Sam, a 32-year-old transgender man, came to the emergency room with severe abdominal pain. He shared his symptoms with the triage nurse and told her that he had a positive pregnancy result that morning, although he thought it might have been a false positive. The nurse ordered a pregnancy test but assessed his symptoms as non-urgent and likely caused by untreated high blood pressure.
In fact, Sam was pregnant. By the time an emergency physician evaluated him and conducted a pelvic exam, his cervix was already dilated and he had a cord prolapse, meaning the umbilical cord was pressed between the fetus and his cervix—an obstetric emergency, identified hours after he stepped through the emergency department doors. He consented to a cesarean section and was taken to an operating room, where an ultrasound found no fetal heartbeat.
Sam delivered the fetus stillborn.
In 2019, Dr. Daphne Stroumsa of the University of Michigan published a case study about Sam’s experience in the New England Journal of Medicine. (Sam is a pseudonym used to maintain the patient’s privacy.) The study noted that a cisgender woman with his symptoms “would almost surely have been triaged and evaluated more urgently for pregnancy-related problems.”
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“Earlier evaluation might have resulted in detection of the cord prolapse in time to prevent fetal death,” the study concludes.
Sam’s story illustrates not only the high stakes of accurately communicating a patient’s gender and their sex assigned at birth, but also the need for health-care providers to factor those details into clinical decision-making. To ensure that takes place, faculty and students are pushing for medical training that better accounts for transgender and intersex patients, from pre-med undergraduate biology classes to rotations to continuing education.
“The students are totally critical for this and are driving it and demanding it,” Dr. Alex Keuroghlian, director of education and training programs at the Fenway Institute and associate professor of psychiatry at Harvard Medical School, told Rewire News Group.
“Over the past several years, [Harvard Medical School has] had a number of [out] trans and gender-diverse students as well,” he said. “They get it. And they want to see the curriculum reflect the full diversity of the communities that we serve and that they come from.”
These curriculum changes include what Keuroghlian called “degendering,” replacing gendered terms like “pregnant women” with “pregnant people.” (Rewire News Group uses “pregnant people” as a rule unless referring to experiences of people of specific genders.)
“A big part of it is training students and faculty in basic concepts and terminology, how stigma is related to health inequities, and then how to build an inclusive, affirming, and responsive health-care environment and educational environment for medical students,” Keuroghlian said. “That includes sensitive, effective communication, [and] inclusive language that doesn’t have implicit bias or false assumptions about gender.”
It also includes using transgender “standardized patients,” actors who medical students can practice interacting, diagnosing, and performing procedures on. Keuroghlian said that they worked with a company that provides these patients to ensure they have transgender and gender-diverse actors.
“We can just shift to a system where we understand there isn’t just one gender that may be pregnant or deliver a baby.”
-Dr. Alex Keuroghlian
Similar changes are necessary for undergraduate biology classes, which are a key part of pre-med programs. Karen Hales, a professor of biology at Davidson College in North Carolina, has made changes to the language she uses when teaching genetics, in which sperm and eggs are often assumed to correspond directly to a person’s gender.
“So the terms ‘mother’ and ‘father’ are of course gendered,” Hales told Rewire News Group. “I wanted to move away from those terms and just to refer to gametes instead of the gendered terms. So I’ll use the terms ‘egg parent’ and ‘sperm parent,’ where an egg parent can be a person of any gender identity and ‘sperm parent’ can be a person of any gender identity. So that still gives the biological accuracy of the asymmetries of sperm and egg, but it also is inclusive to people of all gender identities.”
Hales has also adjusted her use of pedigree charts—family trees for a specific genetically heritable trait, like freckles or sickle cell anemia. Traditional pedigree charts use a square for males, a circle for females, and a diamond for unspecified gender. Many genetic counselors use the diamond shape to represent transgender people, a standard that Hales considers inadequate, at least in the classroom, where students are considering example pedigrees rather than the real-world ones genetic counselors present to clinicians. Geneticists and genetic counselors have considered various alternatives. Hales uses squares for all men and circles for all women, whether cis or trans. Trans men and women are labeled with FTM and MTF to provide information on whether they produce eggs or sperm; nonbinary transpeople are labeled with a diamond symbol along with FTNB or MTNB.
Hales describes these changes in a paper published last year, where she also suggests ways to ensure the genetics curriculum and classroom foster inclusion of disabled people and people of color.
Research paints a dismal picture for medical schools as a whole. A survey in 2015 of 658 New England medical students indicated that the majority, 55.9 percent, felt their schools’ curriculum did not adequately cover care for sexual and gender minorities. Surveys across disciplines and nations, including among U.S. endocrinology fellows, U.S. OB-GYN programs, Canadian medical students, and University of Toronto medical students, indicate similar results.
“People don’t get this in their formative training and then they play catch-up afterwards when they have a patient in front of them once they’re out of training and they don’t know what to do,” Keuroghlian said. “That’s what the National LGBTQIA+ Education Health Center helps with, among other things. It’s continuing education for fully formed health-care professionals, but it should really be part of the early formative developmental educational period that this is part of the standard curriculum.” (Keuroghlian is director of the National LGBTQIA+ Education Health Center, a program based out of the Fenway Institute.)
Transgender patients are acutely aware of these deficiencies. The 2015 U.S. Transgender Study found that nearly 1 in 4 respondents needed to teach their health-care provider about transgender people in order to receive health care. One third of respondents had separate providers for transition-related care and routine health care.
Major medical organizations are advocating for and adopting gender-neutral language. The American College of Obstetricians and Gynecologists (ACOG) used “pregnant individuals” in its statement recommending the COVID-19 vaccine for pregnant people. Back in 2019, the American Medical Association issued an official policy supporting the inclusion of transgender health topics in medical education.
But within published research, the term “pregnant people” is still uncommon. Out of all the citations on PubMed using “pregnant” in 2021, only 0.59 percent used the phrase “pregnant people.” This makes the phrase approximately 110 times rarer than “pregnant women,” but significantly more prevalent than in 2011, when it was used by 0.02 percent of citations. When combined with synonyms like “pregnant patients,” the gender-neutral phrases still appear over 11 times less frequently than “pregnant women.”
“Pregnant people” is gaining traction among media outlets, too. Using the NOW Corpus, which tracks English usage across thousands of news websites, “pregnant people” has risen from less than 1 in 100 million words in 2010 to 64 in 100 million in 2021. In comparison, “pregnant women” averages 525 in 100 million.
While the scientists and clinicians Rewire News Group spoke to said they got little pushback, acceptance of the new terminology isn’t universal. Dr. Dana Beyer, a retired eye surgeon and a transgender activist, agrees on the need for physicians to understand the basics of health care for LGBTQ patients, but she said adopting “pregnant people” isn’t needed, given the majority of pregnant people are cisgender women. Additionally, she worries that the terminology shift will turn off some women.
But Keuroghlian and Hales both disagree. Keuroghlian said terms like “man” and “woman” aren’t “bad words,” and are still used in reference to patients of those genders.
“I think that’s a false choice,” Keuroghlian said. “We can just shift to a system where we understand there isn’t just one gender that may be pregnant or deliver a baby. And I don’t really accept the argument that the majority of people who are pregnant are women, so we should maintain a system that’s exclusionary toward people of other genders. That I think is just discriminatory.”