In this post on naming and framings of violations in maternity care, Mari Greenfield and Yuval Topper introduce a case study to draw attention to unseen violences that occur when trans people rely on NHS perinatal services that enforce sex binaries and structure care according to cisgender and heterosexual frameworks.
When a person transitions gender, they are required to change their sex marker within official systems as part of the 2 year psychological ‘real-life test’ that is required before someone is prescribed hormones in the UK. The only options available are male or female, and the NHS system then treats everyone in these categories as though they are cisgender: there are no categories which recognise the existence of either binary transgender people or non-binary people.
Many transmasculine people retain the ability to become pregnant, and many wish to carry their own child, particularly if they are in a committed relationship with a cisgender man. In this blogpost, we will focus on the experience of one trans man and his partner, to illuminate the difficulties that can occur when NHS perinatal systems insist on a gender binary.
Case study – Oliver and Kai
Oliver was 10 weeks pregnant when a routine early pregnancy blood test showed he had Kell antibodies in his blood. If the baby he was carrying was Kell positive (a 50/50 possibility), the baby would need monitoring in the womb every week. The Kell antibodies circulating in his blood could attack the baby, causing anaemia, and potentially intrauterine death. The baby might require intrauterine blood transfusions to save their life, and might need to be born around 32-34 weeks. The only way to tell whether the baby needs these extreme interventions is to have additional specialist scans by a specialist in Foetal Medicine.
Sadly this pregnancy ended in a miscarriage.
When he became pregnant again, he expected the standard early blood tests to also show the Kell antibodies in his blood, which would then trigger the referral to the Foetal Medicine specialist, who would monitor his unborn baby. However, the initial results returned a negative test. When the midwife contacted the phlebotomy service it emerged that – on seeing the sex marker on the medical records – someone had assumed the midwife had ticked the wrong box, and had decided to run a paternal blood-type test rather than a maternal test for antibodies circulating in his blood. Without positive maternal and paternal blood results, no referral could be made. A second test was requested, but with the same result. It was not until the third test was ordered that a positive result was found. From the requesting of each test to receiving the results took over a week, resulting in significant delay to care for Oliver and Kai’s unborn baby.
The appropriate paternal blood tests were finally ordered. These simple tests show whether a person has Kell positive or negative blood. The results were a formality, as the only way that Oliver could have circulating Kell antibodies would be if the father of his previous babies had Kell positive blood, or if he had had a blood transfusion from a Kell positive donor.
This time the laboratory ordered maternal tests to be run on Kai’s blood sample. The tests showed, unsurprisingly, that Kai did not have maternal circulating Kell antibodies, producing a negative result. As Kai was now recorded as having Kell negative blood, there was in the NHS’s eyes no danger to their baby, and no need for any referral to the Foetal Medicine service.
Oliver and Kai requested emergency meetings with their healthcare providers, insisting the tests were wrong, and demanding an explanation of how Kai’s blood could be Kell negative when Oliver’s blood showed Kell antibodies. At a meeting, they were told that there were only two possibilities; Oliver had received a blood transfusion that he did not remember, or he had conceived a pregnancy with a different partner. As Oliver had definitely not ever received a blood transfusion, the implication was that one of his pregnancies had been fathered by another partner, and that potentially Kai was not the father of one of their two children. The healthcare providers were insistent that they had not got the tests confused this time, and refused to re-run them.
After significant pressure the tests were re-run, and Kai’s blood was discovered to be Kell-positive. The referral to the foetal medicine service was now finally made, but with a significant delay.
In enforcing sex binaries, rather than recognising gender diversity, different parts of the NHS system have come together to create a situation in which the correct pathway to appropriate care is made much more difficult for trans parents-to-be. Trans bodies do not fit within the parameters allowed by NHS policies, forms and processes. Unintentionally, violence is occurring in multiple places in trans masculine people’s journeys to parenthood:
Recent research has found that trans people are not considered in healthcare guidance outside of gender transition care globally. The different health needs that trans people may have to cis people are ignored in healthcare systems internationally, potentially leading to inappropriate healthcare and greater morbidity and mortality.
In this instance, the violence was further exacerbated by the initial refusal from within the NHS to accept that there could have been a mistake in the paternal bloodwork. The suggestion that Kai might be raising children that were fathered by someone else had the potential to compromise the marital relationship. In a different couple, it could also have led to domestic violence, which we know increases during pregnancy in heterosexual couples. The stress that Oliver was placed under by the repeated healthcare mistakes can also be argued to constitute an act of violence against his unborn baby, as we know that stress during pregnancy has longterm negative sequalae for the baby.
All of the mistakes that occurred within this episode of perinatal care would not have occurred if perinatal services were not framed in cisgender and heterosexual terms of one mother (who will be the pregnant person, and also the biological parent) and one father (who is in a relationship with the mother, and is the biological parent). Creating systems which instead revolve around the parents’ role in the child’s life, and which recognises the existence of diverse family forms is essential if we are not to commit violence against LGBTQ+ expectant parents, and their children.
Dr Mari Greenfield, Post-Doctoral Research Fellow, King’s College, London