Key findings: Phase One

Theme One. “It’s amazing how low the bar is we’ve set”:  Low expectations of care

• Participants commonly entered perinatal care with low expectations that they would receive care that was affirming and inclusive of trans people and whānau.

• Low expectations were informed by previous negative experiences of healthcare and awareness of the gendered assumptions surrounding pregnancy and reproduction.

• Having low expectations often meant that participants anticipated and feared that perinatal care would not be a safe or inclusive space for them or their whānau.

Theme Two. “Look at this cool, strong man giving birth”: Creating a bubble of trans affirming and inclusive care

• Participants were proactive in seeking out an LMC who would provide trans affirming and inclusive care, or least one who was open to learning.

• Securing care from a supportive LMC was described as a protective bubble providing some but not total protection from negative and harmful experiences in the wider perinatal system (see also Theme 3).

• Participants feared their LMC not being available, and many described inconsistent care beyond their LMC, especially when receiving hospital-based care.

Theme Three. “This odd not fitting in feeling”: Systemic and interactional cisnormativity in perinatal care

• Participants described encountering pervasive binary gender norms that made them feel out of place or excluded from perinatal care settings.

• These binary gender norms were evident both structurally in perinatal care (e.g., in the physical environments of services) and in participants’ interactions with care providers beyond their LMC bubble, particularly when participants were hospital inpatients.

• The impacts of not feeling seen or able to be oneself in services included losing trust, questioning quality of care or being worried about future care, disengaging from care, loss of joy, and not disclosing their gender.

Theme Four. “Being a witness in the room of how somebody’s being treated”: Advocating for trans affirming and inclusive care

• Participants advocated for themselves and their whānau using a range of strategies when their care was not experienced as affirming and inclusive.

• Self-advocacy was experienced by many participants as a mental/emotional labour that adds layers of stress and exhaustion to the perinatal period.

• Participants expressed relief and gratitude when their LMC or another trusted provider advocated on their behalf for inclusive and affirming care provision, and addressed overt discrimination, particularly when they were hospital inpatients.

Theme Five. “I want to engage, it brings me joy, I feel seen”: The characteristics of affirming and inclusive care for trans people and whānau

• Many participants described aspects of perinatal care that was safe, welcoming, affirming and inclusive for them and their whānau and/or could imagine what this kind of care would mean for them.

• Providers who deliver this care demonstrate common characteristics. They are ‘knowledgeable about and aware of gender diversity’ and they are ‘self -reflective and culturally humble when working with trans people and whānau’.

• Participants described or imagined how safe, welcoming, affirming and inclusive care improves perinatal care experiences, engagement, and outcomes for trans people and whānau.