregnant?” were extracted for analysis. Importantly, while this question was purposively included in the interview schedule, and then purposively selected for analysis in the present paper, the analysis itself was inductive: it did not begin with a specific hypothesis to test, nor, given the limited previous research, an indicative list of likely topics that would be developed from the data.

Having extracted interview responses in relation to becoming pregnant, the first author coded the data according to the approach to thematic analysis outlined by Braun and Clarke (2006). The first step in this process involves familiarization with the data set through repeated readings. The first author read all of the transcripts three times, looking for repeated topics or codes. Thematic saturation (Saunders et al., 2018) was achieved following repeated reading of transcripts from 26 participants, however all participant transcripts were included for matters of completeness. Codes identified are included in Table 1. Having developed codes based on repeated readings of the transcripts, the first author then shared these codes with the second and third authors, who confirmed the codes as representative of the data set in terms of core topics.

Table 1.

Structure of codes and themes and number of participants situated in each.

Code	# of participants	Theme	# of participants
1: Donor conception	20	1A: Choosing a clinic donor: Negotiating ideals and needs 1B: Making kinship with donors: “Spuncles,” uncles, and family	12 8
2: Describing the process of conception	15	2A: “Bumpin uglies”: Conceiving via intercourse with a partner 2B: “We’d do a sporty handoff”: Negotiating the receipt of donor sperm	8 7
3: Challenges associated with conception	12	3A: Challenges associated with negotiating known donors 3B: Challenges associated with accessing fertility clinics	7 5
4: Experiences of conception	11	4: “It’s pretty stress-free": Experiences of conception	11

The first author then developed themes based on the codes. While codes encompass broad salient topics repeated across the data set, themes by comparison organize codes into logical and coherent sets of information. Themes developed are indicative of topics seen as salient by researchers, rather than being exhaustive of all possible readings of the dataset. Further, codes and themes were not mutually exclusive across participants; some gave interview responses located within more than one code or theme.

For the present paper, seven key themes were developed through a process of repeated readings of the initial coded data, and developing codes into coherent thematic groupings. The seven themes are outlined in Table 1. Having identified these, the first author again shared them with the second and third authors, who confirmed the thematic structure. The first author then identified and collated representative quotations for each theme. As such, the quotations included in the results are indicative but not exhaustive of each theme. Having identified representative quotations for each theme, the first author then compiled the thematic groupings and developed the results reported below. Pfeffer’s normative resistance and inventive pragmatism were used as conceptual lenses through which to further interpret themes. In other words, while the thematic analysis itself was inductive, having developed themes in this fashion, the authors then used Pfeffer’s conceptual categories to explore each theme in more detail.

Results

Participants

Of the 51 participants, 18 were living in the United States, 14 in the United Kingdom, nine in Australia, six in Germany, three in Canada, and one in Bulgaria. The mean age of participants at the time of the interview was 33 years. Of the participants, 21 self-reported their gender as “trans man" or "transmasculine," 11 self-reported their gender as "man,” 11 self-reported their gender as “non-binary,” and eight self-reported their gender as either "genderqueer," “androgyne,” “fluid,” or “greygender.” Of the participants’ self-reports of sexuality, 17 were “queer,” ten “pansexual,” seven “bisexual,” five “gay,” and 12 used other terms that include but are not limited to: “panromantic greysexual,” “human-sexual,” “asexual,” “heterosexual,” and “undefined.”

46 participants reported their ethnicity as “white,” “Caucasian,” “Anglo,” or “European,” and five reported their ethnicity as either “Asian,” “mixed race,” “Hispanic,” or “Black.” In terms of intimate relationships, 37 participants reported that they were in a committed relationship or relationships at the time of the interview, and 14 reported that they were single. Of the participants, 25 had one child, 11 had two children, nine were currently pregnant at the time of the interview and had no other children, five had three children, and one had four children.

In terms of conception, 24 of the participants conceived using a partner’s sperm, 15 conceived using anonymous-donor sperm (e.g., via a fertility clinic or an online service that matches donors with recipients), and 12 conceived using known-donor sperm (which included close friends and friends of friends). In terms of pregnancy intentions, 45 participants reported planned pregnancies and six reported unplanned pregnancies.

Themes

Given the nature of the thematic analysis undertaken for the present paper, which aimed to reduce extensive interview responses from 51 participants into coherent thematic groupings, some of the finer details are absent from the analysis presented herein. Specific narratives worthy of comment here before presenting analytic themes include: 1) some participants experienced challenges identifying a potential donor, including numerous "false starts," 2) some participants reported conception difficulties, including pregnancy losses, and 3) some participants reported complex psychological journeys involved in coming to a place where undertaking a pregnancy was viable for them. These complexities and individual journeys will be explored in other publications from these data. In the present paper, we explore the seven themes outlined in Table 1.

Theme 1 A: Choosing a clinic donor: Negotiating ideals and needs

In identifying a potential donor from a fertility clinic, some participants engaged in what might be understood as normative resistance. In her work on lesbian recipients of donor sperm through fertility clinics, Mamo (2005) argues that both recipients and clinics enact “affinity-ties," such that descriptions of potential donors are used as selling points for creating a sense of relatedness, particularly through matching desired recipient characteristics with donor characteristics. By contrast, some participants in our study resisted the idea of donor matching:

Tom: It wasn't an order of preference. It was just these are the options I thought. I didn't want to overthink it. I didn't want to be like, ‘Well he must have this and this.’ I was just like, ‘This bank screens everyone really thoroughly. So as long as they’re healthy, and I kind of get a good vibe with their profile.’ Which is very bare bones anyway. And that's fine (white, United Kingdom).

For Tom, the emphasis was on "healthy" donors and "good vibes" rather than matching the donor to idealized physical or personality characteristics. This constitutes normative resistance to the idea that children should in some way resemble their parents. At the same time, normative resistance is also evident in the reference to “healthy” donors. While this type of account is treated as axiomatic in the context of donor conception, it does not sit outside of normative connotations of health that are wrapped up in eugenic ideologies about “appropriate” and “inappropriate” genetic relationships (Lowik, 2018). Other participants also drew on this type of normative resistance:

Finn: I didn't trust the process to actually select the donors that they said they were offering. Partially because the one person I know to have been a sperm donor would look great on paper and I absolutely would not want as the sperm donor. On paper you're a PhD biologist, part-time musician, tall and handsome. And actually, you're an abusive alcoholic (white, United States).

Here Finn makes a distinction between donors who look ‘great on paper’, but who may, within a particular logic, be framed as less than desirable donors (i.e., ‘an abusive alcoholic’). Here Finn draws attention to the complexities of an idealized account of donor matching, such that while resisting donor matching may constitute a critique of normativity, it may at the same time enshrine a new form of normativity (i.e., one that draws on eugenic ideologies).

In contrast to participants who engaged in normative resistance around donor matching, other participants appeared to more readily accept it. Importantly, however, in the quote below the focus on donor matching may be understood as a form of inventive pragmatism, aimed at meeting the needs of the family members beyond simply (though also including) familial resemblance:

Heb: We used a sperm bank, and we just went online one night, it was a 45-minute process. It was really interesting and we typed in a few characteristics that we thought were important to us as a couple, especially in relationship to our other son, and picked a donor and just went with it… We wanted a donor that matched the characteristics [of my wife and I]… When we typed [the desired characteristics] in, we got three matches and then, from there, we just looked at all three of them and decided we would pick one (white, United States).

For Heb, while there certainly was discussion about matching particular physical characteristics, this appeared largely driven by a desire for the hoped-for child to have a resemblance to the couple’s older child. Certainly, this could be read as a form of normative assimilation to expected ideals of familial resemblance. However, in the context of families such as those involving trans/masculine and non-binary gestational parents, the desire for familial similarities may be an important safety strategy in broader social contexts where discrimination directed toward such families is common (see Riggs, 2015, for more on how this is true in other diverse families).

Theme 1B: Making kinship with donors: “Spuncles,” uncles, and family

This second theme focuses on participants who negotiated the receipt of sperm from "known" donors outside of fertility clinics. These participants engaged in inventive pragmatism as they found creative ways to access donor sperm outside of clinics. For some, this was due to high costs associated with utilizing fertility clinic services. For others, it related to concerns about how fertility clinics might view them as patients (a not unfounded fear, as explored in theme 3B below). For Dee, the process of negotiating a known-donor arrangement allowed him to sidestep bureaucratic requirements:

He’s the kid's spuncle, and in their lives as extended family. His parents are grandspuncle and grandsparkle, and know the kids, and the kids know them. And that's actually been a very rich and lovely process. He's not named on the birth certificate, [partner] and I are. Formally, we should have probably gone through with the second parent adoption. So in public-facing official stories, we've always said, "Oh yeah, talked to a few guys. Who knows which one?" Because actually, if it's unknown sperm, you don't have to. It's only a known donor that you do (white, Canada).

In this quotation, Dee both draws the donor into a kinship narrative, while also explicitly stating that the donor is not named on the birth certificate. This was possible because Dee and his partner had negotiated a known donor arrangement: they had creative liberty through which to represent the conception of their children, rather than being more narrowly bound by legislative requirements that could have arisen if they accessed sperm through a fertility clinic.

For other participants situated in this theme, acts of normative resistance were evident. Despite increased recognition of the rights of donor-conceived children to know about their genetic kin (Ravitsky, 2010), there remains resistance to conceptualizing gamete donors as kin, particularly given legal ramifications (Dempsey, 2004). By contrast, and for some participants (including Dee), there was normative resistance to the idea that donors are not kin, with participants instead actively framing donors as such:

Paul: She [the sperm donor] wanted to be sure that my child knows where my child comes from… And this child has grandparents. I mean [the donor’s] parents are the child's grandparents. We are there three times a year. We celebrate some things together. She does not live here, but when she visits she always stays at our house. Once a year we go to holidays together (white, Germany).

As with Dee, Paul’s child has an active relationship with their donor (a trans woman) and the donor’s parents. This includes holidays and visits that clearly evoke a narrative of kinship, rather than a more typical narrative of gamete donation. Lewis and Charlie (both white and in the United Kingdom), a couple who were interviewed together, also actively framed their donor as kin, describing him as “uncle.”

In a similar but different way, another participant (Denver) brought together the rights of children with a kinship narrative:

I knew someone from my teenage years who is a gay man, and he and I negotiated having children together, so it was outside of a relationship and … more of a donor setup for all three of the pregnancies. He's the same father for all of them and has involvement in their lives to whatever we arrange. For me, I wanted to have him involved, but I was also aware that his relationship with his potential children was his business, not really mine. That's how I felt about it. And I didn't feel like, for the kids, I wanted to step in the way of what they wanted either, so I just sort of left it to him if he wanted to be involved or not, and for them to be able to establish their own relationships (white, Australia).

Of the participants included in this theme, Denver was the most tentative about claiming the donor as their own kin (clearly stating that it was a "donor situation" "outside of a relationship"), but this did not preclude describing the donor as the children’s “father.” This would appear important, as it created a space for Denver to leave decisions about the specific form of kinship relationship to the children and their donor. This is a very specific form of normative resistance: it not only treats kinship as something to be "decided" rather than just determined by genetics, it also treats children’s views as central to the decision-making process.

Theme 2 A: “Bumpin uglies”: Conceiving via intercourse with a partner

For participants who spoke about conceiving via intercourse with a cisgender partner, there was a repeated evocation of normative resistance. Conception as a product of intercourse is typically understood as heterosexual intercourse, and moreover, it is typically understood as involving a female “receptive” and male “insertive” partner. For some participants who were in relationships with cisgender men, however, conception through intercourse involved non-heterosexual intimacies and receptive and insertive partners who were both men/masculine. Of interest in this theme, then, is how participants made recourse to normative tropes to describe intercourse, and in so doing displayed normative resistance to assumptions about what conception as a result of intercourse means and who is involved.

For example, when asked about conceiving, Rich (white, Australia) noted: “Yeah, mine was probably quite similar to the narrative that people are used to. I had a male partner at the time and we got pregnant without any assistance.” While Rich suggests that conception was "probably quite similar to the narrative that people are used to,” the standard narrative of conception via intercourse, as described above, is heterosexual. As such, while Rich normalizes his conception experience, he also implicitly presents resistance to normative assumptions about conception through reference to his male partner.

Dante (white, United States) too made recourse to a normative account of conception: “All of [my pregnancies] resulted from bumpin' uglies with my husband. We didn't do any additional stuff. I didn't take any stuff…. I had to get a progesterone shot… but that was it.” The phrase, "bumpin uglies" is typically used to refer to heterosexual intercourse. For Dante and his husband, however, this was not the case, and the normative meaning of "bumpin uglies" in the service of conception is given new meaning. Luke (white, United States) also described conception as a result of intercourse "the old-fashioned way,” only for this to be given new meaning in the context of his relationship: “We started trying the old-fashioned way and we suffered two miscarriages and then we sought the help of a fertility doctor.”

Another participant, Pyxl (white, Canada), used a normative description to refer to conception as a result of intercourse: “I was tracking my cycle with an app to try to figure out when ideal times would be, but mostly just the conventional way, intercourse as regularly as we felt up for it.” In describing his “cycle," and referring to “conventional” intercourse, Pyxl reworks concepts that have common, gendered, taken-for granted meanings (e.g., menstruation and heterosexual intercourse), and gives them new meanings in the context of his relationship with a male partner. That Pyxl and the other participants included in this theme use such normative terms to describe their own intimate practices signifies a mundane form of normative resistance, such that the reworking of normative narratives is treated as the fabric of negotiating and talking about conception as a man, trans/masculine, or non-binary person.

Theme 2B: "We’d do a sporty handoff": Negotiating the receipt of donor sperm

For those participants who spoke about negotiating sperm donation from a known donor outside of a fertility clinic, sperm receipt was often discussed as mundane. In part, this may be explained by participants engaging in inventive pragmatism: finding creative ways to achieve a goal (i.e., conception) outside of more standardized routes (i.e., fertility clinics). Dylan (white, Canada), for example, spoke about a "sporty handoff" of sperm: “I did it solo. Like [the donor] would come over. I'd give him a little cup. I'd leave the house for ten minutes and then we'd do this sporty handoff and then I'd run upstairs and get that stuff inside of me as fast as I could.” In the everyday, mundane, intimacies that Dylan describes, the process of conception is made routine and, hence, normalized.

Dylan’s description is itself a form of inventive pragmatism, in that it takes something that might otherwise be framed as exceptional – a man, trans/masculine, or non-binary person becoming pregnant – and, instead, treats it as routine. Trent (Asian, Australia) also described the process of conception in routinized ways: “You just get into the central business district within 10 minutes after getting off the plane, stay in a hotel overnight. Meet up with [donor]. He'd basically wank off in a jar. Then, we'd do the insemination. I'd stay overnight and I'd catch the first flight back the next day.” For Trent, it would seem, conception was akin to a business transaction; one that, similar to Dylan, was described through the use of everyday, jocular language. For Trent, the need to travel in order to conceive suggests a form of inventive pragmatism used to work around the challenges of accessing donor sperm through a fertility clinic, as he noted elsewhere in his interview.

Jocular language was also evident in Benjamin’s (white, Germany) account, though this was paired with recognition that an initial attempt at conception via intercourse was challenging for the donor:

I think we had sex once but that was very stressful for him. Because that meant he actually had to perform, in a way. After that, the usual setup was that the sperm donor would either mostly be in a separate room and get the good stuff out, and then there was some experimentation around the tool to use.

Having to "experiment" here is itself a form of inventive pragmatism: making the most of a situation that was in some respects less than ideal, but which was preferable to trying to negotiate the receipt of donated gametes through a fertility clinic, as Benjamin discussed earlier in his interview.

Theme 3 A: Challenges associated with negotiating known donors

This theme offers an important counterpart to the material contained in theme 2 A. In that theme, participants engaged in normative resistance to the assumption that conception results solely from heterosexual intercourse, normalizing and implicitly re-gendering intercourse to show how it also occurs beyond heterosexual relationships. In the present theme, participants offered a different form of normative resistance relating conception to intercourse, namely in resisting requests from donors to engage in intercourse. For these participants, intercourse was framed as an unacceptable route to conception:

Tobias: Eventually we started looking at online connection forums where you can connect with people who want to be sperm donors. People are creepy. [One guy said] ‘Oh, I only do natural insemination.’ I had to Google that. It means they want to have sex with you. I'm like, ‘No, thank you.’ It was a little scary to put yourself out there in general, as a trans person especially (white, United States).

While Tobias engaged in inventive pragmatism through trying to source donor sperm outside of a fertility clinic, absent of access to friendship groups from whom a donor might be sourced, he was nonetheless faced with requests he found “creepy” and “scary.”

While penis-in-vagina intercourse was seemingly normalized for the potential donors he initially contacted, for Tobias it was important to resist this normative injunction. This was also the case for Dan:

So we tracked my ovulation, we went on Facebook, found a donor page and had a look on there, and it was very much touch and go. Loads of people want natural intercourse. And then we found one guy, but he's got like over a thousand kids, so we kind of were like, "No, we want someone that's probably got one or two kids, and not living in this area," and one guy actually contacted me directly and was like, "I've seen your post, I'm happy to help." So we arranged to meet him and get to know him more and for him to get to know us. So we had quite a few appointments, meeting and talking to him before we decided actually this is the right guy or not (white, United Kingdom).

For Dan and his partner, their normative resistance to the expectation of intercourse eventually paid off, highlighting that, for some participants, inventive pragmatism in the form of searching online forums for donors was ultimately productive. This did not mean, however, that there were not challenges associated with looking online for donors (as was the case for Tobias). Rather, the point is that Dan and his partner were able to successfully negotiate the online space in order to conceive.

Theme 3B: Challenges associated with accessing fertility clinics

For some participants, for whom a known donor was not possible or desired, accessing donor gametes through a fertility clinic was necessary. Importantly, however, clinics were not without problems and challenges, requiring inventive pragmatism through creative work-arounds in order to achieve the desired outcome. James, for example, was forced to engage in literal cost-benefit analyses, determining how much he was willing and able to pay to access regulated fertility treatments:

I started looking at fertility clinics. Obviously, cost is a big issue. There are a lot of places that were offering really, really cheap fertility treatments, but only if you had a partner—specifically if you were a male-female couple. And even if you brought in donor semen that you had purchased, they still wouldn't treat you; you had to have a partner sort of thing. So they wouldn't see me at all. They weren't interested, so I ended up going to a more expensive place (white, Australia).

While cost was an issue for James, the requirements of the clinics he initially visited meant that he was explicitly excluded from receiving treatment. Fortunately for James, he was able to afford treatment at a more expensive clinic.

For other participants, such as Mo (white, United States), even putatively inclusive clinics were not always so: “This clinic was significantly better than the first time we did this. We were living in [city], and we went to [fertility clinic] there, which other queer parents that we knew had gone to and were like, ‘Oh, they're wonderful.’ They were not wonderful. I just definitely felt like an alien all the time when I was there.” Despite being recommended by "other queer parents," Mo and his partner found the clinic less than inclusive. In the face of feeling “like an alien,” Mo persisted in treatment from the clinic, achieving his aim of conception.

Stevie (white, United Kingdom), too, reported less than positive experiences when accessing donor conception services: “In the end, it took about two years from my first visit to the GP to actually having the sperm put in, and then that happened to work first time. But like the GPs just knew nothing. In fact, the first GP we spoke to… freaked out a bit when we asked.” In many ways, these examples reflect a very specific form of inventive pragmatism—making compromises to conceive.

It is unlikely that anyone would want less than affirming experiences when accessing a fertility clinic, so accepting less than affirming experiences are not forms of inventive pragmatism in the sense that Pfeffer (2012) describes it. Yet these are conscious decisions, ones that involve weighing suboptimal treatment against the desire for conception. That participants accepted suboptimal treatment speaks to decisions some men, trans/masculine, and non-binary people are compelled to make in the face of heteronormativity and cisgenderism, decisions that are strategic and pragmatic, even if suboptimal.

Theme 4: “It’s pretty stress-free”: Experiences of conception

When asked about insemination experiences, most participants described relatively easy processes. Such framings of conception for men, trans/masculine, and non-binary people may be read as forms of normative resistance, given the assumption that conception for these populations must be challenging (which was true for some participants—e.g., those discussed in themes 3 A and 3B). While not framed as such by participants, it is reasonable to suggest that accounts of "straightforward" conception resist the assumption that conception is necessarily difficult for men, trans/masculine, and non-binary people. This is evidenced, for example, in the account provided by James:

I got pregnant with the first IUI. So my first attempt was successful, which was great. The whole procedure, it's pretty stress-free really and I don't know if anyone else is going to say the same thing. It's basically like a slightly more complicated Pap smear, the IUI. And it was just as quick and I had a really good doctor who did the procedure (white, Australia).

For James, and contrary to the experiences documented in theme 3B, donor conception through a fertility clinic was “great” and “stress-free.” While James acknowledges that other people may not share his experience, other participants did.

For example, Neil (white, Australia) was cautious about sharing news about his attempts at clinic conception with his work colleagues because he “didn't want to get anyone's knickers in a twist before there was anything concrete to report.” Fortunately, the process was "remarkably smooth.” Bob (Black, United States) reported being surprised at learning he was pregnant since he had been told by doctors that his testosterone levels were quite high and that becoming pregnant could be challenging. He described both conception and pregnancy as relatively easy: “It was a really really cool pregnancy and everything went really well,” again demonstrating that assumptions about challenges associated with conception and pregnancy for men, trans/masculine, and non-binary people may not be unilaterally true.

Discussion

Aspects of the findings reported in the present paper connect with the limited previous research on men, trans/masculine, and non-binary people and conception. Similar to research by Charter et al. (2018), for example, the findings reported herein indicate that a majority of participants became pregnant through the use of known donor or partner gametes. For a majority, conception was a positive and straightforward experience. Further, and similar to James-Abra et al. (2015), the findings reported in the present paper suggest that of those participants who accessed donor sperm through fertility clinics, many had less than positive experiences.

The present paper also reports novel findings developed through the use of Pfeffer’s (2012) conceptual framework of normative resistance and inventive pragmatism. Table 2 summarizes the five forms of normative resistance and four forms of inventive pragmatism identified. Importantly, despite the distinction between normative resistance and inventive pragmatism described by Pfeffer and as applied in this paper, there was considerable traffic between the two categories.

Table 2.

Forms of normative resistance and inventive pragmatism identified.

Normative resistance	Inventive pragmatism
Resisting donor matching in terms of family resemblance	Undertaking donor matching in order to achieve particular familial goals
Resisting the idea that donors are not kin	Side-stepping bureaucracy by finding a known donor
Resisting the idea that conception only occurs through heterosexual intercourse	Treating donor conception for men, trans/masculine, and non-binary people as non-exceptional
Resisting donor requests for conception via intercourse	Undertaking cost-benefit analyses when accessing fertility clinics
Resisting the assumption that conception must be difficult for men, trans/masculine, and non-binary people

For example, resistance to, and pragmatism about, donor matching and donors as kin both spoke to recognition by participants of the limitations of donor matching, as well as the potential necessity of donor matching in terms of the situatedness of men, trans/masculine, and non-binary people’s families within the broader context of normative assumptions about kinship. Similarly, resistance to normative assumptions about conception and its potential difficulties for men, trans/masculine, and non-binary people, and inventive pragmatism in treating conception as not exceptional and as potentially requiring concessions in the context of accessing fertility clinics, both appeared to speak to a desire to treat conception for trans/masculine and non-binary people as routine and indeed mundane, and hence not a topic for debate or hyperbole. This is particularly compelling given the spectacle and incredulity often accompanying discussion of pregnant men in the media (Pearce & White, 2019).

Accounts of donors, including in relation to donor matching and kinship, speak to the literature on both cisgender lesbian women and gay men and donor conception, suggesting parallels (Nordqvist, 2011; Riggs, 2018). For some cisgender lesbian women or gay men who are recipients of donor gametes or who are donors, claims to donor matching and kinship may serve an important function—authorizing a sense of relatedness in the context of heteronormativity (Riggs, 2018). For men, trans/masculine, and non-binary people who conceive, recourse to notions of donor matching and kinship with donors may serve a similar function (i.e., to claim a place within normative kinship narratives), as much as it may serve to open up new ways of understanding kinship (i.e., donors as kin).

The routinization of conception for men, trans/masculine, and non-binary people may be understood as also serving a particular function. In a broader social context where trans/masculine and non-binary gestational parents are often treated as exceptional cases, deserving of attention and speculation, the routinization of conception serves to further normalize the lives of gestational parents who are men, trans/masculine, or non-binary, as well as their families (Pearce & White, 2019). Importantly however, the findings presented in this paper suggest that broader societal acceptance of gestational parents who are men, trans/masculine, or non-binary, and their families, should not solely (or indeed even primarily) be the work of this diverse population. Rather, fertility clinics have an important role to play in normalizing and affirming the conception-related needs of men, trans/masculine, and non-binary people. This requires that fertility specialists engage in professional development to better understand the needs of this population around reproduction. This would include routinely asking about gender diversity in all healthcare interactions, inclusive of asking about how individual patients describe their genders and pronouns.

Limitations

The data reported in the present paper represent the largest qualitative study to date of conception among men, trans/masculine, and non-binary people. Its international focus represents a considerable strength of the study. It must be noted, however, that participants were limited to those living in in the Global North, in countries where sterilization is typically not required, and access to gender-affirming treatment is often available. The experiences of men, trans/masculine, and non-binary people who conceive in countries where legislation and access differ more significantly requires further attention in future research.

Similarly, while the diversity of genders and sexualities reported by participants may be considered a strength, the study is limited by low numbers of participants of color. Given that experiences of men, trans/masculine, and non-binary people of color who conceive may include specific areas of focus distinct from those of their white peers (see Ware, 2015), future research should focus on more racially- and ethnically-diverse samples. This should include a focus on the specific barriers that men, trans/masculine, and non-binary people of color may face in terms of specific forms of discrimination (i.e., the intersections of racism and cisgenderism) that limit their reproductive autonomy. Finally, while the post-hoc use of Pfeffer’s (2012) conceptual categories provided considerable analytic leverage, future research would benefit from using this framework to inform and shape research on conception and pregnancy among men, trans/masculine, and non-binary people earlier in the research process.

Conclusions

The findings in this paper make a significant contribution to our understanding of experiences of conception among men, trans/masculine, and non-binary people. They indicate that these individuals engage in diverse practices that normalize their experiences of conception, while also highlighting the unique needs and challenges they face. That, in the face of cisgenderism, men, trans/masculine, and non-binary people who conceive engage in normative resistance and inventive pragmatism is perhaps unsurprising. However, the specific forms this took for the research participants highlights important avenues for future research, clinical practice, and the broader societal inclusion of this population and their families.

Funding Statement

This study was funded by the Economic and Social Research Council, ES/N019067/1.

Disclosure statement

The authors declare they have no conflict of interest

Informed consent

Informed consent or assent was obtained from all individual parties included in the study.