Illustration by Angelica Alzona.

Midwifery care is steeped in a cisgender and heteronormative worldview. Traditionally, when a midwife offers support to a pregnant person, she (there are midwives of all gender identifications, but I’ll default to “she” here) might remind them they will be a great mom, that the female body is a tremendous wellspring of womanly power. It’s not uncommon for a prenatal caregiver to warmly refer to a pregnant woman as “mom.” But what if you don’t intend to be a mom? What if “femininity” doesn’t form a part of your gender identity, despite being in possession of a functioning uterus?

For queer and trans people, the social dimension of childbirth is a sticky wicket, but with supportive caregivers it doesn’t have to be. While at the triennial congress of the International Confederation of Midwives this month, I attended a standing room-only symposium talk by Registered Midwife Cora Beitel, who co-founded the Strathcona Midwifery Collective in Vancouver, which plays an active role in advocating for queer and trans families. Over the past four years, Strathcona has cared for approximately 15 trans-identified pregnant clients or partners, some of whom had traveled far in order to be cared for in an accepting environment. Most of Strathcona’s trans clients opt for a home birth to protect their birthing environment, but hospital transfers or outpatient visits present challenges that Beitel and their team take seriously.

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“The act of getting pregnant and giving birth is held so tightly as a female domain,” said Beitel. “Pregnancy and birth is a physically and emotionally vulnerable time, and that experience can be heightened when your gender identity does not conform with societal norms. As a health care provider we are trying to create a safe and affirming environment for clients who share this experience.”

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In the interest of disclosure, Beitel is one of my oldest friends. We grew up on the same block in Montreal. They were the first of my friends to have kids—we were both 21 when their son was born. By the time it was my turn to have a kid, Beitel had become a midwife. They helped me through the birth of my first son—without them I know my experience would have been immeasurably harder—and today they are at the forefront of the movement to make childbirth inclusive and safe for queer and trans people.

At the conference, Beitel was joined by Trevor MacDonald, a trans man who lives with his partner and two kids on a small farm in Manitoba. Trevor is a writer who has done research and advocacy work for trans parenting in Canada. MacDonald came out as trans in his early 20s, and began taking testosterone. He also had chest masculinization surgery—which does not preclude one from nursing down the line, albeit with a possibly reduced milk supply.

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“One interesting effect that I did not anticipate was that transitioning allowed me to have room in my life for wanting to have a family,” said MacDonald. “I had never dreamed that I wanted to have children. I didn’t even have a partner before I transitioned… When I started taking testosterone, and those physical characteristics began to match how I felt inside, I fell in love with somebody. I met a partner who I married. Honestly, surprisingly soon after that, we realized that we wanted to raise kids together. So then I stopped taking testosterone. My cycles returned regularly. I talked to my family doctor about doing this, and our plans to maybe conceive. He said, quite simply, a lot of people want to have a family, and you should take folic acid. That that was it! I spoke to my endocrinologist about it. And they said, well, when your cycles become regular then I think it would be safe to conceive.”

Beitel remarked that taking testosterone is not birth control. “You can conceive while you’re on testosterone,” said Beitel. After the talk, I followed up with them about this. “There is no reason why transgender people aren’t low-risk obstetric patients,” Beitel said to me, slowly, so that I would get every word down. “There may be other health concerns that are also at play. If you were assigned female at birth, but you now identify as male, and you’ve taken hormone replacement—there are implications, like not making a full milk supply, or experiencing body dysphoria, or having specific birth requests, like a home birth or a cesarean. But as far as being a low-risk pregnancy, there is no reason why that would not be the case.”

MacDonald has interviewed some 22 trans people who have given birth about how their bodies responded to pregnancy, and found that there was a variety of ways that people’s bodies reacted. “Some kept the facial hair throughout pregnancy despite stopping testosterone. Others, the facial hair fell out and did not grow back in during pregnancy. Some who had chest surgery grew a lot of new chest tissue during pregnancy, others didn’t. It really varied. Health care providers often had a hard time believing that I had stopped taking testosterone because my facial hair hadn’t fallen out,” he said.

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This caused some fundamental complications for him right from the start. “I knew early on that I really wanted to have a midwife,” he said. “The idea to me of walking into a hospital, in labor, and trying to explain to every single person I met who I am, was very scary to me. So I called the intake number for a midwifery practice. And the admin person said to me, ‘Congratulations, but I will need to speak to your wife or girlfriend.’ And that was the first person in a long, long line that I would have to come out to.”

Beitel’s clients have shared stories of painful discrimination at outpatient clinics and hospitals. Strathcona goes into what Beitel calls “high-gear advocacy” when a client seeks outpatient care, often calling ahead with a client’s permission to inform the ultrasound clinic or hospital that the patient in question is a trans man and to expect a male-presenting pregnant patient. During a hospital transfer, Beitel and their colleagues try to brief nurses and doctors about caring for a trans patient at every shift change. “Sometimes you’ll go through multiple shifts, and each time a new person comes in, we try to take a moment with them in the hall to let them know who the patient is,” said Beitel.

“People are often assumed to be the partner, and they’ll be asked, ‘Where is your wife?’ It’s this situation of having to repeatedly come out,” said Beitel. “One client had to give a urine sample at a hospital, but the only bathroom he had access to was the women’s washroom, because the patient washroom is a women-identified washroom. So this was a problem both for him—a bearded man—and the women who are accessing the washroom. Why not make it a patient washroom, rather than a woman’s washroom? Why should you have to be a woman to walk into this space?” they said.

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“There was a time I had to go to the hospital—to the obstetrics floor,” MacDonald recounted. “At this particular hospital, after a certain time of night, there is security stationed at intake that you have to get past. So of course I’m asked, ‘Who are you going to see in obstetrics?’ Assuming that I’m the dad. Having to come out to security guards in front of inebriated people trying to access the hospital as well… There was no private space in which I could do this. I was pretty shaken by the time I made it to obstetrics.”

For the past three years, Strathcona Midwifery Collective has hosted a queer and trans parents’ group, and through meeting with these families Beitel has developed a heightened awareness of her clients’ concerns.

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“As a caregiver, don’t make assumptions about identity based on presentation,” they said. “As humans we are categorizing all the time—we are looking for people that we understand because we’ve seen someone else like them. But it’s really helpful to crack open those assumptions and ask, who are you? Is there anything I need to know about you that would allow me to be a better care provider to you? When you ask those questions, you get really good answers. And as midwives, we value taking time with people.”

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Beitel also practices trauma-informed care by slowing down during physical exams, and asking the client what helps them to feel safe. “We want clients to feel safe within their vulnerability,” they said.

Not all North American midwives have embraced the nonbinary approach to care that Strathcona practices. In 2014, the Midwives Alliance of North American took a public stand on using inclusive language in midwifery (including the language on intake forms, on bathroom signs, and verbally), which started a heated debate. The following year, a group called Woman Centered Midwifery wrote an open letter to MANA stating that birth is for women, and that inclusive language does a disservice to women’s place at the center of this biological process. “That brought up some feels,” chuckled Beitel. “One morning I was having my coffee, and was checking the listserv on my phone. That statement had just come out, and it was like, ‘Okay. So this is happening.’” The emerging consensus in the field is to embrace inclusivity as a tenet of fundamental human rights. In 2016, midwifery associations across Canada came up with statements supporting the use of inclusive language, but it’s very far from the norm across the field.

“Midwives have a long history of serving marginalized clients,” said Beitel. “Our philosophies of client-centered care can make us excellent care providers for transgender and nonbinary clients. And inclusive care benefits everyone.”

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More information on trans pregnancy and lactation can be found on Trevor’s blog.

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Kathryn Jezer-Morton writes about parenting for Jezebel and is based on Montreal. Find her on Twitter at @kjezermorton.