“It’s Total Erasure”: Trans and Nonbinary Peoples’ Experiences of Cisnormativity Within Perinatal Care Services in Aotearoa New Zealand

Abstract

Transgender and nonbinary (trans) people can face unique barriers to accessing gender-inclusive perinatal care. The present study explored trans people’s experiences of perinatal care in Aotearoa New Zealand. A thematic analysis of 17 interviews with trans people and their whānau identified seven themes regarding the operation and impact of cisnormativity on participants’ family-building journeys. Findings indicate that cisnormativity manifests as an erasure of gender diversity and creates barriers to affirming and safe care. Importantly, participants’ constant negotiation of cisnormativity in perinatal care had enduring impacts on their well-being. Addressing cisnormativity is fundamental to securing trans reproductive justice.

Keywords:

• Transgender
• pregnancy
• LGBTQ
• cisnormativity
• perinatal

Introduction

Globally, transgender and nonbinary (trans)¹ people are asserting their right to build families through the birth of their own children as part of broader movements for reproductive justice. Reproductive justice insists that reproductive rights can only be realized by attending to the structural, social, and political forces that inform peoples’ reproductive lives (Ross & Solinger, 2017, p. 9); for trans people, this means drawing attention to the influences that undermine their right to have a child and to parent their children in safe and healthy environments. At a structural level, discriminatory laws and policies have inhibited trans peoples’ right to build families. For example, some countries require sterilization as part of legal gender recognition (Nixon, 2013; Radi, 2020). Barriers also persist for trans people wanting to access assisted reproductive technologies to build families, such as fertility preservation (Ker et al., 2021).

As movements for trans reproductive justice gain momentum, the eugenic implications of these laws and policies are being highlighted and addressed (Lowik, 2018; Radi, 2020). Beyond these overt forms of discrimination, attention is also being turned to trans peoples’ perinatal health care needs and experiences, with a noticeable increase of empirical literature (Riggs et al., 2020) and guidelines for care provision (Ellis & Dalke, 2019; Green & Riddington, 2020; Hahn et al., 2019; Kattari et al., 2020; Patel & Sweeney, 2021). While these guidelines include important and largely transferable suggestions for providing gender-affirming care within institutional settings, they are most relevant to perinatal services in the United States and the United Kingdom and do not reflect the midwifery continuity-of-care model of service provision that is unique to Aotearoa New Zealand.

This paper contributes to this literature by focusing on the dynamics of cisnormativity in trans peoples’ experiences of perinatal care. In this paper, we draw on 17 qualitative interviews with trans people and their whānau,² who described their experiences of navigating perinatal care services. Using Ahmed’s (2012) work on institutional inclusion, we describe the work of cisnormativity in making trans people “strangers” within perinatal care and the resulting barriers and blockages in their movement through these services. We argue that bringing cisnormativity into view, and in turn making space for trans people to be known in perinatal care, is a critical task in securing safe and healthy environments for trans parents and their children.

Background Literature

A growing literature on trans perinatal care—most of which has focused on trans men and transmasculine individuals—indicates that, while some trans people report positive experiences with individual health care providers, perinatal care settings can be precarious and unsafe environments for trans people (Riggs et al., 2021). Because pregnancy is perceived to have connotations with womanhood, and reproduction with heterosexuality, trans people and their families face unique challenges when accessing perinatal care. Participants in a study by Falck et al. (2021) of antenatal care services in Sweden often entered these settings expecting that they would be misgendered or perceived as women, and many perinatal environments are not perceived to be safe for trans people to disclose their gender identity (Ellis et al., 2015; Wolfe-Roubatis & Spatz, 2015).

Pregnancy can also be a lonely experience for transmasculine and nonbinary people, both in everyday life and in health care encounters (Berger et al., 2015; Charter et al., 2018; Ellis et al., 2015; Greenfield & Darwin, 2021; Hoffkling et al., 2017). Factors that exacerbate loneliness include the use of gendered language in perinatal environments in everyday interactions and resources (Hoffkling et al., 2017) and lack of opportunities to articulate one’s correct gender when accessing care (Falck et al., 2021). Although the impacts of noninclusive perinatal care on trans people have not been fully explored, some literature suggests that the anticipation or actuality of negative experiences may lead to trans people avoiding perinatal care. For example, survey findings from a comparative UK study found that trans people had higher rates of free-birthing than cisgender women (LGBT Foundation, 2022), suggesting that trans people may avoid care to mitigate negative experiences. Further, low expectations of perinatal care are often associated with poorer mental health outcomes among trans pregnant people and parents (Greenfield & Darwin, 2021). With the exception of few studies (e.g., Walls et al., 2019), little research attention has been paid to trans pregnancy or to transfeminine people’s and trans nongestational parents’ experiences of perinatal care.

Cisnormativity in Reproductive Health

There is growing discussion about the norms that underpin the challenges trans people face in reproductive health care, with some researchers attributing these to normative understandings of bodies and how they function (Besse et al., 2020). The erasure of trans peoples’ identities and bodies in perinatal settings is argued to be a result of gender essentialist ideas that conflate biological capacity for pregnancy with gender (Fischer, 2021; Hoffkling et al., 2017). These observations indicate a need to further identify how binary gender norms operate in perinatal care.

Cisnormativity describes the pervasive assumption that a person’s gender is always determined by their sex assigned at birth. The concept is related to the broader concept of cisgenderism, an ideology that “endorses and perpetuates the belief that cisgender identities and expression are to be valued more than transgender identities and expression and creates an inherent system of associated power and privilege” (Lennon & Mistler, 2014, p. 63). Unlike overt acts of transphobia that are typically grounded in or motivated by the hatred or fear of trans people, cisnormativity manifests in the systemic invisibility of gender diversity and is therefore rarely identified or questioned by people who benefit from the privileging of being cisgender.

Cisgenderism as a concept has been increasingly employed by trans health scholars over the past decade to understand how health care systems are structured in ways that, whether intentional or not, exclude trans people and reinforce binary gender norms (Ansara & Hegarty, 2012; Lennon & Mistler, 2014; Pearce, 2018). Although the application of cisgenderism is growing in health research, few studies in trans reproductive health have investigated cisnormativity in the assumptions about reproduction and family-building and how these affect trans peoples’ perinatal care experiences.

Perinatal Care in Aotearoa New Zealand

Perinatal care in Aotearoa New Zealand is provided by a lead maternity carer (LMC) who is usually a midwife but may be an obstetrician or a general practitioner (family doctor) (Manatū Hauora Ministry of Health [MoH], n.d.). Where pregnancy, birth, and the postpartum period remain uncomplicated, there is no requirement to include any medical personnel in the pregnant person’s care and the pregnant person can choose to give birth at home, at a birthing unit (where available), or in a specialist secondary- or tertiary-level maternity unit. Other health care practitioners may also be involved in their childbirth journey, including fertility specialists, gynecologists, sonographers, anesthetists, neonatologists, lactation consultants, and childbirth educators. Perinatal care is free of charge for eligible people, including citizens and most people with Aotearoa New Zealand residency and regardless of chosen place of birth. Once the pregnant person registers with them, the midwife LMC coordinates all aspects of care including referral to specialist services (MoH, 2012) and provides continuity of care until about six weeks after the baby is born.

The Politics of Stranger Making: Making Cisnormativity Visible in Perinatal Care

Our conceptual framework for this article borrows from Ahmed’s (2012) notion of institutional “stranger making” in her work on racism within universities. There are important parallels to be drawn in the shared task of “thickening our description” of institutions, to attend to that which is too often out of view (Ahmed, 2012, p. 8), namely, the norms that exist within institutions that reinforce who belongs and who is excluded or made stranger in these spaces. Engaging with the politics of stranger making within institutions is, according to Ahmed (2012), a process of making visible that which is not immediately apparent to those who embody and inhabit institutional norms. Asking what processes of stranger making are happening within institutions directs our attention to the “routines, procedures, conventions, roles, strategies, organizational forms, and technologies” that constitute some bodies as the rightful occupants and that constitute others as being out of place (Ahmed, 2012, p. 21).

Ahmed (2012, p. 3) describes how the “stranger experience” can be “an experience of becoming noticeable, of not passing through or passing by, of being stopped or being held up.” In this way, examining the processes of stranger making directs our attention to how institutional norms of belonging/not belonging create blockages and barriers that disrupt the flow of those constituted as strangers through institutions. Epstein (2014) emphasizes the analytical potential of Ahmed’s work for queer family-building scholarship: By turning our attention to the stranger experience within the normative social institutions of reproduction and family-building, we are provided with significant knowledge about the “blockages, restrictions and stoppages” (p. 27) LGBTIQ + people experience in their family-building journeys.

Given the institutional nature of perinatal care, our study aims to respond to two main questions as guided by Ahmed: First, how does cisnormativity operate in perinatal care settings? Second, what impacts does cisnormativity have on trans people accessing perinatal care?

Methods

This article reports on data collected in the first phase of a wider study, the Trans Pregnancy Care Project. Phase One of the project received ethics approval from the Victoria University of Wellington Human Ethics Committee in October 2021 (#0000029879).

Data Collection

Prospective participants were invited to take part in the study using purposive convenience sampling methods. Between October 2021 and July 2022, interview participants were recruited through social media and word of mouth. People were invited to participate if they were aged 18 years or older; were transgender, nonbinary, intersex, or takatāpui³ and gender-diverse at the time of accessing fertility, pregnancy, or birth care; and had accessed this care within the past 6 years in Aotearoa. This study takes a whānau-centered approach consistent with the move toward te Tiriti o Waitangi–based⁴ care in Aotearoa. Whānau-centered care is a collective approach to care that acknowledges the whanau/family as the smallest unit that accesses perinatal care (Te Tatou o te Whare Kahu Midwifery Council, 2022). This means that we invited whānau members to take part in interviews, and we worked with whānau to self-determine who accessed care. This resulted in interviews with trans people who were both gestational and nongestational parents as well as different whanau forms (see Table 1). Participants were also invited to bring non-whanau support people to the interview; however, no participants chose to do this.

Table 1. Participant demographics.

Demographic	Number of participants (n)
Gender (total response)*
Genderfluid	2
Gender nonconforming	1
Nonbinary	10
Agender	3
Trans man	3
Takatāpui	1
Genderqueer/queer	2
Transmasculine	1
Transfeminine	1
Trans woman	3
Ethnicity (total response)^†
Māori	3
Pākehā/New Zealand European	13
Other European	6
Missing	2
Age range (years)
15–19	1
25–29	7
30–34	5
35–40	6
Missing	1
Stage of pregnancy at time of interview
Trying to conceive (TTC)	6
Experienced pregnancy loss	1
Pregnant with first child	2
Postnatal (1 child ≤6 weeks)	2
Postnatal (1 child >6 weeks)	5
Postnatal (2 children or more)	1

*Note. Some participants used more than one term to describe their gender.

^†Note. Some participants used more than one term to describe their ethnicity.

GP, a nonbinary health researcher with a background in clinical midwifery, undertook 16 semi-structured interviews and AK undertook 1 (17 total interviews), all approximately 1 hour in duration. In total, 20 trans people were interviewed as part of whānau who participated in this study (some whānau included two or more trans parents). Most interviews (n = 14) centered around a trans gestational parent. Of all interviews, 13 were held over Zoom and four were held face-to-face, three in the participant’s home, and one in a public space. All participants provided informed consent. Each participant was given a $30 gift voucher in acknowledgement of their contribution to the study.

Participant Demographics

Participants were asked a series of demographic questions at the start of their interview. They described their gender in diverse and sometimes multiple ways, and most identified as NZ European/Pākehā [Table 1]. Most participants had a midwife as their LMC but had also interacted with a range of perinatal care providers including hospital-based midwives, childbirth educators, nurses, obstetricians, sonographers, general practitioners, and fertility specialists.

Analysis

Interviews were audio recorded and transcribed verbatim by an external transcriber who signed a confidentiality agreement. AK removed identifying details from the transcripts to ensure participants’ confidentiality and then sent each participant their de-identified transcript, which they were invited to provide feedback on. Eight people made minor revisions to their transcript. We received ethics approval for participants to use a pseudonym or their own first name in the transcript and publications.

Interview data were analyzed by the coauthors using reflexive thematic analysis (Braun & Clarke, 2019). First, GP and AK performed complete coding on each transcript independently and met frequently to discuss the codes. To understand how our subjectivities as researchers influenced our interpretations of the data, all coauthors coded the same part of a chosen transcript independently and then met to discuss their coding and rationale. AK manually grouped the data excerpts into a coding scheme, and all coauthors checked and used these groupings to develop candidate themes and subthemes. After identifying candidate themes, all coauthors met to discuss the candidate themes until consensus was reached on the central themes.

Trans Standpoint and Researcher Positionality

Our approach to this study was informed by trans epistemology, an emerging field that centers trans people’s voices and experiences in knowledge production about their lives (Radi, 2019). The following analysis was led by AK (transmasculine) and GP (nonbinary) and supported by SM and SB (cisgender). As a team of researchers across various disciplines including health science, midwifery, psychology, and sociology, some of whom (both trans and cis) have lived experience as parents and perinatal health care workers, we were cognizant of the different perspectives we brought to this study, based on our worldviews and social locations. The research team members comprise both pākehā⁵ and takatāpui people.

Findings

We identified seven themes, presented below in three groupings: two on the operation of cisnormativity in perinatal care and one on the impacts of these norms (Table 2). Our findings describe how the erasure of gender diversity in perinatal care worked to make participants “strangers” (Ahmed, 2012) unable to pass smoothly through perinatal care systems in ways that compromised their care and well-being.

Table 2. Summary of themes.

Theme grouping	Theme name
Cisnormative physical environments and structures	No sign of inclusion
	Gendered organization of space
	Exclusion of nongestational partners
Cisnormative language and interactions	Constant assumptions
	Being misgendered
Impacts of cisnormativity	Weighing up the risks of self-advocacy
	Undermining trust

Cisnormative Physical Environments and Structures

No Sign of Inclusion

Participants frequently commented that gender diversity was not recognized or visible within the perinatal settings they accessed. Many described seeking signs of trans inclusion in spaces such as hospital wards, clinic rooms, and antenatal classes to gauge whether these were spaces in which they felt safe to be open about their gender. Almost all participants said that they rarely found visual cues of gender diversity in perinatal care settings and described the pervasiveness of this erasure. As Brodie (nonbinary trans man, gestational TTC⁶) noted, “I mean it’s anything from signs on the walls, to the ceiling, to the application form.”

In instances where individual health care providers made efforts to be gender-inclusive, such as through neutralizing language on intake forms, participants often identified these as isolated efforts that were not reflected in the wider infrastructure of perinatal care services. Participants commonly attributed the erasure of gender diversity to the fact that perinatal systems had not been “designed” or “set up” to accommodate for gender diversity, and therefore their gender was not recognized as intelligible. As Nic (nonbinary, gestational TTC) said, “it felt like the whole way through [the fertility treatment process], the system isn’t set up for me, and I’m not legible to the system.”

Gendered Organization of Space

Cisnormativity was evident in the gendered organization of space, such as maternity wards, mothers’ rooms, and women’s toilets, which presumed that all pregnant people were cisgender women and their partners were cisgender men. Participants often mentioned how maternity wards and spaces labeled for women made them feel like they did not belong there, particularly as there was often no alternative or gender-neutral space. Some participants discussed this as creating dissonance or disempowerment for them.

[Y]ou’re in like, heterosexual and cisgender institution after institution after institution […] it was always me experiencing the discomfort and knowing I didn’t fit somehow, just that there was this odd not fitting in feeling. (Ellis, nonbinary, gestational parent)

Summer (trans woman, nongestational intending parent) also noted that the gendered division of space in the hospital brought the perception of her own gender into question: “I’m like, I’ve never been to this part of the hospital before, and I am a woman, so am I? I think I am, maybe the hospital doesn’t think I am.”

The gendered organization of space was noted by nonbinary participants in particular, who spoke about a lack of gender-neutral facilities and a failure to recognize nonbinary people in a range of spaces and interactions (e.g., childbirth education classes and on intake forms).

[T]here’s a rest room on the [hospital] ward there, but it’s got a sign on it that says that it’s for mothers only […] I was like, I’m not going to use this bathroom, which is perfectly fine, but for whatever reason you’ve decided only these people get to use it. (Rory, agender, gestational parent)

The gendered division of space caused practical difficulties and access barriers, too, such as participants having to leave the maternity ward to use a gender-neutral bathroom, as Rory ended up doing, or not attending childbirth education classes to avoid being misgendered. Scout (Takatāpui, gestational parent) described the decision not to attend childbirth education classes because they “didn’t want to be in a room full of mums and dads.”

Exclusion of Trans Nongestational Parents

Several trans nongestational parents described feeling excluded when they were not perceived to be a parent or were misgendered. For example, some participants were mistakenly assumed to be a support person or made to feel like a “chauffeur” (Taylor, nonbinary, nongestational TTC) rather than being actively involved in their partner’s care. For some nongestational parents, this sense of alienation from perinatal care disrupted the level of support they felt they were able to give their partners and their own emotional connection with the family-building process. Pax (nonbinary, nongestational TTC) described being excluded from the fertility clinic while their partner underwent in vitro fertilization treatment due to COVID-19 rules that privileged cisgender heterosexual couples’ access:

I was sitting there on the floor outside waiting and these like happy couples are going in and out of the [obstetrician’s] office across the hall, holding hands, with their babies […] and maybe if I was a guy at least my sperm would be there […] because I don’t have any physical involvement in it I’m not allowed to be there, and so it’s just so fucking rough.

The division of gestational and nongestational parents based on gender was also evident in participants’ experiences of childbirth education classes. While a few participants described positive experiences of childbirth educators’ efforts to include trans people, some described the discomfort when being the only trans person or queer couple in classes that were designed for cisgender heterosexual couples.

[T]he difficulty was we were the only queer couple [in the antenatal class], and if we ever had to split up I was always split up and had to go with the men, and it was awful, I hated it, but I wanted to be there to support my partner but it was not pleasant at all. (Rex, nonbinary, nongestational parent)

Cisnormative Language and Interactions

Constant Assumptions

Participants spoke largely about how health care providers discussed their pregnancies and health needs in ways that assumed that all people accessing perinatal care services are cisgender. These messages were often communicated through the use of binary gendered language. Although the use of terms such as “mum” and “dad,” or language in resources, were not always directed at individual participants or their partners, they reinforced cisnormative ideas about who perinatal care is for and who belongs in these services.

[I]t just was this assumption that because I am sitting here and because I have certain anatomy features and that I am the one that gave birth to our son, thus I must be a woman, like, “we’ll just keep referring [to you] that way.” (Rory, agender, gestational parent)

Participants commonly described experiencing gendered language in perinatal care settings as confrontational. Some described visceral reactions to being misgendered and using physical metaphors, such as words being “hurled” at participants (Summer, trans woman, nongestational TTC), or each iteration of gendered language having a cumulative effect of experiencing “death by a thousand cuts” (Rory, agender, gestational parent).

Almost all participants noted a lack of opportunities in perinatal care settings to self-determine the language they use around their gender and bodies. The absence of care providers or intake forms asking about their gender was perceived to reinforce the conflation between sex assigned at birth and gender. As Ellis (genderqueer, gestational parent) noted, “it’s total erasure, that’s the thing, like there was just nothing […] no forms, no questions.”

Further, models of gender-inclusive language were largely unavailable for both participants and care providers to draw on. This resulted in some providers not knowing how to respond appropriately to a person’s disclosure of their gender. An exception to the constant assumptions was when midwives, with whom participants had an established and ongoing LMC relationship, made efforts to not assume their gender or health needs. Olly (trans guy, gestational parent) shared that “I felt that [my midwife] was going, ‘well, look at this cool strong man giving birth.’”

Being Misgendered

Almost all participants had experienced being misgendered by perinatal care providers and described their lack of surprise at the pervasiveness of cisnormative language. This was because participants anticipated that perinatal care would be a highly gendered environment, and many had experienced being misgendered in health care before. Olly (trans guy, gestational parent) described having “a lot of experience of medical professionals who have no clue what to do with my gender and will make really harmful comments.”

Although participants largely attributed misgendering to ignorance or habit, rather than ill intent, these experiences contributed to participants feeling like strangers in their own perinatal care. As Ellis (genderqueer, gestational parent) described, “experiencing the discomfort, knowing I didn’t fit somehow, just that there was this odd not fitting in feeling.” Participants’ experiences of gender-affirming care were made sense of as a catching a lucky break, rather than an expectation of their care. Lor (nonbinary, gestational parent) described the gender-affirming care from their midwife as “lucky, it just felt like sort of real one-offs, real one-offs, like lottery wins.”

Being routinely misgendered also presented participants with the dilemma of deciding whether or not to correct their care provider; some participants noted that they were concerned about jeopardizing their otherwise positive relationship with their care provider if they corrected them. For many participants, their experiences of being misgendered throughout their pregnancy care compounded the existing stressors associated with pregnancy.

[The stand-in midwife] just kept misgendering me, and “she-ing” me, and calling me “mum,” or referring to mums in general and me in that, and it was just like a real blow […] if there is something going wrong you are not the person that I want, but I felt like I didn’t have a choice. (Olly, trans guy, gestational parent)

Impacts of Cisnormativity

Weighing Up the Risks of Self-Advocacy

There was a notable tension across participants’ responses to cisnormativity and the erasure of gender diversity in perinatal care. In some instances, participants self-advocated for gender-affirming care and were willing to disclose their gender, yet described this as stressful or risky and as detracting from their ability to focus on their reproductive health needs and transition to parenthood. As Rory (agender, gestational parent) articulated:

[Y]ou walk this really thin line of how much can I push back or just how much can I not? Because I do need to ultimately let you do what you need to do and is that going to affect my care. Like if something goes wrong, is it going wrong because [the health professional] has been careless because you’ve decided I don’t matter anymore?

In other instances, participants decided not to disclose their gender as a form of self-protection, but this was largely considered by these participants as perpetuating the invisibility of gender diversity in perinatal care settings and as carrying its own emotional tax.

Several participants who attempted to disrupt their erasure through advocating for gender-affirming care assumed defensive positions such as being “always on guard” (Jesse, nonbinary, gestational TTC) or on the “front foot” (Olly, trans man, gestational parent) when asserting their needs. Participants noted a range of strategies including explaining their gender and health needs to health care professionals, asking to be referred to by their correct name and pronouns, and sending information on gender-affirming care to their health care providers ahead of their appointments.

[A]ctually I sent [the fertility specialist] an email before the appointment […] “look, I have a lot of medical trauma, these are my pronouns, this is how I identify, my body doesn’t work the same way.” (Raven, nonbinary, gestational TTC)

A number of participants spoke of the energy required to self-advocate as adding an extra layer of stress and exhaustion at an already challenging time as they navigated the significance of pregnancy and birth and, for some, experiences of discomfort about their changing body. Rex (nonbinary, nongestational parent) described how their experiences of navigating cisnormativity had a “massive impact” on their well-being and put them off future engagement with services because “there’s so many things against you.” Similarly, Pax (nonbinary, gestational TTC) reflected:

[T]he focus being on [gender] and then not the focus being on like what we’re actually there for and then you’re feeling like you haven’t (a) got the support and (b) got the attention that you need for that moment, that really important moment, and that’s actually like taking away from what we’re even there to do in the first place.

In a positive light, some participants described their willingness to invest time and energy in relationships with care providers who committed to educating themselves about, and providing, gender-inclusive care. However, participants often prioritized which care providers to educate or explain their gender to in order to minimize exposure to potential inappropriate responses. For one-off clinical encounters, participants were less likely to self-advocate than when building ongoing relationships with care providers, such as their LMC. Giuseppe (nonbinary, pregnancy loss) described a one-off encounter during their miscarriage care, “I didn’t feel safe or like there was any point disclosing about my identity […] all of that [gendered language] did make me feel, really, like I didn’t belong there, because I was really clear that I wasn’t a mother.”

Participants’ decisions not to disclose their gender in certain care encounters, however, or to concede to others’ assumptions about their gender or their relationships, were often due to their perception that self-advocacy would put them, or their babies, in an unsafe position. For some participants, the erasure of gender diversity in perinatal care services meant that it was not always clear how care providers would respond to their disclosure. Participants’ accounts of making the decision to “perform ‘woman,’” as Ellis (genderqueer, gestational parent) put it, were considered a form of self-protection. Yet in doing so, participants felt they were complicit in the stranger making process.

Undermining Trust

Participants’ experiences of having their gender erased or actively questioned typically undermined their trust and confidence in their care. The loss of trust, in turn, affected participants’ perceptions of and engagement with their care.

[Not being acknowledged as a nonbinary person] didn’t give me a lot of trust in the care we were getting there. It definitely puts me into a more cynical space where I go, I don’t know, I’m not safe to be my whole self here and because you haven’t bothered to ask, I don’t know that you’re a particularly good health professional […] I’ll take everything you say with a grain of salt. (Lor, nonbinary, gestational parent)

In some cases, participants experienced overt challenge to and denial of their gender when they attempted to make themselves known. Rory (agender, gestational parent) described a particularly distressing experience where the surgeon about to perform their cesarean section challenged the legitimacy of their pronouns. Pete (transmasculine, gestational parent) described a similar experience of denial of their gender: “Me and my partner went into hospital because I was having some issues with my pregnancy and they called out my name […] and they said, ‘no you’re not.’”

Participants also described many examples where erasure persisted despite their attempts to make themselves visible and known, due to the pervasiveness of gendered assumptions built into the perinatal system.

I did have to fill in a form and I made myself a little box of, you know, “please refer to me as ‘Mx’ and my pronouns are ‘they, them,’” and the person at reception went, “ah, thank you, we need to update our forms,” and I said, “thank you so much, that would be great.” The letter they sent out still said “she.” They still sent it to “Ms” Jesse. (Jesse, genderfluid, gestational parent)

Where cisnormativity persisted despite self-advocacy for gender-affirming care, participants described becoming skeptical or wary, and some questioned whether they and their families were safe in perinatal care. As Rory (agender, gestational parent) described, “[I had to] defend my own identity and then trust [the surgeon] with my life and my son’s life.”

The undermining of trust had both practical and emotional implications for participants as they moved through perinatal care. Some described their dread of perinatal care encounters and their attempts to minimize their engagement with services. Scout (takatāpui, gestational parent) was ill with severe morning sickness but made decisions that minimized their time in hospital: “I did everything I could to avoid [hospital-based care] including being far more dehydrated than I should have been with a tiny person.” A loss of trust also influenced some major decisions about participants’ pregnancy and birth care. Several participants discussed their preference to birth out of hospital, in environments that were affirming and self-determined rather than risking exposure to unsafe and non-affirming perinatal care environments.

[P]art of our reason for choosing a home birth was like, I don’t want to be going to hospital and having to be misgendered all the way through my birth, through this very vulnerable, exquisite moment. (Lor, nonbinary, gestational parent)

Discussion

Our findings suggest that cisnormative language, spaces, and interactions work to render trans people unknown and unintelligible in perinatal care. We have demonstrated how these processes of stranger making (Ahmed, 2012) undermine the safety and health of perinatal care services, an environment trans people must inevitably move through in the process of building their families through gestational parenthood. The experiences of erasure disrupted participants’ flow through perinatal care services when constantly bumping against gendered norms and assumptions that suggest perinatal care, indeed gestational parenthood, is not for them. Participants described the toll that encountering cisnormativity took on them, and their attempts to navigate it through vigilance, self-advocacy, and nondisclosure, as cumulatively stressful, exhausting, fear-inducing, and at times leading to a loss of trust in their care. A further, perhaps less tangible but still enduring implication is how these dynamics undermine joy for trans parents and their families through conceiving, carrying, and birthing their children. As such, our findings suggest that cisnormativity in perinatal care constitutes a reproductive injustice and that efforts to secure trans reproductive rights need to extend to these forms of what Radi (2020, para. 2) identifies as “passive eugenics.”

As discussed earlier, reproductive justice advocates claim that all people with reproductive capacity require a safe and dignified environment which upholds their right to have a child, their right not to have a child, and their right to parent children in safe and healthy environments (Ross & Solinger, 2017, p. 9). Reproductive justice is therefore an important framework for considering the specificities of trans reproduction by bringing into focus the structural and social barriers and blockages to family-building faced by trans people, who are perceived, as Radi (2019) argues, to pose a threat to the binary gender order.

Our findings highlight some important implications for gender-affirming and inclusive perinatal care provision and practice. They affirm that efforts by perinatal care providers to address cisnormativity and respond to gender diversity will likely be a positive health intervention for trans pregnant people and their whānau. It is well established that exposure to trauma, discrimination, and other stress events prior to and during pregnancy undermine the biology and health of pregnant people and their babies (e.g., Thayer & Kuzawa, 2015). Further, a growing body of research is demonstrating the significance of parental mental health to long-term family well-being and that mental distress experienced during the perinatal period can have severe long-term consequences for parents and their babies (e.g., Walker, 2022). Given that trans people are already at higher risk for mental ill health resulting from minority stress (e.g., Tan et al., 2021), perinatal services have an important role to play in reducing trans peoples’ exposure to the stress and distress resulting from cisnormativity. Our findings demonstrate that where perinatal care services do not make space for gender diversity, trans people will frequently take up the role of their own self-advocacy for gender-affirming care, often at a cost to their health and well-being. On this basis, we argue that perinatal care services need to play an active role in trans inclusion and must not rely on trans people and whānau to advocate for themselves.

Given that cisnormativity hides in the everyday routines and procedures of perinatal care, we also observe that efforts at creating space for gender diversity can be undertaken through relatively minor practicable changes to the physical spaces, day-to-day language use, and data collection systems that constitute perinatal care. However, we also observe that these changes need to be underpinned by, and in turn will reinforce, a more fundamental culture shift in perinatal care that acknowledges gender diversity. We suggest that service leadership and perinatal workforce education will likely play a critical role in facilitating this broader cultural shift but more research is needed into successful strategies for moving services toward trans inclusion. We have also found that trans people enter perinatal care with critically low expectations and report feeling lucky when their care is affirming. We urge perinatal care services to be cautious when evaluating the quality of care provided to trans people to ensure they are measuring safety and satisfaction rather than the relief resulting from low expectations of their care.

Our study contributes novel insights into the experiences of trans nongestational parents. Cisnormativity does not only work to make trans gestational parents unintelligible in perinatal care settings but also those trans people who are, or who are intending to be, nongestational parents. In this study, transfeminine, transmasculine, and nonbinary nongestational parents’ accounts of supporting their whanau indicate that cisnormativity exists within a network of norms around reproduction, bodies, sexuality, and relationships that compounded the alienation of perinatal care for trans parents. Cisnormativity is therefore closely related to repronormativity, the assumption that children are conceived through heterosexual intercourse and that both cisgender parents are biologically related to their child (Love, 2022). Similarly, the operation of heteronormativity has been documented elsewhere in literature on LGBTQ + parents’ experiences of perinatal care (Cherguit et al., 2013; Klittmark et al., 2019). We argue that a holistic view that recognizes the significance of partners and wider whānau in perinatal care, and that pays attention to the multiple intersecting norms that erase trans family-building, is needed to secure safe and healthy perinatal care environments. Due to the relatively homogenous ethnic and socioeconomic makeup of our participants, we were unable to explore the intersections of cisnormativity with racism, colonialism, or socioeconomic status in terms of perinatal care experiences and outcomes. Further research is needed to explore the intersecting axes of difference and oppression in trans peoples’ experiences of and outcomes from perinatal care.

Conclusion

It is vital that perinatal care provision attends to and challenges cisnormativity, to increase equitable access to perinatal care services for trans people. This is important, considering the likelihood that more trans people will seek pregnancy care as gender-affirming health care and possibilities for trans people to reproduce become more available. Perinatal care services should play an active role in ensuring gender-affirming and inclusive care. This will help reduce the stress and distress experienced by trans people when navigating these services. As such, challenging cisnormativity should be understood as an important intervention for ensuring a safe and healthy transition to parenthood for trans whānau. We have affirmed this as a key task in movements to secure trans reproductive justice.

Acknowledgements

This project has been expertly guided by our takatāpui trans parent advisor Scout Barbour-Evans. Thanks to Gender Minorities Aotearoa and Intersex Aotearoa for their additional guidance with this project.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Health Research Council of New Zealand under Grant ref 20/1498.

Notes

1 In this article, we use the term trans to include all people whose gender is different from the gender they were assigned at birth, including binary trans and nonbinary people. We recognize that this umbrella term encompasses a diversity of experiences and that not all people in this group use the term trans to describe their gender.

2 Whānau (plural) or whanau (singular) is a Māori concept that is often translated to “family”; however, its meaning is broader than Western understandings of family. Whānau can be self-determined and can include people who are not biologically related.

3 Takatāpui is a Māori identity (indigenous to Aotearoa New Zealand) that originally translated to “intimate partner of the same sex.” In recent years, takatāpui has been reclaimed and expanded to describe Māori of diverse genders, sexualities, and sex characteristics (Kerekere, 2017).

4 Te Tiriti o Waitangi is an agreement negotiated between the British Crown and Indigenous Māori leaders of Aotearoa New Zealand in 1840. It established the modern state of Aotearoa New Zealand. The document outlines the terms and conditions of British settlement and assures tino rangatiratanga (Māori sovereignty) for the indigenous people of Aotearoa.

5 Pākehā is an indigenous term in te reo Māori describing people who are non-Māori, living in Aotearoa New Zealand. The term usually applies to people of European descent but depending on context can include people from various ethnic and cultural backgrounds.

6 Trying to conceive.