Episode #10: Queering Perinatal Mental Health

In this episode, we are joined by Leo Andreas (he/him) and Jenna "JB" Brown (they/he) to explore the unique perinatal mental health experiences of queer, trans, and gender non-conforming people. Leo, a dad of a two-year-old, shares his mental health experiences of his journey to parenthood. And JB, a full-spectrum doula and community educator, explains the positive impact person-centered, radically inclusive care can have on the mental health of queer, trans, and gender non-conforming people during the perinatal period. 

This episode discusses mental health issues and mentions suicide. If you or someone you know is experiencing suicidal thoughts or a crisis, please reach out immediately to the Suicide Prevention Lifeline at 800-273-8255 or text HOME to the Crisis Text Line at 741741. Additionally, the National Maternal Mental Health Hotline provides support before, during, and after pregnancy. Call or text 1-833-9-HELP4MOMS (1-833-943-5746). TTY users can use a preferred relay service or dial 711 and then 988 or 1-833-943-5746. Both services are free, confidential, and available 24/7. 

Resources: 

• National LGBTQ Task Force: Queering Reproductive Justice: A Toolkit 
• RTZ Hope: LGBTQ+ Families 
• Family Equality 
• National LGBTQIA+ Health Education Center 
• Postpartum Support International: Help for Queer and Trans Parents 
• International Journal of Obstetrics and Gynecology: LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review 
• Youth Voices Amplified Podcast (the most recent episodes cover reproductive justice and anti-LGBTQ+ laws)  
• Mom and Mind Podcast: Transgender and Gender Queer Perinatal Mental Health

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Transcript

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[00:00:00] Amani Echols (she/her): Welcome to MCH Bridges, where we lift up innovative ideas and inspiring stories from people in the maternal and child health field. My name is Amani Echols. I'm the Behavioral Health Policy Fellow at AMCHP, and I'm your guest host for today.  

Though our journeys to parenthood may be different, the feelings that come with any reproductive health experience, such as feelings associated with changes in our bodies, the lack of control over our bodies, and even grief are felt by all birthing people. That said, these feelings are often amplified for queer, trans, and gender-nonconforming people. In this episode, I sit down with Leo and JB to discuss the unique perinatal mental health experiences of queer, trans, and gender-nonconforming people and how to better care for them through the physical and psychological processes to birth and parent. 

Before we get started, I'd like to mention that this episode discusses mental health issues and mentions suicide. If you or someone you know is experiencing suicidal thoughts or a crisis, please call the Suicide and Crisis Lifeline by dialing 9-8-8. You can also call or text the National Maternal Mental Health Hotline that provides support before, during, and after pregnancy. More information about these resources can be found in the show notes! 

[00:01:42] Leo Andreas (he/him): He is very independent and strong willed, and I often wonder if he is the result of the pandemic. He has gotten me through a lot. Like I don't think I could have gone through this pandemic without him. I love him.  

[00:01:56] Amani Echols: That's Leo describing his two-year-old son. Leo is a trans person, Cuban American, and a single parent.  

[00:02:03] Leo Andreas: I'm a single parent by choice, so I had my son on my own.It was like a long process to come to that decision. On and off it took me about two years to have him, to conceive him because I had some fertility issues and things like that. 

[00:02:20] Amani Echols: Leo continued to explain how he was required to take a psych evaluation every two years to move forward with the fertility treatment.  

[00:02:28] Leo Andreas: The whole issue of the psych evaluation was because I was using the donor sperm, I needed to prove that I was of sound mind to say that I'm making this decision to use donors sperm and to do it on my own. I know it was like a 90-minute psych evaluation. It was expensive. It was like 200 and something dollars to have it done, and pretty much the whole evaluation was going over your childhood, any mental history, and making sure that you don't have any sort of mental disorders that will I guess disqualify you. 

I had to pretty much lie because, you know, I have PTSD and they also ask my family history. My family history there's a lot of mental illness in my family, so I had to lie. It was very intense because I had to sit there and talk to a psychiatrist and lie. Cause I remember sitting there and just like sweating and I'm like, I dunno if I'm gonna pass this cause I knew that any, any bit of my history would've disqualified me even though I knew I was ready for this and like I went through years of therapy before I decided that, but they, I guess I was qualified and I just went through the next process. But it was really intense. 

[00:03:44] Amani Echols: Leo's experience highlights the ways in which requiring a psychological evaluation to access fertility care can be harmful. I learned that it is common for fertility clinics and agencies to require a psych evaluation for intended parents, no matter if they are partnered or their gender and sexuality. Meaning that this requirement can be quite onerous and intimidating to most people seeking fertility care. But for trans, queer and gender nonconforming people in particular, this requirement can feel especially burdensome and discriminatory and perceived as just another barrier to prevent them from becoming parents. 

It took three failed cycles before Leo was able to conceive, and each attempt cost thousands of dollars. And at the same time, Leo expended his funds to move from taxes to New Mexico and was working at a retail pharmacy.   

[00:04:36] Leo Andreas: I also kept it a secret, so it was a mental journey for me 

[00:04:40] Amani Echols: You kept the pregnancy a secret? Who were you keeping it from?  

[00:04:44] Leo Andreas: Just everyone I knew that I was gonna face a lot of judgment because I was doing it on my own. And because I didn't have a whole lot of money, I was working in a retail pharmacy. So I felt like, and at the time I was living in my car trying to save up money too for housing for an apartment and trying to save money for the fertility treatment. 

So I knew that people were gonna think that I'm nuts, you know, for um, for doing that. And then I also was worried that it wasn't gonna work. And so like I felt like I was gonna do all this work to tell people that I'm trying and then it didn't work. And then I was also worried that something was gonna happen in the first trimester. Like even if I did become pregnant, that I was gonna lose it. Cause all of my life I thought I couldn't have kids. And so I thought that even if I got pregnant, I have to keep that pregnant a secret. Cause I felt like if I lost the baby, then I'm gonna have to deal with the fallout, like of having to tell everyone that I lost it, so I kept it a secret up until 20 weeks. About 20 weeks. Yeah. 

[00:05:46] Amani Echols: The process to create a family as queer, trans, and gender nonconforming people can be financially and emotionally exhausting.  

[00:05:58] Leo Andreas: It was, It was a lot. I, I had a really, I actually had, when I moved to New Mexico, I had a breakdown, and I became suicidal and I went into the hospital to get checked in and it was a really awful experience and luckily, um, this amazing case worker at the hospital, she kind of guided me out of that situation and she found this really amazing therapist for me. And I still have that. I've had that same therapist for like three years now, and it was through that therapist that really got me through that, that mental state that I was in. And, but it wasn't easy. It was definitely not easy. I mean, um, it took a lot of, a lot out of me to get out of that. Even, I even kept it a secret from her telling that I was trying to conceive or I was planning to conceive because I was worried that she was gonna judge me too. Because it goes back to that psych eval. I was like if I tell her what's going on. Cause I didn't, I didn't know all of the laws. So I was like, if I tell her what's going on, is she gonna report back to the fertility doctor and all that? And so I kept it a secret from her too. And I actually didn't tell her that I was planning to conceive until I was about three months pregnant. So I just, I mean, I was going to her every week and she, it was just keeping a secret. And finally, I, I sent her a text saying “Hey”. Uh, cause about nine weeks I was getting, I was trying to make it to the second trimester and I felt like I needed a therapist at that point and I needed to tell the therapist what's going on. I was so scared I was going to miscarry, so I finally did tell her at nine weeks. So it was more of an isolating experience that whole time up until I found that I was pregnant.  

[00:07:49] Amani Echols: I was curious to know more about queer, trans and non-binary people's unique period of mental health experiences. So I spoke to jb, a trans-masculine, non-binary person, a full spectrum doula, and a community educator. 

[00:08:03] JB (they/he): Yeah, I think that there are definitely aspects of queer and trans mental health around reproductive experiences and specifically pregnant that are unique to queer and trans people, and there are themes, and I think a lot of the themes that I notice really do come back to this question of how was the individual experiencing pregnancy socialized? What were they taught to believe about pregnancy in general? That might come from more of their dominant culture, upbringing, whatever their family of origin taught them about pregnancy or what they learned in school or what they learned through media, but also what have they come to learn about what it means to be queer or trans, or whatever specific identifiers they would use to describe themselves. And some of that may be integrated later on in life for many people as they come into queer community or as their access to queer community increases, and there's a lot of messaging within queer community about what really comes down to gatekeeping identity. So messaging about if you are genderqueer or trans or non-binary, but you are a person whose reproductive anatomy allows you to carry a pregnancy to gestate, and you desire that for yourself, that that makes you less, that invalidates the identity that you're claiming to some extent. And so I think that theme is really deeply internalized by a lot of people when in reality, from the standpoint of bodily autonomy, which is the foundation of both reproductive justice and the understanding of queer experience, nobody knows, uh, what that person's full expression of themselves is except for them. And nobody knows how that embodied experience, uh, overlaps and intersects with their mental health, but also their mental landscape, which includes their identity other than them.  
And so for many people, I think that theme of unlearning that messaging and self-validating and finding validation in community who have shared experience at that particular intersection of queer experience and pregnancy is one of the best supports for mental health when folks are moving through pregnancy cause I think many people feel isolated. And again, I think that is true for pregnancy and reproductive experience at large across communities, but the less that you see yourself reflected in that dominant culture narrative of what it means to be pregnant, the more likely you are to feel isolated or for that sense of isolation to be intensified. 

[00:11:04] Amani Echols: In addition to feeling isolated, Leo shared how their gender dysphoria impacted their mental health.  

[00:11:11] Leo Andreas: And through all this, like I was still dealing with my gender dysphoria, so it was like I was just floating over my body like the whole time, you know? And I was a lot of shame too, cause I'm, you know, I consider myself transgender and the whole process was, I guess emasculating like, it just, it was like an out of body experience. It felt like my body was kidnapped to, to be pregnant. It just didn't feel real. And it didn't feel real up until. I think I felt the first kick.  

[00:11:42] Amani Echols: How did you push through those feelings?  

[00:11:44] Leo Andreas: I guess mentally I had to just think that like my body is being borrowed, I guess, to get through it. Just because like I couldn't wrap my head around that there's a baby, like in my uterus I guess. Like I just, I couldn't mentally wrap my head around it, and so, the only way I can get through it was just like it's being borrowed for now and then I'll get my body back. So that's the way I just went through it all, and it didn't really become an issue until towards the end when I had to give birth and be like, be one with my body again to actually give birth to the baby 

[00:12:22] Amani Echols: I asked JB their conceptualization of gender dysphoria.  

[00:12:27] JB: Yeah so important to always just note for those who may not know that gender dysphoria is not a prerequisite for queer, trans, non-binary identity. Not all trans people experience gender dysphoria, and it's also not a experience, gender dysphoria is not an experience that is unique to queer and trans people. Cisgender people also can experience gender dysphoria, and in fact, um, many pregnant women do experience, to some extent gender dysphoria during conception, during pregnancy, during postpartum. For trans people in particular, whether or not they had uh experience with gender dysphoria prior to pregnancy, the body changes that come along with pregnancy can oftentimes, um, be a catalyst for those feelings of dysphoria. So dysphoria just meaning discomfort, but really has so much more depth than that. It's a sense of being out of place in one's gender, in one's body as it relates to their gender. And so fewer people have an understanding of what it means to move through pregnancy as someone who say has had gender-affirming surgery before, it has taken, uh, gender-affirming hormones. One, because the research isn't there, but two, because our culture just doesn't value those stories and experiences. And so there's a lot of invisibilization, there's a lot of erasure of them.  

So in the example of someone who has had top surgery, and then becomes pregnant, they may not know, even their healthcare providers may not know or fully understand, including a surgeon who performs the top surgery. None of those folks in that person's world upon becoming pregnant may have a really clear understanding of what to expect in terms of tissue change in their chest. And the reason why dysphoria in my experience, the people I work with common in pregnancy, regardless of gender identity, the body changes that happen in pregnancy are largely out of our control. Similar to when we as trans people, as non-binary people may take hormones as a part of the affirmation of our identity through medical means. We don't have control over which secondary sex characteristics may emerge as we engage with that hormone therapy. And the same goes in pregnancy. And so I think because those types of experiences run parallel, when they do start to weave together, overlap, and intersect, there is this kinda recurring theme of lack of control over one's body. Dysphoria can be intensified.  

And then of course there are other, uh, particular examples of this in terms of trans pregnancy. There is a phobia, like a medically diagnosable phobia of pregnancy that some trans people will carry. And there are also experiences that will impact the care choices that people make along the way. So, for instance, making the choice to not lactate. And so becoming pregnant, knowing that you're not going to lactate in order to feed your baby. Also having the education, knowledge, or support that your body is likely to produce milk in many cases. Um, and so here are some steps that you can take to suppress lactation, um, or making the care choice to, uh, opt not to have a trial of labor, by which I mean to go the route of elective surgical birth that may be influenced by someone's experience of dysphoria in pregnancy, that engaging with the idea of of a pelvic birth is too dysphoric, is too uncomfortable, feels like an invalidation of who they are, who they know themselves to be in their body in this very deeply embodied way that it impacts the choices that they make along the way. 

[00:16:45] Amani Echols: Leo, did you feel seen and heard as a trans person navigating perinatal healthcare?  

[00:16:51] Leo Andreas: Definitely not. And I, they didn't really, I didn't really was judged in my appointments, but I felt it, and I don't know if it was a mixture that I'm Hispanic and that I'm transgender, that they didn't hear me out or they just didn't know how to deal with someone like me. I don't know. Cause I definitely wasn't heard. Um, and I don't know, and it's so hard to tell because the month that I was gonna give, The world was in the panic.  

[00:17:22] Amani Echols: The panic Leo is referring to is the start of the Covid-19 pandemic.  

[00:17:27] Leo Andreas: It wasn't an easy two years, cause the pandemic happened, he was born March 15th and the state shut down the week I brought him home. So, but because I, I worked through all that trauma, I was able to deal with it. But I did go through postpartum depression, and so it was, it was a really tough two years. I didn't really bond with him that whole year, that whole first year, and we weren't really that close, but I feel like I'm now seeing the light at the end of the tunnel with him and, um, I'm able to parent him and have, have more patience with him and stuff like that. 

[00:18:05] Amani Echols: I'm curious, what was the turning point in which you were able to come out of your postpartum depression and begin strengthening the bond that you were hoping to create with your son? 

[00:18:16] Leo Andreas: I just came out of the fog. I mean, I literally, I came out of the fog and finally I made it back to my therapist. Um, cause I wasn't seeing my therapist at the time because of insurance reasons. And also just the realization that we're in this pandemic for a long time. Like just accepting that, that this is gonna be life. He was hospitalized a few times too and I think that brought us closer too. Cause he got sick like two or three times, and he was hospitalized two or three times. I think I just woke up. I just had that fight in me. 

[00:18:41] Amani Echols: Though mental health ebbs and flows, Leo's in a much better place now. His mental health has improved. He is in better housing, has a better job, and overall is feeling much more stable.  

[00:18:54] Leo Andreas:  I've been wanting to tell my story for a long time and so it feels really good, like I feel like it needs to be. It needs to be like, people need to hear it from my experience because my story is not unique, and I'm pretty sure other people have gone through it the same way. 

[00:19:18] Amani Echols: After chatting with Leo, I continued my conversation with JB to first discuss how reproductive loss is amplified among queer and trans people, and then also explore how to provide better care to queer, trans, and gender nonconforming people.  

JB, can you share about the amplified grieving experience queer, trans, and gender nonconforming people may experience during reproductive loss? 

[00:19:42] JB: Yeah. I think that what has really stood out to me in my work is the presence of grief in all change, and so therefore, like pretty much in all reproductive experience, pretty much in all trans experience, really human experiences is change, right? But, uh, the choices we make, that we make, who we are, and certainly whether or not we use our bodies to conceive, to gestate, to birth, to parent, all of these things revolve around change. And so when it comes to pregnancy loss in particular, I think that is for many people a fairly obvious touchpoint of grief in the realm of reproductive experience.  

For a trans person or for queer person who has been socialized to believe to some degree, based on messaging from various channels, that queer people should not be pregnant, should not parent. That there's something, uh, inherently wrong with that. When they've integrated even the tiniest bit of that messaging, even if like, you know, using their thinking brain, they know that's not true. It's something that's reinforced everywhere. We think about something like marriage equality, which in the United States marriage equality's been around for several years now and yet marriage equality does not protect second-parent rights for queer family. So in the case where, um, a queer family has a child and one person gestates the pregnancy and the other does not, whether or not that other person has contributed genetic material to the pregnancy, marriage equality does not protect their parental rights of that child necessarily. There's no federal law that protects that. To me, that's a reinforcement of that narrative that queer people should not parent. That is legislatively information that may reinforce that messaging that again, comes through media or family or the church or wherever, that there's something perverse about queer people being around children, that there's something perverse about a trans person using their body to gestate. So that's something that's being reinforced constantly. And so it's very likely that for a trans person, for a non-binary person, for a queer person who experiences a pregnancy loss, that that is somewhere inside of them, that learning. And so the experience of a pregnancy loss an experience that again may already be recognized as one that is associated with grief has the potential to validate that messaging.  

There's a lot of self-doubt and blame, and so that kind of self-doubt and blame when coupled with these other underlying queer trans experiences, can really translate to, I'm not supposed to be pregnant as a trans person, as a non-binary person. Everything that they said about me wanting to do this was true. I was wrong, and they were right, which may not always be conscious, right? That's not always happening at the level of conscious awareness. It has immense impacts on the experience of grief. It definitely makes it harder for a person to move with and through their grief to seek support for that grief. Like if you don't know that that is something that is specifically happening for you, that the reinforcement of that messaging is happening, how do you know to ask for support and validation around that?  

And again, the reason why care work is so important and doula work is so important and that work being relationship based and identity affirming and experience affirming, and person-centered, all of that is so vital because in the absence of that meaningful relationship, whether that is a relationship with a care worker or a peer who has shared lived experience, there may be to that person no space for them to articulate all of those interwoven threads of their experience of grief around pregnancy loss, and they might be right in assuming that there's no place for them to express that. There are very, very few mental healthcare providers who are both trans-affirming in like a really real grounded way and also understand reproductive experience and mental health. That's like a pretty tricky place to find, and then you add in insurance and state-by-state licensure and it's, it's like, whoa you really have your work cut out for you to find a mental healthcare provider who can help you out in that moment. 

[00:25:03] Amani Echols: Thank you for that response. I'd love to learn more about how you provide the best individualized care. What does identity-affirming care look like to you, or what do you think of when you hear that term?  

[00:25:18] JB: I think a lot of the time the conversation around identity-affirming care, particularly when it comes to serving, um, queer and trans people and families can get really stuck on things like pronouns and um, language, and certainly that's a part of it. But really what I think of when I think of identity-affirming care is person-centered care, person-affirming care. And a great thing often say this when I'm doing consulting work or continued education work for providers around trans-affirming practice is that these approaches benefit everyone that we serve regardless of their gender identity, regardless of sexuality or family structure because what it really comes down to is being non assumptive, never assuming that even as a provider of care, whether that's community care or clinical care. Never assuming that we know more about what someone's experiencing or what they might need than they know themselves.  

I think the key component of identity-affirming care and person-centered care is that it's relationship based. There's not ever going to be a check box list that you can go down and know that you're doing a good job at being identity-affirming or person-centered, and I think that can be pretty uncomfortable for many people because there isn't always that feedback or validation that we're used to getting in more formal care delivery systems or even professional settings. When we're oriented around relationship and the work that we do, it's ongoing, it's fluid, it's dynamic, and so identity-affirming care and person-centered care to me come down to a concept that I, uh, refer to as “compassionate neutrality”, which is when we're approaching these relationships and building these relationships at a slow pace so that trust can build part of being non-assumptive means that we're really showing up with compassion for the person in a way that someone could disclose something to me, someone could share something with me. Whether that is something like disclosing that they're pregnant or something like disclosing that they're in active substance use. And my response, regardless of my social socialization around how I am quote unquote supposed to respond to information like that, is going to stay very neutral until I have the opportunity to ask reflective questions of that person and know what feedback they're looking. 

I think that is really significant, especially when it comes to something like queer pregnancy, where to provide identity-affirming care to someone who say is uh, trans and has been actively trying to conceive and has just found out that they're pregnant. Our socialization might be to respond to that news that they're pregnant with “congratulations”. Because we know that they have been trying, and we know this is something they wanted, but the reality is that in order to really be identity-affirming and person center moment, the best response is one that is more neutral, which is “how are you feeling now that you are pregnant?” And if they're excited about it and want to celebrate it, they’re going to tell you that. And if you've built a strong relationship that is founded on trust and they're all of a sudden feeling doubtful or feeling conflicted or feeling multiple things at once, they're probably going to disclose more of that complexity to you. But I think so often we bulldoze in our attempt to provide identity-affirming care or person-centered care because we think, oh, as long as I'm using this person's pronouns, and as long as I have an understanding of what it takes to become pregnant if you're trans, and as long as I'm affirming of their partner partners, then I'm doing it. I'm doing the thing. I'm identity-affirming. But really that's just one sliver of who a person might be and what they might need. And it's also based on the conflation of this idea that there's universal experience amongst people who share that identity, that there's a monolith. And so we can follow this monolithic formula in order to be identity-affirming. That's just really never the case. 

[00:29:56] Amani Echols: Compassionate neutrality is a new term for me, so thank you. And my last question is, what drives and energizes you to engage in this care work? 

[00:30:08] JB: In terms of what continues to fuel my drive for this work, I mean, I will be honest. This work is really exhausting and most care workers, most doulas burn out fairly quickly. My mentors, uh, Laura Interlandi and Erica Livingston of Birdsong Brooklyn, um, talk about doulas being a bandaid on a broken arm, which has always really hit home for me. We're seeking to fill gaps that are really like massive structural systems gaps in the ways that we show up for people, in the ways that we care for people. American culture in particular is just so lacking when it comes to serving families. It's really important to have something that like revives passion, uh, for this work. And I talk about relationship a lot as a foundation, uh, to doula work into this type of care work. Not only because I believe that is the like key to showing up in the ways that are actually of service to the people in our communities. In the absence of relationship, I don't really think we're doing much in terms of filling those gaps. But also because the relationship is what keeps me going.  

I love the best thing about my work is witnessing people with whom I have had the opportunity to grow a close, trusting relationship. Witnessing those people in a moment of realization of, Oh my God, I can do this. That's what keeps me coming back is those close relationships and those moments that happen over and over for people as they go through changes and as they experience grief. Along with those changes there are wow, like these thresholds that self-actualization and sometimes we get to watch their kids cross those thresholds too, and like that is just the most beautiful.  

[00:32:25] Amani Echols: I definitely just felt my body warm as you were explaining that, and it's so refreshing to hear your emphasis on relationship building, especially within the last couple years where, you know, we've all felt at times very distant from each other and lacking those intimate and special relationships that keep us moving forward. I just really appreciated hearing that at the end of our conversation.  

It was such a pleasure to speak with you, JB. Thank you so much.  

[00:32:48] JB: Awesome. Thanks, Amani! 

[00:33:03] Amani Echols: Maternal and child health is not solely about cisgender woman creating families within a heterosexual relationship, and birth is not just a physical process but a psychological journey as well. Leo and JB made this very clear. As a queer, black, cisgender woman myself, I constantly question my visibility within the field I work and if the healthcare system is equipped to meet my unique needs when I decide I want to become pregnant. 

The desire to receive person-centered care, birth without fear of poor birth outcomes, and know that your journey to parenthood and family are seen, valued and respected by society and within the healthcare system is a lot to carry for many queer, trans, and gender nonconforming people. This load positions us to experience unique perinatal mental health challenges. 

For the MCH field, acknowledging the existence and meeting the needs of queer families means confronting the gender binary, social norms, and our role in protecting the full spectrum of reproductive healthcare. I am so grateful to Leo and JB for sharing their stories and experiences with us on this episode. My hope is that the voices, leadership, and needs of queer, trans, and gender nonconforming people are prioritized now and in the future of maternal and child. 

[00:34:36] Maura Leahy: Thank you all for joining us on this MCH Bridges. We kindly ask that you take a few minutes to fill out a quick feedback survey and let us know what MCH related topics you're interested in and who you want to hear from on future episodes. A link to the podcast feedback survey as well as the transcript of this episode can be found at www.mcbridges.org. 

Be sure to follow AMCHP on social media. We're on Twitter and Instagram @dc_AMCHP. We hope this episode created new connections for you. Stay well, and I hope our paths crossed on the next MCH Bridges. 

This project is supported by the Health Resources and Services Administration or HRSA of the US Department of Health and Human Services or HHS as part of an award totaling $1,963,039 with 0% finance with non-governmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.