Two weeks ago I attended the 11th annual Philadelphia Trans-Health Conference, a gathering of individuals, advocates and health providers focused on health topics for trans and gender non-conforming people. At the same conference two years ago, I was the sole doula on a panel about parenting while trans and gender non-conforming — and the only person at the conference talking specifically about pregnancy and birth. This year, we had an entire panel dedicated to the topic, with four trans and genderqueer-identified birth workers — two midwives and two doulas.
This shift in attention toward the issues facing trans and gender non-conforming pregnancy is indicative of a bigger shift overall — more and more trans and gender non-conforming people are giving birth. As Pati Garcia, a Los Angeles doula and midwife-in-training put it during our panel: “We’re on the cusp on a trans baby boom.”
Trans health as an overall field is still in its nascency. Our understanding of hormone therapies, gender reassignment surgeries, and much more is still being developed, so it’s no surprise that the field of pregnancy and parenting for trans people is also new and developing. Only in November of last year did the American College of Obstetrics and Gynecology (ACOG) issue a statement regarding treatment of trans patients. It says:
To address the significant health care disparities of transgender individuals and to improve their access to care, ob-gyns should prepare to provide routine treatment and screening or refer them to other physicians, according to The American College of Obstetricians and Gynecologists (The College). In a Committee Opinion published today, The College also states its opposition to gender identity discrimination and supports both public and private health insurance coverage for gender identity disorder treatment.
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It was heartening to see the governing body of this field of medicine acknowledge the needs of the trans community in regards to gynecological and obstetric care, but also indicates the bigger problem beneath that call to arms: very few providers are equipped to provide care to the trans community. If their association has to implore them to simply treat trans patients fairly, their members aren’t likely receiving training on the needs of trans people specifically. While there is a growing body of providers who specialize in care for the trans community, they remain a tiny minority. Those who do provide such care might specialize in hormone therapies, or gender reassignment surgeries, but not necessarily care like pap smears and pregnancy.
Within the needs of trans people in pregnancy and birth is the challenge of addressing what seems like an obvious connection: between pregnancy and femaleness. Trans people are often neglected in the arena of pregnancy and birth because of the strongly-held notion that only female-identified people experience pregnancy and birth. While not all trans people, whether they were assigned female at birth or not, can experience pregnancy (because of infertility or hysterectomy), some can and do, prompting the need for our pregnancy and birth providers to accommodate.
It’s not easy, as it’s a process that is intensely gendered. Everything from maternity clothes to the language of health care providers carries the assumption that the pregnant person identifies as female (and often that the other parent identifies as male). Language is an obvious barrier from the get-go: maternal health, pregnant women, all of the language associated with pregnancy and birth is gendered. From body parts to actors, all is coded in a way that would make a pregnant person who is not identified as a female feel uncomfortable.
Beyond the question of language, though, is the possibly more important issue of adequate care. For as little as we know about hormone therapies and gender reassignment surgeries, we know even less about their impacts on pregnancy and birth. I recently met a young trans man who had gotten pregnant accidentally while on testosterone therapy —his missing period and other indicators made him falsely believe he was safe from pregnancy. Questions of how top surgery might affect breast-feeding, how long before attempting to get pregnant should someone stop testosterone, the impacts of gender surgeries on fertility — all of these areas remain questions that few have evidence-based answers to.
These gaps are the exact reason that conferences like Philadelphia Trans Health were created, to at the very least allow members of the community to gather and share resources. Over the years, providers have joined in, and it’s heartening to see the growing knowledge about trans health needs, even if it’s mostly anecdotal. Until trans health is centered and prioritized though, providers will have to tailor their care to each individual’s needs, which for many means leaving our assumptions at the door.
ACOG puts it well: “We need to make our offices settings that treat all patients with respect. We want the transgender community to know that we, as ob-gyns, care about their health.”