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

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.

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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 variant 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 variant 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.

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