Unintended and teen pregnancy experiences of trans masculine people living in the United States

Abstract

Background

Trans masculine people are more likely than cisgender peers to have a teen or unintended pregnancy, though little is known about the origins of these disparities.

Aims

This study aimed to describe teen and unintended pregnancy experiences among trans masculine people in order to elucidate risk factors and pregnancy-related needs.

Methods

As a part of the United States-based SexuaL Orientation, Gender Identity, and Pregnancy Experiences (SLOPE) study, in-depth, semi-structured interviews were conducted between March 2017 and August 2018 with 10 trans masculine people, ages 20–59 years, who experienced a teen or unintended pregnancy. Audio-recorded interviews were professionally transcribed, then analyzed using immersion/crystallization and thematic analysis approaches. The themes were contextualized using sociodemographic survey data.

Results

The four themes that were developed from participants’ narratives highlighted: 1) how trans masculine people navigated having a pregnant body (e.g., heightened gender dysphoria due to being pregnant); 2) the importance of the cultural environment in shaping experiences as a trans masculine pregnant person (e.g., pregnancy and gender-related job discrimination); 3) the development of the pregnancy over time (e.g., decision-making processes); and 4) how pregnancy (and gender identity) affected relationships with other people (e.g., adverse family of origin experiences).

Discussion

This study identified a number of risk factors for teen and unintended pregnancies among trans masculine people including physical and sexual abuse as well as ineffective use of contraception. This research also identifies unique needs of this population, including: relieving gender dysphoria, combating discrimination, and ensuring people feel visible and welcome, particularly in reproductive healthcare spaces. Public health practitioners, healthcare providers, and support networks (e.g., chosen family) can be key sources of support. Attention to risk factors, unique needs, and sources of support will improve reproductive healthcare and pregnancy experiences for trans masculine people.

Introduction

Pregnancies, including teen and unintended pregnancies, happen among individuals along the trans masculine spectrum (i.e., assigned female at birth and a current gender identity other than female). Compared to cisgender teens, trans masculine individuals appear to be at least as likely to become pregnant during their teen years (Veale et al., 2016). Recent qualitative research has documented experiences of trans masculine people with unintended pregnancies (Cipres et al., 2017; Hoffkling et al., 2017). Research with cisgender women has documented some of the complex origins of teen and unintended pregnancies, including earlier sexual initiation and ineffective use of contraception (Kirby, 2002). Additional unique factors—including gender dysphoria (Olson et al., 2015) and gender identity-related stigma and discrimination (Hendricks & Testa, 2012)—likely play a role in these pregnancies among trans masculine individuals. However, very little is known about trans masculine people’s pregnancy experiences, especially with teen and unintended pregnancies.

Several commentaries and case studies provide pregnancy-related clinical guidance for the care of trans masculine individuals (Hahn et al., 2019; Obedin-Maliver & Makadon, 2016; Richardson et al., 2019). With a few exceptions in recent years (Cipres et al., 2017; Ellis et al., 2015; Hoffkling et al., 2017; Light et al., 2014, 2018), the existing obstetrical/gynecological research with trans masculine individuals (Dutton et al., 2008) has not robustly focused on pregnancy. One existing focus of pregnancy research with trans masculine individuals is fertility preservation, including the desire to build a family later in adulthood (Baram et al., 2019). However, little attention has been paid to common pregnancy experiences, such as those pregnancies that are unintended, as well as teen pregnancy experiences. Without including such pregnancy narratives, the unique pregnancy-related needs of trans masculine individuals cannot be met in sex education, contraceptive counseling, abortion care, and obstetrical care.

To help fill this gap, we examined the teen and unintended pregnancy experiences of trans masculine individuals living in the U.S. as a part of the larger SexuaL Orientation, Gender Identity, and Pregnancy Experiences (SLOPE) study. The aim of this analysis was to begin to understand potential risk factors and identify unique needs related to teen and unintended pregnancy among trans masculine people. Findings can help frame next research steps, which can aid in designing prevention strategies as well as creating evidence-based curricula for healthcare providers to improve pregnancy-related care for trans masculine people.

Materials and methods

Study population

The broader, mixed-methods SLOPE study aims to elucidate the pregnancy experiences of sexual and gender minorities. Qualitative interviews and quantitative surveys were conducted with 40 participants broken into four subsamples—10 cisgender sexual minority participants who became pregnant as teens, 10 cisgender sexual minority participants who impregnated a teen partner (or was at risk of doing so), 10 healthcare providers serving teen and/or sexual and gender minority patients, and 10 trans masculine individuals who became pregnant as teens or who became unintentionally pregnant. For the current analysis, we analyzed data from all SLOPE participants who identified along the trans masculine spectrum (N = 10). SLOPE participants were recruited from multiple sources including support networks, clinics, community centers, and various community events. Participants were also recruited through online methods including social media posts, targeted advertisements, and e-mails to community partners. Participants were eligible for the trans masculine subsample if: 1) at birth, they were assigned female; 2) they become pregnant as teens (i.e., before the age of 20 years) or became unintentionally pregnancy as an adult (i.e., age 20 or later); and 3) at the time of their pregnancy or the time of data collection, they identified as a gender other than woman. Additionally, participants must have been at least 18 years old and currently residing in the U.S.

Teen and unintended pregnancy

Recognizing the complexities in conceptualizing pregnancies as unintended (Potter et al., 2019) as well as measuring intention (Kost & Lindberg, 2015), we used a more granular version of the traditional intention assessment (Kost & Lindberg, 2015) and also incorporated items related to planning and acceptability (Aiken et al., 2016) as well as happiness (Santelli et al., 2009). Participants were ineligible if they indicated they wanted to be pregnant at that time (or sooner) or if they if they scored >5 out of a possible 10 on any of the remaining scaled items (Table 1).

Table 1.

Pregnancy intention assessment.

Topic	Question
Planning	Thinking back to before you got pregnant, on a scale of 1 to 10, how much did you want to become pregnant? 10 is highly wanted, 1 is not wanted at all
	Thinking back to before you got pregnant, on a scale of 1 to 10, how important was it to you to avoid becoming pregnant? 10 is extremely important, 1 is not important at all
Timing	Thinking back to when you got pregnant, which of the following best describes the timing of your pregnancy? I wanted to be pregnant at that time or sooner I wanted to be pregnant in the next 1-2 years, but not yet I wanted to be pregnant in 2+ years, but not yet I did not want to be pregnant then or at any time
Happiness	Thinking back to when you found out you were pregnant, on a scale of 1 to 10, how happy were you to find out you were pregnant? 10 is extremely happy, 1 is not happy at all
Acceptability	Thinking back to when you found out you were pregnant, one a scale of 1 to 10, how acceptable was it to you to be pregnant at that time? 10 is extremely acceptable, 1 is completely unacceptable

Researchers

The research team brought a range of perspectives. Team members included cisgender, binary transgender, and nonbinary individuals with gay, bisexual, and queer sexual orientations. Racial/ethnic identities included white, Black, and Native. Having training in various fields including epidemiology and developmental psychology, team members brought expertise in sexual and gender minority health as well as quantitative and qualitative research methods.

Procedure

Study sessions were conducted between March 2018 and May 2019 in person or via telephone/video conference. Transgender and nonbinary team members led study sessions beginning with obtaining written, informed consent and ending with an offer for remuneration of a $20 gift card and travel/parking vouchers. Study sessions lasted approximately 75 minutes with a 60-minute semi-structured qualitative interview (mean: 51 minutes, range: 29–87 minutes) followed by a 15-minute quantitative survey. Interviews were digitally recorded and professionally transcribed verbatim. Survey data were collected using REDCap (Harris et al., 2009) via electronic tablets or remotely. A safety plan was in place during all study sessions due to the sensitivity of some measures (e.g., childhood abuse). All participants received a resource list including those related to mental and reproductive health, particularly for gender minorities. This study was approved by the institutional review board at Boston Children's Hospital.

Interview guide

The research team developed an in-depth, semi-structured interview guide specifically for this study, in consultation with community partners. After initial development by the research team (which included trans masculine members), the interview guide was also reviewed by additional experts and pilot tested by community members. The interview protocol prompted participants to discuss their gender identity and experiences with a teen or unintended pregnancy. Participants were also asked to describe stressors (e.g., family rejection) they experienced before their pregnancies and coping strategies (e.g., drugs, alcohol). If participants experienced more than one pregnancy, they were instructed to answer questions as related to their first pregnancy.

Survey measures

Surveys primarily assessed sociodemographic characteristics including age, sexual orientation, race/ethnicity, education, and income.

Analytic methodology

Analyses were conducted by three team members (Tabaac, Reynolds, and Godwin) and overseen by Dr. Katz-Wise. Prior to beginning analyses, team members discussed their beliefs about gender identity and pregnancy to ensure any biases and assumptions had limited impact. To analyze the data, a thematic analysis approach was used with immersion/crystallization (Borkan, 1992; Crabtree & Miller, 1992). The team first listened to the audio-recordings and read the transcripts to “immerse” themselves in the interview content and tone. They then “crystallized” the content, noting patterns and deviations. An initial codebook was created using a template organizing style (Crabtree & Miller, 1992). This codebook contained both deductive codes stemming from interview questions and inductive codes based on what arose during the immersion/crystallization process. The codebook was revised during team meetings, then calibrated using two mid-length interviews. The team conducted further codebook revisions throughout the coding process. Coding was conducted using Dedoose software. Each transcript was coded independently by two coders, who resolved discrepancies by consensus through memos reviewed during team meetings. After initial coding, the codes were cleaned by creating large code “bins” and consolidating smaller codes as appropriate. Following code cleaning, the team independently developed themes and subthemes, based in part on inductive code prevalence, code co-occurrence, and memos. Themes and subthemes were then discussed among the team, checked against the data, refined, and organized using a conceptual model. Sociodemographic data from participants’ surveys were used to contextualize qualitative interview data; for example, we used survey data to identify the age at which participants became pregnant and the methods of contraception at that time.

Results

Of the 10 participants, 6 became pregnant as teens and 4 became unintentionally pregnant after their teens. Pregnancies ended as spontaneous abortions (i.e., miscarriages, n = 3), induced abortions (n = 4), and live births (n = 3). Participants’ current ages ranged from 21 to 53 years (M = 34.3; SD = 10.3); racial/ethnic identities included white (n = 9) and Black (n = 1).

Themes

Four themes were developed from participants’ narratives and these themes highlighted: 1) how trans masculine people navigated having a pregnant body (e.g., heightened gender dysphoria due to being pregnant); 2) the importance of the cultural environment in shaping their experiences as a trans masculine pregnant person (e.g., pregnancy and gender-related job discrimination); 3) the development of their pregnancy over time (e.g., decision-making processes); and 4) how their pregnancy (and gender identity) affected their relationships with other people (e.g., adverse family of origin experiences).

Theme 1: Navigating the pregnant body as a trans masculine person

Experiences stemming from interactions among gender, pregnancy, relationships, and the larger culture informed this theme, which reflected how participants navigated their body through a gendered culture and also how others navigated interactions with the participants during the pregnancy.

Gender dysphoria

Several participants described their experiences of gender dysphoria, including heightened dysphoria while pregnant. From a 28-year-old participant: “It really fucked me up. It made me incredibly dysphoric, because I was kinda faced with the, like, ‘You have a uterus, you have reproductive organs. This is an incredibly female experience’ - or at least it's coded as a very female experience.” A 24-year-old participant cited “body horror” as a reason underlying his choice to terminate his pregnancy, describing the lengths to which he would go to relieve that feeling:

Well, delivering a child, oh, I don't think I would've been able to. Like whenever I would have like horrifying nightmares about being pregnant, I was thinking, "What would I do?" And my gut reaction is just like, "Oh, I would just throw myself down a flight of stairs, over and over until I couldn't get up again, and hope that either that got rid of the pregnancy or me.”

Effects of visible “belly” (i.e., abdomen)

A major component of this theme was how participants’ visibly enlarged abdomens increased the extent to which they were misgendered or treated “like a woman” by others, including friends who knew they were transgender. This added a layer of distress, as it did for this 36-year-old participant:

I was really shocked at how much of it came from other people who are genderqueer also. It's like, "Oh, well, now you're pregnant so now I need to shove you into a binary category. And now, you're a girl and your partner [a trans woman] is a man and that's who you guys are." And it's, like, a shitty type of aggression to have leveled at you from within your community. It's profoundly disrespectful and it's super uncomfortable. It's like with, you know, barfing around the clock and trying to walk around while my pelvis is separating….And I'd be like, "you've known me for eight years. You've never even used the pro[noun]-…why would you call me 'she' all of a sudden?"

A 53-year-old participant recalled, “I couldn't get away with being androgynous anymore. They feminized me and female-scripted me until I wanted to throw up. It happened everywhere all the time.” Conversely, receiving masculinizing gender-affirming treatments could result in invisibility as a pregnant individual. A 28-year-old participant described how gender-based expectations about pregnancy guided strangers’ reactions to his body in public spaces:

So the one thing that was particularly hard about being pregnant, but also being a trans man, who everyone thought was a man, was living in the city and having to take public transportation. If it was rush hour and there was nowhere to sit, I'd have to stand even though I was six months pregnant and my feet were swollen, and I was in pain. But I couldn't, like, ask for a seat because they would just think I was a big fat guy who is lazy….I mean, people see what they want to see, and no one expects to see a pregnant man.

Abortion care and gender

Gendered assumptions in abortion settings brought up feelings of exclusion and discomfort for some participants. This 34-year-old reflected on how their experience at an abortion clinic at age 19 (while still identifying as a woman) was mediated by their gender expression:

I guess I would have felt very strange there. I mean, there were couples, so there were definitely men there, but I would have felt different being there on my own if I were more masculine-presenting. You know, I guess, I'd probably… had I gone alone, it would have been uncomfortable.

A 48-year-old participant noted how his experiences as a pregnant trans masculine person were not represented in cultural dialogues about abortion, and how that lack of representation can affect abortion access:

When I talk about being pregnant and having an abortion it's so that people understand that speaking about pregnancy and abortion purely as a “women's issue” is not sufficiently broad. It's oppressing other people who can become pregnant and who need access to abortion. And I think by not talking about the idea that trans people, that transgender people have sexuality…. If you have a uterus and ovaries…if you have the correct organs, that trans people are capable of getting pregnant and might need access to abortion.

Theme 2: Cultural environment shaping trans masculine pregnant people’s experiences

The theme of cultural environment reflected how culture, including society and institutions, influenced and contextualized participants’ pregnancy- and gender-related experiences.

Norms about pregnancy acceptability

Some participants noted how sociocultural norms about pregnancy, socioeconomic status, relationship status, and age influenced others’ reactions to their pregnancy, beyond just gender. For instance, a 31-year-old participant described how conformity to sociocultural norms helped him to accept his pregnancy at age 19:

I think I felt okay with the timing of the pregnancy. Because, like, we were married, we had our own apartment, we both had jobs. So, like, societal views of, like, when it's okay to have a baby, like, we checked the boxes of, you know, what people would deem acceptable….

However, this same participant noted that, despite his embodying certain culturally acceptable norms regarding pregnancy (and his feminine gender presentation at the time), others’ negative views about teen pregnancy impacted his access to resources:

I did get, once, kicked out of the Motherhood Maternity because the lady who was working there was super religious and said she didn't support teen pregnancy, which was fun, because I was, like, legitimately a legal adult and married and pregnant. So technically, I met the criteria of what a “good” pregnancy is. But I didn't feel like having that argument, so I just left.

A 34-year-old participant noted how regional norms could alter these expectations about teen pregnancy: “At a certain point people just expect you to have kids and a lot of girls were pregnant in high school and some even junior high where I grew up. And so nobody is super shocked when you have a child at [age] 18, 19.”

Workplace cultures

Workplaces were typically described as places in which prevailing cultural norms around gender and/or pregnancy created unaffirming or even hostile environments. A 36-year-old participant who was job-seeking while pregnant a few years prior had feared stigma related to both their gender identity and pregnancy:

It was inconvenient in the way that, like, it's very tough to, it's difficult to be approaching a new employer as a queer person, as a gender nonconforming person, as someone who at the time, even more than I look right now, was very visibly gender nonconforming. And then also there's the baggage of, as much as people say they don’t, they don't wanna hire pregnant people.

Theme 3: Development of pregnancy over time

This theme centered on the actions leading up to pregnancy, the pregnancy itself, and changes in participants’ lives resulting from the pregnancy.

Contraception

A number of participants discussed the role of testosterone and contraception. A 24-year-old participant recounted how his unplanned pregnancy at age 21 (ending in induced abortion) was impacted by both his age and his partner’s misconceptions:

At the time, I just lacked a lot of confidence maybe in putting my foot down about what I was willing to do, and I ended up doing some things that weren't smart….My partner knew that I was on testosterone, and he knew that in my family, it's really difficult for any of the females to become pregnant. So, he tried to convince me that that means we didn't need to use any sort of contraceptives.

A 28-year-old participant described how his and his husband’s ambivalence about starting a family combined with his inconsistent testosterone usage resulted in the conception of their first child two years prior:

I had been sort of on and off testosterone and we had sort of wanted kids, but I was also anxious and sort of afraid about having kids. And he was more worried about the financial part of it. I was more worried about, "Oh, God. I'm trans. Why am I wanting to have a baby that's related to me?" So I went off testosterone, and then pretty immediately got pregnant….[Interviewer: Was that related to fertility desires or completely unrelated?] Sort of both. It was more of, I get really anxious giving myself injections and so would lapse giving myself testosterone. And then, you know, I'd get my period and be like, "Oh, crap." So it was a mixture of just lapsing out of anxiety, but also, like, “well if I just stop [taking testosterone], then we'll just see what happens.”

Pregnancy decision-making

Decision-making about participants’ pregnancies was influenced more by perceptions of their current capacity to rear a child than their gender identities. This calculus was illustrated poignantly by this 34-year-old participant, who had an induced abortion at age 19:

I wasn't a safe container for a baby….I had just gotten out of the hospital after having attempted suicide a couple months earlier. And I was just trying to get back into therapy and get my medication right. Yeah, I was, like, momentarily feeling sort of stable but still just drinking and doing drugs.

For some participants, pregnancy decision-making had both gender-related and more universal repercussions, as this 53-year-old participant, who chose to raise two children, reflected:

I think that I would have moved into my…the fullest expression of my identity a whole lot sooner, but I got derailed, and distracted, and had to fulfill [a] parent role. And, well, it cost a lot of money. Boy, kids are expensive. I'd have a retirement fund now, which I don't. Yeah, I mean, I think I would be further along and more stable in expressing who I am in myself than I am with the children because they were counter to who I wanted to be and what I wanted to be.

Meanwhile, a 31-year-old participant described how a spontaneous abortion at age 19 inspired him to work in perinatal bereavement in ways that are inclusive of sexual and gender minorities:

…in this country in particular, we don't support parents when they lose babies earlier than term. Whether it's, you know, a miscarriage or an abortion, we don't have support for families and for parents, particularly the gestating parent.…So in developing, like, my education and my training and my field of practice, like, I want it to be and have made it so that it is fully inclusive of perinatal loss, feeding difficulties, birth trauma, presenting birth trauma, informed consent, and making sure that we're providing space-inclusive care for all people.

Theme 4: Impact of pregnancy (and gender identity) on relationships with other people

The theme of relationships involved how both positive and negative experiences with family, friends, partners, and communities shaped supportive and stressful experiences leading up to and surrounding the pregnancy.

Adverse family-of-origin experiences

For many participants, family relationships added stress to their lives, complicating matters of support and disclosure, particularly during their teen years. Victimization was common among participants. This 28-year-old described how his relationship with an abusive parent led to his suicide attempts:

So I don't talk to my family because they're all abusive fucks. I call my biological mother [MOTHER'S NAME]. I don't call her "Mom." And I guess I was, like, physically and emotionally abused, with emotional incest from the time when I was [age] 5 ‘til the time I was [age] 20. So I ended up attempting suicide when I was [age] 16, I self-injured a lot, and I ended up becoming homeless when I was [age] 19.

For a 21-year-old participant, sexual victimization from a step-grandparent created a dangerous home environment that grew more traumatic due to a resulting unintended pregnancy (ending in spontaneous abortion), which they described as compounded by feelings of guilt and shame:

I was afraid of judgment and repercussions, like the judgments specifically from people realizing… like, different levels of judgment. First, the level, like, of shame around being a victim…and then the shame surrounding the fact that like most familial stuff like that that happens is more like uncle, father… I don't know, closer in age range I guess. And I had never really heard of somebody, like, of that type of situation? And like, then my mind had thrown myself to the point of like, well, “if I think about it this way, then my kid would be my kid while also being like an aunt or an uncle” and that's really weird.

Family experiences also differed by participants’ cultural backgrounds. This Black 34-year-old participant discussed how perceptions of stigma and acceptability surrounding mental illness in Black communities reduced their maternal support and created a barrier for pursuing therapy when they were suicidal in high school:

My mother was sort of hostile to the fact that I was back [home] and that I had dropped out of school. And she was not acknowledging the fact that my suicide attempt was a suicide attempt. And she didn't really want me to be in therapy. She felt like Black families didn't do that.

Chosen families

For some participants, chosen families had positive influences on their early lives; these relationships sometimes facilitated participants’ disclosure of their gender identities or teen pregnancies when it was not possible with toxic families of origin. For instance, this 21-year-old participant, who experienced a pregnancy from incest at age 13, described how school peers provided support in the face of their abusive home environment:

This group, like I really connected with these people and like they understood me really well and it was like the first group of people that like I didn't have to pretend to be somebody else with. So it was really good. And that made using school as an escape a lot better. Like I felt more at home at school than I did at home and actually building a foundation of friends that was really solid friendships and like they're now my family….And so like I had a lot of new and good things introduced into my life then and like that was one of the newest feelings I had, because I had never really had that before….Like that's what gave me the strength to actually disclose everything that was going on because I actually found like a foundation that I could lean on, which was really good.

In contrast to participants with teen pregnancies, those who had an unintended pregnancy in adulthood tended to describe more supportive/positive relationships relative to their pregnancy, because of their chosen peer and community networks. For example, a 36-year-old described how belonging to a community of “queer parents” provided them with unique support:

I have this really great network of parent friends now and most of them happen also to be queer parents. And it's just incredible to have that support. It's really difficult if you're in a typical like mom group and you ask a question that applies to, like, a situation that might be hurtful for your family. And a lot of the time, you get brushed off for speaking over this. It's not, like, people being intentionally shitty; they don't know how to look from their perspective and you get a lot of, "Oh, why is it a big deal?" Whereas in queer parents’ groups, it's so nice to be like, "Do you guys believe this shit? My kid's school is doing, like, wants to make a father's day gift for my wife. She's not a father, you know?"

Discussion

The goal of this research was to better understand the experiences of trans masculine people who had an unintended or teen pregnancy, and specifically to identify potential risk factors and unique needs related to those experiences. The four themes that were developed from participants’ narratives highlighted how trans masculine people navigated having a pregnant body, the importance of the cultural environment in shaping their experiences as a trans masculine pregnant person, the development of their pregnancy over time, how their pregnancy (and gender identity) affected their relationships with other people, and the development of their gender identity.

In theme 1 (navigating the pregnant body as a trans masculine person), participants’ narratives focused on experiences of intensified gender dysphoria during pregnancy. Gender dysphoria can increase for people who do not identify as women because pregnancy is typically an experience associated with a gender with which these individuals do not identify. This gender dysphoria may also be related to the enhancement of physical characteristics, such as breast and hip enlargement, that are typically associated with cisgender women; this hypothesis is supported by the gender dysphoria intensification that transgender people often experience during puberty (Steensma et al., 2011). Increased gender dysphoria may also be related to the inclusion criteria for this study; all participants had either a teen pregnancy or an unintended pregnancy. The nature of these pregnancies may produce increased gender dysphoria because these individuals were not expecting to become pregnant and may have had a more negative outlook on their pregnancy compared to people with intended pregnancies later in adulthood.

Participants also described the receipt of responses from others to their pregnant bodies that were disaffirming to their gender identity. Relatedly, in theme 2 (cultural environment shaping trans masculine pregnant people’s experiences), participants described how sociocultural norms about pregnancy, socioeconomic status, relationship status, age, and gender influenced other’s reactions to their pregnancy. Normative assumptions about pregnant bodies almost exclusively focus on adult, cisgender women with feminine gender expressions who are married to adult, cisgender men. Thus, seeing a pregnant person with a nonbinary or masculine gender expression may be unexpected and could be met with confusion or discrimination from people naïve about or hostile to the transgender community. These expectations intersect with cisnormativity and transphobia, as well as heteronormativity and heterosexism, to create a context within which trans masculine pregnant people, particularly those with a teen or unintended pregnancy, may experience prejudice and discrimination based on their pregnancy. Participants described the workplace as a specific setting in which they experienced prejudice and discrimination that stemmed from both their gender identity and their pregnancy—two well-documented sources of discrimination (James et al., 2016; US Equal Employment Opportunity Commission, 2020). Trans masculine pregnant people likely experience higher rates of workplace discrimination based on both their gender identity and pregnancies.

In the third theme (development of pregnancy over time), participants’ narratives focused on decision-making about contraceptives and pregnancy that were related to adolescence and developmental readiness to be a parent. In adolescence, the brain’s prefrontal cortex, responsible for decision-making, has not yet fully formed, and decision-making may be affected by emotion and social influence (Pulley et al., 2002). In the current study sample, developmental readiness to be a parent was described as a larger factor than gender identity in decision-making about pregnancy. This highlights an experience that may be universal to both cisgender and transgender people in contraceptive and pregnancy decision-making.

In the fourth theme (impact of pregnancy [and gender identity] on relationships with other people), many participants described difficult family relationships that created stressful situations around disclosure of gender identity and the pregnancy. Consistent with prior research (Sterzing et al., 2017), a number of participants also described abuse from family members as well as subsequent abuse from the partner involved in their pregnancy—this well-known cycle of abuse appears heightened among transgender people who often have limited support during their childhood and adolescence. By contrast, many participants described having chosen families that provided support for both their gender identity and pregnancy. Prior research documents the critical support these chosen families offer transgender individuals, particularly those with unsupportive families of origin (Johns et al., 2018).

A number of challenges have plagued research on unintended pregnancies (including those occurring during the teen years) irrespective of gender identity. Some of the most cited publications in the family planning literature (Henshaw, 1998) outline how unintended pregnancies indicate limited reproductive autonomy and lead to adverse health for parent and child. However, numerous insightful critiques challenge these linkages, including a recent commentary (Potter et al., 2019) noting how this research often reinforces the idea that induced abortions are health system failures, valorizes the most effective contraceptive methods without considering the individual’s desires, and stigmatizes fertility among already-marginalized groups. A seminal 1995 report from the National Academy of Medicine outlined numerous adverse consequences of unintended pregnancies; these included greater risk of parental depression and economic hardship and infant abuse and mortality (Institute of Medicine, 1995). Updated reviews of the literature (Gipson et al., 2008) find more mixed evidence, particularly once accounting for confounding by the individual’s demographic and socioeconomic characteristics. In addition to these conceptual problems, there are also methodological challenges in studying unintended pregnancy. Conventional measures of pregnancy intention combine mistimed and unwanted pregnancies into a single “unintended” category and do not allow for gradations (e.g., slightly mistimed by <2 years compared to greatly mistimed), which are differentially associated with health outcomes (Pulley et al., 2002). Therefore, our team used a number of multidimensional measurements of pregnancy intention.

This research has a number of limitations that should be considered. First, the sample size is small and points to the need for further research to strengthen our findings and identify additional factors. However, as the first research to our knowledge to examine both unintended and teen pregnancies among trans masculine people, this study provides an important advancement. Second, nearly all of the participants had a white race/ethnicity. Thus, findings from this study may not be applicable to trans masculine people of color. Racial disparities research is more important than ever during the ongoing maternal health crisis among people of color, particularly Black people (Howell, 2018). Future research should explore narratives about unintended and teen pregnancies from a larger and more racially/ethnically diverse sample. Finally, the sample was too small to examine subgroup differences based on participants who had a pregnancy as a teen and those who had a pregnancy later in life. Similarly, the sample lacked enough statistical power to explore differences between people with binary and nonbinary gender identities.

Findings from this research have implications for public health practitioners and healthcare providers in caring for and counseling trans masculine people. Participants described feeling excluded or uncomfortable in reproductive health settings, particularly abortion clinics. Reproductive health settings are traditionally oriented toward cisgender women, creating a situation in which trans masculine and nonbinary people may feel as though they do not belong. Reproductive healthcare spaces and protocols should be gender inclusive in: how waiting rooms are decorated (e.g., the images that are available to patients in the form of posters, brochures, or magazines); phrasing of questions on intake forms; and clinical protocols, including sexual history-taking procedures (Howell, 2018). Trans masculine pregnant people may also need support from educators and healthcare providers in navigating public spaces, including the workplace, where they may experience either increased discrimination or invisibility as a pregnant person because of their masculine gender expression.

Previous research on trans masculine people’s reproductive health, albeit limited, has investigated topics including fertility preservation (Armuand et al., 2017), fertility desires (Wierckx et al., 2012), provider knowledge (Unger, 2015), and the effects of androgens on reproductive anatomy (Grimstad et al., 2019). To our knowledge, this is the first study to qualitatively highlight trans masculine people’s experiences with unintended and teen pregnancies.

Conclusions

This study reveals a number of teen and unintended pregnancy risk factors among trans masculine people, including physical and sexual abuse as well as ineffective use of contraceptives. These risk factors can provide a focal point for prevention efforts aimed at lessening the burden of teen and unintended pregnancies on trans masculine individuals. Such prevention efforts include the development of evidence-based educational curricula and clinical guidelines such as those related to contraceptive counseling and screening for abuse. This research also identifies unique needs of this population, including: relieving gender dysphoria, combating discrimination, and ensuring trans masculine pregnant people feel visible and welcome, particularly in reproductive healthcare spaces. Public health practitioners, healthcare providers, and support networks (e.g., chosen family) can be key sources of support for trans masculine people who have teen and unintended pregnancies. Attention to risk factors, unique needs, and sources of support will improve reproductive healthcare and pregnancy experiences for trans masculine people.

Funding Statement

National Institutes of Health (F32HD084000, F32HD100081, R00HD082340), American Cancer Society (MRSG CPHPS 130006), Maternal and Child Health Bureau (6T71MC00009), Society of Family Planning (SHPRF9-18), Aerosmith Endowment Fund for Prevention and Treatment of AIDS and HIV Infections at Boston Children’s Hospital, and the Boston Foundation.

Disclosure statement

No potential conflict of interest was reported by the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.