Transgender patients face challenges in health care – Lyon-Martin in the News!

Posted Thursday, November 20, 2014

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By Erin Allday, November 19, 2014

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Cameron McCaugherty would like to get pregnant someday. And that’s not a desire, he says, that contradicts his identity as trans-masculine and genderqueer.

“People who know me and see me as masculine, they say, ‘Really? You would want to be pregnant? Don’t you want to be a dude?’” said McCaugherty, 27. “And I’m like, ‘I don’t want to be a dude, I want to be me.’”

McCaugherty’s thoughts on pregnancy were reflected in a study released earlier this month by UCSF scientists who surveyed 41 transgender men who had given birth. McCaugherty was not part of the survey. He said he doesn’t really identify as a transgender man anyway, but he wasn’t surprised to learn that participants’ responses ran a wide spectrum.

Some transgender men found pregnancy distressing and awkward, while others said the experience helped them feel more comfortable in their own bodies. Several respondents said they saw pregnancy as a necessary but unpleasant means to creating the family they wanted — others looked forward to and enjoyed the experience.

The survey, due to its small size, raised more questions than answers about transgender pregnancy. The participants’ experiences in some ways matched those of non-transgender women, but in other ways were decidedly nontraditional. On the whole, the study underscored a host of health problems and disparities that are barriers to care for the larger transgender population and not just transgender men having babies, the UCSF team said.

“Trans people are invisible within health care. They’re seen as this very fringe minority,” said Jae Sevelius, a psychologist with the Center of Excellence for Transgender Health at UCSF and one of the pregnancy paper authors.

“But the main thrust of this paper is that transgender people are out there, they’re everywhere, and the health care field is not adequately serving them,” Sevelius added. “We’re not equipped to answer their questions, to anticipate how we can best support them. And trans people are having really negative experiences in seeking health care.”

An umbrella term

“Transgender” is an umbrella word used to describe people whose gender identity is different from the sex they were assigned at birth. Some transgender men undergo surgery or take the hormone testosterone to change their bodies, but others identify as transgender without any medical intervention.

Transgender men and women are at higher risk of developing a wide array of health problems, and they often have less access to health care due to low rates of employment or insurance coverage. When they do seek treatment, transgender people may face stigma or outright hostility from those providing health care.

Even in “safe” places like transgender clinics, they still may fear discrimination or have to deal with assumptions about their health needs that aren’t fair or accurate, said Dr. Nick Gorton, an emergency room doctor who volunteers at Lyon-Martin Health Services in its transgender clinic.

“I’ve had people come in here and be freaked out and defensive. As soon as they come in, they’re sweating and their heart is racing — and that’s here, at the Lyon-Martin clinic,” Gorton said. “That speaks to their expectation. And it’s not an unfounded fear.”

Research into transgender health issues is slim, and it is often focused on care related to transitioning from one sex to another. In the lesbian, gay, bisexual and transgender community, research first was focused on gay men because of the AIDS epidemic, and it’s since drifted toward lesbians and to other groups like people who are bisexual or men who don’t identify as gay but who have sex with other men.

But transgender health has been largely unstudied, the UCSF researchers said. Dr. Juno Obedin-Maliver, an obstetrician and gynecologist who has been active in the LGBT community for years, said she hadn’t thought much about transgender patients until one particularly upsetting experience.

“I was watching a transgender patient being mis-gendered at the time of their death, and understanding how profound that was, to both this person and their family,” Obedin-Maliver said. “Not to diminish the needs of LGB people, but this is a whole other level of discrimination and lack of access to care that affects transgender people, and it really needs some focused attention.”

The pregnancy study arose from a medical student, Alexis Light, wondering what to tell transgender friends who had questions about testosterone and the possible effects on pregnancy and childbirth. Light, who is now an obstetrician and gynecologist at Washington Hospital Center in Washington, D.C., realized she couldn’t give them factual, science-based answers, and decided she wanted to learn more.

The study was too small to answer specific questions about testosterone. But the research clearly suggests that doctors need to be doing a much better job discussing contraception, fertility and other family planning issues with transgender patients, Light said. In the survey, roughly a third of the respondents had unplanned pregnancies, and a little more than a third reported not using contraception regularly.

Many possible explanations

There may be many explanations for doctors not having conversations about family planning with transgender patients, said Light. Doctors may not know their patients are transgender. Also, doctors and patients alike may feel uncomfortable bringing up the subject.

Or in the case of transgender men, both patients and doctors may be so focused on transitioning from one sex to the other that issues of fertility aren’t a priority.

If one clear point comes out of the UCSF survey, it’s that transgender men are indeed getting pregnant and having babies, and it’s critical that mainstream health care providers acknowledge their medical needs, said Dr. Jennifer Kerns, a UCSF obstetrician and gynecologist who was senior author of the pregnancy paper.

“We need to pay attention and come up with an acceptable counseling approach to transgender men about fertility and what their desires are, just as we would with anybody coming into our offices,” Kerns said.

The survey respondents were much more likely to seek prenatal care from nontraditional sources, such as midwifes, than non-transgender women. They were also less likely to give birth in a hospital and more likely to have a baby at home.

Kerns said that as far as she knows, she’s never treated a transgender man who was pregnant. But she acknowledges that even though she’s worked with people in the LGBT community for years, she may still have patients who aren’t comfortable revealing that they are transgender to her.

And that, she said, is something that doctors have a responsibility to address. Rather than assume all of her pregnant patients — or any patients seeking gynecological care — identify as female, Kerns said she should probably be talking, and listening, to patients to make sure that’s the case.

“It’s the same lesson again and again — ask your patient who your patient is,” Kerns said. “Ask open-ended questions: ‘What was the experience of getting pregnant? Do you have a partner? Who is your partner? How do you identify?’ Often times, just asking those open-ended questions sets the tone that this could be a safe environment.”

Survey participants reported a wide range of responses from health care providers to their pregnancy, but several people said they’d had to deal with improper pronoun use, rude treatment and even being refused care. One participant, who was quoted in the survey, said he was reported to child protective services because “a tranny had a baby.”

Several survey respondents said they felt lonely or isolated during their pregnancy, since they didn’t know anyone else who shared their experiences.

Mixed reactions

McCaugherty said he has often felt as if it was his job to train his physicians and other health care providers how to appropriately talk to and work with transgender patients. He has a speech he gives new providers, and most appreciate it, but some are confused or judgmental.

Even McCaugherty, who works as a front-office manager at Lyon-Martin and is fairly confident talking about his gender and sexuality, said he has had terrible experiences with doctors. He has had new doctors call him by his given, female name, even though his chosen name is in his medical record. Health care providers have used the wrong pronouns for him, and once, a doctor assumed he was a lesbian.

“I’m usually an outgoing, honest, forthcoming person, and I’m used to people asking about my gender, my body and trans health,” McCaugherty said. “But with a doctor, it’s like I get shy and awkward. You’re so vulnerable with doctors. You want to get good care, and you don’t want to alienate anyone.”

Erin Allday is a San Francisco Chronicle staff writer. E-mail: eallday@sfchronicle.com

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