Science & Sensibility

In the occasional series on Welcoming All Families, we have explored how to make our classes and practices welcoming for women of size and lesbians.  Today on Science & Sensibility, Certified Nurse Midwife Simon Adriane Ellis shares how to offer care and classes that are sensitive to gender variant families. Recently the American College of Nurse-Midwives (ACNM) released a position statement on Transgender/Transexual/Gender Variant Health Care. The ACNM stated that they “support efforts to provide transgender, transsexual, and gender variant individuals with access to safe, comprehensive, culturally competent health care and therefore endorses the 2011 World Professional Association for Transgender Health (WPATH) Standards of Care.”  Simon Ellis served on the task force and played a significant role in writing and advocating for this recently released position paper and worked with ACNM to see it through Board of Director approval in December 2012. – Sharon Muza, Science & Sensibility Community Manager

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Note: The term “gender variant” is used throughout this post to describe individuals whose gender identity is in some way different than the sex they were assigned at birth. Other related words you may have heard before include transgender, gender non-conforming, and gender non-binary. In this post, I specifically address the needs of gender variant people who undertake pregnancy. The needs of gender variant partners and family members also warrant deep consideration, but will not be the focus of this piece. 

When asked, many birth professionals will tell you that they’ve never cared for a gender variant patient. Many of us claim that we don’t have the skills or the knowledge to do so. Turns out we’re usually wrong, on two fronts. First, chances are many of us have served gender variant people, without knowing it. And second, we are competent, compassionate, and well-trained professionals who already have what we need to provide excellent care and services to our gender variant patients. This post will provide a basic framework for approaching care, as well as some specific resources and suggestions to make your practice more inviting. I write it from both my perspective as a practicing Certified Nurse Midwife, and my perspective as a gender variant person (female-to-male).

Focus on What You Bring to the Table

We all bring ourselves – rich in beauty and flaws and experience – to each client encounter. We are our own building blocks of clinical or professional practice. Accordingly, when striving to provide care or services across difference, the first place to start is within ourselves. What do we bring? Among other things, we bring skills and biases.

Skills

As professionals who serve families in pregnancy and birth, the core of what we provide is compassion; we are incredibly dexterous at meeting people where they are at. We offer a strong and loving presence even in the intense terrain of labor, which takes a whole lot of humanity and skill. This is your number one asset for providing culturally responsive care to gender variant patients and clients. So keep doing what you do best! 

Biases

If someone asks you why you choose to do birth work, what do you say? Many of us would say that we are passionate about serving women, that we value women’s bodies and autonomy and we honor the journey to motherhood. Which is fantastic! We should! But what if your pregnant client doesn’t happen to identify as a woman? Does that change anything about the importance of their journey to parenthood? Does it make their birth experience less authentic and worthy of support? Of course not. Birth is birth, regardless of gender identity. And birth is our specialty. But many of us have a very hard time imagining pregnancy outside the concept of “woman,” which casts doubt on gender variant people who choose to carry a pregnancy. Being aware of and challenging your own biases and personal attachments to the concept of gender will help you prepare yourself for working with a more diverse client base. 

Don’t Pass the Buck

It is convenient to fall back on the idea that we, as birth professionals, are only trained to work with women and therefore are simply not qualified to work with gender variant people. In saying this, we falsely join two separate concepts – sex and gender – and we falsely absolve ourselves from responsibility. The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s wellbeing. But the truth is: with very few exceptions, there is no one with more experience.

In my work with gender variant parents, every single one of their doulas, childbirth educators, midwives, and OBs stated they had never before worked with a gender variant patient. There was no research these providers could review on the physical and emotional health needs of this population, no information on best practices. Each provider had to rely on the skills and knowledge base they already had, and do the best they could. And with compassion and clinical/professional acumen as their guide, it turns out they usually did an awesome job. The lesson to take from this is that 1) you are capable of doing a good job, and 2) a suggestion that the patient see “someone who has more experience” is usually little more than a referral to nowhere. 

Make Your Practice More Inviting

While there is no simple list of do’s and don’ts that you can follow (and the golden rule is, as always, to cater your approach to the needs of the specific client), I do think there are some basic principles that can be helpful in adapting your practice to meet the needs of gender variant patients and clients.

1. Build trust and offer accommodations

Fear of discrimination by providers and fellow patients or class participants presents a huge barrier to care for gender variant people. It is a source of great emotional and physiological stress. I can tell you that it is truly a terrible feeling. Take time to build trust, and to assess your client’s need for accommodations. Some clients will desire as much anonymity as possible, in which case you can offer one-on-one class sessions or facility tours, appointments at the beginning or end of the clinic day, assurances of privacy, and continuity of care. Other clients will desire facilitated integration, in which case you can offer assurance that you will address problems proactively, be available to address questions raised by other clients, and make a point to check in regularly on how things are going. If you need to refer the client to another provider, be sure to offer to call ahead and provide the patient’s background. Taking over the burden of explanation can be an enormous weight off your client’s shoulders.

2. Plan to offer additional emotional support

We all know that pregnancy is an intense and vulnerable time. Gender variant parents-to-be often have the additional struggle of profound isolation, coupled with the likelihood of heightened gender dysphoria during the course of pregnancy. With these things in mind, make yourself available to provide additional emotional support as necessary. Research LGBTQ friendly mental health providers in your area so you are able to make appropriate referrals if needed.

3. Keep your wording flexible

The language of birth work is extremely gendered. This can be isolating for gender variant clients. Work to make your language more inclusive by incorporating terms such as “pregnant parents,” “parents-to-be,” “new parents,” and “gestational parents.” Ask your clients what name, pronoun, and parenting term they would like to be addressed by, then respect their wishes in both individual and group settings. If you slip up and use the wrong name or pronoun, acknowledge it promptly and succinctly, then move on. If you work with a staff, make sure that all staff members are addressing the patient or client appropriately as well. Including fields asking for “preferred name” and “pronoun” on your intake or registration forms will send a clear (and very relieving!) signal to potential clients.

4. Don’t let curiosity get the best of you

I can tell you from personal experience that gender variant people are constantly asked about our gender identities. Regardless of the context or topic of discussion, we are expected to be willing and able to explain our innermost sense of self (or defend our right to exist!) at all times. This is stressful! While your curiosity may stem from a desire to better understand your client’s gender experience, and you should be open to hearing about their experience, focus on the pertinent issues at hand. Maintain your professional integrity and ask only what you need to know in order to provide excellent care.

5. Address issues proactively, especially in group settings

If you see clients in a group setting, consider a handout or brief talk at the beginning of each class (regardless of who is in attendance) affirming that there are many different types of families and that intolerance will not be allowed. Name behavior firmly but gracefully when someone acts inappropriately, and follow up with them individually outside of the class setting. Do not place the burden on your gender variant clients to defend themselves – instead, show them that you are a dependable professional who has their back and is willing to help other clients grow and become more accepting.

Thank you so much for your commitment to serving gender varient people!

Creating a class or practice that is welcoming to all families can involve sharing stories of all different families.  Choosing your media, handouts, posters and class material that includes all the different ways that families can look is important.  Please share your favorite resources for these types of supplies.  There is not a lot to choose from and we can all benefit from sharing information.  What do you do (or what have you done) to welcome gender variant families into your classes and practices?  Please share your experiences in the comments section.- Sharon Muza

Resources

Resources on this issue are few and far between, unfortunately, but here are some good places to start:

Basic vocabulary and introduction to the issue of gender variance: http://srlp.org/trans-101

2010 healthcare discriminatory survey: http://www.thetaskforce.org/downloads/resources_and_tools/ntds_report_on_health.pdf

Blog by a transgender dad who breastfeeds his son – lots of good information as well as personal reflections: http://www.milkjunkies.net/

Resources for gender variant parents – includes legal resources and family support resources: http://www.transparentcy.org/Resources.htm

Gender and the Childbirth Professional Facebook group – connect with other providers who work with gender variant clients, ask questions, post resources, etc.: https://www.facebook.com/groups/265359336861854/?fref=ts

My personal blog – occasional updates on midwifery, sexual health, and what’s it’s like to be a gender variant midwife: www.boimidwife.wordpress.com

It’s My Body, My Baby. My Birth – DVD for use in class that shows 7 natural births and interviews the couples.  One couple is gender variant.  http://www.itsmybodymybabymybirth.com/Home.html

Additionally, the ACNM Position Statement contains additional resources on this topic.

Thank you so much for your commitment to serving gender varient people!

 About Simon Adriane Ellis

Simon Adriane Ellis is a Certified Nurse Midwife, trained doula, and queer and gender variant person. He has a long history of social justice organizing around issues of racial and economic justice and LGBTQ rights, and brings these values to his work as a midwife. His practice is focused on providing empowering sexual and reproductive health services across the lifespan for people of all gender identities. He is currently working to publish his original qualitative research on the conception, pregnancy, and birth experiences of gender variant gestational parents. He hopes that this work will provide a broad call to challenge conventional assumptions about what pregnancy looks and feels like for all of our clients, regardless of gender identity. Simon can be reached through his midwifery practice, Essential Healthcare + Midwifery Services.

Sharon Muza Childbirth Education, Guest Posts, Legal Issues, Midwifery, Series: Welcoming All Families ACNM, ACNM Position Statement, American College of Nurse-Midwives, Childbirth Education, Gender Variant, Midwifery Care, midwives, Sharon Muza, Simon Adriane Ellis, Transgendered, welcoming all families

By Christine H. Morton, PhD

The American Congress of Obstetricians and Gynecologists (ACOG) has undertaken the reVITALize Project and they want your help, thoughts and input. A significant revolution is underway in maternity care.  With increased attention on maternal health outcomes, the measurement and reporting of key maternal quality metrics is on the agenda of childbearing women, maternal health advocates, payers and purchasers, hospitals, regulatory agencies and maternity care clinicians.    An important element of this revolution is an effort to clearly define what we mean when we talk about pregnancy and childbirth in the data sources most utilized in developing these measures – patient medical charts, registries, electronic medical records, patient discharge data, and our vital statistics (birth certificates).

This is an important and critical opportunity for all stakeholders in US Maternity Care to contribute to the national dialogue on measuring maternal health outcomes.

From the ACOG website: 

The reVITALize Obstetric Data Definitions Conference in early August 2012 brought together over 80 national leaders in women’s health care with the common goal of standardizing clinical obstetric data definitions for use in registries, electronic medical record systems, and vital statistics. Over the course of the two-day in-person meeting and the months that followed, more than 60 obstetrical definitions were reviewed, discussed, and refined.  Data elements included: induction of labor, gestational age and term, parity, TOLAC, and more. The full executive summary of the reVITALize Obstetric Data Definitions Conference can be read here.

The public comment period for the definitions of these data elements ends January 15, 2013. To submit comments, click on one of the category links below to open the respective Public Comment form. The data elements contained within each Public Comment form have been grouped according to category; the data elements assigned to each category are listed under the category heading below. You are permitted to comment on any number of categories. You can also view an alphabetical listing of all data elements available for comment here.

Delivery
• Cesarean Delivery
• Date of Delivery
• Forceps Assistance
• Malpresentation
• Perineal Lacerations
• Placenta Accreta
• Primary Cesarean Delivery
• Repeat Cesarean Delivery
• Shoulder Dystocia
• Spontaneous Vaginal Delivery
• Vacuum Assistance
• Vaginal Birth After Cesarean
• Vertex Presentation

Gestational Age & Term
• Preterm
• Early Term
• Full Term
• Late Term
• Post Term
• Estimated Date of Delivery
• Gestational Age (calculation formula)

Labor
• Artificial Rupture of Membranes
• Augmentation of Labor
• Duration of Ruptured Membranes
• Induction of Labor
• Labor
• Labor After Cesarean
• Non-Medically Indicated Induction of Labor or Cesarean Delivery
• Number of Centimeters Dilated on Admission
• Onset of Labor
• Pharmacologic Induction of Labor
• Physiologic Childbirth
• Pre-Labor Rupture of Membranes
• Spontaneous Labor and Birth
• Spontaneous Onset of Labor
• Spontaneous Rupture of Membranes

Maternal Indicators: Current Co-Morbidities and Complications
• Abruption
• Antenatal Small for Gestational Age
• Any Antenatal Steroids
• Clinical Chorioamnionitis
• Depression
• Early Postpartum Hemorrhage
• Oligohydramnios – HOLD; Pending Further Revision
• Polyhydramnios – HOLD: Pending Further Revision

Maternal Indicators: Historical Diagnoses
• Chronic Hypertension
• Gravida
• Maternal Weight Gain During Pregnancy
• Non-Cesarean Uterine Surgery
• Nulliparous
• Parity
• Plurality
• Positive GBS Risk Status
• Pre-Gestational Diabetes

How to Submit Effective Comments In order to make the process as productive as possible, please keep the following in mind when commenting: • Be clear. Clearly identify the issues on which you are commenting and explain your reasons for your position. • Be concise. Although there is no minimum or maximum requirement for comments, it is best to keep your comments short and to the point. • Suggest alternatives. If you identify a problem with the proposed definition on which you are commenting, consider suggesting an alternative. • Spread the word. If you know others who can provide helpful comments, please direct them to www.acog.org/revitalize  for more information.

What happens to comments after they are submitted?

All comments received during the Public Comment period will be reviewed and logged for consideration and careful review by reVITALize leadership. The leadership teams are comprised of both clinical and operational members. Comments will be reviewed and responded to accordingly and will help to form the basis for any additional changes that need to be made to the refined definitions prior to final approval. Should comments require further clarification, the individual submitting the comment may be contacted during the review period to obtain any clarifying information needed to make an informed and appropriate decision regarding a potential revision.

Thank you for your help in making this initiative a success! Any questions or concerns should be directed to QI@acog.org

Christine Morton ACOG, Evidence Based Medicine, Guest Posts, Legal Issues, Maternal Quality Improvement, Research, Research Opportunities ACOG, Christine Morton, guest posts, Maternal Quality Improvement, research

Lamaze International is delighted to be offering a convenient and complimentary breastfeeding webinar for birth professionals on Wednesday, August 15, 2012.  This webinar is being presented by Elizabeth C. Brooks, JD, IBCLC, FILCA.  Ms. Brooks brings the unique perspective of being both a certified lactation consultant and an attorney.

Moms, Babies, Milk and the Law: Legal and Ethical Issues When Teaching Breastfeeding
Date: Wednesday, August 15, 2012
Time:1:00 PM – 2:00 PM EDT

Presented by Elizabeth C. Brooks, JD, IBCLC, FILCA

This presentation will describe the difference between a legal and an ethical responsibility as a health care provider as well as common ethical considerations when teaching breastfeeding in prenatal and postpartum settings.

This activity has been planned for 1 Lamaze Contact Hour, and one Nursing Contact Hour. Attendees may earn contact hours upon purchase and completion of a quiz.

Don’t hesitate! Reserve your Webinar seat now at:
https://www1.gotomeeting.com/register/926390753

Sharon Muza Babies, Breastfeeding, Childbirth Education, Continuing Education, Legal Issues, Webinars breastfeeding, Childbirth Education, IBCLC, lactation consultants, legal, Legal Corner, legal issues about maternity care, teaching community breastfeeding classes, tips for the childbirth educator, Webinars

Lamaze International is offering childbirth educators and others the opportunity to participate in a free hour-long webinar with Raymond De Vries, Ph. D.  The webinar is scheduled for Wednesday, July 18th , 2012 from 1:00-2:00 PM EDT.

Dr. De Vries is a Professor at the Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School.  Dr. De Vries has written several published papers and was most recently quoted The Atlantic Monthly article; “The Most Scientific Birth Is Often the Least Technological Birth”.

At the end of this webinar session, learners will be able to define how to apply the Lamaze code of ethics to pre-natal education by adopting a sociological approach to thinking about and resolving ethical dilemmas of birth which takes into account the social, economic, and political context within which ethical problems exist.

 Please click here to register for the free “Ethics in Childbirth” webinar.

Sharon Muza Childbirth Education, Continuing Education, Legal Issues, Uncategorized, Webinars Childbirth Education, Continuing Education, ethics, Lamaze Code of Ethics, Lamaze International, Lamaze webinars, Raymond De Vries, Webinars

[Editor's note:  Today, we are pleased to re-post a poignant piece, recently published on The Feminist Breeder, as a part of our Legal Corner Q&A series.  Thank you, Gina, for sharing your story with us, and with all women!]

When I found myself pregnant in August of 2010 – eight months after we began trying for our third baby – it only took a quick calculation to realize the baby was due right smack in the middle of my Spring semester of school. As I’m nearing the end of my combined B.A. and Paralegal Certificate program, every single class counts, and there’s no time to postpone any courses if I want to begin law school, as planned, in the fall of 2012. This meant that I’d have to find a way to keep up my full-time course load and have my baby at the same time. I knew it wouldn’t be easy, but I’m good at juggling the seemingly impossible. That’s how I’ve come this far with a family, many jobs, and a near-perfect academic record.

I attend a major Chicago university that prides itself on diversity, community service, and exceptional academic programs. My particular program is geared for adult, busy students seeking a first or second degree. The classes are accelerated and concentrated, running for four hours on one night of each week for eight weeks. There are two sessions per semester, which allows adult students to take a full 12-hour semester by only taking two classes at a time. However, since the classes are four hours a week, missing one class is like missing two weeks in a regular program. Missing even one class in a session isn’t something a student wants to do, yet still, the professors understand that sometimes absences are unavoidable. In my three years in this program, I’ve never seen or heard of any professor punishing a student for missing a class, especially for an extenuating circumstance such as illness, family emergency, or even a work emergency. Our professors know that we’re adults who take the program very seriously, while also trying to balance adult responsibilities with our academics. Three years ago, I had to pump breastmilk for my younger son in the middle of every single class for a whole year, and I never had a professor who was anything less than understanding and accommodating. Many were even openly proud of my effort to remain a committed student and a committed mother at the same time.

For this reason, I fully trusted that my pregnancy and impending birth would be respected by whichever professors I ended up with in the second session of the Spring 2011 semester. I felt that my outstanding academic record would illustrate what a committed student I am, and that the professors and administration would not only be understanding, but also accommodating, when I needed to take a week or two off to have my baby.

At 40 weeks pregnant, I discovered I was wrong.

At 36 weeks pregnant, the second session of the Spring semester began. I was enrolled in two courses, both required to complete my degree program. On the very first night of Class X, I approached Professor X, and pointed out that we needed to have a discussion about the giant belly in the room. I told her when I was due, and that I planned to only take one week of classes off to have my baby IF the delivery was uncomplicated, but possibly more if I needed extra time to heal, or if the baby wasn’t well. I also asked her permission to bring the baby to class with me so that I could nurse on demand, which she agreed to. The professor seemed completely accepting of the fact that I’d have to take time out of class to have a baby, which, given all of my other experiences with my university’s faculty, I expected. She even offered to let me take an Incomplete if I needed, but I explained to her that I did not want to drag the class out any longer, which is why I wanted to come straight back with the baby, buckle down, and wrap up the class with my usual A.

Everything was fine until the fourth week of class. I was 40 weeks pregnant, and my midwife stripped my membranes to assist the prodromal labor I had been having for weeks. I left the appointment having contractions and lots of bloody show, feeling like labor was imminent. I also had a ridiculous head cold that was making me all sorts of miserable. Still, I knew I had a midterm exam in Class X that night, so I dragged myself — headcold, contractions, bleeding and all — to sit in class and take my exam. After I finished the exam, I decided that I needed to get myself home before I ended up starting labor in the middle of class.

A few days later, still pregnant, I checked Blackboard to see my grade from the exam, and I noticed that the professor had given me only 5 out of 25 points for “Attendance & Participation” on the day I left class early.

I wrote to her immediately and asked why I had been docked 20 points, and she explained that I couldn’t earn those points unless I was sitting in class. I wrote back and asked her if she planned on docking me the full 25 points for each class I missed for the birth, and she said that Yes, she was planning to dock me while I had my baby. A little quick math told me that there was no chance of me earning an A, B, or even C in that class if she planned on withholding points while I was out for the birth. She told me that the university handbook allowed her to make any attendance policy she wanted, and there were NO exceptions to it.

I quickly called my advisor and asked him what I could do, and he said “Well, she can set any attendance policy she wants, and it’s not fair to everyone else if you get points when you’re not there.” I explained to him that I could end up failing the course if I missed a few classes for the birth, so he offered to let me “back withdraw” from the course, meaning that I could drop out without it appearing anywhere on my transcript. I thought that was a horrible option – I had already completed half of the coursework, and all my work would be going to waste. Plus, I desperately needed that course to stay on track for graduation. Taking it all over meant not graduating on time. However, it seemed like my only option. Either risk failing the course while I’m giving birth, or withdraw. I emailed the professor, copied in administration, and regrettably withdrew from the course.

Then – I went on Facebook.

I posted an update angrily complaining about being forced to back withdraw from this class simply because I was having a baby while suffering the untimely misfortune of being enrolled in a course taught by uncompromising professor. Several people had stories of similar things happening to them, and then, one commentor completely changed the game for me.

This particular commentor, named Melanie Ross Levin, works for the National Women’s Law Center in Washington. Melanie told me that, according to Title IX of the Education Amendments Act, my professor was required by law to give me time off to have my baby, and was required to give me the same chance to earn my A as any other student in the class. This law, enacted way back in 1973, specifically prevents the same type of forced withdrawal that I was experiencing. At first, I really didn’t believe Melanie, so she told me to call the NWLC and talk directly to one of their lawyers, which I did. The amazing lawyer on the other end of the line completely had my back, and explained all my rights to me. She offered to help me in any way she could, and displayed true compassion when helping me navigate this stressful situation I found myself in ON MY DUE DATE.

But why hadn’t I heard of this? Why hadn’t my professor? Why hadn’t my advisor? Why hadn’t the school administration? You’d think if this was a law that I could use, somebody on my campus would know something about it.

Well, at least one person on my campus had definitely heard of Title IX. In fact, every single school receiving federal funding (read: basically ALL of them) are required by this law to have a Title IX advisor somewhere on campus – that’s a whole person whose job it is to know this law, and what it does for their students.

I called around and found that the Title IX advisor at my school was the VP of Human Resources (makes sense) and this person was able to mediate with the administrators in my program to help resolve my situation. When I first mentioned the possibility of Title IX discrimination to my professor and administrators, my professor responded saying that she’d only give me the opportunity to complete 25 points of “extra credit,” to try to make up for my absence, and it had to be complete within 14 days of the last class in the course. However, her “compromise” wasn’t nearly enough to make up for what I could miss out on, and she treated me like she was just doing me a favor. But when the Title IX advisor got in touch with my school’s Provost, together, they must have realized that the professor was treading dangerous, discriminatory ground, and they announced to me that they were coming up with an appropriate solution. They explained that, by law, I was entitled to the same consideration as any student experiencing a medical condition or emergency. This meant that I must be given the opportunity to earn all the points available in the class, even the Attendance & Participation points, even if I couldn’t physically be sitting in class with the other students.

When the dust settled, the administration outlined a plan that allowed me to do written work to make up for any absences, and gave me a full six weeks after the last class to submit all of my work. And after all of that? I returned to that class just SIX days postpartum, with my newborn baby strapped to my chest, and finished out the semester alongside my classmates. I decided I’d rather just go to class than do the extra written work that was piling up from missing class. It was honestly just easier to sit there nursing my baby and participating in class discussion than it was to try to write pages upon pages of papers with her at home. And for the record, my fellow students (mostly mothers) were outraged at what I had been put through, and felt I should have been allowed to simply miss the class during the birth without being forced to do makeup work. Contrary to my advisor’s statement, my fellow students weren’t worried about what was “fair” to them – they just wanted me to have my baby without being stressed out.

Either way, six weeks after the class was over, all of my coursework was turned in, and I received my grade. An A-.

Inside just a few short weeks, I had an A- and a baby. I’ll take that.

Not for nothing, I also earned a perfect A in my other class – the class with the professor who never once batted an eye at me missing class to have my baby, and who didn’t make me do even once ounce of extra work to make up for it.

The moral of this story is this: Pregnant students have rights. It is your right to stay in school. It is your right to be treated fairly and equitably by the faculty and administration. It is your right to earn the same points available to any other non-pregnant student. It is your right to have a baby, and a career. Forty years ago, women worked very hard to get these protections written into federal law, so know they are there, and spread the word.

Breastfeeding, Guest Posts, Legal Issues Facebook, Gina, Legal Corner, Melanie Ross Levin, National Women's Law Center, pregnant student, pregnant women's legal rights, The Feminist Breeder, Title IX of the Education Amendments Act