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Obstetrical Nursing Care of Transgender Men

Male pregnancy is the changing face of labor and delivery

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Labor and delivery nurses are used to women delivering babies. What happens when men get pregnant and deliver babies? How can the obstetrical nurse care for this pregnant man?

Biologically, it is impossible. Men do not have the anatomy and physiology to gestate. Studies have documented how different transgender men have given birth to children. In 1999, Matt Rice gave birth to a son. In 2011, another Transman, Yuval Topper, an Israeli gave birth to a child. A married transgender man, Thomas Beatie, gave birth to a daughter and two sons between 2008, 2009 and 2011 1,2,3.

A Transman is a person who is assigned a female at birth but chooses the gender identity of a male. The Transman may accept medical help to become a man. The sexual orientation of a Transman may be asexual, bisexual, heterosexual, homosexual, or he may not sexually identify with any orientation 4, 5, 6.

Healthcare and Transmen
Pregnant Transmen may not have the support, resources, and adequate healthcare assistance. This lack of services and awareness may lead to the lack of sufficient and safe pregnancy for these men. Due to internalized stigma, these patients may be unwilling to attend to their health-care needs and view themselves as undeserving of competent care, resulting in their compliance with discriminatory policies and practice 5, 6.

Earlier studies within Canada and the United States have identified unreasonable discrimination against the LGBT population within health-care systems 7. Surveys of LGBT patients have revealed adverse communication from health-care providers such as verbal and emotional abuse, refusal of medical treatment, rude behavior, and inadequate treatment 8.  Consequently, most of the members of this cohort may delay or postpone seeking needed care due to disrespect and discrimination 8,9.

Obstetrical Needs of Transmen
LGBT men and women progress through the process of obstetrics in the same manner as their heterosexual counterparts: they conceive, gestate, and deliver. They also endure the process of bereavement following the loss of a fetus. Although this population does not represent societal norms, obstetrical nurses must strive to provide an obstetrical experience free of prejudice and discrimination 10, 11. A study documented that not all nursing staff is particularly comfortable with these patients and their families. Some nurses are uncomfortable taking the health and sexual histories of LGBT patients, they can fail to inform their patients appropriately on labor and delivery processes, and they are frequently uncomfortable providing emotional support to these patients and their families 11.

Female-to-male transgender (Transmen) patients may require labor and delivery care. During their transitioning phase from female to male, most transmen retain their female reproductive organs. This decision to keep their female organs means that these men still have all the functioning female anatomy and may still get pregnant 12. These pregnancies may be planned or unplanned. Per the American College of Obstetrics and Gynecologist, Transmen may conceive while they are on testosterone replacement therapy 13.  The obstetrical nurse should be prepared to deal with a pregnant Transman, who may not look like a woman. Some pregnant Transmen may have masculinizing physical changes such chest contouring (mastectomy), chest and facial hair, enlarged clitoris, increased muscle mass, hairy chest, back and stomach, acne, male pattern baldness, and deepened voice 10. The obstetrical care of the transmen should be the same as their Cisgender (non-transgender women) counterparts with some exceptions.

Obstetrical Nursing Assessment
A fundamental and critical issue with lesbians and gay patients is withholding their actual sexual orientation and other pertinent information due to past experiences with prejudice from health-care providers. Such lack of disclosure could result in detrimental consequences, such as exacerbation of chronic illness and to quality care 11. During the initial prenatal history, in addition to obtaining a comprehensive medical, sexually and physical assessment, the nurse, should ask the patient their assigned sex at birth, gender identity and about the desired name and pronouns to use when addressing the pregnant man 11,14. These essential questions help the healthcare providers to understand the patient's medical history and to provide efficient obstetrical care to the patient and their significant others. Hence, the obstetrical healthcare needs of the Transman will be managed adequately, leading to a better outcome of the pregnancy. Additionally, the transgender patient feels more comfortable discussing any concerns with the obstetrical staff 9,11

Prenatal
Pregnancy brings about extensive physiological and psychological changes. For the transmen, these changes may lead to depression, distress, and isolation. Most transmen may be distressed about some of the body changes such as breast engorgement, weight gain, fluid retention, stretch marks, lordosis, linea nigra, and an increase in vaginal discharge. These pregnancy changes may cause anxiety to the Transman, who was working hard to get rid of the feminine body. Some transmen may go through periods of ambivalence, grief, stress and acceptance of the pregnancy. The nurse should continue to establish trust with the transgender man by exhibiting non-judgmental behaviors. The nurse should provide education about the physiological and psychological adaptation to the pregnancy to the Transman and his family. It is essential to support the Transman and his significant others as they go through the pregnancy, and modify their developmental tasks 10, 11.

The general public is not used to pregnant Transman and may make the patient uncomfortable. While in the general waiting area, the Transman may be subjected to stares and curiosity of the other patients. The nurse should make alternative provisions to ensure that that the Transman is comfortable. The Transman should be given the choice for very early, late or weekend appointments when the clinic census is likely to be low. Non-gender bathrooms should be available in the clinic to accommodate the Transman. The obstetrical prenatal clinic environment should be conducive for Transmen. For instance, the magazines and the pictures on the wall should show support for all types of families 11, 14.

Labor and Delivery
During labor and delivery, the nurse must provide privacy and ensure that all the healthcare team involved in the care of the patient knows about the patient's assigned sex at birth, gender identity and about the desired name and pronouns to use when addressing the pregnant man. The nurse should continue to provide emotional and physical support as the patient labors and delivers. The nurse must initiate immediate bonding with the newborn.

The Transmen can chest (breast) feed. Chest feed is a better terminology for Transmen who are distress and discontentment about their female anatomy or assuming a traditional role of women. Transmen who have had a mastectomy may still chest feed with a special device 12. Before discharge, the nurse must teach the Transmen to monitor when to reinitiate the testosterone because it may stop the production of breast milk. Literature shows that while testosterone does not appear to pass significantly into breast milk or have a short-term impact on infants 12,15.

SEE ALSO: Skin-to-Skin Bonding

Postpartum
During the postpartum period, the nurse must assess for depression. Literature shows that there are high incidences of depression, suicide rates among the transgender cohorts as a result of loneliness and lack of support from families and health care providers 9. Transmen may be mourning the pregnancy and birth as still having the retention of the female anatomy.  This experience of gestation and birth may elicit the negative symptoms of gender dysphoria such as eating disorders, low self-esteem, and repulsion with their genitalia, social isolation from their peers, anxiety, loneliness and depression 9.

Efforts should be made to provide psychological and community supports. It is necessary to consult with the social workers to provide professional assistance and community resources. At discharge, the Transman may need home care assistance with adjusting to his new role as a father of a newborn. For the Transman without family support, home care assistance will help to mitigate or prevent the negative psychological symptoms of gender dysphoria. Part of the discharge plan for the transgender man includes family planning and the available birth controls and importance of safe sex 10.

As the society is changing, the care of obstetrical nurse needs to change to account for the obstetrical care needs of different cohorts. Every obstetrical patient and their families need the quality, culturally-congruent and comprehensive care. Nurses must continue to use up-to-date research to provide excellent care.

Chinazo Echezona-Johnson is director of Nursing/Women and Children Nursing Education at Metropolitan Hospital Center in New York, NY.

 References

1. Beatie, T (2008). "Labor of Love: Is society ready for this pregnant husband?", The Advocate,  p. 24

2. Brener, N(2011). "Israeli man gives birth". Israel: Ynetnews.com.-12-30.

3. Califia-Rice, P. (2000). "Two Dads With a Difference - Neither of Us Was Born Male". The Village Voice.

4.Echezona-Johnson, C. (2014). Equitable Obstetrical Care for the Lesbian, Gay, Bisexual, and Transgender Community (Doctoral dissertation, WALDEN UNIVERSITY).

5. Kelley L., Chou C. L., Dibble S. L., & Robertson P. A. (2008). A critical intervention in lesbian, gay, bisexual, and transgender health: Knowledge and attitude outcomes among second-year medical students. Teaching and Learning in Medicine, 20(3), 248-253. doi:10.1080/10401330802199567

6. Makadon, H. J. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78(4), 220-224.

7. Obedin-Maliver, J., Goldsmith, E. S., Stewart, L., White, W., Tran, E., Brenman, S., . . . Lunn, M. R. (2011). Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA: The Journal of the American Medical Association, 306(9), 971-977.

8. Sears, B. (2009). Delaware - sexual orientation and gender identity law and documentation of discrimination. Los Angeles, CA: Williams Institute.

9.Grant; Jaime, M.; Mottet, Lisa; Tanis, Justin; Harrison, Jack; Herman, Jody; Keisling, Mara (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (PDF). Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. 

10. Echezona-Johnson, C. (2014). Nursing Care of the Transgender Patient. Nursing.

Advanceweb.com. Retrieved July 10, 2016.

11. Center of Excellence for Transgender Health. Online Learning: Acknowledging gender and sex. Transgender Health Learning Center. http://transhealth.ucsf.edu/video/story.html (2014, accessed July, 10th, 2016

12. Obedin-Maliver J, Makadon, H.J.(2015). Transgender men and pregnancy. Obstet Med. 2016 Mar; 9(1):4-8.

13. Light, A.D., Obedin-Maliver J, Sevelius, J.M., et al.  (2014). Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstetr Gynecol; 124: 1120-1127. 

14. Makadon, H.J., Mayer K, Potter J, et al. (2015). Fenway guide to lesbian, gay, bisexual, and transgender health, 2nd ed. Philadelphia: American College of Physicians.

15. Glaser, R.L., Newman, M.M,, Parsons, M.M., et al.(2009). Safety of maternal  testosterone therapy during breast feeding. International Journal of Pharmaceutical Compound ; 13: 314-317.

 

 

 


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This is an interesting article and educative. They are smart they keep their feminine organs intact; not all but some.

Gloria Arce,  Birth Registrar,  Metropolitan HospitalDecember 15, 2016
Manhattan, NY




     

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