The meaning of a noun

Language evolves, and perhaps nowhere is that more apparent than in clinical settings. Some would argue that perhaps nowhere is any evolution more important, especially when it comes to using inclusive language that encompasses the totality of the human experience. It can impact everything from how one is treated within a medical facility to research.

Two editorial advisory board members of Contemporary OB/GYN®—Sarah J. Kilpatrick, MD, PhD, and Christian Pettker, MD—sat down with Senior Editor Angie DeRosa to discuss the topic. Kilpatrick is the Helping Hand of Los Angeles Chair in obstetrics and gynecology, chair of the department of obstetrics and gynecology and professor, and associated dean of faculty development at Cedars-Sinai Medical Center in Los Angeles. Pettker is professor of obstetrics, gynecology, and reproductive sciences; associate chief quality officer; and chief of the Department of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine in New Haven, Connecticut.

For print purposes, this content has been edited for clarity and to fit within the pages of the magazine. The full video interview is accessible online at: www.contemporaryobgyn.net/view/board-members-debate-noun-use-pregnant-woman-or-pregnant-person-.

DeRosa

What is the purpose of this change in language?

Kilpatrick

I think this change in language, which is specifically the change of pregnant women to pregnant persons that we’re talking about, to me, the purpose of this is twofold. The first is to increase the belief in inclusion and decrease discrimination toward transgender people and, specifically in the realm of pregnancy, transgender men. And that is an incredibly important purpose. The second purpose, though, which I think is equally important, is to be able to create more education and learn more about transgender men and pregnancy so that, ultimately, we can even take care of them better because we don’t know that much about transgender male pregnancy. So I think, ultimately, the purpose of this change is to facilitate both of those aims.

Pettker

I would just echo those comments and add that pregnant people who do not identify as women and don’t accept the term or don’t use the term pregnant women face a lot of bias and exclusion and discrimination, and they’re a very small proportion of the population. And we are acknowledging their presence in our population, the existence of the bias and discrimination against them, and we’re trying to reduce the barriers of them getting really exceptionally good care and trying to include them in our policies and our institutions that take care of pregnant patients.

Kilpatrick

I agree with that. However, I don’t think changing the name from pregnant women to pregnant persons will, in and of itself, do that. I think that what we need to do, frankly, instead of going more general, we need to be more specific. So I think we need to talk about pregnant transgender men, for example.

And as you pointed out, Chris, if you look at the best data, the percent of US people who are transgender is about 1%. Let’s say half of those are transgender men, so half a percent of the entire US is a transgender man. So that number who are pregnant, obviously, is much smaller than that. So it’s a very small proportion of people. Nonetheless, we want to create an inclusive environment for anyone who needs pregnancy care.

But just changing the names to persons doesn’t help. We actually need to identify those transgender men so that we can learn from them and study what they need to make their care smooth. What do we need to do in the health care systems, not just us, the doctors, but the health care systems, so that they’re not surprised if they see a man who’s coming to a pregnancy clinic.

I personally think we need to do much more in terms of education of health care people and systems within the health care environment that a transgender man might encounter so that they are more accepting. We need to do things like change the pictures in our offices. We need to do things like use symbols, use pictures of flags. I mean, there’s actually a trans pride flag, for example, that could be along the name of a women’s health clinic. That’s a whole other topic of change of name. But, you know, women learned this.

Why do we have women’s health? Because untilwomen named their healthneeds, they weren’t studied. And even now, we don’t have enough research on women’s health. So I think of transgender men in the pregnancy world in the same fashion. Until we name them, we can’t study them, we can’t learn about them, and we can’t talk about them—and just saying a pregnant person doesn’t help that.

Pettker

I think it’s a really useful distinction to make. And I think you’re right. That is such an important point. And I am happy that we’re doing so much more research, although it’s a small amount of research, and we do need to advocate more for it on this special population and what their health care outcomes are and what their barriers are. It’s a terrific point. But I do think on a global level, our education and our institutions showing an openness to see pregnancies of all types is still helpful.

Kilpatrick

No, I agree with that. And I think again, it comes down to vocabulary. I think educating people about gender diversity, meaning the concept that gender is not necessarily binary, is what we’re talking about. And one of the very first things we have to do is when any patient comes into the health care system, they need to be asked, “What’s your race/ethnicity? Self-identify. What is your gender?” And that should be part of it. And you and I know, Chris, that every EMR [electronic medical record] can’t accommodate that. We are doing better. Epic is doing better. But right now, at Cedars-[Sinai], we do that, and people don’t have to answer if they don’t want to. But that’s the very first thing we need to know—how do they want to be, and what are their pronouns? How do they want to be referred to? Until we can do that and teach our compatriots that this is important, to provide the best care, we need to recognize the individuality of the person and then design our care around that as we learn more information about their gender identity [and] how their gender identity affects their health and their health outcomes.

Pettker

That’s such an important point. You know, I think we are talking about the same thing, even though we might disagree on whether or not the term pregnant person achieves the goal that we’re each specifically talking about. The electronic health record example is so important because a few years ago, we had a pregnant man in our office and I couldn’t assign him a pregnancy. I couldn’t use the pregnancy calculator.

And this is actually what opened my mind to using a broader and more inclusive term because I wondered what that patient faced when he called our office—and what did our office say when they heard that it was a man registering for an appointment for a pregnancy—and all the barriers that that person might have faced. So we did create something in the electronic health record that would allow a man to be pregnant.

But just recently, in our hospital, a region of our hospital that’s a bit more open but is limited to admitting women, we had a pregnant man that we needed to admit to that area. And we had to go to do some bed reconciliation and work on that. And it does point to your point of keeping that person within our administrative database as a “pregnant man” so that we can trace that person’s health outcomes, include them in research. It does speak to your point on maintaining that specificity of how we talk about gender on an individual level while we’re also trying to be inclusive.

Kilpatrick

Those are great points too. And I think about the current trend now in research and journals requiring this change. And I just think we’ve been too quick to adopt this. For example, if you have a paper—and you’ve done your research, and it’s on pregnant women—and now you’re calling them pregnant persons when every single person in that study was a woman, it becomes a little odd. And I think does a little bit [of a] disservice to the women who were in your study that the name “woman” is now lost from pregnancy.

And going back to the fact that women in general need more research and have fought hard to get research about them done in other specialties, now in the one area that we consider, let’s say, needs a woman’s body at the moment—maybe there’s going to be male uterine transplants at some point, but we’re not there yet—and all of a sudden, we’re taking the term away from that. So I think we need to be more inclusive. Absolutely. But we need to think of ways that will really make us more inclusive and not by just changing this name because it’s become politically correct to do. We haven’t thought through the impact of this.

Pettker

Well, it’s interesting, Sarah, because you talk about the research [for which] the studies might have researched pregnant women. But how sure are we that the study did not include a pregnant man if we’re not asking it at our registration? We are making assumptions in the research that...everybody who had a pregnancy was a pregnant woman. The statistics would say, most of the time, yes. But if we’re not asking those questions right at the front, our research actually might be based on some assumptions that aren’t correct. So you know, again, we’re still talking about the same thing. We’re supporting each other’s argument.

Kilpatrick

No, that’s a fair point. You’re absolutely right. I think in this arena of health care, [to reach] our goal of best health outcomes and best acceptance and respect for all patients that we see, the more specific we are in categorizing them in a way that they want to be categorized, the more able we are to be both more inclusive and to provide better care.

You know, I read some articles for this. And there’s one article—there are not many out there—[but] there is one article [about] 41 transgender male pregnancies, men with pregnancies.1 [It provides] interesting data, but [for] one of the [questions asked], “What [is your] gender identity?” you would expect that 100% of them would say, male or trans male—and actually 25% did not. So even in that population of men who were transgender men and pregnant, 25% of them...said they still identified as something else and not male or transgender male. So again, it shows the complexity. Like all humans, you know, we all have trouble fitting into categories sometimes.

But for us to provide the best care, we need to know, directly from research with transgender men, about their pregnancies. And we need to categorize all people correctly, if they’re comfortable being categorized. We can make the same argument for race and ethnicity, right? That we say you’re Hispanic. Well, there’s a whole lot of different Hispanics. I mean, categories that...say you’re Black....It’s interesting, we want to be more inclusive, but to do that, I think we actually have to be more specific [for better patient outcomes]. It’s part of the African American/Blackdiscussion we’re having now. To better understand what Black women want in their pregnancy, we have to listen to them and not make assumptions.

DeRosa

Dr Kilpatrick, have you seen in your own practice, as Dr Pettker talked about, any trans individuals who are pregnant?

Kilpatrick

We’ve had one transgender man pregnant, and we faced many of the things that Dr Pettker just mentioned. It was after that person that we changed some things in our EMR, but even with that man, and with what we thought was correct preparation of people that were going to interact with him, we still had issues. We could have done a better job. And his experience could have been better if we had more discussion. I think what we need to do here in our field is just have more general discussion of transgender people—men, for us mostly, but maybe not always—because their care is complex. It’s not just about pregnancy. What about contraception? What’s the effect of transgender men being on testosterone? Plus, do they still need contraception? Well, the answer is yes. What kind of contraception are they comfortable with? What do they want to call their body parts?

There are a lot of things that we need to educate everyone about, and it shouldn’t be education in the closet. It should be education out there. In Contemporary OB/GYN®, that’s a forum for education. And just the language here, many people couldn’t even give you the maybe 6 or 7 categories that now are in the gender diversity list....You can categorize yourself as A-gender or gender fluid.So on Wednesdays, you’re female, and on Thursdays, you’re male—and that’s a category. So there’s a lot that everyone needs to learn, and [they need to] be comfortable with the language to provide the best care and inclusion for patients who are transgender.

Pettker

So Sarah, I’m curious...if you’ve made any changes with the language [that you use in different circumstances], and it sounds like maybe you haven’t, but I won’t make any assumptions....For instance, I’ve changed my language a lot when I write guidelines. And when we were working on our [COVID-19] vaccine strategy at Yale New Haven Health and the recommendations given related to pregnancy in the vaccine, we just decided we were going to be all in and say pregnant people who wanted the vaccine or pregnant people should be offered the vaccine. And we made that intentional flip to be inclusive. I actually did not face any organizational restrictions or get any feedback. The CEO didn’t call me and say, “What are you thinking?” They were all very supportive, and I’m glad for that

I’m wondering what your thoughts are on using language like that because we did want to make sure that everybody came for a vaccine and [that] everybody thought they were part of these guidelines and recommendations.

Kilpatrick

No, we haven’t made any, and frankly, this is where we disagree. I don’t think that’s a useful change. I think removing the term “woman” is fraught with [risk of] taking attention away from women....And this is nothing about not being inclusive to transgender men. I just think this is a trend that has happened way too quickly, and I think it needed to be coupled with much better education.

I think there will be women who will think, “What is it pregnant person? What does that mean? Why are they taking ‘woman’ out of there?” And “What are they trying to do?” I mean, now should we take “men”—if we could take this to the extreme, every single person could be categorized as a pregnant person or a nonpregnant person. That would cover everyone, 100%. We could do away with “men” and “women” altogether. So why this is focused on removing “woman,” but what’s happening in all the other specialties?

Pettker

What if we said a “pregnant patient” instead? Which we use all the time on the floors. I used it 20 years ago, “This is a pregnant patient.” What if we use that kind of word?

Kilpatrick

That’s better than a “pregnant person,” I think. But I do think it’s ironic that, where’s this inclusivity coming on the nonpregnancy world? Right? Nobody else is picking this up. Like, how are the nonpregnancy, male specialties dealing with transgender women? You know, I just feel like [this specialty is] a little bit of an easy target. Again, nothing to do with [needing] better inclusivity. But as we say, language is everything. And I go back to my question: Why do we have women’s health? I mean, people are talking about maybe we need to get rid of the word “gynecology.”

DeRosa

Why would that be? What is the argument for that?

Kilpatrick

Well, it’s a female, right? That is insight for, OK, this is how extreme this is going. And so we’re going to get rid of every term that means “female”?

Pettker

Well, yeah, I am afraid to tell you that I’ve incorporated the use of the word “they” as a singular pronoun a lot more into my practice and my writing. And that change is probably something you might frown upon.

Kilpatrick

I think the interesting thing is, I think “they” is an appropriate pronoun for people who want to be called “they,” right? If you’re going to get rid of “she,” you have to also get rid of “he,” [and] then everybody becomes a “they.” But I think asking people what their pronouns are is important. He, she, they. And we all know people, I'm sure, who have a “they” pronoun, and it is awkward to use it. It really makes your mind sort of skip a beat when you’re trying to use it appropriately. But to change all of our language to “they”? I don’t know that it is helpful.

DeRosa

It begs the question, going back to what I think Dr Kilpatrick’s point is, in the rush for political correction and inclusiveness, are we not being thoughtful in areas such as this specialty? I mean, you look at the UN, where they had broadly attempted to make this change and any of the associations or societies that either of you deal with, what are the implications then for language evolution and what that means for categorizing all the different variants of a human being

Kilpatrick

Right. It’s amazing how quickly this has all happened. I mean, 2 major journals, JAMA and the New England Journal [of Medicine] are both, [as well as] Diana Bianchi [MD, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development], [using] this now, this new language. And it’s like, really?

Let’s just think through the implications of all this and get focused on what we really want to do—which is, we want to show inclusivity. This is where I think symbols can be really helpful. I mean, churches do this, right? Churches, the Episcopal Church underneath, you’ll see the gay pride flag. They don’t have to write out all the words. There’s a symbol that “We welcome difference.” And I think that’s an easier place to go as we do the educational steps that we really need to do and as we make the medical system able to categorize people so they get the care they want and get called what they want, before you actually change all of the language. Because that’s a huge, huge, huge step. It’s really sort of, it’s very surprising, how quickly [it is happening].

There’s no doubt that trans people are facing discrimination all the time and violence, etc. But you know, so do women, all around the world. And when you think about that, and you’re taking away the term “woman” to replace with a term that’s friendly for trans—and you think about the difference in the proportion of people who fall into those groups—women face no less violence than trans people. So I think it’s just interesting how quickly this has all happened. Then it’s a train that looks like it’s going to be very impossible to stop.

And yet, we haven’t improved trans care. We haven’t improved inclusivity. Yet. Because we haven’t done the work that really needs to be done, [which is the granular work]. It’s really granular, and it’s really focused on our structural systems and on educating people.

Pettker

I think the pendulum will keep swinging. The more we can have discussions like this, and get this out in the open, and have interested listeners in these conversations, the more we’re going to get it right—the more that it’s not going to be one group leading the discussion....We’re going to have the differences of opinion all get aired so we can get this right so that our patients can be well taken care of, so that we can reduce the barriers and biases and the things that all of our patients face to create barriers to good care.

So I’m just very thankful that we can have these open conversations, and I hope that people can listen to this with an open mind and a respectful heart and really try to understand all the intricacies with using language like this so that they can work to get it right. I know I learned a lot from having this discussion. And [it’s] helpful for me to chart the course and [how] our organization, and my own work, and how the various societies and professional organizations that I work with can do a good job at this.

Kilpatrick

I agree with all that, Chris. And as we started, I think we basically agree we just have a difference of opinion about the strategy to get there.

DeRosa

It’s interesting, too, to think about from the perspective of a medical office level. You don’t want those patients walking in—or not walking in at all—and not get the care that they deserve.

Kilpatrick

In this study of 41 patients, 17% delivered at home.1 That’s definitely understandable if you are afraid. This is a group of patients, even before pregnancy, even before they might be pregnant, who are cautious or afraid of the health care system already, so we definitely want to create an environment where they feel comfortable. And the other thing is, I think this is really a subspecialty group. A transgender man who’s pregnant brings complicated issues to the pregnancy, including how this may challenge their own mental health if they think of themselves as a man and yet they decided to stay pregnant or get pregnant. That is contradicting, I’m sure, in their mind [regarding] how they feel about themselves. So that whole aspect of their care really takes a care provider who is an expert in this

Chris, you and I have taken care of a pregnant patient who has got bad maternal cardiac disease. That’s rare, [but] we wouldn’t expect a general ob/gyn to be able to manage that patient fully. And in this context, there are not going to be that many people around the country because there are not that many pregnant transgender men. But you would expect that there would kind of be centers of excellence that people could contact to help them. Otherwise, that person won’t have all of their needs met as they come in, even if it’s a friendly office. They may be friendly—in that they don’t get shocked that a man walked in and he’s pregnant—but they may not understand the issues that are going on with respect to the rest of his life and how he feels about himself in this time. I think it’s also simplistic to think that by changing the name, we’re going to make every OB-GYN comfortable managing a patient [such as this].

Pettker

The care has to be so individualized, and generalities aren’t going to take good care of the patients. Absolutely.

Reference

1. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127. doi: 10.1097/AOG.0000000000000540