Title: “The Best Revenge is Living a Good Life”
Description: This dissertation explores multidimensional social support across the perinatal period among sexual and gender-diverse (SGD) childbearing individuals living in the United States. The Social-Ecological Model (SEM) of Health Promotion and resilience theory guided this dissertation. Chapter One provides an overview of emerging health disparities among SGD childbearing people and compelling evidence of their risk for mental health disparities. It also identifies our limited understanding of perinatal social support among this population — an important modifiable risk factor for adverse mental health. Thus, social support was identified as a promising topic for this dissertation that could promote perinatal health and well-being among an understudied childbearing population. Chapter Two, Childbearing at the Margins: A Systematic Metasynthesis Review of Sexual and Gender Diverse Childbearing Experiences, evaluated and synthesized data from 25 studies on SGD childbearing. Three main themes were identified (1) Systematic Invisibility: Erasure, Structural Exclusion, Discrimination; (2) Creating Personhood Through Parenthood; and (3) Resilient Narratives of Childbearing.

We found widespread structural and interpersonal harm and discrimination across the childbearing period while also emerging evidence of positive social experiences and resilience. Gaps in the literature were identified, including data on racially and geographically diverse SGD childbearing populations, perinatal support experiences beyond the healthcare context, and data derived from prospective studies. Chapter Three, “Through Our Resiliency We…Find Joy”: A Community-Placed Qualitative Study of Social Support Among Sexual And Gender Diverse Childbearing People, introduces The Study of Queer and Trans Perinatal Resilience and Experiences of Gestation (PREG). This chapter sought to understand perinatal risk and resilience among SGD childbearing individuals at the inter-and intrapersonal levels of the SEM — namely, coping skills and social support. Four main themes were identified: 1) Entering a New Season of Life, 2) Community is Family, 3) The Pain We Bear, and 4) Obligatory Resilience.

We found that this new season of life came with unique support needs and sources of support. Support systems were robust and generally diffuse. Family formation signaled a time to heal old wounds among families of origin while simultaneously a time of increased harmful experiences and sacrifices to maintain access to support. Due to a history of stigma and discrimination, SGD individuals had well-developed coping strategies that mitigated harm. They found building a family a profoundly meaningful experience that provided great joy and purpose. Chapter Four, “You’re Preparing for People to Assess Whether You Can Have Your Own Child”: Structural Failures to Support Sexual and Gender Diverse Childbearing Parents, explores social support and social needs at the community, organizational, and policy levels of the SEM to understand how structural factors support or fail to support SGD childbearing people. Three main themes were identified: 1) When Protections Fail to Protect, 2) The Burden Is on Our Shoulders, and 3) When Privilege Is Protection.

We found that despite advances in legal protection of SGD people, numerous factors undermine the ability to access protections across the childbearing journey. Thus, SGD individuals are faced with impossible choices when building their families and are forced to advocate for themselves, educate others, and pay to access structural support. Class and racial privilege may play a role in protecting SGD people from these burdens. Chapter Five summarizes the findings from the three manuscripts in this dissertation, highlighting the strength and weaknesses of the studies, and research, clinical practice, and policy implications. Taken together, the heterocisnormative framework of family formation creates structural stigma and contributes to interpersonal conflict and exclusion that may increase vulnerability to perinatal mental health disparities among SGD childbearing individuals. However, SGD individuals also demonstrated resilience by using well-developed coping strategies and robust social support networks, achieving what was for many a lifelong dream of having a family.

This dissertation provides an important contribution to the scientific literature by describing and characterizing perinatal resilience and stigma at each level of the SEM and, in doing so, provides a roadmap to inform clinical practice, policy, and future research in pursuit of promoting perinatal health equity among a marginalized childbearing population.