Pregnancy, birth and fertility care need to be more gender inclusive, advocates say


TORONTO —
Fertility, pregnancy and childbirth are not solely experienced by women, and advocates and experts say that it’s time to change the narrative to be more gender inclusive.

From patient intake forms to online forums and communities, pregnancy is portrayed as something that only happens for women, more often than not excluding non-binary and trans people, and advocates say this exclusion isn’t always accidental.

“It’s often a lot more active, intentional and hostile and often coming from a place where people would call themselves inclusive, or equitable or feminists, but are also trans exclusionary,” Anna Penner, non-binary gestational parent of three, and Seed and Sprout program ambassador and birth and postpartum doula with Birth Mark, told CTVNews.ca in a Zoom interview on Friday.

From the first online search for fertility and pregnancy related information, it’s nearly impossible to avoid gendered terms.

“When you Google anything to do with pregnancy or childbirth you automatically get guided to these places and spaces that only use binary language,” Gabrielle Griffith, a non-binary parent, co-ordinator and doula with Seed and Sprout, told CTVNews.ca in a Zoom interview on Friday.

Terms like ‘mamas,’ ‘papas,’ ‘ladies,’ and the like are frequently used in pregnancy and fertility related forums. Entire groups dedicated to mothers and fathers exclude non-binary people entirely. But it’s not just gendered terms like these that make these spaces fraught with gender.

“Lots of spaces talk about pregnancy being the utmost feminine experience, and what it means to be a woman and all of these things that are inherently problematic for a lot of reasons,” said Griffith. “One of those reasons being that it is not inclusive, and it’s also not true.”

Griffith said that there’s a lack of education and awareness that results in these female-centric education and online resources.

“Which is what really inspired the Seed and Sprout community program that we have here at Birth Mark Support, which is completely focused on queer and trans-affirming reproductive care, education and support,” they added.

Like gender, not everyone’s experience with fertility and pregnancy is the same. Griffith was young when they became pregnant, adding another stigma to their experience, whereas Penner sought fertility treatments though a fertility clinic.

“I was 30 when I first got pregnant, and I got pregnant through a fertility clinic using an anonymous donor,” Penner said.

But finding a queer friendly fertility clinic was difficult for Penner and her partner. They used the knowledge collected by their friends and community who’d gone through similar processes to find a fertility clinic that would be inclusive, but even then the experience wasn’t ideal.

“Even when I chose that most inclusive space, it was still really not,” Penner said.

Penner also emphasized and acknowledged her own privilege in being a white middle-class person who is able to access services like fertility care.

Patients at fertility clinics don’t always see the same doctor or nurse practitioner on each visit, making it difficult for Penner to prepare for what she was going to experience each time. Even after the birth of her first child, struggling with undiagnosed postpartum depression they didn’t know where to turn and had no choice but to turn to the communities they didn’t fit into.

“Trying to find a community and build community because I was feeling really isolated as a new parent who was dealing with some postpartum depression undiagnosed, and every space being mamas, not even mamas and papas because there are no dads in this space, it’s all just mama,” said Penner.

But Penner felt that she either needed to fit into the mould of these communities, or have no community at all.

“Just like feeling really like the sore thumb in all of these spaces, but not being able to articulate it, because I was a new parent, I didn’t have the bandwidth, I didn’t have another community to go to,” Penner said. “So it was either squeeze myself into those spaces that didn’t fit, or have no space at all.”

These situations can be all the more difficult for people living outside of cities, in smaller towns or rural areas where queer and trans-affirming care isn’t even an afterthought.

“It’s weird to say that pregnancy is gatekept like that, but there are a lot of people that are just like, ‘Oh no, if you’re not a mother like, what are you even doing getting pregnant?’” LA Kress, a non-binary soon-to-be-parent based in Kitchener, Ont., told CTVNews.ca in a phone interview on July 6.

And they’re not expecting to get exemplary care in terms of gender inclusivity when they do give birth — already they anticipate being misgendered in hospital and has dealt with it throughout their pregnancy.

“The pronoun thing is just, you have to toss that out the window because it’s not happening,” said Kress.

They hope that when they are in labour they’ll have a young doctor or nurse on their team who will advocate for them and make sure to use correct pronouns, but even watching birthing videos online they said there’s a lot of ‘you go girl!’ and gendered cheering that takes place.

They said their partner will be there to support them and correct people for using the incorrect pronouns, and also calm them if incorrect pronouns are used, but ideally gendered language stays out of the delivery room.

“I just know that that’s going to be ringing in the back of my head,” Kress said.

Despite not feeling included in the space, they still peruse the pregnancy forums that use gendered terms, but they participate in them in a different way.

“It’s like when you read a book and you put yourself into the first person,” Kress said. “You just have to be like, ‘OK let’s just separate this from who I am, they’re not writing directly to me’.”

But this unnecessary gendering of fertility, pregnancy and childbirth extends well beyond a doctor’s office or online forum. The world, in general, expects a pregnant woman.

“What I found really difficult was that the world wasn’t made to fit the intersection of my gender, and my pregnancies,” said Penner.

Many pregnancy related items, including clothing, are not made for non-binary people or transmen.

“Maternity clothing, total nightmare, finding anything to wear for five to nine months was just completely terrible, impossible and dysphoric, so it wasn’t my body it was what was there to fit my body,” Penner said.

Nursing and lactating was also very difficult for Penner, but it was something she couldn’t share in many of the communities online that are so heavily focused on women.

“Postpartum I found nursing really dysphoric,” Penner said. “I found those changes and lactation really dysphoric and didn’t have space to express that.”

When a health-care provider told them that they were a “natural” at nursing, for Penner it felt anything but.

“In that moment, it felt like the least natural thing that had ever happened to my body, but that assumption that it was something that would just be fine, really came up against my experience, but prevented me from then talking about it,” she said. “Having been told it was natural, and it was great and everything was going great, I didn’t feel like there was actually any space to voice my experience or my discomfort.”

Griffith agreed, using their body to feed their baby was an uncomfortable experience.

“It almost always led to a disassociation. Maybe that was postpartum, maybe that was gender feels,” they said. “I think I’ll never really know because I didn’t have the space to talk to people about it and process it while it was happening in real time. “

Despite all of this, pregnancy and birth helped affirm Griffith’s gender.

“My pregnancy and birthing my baby and raising my kiddo helped me come to a clear awareness of being non-binary,” they said.

CLINICAL REPRESENTATION

Gendered language is just one small hurdle that trans and non-binary people face when navigating fertility, pregnancy and birth. Medical spaces like hospitals and clinics have been notoriously unsafe spaces for queer individuals.

“There’s the general health-care barriers, which are many. There’s a limited availability and visibility of trans-competent and trans-positive services,” Dr. Helena Frecker, a Toronto-based OB/GYN, told CTVNews.ca in a phone interview on July 1.

There’s also a lack of training and sensitivity among staff in the health-care setting, she added, but there’s also a lack of competency on trans health care where trans people often have to educate their health-care providers on how to properly care for them.

There are also structural barriers, said Frecker.

“Gendered washrooms, intake forms that don’t allow for people to indicate pronouns, or if it’s different from their health card, really sort of inappropriate relationship status, such as only married or single,” she added.

And it doesn’t stop there — technological barriers are also in place.

“Like in electronic medical records, the inability to even put a name aside from the name that’s on the health card,” she said.

There’s also the question of trans fertility, which is an under-researched area.

A study conducted by Boston IVF found that trans people using testosterone still had good ovarian reserves and could produce eggs for freezing or to use for in-vitro fertilization procedures, in which eggs are retrieved from the ovaries and at a later date an embryo is placed in the uterus to grow. But even this isn’t a guarantee.

“Starting puberty blockers at a young age before puberty can irreversibly affect the ability for people to be able to harvest their own sperm or eggs later in life,” said Frecker.

Trans people are usually encouraged by their doctors to undergo fertility preservation procedures before beginning hormones, but these procedures are costly and are only covered under government health insurance in Ontario, and those come with a wait time.

People who go ahead with hormones prior to fertility preservation services, whether it be to save up for the cost, while they wait on a waitlist or they’ve changed their mind about biological children, will have to go off of the hormones in order to retrieve eggs or bank sperm, said Frecker.

“If I had to lay out all of the barriers for people accessing fertility therapy I would say that one of the biggest ones is coming off of gender affirming therapy or delaying its initiation,” she said.

In 2019, according to CARTR Plus data provided to CTVNews.ca, of 35,896 IVF cycles, 58 patients who used their own sperm were female and 14 patients who used their own eggs were male. Fewer than six people who did IVF that year identified as non-binary and 5,008 people didn’t specify gender. However, the data collected by CARTR Plus, a registry of Canadian fertility treatment data, does not directly capture those who identify as transgender so this data may not represent all transgender people who used IVF fertility treatments.

Eileen McMahon, a nurse practitioner at Mount Sinai Fertility and former president of the Canadian Fertility and Andrology Society, works directly with patients banking eggs and sperm for fertility preservation. She said that a lot of the clinics are different in their clinical practices when treating trans people who’ve been on hormones.

For trans women who want to bank sperm but have been using hormone replacement therapy (HRT), they would have to go off of hormones for three to four months, she said, and there’s no guarantee that break in hormones would result in viable sperm. For trans men, going off hormones would be just four weeks at Mount Sinai, she added, but some clinics want HRT to stop three to four months before treatment and others retrieve eggs while patients are still on testosterone.

“The World Professional Association for Transgender Health (WPATH), they have standards of care that clearly articulate that anybody starting gender affirming hormones needs to be counselled about the risk to their fertility,” said McMahon.

At Mount Sinai, they’ve seen an increase in these types of referrals which McMahon said shows that people are heading this advice.

“Our referrals have definitely increased in the last couple of years, but many are quite young, and they’re not in a place where they know whether they want biological children,” she said. “They’re not sure whether they want to go through this.”

Egg retrieval can be quite invasive; it involves vaginal ultrasounds, taking hormones so the ovaries produce multiple eggs, and retrieval involves inserting a needle into the vagina to collect the eggs from each ovary, all of which McMahon says can be a triggering experience.

“Some of them have never had anything internally in their life and the prospect of having ultrasounds and a procedure is quite scary for them,” she said. “And some trans women aren’t able to masturbate a sample.”

LANGUAGE MATTERS

While changing the language is just a part of changing the narrative of who accesses fertility, pregnancy and birthing services, it is an important step.

“I think that using inclusive terminology doesn’t take away from the experiences of people who are female-identified, I think it allows for everyone to feel more included and more reflected in the care that can be provided to them,” said Frecker.

“The UN has a system wide strategy on gender parity and they say that given the role of language in shaping cultural and social attitudes, using gender-inclusive language is a powerful way to promote gender equality,” McMahon said.

She emphasized what Dr. Muna Abdi once tweeted: “It is not Inclusion if you are inviting people into a space you are unwilling to change.” (https://twitter.com/muna_abdi_phd/status/1406236697306804224?lang=en)

“It doesn’t mean we can’t also talk about women’s experiences, it doesn’t require the negation of femaleness,” she added. “It just means we accept that women’s rights need not be one at the expense of other people, and when we are inclusive we’re including all those people we’re not erasing anyone.”

There is a belief among some women, particularly among trans exclusionary radical feminists, that using gender-inclusive language, such as pregnant people instead of pregnant women or pregnancy care instead of maternity care, erases women, but McMahon says that’s not the case.

For Penner, this sort of exclusionary attitude is more difficult than some of the other hurdles, and emphasizes the need to go beyond just using inclusive language.

“That can be a lot harder to combat when it’s not just omission, but a real refusal to be inclusive in the space, to even consider the possibility,” she said.

For Kress, it’s frustrating when people believe this line of thinking, because it doesn’t stop anyone from identifying, or being, a mother.

“That makes me angry and it’s like, why are you including yourself in something that doesn’t apply to you? If you like the word mother, great, I love that for you, but maybe I want to just be the parent. What’s so bad about that?” 





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