Chapters Transcript Caring for People with Diverse Gender Identities in Pregnancy and Beyond Course: Improving Practice In Obstetrics & Gynecology 2024 Annual Symposium Um, I'm gonna be talking about caring for people with diverse gender identities and pregnancy and beyond, um, I don't have any financial conflicts of interest to disclose, um, but I like to tell the audiences that I speak about this topic with, um, a little bit about me, uh, cause these are characteristics of myself that inform how I look at this topic. Um, first, I've, as mentioned, I'm a maternal fetal medicine subspecialist. I'm a cisgender and heterosexual man. I'm very aware of the privileges that comes with those uh characteristics. Um, I keep that in mind as I perceive myself as an ally in this space. Um, and I'm also, uh, the parent of a gender diverse teenager. When I started giving these talks, I used to say, uh, a gender diverse. Kid or child, uh, but my, uh, my, my child is now 13 and uh is officially a teenager. So all of this comes together to inform how I look at this topic, um, and, um, why I'm so interested in, um, promoting, affirming and inclusive care in our spaces. Here are my objectives for the talk. Um, we'll start with the basics and, and really delve into concepts that we all need to know, uh, including gender and sex. Then we'll talk about a framework for caring for people with diverse gender identities, a framework that I found to be very useful. And then we'll talk about pregnancy. Uh, we're specifically focusing on transgender men and gender diverse people who are assigned female sex at birth. We will talk about pregnancy management and outcomes. Um, and then finally, we'll conclude with the discussion about strategies to promote inclusive care in all of the clinical spaces that we're working in. So we'll get started with some background and I like it to be the basics, so we're all on the same page. Um, I, I think we live in a very binary society. I am I encounter this every day in the ultrasound unit when patients come in for their anatomy ultrasound. The first question is not, is this baby structurally normal or is the growth good? No, uh, it's, is it a boy or a girl? Uh, so we live in a very binary society. But not everyone fits into this, uh, this society, these binary notions. Um, many people don't have, uh, you know, binary, uh, man or woman identities, and, uh, they may not feel comfortable coming to us for care, um, and so that's why we're here today, at least I'm talking about this, how, uh, we can make everyone feel comfortable coming to us for care. How big is the LGBTQ community in the United States? Uh, we can turn to the 2024 Gallup poll for some information on this. Um, this is a survey of American adults, um, and, uh, with 2023 data, we see that the prevalence of LGBTQ identities among adults in the United States is 7.6%. Uh, we've noticed the last couple of years that this numbers really plateaued. Um, I'm not sure if that's just because this is the actual size of the community, or if there's a little bit of fear about being open about, um, honest identities, uh, in the current political and cultural climate here. So 7.6% is the prevalence of uh LGBTQ identities among American adults. The um Williams Institute published some data in June of 2023. Uh, at least 1.3 million adults identify as transgender in the United States. That's a lot of people with birthing potential who will be getting care with us, um, and many, uh, over 300,000 youth identify as transgender as well. I love these statues. I find them to be very interesting. These are sculptures. I don't know if anyone's ever seen them before. They were unveiled in 1943. Um, a sculptor, an artist named Abram Belsky was working with an obstetrician to create um sculptures of the typical man and the typical woman, Norman and Norma. Um, that's the, that's their, their names. Um, they took anthropomorphic measurements of over 15,000 people, men and women, mostly white people, to create sculptures of what they thought were the typical man and the typical woman. The problem with this exercise is gender is an internal and personal perception of oneself. What someone looks like externally does not always align with one's gender identity. So I give these two gentlemen credit uh for this, this uh experiment, but I think it's a failure because it doesn't actually reflect typical man or woman. So, how can we delve into identity and gender and sex? So let's talk about the four pillars of identity. Uh, this is one way to do this, and I think it's very easy, and I'm gonna go through it again at a basic level, just so we're on the same page. Um, and this is somewhat simplified. So sex is typically assigned at birth based on the appearance of external genitalia, what's between the legs. Um, male and female are sex categories. Obviously some intersex people don't fit into this, but for simplicity, male and female are sex categories, and that is determined based on, uh, the, you know, what, what, what we find at birth, um, you know, the external manifestations of, of sex. Um, gender identity again is a perception, a personal perception of oneself on the spectrum of man to woman. Many people are non-binary and don't conform or are not even on the spectrum, but just for simplicity, man and woman are gender categories, whereas male and female are sex categories, and generally these two align and that those people who have aligning sex assigned at birth and gender identities are cisgender. When there is not alignment, those people are transgender. Um, gender expression is how one hourly manifests their gender identity, uh, as masculine or feminine or other, um, I manifest with, uh, with a tie and a beard as as masculine, or at least I try to, um, and, and, uh, sexual orientation can be further divided into practice and behavior, um, you know, uh, spectrum of attracted to men, practiced women, attracted to both or attracted to nobody. OK, so, this is my pillars. Um, I've already alluded to this. You don't usually get this amount of insight into the person speaking to you. Bear with me. So I was assigned male sex at birth. My gender identity is that of a man. I am cisgender. Um, again, I told you a little about how, how I manifest my, my, uh, gender, uh, identity, my masculine gender expression, and I'm attracted to women or more specifically to my wife. That always gets a laugh. All right, um, now I'm gonna, so I'm a, I'm a cisgender heterosexual man, that's me. Now, I'm gonna turn to my, my colleague, my friend, my mentor, Tristan Rees, who is a trans advocate in Oregon. Um, his pillars are very different than mine. Um, Tristan was assigned female sex at birth based on the appearance of external genitalia. Um, he was, uh, assigned female sex at birth, but knew from a very young age, was a boy, and he grew into a man. So, uh, Tristan is a cisgender, excuse me, he is a transgender man. Now his manifestation of his gender identity, this is where he puts himself close to the masculine spectrum. He says he uses his hands and just just gesticulates in a certain way that may not be entirely masculine, but that's his manifestation of his external um uh gender expression, and he wears it has a beard, that's that's Tristan. Uh, Tristan is married to a man, he is a gay man, um, and he, he, they have 3 children together. Um, so, so, um, and including one that Tristan had biologically. So this is Tristan's pillars. He's a transgender man who is gay, um, and again, you can't assume, uh, one's identity just based on their appearance, we really have to ask to really tease this out. I've already gone over this just to be clear, cisgender people have gender identities that align with their sex assigned at birth, whereas transgender people have gender identities that do not align with their sex assigned at birth, and gender diverse people may not have the gender identity that can, um, that sort of conforms to the prevailing notions of gender. You, you've heard a lot of terms for this, gender fluid, gender expansive, gender creative, um, gender diverse is the preferred term right now, all, all saying the same thing. What about transitioning? Um, transitioning is the process whereby somebody lives outwardly in their true identity and self. Um, the transition process has various aspects and it is personal and it is unique and everybody is on a different stage. So you can be sitting in front of somebody who looks like a woman who is who in their heart identifies as a man, and they're just maybe beginning their journey, or that's their journey. They don't want to outwardly look like a man. So we can't assume, and everybody's transition journey is is different and unique. The reason I like to emphasize this, because if we think about it, We care for people every day who have diverse gender identities. We may not recognize this. When I was just starting in this field, I said to some of my colleagues, I said, where are the transgender people? I want to get to know them. I wanna take care of them. Where are the non non-binary people? And the the my colleagues in this field said, you're just not asking the questions, they're in front of you every day, so please keep that in mind. All right, that is part one, that is the background, and now we're gonna jump into a very useful framework for interacting with people who have diverse identities, uh, one that I find very useful, this was proposed by Juno Obiden Maliver, um, in 2019. It's the three principles, and I, I find it very useful. Principle number one. Principle number one says that transgender and gender diverse people are different from cisgender and heterosexual people. What are we talking about here? Here we're talking about minority stress theory. People who are transgender or gender diverse face challenges living in our our binary world. Lots of studies have come out that have shown that transgender or gender diverse people face discrimination, stigma, neglect, and poor treatment, even in their doctor's office. Um, they have to teach their doctors how to care for them. Um, and they're less likely to obtain preventative care, and when they do come for care, it's often in advanced stages of disease where outcomes are worse. So this is minority stress theory. I'm gonna further illustrate principle number one with this figure. This comes from the 2015 US Transgender survey. At the time, it was the largest survey of transgender adults in the United States. Um, and this figure asks, uh, transgender people about their negative experiences, including homelessness, suicide, and psychological distress. The respondents' answers were stratified based on the dark blue row, which is the percent of respondents who came from families that were supportive. And then the light blue row is the percent of respondents who came from families that were not supportive. So, if you look at the light blue row, trans people who come from unsupportive families obviously have extremely high rates of homeless, suicide, and psychological distress. They don't get support anywhere. Take a look at the dark blue row. These are transgender people who come from supportive families, and they still experience extremely high rates of homelessness, suicide, and psychological distress. We, we as parents and family. We can provide support, but we cannot block all the impact of society, right? Society is huge and this really speaks to principle number one, reminds us about minority stress that um transgender gender diverse people who are different from people who are cisgender heterosexual. Principle number 2. Transgender and gender diverse people are the same as cisgender and straight people. What are we talking about here? Fundamental principles of biology and anatomy. If you are born with a vagina, a uterus, and ovaries, you are at risk for complications related to those organs. Um, transgender people, gender diverse people need routine preventative health care, full spectrum family planning, cancer, and STIs, uh, screening and treatment. Um, this is just biology and anatomy. So to illustrate principle number 2, I will share a case report, a case report that was high enough impact that it was published in the New England Journal of Medicine in 2019. Um this is published by Daphna Strumsa and their colleagues from the University of Michigan. And this is the story or the case of Sam, who, uh, at 32 years of age, um, was a transgender man. He lost his insurance and he had to stop his testosterone, and he had to stop his anti-hypertensive medications. One day Sam awoke with abdominal pain, severe abdominal pain. He had no idea what was going on. He took a pregnancy test and it was positive. He didn't know what to make of that. So he went to the hospital. And when he arrived at the hospital, he gave the information that was relevant to the team taking care of him. He was a transgender man, he stopped taking his medicines. When he lost his insurance, he had pain. What the team saw was a, was a man who was hypertensive. It turns out he was profoundly hypertensive and in the context of the pain, the most likely explanation here was hypertensive urgency, and that's how Sam was evaluated and initially treated. And it was not till several hours later that it was recognized that Sam was pregnant, and that Sam was pregnant at advanced gestational age, um, and then when he was ultimately examined, he was 4 to 5 centimeters dilated with a cord prolapse and a, and a fetal demise. So a very sad case that illustrates the powers and limits of classification, um, but also reminds us about principle number 2, that transgender and gender diverse people are the same. OK, and I think this is really my favorite principle, principle number 3, which is that, um, everybody is unique, everybody's different, transgender, gender diverse people are unique from one another and from others. Um, there are so many experiences and uh You know, aspects of our lives that inform who we are and how we look at the world and how we interact with healthcare. Nobody wants to be thought of as the diabetic in room 2. Nobody wants to be thought of as the transgender man who's pregnant. There's so many different aspects of our lives that we need to keep into consideration when we're interacting with people who have diverse identities. So those are the three principles. I think they're very useful way of framework to to interact with and use when we're when we're engaging uh people of diverse gender identities uh in pregnancy and beyond. OK, so I'll take a breath for a second. We're moving to the, the meat of this presentation, which is, uh, pregnancy, um, and that's where we'll talk about next. The community of transgender men who are getting pregnant seems to be getting bigger. Um, we see images of men who are pregnant on in the lay media all the time. Um, the data that has emerged to inform our understanding of their outcomes and care has not caught up. I think what I'm gonna share with you now really is derived from cross-sectional surveys, uh, case series, expert opinions. Um, we need a whole lot more high quality data to really understand the unique needs, risks, and, um, strategies to optimize care for transgender men and gender diverse people, but I'm gonna share with you the best available data that we have. The first question that comes up often is how many transgender people can get pregnant. Um, And what we've learned is that most transgender men and gender diverse people retain their reproductive organs and their ability and their capacity to get pregnant. Uh, if we turn to that 2015 transgender survey that I mentioned previously, um, uh, these adult respondents were asked about the surgeries that they had had in the past and the surgeries that they wanted to have in the future, and among transgender men, 14% had had a hysterectomy, 2/3, about 57%, were thinking that they would want to have a hysterectomy someday. So most retain their uterus. This figure is um non-binary respondents uh or the term we use now uh gender diverse people. Only 2% had had a hysterectomy in the past, and about a third were thinking about having in the future. So among transgender men and gender diverse people were assigned female sex at birth, the majority retained their their reproductive organs and their capacity to get pregnant. What about intent? Intent, um, well, gender identity doesn't seem to to impact, um, reproductive intent. The, the interest in pregnancy appears to be the same for transgender people and cisgender people. Pregnancies are highly desired and uh intended, um, they are perceived sometimes as that just thing you gotta do that that necessary. To, to have your, your family, um, and of course there's a whole lot of unintended pregnancies in the trans community and the gender diverse community and in the cisgender community. So, so the one's gender identity doesn't actually seem to impact or change uh reproductive desires. So we know that transgender men have their uteruses and many of them want to get pregnant. What is the actual prevalence? I've already told you, it appears that the community is growing in size, at least on the the lay uh media. Um, it's really not clear, um, the demographic breakdown remains understudied, but we can turn to some data for information and In particular, there was a cross-sectional survey that was published by Heidi Mosson and her colleagues at Stanford. Um, it was in 2020 when this data came out. It was a cross-sectionual survey of about 1600, actually 1694 transgender and gender diverse people. They were all assigned female sex at birth, and they were asked about their prior pregnancy experience. They limited the analysis to those people who were under the age of 45, those people who had not had a hysterectomy. Um, and those people who had sex where sperm was released in or near a vagina, and they found that 12% of patients in this population had a prior pregnancy for a prevalence rate of about 16.8 per 1000 pregnancies. So this is really the best estimate of what we have about transgender gender diverse pregnancy currently in the United States. What about testosterone. Testosterone is gender affirming hormone therapy, it's masculizing hormone therapy, it's life saving hormone therapy. Um, it is medication that leads to secondary sex characteristics and other changes like thickening the vocal cords, some more male sounding voice, um, not. All people who are transgender or gene verse use testosterone, but it is potentially tratogenic, can lead to virilization of the female genitalia of a fetus. And so we encourage patients who are considering pregnancy to stop T prior to pregnancy or to stop it as soon as they get pregnant. Antipartum care Maybe this isn't so surprising, but antepartum care for transgender and gender diverse people, for the most part is the same as for cisgender people. One's one's gender identity doesn't really impact most of what we do. Prenatal diagnosis and screening is the same, uh, so ultrasounds, fetal surveillance, it's, it's for the most part the same. So the majority of the care we provide to transgender and gender diverse people who are pregnant is exactly the same. I think we think a lot about The potential psychological challenges that come with being pregnant. Um, pregnancy is an extremely gendered act or or process, um, and it can cause psychological distress for some people. Um, many people in this community spend their whole lives transitioning from their sex assigned at birth, and pregnancy pushes them back, and that can be hard for some, but not all people. Um, pregnancy really forces those individuals to face the fact that they have female reproductive organs, like they have a uterus, um, that can be hard, um, and that can trigger, uh, gender dysphoria. The definition of gender dysphoria, just to be clear, is the psychological distress that some, but not all people experience when there's a conflict between one's gender identity. Um, and their sex assigned at birth. Some, but not all people experience this, but it's something we have to look for, we have to make sure we're, we're attuned to that and providing appropriate support. Like I said, some but not all people experience gender dysphoria or worsening depression in pregnancy. Not all of them do. Not all people in this community do. In fact, many have wonderful pregnancies and they um they don't have problems with it. But one transgender man said, pregnancy and childbirth were very male experiences for me. When I birthed my children, I was born into fatherhood. I think this is a really neat idea. It's actually funny cause my wife said to me many times, I wish you could experience one second of a pregnancy to know what I'm going through, uh, which I, I, I have not been able to do, but this gentleman can. So to experience pregnancy and to have that be a male experience is a really interesting idea, but as providers, we have to help. We have to find ways to affirm their identities in labor during the pre the pregnancy process, and there are simple ways we. Can do it in some cases like using the word dad. If a patient says, I'm not a mom, I'm going to be a dad, then when that person's pushing, we can encourage dad to push harder, things like that. Finding ways to affirm one's male identity or non-binary identity, it's affirming and can allow these people to have a wonderful experience in pregnancy. Where do transgender and gender diverse people come for care? Um, What we have learned is the majority of transgender men will come to obstetrical care in hospitals and deliver with physicians. Um, but, um, what we see is that this population prefers to get care with non-physician providers and to deliver in alternative locations like home at much, much higher rates. This is, this is data from an early survey of transgender men, almost 60% delivered with non-physician providers and almost 20% delivered at home, way. More than the cisgender population. What's the reason for this? Um, I think it's unclear if we're looking at what the science says, but I think it's probably true that this is largely because of our negative experiences in the traditional healthcare system or concerns about prejudice or mistreatment. Um, and I think this is something we should all acknowledge is, is an opportunity. We want all patients to feel comfortable coming uh to us for care. I especially want patients delivering not at home, come to us for care. OK. What about mode of delivery? Um, this is actually one of the things that was most surprising to me when I, uh, engaged this population. The majority of transgender men will have vaginal births. Now they, they may not like the term vaginal birth very much and prefer different terms. I've had patients prefer terms like genital delivery. It was a little awkward to me, but that's not the goal. The goal is to make patients comfortable and preferring picking a term that aligns with what they want to refer to that, that process. So in Heidi Mosson's study, the one where we learned the transgender pregnancy prevalence, 77% of those transgender and gender diverse people had vaginal births. Uh, but in a smaller study, we saw a trend towards more people who had received testosterone in the past having C-sections. In fact, in that one survey, we saw only uh cesareans by birthing person requests, the elective C-section, in among the transgender men who had had testosterone in the past. So it's, it's a conversation allowing patients to make a decision that is best for them, but we have to not assume that all of these people are gonna want a C-section. They actually often are supportive of a natural birth. What about outcomes? Um, I mentioned we don't have enough data on this, um, but in, in, um, California in 2016, birth certificates were modified to allow parents, uh, and specifically the birthing parent to identify as a mother, a father, or a parent. So from this change. In the birth certificate, we were able to gather data about birthing fathers and explore their obstetrical outcomes. Um, so the question posed, this is by Stephanie Leonard also out of Stanford, uh, compared to mother father partnerships, what are the risks of adverse outcomes when the father is the birthing person? And this is a table that has, it's hard to read. I apologize. We had 1.4 million mother father partnerships where the birthing person was a mother, just about 500 father birthing people, presumably transgender men, and the outcomes were really good. Um, we did see an increase in multi fetal gestations among transgender men. Um, this is probably attributed to the use of cis reduction in this population, but generally speaking, there was not an increase in hypertensive disorders, cesarean birth, postpartum hemorrhage, severe morbidity, and and for this they're actually talking about severe maternal morbidity, but just referring to it in an inclusive way as severe morbidity, no increase. Um, so really this was a lot of reassuring data. It's probably flawed by misclassification bias. I recognize that, um, and we need more granular data here, but at least this picture suggests that transgender men who are having pregnancies and outcomes uh are having similar results to cisgender people. What about chest feeding? Uh, so what is chest feeding? Chest feeding is breastfeeding, it's just that the gender neutral term for it. Um, chest feeding is extremely gendered, um, and is triggering for many people, but what we have learned is many, many transgender people will chest feed. Um, in fact, interestingly, many people who want to have top surgery or mastectomy will defer surgery till after the childbearing years, so they have the opportunity to, uh, to nurse their, their babies themselves, which I think is pretty cool. Um, so most, or not most, many transgender men and gender diverse people will chest feed. Um, it's, it's, uh, it's helping patients to make the decision that's best for them, being nonjudgmental and supporting those people who want to do it. Um, in one study, 51% did chest feed. Um, testosterone is not recommended, uh, with, with, with chest feeding, um, probably small amounts across the into the into the milk, um, the risk is unclear, but we're just conservative at this time in saying that testosterone is not recommended with uh breastfeeding with or with chest feeding. All right, testosterone and uh contraception. Um, For those people who are not chest feeding, um, we generally say it's OK to resume, uh, testosterone at 4 to 6 weeks, um, after delivery. Now, there are some people who think that's way too long to wait and they want to get it restarted as soon as possible and shared decision making, and some patients may choose to restart testosterone at, uh, you know, even sooner than waiting 4 to 6 weeks. But the data is not great to inform this practice, and we just sort of follow guidelines for a resumption of oral contraception. What about contraception, uh, in general, um, the actually the um most utilized method, uh, in this population is condoms, um, and, um, it's a great option if it's used consistently, um, and actually significantly underutilized method is uh uh long acting reversible methods, uh, like the progestin only IUDs. Um, when I have talked about this with patients, I always reinforce that the progestin only methods are highly effective and reliable. They also don't interfere with masculinization therapy if you're on tea or testosterone, um, and they make a favorable menstrual profile for lots of people. So it's a great option, but again, we want patients not always to get the most effective method of contraception, we want them to get the best method for them, um, but it's just a conversation. All right. So that's part three, it's a deep dive into what we know about uh pregnancy, and the concluding portion of the talk, we're gonna talk about strategies to promote uh inclusion and uh gender affirmation in our clinical practices. Why do I think this is important? And just to be clear, um, I think that when we take these little steps to affirm the identities of our patients, what we're doing here is building uh that trusting relationship. It's, it's about that patient and physician or provider trust, um, and I think many in this community don't. Have at right now and it's because of prior negative experiences and concerns about future negative experiences. Little things that we do, little changes in our interactions have a big impact in bringing that trust and strengthening that stress, um, so that's what we're gonna talk about now. Heidi Moson published a really nice paper in the Green Journal a couple years ago where she talked about strategies that we can employ in clinical settings in research settings and in other academic settings, uh, to move away from those marginalizing practices that are part of what we do every day and to move in towards inclusive practices as well I'll just share a couple of examples or 3 examples. Instead of us asking consistently uh for patients' legal names. Or or their sex, we should systematically allow patients to indicate their gender identity and how they wish to be addressed, systematically allow patients to indicate their gender identity and how they wish to be addressed. Instead of relying on patients to offer uh for their pronouns, create a culture in which clinic staff introduce themselves with their pronouns and include pronouns on staff identification badges. These little badges, signs of allyship, they're little, but they go a long way. Instead of assuming clinical terms for body parts, you have to ask questions, what body parts do you have? um, and how do those patients want to refer to their body parts? That's always a little bit in an interesting conversation too, cause everybody has interesting names for how they like to refer to their their genitalia, very, very interesting area um to explore with your patients. OK. We also have to remember the principles of trauma informed care. This came up in the last talk, which was excellent, by the way, um, we have to acknowledge that many transgender and gender diverse people have experienced traumatic events and that that that have affected their lives and how they interact with and engage with health care. Um, it is, it is really true that some of the things that we do can actually re-traumatize our patients. Uh, we think of a pelvic exam. Um, it's a, it's an opportunity. Um, there are ways where if we employ, uh, trauma informed care where we can be mindful of this, uh, for example, when you're going to do a pelvic exam, some people prefer the term lower genital exam, have a support person in the room for hand holding or support. That's, that is a simple step that you can do. Uh, there are some situations where maybe we don't need to actually do the exam. We can have the patient collect a GBS swab for themselves or uh STI swabs. This has been done in the GYN world and absolutely can be done in obstetrics too. So trauma informed care. How about creating an inclusive environment, um, this involves sort of structural changes um to our system. Um, we think about talking and training for people who are, um, seeing patients, patient facing, but we need to remember that the patient's experience starts the second they walk into our system. And so we need to make sure that everybody gets training to care for people with diverse identities, not just the clinicians and the, the physicians, uh, the patient facing folks, um, again, lobotomists, the person who opens the door, elevator people all, all people need this training. Uh, we need to review office spaces to ensure that images chosen represent all individuals who seek care. Um, we need to clearly post a sign, uh, with the office's nondiscrimination policy. I'd love to see that when I walk into an office and it's right in the lobby. I love that. Um, and I also love it when we can ensure that there's at least one gender neutral restroom that's accessible and visible for all patients. These guidelines came from ACOG, um, and ACOG's been a good friend to the, to this community, and I, I, these are simple. Strategies we can, we can take to uh change the built environment and make a more inclusive and welcoming place. So I found this online. This is not NYU, um, this is a fairly typical gynecologist's office. But what is, what is this saying? What are these bathroom signs saying? What they're saying is, we care for cisgender women here. And there's lots of people who have the need for medical care, who don't identify or who are not cisgender women, so we can do better. Here are a couple of examples. Um, on the left here is the AMA's sample, uh, non-discrimination policy. It's, it's very simple. It says we do not discriminate based on race, age, religion, ability, marital status, sexual orientation, sex or gender identity. It's perfect. Um, and on the right is a all gender restroom sign. I like this sign because it doesn't have a figure of a man or a woman, right, that to somebody who's in the know about this, that that man and a woman is a cisgender man and a cisgender woman. This just tells you what's there, there's a toilet, and anybody can use it. Here's what we have at Tish on the left. I'm excited about this. I'm proud of this. We, uh, before I joined the faculty, um, they got rid of the mother baby floor and renamed it the family care suite. It's an inclusive name that really covers all the people who are gonna be getting care there. Um, and then, um, at our fifty-Third Street Ambulatory care center, we got rid of the, the, the bathroom signs that had little man and little woman, and we, we replaced it with this. This was approved by the, the enterprise, um, but it's, it's for those in the know, it's an affirming sign. It says anybody can use this bathroom and nobody has to feel uncomfortable because there there's a bathroom that's not for them. All right, so the last part of my talk here is just about research. I think we need a whole lot more high quality research so we know how to take better care for people with diverse gender identities, um, and I also think we need to adhere to gender inclusive research practices. When we adhere to inclusive research practices, we are going to include those individuals who've historically been excluded from research, and we're gonna get a whole lot more high quality data. Um, one of my fellows, um, and I did a small study, we looked at all OBGYN journals that are indexed in PubMed, and we looked at the submission, excuse me, author submission guidelines and the requirements. And we found that 41 or about uh almost 34% of OBGYN journals had specific instructions for the use of inclusive research practices and inclusive language requirements. Only a third of our journals in OBGYN recommended the use of inclusive practices in the, in their, in their research. Um, interestingly, what we found is that those inclusive journals that had this, these requirements had significantly higher metrics for research influence, so much higher journal impact factors, those papers got more citations. Um, so although this is an early and small study, it gives us two things to think about. When we use inclusive research practices, we include those people who've historically been excluded from research. I think that's that's important, and for those of us looking to get promoted, higher metrics of research inputs, more citations, higher age scores, it's all good. All right. Um, now, uh, another small study was performed by a group in 2022. They took a random sample of 500 articles in in OBGYN journals, but also in general medicine and surgery journals, and they just asked the question, how many of those papers used gender inclusive language, and they found that 1.2% of these 500 articles actually used inclusive language. Now, the authors of this paper. They are very clear about it. They say this is just bad, this is just bad, we can do better. But I wanna add some nuance here and say I slightly disagree with the author's conclusion, OK? So, this is a table where we're going to distinguish between gendered language, gender inclusive language, and gender additive language, OK? So if we are doing a research study and if we are sure that a group is uniformly cisgender women, we should refer to the group as cisgender women or as women, pregnant women, pregnant women, very simple. If we're not sure and that's where I would say we need to think about this, most of the time we're not systematically evaluating the gender of our our sample sizes or our groups. Um, and in that case, I think it is more accurate to use language like pregnant people or birthing people because we're not sure that includes some people who are women and some people who have, who are, who have non-binary or gender diverse identities. I also love this concept of gender additive language. Lots of people like this, so we're recognizing that there are women in a group and there are birthing people who do not have women identities or mother identities, and so we would refer to the group of women and people. So that's gender additive language. So although I should. Shared the data from the prior slide where a group said we should always use inclusive language. I just want to point out that if we know the group is uniformly women, we should be referring to women when we're not sure that's when we should be using either inclusive language or gender added language. So just some examples of research strategies that are inclusive. So when we're making our demographics stable, we need to make sure we're considering all relevant identities. That's how we capture those people who've been historically excluded from research. Lean into your four pillars if you want guidance there. Um, what about inclusion exclusion criteria? Do we want women to be in this study of her pregnancy or do we want all people who have birthing potential, right? If somebody is a cisgender woman who's had a hysterectomy, they're not gonna be able to write answers about pregnancy study too, right? So be specific about your inclusion criteria. Um, administrative data. So administrative data is, is widely used and gives us a whole lot of information, um, about, uh, outcomes for patients in, in all fields. The, those administrative data sets usually break down people into men and women, gender categories, but really I'm gonna argue that's actually not right. Those are actually sex categories, and when we use administrative data, we should be talking about males and females, sex categories, not men and women, which are gender categories. And then finally, um, if we want to promote research like this, we need to make sure we have community engagement and that we have editorial boards that have diverse staff, people that include LGBTQ folks who are going to advocate for making sure we have inclusive research practices and that all people are included in this type of research. Um, in 2021, on behalf of the Society for Maternal Fetal Medicine, um, I authored this statement, um, again on behalf of SMFM, and it, it really just reminded all of us that it is our professional obligation to adhere to, um, inclusive and affirming practices in in the clinical settings where we work, but also in in the teaching and in the research that occupies so much of our time. So what can we do today, what should you do today? It feels overwhelming to change everything. Some simple things you can do right now, if you haven't already done that, I've done this. Number one, introduce yourself to your patients, their name, your title, and your pronouns. Put on a pin if that's easier for you. Um, add your pronouns to your signature line of your emails, especially in patient facing correspondence. It's very small but effective task, uh, thing to do. Um, and then I would encourage us to ensure that our office registration forms have multiple gender options including woman, man, non-binary or or gender diverse, another and give people the opportunity not to disclose as well. If you're looking for um an educational resource, you can um you can scan this QR code. I know that these slides will be available afterwards as well. And uh thank you. I'm available to talk if anyone has any questions. Published November 15, 2024 Created by Related Presenters Justin Brandt, MD View full profile
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