SCIENTIFIC EVIDENCE ON EXPERIENCES OF PREGNANT TRANSSEXUAL MENABSTRACT
Objective: to analyze the scientific evidence about the experiences of pregnant transsexual men.
Method: a descriptive, integrative literature review study without a defined time cut, carried out in January 2021 in the following Databases: Medline, CINAHL, LILACS, CUIDEN, SCOPUS, WoS, EMBASE, PSYCINFO and BDENF, in Portuguese, English and Spanish; using the DECs and MeSH descriptors: “Transgender People”, “Pregnancy”, “Reproduction”, “Fertilization”, “Insemination”, “Prenatal Care”, “Postpartum Period”, “Lactation”, “Mispontaneous Abortion” , “Habitual abortion”, “Reproductive health” and “Health Care” and their respective synonyms. The elaboration of the guiding question was conducted by the PICo Strategy: (Population): transgender men; I (Interest): experiences during the puerperal pregnancy cycle; Co (Context): reproductive health and health services. The final sample was submitted to the Thematic Analysis Technique.
Results: a total of 1,011 studies were identified, 10 of which composed this review after the selection process and peer review. The analysis resulted in two thematic categories: “Pregnancy-puerperal cycle: challenges and experiences” and “Pregnant bodies: perceptions and social relationships”.
Conclusion: the experiences of pregnant transsexual men are marked by concerns related to pregnancy, childbirth, birth and the puerperium, causing unexpected psychological and/or emotional impacts, evidencing cisheteronormativity and transphobia as structuring aspects which add an additional part to fear of childbirth and violations of rights.
DESCRIPTORS: Transgender people; Pregnancy; Reproduction; Fertilization; Insemination; Prenatal care; Nursing
RESUMEN
Objetivo: analizar la evidencia científica sobre las experiencias de los hombres transexuales embarazados.
Método: estudio descriptivo, tipo revisión bibliográfica integradora, sin corte temporal, realizado en enero de 2021 en las siguientes bases de datos: Medline, CINAHL, LILACS, CUIDEN, SCOPUS, WoS, EMBASE, PSYCINFO y BDENF, en los idiomas portugués, inglés y español; utilizando los descriptores DeCS y MeSH: "Personas Transgénero", "Embarazo", "Reproducción", "Fertilización", "Inseminación", "Atención Prenatal", "Período Posparto", "Lactancia", "Aborto Espontáneo", "Aborto Habitual", "Salud Reproductiva" y "Atención a la Salud" y sus respectivos sinónimos. La elaboración de la pregunta guía fue realizada por la estrategia PICo: hombres transgénero (P - Población); experiencias durante el ciclo gravídico-puerperal (I - Interés); salud reproductiva y servicios de salud (Co - Contexto). La muestra final se sometió a la técnica de análisis temático.
Resultados: se identificaron 1.011 estudios. Después del proceso de selección y la revisión por pares, 10 compusieron esta revisión. El análisis se ha centrado en dos categorías temáticas: "Ciclo gravídico-puerperal: desafíos y experiencias" y "Cuerpos embarazados: percepciones y relaciones sociales".
Conclusión: l as experiencias de hombres transexuales embarazados están marcadas por inquietudes relacionadas a la gestación, el parto, el nacimiento y el puerperio, ocasionando impactos psicológicos y/o emocionales inesperados, evidenciando la cisheteronormatividad y la transfobia como aspectos estructurales que incorporan una parcela adicional al miedo del parto y violaciones de derechos.
DESCRIPTORES: Personas transgénero; Embarazo; Reproducción; Fertilización; Inseminación; Atención prenatal; Enfermería
RESUMO
Objetivo: analisar as evidências científicas sobre experiências de homens transexuais grávidos.
Método: estudo descritivo, tipo revisão integrativa de literatura, sem recorte de tempo, realizada em janeiro de 2021 nas seguintes Bases de Dados: Medline, CINAHL, LILACS, CUIDEN, SCOPUS, WoS, EMBASE, PSYCINFO e BDENF, nos idiomas português, inglês e espanhol; usando os descritores DECs e MeSH: “Pessoas Transgênero”, “Gravidez”, “Reprodução”, “Fertilização”, “Inseminação”, “Cuidado Pré-Natal”, “Período Pós-Parto”, “Lactação”, “Aborto Espontâneo”, “Aborto habitual”, “Saúde reprodutiva” e “Assistência à Saúde” e respectivos sinônimos. A elaboração da questão norteadora foi conduzida pela Estratégia PICo: (População): homens transexuais; I (Interesse): experiências durante o ciclo gravídico puerperal; Co (Contexto): saúde reprodutiva e serviços de saúde. A amostra final foi submetida à Técnica de Análise Temática.
Resultados: foram identificados 1.011 estudos. Após o processo de seleção e avaliação por pares, 10 compuseram esta revisão. A análise resultou em duas categorias temáticas: “Ciclo gravídico-puerperal: desafios e experiências” e “Corpos grávidos: percepções e relações sociais”.
Conclusão: as experiências de homens transexuais grávidos são marcadas por inquietações relacionadas à gestação, ao parto, ao nascimento e ao puerpério, ocasionando impactos psicológicos e/ou emocionais inesperados, evidenciando a cisheteronormatividade e a transfobia como aspectos estruturantes que acrescentam uma parcela adicional ao medo do parto e violações de direitos.
DESCRITORES: Pessoas transgênero; Gravidez; Reprodução; Fertilização; Inseminação; Cuidado pré-natal; Enfermagem
INTRODUCTION
Although studies on the experiences and healthcare of transgender men (i.e. people identified as being female at birth, but who recognize themselves as belonging to the male gender and claim to be male) have increased substantially in the last 10 years, there are still gaps in the knowledge production which address the singularities of this group1-3.
It is noteworthy that power relations based on the heterosexuality of bodies presuppose that bodies are cisgender - subjects who recognize themselves with the gender to which they were assigned at birth from their biological sex. Thus, by the logic of common sense, the so-called female body will always coincide with a body with a vulva and vagina, and the male body always with a penis and testicles, and these bodies will attract each other because this is the order naturalized by heteronormativity4.
With regard to reproductive healthcare, these men go through a continuous process of obfuscation in health spaces organized under the logic of cisheteronormativity, in which pregnancy, childbirth and breastfeeding experiences, for example, are treated as exclusively “female” events of cisgender and heterosexual women5-6. These conceptions influenced by norms and socially established gender roles have generated significant impacts on the health status of transsexual men.
Childbirth, like pregnancy, is a process that requires frequent interaction with health services. The presence of these people in public spaces considered “feminine” leaves them vulnerable to transphobias and consequently to the onset of psychological illnesses, requiring the social support of family and friends who intervene as protective factors. The present study aimed to analyze the scientific evidence on the experiences of pregnant transsexual men.
METHOD
This is a descriptive, bibliographic, integrative literature review study without a time frame, operationalized by the following steps: 1) establishment of the research question; 2) establishment of inclusion and exclusion criteria; 3) definition of the information to be extracted from the selected studies and characterization; 4) evaluation of included studies; 5) interpretation of results; 6) presentation of the review/synthesis of knowledge8-11.
The PICo strategy was used in order to elaborate the guiding question: P (Population): transsexual men; I (Interest): experiences during the pregnancy-puerperal cycle; Co (Context): reproductive health and health services12. Thus, the following guiding question was constructed: what is the scientific evidence on the experiences of pregnant transsexual men?
Next, an advanced search was used to systematize data collection considering peculiarities and characteristics intrinsic to each Database. The descriptors were combined with each other with the Boolean connector OR, in each set of terms of the PICo strategy, then crossed with the Boolean connector AND, shown in Chart 1.
Primary articles presented in Portuguese, English or Spanish were established regarding the inclusion criteria. Then, review articles, duplicate publications (including the publication that is available in the largest database depending on the publication number), theses, dissertations, monographs, books, book chapters, congress abstracts, proceedings, government programs and reports, and other gray literature and predatory publications were considered as the exclusion criteria.
A double-blind literature survey by independent researchers was carried out in January 2021 through consultations in the following databases via the Virtual Health Library (BVS): Medical Literature Analysis and Retrievel System Online (Medline), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature in Health Sciences (LILACS), CUIDEN, The Largest base of abstracts and references from peer-reviewed scientific literature (SCOPUS), Web of Science (WoS), EMBASE , American Psychological Association database (PSYCINFO) and Nursing Databases (BDENF).
The following Health Sciences Descriptors were used (DeCS) to search for articles: “Pessoas Transgênero”, “Gravidez”, “Reprodução”, “Fertilização”, “Inseminação”, “Cuidado Pré-Natal”, “Período Pós-Parto”, “Lactação”, “Aborto Espontâneo”, “Aborto habitual”, “Saúde reprodutiva” and “Assistência à Saúde”, as well as their equivalents in English available in Medical Subject Headings (MeSH), which were: “TransgenderPersons”, “transgenders”, “transgender”, “transsexualism”, “Pregnancy”, “Gestation”, “Pregnancies”, “Reproduction”, “Fertilization”, “Insemination”, “PrenatalCare”, “AntenatalCare”, “Care, Antenatal”, “Care, Prenatal”, “PostpartumPeriod”, “Puerperium”, “Lactation”, “Paternity”, “Abortion, Habitual”, “Abortion, Spontaneous”, “Reproductive Health”, “Health, Reproductive”, “Delivery of Health Care”, “Health Care” and “Delivery of Healthcare”.
After surveying scientific publications, the studies were organized using the Zotero data manager and references, and duplicates were enumerated and excluded. The title and abstract of the studies were read by pairs (double-blind independent researchers) using the Rayyan QCRI application, and those who were closely related to the study theme were included in the sample. Then, a third collaborator established a consensus among the pairs in cases where there were discrepancies in order to minimize bias.
Next, the articles were read in full to confirm eligibility, and after reading the material, those which did not answer the guiding question and those which did not collect data with transsexual men as well as those which were not available in full were excluded, obtaining the final sample. The corpus of analysis was characterized in 10 scientific articles; then, the articles were evaluated regarding the evidence level supported by the categorization in accordance with the methodological approach of the Agency for Healthcare Research and Quality (AHRQ), namely: Level I - Systematic reviews or meta-analysis of relevant clinical trials; Level II - Well-designed randomized controlled trial; Level III - Well-designed clinical trials without randomization; Level IV - Well-designed cohort and case-control studies; Level V - Systematic review of descriptive and qualitative studies; Level VI - Evidence derived from a single descriptive or qualitative study; Level VII - Opinion of authorities or report of expert committees13.
In the analysis of the results, the qualitative analysis was privileged based on the thematic analysis, which enabled classification into two categories14. Chart 2 was created identifying the characteristics and evidence level, and Chart 3 with the thematic categorizations and a synthesis of the experiences of pregnant transsexual men. The flowchart in the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-2020) was also presented in order to show the methodological rigor and presentation of the results (Figure 1)15.
Distribution of articles according to authorship, year of publication, research design and level of evidence. Recife, PE, Brazil, 2021.
RESULTS
A total of 1,011 primary articles were identified and 10 studies were included at the end of this process. The selection steps are described in Figure 1.
Flowchart of selected studies adapted from the PRISMA model - 2020. Recife, PE, Brazil, 2021.
Regarding the country where the study was carried out, the United States of America (USA) presented six articles, while only one article was found in each of the following respective countries: Sweden, Australia, Canada and Brazil. The predominant language was English and the publication date was between 2014 and 2020.
Articles from CINAHL (n=3), SCOPUS (n=3), EMBASE (n=2) and WoS (1) databases were indexed. Articles with a qualitative approach predominated regarding the methodological design. In synthesizing the knowledge produced regarding the level of evidence, all articles present level of evidence VI. Taking into account the converging ideas presented by the authors, the results were grouped into two thematic categories, namely: I) Pregnancy-puerperal cycle: challenges and experiences; and II) Pregnant bodies: perceptions and social relationships.
DISCUSSION
C1 - Pregnancy-puerperal cycle: challenges and experiences
The experiences of transsexual men during the pregnancy-puerperal cycle are related to the fear of the parturition process, which is the moment when healthcare is provided during labor and birth. This moment can result in unexpected psychological and/or emotional impacts: loss of emotional control, panic attacks and risk of death are frequent reports16, corroborating another study developed which identified anxiety as a potent marker in the mental health of transsexual men, being the same trigger of several diseases such as panic syndrome and depression26. In addition, there are studies which have reported the concern of transsexual men with possible intense pain, injuries and complications during childbirth16,26.
In a study carried out in Sweden, pregnant transgender men expressed fear of an emergency cesarean section and others reported a preference for planned cesarean section, since the idea of having a vaginal delivery with their genitals exposed for long periods is emotionally disturbing. This thought may be related to the violations experienced by these men in a context of institutional transphobia, who do not recognize this “abject” body as possible to “gestate” and because they are inserted in health spaces such as “maternity hospitals” designed for the care for cisgender women16,24,27.
The discomfort of trans men with their own body or genitals has been a major problem during consultations in health services where there is a need to perform vulvo-vaginal exams, as it is assumed that the technical procedures performed by health professionals are invasive and performed without dialogue for their consent. One should also consider the use of masculinizing hormones prior to pregnancy, such as testosterone, which cause changes in the genital tissue and dryness of the vaginal canal, which can cause greater discomfort16,18.
Faced with a lack of training for health professionals to care for the pregnancy-puerperal cycle of transsexual men, especially nurses and obstetricians, the result is the reproduction of a discriminatory professional practice. This context affects access to health services with professionals trained to guarantee quality prenatal, childbirth and postpartum care that respects the subjectivities of transsexual men18-19. It is evident that cisheteronormativity and LGBTphobia add an additional share to the fear of childbirth, with reports of previous experiences of violence perpetrated by health professionals against transsexual men, which increased the fear of childbirth16,24.
A study carried out in the United States of America (USA) showed that pregnancy, delivery and birth outcomes did not differ according to the previous use of testosterone by transgender men, however, they present some varieties of perinatal complications, including systemic arterial hypertension (SAH), premature labor, placental abruption and iron deficiency anemia18. The clinical management process of hormone use among transgender men in follow-up with a multiprofessional health team is a safe procedure that contributes to acquire body characteristics compatible with their gender, having positive influences on their well-being and quality of life. However, the recommendation to discontinue testosterone during pregnancy stands out28-29.
Regarding the delivery mode, a proportion of those who used testosterone underwent cesarean delivery compared to those who did not report using testosterone. Among those who underwent cesarean section, elective cesarean section was indicated. Those who had previously used testosterone were statistically less likely to breastfeed their child than those who had not previously used testosterone18,24.
Whether or not performing masculinizing mammoplasty surgery before becoming pregnant and the type of surgical technique were the main factors with regard to breastfeeding which affected the decisions surrounding this experience. Transsexual men who had breasts chose to breastfeed their children during the puerperal period. Some of those who underwent masculinizing mammoplasty surgery before pregnancy produced enough milk and fed their children for more than 6 months, some reported a “swelling” at the surgical scar site, some of the breast tissue grew back or even reached the size before surgery, but did not breastfeed, and others did not experience swelling or lactation19.
Another study mentioned a resignification of the breasts, a part of the body normally associated with discomfort, which could provide nutrition for their children, and therefore infant feeding was planned in advance and information and support were sought for their choices considering the benefits to the child’s health and the usefulness of breastfeeding for the baby and promoting the creation of bonds between father and child. Some reports mention that many felt comfortable breastfeeding in public spaces, which was a political act20.
Some participants in one of the studies found in this review had to deal with physical challenges in the postpartum period: two participants reported that they had undergone masculinizing mammoplasty surgery prior to pregnancy and experienced breast engorgement and early signs of mastitis, while health professionals were not prepared for the management of these diseases. In addition, they report having been touched on their breast without consent, an experience which caused anguish during an already challenging time20.
It is necessary to use other possibilities of infant feeding for children of transsexual men who do not choose to breastfeed, such as the use of milk banks or milk formulas, and it is the responsibility of professionals to communicate these during prenatal care, respecting different options, not putting pressure on the user and respecting their autonomy20. As breastfeeding continued, participants had to make choices about how to balance body discomfort with feeding their children in the midst of the gender affirmation process20.
There is a report in the literature in which a transsexual man used testosterone while breastfeeding and claimed to have had a positive experience. He noticed that “tying up” or wearing “chest bands on the breasts” and making use of testosterone allowed him to present himself as a man and feed his son from early childhood. However, the recommendation of the health professionals who accompanied him was to carefully observe the child for any signs of precocious puberty, such as growth of body hair. There was no decrease in milk production during his experience, and it coincided with the resumption of hormone therapy when his child was approximately 21 months, equivalent to 1 year and 9 months20.
Transgender men often describe thoughts and feelings about having masculinization of their chest after weaning. Three participants in one of the studies included in this review mentioned that they never experienced gender dysphoria while breastfeeding, but did experience intense gender dysphoria shortly after weaning; having breast tissue and using it to breastfeed did not appear to be problematic for these participants20.
There are several reports of lack of adequate conduct of the care provided during prenatal care in being faced with a lack of preparation of health professionals to deal with mood swings during the puerperal period of a pregnancy of transgender men, including preparing them for the postpartum risks, such as postpartum depression and making them feel insecure about the identification to differentiate between depression and mood swings. Despite this, positive experiences were reported during healthcare, as characterized by clinical meetings that provided privacy, naturalization of the transsexual pregnancy, recognition of their paternity and absence of vexatious attitudes19.
The understanding of pregnancy and birth were reported as a possibility for effective paternity. Pregnancy has been more and more desired among transsexual men and is configured as necessary to establish relationships that break with the traditional “family” logic.
Pregnancies are generally not planned. It is also important to highlight that there are reports of spontaneous abortion and induced abortion among this population, in the sense that health services guarantee them adequate and humanized management of risk situations and comprehensive care23. The violence and prejudice suffered in health services by people who cause abortion is not restricted to transgender men, but it is a reality that violates the right of choice of men and women who become pregnant23,25. It is noteworthy that health information systems have not yet included transgender men, which makes it difficult to access health facilities and produce indicators to assess their needs21.
C2 - Pregnant bodies: perceptions, representations and social relationships
The gender affirmation process for pregnant transsexual men can be impacted by the interruption of masculinizing hormone. In addition, the representation of the pregnant body is still associated with a characteristic, essentially, “feminine and cisgender” person. The consequences of losing some stereotypes considered socially “masculine” can reduce “passability”, meaning when an individual seeks to reach and be able to “pass” as cisgender, configuring as a self-protection strategy in intolerant contexts17,30. This experience becomes distressing and can result in pregnant transsexual men not seeking prenatal services due to the invisibility of their existence and their specificities17.
In a study carried out in Australia17, the reports of transsexual men mentioned discomforts related to experiences with pregnancy: dissociation in the recognition of their pregnant bodies as a biological event. The experience mentioned as the most challenging was changes in the chest, with enlargement of the breasts. These men often use strategies to hide their breasts, such as “binding”, but they are not effective during pregnancy. This context results in isolation due to the “fear of being discovered” which can last until the puerperium16-17,30.
Postpartum breastfeeding has also been reported as a triggering and deeply distressing factor. In this sense, it is necessary to reinforce the importance of the social support network, above all, the participation of the partner during the pregnancy-puerperal cycle, in addition to family members and close friends who can support positively17. In a study carried out in the United States of America, some participants cited their support communities as a source of resilience against the challenges they faced. A particular source of support was a Facebook group, in which they could exchange experiences among peers19.
Being recognized as a man with the consistent use of masculine names and pronouns was referred to as fundamental to their sense of emotional security, well-being and promotion of their quality of life. For some, being treated as a pregnant man was a political act19.
Using pregnancy concealment strategies by some transgender men were part of their experience in order to avoid transphobic violence and increase feelings of security, which are: 1) impersonating a cisgender woman, increasing the external affirmation of the pregnancy and denial of his affirmation as a subject with male gender identity; 2) Acting so that people could recognize you as a cisgender man increased the external affirmation of the male gender and decreased exposure to transphobia, but also decreased the external affirmation of pregnancy. Because they were not visible as pregnant, they were denied some basic rights: social support, care from a multiprofessional health team and recognition of their subjectivity. Those posing as cisgender men reported “being perceived as an obese man and never as a pregnant woman”. In contrast, other transgender men became publicly visible as pregnant transgender men, with the affirmation of their transmale gender identity and pregnancy. However, some participants feared an increased likelihood of transphobic violence19.
The increase in breast volume has become one of the main problems in relation to other people’s perception of their gender. Having prominent breast tissue can result in individuals being identified by others as cisgender women more often than other typically female secondary sex characteristics, including the pregnant abdomen. These men noticed that their pregnancies were often identified as obese and were generally easier to disguise with clothes than their breasts20,23.
Transsexual men sometimes cannot move in gendered spaces,31 meaning those marked by so-called female/male specificities. The idea of trans men “not belonging” to these places, for example, health services, accentuates vulnerabilities in relation to physical and psychological health7.
In this study, gaps in scientific production were identified in the context of pregnant transsexual men. These result from a lack of studies which have addressed the experiences of nurses during prenatal care, childbirth, birth and puerperium, especially on the experience of breastfeeding.
It is therefore recommended to develop empirical studies in the field of Health Sciences that can foster the debate about this identified gap, especially during the training of nurses, to break the barriers of conservatism and reorient comprehensive care to transsexual men and transmale people32.
CONCLUSION
The scientific evidence analyzed in this study showed that the experiences of transsexual men during pregnancy, childbirth, birth and postpartum were associated with unexpected psychological impacts. The studies showed the unpreparedness of health professionals in recognizing the demands of transsexual men throughout the pregnancy-puerperal cycle. This context was associated with a perpetuation of the cisheteronormative model in providing healthcare, which contributes to the fear of transsexual men in giving birth and the violations of their rights.
The most common strategies used during pregnancy concealment among transgender men were evidenced, such as impersonating a cisgender woman or acting in a way that people could recognize them as a cisgender man. Others made their transmasculine gender identity and pregnancy visible, but exposed themselves to the risk of transphobic violence.
It is therefore suggested to carry out empirical research that discusses other experiences focusing on the healthcare of transsexual men during reproductive planning, prenatal care, childbirth, birth and the puerperium, giving visibility to the existence of these people and the need of equitable and comprehensive care operationalized through respect for differences.
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NOTES
Edited by
Publication Dates
-
Publication in this collection
10 June 2022 -
Date of issue
2022
History
-
Received
08 Nov 2021 -
Accepted
24 Mar 2022
