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Series: Welcoming All Families; Working with Gender Variant (Transgendered) Families

January 24th, 2013 by avatar

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. 

http://flic.kr/p/5vHahr

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.

Childbirth Education, Guest Posts, Legal Issues, Midwifery, Series: Welcoming All Families , , , , , , , , , ,

Close Up on Midwifery Care: A New Study Published in the Journal of Perinatal Education

December 14th, 2010 by avatar

The journal article referenced in this post may be accessed here (http://tinyurl.com/2azmhmg) for free, in the event you do not have access to the Journal of Perinatal Education on line—a benefit of Lamaze membership.

Introduction
As a childbirth educator, the Journal of Perinatal Education has been an amazingly helpful tool to me over the years.  Look through my copies of JPE, and you’ll find dog-eared pages, underline marks in varying ink colors, notes in the margins regarding how to implement a certain piece of knowledge into my class curriculum.

The current issue of JPE delivers yet again, and I want to highlight one article in particular, which I found interesting.

Maternity care and childbirth is, at the very heart of things, an intimate business.  And because so many of us have a vested and impassioned interest in how maternity care plays out—no matter what side of the fence we find ourselves on—there have been hundreds of studies completed and published about birth and all things related.

The purpose of this phenomenological study, Midwifery Care:  Reflections of Midwifery Clients, by Mary Ellen Doherty, PhD, RN, CNM, “was to describe the lived experience of midwifery clients throughout the life span.”  Not only did this study collect lived-experience data on women’s impressions of their midwifery care during pregnancy, labor and birth, but before, during and after their childbearing years as well.

There’s a lot to be said for the value of gathering data on care delivered by health professionals from the recipients of that care.

Methods
In-person interviews between Dr. Doherty and self-selected participants from four different New England midwifery practices took place over a three-month period.  The interviews, prompted by the open-ended question, “What has been your experience with midwifery care?” and following brief screening telephone calls, were audiotaped and transcribed verbatim, before grouping responses into broad, and eventually more detailed theme clusters.

One of the theme clusters that emerged during the data compilation and analysis phase of the study was Nurse-Midwives as Primary Health-Care Providers Throughout the Life Span.  Many people assume midwives deliver pregnancy-related care only.  And, in my experience, some midwives do choose (or are trained) to only offer perinatal care services—as is typical of Certified Professional and Direct Entry Midwifery training.  But take a look at the curricula offered by all nurse-midwifery programs, and you’ll find several courses on women’s health across the lifespan within each program.  This is, in fact, one of the core competencies as outlined by the American College of Nurse-Midwives.  This element of midwifery care—tending to women from menarche to menopause—seemed to be a recurrent theme in the study participants’ responses, as exemplified by this remark:

“I have been going to the same midwifery practice for about 10 years now…I started with my first pregnancy and never left.  The midwives do my annual exams, pap smear, check my diaphragm to make sure the fit is still good for birth control, and they have even cured a few vaginal infections along the way.”

Along with the theme of midwifery care across the lifespan, other topics that apparently emerged with great frequency were: Decision to Seek Midwifery Care, Working Together in a Therapeutic Alliance, Formulating a Birth Plan and Childbirth Education.  Epitomizing the reason a woman might choose midwifery care, came this statement from one study participant who also happened to be a former pediatric nurse:

“I guess I feel safe with nurses and totally subscribe to the belief that nurse-midwives are experts in normal birth and know when to get help if needed.  I like the fact that they stay with you during labor and don’t just come in at the last minute to catch the baby.”

Doherty goes on to provide many additional quotes from study participants, demonstrating their experiences with midwife-taught childbirth education classes, birth plan formulation and approaching a woman’s health care as a team:

“My midwife coached and supported me.  She always made me feel involved in the decision making and was so positive and encouraging.  She really tuned in to my feelings and behaviors during labor.  There was so much sensitivity.”

Analysis
The twelve participants in Doherty’s study seemed to lack the diversity I would like to have seen:  on average, they were Caucasian, highly educated and married to their baby’s father with a self-proclaimed financial status of “middle class.”  There was some variability in parity (nulliparous through multiparous x 4) and their average age was 34.5 years old.  Lastly, the women included in Doherty’s study all experienced vaginal, non-complicated births following low-risk, singleton pregnancies.  Resultantly, one could argue this subset of participants possessed a commonly biased experience of midwifery care.  For these reasons, I initially found myself questioning the overall generalizability of this study and was compelled to want to know more:  how many of the women who initially responded to brochures they saw/received at their health care provider’s office or the hospital laboratory were actually accepted into the study?  What were the inclusion criteria for this (beyond the stated basic criteria of ability to read, speak and comprehend English)?  What would the response theme clusters (and individual data) look like with a larger number of participants?

Some of these limitations are addressed by Dr. Doherty and countered with the stipulation that she felt data saturation had been sufficiently achieved during the interview process.  She also acknowledged the potential lack of generalizability, but explained this as a common and expected side effect of a phenomenological study.  Likewise, the number of study participants becomes less important than in, say an RCT, because data saturation suggests generalizability, in and of itself.  An enlightening follow-up study then, (as suggested by Dr. Doherty and expanded upon by yours truly) might be to assess and compare lived experiences of more subjects with varying characteristics, as well as across different models of maternity care (provided by different types of midwives, as well as family physicians and OBs), yet using the same interview question:  “What has been your experience with your health care provider?”

Final Thoughts
In re-visiting the themes that arose from the participants’ own depictions of their midwifery care experiences, the process and outcome of their birth experiences was, interestingly enough, not considered a major theme in and of itself.  The experiences associated with midwifery care which seemed to leave a lasting impression on these women revolved around what prompted them to choose midwifery care in the first place, along with the nature and quality of interaction between themselves and their midwives throughout the duration of their care.  Resultantly, this study offers us a categorical glance at the experience a woman might expect to have throughout the spectrum of midwifery care.  Aptly put, one of Dr. Doherty’s concluding remarks suggests,

“It is important for all women to learn about midwifery care, and one of the best ways to accomplish this is for them to listen to the voices of other women as they tell their stories.”

What are we, as maternity care professionals, doing to facilitate this sharing of stories?  Is it our role to connect women with each other and facilitate the oral exchange of lived experiences?  If so, how can we best do this?

Post by:  Kimmelin Hull, PA, LCCE

Healthy Care Practices, Journal of Perinatal Education, New Research, Research, Uncategorized , , , , , , , , , , ,