If the mantra of “do not harm” is to be carried out by medical practitioners, one area in which this can truly be practiced is in the care of transmasculine or non-binary patients who want to become pregnant or are already pregnant, according to a session from ACOG’s annual Clinical and Scientific Meeting.
Elizabeth Cronin, MD, an assistant clinical professor of ob/gyn at Brown University/Women & Infants Hospital in Providence, Rhode Island, led session attendees in care considerations for this population.
The goal was to provide attendees with ways in which they can help create more welcoming environments, help patients with local resources, and describe training considerations and best practices for serving this patient population.
Cronin began with definitions, an approach that underscored the importance of language selection in working with these patients. Sex, for example, is the presence of specific anatomy at birth that identifies biologically the male or female sex. Gender is a social construct, she said. In transgender individuals, gender identity does not align with sex assigned at birth. In cisgender individuals, gender identity does align with sex assigned at birth. Nonbinary refers to those individuals who do not identify with either sex assigned at birth.
“The desire for pregnancy should always be discussed in presence of one’s gender identity,” she said. “We need to be thinking about how we can provide the best care for all of our patients.”
Citing data from a 2015 survey, she said that one-quarter of individuals had reported they hadn’t seen a health care provider. It’s up to practitioners to educate themselves, to understand the barriers to care, insurance considerations, lack of staff or providers, individuals’ fear of being stigmatized, or being outed to employers.
Preconception counseling is not going to be a whole lot different in these patients, she said. You can begin by asking “Would you like to be pregnant within the next year?” and then take the conversation from there. They should start prenatal vitamins and track cycles.
For those who need donor sperm, do they have a partner who has sperm? The counseling can involve thinking through and helping a patient navigate all those pieces such as whether they have a partner whose sperm they can use, and how that works if they don’t. Patients should also be counseled on potentially irreversible effects of hormonal therapies they are using and the impact on fertility.
The physician will have to discuss the length of time the patient will have to be off their testosterone hormones and set realistic expectations for achieving pregnancy. Providers also will want to consider helping people to understand what local parentage laws are, what local resources there are, and especially financial considerations such as local experts who may offer pro bono services.
When it comes to serving this patient population, providers also want to think about how their facilities are designed and what signage is displayed. “Think about what do you have up on the walls? What does your paperwork say? What do forms say? Are there things you can do to change your office setting so that it is more welcoming for all?” Cronin asked.
When it comes to postpartum, will the patient want to chest feed or breast feed? Think carefully about word choice here too, Cronin advised. What phrasing does your patient prefer? “Also talk with patients about options for chest feeding if they do not get a sufficient supply,” she said. You can, for example, talk also to local lactation specialists. Who is around who could be helpful and comfortable helping? The very practice of breast feeding is gendered and women-focused, so being sensitive about the needs of a transmasculine or non-binary patient is crucial.
There also are the psychological considerations throughout the pregnancy experience, including lack of role models. Cronin said that one benefit of the pandemic has been that a lot more resources have become available, especially online. Patients also have considered home births because they feel safter at home. They need to feel that they can safely come to a hospital and feel that they will be well cared for. In terms of Postpartum depression, what resources exist? What is it like to have your body go through this? There are hormonal implications of that, and providers can help patients navigate potential issues and concerns.
One other consideration is abortion services for transmasculine or non-binary. Statistically speaking, unwanted pregnancies track with this population similarly to that of the general population. “What it would be like to obtain abortion care for someone who doesn’t identify as a woman?” Cronin asked.
Consistently training staff is one of the ways in which providers can begin to address the needs of this population. “What can I do with my staff?” Cronin asked. “Look at signage, paperwork, how can I make a restroom that is gender-neutral? Take a walk through your spaces. How gendered is my labor room? We can make sure that everyone feels more welcome in our spaces.”
She used a personal example for why training of all staff is so necessary, citing an incident with front desk staff that reminded her that training is an ongoing process. “Patients can get all the way to your exam room, and if they have been misgendered and felt isolated, no one is going to want to come back to your office,” she said.
One session participant offered a list of best practices: create and follow a protocol for noting chosen names and pronouns; have clear lines of referral for questions; appoint a point staff person who will provide guidance, assistance with your procedures; referrals to other trans-competent and safe providers of myriad services, and complaints; accountability for trans-negative responses; ongoing training and retraining as needed; and lead by example in all cases.