Stigma, reproductive and mental health among transgender and gender diverse individuals

<p dir="ltr">Background</p><p dir="ltr">Transgender and gender diverse (TGD) individuals are exposed to widespread stigma since they break gender norms dictating that all individuals should identify, look and behave according to binary gender expectations determined by the sex they were assigned at birth. The positioning of TGD individuals as abnormal and inferior is used to marginalize and control them, diminishing their access to resources and autonomy. The stress that stigma entails harms their mental health, causing important health discrepancies. On a structural level stigma against TGD individuals is present in discriminatory laws, policies and negative population attitudes that systematically disadvantage them or fail to protect their rights. This includes legislation that enforces mandatory sterilization before legal gender recognition can be approved. It remains unclear how legislation and population attitudes affect European TGD individuals health care encounters and ability to build a family. Moreso, the health care needs of gestational TGD individuals require further exploration.</p><p dir="ltr">Aim</p><p dir="ltr">The broader aim of this thesis was to explore how structural stigma affects health care seeking behaviors, health care encounters and the ability of TGD individuals to build a family and sustain their mental health as parents. A secondary aim was to deepen the understanding of gender dysphoria, stigma exposure, mental health concerns and health care needs among gestational TGD individuals to support law reforms and improve the mental health and quality of care for TGD individuals.</p><p dir="ltr">Methods</p><p dir="ltr">This thesis includes four studies involving quantitative and qualitative methodologies. Studies I and II are qualitative. They explored the experiences of TGD individuals who have undergone pregnancy and childbirth in Sweden after mandatory sterilization was removed from the law on legal gender recognition. The studies used inductive thematic content analysis based on face-to-face interviews.</p><p dir="ltr">Studies III and IV are cross sectional. They mainly used multilevel logistic regression to assess the association between country level structural stigma and individual outcomes among TGD individuals living in Europe. These studies relied on a composite index, measuring structural stigma at the country level based on legislation and population attitudes. Two large scale cross-European surveys on discrimination provided the individual level data.</p><p dir="ltr">Results</p><p dir="ltr">Study I: Health care providers in gender-affirming, antenatal and obstetrical care were perceived to regard pregnancy and masculinity as incompatible. Participants were systematically marginalized in reproductive health care, experienced microaggressions, and a lack of knowledge. They took the lead to ensure that their health needs were met. Former sterilization regulations compromised trust and expectations on health care providers, limiting disclosure. The quality of care was inconsistent.</p><p dir="ltr">Study II: The ability to sustain gender congruence during pregnancy was central to participants. Gender norms, gender dysphoria and the coming out process affected family planning. Pregnancy and masculinity could be reconciled by renegotiating the feminine connotations of pregnancy, accessing gender- affirming treatment, dissociating from the pregnant body and hiding the pregnancy. Peer interactions contributed to resilience. Body changes and interpersonal stigma strained participants mental health, making it harder to handle microaggressions and claim their gender identity.</p><p dir="ltr">Study III: Country-level structural stigma varied greatly across countries in Europe and was negatively associated with access to gender-affirming care and positively associated with gender identity concealment in health care. Gender identity concealment was associated with a lower exposure to discrimination in health care in lower and higher structural stigma countries.</p><p dir="ltr">Study IV: Parenthood prevalence among TGD individuals in Europe was 8.3%. There was no statistically significant association between country-level structural stigma and parenthood. Biological parenthood was twice as common among participants AMAB than AFAB. The odds ratio of biological parenthood differed according to gender identity. Parenthood status and structural stigma did not predict depressive symptoms.</p><p dir="ltr">Conclusions</p><p dir="ltr">Structural and interpersonal stigma affect trust in health care providers, limiting disclosure of clinically relevant information and access to gender-affirming care. Structural stigma marginalize gestational TGD individuals in reproductive health care, exposing them to health risks. Health professionals are at risk of conflating legal and medical boundaries when making decisions. To support health equity policy makers should eliminate structural stigma against TGD individuals. Meanwhile clinicians can empower TGD individuals who wish to undergo pregnancy by supporting their gender congruence and mental health. Further research is needed to assess the influence of structural stigma on TGD family building and parental health.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Falck, F.</b>, Frisén, L., Dhejne, C., & Armuand, G. (2021). Undergoing pregnancy and childbirth as trans masculine in Sweden: experiencing and dealing with structural discrimination, gender norms and microaggressions in antenatal care, delivery and gender clinics. International journal of transgender health. 22(1-2), 42-53. <a href="https://doi.org/10.1080/26895269.2020.1845905">https://doi.org/10.1080/26895269.2020.1845905</a></p><p dir="ltr">II. <b>Falck, F.</b><b> A. O. K.</b>, Dhejne, C. M. U., Frisén, L. M. M., & Armuand, G. M. (2024). Subjective Experiences of Pregnancy, Delivery, and Nursing in Transgender Men and Non-Binary Individuals: A Qualitative Analysis of Gender and Mental Health Concerns. Archives of sexual behavior. 53(5), 1981-2002. <a href="https://doi.org/10.1007/s10508-023-02787-0" rel="noreferrer" target="_blank">https://doi.org/10.1007/s10508-023-02787-0</a></p><p dir="ltr">III. <b>Falck, F.</b>, & Bränstrom, R. (2023). The significance of structural stigma towards transgender people in health care encounters across Europe: Health care access, gender identity disclosure, and discrimination in health care as a function of national legislation and public attitudes. BMC public health. 23(1), 1031. <a href="https://doi.org/10.1186/s12889-023-15856-9">https://doi.org/10.1186/s12889-023-15856-9</a></p><p dir="ltr">IV. <b>Falck, F.</b>, Smart, B. D., Frisen, L., & Bränstrom, R. (2025). Structural stigma, parenthood patterns and depressive symptoms among transgender and gender diverse individuals across 30 countries in Europe. International journal of transgender health. 1-17. <a href="https://doi.org/10.1080/26895269.2025.2537879" rel="noreferrer" target="_blank">https://doi.org/10.1080/26895269.2025.2537879</a></p>