Queering pregnancy

The first thing I learned about pregnancy is how incredibly bizarre it can be, in ways that no one ever mentioned until I personally joined the pregnancy club. The second thing I learned was that, even when braced with a world of pregnancy facts, trivia, and horror stories that people were suddenly sharing with me, I was still having a more horrifying time than most. Some of this may have been due to my “elderly” maternal age and the quirks of my individual body, putting me at greater risk for high blood pressure and related conditions like preeclampsia (which I contracted).1 Some other portion seems to be heritable, given that immediate family members also recounted terrible times. This was the likely culprit behind my extreme nausea; by the time I gave birth, my clothes were falling off every part of my body that wasn't my belly. And these were just the major problems in my pregnancy. Consequently, I discovered a wide array of “normal” pregnancy symptoms early on, and in response, I often found myself doing what so many of us do in the early 21st century when confronted with dis-ease: I asked Dr. Internet. So the third thing I learned was how utterly useless most pregnancy advice actually is. In this essay, I want to discuss the origins of this uselessness and how I think we could do better by queering the way we understand and treat pregnancy. My goal is to bring pregnancy into dialogue with trans experiences, naturalizing the “queer” and queering the “natural,” and in the process, building empathy for some of the most vulnerable people in society. This explicitly includes both pregnant and trans people. So why is pregnancy advice so pointless and dismal? One reason is that we actually have very little knowledge about how medical treatments work during pregnancy. For example, Smith et al. (2020) noted that pregnant subjects were explicitly excluded from the majority of studies worldwide about COVID-19 therapies. A remaining plurality implicitly excluded them, and only a tiny fraction (1.7% of studies reviewed) directly addressed COVID-19 therapies during pregnancy.2 What is true for COVID-19 obtains for nearly everything else. This lack of research is in part because of deliberate administrative and ethical blocks that are meant to protect pregnant research participants and their prospective children. I sat on my former institution's research ethics board, so I know how hard it can be to design a useful study within those constraints. But closely connected to this (over)protective attitude surrounding research is the heightened caution many medical practitioners employ when recommending anything with even a small possibility of negative fetal effects (or with effects that are unknown). The lack of research perpetuates itself: We can never do anything because we never know what might happen. Consequently, while the quality of medical information online can be easily criticized, I ultimately did not find in-person guidance from medical professionals to be substantially more helpful than the Mayo Clinic website. In the review of COVID-19 research cited above, the authors noted that “in an effort to protect mothers and their fetuses from research-related risks, both will be placed at potentially greater risks related to the use of understudied or off-label treatments” (Smith et al., 2020, 797). Medical researchers have called for more studies involving pregnant patients to prevent these harms and afford new pathways for treatment, but so far, little has changed in terms of the number of pregnant subjects enrolled in clinical trials (Biggio, 2020; Little & Wickremsinhe, 2017). The medical community's neglect of feminine-coded suffering doubtless compounds the lack of pregnancy research, as we see with other understudied gynecological issues like endometriosis (As-Sanie et al., 2019) or pain during medication abortion (Reynolds-Wright et al., 2022). Nor is it only when dealing with issues related to sex anatomy that patients classified as “women” by doctors and researchers tend to have their pain disregarded. There is an established literature on gender disparities in pain management, and Lloyd et al. (2020) propose that this is related to stereotypes and perceptions of women as more emotional and less reliable. The advice one receives during pregnancy when asking for relief tends to be tremendously anodyne as a result of this troublesome mix of willful ignorance, restrictive caution, and an insufficient conception of pregnancy discomfort as a problem. The problems are only magnified when sufferers are racialized in addition to being marginalized by their gendered bodies. Davis (2019) calls attention to “obstetric racism,” a phenomenon that exists at the intersection of the ways that obstetric care can turn violent and racist assumptions about the kind of care that Black patients (don't) deserve within medicine more broadly. The negative outcomes of obstetric racism include, but are not limited to, higher rates of death for Black birthing parents and their children. When we try to erase suffering, we cause even more of it. But this brings me to an additional reason that pregnancy advice generally ranges from terrible to useless, more rarely stated explicitly than the others. It consists of a complex of ideas surrounding the naturalness of pregnancy, the suffering inherent to childbearing—specifically, to mothers—and a belief that prospective parents should be prepared to tolerate this misery as a necessary warm-up exercise for the constant self-abnegation of parenthood—more specifically, of “intensive mothering,” a dominant parenting ideology in Western contexts that can also structure pregnancy (Budds, 2021; Tiidenberg & Baym, 2017).3 But conception, pregnancy, and postpartum recovery occupy, at minimum, a full year of someone's life that they must somehow live through, often with too few affordances for time away from paid labor or other social or familial obligations. Moreover, discomfort and stress are not a beneficial exercise but conditions that negatively affect maternal and fetal well-being (Dunkel Schetter & Tanner, 2012). This pain too is racialized and unequally distributed. In addition to the widespread assumption that Black people feel less pain (Hoffman et al., 2016), there is also an extensive literature on the negative health effects of an extended, lifetime experience of racism (Williams et al., 2019). Black birthing parents are disadvantaged even before they conceive, and fewer doctors are willing to credit their reports of pain or sickness. So regardless of how it is justified, advice to simply “grin and bear it” does not serve anyone well. For my own part, I have been infuriated by the lack of recognition that my pregnancy experience mattered—both per se and for the health of my child—and by the fact that medical professionals are often incapable of, or unwilling to, offer anything resembling a decent quality of life to their pregnant patients. In trying to think through the depths of my anger while also solving practical pregnancy problems, it occurred to me, far too slowly, that many nonpregnant people were experiencing similar changes in their bodies due to increased levels of the same hormones or similar changes. And this is where pregnancy gets queer: I want to postulate that we can help both pregnant and trans people by recognizing pregnancy as one physical and social transition among many others that humans may experience in the course of their lives, be they medically assisted or spontaneous. My primary focus here is on connections between pregnancy and hormone replacement therapy (HRT), especially as used in transgender care, but I will briefly note that puberty, menopause, intersex care, and many other conditions also fall under the large umbrella that I want to hold up. But I focused first on HRT, probably because it was my trans friends who were already giving me much-needed perspective on my experiences by narrating their own, their partners’, and their friends’ experiences of HRT. They told me about hormonal side effects that no one had warned them about, but that they had learned of through their own experiences or via informal networks of information sharing among trans friends and peers. Such community transition support, including medical practice, has a long history (e.g., Dodds, 2022).4 I had an inarticulate sense that my pregnancy was the queerest thing I'd ever done; my queer community gave me language to express how I was transforming, how my social and physical selves were being reshaped. It also occurred to me that these hormones and their symptoms, and the advice available to people encountering them, might be dealt with very differently (and possibly more helpfully) in fora where they could be discussed absent the practical and ideological concerns surrounding pregnancy. While the discomforts of pregnancy are presented as a fait accompli, other hormonal transitions and treatments are understood as entailing side effects that can and should be minimized, avoided, or treated. Consider the wide range of hormonal birth control methods to suppress ovulation (as in pregnancy) that have been developed precisely because so many of these therapies have awful side effects, and different patients may find some formulations more pleasant than others (Barr, 2010 provides a clinical guide). Reactionaries may want to limit the availability of gender-affirming HRT and hormonal birth control as well, but even they at least superficially agree that it's important to know how these hormones affect human bodies (if only to scare people away from these treatments or justify fully outlawing them). And so I wondered: Perhaps pregnant people could learn from existing discussions of body dysmorphia and gender dysphoria, which are incredibly common during pregnancy. Pregnant bodies can morph out of recognition in ways that are visible and public, affecting how we are gendered and understood by others. Transmasculine and nonbinary gestational parents are uniquely positioned to comment on this. Nonbinary author Rhea Ewing (2022) describes transness as having prepared them for pregnancy by teaching them to negotiate hostile and disempowering medical systems, contend with dysphoria, and hold onto an awareness that feeling good about their body and hormone levels had been possible in the past and therefore would be so again. I thought specifically about Ewing's account as I wrestled with well-meaning but probably overworked nurses in the delivery ward who referred to me as “Mama,” instead of by my name. And while wrangling the discomforts of my transitional body, I thought, perhaps trans femmes experiencing breast growth because of HRT might know how to handle the accompanying pain, also experienced during pregnancy, lactation, and nursing. This all makes sense when we consider that becoming a parent, even for cis women, entails becoming a different kind of woman, whose body, social role, and gender are perceived and articulated differently. (As a trivial example, consider phenomena such as “mom jeans”—a subset of women's trousers imagined to specifically be worn by mothers, as opposed to not only other genders but other types of women.) The trans community helped me grapple with the social changes as well as the physical changes. The comparisons do not extend only to pregnancy and feminizing HRT. Rather, an array of transition and pregnancy experiences overlap across genders. Hormones can produce similar physical changes in our bodies (e.g., breast growth and pain, as mentioned already, but also redistribution of weight). Alongside these physical changes comes the need to learn new ways of moving and carrying oneself, as our bodies gain new physical and social centers of gravity. We must likewise contend with changes in how we are received by others because we have visibly masculinized, feminized, growing, (de)sexualized, or pregnant bodies. And we often need to bring healthcare professionals into our lives to help us manage these transitions and their risks. So we all—social scientists, clinicians, and people just living in their bodies as comfortably as they can—might be better served by conceptualizing all of these experiences as variations on a common human theme of social-hormonal transition, rather than as disparate phenomena. Doing so could help us share medical and social information as well as build a common language for discussing our bodies and lives across categories of “queer” and “pregnant” that are too often assumed to be at odds—that queerness precludes biological reproduction, or that pregnancy is the peak of heterosexual existence. Because pregnancy is indeed a transition—a crossing over from one sense of self, one life experience, one body, to another that will never be the same. And like all such transitions, pregnancy regenders people, making those who go through it into “mothers” through the transformative process of pregnancy and the literal rite of passage that is birth. As mentioned above, this applies even to nonbinary or transmasculine pregnancies. Krys Malcolm Belc (2021) describes his frequent disorientation as a transmasculine gestational parent who felt that his body was illegible to his midwives, his neighbors, and even sometimes himself by virtue of being a pregnant subject who refused “motherhood” as an identity or possibility. His gender meant he was not—could not be—doing pregnancy correctly. What I hope I have adequately suggested by discussing pregnancy as “transition,” and as therefore inherently queer, is that gender transitions of some degree are something most people will experience at some point and that in many instances, these transitions will be mediated by hormonal changes—endogenous and exogenous, cultural and technological—that visibly transform our bodies as we enter new social roles. By considering all of these social/hormonal changes together as similar processes, by uniting the “queer” and the “natural,” I am convinced that we only stand to gain in terms of knowledge and solidarity across marginalized communities, both scholarly and practical. In conclusion, I would like to briefly suggest some practical next steps. We can start sharing information across communities by uniting perspectives from them in our research, writing, teaching, and advocacy because useful, shared information is precisely what we lack. We should be purposefully including trans and pregnant perspectives in anthropological work wherever relevant and possible and making sure that our studies of pregnancy are gender-diverse as well as racially and socioeconomically diverse, since all of these, in all the ways that they are tangled together, impact the medical care any patient receives. We need to work to normalize living in a changing body, a transitional body, because ultimately, we all do so. Pregnant people and trans people are subject to some of the worst discrimination and violence we see in the present day, and much of that is related specifically to the facts of being trans or pregnant, of occupying a queer and changing body that discomfits others, full of unsettling possibilities. We owe it to ourselves, whether or not we ourselves are trans or queer or pregnant, to build trans and pregnant participants into research where their perspectives have been lacking, to give voice to the normalcy and familiarity of transition experiences, and to build larger communities of support. I know that will be my next project.