Affirming pregnancy care for transgender and gender-diverse patients

Transgender and gender-diverse (TGD) patients who are pregnant or who are planning to become pregnant often have negative experiences accessing health care and may face barriers to care or discrimination from providers.¹ Perception of exclusion by health care providers leads 2SLGBTQ+ patients to be fearful of mistreatment and to underuse health care services.² Repeated exposure to stigma and discrimination increases the risk of negative pregnancy outcomes.¹ Education can increase competency so health care providers can provide affirming care to those identifying with diverse sexual and gender identities. Some key terminology is outlined in Box 1.^3-5

Box 1. Key TGD terminology and examples of how these concepts can manifest.

Heterosexism

• Prejudice toward a person who is not heterosexual or any act or idea that is not heterosexual

• Privilege toward people who are heterosexual

Homophobia

• Negative attitudes (including fear, disgust, or hatred), feelings, or actions aimed at individuals who have romantic or sexual attraction to members of the same sex, or homosexuality in general

• Belief that same-sex sexual attraction is contagious and threatening to the traditional family structure

• Can be cultural, institutional, personal, or interpersonal

Cissexism

• Prejudice toward people who are transgender or gender-diverse

• Privilege toward cisgender people

Transphobia

• Negative attitudes, feelings, or actions against transgender people or transness in general

Cisnormative language

• Assumes the patient and support person are both heterosexual and cisgender

  • -
    Wife, husband, boyfriend, girlfriend
  • -
    Men’s or women’s health, born male or female
  • -
    “Do you and your girlfriend use birth control?”
  • -
    Vagina, vulva, penis, testicles, ovaries, uterus, cervix, prostate
  • -
    Pregnant women; mother or father
  • -
    Breastfeeding

Neutral language

• Does not assume a certain sexual orientation or gender

  • -
    Partner(s), significant other(s), or chosen name(s)
  • -
    Reproductive and sexual health; assigned female or male at birth
  • -
    “Are you in any intimate relationships right now, either sexual or emotional?”
  • -
    Genitals, patient-named (eg, front hole), pelvic organs, internal sexual and reproductive organs
  • -
    Pregnant people, patients, or clients; parent, birth parent, non–birth parent, gestational surrogate
  • -
    Lactating, chestfeeding, pecfeeding, bodyfeeding, human-milk feeding

TGD—transgender and gender-diverse.

Terminology from Warner,³ Balsam and Heyne,⁴ and Nadal.⁵

Why is language important?

Cisnormativity is the assumption that everyone is cisgender until they say otherwise, and that cisgender is the “normal” or “correct” way to be. This leads to cissexism and transphobia, where there is privilege toward cisgender people and negative attitudes, feelings, or actions aimed at TGD people. This occurs on many levels, including interpersonally, institutionally, and structurally. Transphobia may be demonstrated by the way a transgender person is treated by another individual. However, it can also be experienced as a result of environments or policies. Examples include a physician’s office with only gendered bathrooms, or an electronic medical record that does not allow the patient’s gender to be different from what is on their health card.

Cissexism and transphobia may be heightened in the context of pregnancy, which is strongly associated with female gender for many health care providers. Gendered language is often used when speaking about pregnancy and childbirth, such as pregnant woman, mother, or maternity.⁶ These words exclude pregnant people who do not identify as women or mothers.⁷ It is also important to recognize that equating pregnancy with motherhood may exclude non–birth parents who view themselves as mothers. Lack of inclusive language can indicate to TGD patients that they are not recognized or welcomed in the clinical environments where we provide pregnancy care.

Transgender men who are considering or carrying a pregnancy seek obstetric providers who accept their gender identity and can support them throughout,⁸ as pregnancy may trigger or worsen gender dysphoria for many reasons, including physical changes that occur during pregnancy and emotional and psychological implications of carrying a pregnancy. Testosterone is contraindicated in pregnancy, so cessation of this gender-affirming hormone therapy may be distressing, both mentally and physically.⁹ It is important to focus on anatomy, and not gender, when it is appropriate.

How should we speak to and act with our pregnant and parenting patients identifying as TGD?

Case 1. A pregnant transgender man is admitted to the labour and delivery ward. His gender is recorded as female in his health record. His care providers unknowingly—but incorrectly—use she/her pronouns.

In this case, the providers used cisnormative language. There should be education for staff on inclusivity for all sexualities and gender identities, with the capacity to record the correct gender and pronouns in the medical record. It is important to sensitively communicate gender identity to all team members.

Case 2. A patient who was assigned female at birth, identifies as gender fluid, and uses they/them pronouns presents to the urgent care clinic with abdominal pain. They are taking testosterone and do not menstruate. They do not use contraception. Based on assumptions and incomplete history taking, the treating physician does not consider the possibility that this person could be pregnant.

This could be mitigated by taking a thorough sexual history that sensitively inquires about the patient’s anatomy and sexual activity and remembering that testosterone is not a contraceptive.⁸

Neutral language (Table 1)^3-5 is more inclusive for people who do not identify as male or female. Examples of neutral terms include parent, partner, and pregnant person.⁹ Pronouns can be part of a person’s gender expression. Some patients use the gender-neutral pronouns they/them or neopronouns such as ze/hir. Clinicians should ask for a patient’s pronouns and use them consistently and correctly. Neutral language can be used to refer to a person’s anatomy—for example, genitals, reproductive organs, or chestfeeding.¹⁰ It can be helpful to ask patients how they name their anatomy and to mirror those terms.¹¹ When in doubt, ask!

Table 1.

Comparison of cisnormative and neutral language: Use neutral language with 2SLGBTQ+ parenting and pregnant patients.

CISNORMATIVE LANGUAGE	NEUTRAL LANGUAGE
Wife, husband, boyfriend, girlfriend	Partner(s), significant other(s), or chosen name(s)
Men’s or women’s health; born male or female	Reproductive and sexual health; assigned female or male at birth
“Do you and your girlfriend use birth control?”	“Are you in any intimate relationships right now, either sexual or emotional?”
Vagina, vulva, penis, testicles, ovaries, uterus, cervix, prostate	Genitals, term used by the patient (eg, front hole), pelvic organs, internal sexual and reproductive organs
Pregnant women; mother or father	Pregnant people, patients, or clients; parent, birth parent, non–birth parent, gestational surrogate
Breastfeeding	Lactating, chestfeeding, pecfeeding, bodyfeeding, human-milk feeding

Terminology from Warner,³ Balsam and Heyne,⁴ and Nadal.⁵

Pregnant people who identify as TGD benefit from supports that are tailored toward their needs. This might include infant feeding classes that do not use the term breastfeeding, or programs that refer to reproductive and sexual health providers rather than women’s health providers.¹²

Conclusion

Family physicians have a responsibility to provide affirming care to TGD patients before conception and during pregnancy. This is also true if we do not provide intrapartum care. It is essential to demonstrate inclusive behaviour and to create inclusive policies and physical environments. Many health care providers associate pregnancy and childbirth with female gender, so it is important to decouple these concepts. Pregnancy can be a challenging time for TGD patients, which is why it is crucial to tailor our care to meet their needs.

We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (https://www.cfp.ca) under “Authors and Reviewers.”