How doulas can help LGBTQ2 parents navigate childbirth

Kelsey Carroll remembers him well: A transgender male who, after becoming pregnant, had to legally change back to female pronouns in order to have his hospital delivery costs covered by his insurance. The process took a lot of paperwork, time and energy. He’s the type of parent Carroll specializes in assisting.

Carroll is not a social worker or a lawyer. She’s a doula—a trained companion to birthing parents. In October 2019, she founded Rainbow Doula DC, a Washington D.C.-based collective aimed at supporting LGBTQ2 parents and families through the birthing process. Although the support she provides to her clients is, in many ways, identical to what she’d give to parents outside the LGBTQ2 community, queer parents often benefit from the guidance she provides, particularly outside of the labour room.

Carroll is part of a growing network of doulas who specialize in coaching sexuality- and gender-minority parents throughout the birthing process. As birth coaches, doulas provide moral support and comfort to birthing parents during labour. They usually meet parents around two-thirds of the way through a pregnancy, at which time they often help develop a birth plan to outline details like the parents’ plans for drug use and pain management during labour. During labour, doulas offer encouragement and take measures to relieve pain and stress, and sometimes conduct postpartum visits to assist parents with breastfeeding. Doulas do not provide medical care, and while no particular licensure is required to work as a doula, many are certified by one of many organizations that offer specialized training.

The continuous one-to-one emotional support doulas provide has been shown to improve outcomes for a wide variety of women in labour—including those who are financially disadvantaged. In studies of low-income American women, doula care was associated with reduced rates of caesarean section and preterm births and near-universal initiation of breastfeeding. Doula involvement is also thought to lead to improved birth outcomes in other underserved and marginalized communities. While there is little published research about the impact of doula care on the outcomes of LGBTQ2 pregnancies, queer and trans people often struggle to find affirming healthcare and gender-variant parents frequently describe pregnancy as a deeply lonely experience. The health literacy and social support needs queer parents can face are ones doulas are well equipped to meet.

But finding a queer-inclusive doula isn’t always easy. Neither the Childbirth and Postpartum Professional Association (CAPPA) nor DONA International—two of the more prominent doula-training organizations worldwide—offer LGBTQ-inclusive content as part of standard doula training, although representatives of both organizations said they are working to improve queer and trans inclusivity in their educational materials, and CAPPA CEO Jill Reiter noted that the organization is also prioritizing improved LGBTQ2 inclusivity internally. While both organizations maintain a searchable directory of providers, only CAPPA’s allows users to search by terms such as “LGBTQ.”

It’s not enough for a doula to just “not have an issue” with LGBTQ2 people, says Laura McGuire, a central Florida doula and sexologist. “Unless they truly understand the culture, the terminology, how we have processed the world around us and how many barriers exist, how many assumptions and biases we’re fighting against on a daily basis—especially in a birthing space—it’s not really going to meet that person’s needs,” she says.

As birth coaches, doulas provide four main types of support to birthing people, Carroll says, beginning with informational support, such as reassurance about what’s normal during the stages of childbirth. Emotional support often takes the form of a caring ear during the long and often lonely hours of early labour, and physical support can manifest as massage or pelvic counterpressure to ease labour pains.

The last form of support—Carroll’s favourite—is advocacy. “In queer spaces, this one I think pops up more than perhaps in cis-hetero spaces,” she says. To her, advocacy support means understanding what her client wants during birth and speaking up on their behalf. That can mean asking medical and support staff to use parents’ pronouns, but it can also mean proactively addressing well-intentioned questions on behalf of an exhausted labouring parent. “Doulas create space in an environment where a person is under a lot of emotional stress and their partner is under a lot of emotional stress,” Carroll says, which serves as a buffer of sorts between the family and curious providers or staff. “I truly don’t blame people for having curiosities,” she says, “but the labour room is just not the place.”

Advocacy support can also be particularly important for queer parents because they’re sometimes more hesitant than other parents to speak up for themselves if something is uncomfortable or seems awry in the labour room, says Corina Tudor, director of the Toronto-based Spectrum Doula Collective. The reasons for that hesitation may vary, but Tudor says it often seems like a product of a desire to blend in. “We don’t want to make a big deal out of it,” she says. “We want to be treated like everybody else.”

A doula can facilitate other conversations and choices outside of the birthing room. Carroll recalls a couple that had grown tired of repeatedly clarifying that one partner was carrying her transgender husband’s donor-fertilized egg. In cases like theirs, having an intermediary to do some of the explaining outside the birthing room can be a welcome relief. Carroll has also helped LGBTQ2 families navigate the often tangled intersection of American state laws and insurance regulations that can have a major impact on the cost of pregnancy and delivery. She also provides families with information about regulations that vary state-by-state to facilitate decisions about where to deliver, such as those governing the legal recognition of non-birthing partners as parents, or allowing medical providers to claim religious exemptions when it comes to providing non-discriminatory care to LGBTQ2 people. In Canada, Tudor says, laws regulating family equality are made at the federal level, so there’s no real variation between provinces.

Tudor says that where LGBTQ2 families often benefit from her care is during the postpartum period, when navigating parental roles can be tricky for couples—especially when only one parent has a biological link to the child. “For a lot of people that absolutely doesn’t matter, but for some people they think it doesn’t matter…And then it seems to sort of matter,” she says. The jealousy and resentment that sometimes develops can be easier to navigate when families have heard about the complex emotions a newborn can bring before that same newborn is routinely depriving them of sleep.

In response to the unmet need they see, some doulas are creating educational opportunities to equip trainees with the skills to provide affirming care. Laura McGuire will roll out her first “full-spectrum” doula certification course this spring. The course will to train doulas to provide support to queer parents and anyone else who might feel misunderstood by healthcare providers, including people with disabilities and survivors of trauma and sexual assault.

The skill set needed to provide LGBTQ2-affirming care is “not something that people are necessarily going to just know unless they’ve really taken the time to understand all of the complexities and nuances,” McGuire says. She expects doulas who complete her program to have the tools necessary to support a broad range of people in the birth room, including people who don’t usually face structural barriers in healthcare. If they are trained to meet the needs of the marginalized and oppressed, she says, they will also be more prepared to meet the needs of people who don’t face structural barriers in healthcare.

While maintaining that focus in their work may be a matter of justice to some LGBTQ2-affirming doulas, it can also be a good business choice. In the four months since Kelsey Carroll founded her collective, she has had nine clients: “Really amazing for this type of work,” she says.

“The proof is in the numbers there. There’s definitely a demand.”