Pregnant transmen and barriers to high quality healthcare

A transman presents for prenatal care with a planned, desired pregnancy and no underlying medical issues. Clinicians caring for him are initially unable to initiate a pregnancy episode in the electronic medical record (EMR) secondary to his legal designation as male, and must change the gender marker in the EMR to female in order to document the pregnancy. This situation illuminates the systemic challenges faced by transmen seeking health care, especially in the area of obstetrics. This article will review language used to define the trans* community, highlight trans* healthcare disparities, review the context in which transmen receive perinatal care, discuss what is known about their experiences, and make recommendations for improvement in healthcare systems to eliminate barriers to safe, effective, and culturally-competent care. University of Iowa, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa University of Iowa Hospitals and Clinics, Department of Obstetrics and Gynecology, Iowa City, Iowa University of Iowa Hospitals and Clinics, Department of Family Medicine, Iowa City, Iowa The Trans* Community Defining the Trans* Population Trans* is an all-inclusive term that captures any individual with an internal gender identity that differs from the sex they were assigned at birth. These individuals can identify as the “opposite” gender (i.e., man or woman), as agender (i.e., genderfree, non-gender, genderless, or ungendered), as multiple genders (i.e., bigender or pangender), or as fluctuating genders (i.e., genderfluid or genderqueer). Many of these identities have recently evolved in conjunction with a greater societal understanding that gender identities fall along a spectrum, as opposed to a strict binary (female versus male). Cisgender individuals, conversely, are those whose internal gender identity is congruent with the sex they were assigned at birth. Transmen are defined as individuals who were assigned the female sex at Proceedings in Obstetrics and Gynecology, 2015;5(2):3 Pregnant transmen and healthcare 2 birth, but identify with a masculine experience of gender. Historically, a transman desiring medical means to affirm their gender has been referred to as a “female-to-male (FTM) transsexual.” However, this designation reflected a binary gender system prior to the evolution of newly defined nonbinary gender identities. The terms transman or trans* masculine allows for a diversity of experience within the community that at times includes the molding of the female/male gender binary into a gender spectrum. To reflect this increased variability, many trans* individuals have adopted the term “affirm”, as opposed to “transition”, as it more accurately conveys a sense of becoming one’s true self, as opposed to changing who one is. The gender affirming process, and, by extension, the involvement of healthcare professionals, differs for each trans* individual. Cross-sex hormones, gender-affirming (“top”/”bottom”) surgeries, pronoun/name changes, among other things are not a mandatory part of this process. Hence, the extent of medical intervention is determined by however much is required to treat an individual’s gender dysphoria. Gender dysphoria replaced the term Gender Identity Disorder in the 2013 updated fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnosis of gender dysphoria requires the presence of chronic distress and disability that trans* individuals often experience while living as a gender inconsistent with their internal gender identity. It is important to distinguish the difference between gender dysphoria and gender nonconformity. Gender non-conformity is a non-pathologic, normal variation in gender expression; it is not always accompanied by feelings of distress or dysphoria. Given that not all trans* individuals undergo gender-affirming surgeries including removal of their reproductive organs, healthcare providers must remain aware of the risk factors associated with a trans* individual’s biological sex (e.g., breast and cervical cancer for transmen, prostate cancer for transwomen, etc.), along with an awareness of the health-related risks specifically associated with the trans* community. Furthermore, many choose to preserve their fertility. Transmen, specifically, can discontinue testosterone treatment, which may lead to a resumption of the ovulatory process and a return of fertility. The details of pregnancy in transmen, along with the associated healthcare delivery considerations will be discussed in greater detail below. Estimates of the Trans* Population A meta-analysis of 12 prevalence studies found the overall calculated prevalence of “transsexualism” was 4.6 in 100,000 individuals. Many of the studies included in this meta-analysis, however, have been criticized for using inadequate surrogate variables. In response to these critics, one review study utilized mathematical models to account for the sampling errors, calculating that the overall prevalence of trans* individuals is likely between 1 in 500 to 1 in 2000. Proceedings in Obstetrics and Gynecology, 2015;5(2):3 Pregnant transmen and healthcare 3 Historically, studies have calculated prevalence by varied, yet insufficient means. Suggestions for accurately calculating prevalence would require sampling all persons in a given area with a two-part question: “what sex were you assigned at birth?” and “what gender most closely aligns with your internal sense of gender?” While a difficult task, an accurate estimate of the prevalence of trans* individuals is essential for the adequate allocation of resources for trans*-specific healthcare needs. Trans* Healthcare: An Overview