ASSOCIATION OF ONTARIO MIDWIVES
Represents Registered Midwives and Promotes the Profession of Midwifery in Ontario
Tip Sheet - Providing Care to Trans Men and All “Trans Masculine Spectrum” Clients
In this tip sheet, you will find the following sections:
1. Create a Trans-Positive Environment
2. General Guidelines for Forms and Client/Midwife Discussions
3. Language and Confidentiality
4. Be Knowledgeable About Health Issues that Affect Trans People 5. Be Knowledgeable About the Trans Health Care Community
1. Create a Trans-Positive Environment
like “door birth” or “window birth” instead of vaginal or caesarean-section more comfortable.
gynaecological care and health care providers in general. Hence, records from screenings such as pap tests, chest (not “breast”) and pelvic exams may be unavailable.
6 Adams ED. If transmen can have babies, how will perinatal nursing adapt? Am J Matern Child Nurs 2010 Jan/Feb;35(1):29.
7 Scanlon K. Trans-Health.com. Lower Income Trans Health Concerns. URL: www.trans- health.com/displayarticle.php?aid=84
Key terms
Binding: Using specially designed clothing, or ACE bandages, to flatten breast tissue in order to create a male-appearing chest. Many FtMs (females-to-males) need to bind 24/7 to feel like themselves, some do not bind at home or in private.
Bottom surgery: Also called “genital reconstruction surgery,” includes hysterectomies, metaoidioplasties, centurions and phalloplasties for trans men.
Chest surgery, chest reconstruction surgery: Surgical reconstruction to create a more male or more female appearing chest. Sometimes also referred to as “top surgery.” Chest reconstruction surgery (NOT double mastectomy: a different procedure) is the most common surgical procedure sought by FTMs.
Cisgender: A newer term to describe typically-gendered people. Trans means “across,” cis means “on the same side.”
Crossdresser: Someone who wears clothes of another gender/sex. Most frequently used to describe a heterosexual male who crossdresses as a female some of the time, often mostly in private or for special occasions. Transvestite is a similar term that is generally disappearing from use.
Gender binary: The idea that there are only two possible, opposite genders: man OR woman, and that it is “natural” for all human beings to be strictly one or the other.
Gender dysphoria: The state of acute discomfort felt by transsexuals and some transgender people caused by the incongruity between one’s physical sex and one’s gender-identity. Cannot be measured by tests – a strictly subjective experience.
Gender identity: A person’s internal self-awareness of being either male or female, masculine or feminine, something in between, or something other. Gender functions independently of people’s physical bodies (their sex) and also of sexual orientation (who they desire). Most of us have bodies that match our internal sense of gender but some of us do not and these people are referred to as transgendered or transsexual.
Gender expression: How we try to show the world what gender we are. This may be masculine, feminine, androgynous, butchy, femmy and myriad combinations thereof. Note that this is separate from gender identity. For example, a transgender person may suffer deeply from not being allowed the gender expression that fits their gender identity.
8 This list of key terms was developed by Hershel Russell. 8
Gender Identity Disorder (GID): A psychiatric diagnosis wherein a person who has been assigned one gender at birth identifies strongly as belonging to the “other” gender. Debates continue within trans communities regarding the need for a diagnosis.
Intersex: The condition of being born with ambiguous genitals, and/or mixed internal organs, and/or unusual chromosomal qualities, and/or unusual hormone balance. The term “hermaphrodite” is now considered negative and inaccurate.
Sex: Is between your legs; gender is between your ears.
Sexual orientation: The desire for intimate emotional and/or sexual relationships with people of the same gender/sex, another gender/sex, or multiple genders/sexes. Examples: gay, straight, bisexual, trans-amorous, pansexual, autosexual, asexual. Not to be confused with transgender. Transgender people can be gay, straight etc.
Top surgery: see “chest reconstruction surgery”
Transgender: An umbrella term to encompass all those whose gender identity does not fit, or
only partially fits, with the gender they were assigned at birth.
Transition: The act(s) of changing from one sex to the other, and/or the act(s) of changing one’s physical body and/or appearance as part of a sex/gender change. For most trans people, transition is not a single, discrete event, but a gradual set of changes over a period of time. It is difficult to determine exactly when transition begins and when it ends.
Trans man: An identity label sometimes adopted by female-to-male transgendered people to signify that they are men while still affirming their history as females.
Transphobia: The irrational fear or hatred of those who are gender variant.
Transsexual: An individual whose gender identity does not fit the gender that was assigned to them at birth. Transsexual people seek hormonal and/or surgical treatment in order to bring their body into alignment with their gender identity. People who have completed surgery may no longer consider themselves transsexual, i.e.“I used to be transsexual. Now I am a woman.”
Two- spirit: They may have distinct gender and social roles from their own traditional teachings, which vary widely from one First Nation to another. It is not respectful for White transgender people to use this term. “Two-spirit” can refer to people who are lesbian or gay- identified as well as to people who are transsexual or transgender.
ASSOCIATION OF ONTARIO MIDWIVES
Represents Registered Midwives and Promotes the Profession of Midwifery in Ontario
Tip Sheet - Providing Care to Trans Men and All “Trans Masculine Spectrum” Clients
In this tip sheet, you will find the following sections:
1. Create a Trans-Positive Environment
2. General Guidelines for Forms and Client/Midwife Discussions
3. Language and Confidentiality
4. Be Knowledgeable About Health Issues that Affect Trans People 5. Be Knowledgeable About the Trans Health Care Community
1. Create a Trans-Positive Environment
- Welcome trans-identified clients by getting the word out about your services to community and health centres that serve lesbian, gay, bisexual and trans-identified (LGBT) people.
- Display trans-friendly and queer-friendly markers in your clinic/office. Display rainbow flags, pink triangles, posters showing racially and ethnically diverse trans people and same-sex couples and other LGBTQ-friendly symbols or stickers. Your practice may also choose to display a diversity policy statement.1
- Make sure there is a washroom easily accessible to your clients that is not specifically for women. Your bathroom could be labelled “all genders,” “unisex” or “bathroom.” Bathroom harassment is frequent for anyone who does not neatly fit into the male or female gender norms and can be very stressful.
- Be aware of any negative feelings about or discomfort with trans people in yourself and your practice. Despite widespread struggles for equal rights for trans people, there is prevalent social anxiety about trans people, especially as parents. A lot of these anxieties are based on the assumptions that trans people are confused about their gender and are unfit parents. For example, see AOM's Statement on Diversity, Equity and Inclusion: www.aom.on.ca/Communications/Position_Statements/DiversityStatement.aspx Be conscious of how often you use words like “women” or “lady” when talking about clients. Practice talking about “pregnant people,” “birth parents” or using other gender- neutral terms.
- If you or your practice are experienced in working with trans clients, you may consider joining the Rainbow Health Ontario's Provider Directory for LGBT-friendly program and services: www.rainbowhealthontario.ca/lgbtHealth/find.cfm
2. General Guidelines for Forms and Client/Midwife Discussions - The intake form sets the tone for how welcome clients may feel about sharing their gender identity/expression, sexual history or sexual orientation. The staff member who has the first contact with potential clients should be aware that some individuals who are looking for midwifery care do not identify as “women.”
- The staff person should recognize that some trans clients - as with many non-trans (cisgender) clients - prefer to be addressed by names that are different than that the names that appear on their health cards.
- Be sensitive to the fact that some trans men may look like women to you, while some people who may look very masculine to you may, in fact, identify as women or butches. When unclear about someone's gender, it is better to ask, respectfully, than to make mistakes.
- Once you know the client’s gender identification, express your respect by using the correct pronoun. If you should make an error, know that it is likely to cause your client considerable pain, but don’t dwell on it. Apologize and move on.
- Be aware that not all clients who identify as “trans” also identify as “male” or “men.” There is a very broad range of ways to identify gender. Follow your clients’ lead. Ask when you are unsure.
- If it doesn’t already, the client intake form should use gender-neutral language such as “partner(s)” or “significant other(s).” Use “relationship status” instead of “marital status” or do not include this as part of the intake form at all.
2 For examples of some of these stereotypes, see "Transsexual Transgender (ts/tg) Parenting: Basic Information for Our Friends and Families developed by the Sherbourne Health Centre”: www.lgbtqparentingconnection.ca/resources.cfm?mode=3&resourceID=129c5d32-3048-8bc6-e81b-6c814b098183
- Avoid heterosexist assumptions. For example, do not assume that the client’s partner identifies as female just because the client identifies as a man and/or a trans man.3 Be aware that the partner of any of your clients may be trans.
- Avoid gender-based assumptions, for example do not assume that everyone who looks like a woman was born that way, nor that there are only two possible genders.
- As with all client contacts, avoid making assumptions about the client’s gender identity or sexual and health behaviours based on their appearance, physical, mental, intellectual and linguistic abilities or racial, ethnic and religious backgrounds. Let the clients tell you about themselves and their issues.
- Allow space for the client to define who they want involved in their care. Recognize that trans people may define family members beyond biological kin. Your client may prefer to be supported by their “chosen” family, especially if their biological family members are unsupportive of their pregnancy, gender, and/or sexual identities or expressions.
- While some trans people have a consistent gender presentation, some do not. Be aware that your client’s gender presentation and preferred pronouns at one visit may be different from the next.
- As with all client contacts, approach discussions with empathy and open-mindedness. Ask open-ended questions to solicit information about stressors and supports. Many trans people have a history of avoiding health care services for fear of discrimination. Indeed, most trans people have already experienced insensitive or outright discrimination from health care providers.
- Sensitivity towards issues facing trans people is especially important since a disproportionate number of trans people have been victims of physical, mental and/or sexual discrimination, intimidation and abuse when compared with the general population.4 Many trans people also face multiple types of oppression, such as racism and classism in addition to transphobia and/or homophobia.5
3. Language and Confidentiality
Some of the language involved in addressing trans issues can be confusing. Begin to familiarize yourself with the terms and language used in local trans communities. A list of key terms accompanies this tip sheet. Be aware, though, that different trans people may use different terms or the same terms differently. Follow your client’s lead. - 3. In a 2010 Ontario-wide survey of trans people, trans people identify with a variety of sexual orientations and ethnoracial backgrounds. “Trans Pulse. Who are Trans People in Ontario?” 2010 Jul. vol1, issue 1. URL: http://transpulse.ca/documents/E1English.pdf
- 4 For more information on the adverse impact of gender and sexual discrimination on trans people in Canada, see www.qlinks.ca/transsexual-health and www.trans-health.com
5 For a thorough discussion of various factors that play significant parts in trans health, see "Low Income Trans Health Concerns." URL: www.trans-health.com/displayarticle.php?aid=84
- Use the name that your client indicates on the intake form. If it is unclear, it is appropriate to ask “What name do you prefer?” If their preferred name is different from their legal name, make sure that all correspondence and interactions between you, the clinic, and the client reflect their preferred name.
- Similarly, if they prefer male identification, make sure that all correspondence and interactions reflect his preferred pronoun.
- It may be helpful to have a note on the front of your client’s file so that all staff can get their name and gender right without subjecting the client to frequent questions.
- You may have questions from co-workers or other service providers about the gender identity or status of your client or their partner(s). You may want to check with your client during an early visit about how they would like you to handle such questions. Some clients may want you to give an unequivocal answer, some may want to answer all questions themselves, and some may not want to discuss it at all.
- Attention to the client’s preferred and legally registered names and pronouns is especially important when dealing with third parties, such as lab technicians and hospital colleagues. Some trans people choose not to change their legal name and legally registered sex for a variety of personal, professional and insurance-related reasons.
- You may want to discuss with your client how they want to notify third parties of their preferred names. For instance, they may want to notify the third parties themselves or may want you to do so on their behalf.
- If you are accompanying your client to hospital, your client may ask or you may suggest that you act as a buffer for them on this issue. They will be (realistically) expecting some discriminatory treatment at the hands of different care providers.
- If you are ordering tests that will be compared to a sex-specific reference range, you may want to state what reference range should be used, or order two sets, male and female.
- Be aware that a male-identified client may want to be addressed as the “father” and “dad” of the baby rather than the “mother” and “mom.” Again, if you are in doubt, it is respectful to ask the client.
- Pick up cues from your trans client as to how they refer to their body parts or ask what terms they prefer. For example, some clients may use “front hole” or “frontal opening” to describe what is medically referred to as a vagina. It is important to clients that their understanding and names of their bodies be respected and used. Clients may find terms
like “door birth” or “window birth” instead of vaginal or caesarean-section more comfortable.
- Be aware that terms such as “normal” may be quite triggering. “Optimal” or “healthy” can be alternatives.
- It is especially important not to rush the first physical assessment. It may take time for your client to become comfortable with being seen and with your touch. Be aware that genital exams and chest (probably not “breast”) exams are often extremely stressful for trans clients.
- Ask whether your client would prefer to have their support person present. Ask whether they prefer to have you explain what you are doing or prefer silence from you. Make sure they have a signal to tell you to stop if they need to. Ask afterwards if there is anything you might do or not do to make them more comfortable.
- Trans people are often subject to unnecessary questions about their bodies arising more from curiosity than from medical need. Be sure that all your questions are necessary for optimal care, and as with all client contacts, explain to your client why such questions are relevant and important. Be aware that other health care practitioners may be curious about your trans client. Be protective of your client's privacy.
4. Be Knowledgeable About Health Issues that Affect Trans People
- Begin familiarizing yourself with the many different ways trans people choose to transition from their assigned sex and gender to their correct sex and gender. While some trans people choose not to undergo sex reassignment surgeries, others have strong needs to do so.
- Similarly, some trans-masculine people take testosterone as part of their transitioning and others do not. The dosage may vary greatly from one client to another. If a client is pregnant and taking testosterone there is a risk of serious health consequences for the infant – testosterone is teratogenic. If a client once took testosterone and stopped taking it in order to get pregnant, they may have strong feelings about how their bodies are re- feminising. Knowing what this transition means for this particular client is integral to evaluating their pre- and postpartum health.
- While it is not common, it is possible for some trans men to become pregnant while taking testosterone. There are trans men who have become pregnant unintentionally while taking testosterone.
- Keep in mind that this may be the client’s first time having an internal exam, or they may have had traumatic experiences with other care providers. Due to experiences with transphobia in the medical system, many trans people have stayed away from regular
gynaecological care and health care providers in general. Hence, records from screenings such as pap tests, chest (not “breast”) and pelvic exams may be unavailable.
- Your client may have had “chest surgery” (not “mastectomy”) and may be concerned about what will happen to his chest as pregnancy progresses. Be sure you are well- informed about this. Many trans masculine people have complex feelings about their chests and may have difficulty being touched in that area. Take the time to discuss this.
- Do not make assumptions about how a trans client will feed a baby once the baby is born. Trans clients may be interested in nursing or not. Be sure that choosing not to nurse is accepted as a valid choice. Be sensitive that choices not to nurse may be based on physiological or mental health reasons. For many trans clients, “nursing” may be a more comfortable language choice than “breastfeeding.”
- Take note of what the posters in your waiting room advertise. The pressure to nurse can be intense for many trans and non-trans people and your office should to be a safe place for all clients.
- Appointments also provide an opportunity to discuss and educate about preventative screening options and testing for STIs. Pap tests are especially important for trans clients who have taken testosterone. Testosterone usage can cause changes in the cervix that should be regularly monitored and that the lab may misinterpret if they are unaware the client is taking testosterone.
- As with all clients, screen for symptoms of anxiety and depression. Reports show that coping with prolonged discrimination such as transphobia, racism and sexual discrimination can lead to anxiety and depression. When untreated, anxiety and depression have been linked with increased incidence of postpartum depression.6
- Recognize that poverty may have or still play a large part in your client’s life. A recent survey shows that 80% of trans people in the province are living below the poverty line. Like many people who are low income, the overall health of many trans people is adversely affected by the lack of access to necessities such as food, shelter and medicine.7
5. Be Knowledgeable About the Trans Health Care Community
6 Adams ED. If transmen can have babies, how will perinatal nursing adapt? Am J Matern Child Nurs 2010 Jan/Feb;35(1):29.
7 Scanlon K. Trans-Health.com. Lower Income Trans Health Concerns. URL: www.trans- health.com/displayarticle.php?aid=84
- Be aware that even in major metropolitan areas, there is a severe shortage of trans- knowledgeable and trans-friendly resources. This is especially true of medical resources.
- Find out whether a group in your area offers workshops on providing health care to trans people. If yes, attend them or ask the organization to conduct a workshop for your practice. Consult the Rainbow Health Ontario education and training program to find out about workshops available in your area: http://rainbowhealthontario.ca/training/trainingEducation.cfm
- Make referrals with sensitivity. If your client has trusted you with their gender history and identity, keep this in mind during referrals. It is useful to keep a list of practitioners and clinics that have an explicit trans-friendly mandate, but bear in mind that those who have experience with trans patients will be hard to access. Try and have a relationship with a clinic or physician who may be willing to take your client into their practice.
- Keep in mind that transphobia exists in all communities, including the lesbian, gay, bisexual and queer communities. If possible, look for providers who have a positive and recognized history of caring for trans clients.
Key terms
Binding: Using specially designed clothing, or ACE bandages, to flatten breast tissue in order to create a male-appearing chest. Many FtMs (females-to-males) need to bind 24/7 to feel like themselves, some do not bind at home or in private.
Bottom surgery: Also called “genital reconstruction surgery,” includes hysterectomies, metaoidioplasties, centurions and phalloplasties for trans men.
Chest surgery, chest reconstruction surgery: Surgical reconstruction to create a more male or more female appearing chest. Sometimes also referred to as “top surgery.” Chest reconstruction surgery (NOT double mastectomy: a different procedure) is the most common surgical procedure sought by FTMs.
Cisgender: A newer term to describe typically-gendered people. Trans means “across,” cis means “on the same side.”
Crossdresser: Someone who wears clothes of another gender/sex. Most frequently used to describe a heterosexual male who crossdresses as a female some of the time, often mostly in private or for special occasions. Transvestite is a similar term that is generally disappearing from use.
Gender binary: The idea that there are only two possible, opposite genders: man OR woman, and that it is “natural” for all human beings to be strictly one or the other.
Gender dysphoria: The state of acute discomfort felt by transsexuals and some transgender people caused by the incongruity between one’s physical sex and one’s gender-identity. Cannot be measured by tests – a strictly subjective experience.
Gender identity: A person’s internal self-awareness of being either male or female, masculine or feminine, something in between, or something other. Gender functions independently of people’s physical bodies (their sex) and also of sexual orientation (who they desire). Most of us have bodies that match our internal sense of gender but some of us do not and these people are referred to as transgendered or transsexual.
Gender expression: How we try to show the world what gender we are. This may be masculine, feminine, androgynous, butchy, femmy and myriad combinations thereof. Note that this is separate from gender identity. For example, a transgender person may suffer deeply from not being allowed the gender expression that fits their gender identity.
8 This list of key terms was developed by Hershel Russell. 8
Gender Identity Disorder (GID): A psychiatric diagnosis wherein a person who has been assigned one gender at birth identifies strongly as belonging to the “other” gender. Debates continue within trans communities regarding the need for a diagnosis.
Intersex: The condition of being born with ambiguous genitals, and/or mixed internal organs, and/or unusual chromosomal qualities, and/or unusual hormone balance. The term “hermaphrodite” is now considered negative and inaccurate.
Sex: Is between your legs; gender is between your ears.
Sexual orientation: The desire for intimate emotional and/or sexual relationships with people of the same gender/sex, another gender/sex, or multiple genders/sexes. Examples: gay, straight, bisexual, trans-amorous, pansexual, autosexual, asexual. Not to be confused with transgender. Transgender people can be gay, straight etc.
Top surgery: see “chest reconstruction surgery”
Transgender: An umbrella term to encompass all those whose gender identity does not fit, or
only partially fits, with the gender they were assigned at birth.
Transition: The act(s) of changing from one sex to the other, and/or the act(s) of changing one’s physical body and/or appearance as part of a sex/gender change. For most trans people, transition is not a single, discrete event, but a gradual set of changes over a period of time. It is difficult to determine exactly when transition begins and when it ends.
Trans man: An identity label sometimes adopted by female-to-male transgendered people to signify that they are men while still affirming their history as females.
Transphobia: The irrational fear or hatred of those who are gender variant.
Transsexual: An individual whose gender identity does not fit the gender that was assigned to them at birth. Transsexual people seek hormonal and/or surgical treatment in order to bring their body into alignment with their gender identity. People who have completed surgery may no longer consider themselves transsexual, i.e.“I used to be transsexual. Now I am a woman.”
Two- spirit: They may have distinct gender and social roles from their own traditional teachings, which vary widely from one First Nation to another. It is not respectful for White transgender people to use this term. “Two-spirit” can refer to people who are lesbian or gay- identified as well as to people who are transsexual or transgender.