Pregnancy care and childbirth have long been considered "women's healthcare." But ob/gyns also care for many gender-diverse individuals who have babies – and they can take simple steps to affirm the identities of those patients in their practice.
Transgender people, nonbinary individuals, and those with other gender-fluid identities who have a uterus may choose to have a baby. While gender-expansive individuals have unique needs, experts say pregnancy care for these patients is not necessarily more complex.
"The biggest misconception is that it's really complicated," said Justin Brandt, MD, a maternal-fetal medicine specialist at Rutgers University in New Jersey. There is no medical reason why a transgender or gender-expansive person needs to be referred to a high-risk pregnancy specialist, but Brandt said these patients are often sent to him for their apparent complexity of care.
"The biggest challenge is addressing the social and emotional challenges that transgender people may face," Brandt told 鶹ý.
While pregnancy care for transgender patients and nonbinary individuals is not much more medically complex than the care of cisgender women, providers can focus on affirming their gender identities and addressing their social and emotional needs. Experts told 鶹ý there are four key areas to achieving that: using specific and accurate language, starting conversations early, creating facilities that are inclusive, and promoting education.
Use Specific, Accurate Language
Trystan Reese, an activist who facilitates trans competency workshops, told providers in a recent session at the Society for Maternal-Fetal Medicine (SMFM) annual meeting that they should aim to be as specific as possible when addressing gender-diverse patients.
Instead of using the word "maternal," for example, providers can talk about the specific subset of patients they are referring to, such as "perinatal," or "postpartum." Additionally, they should change language around breastfeeding to "lactation supply" or "chest-feeding" for transgender male patients to promote inclusivity.
When Reese, who is a transgender man, got pregnant a few years ago, he said that the providers who used specific, gender-affirming language made him feel the most confident in his care. For example, when Reese began seeing a new therapist at the start of his prenatal care, he expressed to her how his partner, who is a man, felt towards the pregnancy.
"She very easily said, 'Oh, many non-gestational parents have that experience,'" Reese recalled. Rather than saying many husbands, or many dads, Reese's therapist used language that included the experiences of his own family – and improved how he felt about the quality of care. "It's like she spoke my language," Reese told 鶹ý.
Start the Conversation Early
Brandt said ob/gyns should use specific language with all patients as early as possible in their pregnancies.
When physicians conduct an ultrasound around 20 weeks' gestation, expecting parents usually want to know if their baby is a boy or a girl. But Brandt, who is a member of the SMFM Diversity and Inclusion Committee and co-author of a , said the ultrasound presents an opportunity to promote use of accurate language around fetal sex versus fetal gender.
"We can say to a patient, 'we can identify whether there are genitalia that appear male or female, but we cannot identify this baby's gender. This child will tell us his or her or their gender, when this child is ready to describe how they feel,'" Brandt said.
Hospital-Level Changes
Many people with diverse gender identities do not feel comfortable in healthcare settings due to previous negative experiences. Brandt said that systems-level changes ranging from creating gender-neutral spaces to the registration process are necessary to provide quality care.
Clinical settings should establish gender-neutral bathrooms, and make nondiscrimination policies visible to promote inclusivity, Brandt said. Additionally, changing medical registration forms and using inclusive electronic health records can remove a number of procedural hurdles for transgender and gender-expansive patients.
Medical registration forms should include fields for both a patient's legal name and their chosen name, their preferred pronouns, and gender identity. Additionally, conducting a sexual organ inventory – a series of questions that allow a patient to tell providers what organs they have and how they refer to them – may help patients feel more comfortable talking about their body.
Educating Providers and Staff
Many transgender patients have to teach their providers about their medical care, and act as self-advocates. One of the reasons for this, Brandt said, is because there is a lack of training in graduate medical settings.
"Residency education lacks sufficient exposure to transgender people and transgender health curriculum in general," Brandt said. "If we can promote education among our trainees, our residents, and our fellows, when they become attendings they'll be more comfortable."
It is also important to promote workforce diversity, providing medical training pathways and leadership opportunities for transgender and gender-expansive people.
Brandt added that education and inclusivity training for all staff -- including those who are not in patient-facing positions -- is needed to improve the experiences of transgender and gender-expansive patients.
As clinicians consider promoting inclusion for transgender and gender-expansive patients, Brandt said there is no reason to think this takes away rights from other groups.
"I think we're really taking steps so that everybody who gets care can feel comfortable in the obstetrical services and the essential care that we're providing," Brandt said.