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If the oath “First, do no harm” is to be carried out by medical practitioners, one area in which this can truly be practiced involves the care of transmasculine or nonbinary patients who want to become pregnant or are already pregnant, according to a session from the 2021 American College of Obstetricians and Gynecologists (ACOG) Clinical and Scientific Meeting.
Elizabeth Cronin, MD, an assistant clinical professor of ob/gyn at Brown University/Women & Infants Hospital in Providence, Rhode Island, discussed care considerations for this population, providing attendees with ways to help create more welcoming environments, connect patients with local resources, and describe training considerations and best practices for serving them.
One of the best ways to do so is by understanding the following terms: sex, transgender, cisgender, and nonbinary. Sex, for example, is the presence of specific anatomy at birth that identifies biologically the male or female sex, Cronin explained. 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 aligns with sex assigned at birth. Nonbinary refers to 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,” Cronin said. “We need to be thinking about how we can provide the best care for all of our patients.”
Results of a 2015 survey, she explained, found that a quarter of individuals had reported they hadn’t seen a health care provider. It’s up to practitioners to educate themselves and understand barriers to care, insurance considerations, lack of staff or providers, individuals’ fear of being stigmatized, or being outed to employers, she said.
Preconception counseling is not going to be a whole lot different in these patients, Cronin said. Providers can begin by asking “Would you like to be pregnant within the next year?” and move the conversation forward from there. They can also have patients start prenatal vitamins and track cycles.
Individuals will need to consider if they have a partner whose sperm they can use or if donor sperm will be needed. The counseling of these patients can help them navigate this piece. In addition, patients should be counseled on potentially irreversible effects of hormonal therapies they are using and the effects 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 understand local parentage laws, available local resources, and financial considerations, such as local experts who may offer pro bono services.
Signage within facilities is also an important consideration. “Think about what you have up on the walls,” Cronin said. “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?”
When it comes to post partum, will the patient want to chestfeed or breastfeed? Word choice should be carefully considered for patient preference, Cronin advised. “Also talk with patients about options for chestfeeding if they do not get a sufficient supply,” she said. For example, have them reach out to local lactation specialists. Who is around who could be helpful and comfortable helping? She emphasized finding those people. The very practice of breastfeeding is gendered and women focused, so being sensitive about the needs of a transmasculine or nonbinary patient is crucial.
Psychological considerations must also be acknowledged throughout a transmaculine or nonbinary patient’s pregnancy experience, including lack of role models. A benefit of the COVID-19 pandemic is that a lot more resources have become available, especially online, Cronin said. She also explained the importance of making a patient feel safe and well cared for when they come to a hospital, since some patients have opted for home births because they feel safer.
And then there is postpartum depression: What resources exist? What about the physical effects to the patient? Providers can help patients navigate potential issues and concerns.
Abortion services should also be evaluated. Statistically speaking, unwanted pregnancies track with this population similarly to that of the general population, Cronin said. “What would it be like to obtain abortion care for someone who doesn’t identify as a woman?” she asked.
To address the needs of the transmasculine and nonbinary patient population, providers can consistently train staff. “How can I make a restroom that is gender neutral?” Cronin asked. “Take a walk through your spaces. How gendered is my labor room? We can make sure that everyone feels more welcome in our spaces.”
Cronin used a personal example involving an incident with front desk staff, which 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; select a point staff person to provide guidance and assistance with procedures; offer referrals to other trans-competent and safe providers of myriad services and complaints; take accountability for trans-negative responses; provide ongoing training and retraining, as needed; and lead by example in all cases.