Ellise D.

Adams, MSN, CNM

Abstract Introduction
Reproductive technology has made it possible for those born This article introduces maternal child nurses to the concept
of transmen (biological women who have transitioned to
biologically female and who have partially transitioned to the
the male gender) becoming pregnant and giving birth. This
male gender via hormones to become pregnant and give birth. exact situation was documented in the popular culture in the
This article explores the role of the perinatal nurse in providing United States during the recent past, and inspired this author
to wonder how much nurses who encounter patients in this
care during the obstetric experience for a transgender male
situation know about transgender issues, and whether the
and his significant other. A carefully executed plan of care can professional literature has dealt with this previously.
assist the nurse in providing nonjudgmental, nondiscriminatory American society is a gender-based society. Many preg-
nant families seek to know the gender of their baby prena-
physical and emotional nursing care, and ensure that the fami-
tally. Some even pursue genetic screening to determine the
ly’s healthcare needs are met and that their transition into par- likelihood of producing a child of a specific gender. When
enthood is effective. an infant is born, one of the first questions asked is, “Is it a
boy or a girl?” Additional evidence of our gender-based
Key Words: Transgender; Intrapartum nursing; Transman; Peri-
society is the fact that perinatal nurses enter their special-
natal nursing. ization with the assumption that the adolescent and adult
patients who are admitted to their care will be female.
While fathers and male infants are definitely a common
finding in obstetric units, it is completely unexpected to
have a male patient admitted with a diagnosis of intrauter-
ine pregnancy. The recent case of Thomas Beatie challenges
this assumption. While Beatie is not the first pregnant man
on record (Barkham, 2008), he is the first to speak of his
experience publically and record the occurrence in his own
words in the book, Labor of Love.

26 VOLUME 35 | NUMBER 1 January/February 2010

 Reproductive technology makes it possible for those is a term used to designate an individual who identifies
born biologically female, who have partially transitioned to with and expresses a gender that differs from their biologi-
the male gender via hormones, and have legal status as a cal sex at birth (Dutton, Koenig, & Fennie, 2008). “Trans-
male to become pregnant and give birth. In keeping with man” is the transgendered male who was born female and
these technology changes, perinatal nurses need to become transitioned to male (APA, 2006). This transition can be
prepared should they find themselves caring for a patient temporary or permanent. Following transition, the individ-
such as this, with all the special needs involved. ual may apply for a legal change of gender.
It is estimated that 2% to 3% of the lesbian, gay, bisexu-
Transgenderism: General Concepts al, and transgender community are considered transgender
Due to the infrequency with which this topic is addressed (Burdge, 2007). The transgender individual who seeks
by nurses, a definition of terms is necessary. “Transgender” to definitively resolve the sex/gender conflict may choose

January/February 2010 MCN 27

to surgically alter their biological assignment. Those desir- transition, and also needed documentation of a surgical
ing to alter gender and secondary sexual characteristics procedure to alter his gender. Tracy subsequently had a
only may decide to use hormonal therapy to effect these bilateral mastectomy, began testosterone therapy, and legally
changes, while retaining the anatomy present at birth. Once changed her gender to male. Thomas retained his uterus,
the change in gender has been made, whether temporary ovaries, and vagina. During the time of gender transition,
or permanent, everyone who cares for this patient should Tracy met Nancy, and following transition, the couple were
then address the transman (in the case of the female to legally married as man and wife.
male transition) with the masculine pronoun. While using The couple sought medical assistance to achieve preg-
the gender of the patient’s choosing, the nurse conveys re- nancy and bring a biological child into their lives. In a re-
spect and validation to the patient. cent interview, Beatie stated that this desire for a child is a
Because fertility can be maintained in both the male to human desire and is not gender related (Bone, 2008). He
female transgender female (transwoman) and the transman, claimed that the desire for a pregnancy was a “desire to
the possibility for reproduction does exist. For the create what (he) lacked in childhood – a loving and nurtur-
transwoman, sperm banking is the most viable option to ing family” (Beatie, 2008, p. 7). These statements explain
participate in future reproduction. For the transman, the the emotional investment this couple had for achieving con-
ovaries, fallopian tubes, and/or uterus must be maintained. ception, and set the stage for disappointment and even de-
Testosterone therapy must be discontinued for the trans- spair if their plans were not realized.
man who desires pregnancy in order to return to the female Nancy was unable to become pregnant due to a previous
hormonal cycle and to achieve pregnancy. Other options hysterectomy. Since Thomas had not had his uterus or
for reproduction in the transgender individual include in ovaries surgically removed and his transition to the male
vitro fertilization, gamete intrafallopian tube transfer, and gender was therefore not complete, he was able to discon-
oocyte and embryo banking through the process of cryop- tinue testosterone therapy, and return to regular menstrual
reservation (Gorton, Buth, & Spade, 2005). cycles and ovulation. The couple purchased donor sperm
and eventually achieved a viable pregnancy (Beatie, 2008).
Clinical Exemplar In an interview with People Magazine, Beatie stated that
The case of Thomas Beatie can be examined as a clinical the viable pregnancy resulted from introducing the sperm
exemplar by nurses for the general care of the population. himself via self-insemination (Tresniowski, 2008). The fam-
Thomas Beatie has appeared many times on television in ily saw no other choice but to attempt to have the insemi-
the United States as a “pregnant man” and has written a nation at home, due in part to their inability to secure an
book on his experiences; thus, his real name is used in this infertility specialist and partly because of their previous
article. negative experiences with the medical system.
A 34-year-old transman, Beatie and his wife Nancy gave These negative experiences included instances of nurses
birth to Susan Juliette in 2008 in Oregon. Prenatal care was who refused to use the proper pronoun when referring
provided by an obstetrician and certified nurse–midwife to Thomas, doctors who warned that people would try
team. Thomas carried the pregnancy full term, labored to harm the baby, being laughed at openly, and lack of
40 hours, and gave birth vaginally. Nancy served in the role support from family and friends. Thomas’ brother even
of the labor support, cut the umbilical cord, and breastfed called the baby a monster (Bone, 2008). The family report-
the infant (Bone, 2008). While breastfeeing in such an in- ed many healthcare providers who asked them questions
stance may seem unusual, in fact women with an intact hy- that other pregnant couples would not have been asked,
pothalamo-pituitary axis are capable of initiating lactation such as questions about the birth certificate and the gender
(for a complete discussion of induced breastfeeding see Wit- of the baby’s mother; frequent questions about their psy-
tig & Spatz, 2008). chological health; explanations about the discourse they
Beatie’s transition from female to male began in early would have with their child when they described the baby’s
adulthood. Thomas was raised as Tracy, and was a self- conception; and what they would tell the neighbors.
professed tomboy who attempted to be outwardly female Thomas was asked to shave his facial hair before coming to
but inwardly was gender confused. Thomas felt from early one obstetrician’s office. Lawyers warned that Thomas’
in life that his insides did not match his outside (Beatie, pregnancy “could lead to (their) marriage being deemed in-
2008). “For as long as I can remember…I wanted to live valid” (Beatie, 2008, p. 251). They were not supported by
my life as a man…I always knew, long before I could artic- national transgender organizations and in fact were
ulate it, that I was really male” (Beatie, 2008, p. 6). In order warned by these organizations that the pregnancy
to legally change gender in the state where he lived (Hawaii), “could have a negative impact on an upcoming vote in the
he was required to have an official letter from a therapist California Supreme Court on whether to continue the
and/or physician that he was under their care for gender state’s ban on same-sex marriage” (Beatie, 2008, p. 254).

28 VOLUME 35 | NUMBER 1 January/February 2010

 Feinberg (2001), a transgender ac- pregnancy. Appropriate screening
tivist, reports that negative experiences and treatment for these conditions
with the medical community abound during the prenatal period should
for the transgendered individual. Fein- occur, for they have been linked
berg cites incidences of pronoun con- with increased incidence of postpar-
fusion, snickering amongst staff tum depression (Robertson, Grace,
members upon reading a transgen- Wallington & Stewart, 2004).
der’s chart, and most disturbing, the Discrimination is an emotional is-
refusal of care even in emergency situ- sue encountered by the transgender
ations. Terms of intolerance and hatred individual. It may be expressed physi-
such as “alien” and “it” have been cally, verbally, or emotionally, through
used in reference to the transgendered bullying or incivility. Attempting to
individual. These attitudes keep the cope with frequent discrimination
transgendered individual from seeking
Reproductive can lead to anxiety, depression, and
healthcare, and in some cases hinder technology has made thoughts of suicide (Gorton et al.,
them from obtaining healthcare. 2005). Testosterone therapy can also
Shame, low self-esteem, harassment, it possible for those cause mood swings, aggressive feel-
and discrimination as well as lack of ings, and increased anger reactions
healthcare insurance are other reasons
born biologically (Gorton et al., 2005). The perinatal
why the transgendered individual female, and who nurse should be aware that these in-
seeks healthcare in emergency situa- tense emotions can occur during and
tions only (Dutton et al., 2008). have transitioned after pregnancy, and provide appro-
priate referrals when necessary.
Healthcare Needs of the to the male gender
Transgender Population via hormones, to Physical Needs
Reviewing the healthcare needs of the Common health risks related to trans-
transgender population can assist the become pregnant genderism and its concomitant se-
perinatal nurse in providing optimal quellae include substance abuse, self-
care for the transgender patient. Be-
and give birth. mutilation, homelessness, prostitution,
cause nursing practice is considered HIV, and suicide (Gorton et al., 2005).
holistic, the nurse plans client care that Some of these risks and needs can
includes physical, mental, emotional, form a cascade of physical problems;
and spiritual aspects. McEvoy and Duffy (2008, p. 418) for instance, homelessness increases the risk for inadequate
define holistic nursing as embracing “the mind, body, and nutrition, violence, and substance abuse during pregnancy
spirit of the patient in a culture that supports a therapeu- (Little, Shah, Vermeulen, Gorman, Dzendoletas, & Ray,
tic nurse–patient relationship resulting in wholeness, 2005). Perinatal nurses caring for transgender patients
harmony, and healing.” should be aware of these risks, and arrange for appropriate
screening and treatment.
Emotional Needs Transmen who have maintained their female reproduc-
The transgender individual is often emotionally conflicted tive organs may have never (prior to pregnancy) experi-
because their inner self does not correspond with their enced regular gynecologic preventative care due to their
outward appearance, creating the risk for gender identity fear and shame. Therefore, historical data from screenings
disorder (Peate, 2008). The Diagnostic and Statistical such as breast self-exam, mammograms, and Pap smears
Manual of Mental Disorders states that gender identity may not be available. Lack of health wellness behaviors in
disorder is a condition arising when individuals experience the transgendered individual is not related to knowledge
intense, persistent gender dysphoria, a state of incongruence deficit, but to fear of self-exposure and worry about health-
between external appearance and how the person feels care provider response (Dutton et al., 2008). Pregnancy and
internally (Peate, 2008). This incongruence often manifests early postpartum are optimal opportunities for the perina-
as anxiety and depression, and causes the individual to seek tal nurse to discuss the importance of preventive screening
a change in gender. methods in the future and encourage the patient to develop
If the transgendered obstetric patient suffers from a relationship with a provider who is sensitive to the special
gender dysphoria or depression, or is treated with lack of needs of the transgendered individual in order to obtain
respect, this anxiety/depression may continue during ongoing healthcare.

January/February 2010 MCN 29

 Another health risk is for cardio- opportunities to discuss concerns
vascular disease, cerebral vascular honestly in a safe environment with-
accidents and myocardial infarction out fear of retribution.
due to long-term testosterone therapy While nurses have basic knowledge
(Gorton et al., 2005). Changes in lipid regarding nondiscriminatory care, an
profiles including decreased high- ethical discussion with antepartum,
density lipoprotein, increased low- intrapartum, nursery, and postpartum
density lipoprotein, and increased nurses prior to the admission of the
triglycerides may also occur. Increased transgender patient is appropriate due
abdominal fat and decreased sensitivi- to the fact that this type of patient is
ty to insulin in transmen also increase infrequently encountered in the clini-
their risk of cardiovascular disease. Shame, low self-esteem, cal setting. The Code of Ethics for
The antepartum setting can provide Nurses with Interpretive Statements
opportunities to obtain cholesterol harassment, and (American Nurses Association, 2001)
and glucose screening as well as dis- requires nurses to respect human dig-
cussions of weight management. Heart
discrimination as well nity and commit themselves primari-
healthy behaviors such as proper as lack of healthcare ly to their patient and the needs of
nutrition, exercise, and smoking ces- that patient. This document states
sation should also be mentioned to insurance may cause that nurses need “to examine their
assist in the reduction of risk for conflicts arising from professional
cardiovascular disease in the trans-
the transgendered and personal values and resolve
gender patient. individual to seek these in a way that ensures patient
Testosterone therapy puts the pa- safety and preserves the professional
tient at risk for other issues as well. It healthcare only in integrity of the nurse” (p. 9). The na-
can cause changes in body odor and ture and unusual situation presented
physiologic acne, and there is an in-
emergency situations. by the pregnancy of a transman call
crease in the incidence of polycystic for a review of this code. The perina-
ovarian syndrome (PCOS) for the tal nurse, adhering closely to the
transman who retains his female reproductive organs. Un- Code of Ethics, can administer nursing care without bias
treated PCOS is associated with increased risk of endome- or judgment to this patient.
trial, breast and ovarian cancers (Gorton et al., 2005). The
perinatal nurse is uniquely positioned to provide patient Intrapartum Care
education regarding these risk factors, teaching the patient During hospitalization, patient information is at risk for ex-
about the warning symptoms that should be reported and posure. The sensational situation of a transman pregnancy
about the importance of preventive behaviors such as limi- calls for review of privacy issues and possibly creation of a
ting alcohol intake and eating a low-fat diet (Hardiman, formal policy to address admissions related to high-profile
Pillay, & Atiomo, 2003). cases (Thompson Healthcare, 2006). Unfortunately it is not
uncommon for hospital employees to attempt to gain ac-
Clinical Implications for the cess to private medical records, sometimes for profit. In
Perinatal Nurse 2008 the University of California in Los Angeles Medical
Antepartum Care Center found that 127 hospital employees had gained im-
When a transman presents in the antepartum period, col- proper access to the medical records of celebrities (AHC
laboration with the obstetrician, and/or nurse–midwife, and Media, 2008). High-profile information is in constant
birth facility should begin immediately in an effort to devel- demand from news sources. The Standards for Privacy of
op an effective plan of care for when the hospitalization of Individually Identifiable Health Information (DHHS, 2002)
this patient takes place. The plan should include all aspects must be reviewed by all providers of healthcare to ensure
of care from admission, to security, to intrapartum, to nurs- compliance with the Health Insurance Portability and
ery and postpartum nursing care, and should also include Accountability Act of 1996. Measures to ensure this priva-
discussions with all ancillary departments that will con- cy are particularly essential for high-profile admissions
tribute to the healthcare of the patient. All staff (nursing, such as that of a pregnant transman. It is entirely appro-
clerical, nutrition, housekeeping, laboratory, etc.) should be priate to plan for a security officer to provide escort serv-
provided with educational opportunities to discuss issues ices and be stationed outside of the patient’s door to
related to the care of the transman in obstetrics, including prevent unauthorized entry (Thompson Healthcare,

30 VOLUME 35 | NUMBER 1 January/February 2010

2006). The infant can be assigned to Intrapartum care of the transman
the patient’s room to avoid numerous should be not much different than for
transfers to the nursery when media patients who have not changed their
might intercept. The use of an alias gender. Assessment of the labor and
for the newborn should also be con- the fetus proceeds as usual, and pain
sidered. In cases such as this, the flow management and safety issues will be
of information about the patient and the same. Physical assessment of the
family must be tightly controlled, and laboring patient will depend on sur-
staff must be alerted that absolutely gical alteration, for instance, in Beat-
no information can be given over the ie’s case a breast exam would not be
phone. Written medical records can be necessary but a perineal assessment
housed in the patient’s room to avoid When a transgender would be appropriate.
unauthorized access. The public rela- Due to the unique nature of the
tions department of the birth facility patient presents in pregnancy, the transman may present
should be the media’s only contact. the prenatal period, in labor with significant anxiety. Emo-
The privacy of the other patients tional care of the transman may be-
admitted during the hospitalization of collaboration with the come a priority nursing intervention,
a high-profile patient should also be with extra support needed to address
taken into account. Patients may be obstetrician, and/or anxiety, including distraction, caring
surprised to see the flurry of activity nurse–midwife, and attitude, presence, therapeutic use of
and security in the unit and express humor, refocusing, and spirituality
natural curiosity. Nurses in the unit birth facility should (Adams & Bianchi, 2008).
should therefore be prepared to re-
duce the anxiety of new families with- begin immediately in Postpartum Care
out exposing sensitive patient infor- an effort to develop an Patient literature and teaching mate-
mation about the transman. If it is rials contain references to the mother
possible to add additional staffing effective plan of care in the feminine pronoun and may re-
during this patient’s hospitalization, veal pictures of mothers only. If a
that should be considered. for the hospitalization transgendered patient is expected for
Willingness of the transgendered in- of this patient. admission, a careful review of con-
dividual to disclose health information sent forms, patient teaching litera-
to a healthcare provider has been ture, and videos used for newborn
linked with the healthcare provider’s and postpartum care would allow
level of acceptance (Dutton et al., 2008). In situations such the staff to decide which literature contains elements of
as these, it is more important than ever for the nurse to gender discrimination, and which is the most appropriate
work toward developing a trusting relationship with the for this family.
transgender family. The nurse can ask the patient how they The physical environment should also be carefully con-
would prefer to be addressed (name and pronoun), honor- sidered. Using the same approach as is used for new fami-
ing this wish with each interaction (Peate, 2008). The la- lies who experience traumatic events related to childbirth,
boring patient should be referred to as “dad” instead of nurses caring for a transgender family might be tempted to
“mom.” As in the Beatie case, in which the partner planned transfer this family to a unit away from other new families
to breastfeed, patients who have had a mastectomy should to maintain privacy. This is an issue that should be dis-
not be asked “will you breastfeed?” but instead be asked cussed with the transgender family prior to the birth experi-
“what are your plans for feeding the baby?” ence. In general, the transgender family should be provided
Health history forms and other forms of documentation with the advantage of being admitted to the postpartum
often contain gender bias. Using open-ended questions unit in an attempt to maintain normalcy and receive social
regarding gender allows the individual to give more appro- support from other new families. Disadvantages such as
priate information, and not be forced to check a box beside recognition by the public and difficulty in maintaining pri-
female or male. Transgender individuals often report a con- vacy, however, should also be considered.
flict when trying to determine if the healthcare provider Social support has been linked to increased satisfaction
needs to know biological sex or transitioned gender (Dut- and positive patient outcomes in the obstetric experience
ton et al., 2008). Official listing of sex on hospital bracelets (Miltner, 2002). In antepartum meetings with the trans-
and medical records need to reflect the patient’s desired sex. gender family, these advantages should be discussed and

January/February 2010 MCN 31

 Ellise D. Adams is a Clinical Assistant Professor at Univer-
SUGGESTED CLINICAL IMPLICATIONS sity of Alabama in Huntsville. She can be reached via
Nurses who work with transgendered families in perinatal e-mail at Ellise.adams@uah.edu
settings should: The author has disclosed that there are no financial rela-
tionships related to this article.
• Ensure that everyone involved in the family’s care deliv-
ers nonbiased, nonjudgmental care in a sensitive manner. References
Adams, E., & Bianchi, A. (2008). A practical approach to labor support.
• Help to maintain client privacy throughout the pregnancy Journal of Obstetric, Gynecology, and Neonatal Nursing, 37(1), 106-115.
and birth. AHC Media. (2008, May). Celeb privacy breach bigger than reported.
Healthcare Risk Management, 30(5), 49-60.
• Work with other departments in the institution that will be American Nurses Association. ( 2001). Code of ethics for nurses with
interpretive statements. Washington, DC: ANA Publications.
involved in the patient’s care to be sure that the patient American Psychological Association (APA). (2006). Answers to your ques-
and family are protected from media intrusion. tions about transgender individuals and gender identity. Washington,
DC: APA Publications.
• Ask the patient what pronoun is preferred, and then use Barkham, P. (2008). Being a pregnant man? It’s incredible. The Guardian.
Retrieved November 5, 2008, from www.guardian.co.uk/lifeandstyle/
the appropriate pronoun to reflect the patient’s chosen 2008/mar/28/familyandrelationships.healthandwellbeing.
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nancy. Berkley, CA: Seal Press.
• Assess for emotional health risks associated with trans- Bone, J. (2008, July 4). Pregnant man, Thomas Beatie gives birth to baby
girl. Times Online. Retrieved September 5, 2008 from www.timesonline.
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• Review available parent education literature and use tenance for transgender men: A guide for health care providers. San
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Thompson Healthcare. (2006, December 1). Celebrities in the ED: Managers
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Lactation support will need to be offered to the female Retrieved February 11, 2009, from www.ahcpub.com/products_and_
services/ edm2006
partner of the transman if she intends to breastfeed. A peri- Tresniowski, A. (2008, April 14). He’s having a baby. People Magazine, 55-60.
natal nurse who is knowledgeable about initiating lactation Wittig, S. L., & Spatz, D. L. (2008). Induced lactation: Gaining a better
understanding. MCN The American Journal of Maternal Child Nurs-
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period and be available for assistance upon discharge from
the healthcare facility.
ONLINE

Conclusion Gender Talk.

www.gendertalk.com/
Transmen giving birth is a rare event, however, excellent
nursing care that provides validation and respect should be National Gay and Lesbian Task Force.
offered to these laboring patients. Proactive planning and www.thetaskforce.org/
implementation can make the birth experience memorable
for the transgender family and rewarding for the perinatal Transgender Care.
nurse. ✜ www.transgendercare.com/

32 VOLUME 35 | NUMBER 1 January/February 2010