Affirming pregnancy care for transgender and gender-diverse patients

Why is language important?

Cisnormativity is the assumption that everyone is cisgender until they say otherwise, and that cisgender is the “normal” or “correct” way to be. This leads to cissexism and transphobia, where there is privilege toward cisgender people and negative attitudes, feelings, or actions aimed at TGD people. This occurs on many levels, including interpersonally, institutionally, and structurally. Transphobia may be demonstrated by the way a transgender person is treated by another individual. However, it can also be experienced as a result of environments or policies. Examples include a physician’s office with only gendered bathrooms, or an electronic medical record that does not allow the patient’s gender to be different from what is on their health card.

Cissexism and transphobia may be heightened in the context of pregnancy, which is strongly associated with female gender for many health care providers. Gendered language is often used when speaking about pregnancy and childbirth, such as pregnant woman, mother, or maternity.⁶ These words exclude pregnant people who do not identify as women or mothers.⁷ It is also important to recognize that equating pregnancy with motherhood may exclude non–birth parents who view themselves as mothers. Lack of inclusive language can indicate to TGD patients that they are not recognized or welcomed in the clinical environments where we provide pregnancy care.

Transgender men who are considering or carrying a pregnancy seek obstetric providers who accept their gender identity and can support them throughout,⁸ as pregnancy may trigger or worsen gender dysphoria for many reasons, including physical changes that occur during pregnancy and emotional and psychological implications of carrying a pregnancy. Testosterone is contraindicated in pregnancy, so cessation of this gender-affirming hormone therapy may be distressing, both mentally and physically.⁹ It is important to focus on anatomy, and not gender, when it is appropriate.

How should we speak to and act with our pregnant and parenting patients identifying as TGD?

Case 1. A pregnant transgender man is admitted to the labour and delivery ward. His gender is recorded as female in his health record. His care providers unknowingly—but incorrectly—use she/her pronouns.

In this case, the providers used cisnormative language. There should be education for staff on inclusivity for all sexualities and gender identities, with the capacity to record the correct gender and pronouns in the medical record. It is important to sensitively communicate gender identity to all team members.

Case 2. A patient who was assigned female at birth, identifies as gender fluid, and uses they/them pronouns presents to the urgent care clinic with abdominal pain. They are taking testosterone and do not menstruate. They do not use contraception. Based on assumptions and incomplete history taking, the treating physician does not consider the possibility that this person could be pregnant.

This could be mitigated by taking a thorough sexual history that sensitively inquires about the patient’s anatomy and sexual activity and remembering that testosterone is not a contraceptive.⁸

Neutral language (Table 1)^3-5 is more inclusive for people who do not identify as male or female. Examples of neutral terms include parent, partner, and pregnant person.⁹ Pronouns can be part of a person’s gender expression. Some patients use the gender-neutral pronouns they/them or neopronouns such as ze/hir. Clinicians should ask for a patient’s pronouns and use them consistently and correctly. Neutral language can be used to refer to a person’s anatomy—for example, genitals, reproductive organs, or chestfeeding.¹⁰ It can be helpful to ask patients how they name their anatomy and to mirror those terms.¹¹ When in doubt, ask!

Pregnant people who identify as TGD benefit from supports that are tailored toward their needs. This might include infant feeding classes that do not use the term breastfeeding, or programs that refer to reproductive and sexual health providers rather than women’s health providers.¹²