Supporting transgender and gender-expansive individuals in reproductive health care

Justin S. Brandt, MD. Assistant Professor, Rutgers Robert Wood Johnson Medical School

Kacey Eichelberger, MD. Chair, Department of Obstetrics & Gynecology
University of South Carolina School of Medicine Greenville/Prisma Health-Upstate

Trystan Reese. Founder, Collaborate Consulting, LLC

Melissa S. Wong, MD MHDS. Assistant Professor, Maternal-Fetal Medicine
Cedars-Sinai Medical Center

During a roundtable at the Society for Maternal-Fetal Medicine’s 42nd Annual Pregnancy Meeting, held virtually, participants engaged in 2 case-based discussions that highlighted opportunities for practitioners to improve the care and reproductive health experiences of people with diverse sexual and gender identities in various settings. Roundtable leader Justin Brandt, MD, was joined by Trystan Reese, Kacey Eichelberger, MD, and Melissa Wong, MD, MHDS. Reese is an author, transgender man, and LGBTQ+ advocate.

Wong presented the first case:

You are the residency program director at the start of the new academic year. One of the volunteer private practice physicians with whom your residents rotate for 1 month, has asked to speak with you regarding your intern Sam, a transgender woman. She states that she is very supportive of Sam, but her staff have expressed concerns about having the resources to chaperone during physical exams (which they do for male residents). In addition, she says her patients seem uncomfortable, so she wonders if the remaining weeks could be spent shadowing another physician. How do you respond to this?

“Sam is a transgender woman and has unique needs in the health care system, as a clinician and as a provider. It’s very important to support people of diverse gender identities when they are in medical care, so that patients can look to their doctors and…see themselves reflected in those people and have greater trust and support. How can we be more supportive of Sam first before we talk about how we can address the concerns of Dr. Desai?” asked Brandt.

A first-year residency intern chimed in to share her perspective. “In my program, we have to have a chaperone for every single resident who sees a patient. I would be uncomfortable having my identity perhaps outed to patients…by having a dichotomy of male residents needing a chaperone, whereas female residents do not. That would be the first place I would want to start.”

Reflecting on current policies and practices may lead to positive change, Reese said. “We have an opportunity when a trans person comes into a space to say, ‘Oh, why are we doing it this way?’ Often, if it doesn’t serve one person, it’s not serving a lot of people.”

“I’m wondering whether Dr. Desai is actually using her staff as an excuse for her own discomfort,” another participant said. “It seems like one of the important conversations with Dr. Desai is about recognition and acceptance of diversity of all kinds, and whether it's transgender, race, ethnicity, age or size, as a private practice physician in a teaching group, she would need to put that in perspective.”

The idea that Dr. Desai may be harboring unintentional bias is not uncommon, according to Reese. “When I work with providers for whom this is true, it’s not conscious. She likely doesn’t know she is [most likely] projecting her own discomfort about having this person on her team, and she is seeing concerns where there aren’t any.”

“I so loathe to compare a transgender experience to other experiences of marginalization, because they're all obviously extremely different,” Reese said. “But sometimes, using the power of empathy can help you see that there are some pretty clear, specific, and effective ways of grappling with challenges.”

The second case, presented by Eichelberger, touched on the issue of inclusive language: pregnant women or pregnant people. The case illustrated a worry that, in moving toward inclusion, we are losing some aspects of medical accuracy and specificity.

During departmental grand rounds on COVID-19 vaccinations in pregnancy, the invited speaker consistently uses the expressions “pregnant people” and “pregnant person.” During the Q&A session, a thoughtful member of your faculty thanks her for her presentation and expertise, and then notes the following: I've been practicing as an ob-gyn for 25 years and truly love my patients, including two trans men who I've been fortunate enough to take care of. That said, I'm becoming more and more alarmed about the erasing of the use of the word “women” in our field. I just feel like we fought so hard to get where we are as women's health specialty, why can we not say “pregnant women” anymore without being accused of being non-inclusive? It feels like “woman” is becoming almost a bad word these days, and I just don't like it. How do you respond to this?

“In the obstetric world, it doesn't come just with taking the woman name out of pregnancy. It comes with education and knowledge and images of inclusivity,” a participant said.

“We have seen sometimes the alternative of ‘women and others’ and ‘women and other individuals’ needing obstetric care. I like that it's more specific and it addresses the concerns presented in this case. But we're literally using the word ‘other,’ which seems to be exactly what we're trying to avoid,” another participant said.

Another participant posed the question of fear, and through a conversation she had with another practitioner, discovered that the issue may be deeper seated. “What do you think is going to be lost? What is your worst fear?” Ultimately, it boiled down to a deep-seated issue—gender-based trauma. “It was really about the ways that men have seeped into every aspect of places that have felt safe for women and have taken it over and taking credit for it and spoken over.”

“For so long, only one group has had to be uncomfortable. Only the marginalized group,” Wong said. “It’s okay for us to be uncomfortable.”

Reference

1. Brandt J, Eichelberger K, Wong M, et al. Optimizing Reproductive Health Experiences and Outcomes for Transgender and Gender Expansive Individuals. Luncheon Roundtable. 2022 Virtual SMFM Annual Meeting. February 2, 2022.