A pregnancy loss is always devastating, but those who are transgender face additional challenges in managing their physical and emotional pain.

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A 32-year-old man with obesity, Sam, arrived at the emergency room to be treated for intermittent abdominal pain that had been going on for 8 hours, according to a case described in the New England Journal of Medicine in 2019.

A triage nurse chalked this up to his “untreated chronic hypertension” and designated his symptoms as “nonurgent.”

Sam told the nurse that he was transgender, had taken a pregnancy test that was positive, had not menstruated in years, and had “peed himself” earlier that day. Yet the nurse still “deployed implicit assumptions about who can be pregnant” because she had “no clear classificatory framework for making sense of a patient” like him.

Essentially, because of deep-seated assumptions that only women can be pregnant, the fact that Sam could be pregnant just didn’t compute.

It took several hours for a physician to discover that Sam was actually pregnant and in labor. Tragically, Sam delivered a stillborn baby after no heartbeat could be found.

Even though Sam hadn’t planned or known of the pregnancy, he was “heartbroken” at the loss and had a major depressive episode. According to the 2019 article, “despite having significant dysphoria related to menstruation, he has not resumed testosterone treatment, since he prefers to have continued menses that reassure him that he is not pregnant.”

Sadly, this outcome may have been able to be avoided if the nurse had not had the assumption that men can’t be pregnant.

In reality, many people who are not women (nonbinary people, transgender men, and others) get pregnant. One 2019 Rutgers study suggested that up to 30 percent of transgender men have unplanned pregnancies.

Naturally, those pregnancies can also be lost, just like cisgender women’s. The emotional toll of a miscarriage or stillbirth is devastating for anyone, regardless of gender, but there are additional factors weighing on transgender people’s recovery from this loss.

Sam, for example, will have additional trauma to heal from because of the missed hours of care at the hospital and the experience affecting his transition.

A 2020 study published in BMC Pregnancy and Childbirth summarized interviews with Americans, Europeans, and Australians who experienced pregnancy loss and identified as men, nonbinary, gender-fluid, agender, or transmasculine. Many participants described the loss as “devastating.”

One said that he went “off the rails, absolutely nuts” after the loss. Another described it as “heartbreaking” and “terrible.” Another called it “traumatizing.” All of this could be expected of a person of any gender in this tragic situation.

But in addition to the understandable grief and trauma, many people in the study talked about lack of support from their families or medical providers.

“I got sent away. There was no offer of counseling, no ‘do you need to talk about it,’ none of that,” said one participant. Others never told their families they were pregnant all, thinking that they wouldn’t understand.

As noted in this study, and by the Australian Psychological Society, it’s important to recognize that the implicit focus on heterosexual couples in pregnancy loss services and resources can make it difficult for those with a different experience to receive appropriate care or to find connections to others with similar stories.

The authors of the 2020 study recommend hospital staff and grief counselors participate in training on how to work with this population specifically. They advocate for the importance of correctly recording and using names and pronouns in the pursuit of “ensuring that medical experiences following a pregnancy loss do not further compound the potential grief experienced by men, trans/masculine, and non-binary people and their partners.”

Friends and family also have a role to play in supporting a trans person through a pregnancy loss. Simply listen to and validate their feelings like you would for any friend, while continuing to affirm their gender identity. (Read over this advice from a therapist on what not to say to someone going through a miscarriage.)

Ben, a trans dad in Kent, England, delivered his son Nico at 16 weeks in 2018. His husband Shane Lewis-Evans, also a trans man, shared that “losing Nico was the hardest thing we’ve dealt with as a couple and individually.”

Ben went on to deliver their daughter Ariyah in 2019 and with both pregnancies the couple is grateful for the trans competent care they received: “The day we lost our son, the midwife who delivered him had a family member who was trans, so she really understood and made the worst time a little bit easier. She crossed out and wrote ‘male’ or ‘dads’ on the forms. She treated us as male the whole time as did other staff.”

One specific element they appreciated is that whenever a staff member slipped up and accidentally used incorrectly gendered language they would quickly correct themself and move on.

Ben and Shane took 5 months after losing Nico to conceive Ariyah, encouraged to try again quickly because they heard chances of conception were higher the sooner after a miscarriage you tried.

Trystan Reese, a trans dad in Oregon married to his husband Biff Chaplow, also tried again soon after his miscarriage at 6 weeks, but for a different reason.

Reese had stopped taking testosterone while trying to conceive and his mood swings from going off of testosterone and getting pregnant were what his medical provider called the equivalent of someone with bipolar disorder.

He would either need to go back on testosterone until he was ready to try again and then come off it again, and it seemed better for his mental health to just stay off of testosterone and try to conceive right away. Happily, Reese birthed their son Leo in 2018.

From healthcare response to planning a rainbow baby, trans people who miscarry have specific concerns that cisgender women don’t, but in the end, the pain of losing a pregnancy is universal regardless of the parents’ genders.

Lewis-Evans sums it up: “Trans daddies need support just like women who lose a child. There are many trans parents out there so reach out for support.”

Sarah Prager’s writing has appeared in the New York Times, The Atlantic, National Geographic, HuffPost, JSTOR Daily, Bustle, The Advocate, and many other outlets. She’s the author of two books for youth about LGBTQ+ heroes of history: “Queer, There, and Everywhere: 23 People Who Changed the World” and “Rainbow Revolutionaries: 50 LGBTQ+ People Who Made History.” She lives in Massachusetts with her wife and their two children. Learn more about Sarah here.