Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach

Abstract

Background:

Little is documented about the experiences of pregnancy for transgender and gender diverse individuals. There is scant clinical guidance for providing prepregnancy, prenatal, intrapartum and postpartum care to transgender and gender diverse people who desire pregnancy.

Case:

Our team provided perinatal care to a 20-year-old transgender man, which prompted collaborative advocacy for health care systems change to create gender-affirming patient experiences in the perinatal health care setting.

Conclusion:

Systems-level and interpersonal-level interventions were adopted to create gender affirming and inclusive care in and around pregnancy. Basic practices to mitigate stigma and promote gender-affirming care include: staff trainings and query and use of appropriate name and pronouns in patient interactions and medical documentation. Various factors are important to consider regarding testosterone therapy for transgender individuals desiring pregnancy.

Precis:

Health care teams can create gender-affirming patient experiences for transgender men and gender diverse people in and around pregnancy through advancing changes in perinatal health care settings.

Introduction:

Pregnancy in transgender men and other gender diverse people who were female sex assigned at birth is an experience gaining visibility in medical literature over the last decade.^{1, 2, 3} Gender-affirming treatment for transgender and gender diverse people may include psychosocial support, hormone therapy, surgery, and other interventions aimed at aligning their bodies and daily physical experiences with their gender identities.^{4, 5} Common gender-affirming treatments for transgender people include testosterone, chest binding, and masculinizing chest surgery.⁵ While some gender-affirming treatments such as hysterectomy or oophorectomy eliminate fertility, transgender men may retain or desire reproductive capacity, even in the case of prior testosterone use.² Studies indicate transgender people have experienced pregnancy after undergoing gender-affirming processes and treatments (be it social, medical, or surgical) and some desire a future pregnancy.^{3, 6, 7} Only 8% of transgender people who were assigned female sex at birth have had a hysterectomy, many engage in sexual behavior that could result in pregnancy, and there is evidence to support there is an unmet contraceptive need in this community.^{6, 8, 9} Studies indicate transgender people have experienced intended and unintended pregnancy after undergoing gender-affirming processes and treatments, and many desire a future pregnancy and parenthood at different ages and stages of transition. ^{3, 7, 10, 11} For transgender and gender diverse people who desire pregnancy, there is little clinical guidance for fertilization, prenatal, intrapartum and postpartum care.

Given the dearth of perinatal guidance for transgender and gender diverse people, we share our experience caring for a transgender man during his pregnancy. With the goal of creating an inclusive, compassionate, and equitable health care experience for him and his partner and other gender diverse people, the team worked in collaboration with multiple stakeholders throughout the health care system to create new systems and transform existing ones to assure patient-centered care.

Case:

W is a 20 year old healthy transgender man who initiated gender-affirming testosterone therapy with his primary care physician 5 months prior to pregnancy. Prior to starting testosterone therapy, he was clear that he desired the option of future pregnancy and had not undergone any other gender-affirming medical or surgical treatments. He was counseled on contraceptive and fertility preservation options and risks and benefits of testosterone therapy. His gender non-binary partner was assigned male sex at birth and was living with HIV^.12

Care coordination for the couple ensured W’s partner had consistent HIV suppression and included W taking pre-exposure prophylaxis prior to and during pregnancy. The PCP sought advice on W’s testosterone use in pregnancy through consultation with the TransLine,¹³ an expert clinical consultation service which recommended stopping testosterone prior to fertilization, given the potential androgenic effects of testosterone on a developing fetus. After consultation, W subsequently decided to discontinue testosterone therapy while attempting pregnancy. Two months after discontinuing testosterone therapy, W achieved pregnancy through penis-in-vagina intercourse. W was referred to the San Francisco county hospital’s multidisciplinary perinatal HIV care team for prenatal care at 7 weeks gestational age.

During prenatal visits, W was asked preferred terminology for anatomical parts and functions (some transgender men prefer terms like frontal pelvic opening):^14,15 his preference was medical terminology (e.g., vagina, uterus). Individual health care provider and systems changes were undertaken to consistently use W’s correct pronouns - from registration, to intake with medical assistants, to health care provider visits. We notified staff and health care providers of the patient’s appropriate gender and pronouns via posting a “clinical alert” in the patient’s EMR chart. This information was also communicated to the entire care team during pre-clinic huddles.

Trainings on culturally appropriate care provision for transgender patients were conducted with prenatal clinic and labor and delivery clinical staff. Sonographers were trained to use gender-neutral language and techniques to assure an inclusive and welcoming experience during ultrasounds for this patient and all patients who follow. A social worker provided intensive case management and psychosocial support, including assisting in aligning W’s identity documents with his affirmed gender, and confirmed with the hospital’s birth certificate office that the patient and his partner could be listed as co-parents including their preferred names and gender identities. Attempts to change W’s electronic medical record (EMR) to reflect his gender identity were unsuccessful due to technical limitations of distinguishing sex and gender within the EMR system, and were further complicated by the inability of the EMR system to register an admission of a non-female patient to the labor and delivery floor.

At the end of the 2^nd trimester, W and his care team began proactively discussing future fertility, contraception, and options for resuming gender-affirming testosterone therapy postpartum. He expressed desire to restart testosterone therapy once he finished chestfeeding,¹⁶ and was unsure if or when he might desire pregnancy again. Given that testosterone therapy likely reduces significantly, but does not eliminate, the chance of pregnancy,¹⁷ he decided on a postpartum etonorgestrel subcutaneous implant for contraception. Prior to delivery, W and his partner were offered a private tour of labor and delivery as well as labor and chestfeeding preparation workshops by a health educator who had been trained in transgender-inclusive health education. He had an uncomplicated labor and vaginal delivery after spontaneous onset of labor at 40 weeks gestational age. The healthy male infant had no signs of androgenizing effects from in utero testosterone exposure. W’s postpartum course was uneventful. He initiated successful chestfeeding immediately postpartum with support from lactation consultants and nursing staff. The patient and infant attended joint post-partum and well-child visits at a family-oriented primary care clinic affiliated with the county hospital, with the family physician who also served as his prenatal provider. At approximately 12 weeks postpartum, W discontinued chestfeeding and resumed testosterone therapy.

Discussion:

Many transgender and gender diverse people have the capacity to become pregnant either through sexual intercourse or assistive reproductive interventions.^{2, 6} This case highlights the utility of engaging in discussions pertaining to reproductive autonomy and taking a comprehensive sexual history, including desire for pregnancy and pregnancy prevention, to guide appropriate medical interventions and motivate necessary system changes as part of primary care and supporting gender affirmation.

This case also highlights the need for supporting care providers to access and utilize information regarding the effect of testosterone on ability to conceive, maintain a healthy pregnancy, have healthy offspring, and chestfeed successfully. In a cross-sectional study of 41 transgender men who became pregnant, 61% reported using testosterone prior to becoming pregnant and 20% became pregnant while still amenorrheic from testosterone use.² Transgender and gender diverse patients who retain a uterus and ovaries may maintain reproductive capacity after initiating testosterone, and testosterone does not always reliably prevent unintended pregnancy.² There are no well-powered human studies examining the use of exogenous testosterone in pregnancy. It is generally theorized that testosterone may androgenize the fetus based on limited animal models.¹⁸ A small study of 147 cisgender women found that increases in levels of endogenous testosterone were negatively correlated to fetal length and weight.¹⁹ Lastly, very limited data suggest increased levels of endogenous testosterone production has been associated with delayed and decreased milk production;^20,21 though a case study found no adverse effects at 5 months of age on an infant who was breastfed by a mother who received a low-dose (100 mg) subcutaneous testosterone pellet while breastfeeding.²² Currently there are insufficient safety data to recommend the use of testosterone during pregnancy and chestfeeding, and the drug is classified as pregnancy category X by the FDA.²³

Transgender and gender diverse individuals routinely face stigma and discrimination navigating the health care system, including gender insensitivity, denial of services, and verbal abuse in medical visits.²⁴ In a national survey, 23% of respondents reported avoiding seeking care due to fear of mistreatment as a transgender person.²⁴ Prenatal care for transgender men may be further complicated by cultural beliefs of pregnancy as a “woman-only” experience. Feelings of gender dysphoria may be pronounced in the absence of testosterone use during the fertilization and peripartum period.¹⁸ Practices to mitigate stigma and promote gender affirmation throughout the perinatal process include staff trainings, query and use of appropriate names and pronouns in patient interactions and in all documentation including the EMR and birth certificate, and gender-neutral, transgender-inclusive language for patient care spaces. Please refer to Table 1 for a summary of recommendations.

Table 1:

Recommended systems-level and interpersonal-level interventions for trans-inclusive care in and around pregnancy

	Intervention	Audience
General principles:	Train and monitor that all front desk staff ask patient’s chosen names, and to respect and document pronouns	Clinic, Hospital administration
	Train and evaluate that all medical assistant and nursing staff ask patient’s chosen names and pronouns	Clinic, Hospital administration
	Discuss with clinic and hospital administration the need for transgender and gender diverse -inclusive sexual orientation and gender identity (SOGI) training and data collection for patient medical records	Clinic, Hospital administration
	Encourage all health care providers to attend focused trainings on transgender and gender diverse -inclusive health care and clinical practices	Medical providers
	Provide information and assistance to support changing and updating legal documents to reflect patient’s gender identity.25	Social work, Legal administrators (e.g., DMV, medical records personnel, durable power of attorney)
Improving the clinical environment:	Work with clinic and hospital to implement welcoming environment to diverse patient populations (e.g., display trans-inclusive signage and flyers in the clinic)	Clinic, Hospital administration, Building supervisor
	Discuss the use of gender-neutral language for spaces, consider names such as “Sexual and Reproductive Health Center” versus “Women’s Health Center”26	Clinic, Hospital administration
	Offer all-gender restrooms in clinic and hospital	Clinic, Hospital administration, Building supervisor
Preconception:	Regularly discuss patient’s reproductive desires informed by a reproductive justice framework for full spectrum contraception, abortion, and family-building	Medical providers
	Do not assume reproductive desires based on sexual orientation, gender identity, gender expression, sex assigned at birth, or family configuration	Medical providers
	When discussing hormone therapy consider medication effects on fertility; ask about current and future fertility desires before initiating gender-affirming hormones or puberty-suppressing medications	Medical providers
	Providers and staff can consult Transline: Transgender Medical Consultation Service https://transline.zendesk.com/hc/en-us or reference the growing numbers of clinical resources27, 28, 29 for assistance with clinical questions regarding transgender health care	Medical providers, Hospital and clinic staff
Pregnancy:	Offer training to enhance environment sensitivity, equity, and inclusion for people of all genders among all staff in outpatient and inpatient settings who may encounter patients during pregnancy	All staff who may encounter patients in outpatient and inpatient settings (e.g., health care providers for the prenatal patient and the infant, nursing staff, clerical staff, birth certificate office staff, radiology technicians, janitorial staff, meal service staff)
	Train sonographers regarding difference between sex and gender and use of gender-neutral language during ultrasounds for patient and fetus	Sonographers and other ultrasound clinical staff
	Prepare staff to offer patients psychosocial support if they experience gender dysphoria due to pregnancy or change in hormone therapy (body changes, more difficulty passing or being misgendered)	Social work, Hospital and clinic staff, Mental and Medical Health providers
	Routinely ask about patient experiences navigating the health care system with referral for necessary social work support	Social work, Medical providers
Approaching delivery:	Offer tour of labor and delivery unit prior to delivery in order to orient to the space and ideally meet staff beforehand	Health educators, labor and delivery staff
	Offer to speak with birth certificate office to ensure that preferred titles and names are written on the birth certificate document (e.g., able to list 2 fathers, or people with non-binary genders)	Birth certificate office
	Offer labor, birth preparation, and infant care preparation workshops with workshop facilitators trained in transgender and gender diverse inclusivity	Health educators
	Discuss contraception options using shared decision-making, consider future fertility desires	Medical providers
Intrapartum:	Refer to patient by correct pronouns during labor (e.g. referring to “parental heart rate” instead of “maternal heart rate”)	Medical providers and labor and delivery staff
	Offer capacity for non-gendered tracking of children on the labor and delivery suite and nursery (e.g. Baby Smith instead of Baby Boy Smith)	Labor and delivery, nursery providers and staff, lactation consultants
Post-partum:	Offer support for informed infant feeding including options for chestfeeding and formula feeding.30	Medical providers
	Ensure that hospital providers and staff are aware and supportive of patient’s desire to chestfeed and of safety of chestfeeding	Labor and delivery, nursery providers and staff, lactation consultants
	Counsel about contraception options in the context of future fertility desires and future plans for hormone therapy	Medical providers
	Counsel that progestin-based contraception, including the IUD and implant, are not thought to interfere with masculinization (some may enhance androgen activity), and can be used in transmasculine patients	Medical providers
	Ensure social support in caring for infant and in post-partum recovery	Social work, Medical providers
	Counsel about anticipatory guidance re: post-partum depression	Social work, Medical providers
	Discuss desire to restart hormone therapy, coordinate with desired timing and duration of chestfeeding	Medical providers

Teaching Points:

• Testosterone should not be considered a contraceptive. Testosterone may lead to amenorrhea and cessation of ovulation. However, while testosterone may reduce fertility, fertilization is possible despite prior or active use of testosterone and while amenorrheic from testosterone.

• Testosterone is not currently recommended during pregnancy due to possible irreversible fetal androgenic effects. An optimal interval between discontinuing testosterone and conceiving is unknown at this time.

• While transgender and gender diverse people previously on testosterone may adjust well to pregnancy, lack of testosterone use during fertilization and pregnancy may lead to or exacerbate gender dysphoria.

• Testosterone may be excreted in small quantities in human milk, and may affect milk production. Currently, it is not recommended to use testosterone while chestfeeding, until more information is known about the effects of testosterone use on human milk.