After having their first child, Zoë Williams had what they call “horrible dysphoria issues.”

“My medical doctor kept telling me I had postpartum depression and anxiety, but I knew it was not that,” Williams said. “On a decent day with dysphoria, the feeling is almost wearing shoes on the wrong feet. It is uncomfortable to do pretty much anything, but I can get through it. On bad days, I feel like I am stuck in a fight between my heart and my body.”

Pregnancy—when your body undergoes significant and sometimes very rapid changes—can be especially difficult for trans and otherwise gender-nonconforming people. “I’ve felt some degree of dysphoria during all three pregnancies,” Williams said.

Most conversations surrounding trans birth and parenting—when they exist at all—center on the struggles of trans men. The vast and complex nonbinary community, of whom Williams is a part, doesn’t tend to be as visible. With more people actively identifying along various points of the gender spectrum, those in the community say, the medical establishment frequently has trouble keeping up. And, as in any area of reproductive health-care services, this isn’t simply a matter of gender: Race, class, and geography can play a huge role in whether nonbinary people are able to access inclusive, affirming birth care.

Pregnancy and birthing can be incredibly complex, vulnerable periods in people’s lives, particularly at a time when bodily autonomy is constantly under attack. Pregnancy is also highly gendered; stalwarts of the feminist movement talk about it within the framework of “women,” which excludes some pregnant people and can also silence women who don’t have access to these life experiences.

Regardless of gender, pregnant people share some common goals: They want to find the health-care providers and setting that will support a healthy pregnancy and allow them to have a supportive birthing experience. This includes making decisions about who to include on a care team—obstetricians, certified nurse-midwives, midwives, doulas—and where to give birth. But these issues can be more fraught for trans and otherwise gender-nonconforming people, who have to navigate a layer of health-care discrimination to get there.

Will health-care providers respect my gender? How much will I have to educate them about my body? Will people around me use the correct pronouns and respect my choices for my children? Will my doctor provide me with tools to help me manage pregnancy-related dysphoria, if it arises? Will I get support for breast or chestfeeding, if I choose to pursue it? These are the kinds of questions trans people, including nonbinary parents, ask themselves—and the answers aren’t always satisfactory.

Failure to affirm and respect gender during perinatal care can have a tremendous impact on physical and psychological well-being. Gender-affirming care can improve health outcomes for patients, while misgendering can cause psychological harm. In a detailed study on trans health–care discrimination, 50 percent of participants reported that they had to educate their own care providers about trans health, while 19 percent were denied care on the basis of their gender status. Being “out” radically increased the risk of discrimination.

This is one reason why Peregrin Winkle had their hospital birth without disclosing their status as a nonbinary person. Winkle, who felt isolated in a care environment centered around women, said they “gritted [their] teeth and dealt with the misgendering silently.” At the time, Winkle didn’t know finding a trans-friendly provider “was an option.” Williams, meanwhile, chose a home birth, in part to have access to care providers they could educate about their needs.

Even when individual care providers have pursued LGBTQ-centric education, pregnant people may meet with multiple care providers over the course of perinatal care, and sometimes don’t even know who will be delivering their babies when the day comes. Many birthing centers and hospitals adopt a rotational schedule, rather than calling in specific providers.

This is a concern for Rebekah Viloria, an OB-GYN at Fenway Health, an LGBTQ-focused health center in Boston. Her work has included conducting education and in-service training at Beth Israel, their hospital affiliate, to create a safe environment for her patients, down to adopting gender-neutral language in postpartum care and on hospital forms. But few medical practices are grounded in LGBTQ health like Fenway is—many care providers are unfamiliar with these issues, and some are uninterested in educating themselves.

For some, pursuing care through midwives and home birth can be one way to try to ensure a more affirming experience. It may be easier to locate a trans-inclusive provider (especially in urban areas, with a large distribution of midwives and birthing collectives) this way, and some people may also feel more comfortable birthing at home. But Marinah Valenzuela Farrell, a Phoenix-based midwife with a practice rooted in indigenous family tradition, says midwifery can feel inaccessible for some people of color, trans people, and disabled people.

“What ended up happening was that in Canada and in the United States, [midwifery] almost disappeared, and then it got colonized. It was completely stomped out and then got repackaged by white people who had access and privilege, and who could fight the system,” Farrell said. She’s heartened by signs of change, including a movement for more inclusiveness among younger generations of midwives, as well as the reclamation of indigenous midwifery in the Americas.

But, Farrell cautioned, “midwifery is expensive, especially homebirth midwifery. If insurance covers it, it’s [often] out of network.”

Even with midwives and collectives working to bring costs down, patients might not be able to afford home birth—or be aware that it’s an option available to them.

For others, hospital birth is the only, or best, available option. Working with a trans-inclusive doula or a hospital-based midwife in those cases can empower people at a time when they may feel vulnerable, but it doesn’t relieve nurses and doctors of their duty of care. Williams provides formal training to birth care providers, and said that using gender-neutral language and asking for the names and pronouns people use, regardless of identification or names on insurance cards, is both welcoming and a subtle nod to nonbinary patients looking for a practice where they will feel at home. They also suggest investing in training for providers to ensure that everyone at a facility is trans-competent, or working on getting there.

Viloria adds another important note for health-care providers as they approach trans patients. In pregnancy care, there’s a lot of touching, especially while birthing: “There is touching to be able to see when you’re ready to push, someone or myself will need to check the vagina or check the cervix, but that means putting a gloved hand into the vagina.”

In many hospitals, that happens fast and without discussion or consent, which can be traumatic for anyone, but especially for a trans person dealing with acute dysphoria, particularly a nonbinary person who may be surrounded by misgendering or disrespect. Some trans and otherwise gender-nonconforming patients find touching of or discussion about their genitals very upsetting, as it can evoke dysphoria or memories of past trauma. When unexpected or nonconsensual contact takes place in the context of a highly emotional situation, like a delivery room, it can exacerbate distress—which isn’t good for the laboring patient or the baby.

Viloria says she makes an effort to communicate and establish consent during care, but she also starts earlier: by having multiple conversations throughout pregnancy with patients, preparing them for the experience of labor and delivery, and working to make birthing a safe and affirming experience for them. In some cases, that may include an elective cesarean section for patients who feel unprepared for vaginal birth.

She also addresses the role of dysphoria in trans pregnancies, starting with pre-conception counseling with trans patients considering pregnancy and continuing through to postpartum screenings. “At every visit, I ask: ‘What have you noticed? How has your body changed? How are you feeling?'”

Ultimately, meeting pregnancy care challenges for nonbinary people—as well as trans men—may rely on the development of a trans-inclusive framework, in which respect for gender and trans bodies runs throughout a hospital, clinic, or other health-care facility: so normalized that the kind of discrimination many trans people face today is unusual. That requires both interest in training to mitigate bias and the availability of quality education.

It is also vital to remember that a care team that considers issues like respecting names and pronouns, consulting with patients before touching them, and using language about genitals and gender that affirms the desires of patients can create a respectful environment for everyone on the gender spectrum. This applies to hospital, birthing center, and home birth settings. As Farrell notes, many corners of midwifery are still filled with rhetoric about moon goddesses, woman power, and other yonic imagery that’s a turnoff for some cis women, and actively alienating for many trans people.

This issue is likely to amplify in coming years with a more visible nonbinary community, as well as a more active movement to reframe the way we look at pregnancy and birthing. Trans people—binary and otherwise—are some of the biggest stakeholders in the conversation, and they’re contributing with inclusive birthing classes and provider training in addition to working as care providers themselves.

But change isn’t possible without willingness to do so from the inside, such as placing trans people in leadership positions, and openness to reframing core educational documents and teaching approaches. And a change that benefits only the most privileged is no change at all—something advocates like Farrell say should ground the work of everyone, including midwives, doulas, and OB-GYNs.