In 2015, 23-year-old Rollie was living in Houston. He had a great job at a restaurant and a loving boyfriend, and he was finally starting to put words to a gnawing feeling he’d had his entire life: He wasn’t a woman like it said on his birth certificate. Rollie was a trans man.

Around that same time, he began to have another type of feeling: nausea, mostly. His breasts were sore, too. He hadn’t had his period in weeks either. In other words, Rollie didn’t need to pee on a stick to confirm he was pregnant. Very pregnant, actually — when he showed up for an ultrasound appointment, his gynecologist told him he was 14 weeks along. But when they turned the monitor toward him to show him his baby and describe what it looked like — something doctors in Texas are legally required to do — Rollie looked away. It would be gone soon, anyway. In a few short days, he’d be getting an abortion.

“It was the right thing to do,” Rollie says over a late-night Skype call from the Netherlands, where he now lives. “I’ve always wanted kids, but neither of us were in any position to support one at the time.” And while making that decision can be difficult for some (and very straightforward for others), Rollie says the fact that knowing he was a man, despite presenting as female at the time, made getting an abortion somewhat of a “unique” experience.

“The ability to get pregnant and choose whether or not to have children is the literal definition of womanhood for most of society,” he explains. “So, when you’re a man, being confronted with the extremely ‘female’ experiences of pregnancy and abortion makes it really hard to ignore the parts of you that you probably wish you didn’t have. You’re just hit with this feeling like, ‘This isn’t supposed to be happening to me.’”

For Rollie, that feeling didn’t just come because he didn’t plan on getting pregnant or because he wasn’t ready to be a parent. Rather, it came about because on a “fundamental and cellular level,” he felt that what was happening inside his body “should have been happening to someone else.”

Dakota Grey, a trans man who got pregnant at 19 after a sexual assault by an abusive partner, also knows what it’s like to feel that way. And while he got an abortion before he knew he was trans, he echoes Rollie’s experience as a man grappling with an experience deeply coded as female. “It also makes people uncomfortable, to reconcile the fact that people can be men and become pregnant, because it makes them question what being a man really is.”

Within our culture’s rudimentary-but-expanding understanding of gender, pregnancy is still believed to be something only a woman will experience. But trans men and non-binary people can and do get pregnant, though inadequate research, small sample sizes and a general lack of understanding about trans people in both academia and medicine makes it difficult to know exactly how often trans pregnancies result in abortion. Preliminary data from a 2018 study of 450 trans men and gender non-conforming individuals seems to suggest that of the six percent who experienced an unplanned pregnancy, 32 percent opted to terminate it, but beyond that limited data — which fails to describe how the other 68 percent of trans men deal with their pregnancies — the important details of trans men’s abortions can be summed up with the unfortunate statement: “We don’t know.”

In fact, according to Juno Obedin-Maliver, a Stanford University OBGYN professor, trans researcher and co-director of the ongoing, trans-focused PRIDE study, the only thing we know for sure is that no two trans men’s abortions are alike. “Trans and gender diverse people are different from each other,” she says. “Just like seeing one cisgender woman’s abortion doesn’t mean you’ve seen them all, one trans man’s abortion probably isn’t going to represent all of their experiences. At the same time, while everyone’s abortion is different, it’s important to notice that these two groups have similar healthcare needs.”

Many trans men are capable of the exact same reproductive functions cisgender women are — even when taking tesosterone, pregnancy can still occur — yet trans men are often left out of the abortion conversation entirely. “There’s a huge lack of information publicly available about trans men,” explains Dakota. “And the stories that do get highlighted either praise traditionally masculine trans men, or demonize them for not following traditional masculinity, like the coverage of Thomas Beatie carrying his child.”

Beatie became a media sensation in 2007 when he was the first legally recognized man in the U.S. to become pregnant. Beatie, a “passing” trans man but for the baby bump, appeared in everything from tabloid headlines to network news to Oprah, and he was many Americans’ introduction to trans masculinity. Perhaps most difficult to process for the general public was his assurance in his masculinity and highly public assertions that being pregnant didn’t make him any less of a man. Amid the media controversy around his atypical path to fatherhood, Beatie gave birth in 2008. Dakota remembers the media circus as both his first exposure to a trans man in popular culture, and one of the few he’s observed since.

At the same time, being included in the conversation isn’t always a seamless experience. “Talking about abortion can be really uncomfortable for some trans men because of how it can conflict with their gender and all that comes with it,” says Rollie. “Some of us are comfortable talking about it, but I know a lot of guys who don’t want to go there. It’s too dysphoric sometimes.”

Dysphoria has many meanings, but when applied to the transgender and gender non-conforming communities, it refers to the disorienting feeling that the sex they were assigned at birth doesn’t match their gender identity. This can manifest physically, but also socially and on a mental, emotional and spiritual level. Not all trans people feel dysphoria, but when they do, it can feel stressful and produce anxiety.

Importantly for trans men in need of abortion, those feelings can be triggered by abortion providers themselves. “Though awareness about trans health care has evolved in the past few years, very few medical professionals are used to dealing with pregnant men, so they’re often challenged every step of the way,” says Obedin-Maliver. “I often hear about trans men feeling invisible, discriminated against and stigmatized, not just when they get abortions, but in health care in general. They often feel poorly treated, misunderstood and like they don’t belong in that space.”

Much of that has to do with the fact that many doctors and abortion providers receive little to no training on how to work with trans men. In fact, as one 2017 survey found, there’s currently no formal curriculum on the care of transgender patients in any OBGYN program in the country. That lack of training translates directly to the exam room, where the The National Center for Transgender Equality’s landmark 2015 survey of transgender Americans found that 23 percent of respondents didn’t see a doctor when they needed to because of “fear of being mistreated as a transgender person.”

This fear isn’t unfounded: The report also includes the harrowing statistic that a full third of survey respondents who had actually visited a doctor or another health-care provider in the last year “reported having at least one negative experience related to being transgender, such as verbal harassment, refusal of treatment or having to teach the health-care provider about transgender people to receive appropriate care.”

In the late 1990s, transgender man Robert Eads sought medical care to treat his recently diagnosed ovarian cancer. Eads was turned away by a number of doctors and clinicians who were unwilling to treat a transgender patient. (This discrimination is now illegal under the Affordable Care Act, but the recent passages of the Trump administration’s Title X “gag rule” defunding Planned Parenthood and a Department of Health and Human Services “moral conscience” directive that allows doctors to refuse to treat trans people based on religious beliefs could change that.) Due to the delay in being able to find a practitioner who would treat him, the cancer spread, and Eads passed away in 1999 at the age of 53. The final year of Eads’ life is the subject of the acclaimed 2001 documentary Southern Comfort.

And while Obedin-Maliver is quick to point out that overt discrimination like that doesn’t reflect all trans men’s experiences — “Some guys have perfectly safe and respectful abortions,” she says — there can also be more subtle markers of transphobia or trans illiteracy in medical spaces that confound the experience. For example, drivers’ licenses, insurance information and medical records operate almost exclusively on a binary gender system (though that’s changing in some states). And while that might not come off as intentionally transphobic, it can mean that trans men have to deal with additional obstacles during the abortion process that cisgender people don’t.

Obstacles like when you call the receptionist at the clinic for a follow-up appointment, and they won’t make one for you because your voice doesn’t sound like a “Jessica.” Or when doctors question your gender during an examination. Or when your insurance provider covers abortion services for women, but not for men. Or when your insurer doesn’t cover abortion at all. Rollie’s didn’t, and he had to pay $1,200 out-of-pocket. “It decimated my savings,” he says. Worse yet, his job let him go after he told them he couldn’t come in because he was having an abortion. His boss — who was a friend of his — told him that working through the pain was “just what you did,” and that if he didn’t show up, he’d be fired.

Many trans men also feel alienated by the distinctly “female” branding of abortion clinics and contraceptive ads. Usually, they’re things are pink, effeminate and use binary language, something that can give trans men the impression that despite being in need of these services, they’re not “for” them. “I’m a cis woman, and even I don’t feel represented by the branding of those ads and clinics,” says Obedin-Maliver. “I can only imagine what it must be like to be a trans person confronted with them.”

Planned Parenthood does seem to be the exception to the rule. According to Maureen Kelly, the Vice President for Programming and Communications at Planned Parenthood of the Southern Finger Lakes and the founder of Out for Health, Planned Parenthood’s LGBTQ Health and Wellness Program, they were motivated to fill the void in trans-literate reproductive health care after hearing stories of discrimination, and have taken it upon themselves to institutionalize trans inclusion and literacy into their program.

“What we know is that far too many providers lack training and some also lack compassion,” she says. “Many of our transgender patients have sought care from other providers prior to finding Planned Parenthood. Many share stories ranging from pain of microaggressions to outright bias and discrimination. Some even report being turned away from care. This is unacceptable. When a young man is checking in at a health center [for his] cancer screening pap test, birth control or an abortion, it’s our responsibility to make sure our staff is welcoming and our paperwork is affirming and sees the lived experience of transgender men seeking care with us.”

On their website, there are no stereotypically gendered color scheme, there is no gendered language that would suggest their services are only for cisgender women and there are multiple places where if the language doesn’t fit the context, they add an additional sentence or two directly addressing trans folks.

If a clinic hasn’t taken these types of steps — or a trans guy is still processing their gender identity and how they want to be “out” in the world — the experience of abortion can exacerbate mental health issues like depression and anxiety, says Obedin-Maliver. That’s why Rollie, like many other trans men, choose to go through the abortion process “undercover,” in what he calls his “female form.” This was relatively easy for him — he hadn’t transitioned yet, and was still presenting as a cisgender woman replete with “girl clothes,” long brunette hair and meticulously architectured cat-eye makeup that gave his doctors no pause when checking the “female” box during his intake. “For me, it meant one less burden to deal with during what was already the most difficult time in my life,” he says. “I was never going to see these people again. What did I care if they knew who I really was? I had no reason to tell them I was a man.”

Consequently, Rollie was never harassed for his gender during the abortion process. And though he was mistreated in a variety of other ways by his gynecologist and a nurse who worked in his office — the former took him off his antipsychotic medication for no reason and the latter cornered him and begged him to keep the baby — his masculinity played less of a part in his overall experience than he expected.

A bigger, less expected factor, he says, were the pregnancy hormones. Though he and his partner had always agreed he’d get an abortion if he got pregnant because he wasn’t ready to be a father, Rollie says being pregnant made him question the plans he had for himself. The emotions and physical sensations he experienced completely conflicted with his self-concept and his life plan — which, at the time, included an eventual transition — and he found himself wondering if parenthood was the right path for him after all, trans identity or not.

“Though I felt really unnatural, and like I was wearing this strange suit, there was this unexpected attachment that I felt to something that represented the most enormous fucking obstacle I could think of at the worst fucking point possible in my life,” he says. “There was nothing I wanted less at that time, but also nothing I wanted more. It was confusing, to say the least.”

Dakota, on the other hand, found abortion to be a clarifying moment around his masculinity, and something he credits for helping him eventually come out. “It was a huge push to understanding that I was trans,” he says. “It also made me become very aware of my body in a way that I’d avoided previously. I realized how much I hated any notion of ‘womanhood’ and all the parts of my body that would be described as ‘woman.’ It wasn’t the sole trigger in coming out as trans, but it was a push in the right direction.”

Obedin-Maliver says she’s talked to several trans men who found that these things helped them make sense of their anatomy, in a “finally, I understand why those are there” kind of way. Others have told her in research interviews that they were excited to know they could become parents when they were ready to, and it was comforting that being a trans man didn’t preclude them from starting a family.

“Sometimes, the feelings and processes of pregnancy can exist outside of gender,” Obedin-Maliver explains. “Same goes for abortion. It doesn’t always have to feel particularly ‘male’ or ‘female.’ Sometimes, it’s one or the other, sometimes it’s both, and other times, it’s something else entirely.” The important part, she continues, is that we try to understand what abortion is like for trans men so that we can include them in conversations about abortion policy and care.

“Trans folks present us with the possibility to expand our notions of what is medically and socially necessary and to make sure that our services are flexible and responsive to all people,” says Obedin-Maliver. “Cisgender straight folks aren’t going to be harmed in any way by making these services more accepting, inclusive and affirming for everyone, but if we do it right, trans and gender-diverse folks will feel better and get better care, too.”

The first step toward creating that kind of care, says Rollie, has to be changing the language. “Stop directing it only at women,” he says. “Stop saying all women can get pregnant, because many of them can’t. Stop saying men can’t get pregnant, because many of them can.”

One easy way to include trans and gender non-conforming people in the abortion discussion is to alter the subject of popular sayings like a “woman’s right to choose.” By simply dropping the “woman” part of that sentence, it becomes “the right to choose,” a minor edit that instantaneously speaks for everyone who’s affected by abortion, and moreover, the pro-choice movement as a whole. This is something many reproductive rights organizations have already begun to do. The National Network of Abortion Funds, for example, refers to people have abortions as, well, “people who have abortions.”

Of course, some people — including many trans men themselves — have pointed out that nitpicking over semantics isn’t the best idea during a time when cis women make up the vast majority of people being victimized by anti-abortion legislation, but Rollie argues now is actually the best time to be vigilant about language.

“We need to include all the voices we have in this discussion because at the moment, the pro-choice movement needs all the help it can get,” he says. ”This isn’t an issue of cutting us loose from the movement and justifying our exclusion because the minor changes in language some of us have requested give us too much weight. If we’re so insignificant as to be ignored, then why do some people say we’re hindering it? We must matter if we create so much controversy — and of course, we do.”