[Originally submitted as an assignment for MPH @ University of Manchester]
Community and Public Health Issue
The community in focus is the England’s transgender male and non-binary[1] childbearing community. Trans people are individuals whose gender identity falls outside the stereotypical gender norms of their biological sex. No definitive figures exist for how big the trans community is due to lack of research, fear of reprisals, no standardisation in definitions, and outdated data systems lacking recording capability[i] [ii] [iii] [iv] [v]. An approximation suggests around 600,000[vi] trans people live in the UK. We can assume the number of trans people is likely rising due to the increase in referrals to gender dysphoria clinics[vii]. Therefore, the trans childbearing community is likely rising too – although subject to the same recording and accuracy issues as the wider trans community – meaning providing gender-inclusive perinatal care is becoming more of a pressing concern for service providers.
Trans individuals are likely to have had previous negative experiences within healthcare settings and suffer from healthcare professionals (HCPs) not understanding their specific needs adequately[viii]. The trans childbearing community are trying to access services created for heterosexual ciswomen[2][ix] so information, clinical space and HCPs are usually heavily gendered, making it more difficult to access services from outside that binary. If trans people are unwilling or unable to adequately access perinatal services their and their baby’s health is risked. A public health central tenet is to prevent disease and improve health by offering services accessible to all; therefore ensuring gender-inclusive perinatal services is a public health issue.
Theory of Change
Problem:
Perinatal care is essential for the perinatal dyad; without it there are increased risks of adult and child morbidity and other serious adverse outcomes[x]. Trans people are at increased risk of not accessing healthcare services due to real or perceived stigma, discrimination and bias from HCPs, lack of cultural competency, systemic barriers such as inadequate IT systems and sociocultural barriers such as increased mental health challenges[xi] [xii] [xiii]. This is particularly an issue in perinatal healthcare where services are largely created by and for ciswomen, adding an additional cis-centric dynamic to accessing care, and where it is possible any experienced gender dysphoria can worsen.
Long-Term Goal:
Strategic aims of this health plan are to:
- Reduce the real/perceived stigma faced by trans childbearing people that stops them accessing perinatal care
- Improve the experience of the trans childbearing community accessing perinatal care
- Improve the health of trans childbearing individuals and their infants through the perinatal period.
These goals will be met when all trans childbearing people who want to access perinatal care do so, and in doing so no harm is caused emotionally or physically to the dyad.
Key Audience:
Stakeholders involved in this strategic plan will be trans childbearing individuals, perinatal care workers (including midwives, obstetricians, infant feeding workers, health visitors), and other HCPs e.g. endocrinologists, together with representation from Clinical Commissioning Groups and the VCSE sector.
Backwards Map from Goal:
Examination of the preceding stages from the long-term goals necessitate a collaborative approach from all identified stakeholders so all necessary changes before the goal can be met are considered.
To reduce overall stigma and improve the experiences of trans individuals accessing perinatal care there needs to be:
- Reduction of internalised stigma
- Reduction of healthcare stigma from individual practitioners
- Reduction of structural stigma
Which needs:
- Motivation to change from the institution and HCPs within it
- Belief from trans childbearing individuals that cultural change can occur
Which leads to accessibility of perinatal services for trans people through:
- Improved understanding of the challenges faced by the trans childbearing community leading to an increase in desire to help overcome these challenges
- Equipping HCPs with the skills and competencies needed to support the trans childbearing community
- Cultural changes in the behaviour of HCPs which leads to a visible awareness for the trans childbearing community
- Improvement in the existing structural systems
- Motivation of individuals to access a changing system for health gain
No change is independent of any other or relates only to one long-term outcome; they are symbiotic in nature therefore it is unrealistic to assume that a singular change will lead to a singular outcome. Coproduction is a vital part of the plan to ensure that the assumptions and underlying logic of approaches are valid and fit for all stakeholders, but particularly the service users.
Strategies and Interventions:
There is a paucity of research about trans childbearing experiences of pregnancy care in England; what little exists are small-scale qualitative studies, often undervalued in the medical world[xiv]. This failing of research existence results in organisations having little solid evidence to base the redesign of services on[xv].
A key principle underpinning all strategies is that they will be developed through true coproduction with relevant stakeholders including service users, to ensure they best fit the needs of the community (while recognising that the trans childbearing community has not one homogenous voice).
Strategies which have been published can be broadly grouped within the following themes.
Culturally Competent Training
HCPs often lack understanding and awareness of the trans childbearing community and the specific problems they face when accessing highly gendered healthcare services. To help alleviate this, cultural competence education including use of appropriate language should be given to staff[xvi]. Cultural competency can help staff interact with people they care for in a way that does not cause mental harm; for example, using correct pronouns, not deadnaming[3], misgendering or conflating gender identity with sexual orientation[xvii]. Fit-for-purpose cultural competency training can ensure HCPs provide appropriate medical care rather than subjecting trans individuals to superfluous and sometimes voyeuristic practices[xviii], or giving incorrect medical information[xix].
Cultural competency training would be included in this strategic plan to help meet the long-term goals. Training would be offered firstly to all core perinatal HCPs and then rolled out to affiliate HCPs. The training would impact on:
- improving understanding of challenges faced by the trans childbearing community by HCPs
- increasing HCPs’ skills and competencies to deal with diverse challenges
- increasing vocalness and visibility of trans rights and needs in pregnancy making perinatal care more accessible for the trans childbearing community
- reducing healthcare stigma, discrimination, and bias
- improving the experience of trans individuals accessing perinatal care
- improving the health of the trans childbearing community.
Limitations recognised by the strategic plan of this intervention are that:
- the trans childbearing community are not a homogenous group therefore their needs may be disparate; poorly designed training courses may give HCPs the impression that a one-size-fits-all approach is possible
- this specific type of education is relatively new; no research exists to evidence its efficacy other than anecdotal feedback. However, it is likely that it will have the same level of positive impact on patient outcomes as other types of cultural competency training[xx].
Assumptions made regarding training as a strategy to meet the long-term goal of this strategic plan are that:
- HCPs are not transphobic and any failings in service provision come from lack of understanding which can be overcome
- HCPs are motivated to better their awareness and understanding of the challenges faced by the trans childbearing community
- HCPs have the time to do additional training outside their caseloads
- the interpersonal skills needed to enable HCPs to provide care to trans people are teachable
- there is a supportive space for HCPs to learn in and competent experts to provide the training.
Although there may be logistical challenges in staff finding time for training these are not insurmountable, and it is likely an organisation considering such training will be supportive of people in that learning sphere. It is probably best to assume the good intentions of all workers to be motivated to do better unless proven otherwise[xxi] – which can be dealt with under an organisation’s disciplinary policy.
Individualised Care
The trans childbearing community are not a homogenous group and cannot be treated as such, needing a heterogeneric approach to care to match their diverse experiences. Personalised care is an integral to the NHS’ Long-Term Plan[xxii] and should be prioritised for the trans childbearing community through proportionate universalism.
One individualised approach needed is regarding language used. Some trans individuals have a definite preference for their gender identity, some are comfortable with a variety of terms (e.g. male, female-to-male, transman, assigned-female-at-birth)[xxiii]. Alongside this is pronoun choice; trans people have a more positive healthcare experience – and therefore less exposure to mental harm – when correct pronouns are used[xxiv]. There is also the degree of ‘outness’ both in terms of gender identity and pregnancy to consider: for some, being seen as male but not pregnant is critical to good health, for others being out as male and pregnant is important, for others passing as a cisgender woman while pregnant is how they feel safest[xxv]. Birth tends to be pathologised in England[xxvi] and it is possible that being trans in itself may put individuals onto a high-risk pathway even if there is no medical indication, increasing intervention rates with the potential of increasing physiological and mental harm[xxvii].
Specific interventions within this strategic theme to be implemented are:
- ensure individualised care through thoughtful conversations between pregnant person and culturally competent HCPs
- reduce the need for the “trans story” to be repeated (thereby causing mental trauma) by having continuity of carer, a strategy which itself improves perinatal outcomes for parent and child[xxviii]
- have language needs clearly identified “at a glance” on notes so professional contact remains consistent and accurate[xxix]
- not place on an obstetric pathway for trans status alone[xxx].
The impact on the strategic plan’s long-term goals is to:
- reduce stigma for the individual by building a close, personable relationship with a small team of carers
- increase the belief that ‘the system’ can meet the needs of a subjugated community, therefore making it more likely individuals within the trans childbearing community will seek future healthcare
- improve individuals experience within the perinatal system, reducing mental distress
- improve the health of the perinatal dyad by ensuring accessibility to fit-for-purpose services and staff.
The limitations of these interventions within this strategic plan may be that:
- self-identity is complex and may change as a pregnancy progresses, and may need more time, patience, and experience than an HCP has to give
- the maternity system is not resourced adequately to staff a pathway that requires more time; although continuity of carer pathways should be implemented for “most” birthing people by 2021[xxxi] there are already severe shortages in midwifery[xxxii] that means this is not happening[xxxiii].
Assumptions made with these strategic interventions are that:
- it matters to trans childbearing people how they are identified by others
- maternity services are resourced adequately to provide continuity of care and properly individualised care – not just lip-service.
These assumptions can be overcome by conducting transparent and open conversations with each individual. Resourcing is not so easy to challenge however the financial benefits of keeping parent-and-child healthy in the perinatal period can be used as a basis for a proposal for extra resources.
Systematic Change
The system within which perinatal services exist also needs change to meet the trans childbearing community’s need. There is institutional erasure of trans pregnant people: only one trans-inclusive maternity policy exists in England[xxxiv], IT systems do not have capacity to accurately record gender[xxxv] [xxxvi], physical space is aimed almost exclusively at women[xxxvii], and educational literature features predominantly heterosexual ciswomen.
Interventions which may positively impact on this area and will be included in the strategic plan are:
- creation of perinatal guidance and policies which are gender-inclusive
- redevelopment of physical space and literature to ensure representation
- upgrading of IT systems so perinatal gender options are representative.
The interventions would:
- improve the environment in which trans childbearing people access perinatal services, making services more accessible
- make it easier to accurately record a true gender identity, helping increase visibility and break down stigma, both individual and structural.
The limitations of these interventions are that:
- it may be costly to implement wide-scale change on infrastructure that is nationally devolved
- systematic change takes time
- there is likely to be resistance from people who lack education around the trans community[xxxviii].
Assumptions made regarding the implementation of this strategy are that:
- there are resources to implement wide-scale change
- there is appetite to do so on a wide-scale; national change needs a top-down approach and if the most senior leaders do not understand the importance of change it cannot happen at the scale it needs to.
Mental Health Focus
Poor mental health is a common theme for trans people navigating healthcare systems, especially perinatal services, therefore it is imperative that action is taken to improve the trans childbearing community’s mental health status.
Gender and genitalia dysphoria before pregnancy, antenatally, intrapartum, postpartum, and longer-term postnatally including infant feeding choices is a big concern for trans childbearing people, and a situation that can shift and worsen significantly as a person passes through these experiences[xxxix] [xl]. It is essential that culturally competent carers understand the impact of dysphoria during the perinatal period and that there is access to culturally sensitive specialist counselling[xli], interventions which are included in this strategic health plan. Alongside professional support is the value of peer support: feelings of isolation cause great distress for trans childbearing people[xlii] and appropriate, specific peer support can be invaluable – HCPs need to be able to signpost this support effectively[xliii].
These interventions would help:
- reduce internalised stigma through visibility, reducing isolation and improving access to health education in an informal setting
- improve mental health leading to greater accessing of healthcare and reducing poor physical outcomes.
The assumptions underlying these interventions are that:
- trans people will want to access perinatal services if mental health is nurtured
- specific peer support is accessible.
Mitigating these assumptions may take time and resources to increase knowledge and earn trust, and there may be a chicken-and-egg scenario of trans childbearing people peer support not being ‘lumped in’ with generic LGBT support groups – there needs to be volume to necessitate support but without such support the true volume of need may not be known.
Responsibilities:
Providing the space (physical and mental) and resources for the interventions listed to be adequately provided are the responsibility of the HCPs responsible for this strategic plan. The community will decide whether this is enough for them to overturn previous negative experiences and engage with perinatal services, however it is noted that it takes time for underserved communities to develop trust and engagement with a service that has historically overlooked them. There must be an element of goodwill belief from the trans childbearing community that things can change; while this will be true of some there will be others who make a choice never to engage.
Outcome Measures:
Strategic interventions will be measured and evaluated through a framework of user experience data-collection tools. Baseline data prior to the implementation of intervention will be needed so outcome metrics can be tracked against implementation.
- Friends and Family Test[xliv]
- CQC Maternity Services survey[xlv]
- Locally designed Maternity Voices Partnership care survey[xlvi].
Wider benefits should also be seen in health outcomes for both parent-and-child, increasing positive outcomes in maternity dashboard[xlvii] figures generally.
Programme Narrative
The needs-based approach to health improvement of the trans childbearing community holds the assumption that the community face disparity in health outcomes during the perinatal period. This has been evidenced through an assumptive approach based on the wider trans community’s relationship with accessing healthcare and the limited research available on the trans childbearing community and perinatal care experience.
A big limitation of the programme is that the trans childbearing community in England is unknown due to systematic failure of data capturing and heterogeneous approaches to self-identity, exacerbated by fear of stigma, discrimination, and bias. The trans community is growing and even if not the trans childbearing people deserve to have access to appropriate healthcare.
Within the framework of perinatal services provided by the NHS in England, the programme will adopt an integrated approach to improving the health of the trans childbearing community which places individuals from the community at the heart of the proposed strategic interventions. The programme will take a symbiotic approach to the interventions of cultural competency training, individualised care, systematic change, and a focus on improving mental health.
Through partnership working of all stakeholders and in particular collaboration with the community using (or intending to use) the service, the programme will implement strategies that increase awareness and understanding of the additional vulnerabilities and challenges the community face, ensure supportive care that meets the unique needs of the community, changes the system within which perinatal care currently exists, and ensure mental health is as protected as physical health. This will allow broader goals of reducing real and perceived internalised, healthcare, and structural stigma; improve the experience of navigating the service, making it more accessible and giving HCPs the skills needed to provide care to a vulnerable and diverse community; and improving the long-term health of parent-and-child, impacting not just on them as individuals but the wider communities they exist within. Long-term one of the benefits of the programme is that this underrepresented in healthcare community group will be more likely to access perinatal care as they know their community is understood and represented.
Although the strategic themes have been identified through this programme this truly will be a collaborative community health programme and relevant stakeholders but especially the trans childbearing community themselves will coproduce the final programme strategy, implementation, and evaluation methods to ensure they are flexible and adaptable to maintain community relevancy through emerging and changing needs, priorities and in response to any future published evidence.
Sustainability of the programme will be supported through participatory actions of the community themselves and by ensuring that interventions are measured against the long-term goals of the programme with a mechanism for future growth and development of the programme as the long-term goals are achieved.
[1] For the purpose of this essay the umbrella term ‘trans’ will be used throughout unless specifically noted.
[2] A woman whose gender matches their assigned sex at birth.
[3] Using the birth (or legal name if not yet changed) of a trans person even though it is not their preferred name. This can be accidental or intentional.
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[xxxiv] Brighton and Sussex University Hospitals. Perinatal care for trans and non-binary people. [Online]. 2020. [Accessed 26 April 2021]. Available from: https://www.bsuh.nhs.uk/maternity/wp-content/uploads/sites/7/2021/01/MP005-Perinatal-Care-for-Trans-and-Non-Binary-People.pdf
[xxxv] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1
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[xxxvii] Hoffkling, A, Obedin-Maliver, J, Sevelius, J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth [Online]. 2017. 332. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-017-1491-5#Bib1
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[xxxix] MacDonald, T, Noel-Weiss, J, West, D. et al. Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth [Online]. 2016,106. [Accessed 29 April 2021]. Available from: https://bmcpregnancychildbirth-biomedcentral-com.manchester.idm.oclc.org/articles/10.1186/s12884-016-0907-y
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