Trans men and paternal pregnancy: experiences during the pregnancy-puerperal period

Mascarenhas, Rebeca Nascimento dos Santos; Santos, Vitória Valéria Cristo; Santana, Bruno Silva de; Monteiro, Anne Alencar; Couto, Telmara Menezes; Sousa, Anderson Reis de; Pereira, Danilo Martins Roque; Almeida, Lilian Conceição Guimarães de

doi:10.1590/1413-81232024294.16172023EN

Rebeca Nascimento dos Santos Mascarenhas

conception and development of the research

writing of the manuscript

conception and design of the study

literature review

data acquisition

data analysis and interpretation

writing

besides working actively in approving the final version of the manuscript

Escola de Enfermagem, Universidade Federal da Bahia (UFBA). R. Basílio da Gama 241, Canela. 40231-300 Salvador BA Brasil. rebeca.nascimento@ufba.br

http://orcid.org/0000-0001-6155-0290

Vitória Valéria Cristo Santos

conception

development

writing of the manuscript

formulating the manuscript’s design

besides the collection

analysis, and interpretation of the data

literature review

data acquisition

data analysis and interpretation

writing

approval process of the final version of the manuscript

Departamento de Ciências da Vida, Universidade do Estado da Bahia. Salvador BA Brasil.

http://orcid.org/0000-0002-6374-9532

Bruno Silva de Santana

regarding the activities related to the research

comprehensive development of the manuscript

analysis and interpretation of the data

writing with valuable contributions

approval process for the final version of the manuscript

Universidade Estadual de Feira de Santana. Feira de Santana BA Brasil.

http://orcid.org/0009-0003-6501-2432

Anne Alencar Monteiro

writing and reviewing the content

approval process for the final version of the manuscript

UFBA. Salvador BA Brasil.

http://orcid.org/0000-0002-5769-845X

Telmara Menezes Couto

developing the theoretical framework

analyzing the data

critically reviewing the manuscript

approval of the final version of the work

Escola de Enfermagem, Universidade Federal da Bahia (UFBA). R. Basílio da Gama 241, Canela. 40231-300 Salvador BA Brasil. rebeca.nascimento@ufba.br

http://orcid.org/0000-0001-6836-8563

Anderson Reis de Sousa

developing the theoretical framework

data analysis

interpretation

critical review of the manuscript

approving the final version of the work

conducting a thorough analysis of the content to ensure its quality and academic rigor

Escola de Enfermagem, Universidade Federal da Bahia (UFBA). R. Basílio da Gama 241, Canela. 40231-300 Salvador BA Brasil. rebeca.nascimento@ufba.br

http://orcid.org/0000-0001-8534-1960

Danilo Martins Roque Pereira

conception

development of the research

writing of the manuscript

outlining the study design

analyzing and interpreting the data

critical review

analysis

approving the final version of the manuscript

Programa de Pós-Graduação em Enfermagem, Universidade Federal de Pernambuco. Recife PE Brasil.

http://orcid.org/0000-0002-0962-2127

Lilian Conceição Guimarães de Almeida

conception

development of the research and writing of the manuscript

outlining the study design

analyzing and interpreting the data

critical review

analysis

approving the final version of the manuscript

Escola de Enfermagem, Universidade Federal da Bahia (UFBA). R. Basílio da Gama 241, Canela. 40231-300 Salvador BA Brasil. rebeca.nascimento@ufba.br

http://orcid.org/0000-0001-6940-9187

Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Case description

Case: [...]gestational follow-up in a specialized hospital, a reference in the care of transgender people in the pregnancy-puerperal cycle. The patient was a middle-aged, self-declared Black transgender man, who identified himself as a Candomblé adept, lived in an urban area, in a suburban region, had studied until high school, was unemployed, and worked in informal occupations to generate income. He had no previous references to associated comorbidities, nor any history of surgery, alcohol and tobacco use, use of other drugs, or known allergies. The laboratory tests he underwent showed no hematological or serological alterations (non-reagent serologies). He was experiencing mental health issues, had received a medical diagnosis of bipolar disorder, accompanied by gender dysphoria (anxiety, dysphoria, and suicidal thoughts), and was being monitored by a team from a Psychosocial Support Center. [...] as for the pregnancy and puerperal period, he had an obstetric history of two pregnancies, one normal birth and zero miscarriages. The second pregnancy was a single, topical pregnancy, identified on ultrasound, resulting from home insemination, planned by the couple and previously accepted by the parturient. The decision to get pregnant was motivated by the fact that the cisgender partner had known gestational risks. The pregnancy was monitored in a hospital because of the manifested psychological distress associated with the pregnancy changes experienced. Three prenatal care visits were performed. The assessment of fetal vitality was normal, with adequate fetal growth, according to the ultrasound (obstetric doppler). The gestational age was 33 weeks and one day, and was experienced with complaints of frequent pelvic pain, low back pain, dental pain, nausea episodes, feelings of anguish, anxiety, negative thoughts and self-mutilation. [...] motivated by mental health issues, expressed by the patient’s free will, a protocol termination of pregnancy was recommended. The birth occurred in an obstetric surgical center, at 34 weeks and 2 days, without complications, resulting in a newborn, identified as male, with an APGAR* index/score of 9/9, on a scale of 0 to 10, and a weight of 2,510 kg.

Case description

Case report: [...]it was about a middle-aged, obese, cisgender woman, who was accompanying the pregnant transgender man throughout the pregnancy-puerperal period, the mother of the child [...] the desire to breastfeed came from the partnership, but due to the high cost of hormones, the lactation induction was interrupted [...] people made fun of her; they didn’t want her to say or answer anything; they referred to her as a companion and not as a mother. We heard a lot of things from the health professionals: “Oh, you’re just a companion, you can’t see the child, you’re not considered to be the mother”. She didn't have the right to take part in all the birth monitoring and initial care; it was all very protocol-like, and she wasn’t allowed to see any of my tests, although she was the mother. She was the mother, but couldn't take part in everything, including the ultrasounds. When the declaration of live birth was being made, my wife would say “put my name on it, I'm the child's mother, not him, he's the father". My wife also found it strange that they hadn't put her name on the baby's ID bracelet after the birth. They put the bracelet on my arm, but they didn't put it on the mother's arm [...] nobody worried about her health conditions, although they knew that professionals had important bodily needs to take care of [...] to feed the child. She couldn’t breastfeed directly. We're having to buy milk, which is very expensive, causing us financial hardships [...] as my wife didn't have the right to register the child, we're experiencing difficulties caring for the child, such as having access to the milk provided by the government. My wife has struggles accessing her child's milk. It's as if she hadn't given birth. This is very sad, because it's the child who suffers. The services don't recognize that a man gave birth to the child and not the woman. Seeing my wife look at the birth certificate and not seeing her name makes me feel anguished. So, all these things have made the process more difficult.

Case description

Case contextualization: [...]Our nursing team faced significant challenges that deserve attention during trans patient care. One of the main obstacles was the appropriate use of pronouns and the fear of making mistakes that could be interpreted as obstetric violence. Moreover, having experienced the case raised personal questions. Why did the patient plan the pregnancy and then develop a phobia about the pregnant body? This question raises the importance of psychological support for trans patients in situations of vulnerability, from before conception, so that they can prepare for the bodily changes [...] the decision to terminate the pregnancy was not taken in consultation with obstetricians, as is common, but with a psychiatrist, due to the psychiatric risks involved. Moreover, it was necessary to carefully assess the pros and cons of this interruption, considering the advanced stage of the pregnancy, which was at 34 weeks, which would result in the birth of a premature newborn [...] Therefore, taking care of mental well-being is equally important for overall care, as is with the physical body [...] drawing up a birth plan was fundamental. This allowed the obstetric nurses to follow the labor and birth good practice protocol. However, through this lad’s birth plan, I realized that these practices may not be desired by everyone in the immediate postpartum period, such as immediate skin-to-skin contact between the baby and the parturient and breastfeeding in the first hour, which we learn is important, but not everyone wants at the time. [...] Another issue with this same case was that I, as an obstetric nursing resident, didn't feel comfortable carrying out the physical examination on this vulnerable patient, because he didn’t like the breasts and the pregnant body, and there I was, having to inspect, palpate and auscultate extremely sensitive areas for that person, in a ward shared with several women there and we didn’t have anywhere else to put this lad, separately, because of the structure.

Case description

Case discussion: [...]the pregnancy was planned, but difficulties arose right from the start, as we carried out a home insemination with practically no support from health professionals. For health reasons, my wife was unable to carry the child. We couldn't afford the cost of an insemination carried out with the support of a professional [...] it was only after the home insemination had been carried out, with the support of a family member, that we spoke to a doctor, who ordered tests for both my wife and me, such as a preventive uterine exam [...] It was complicated to carry out prenatal care as well. I only had three appointments, because every time I scheduled appointment, I faced difficulties in scheduling and availability at the unit, which was also undergoing structural renovations [...] I experienced moments of acute pain, to the point where I had to go to the hospital called the maternity ward, and it was because of the stress and anxiety that increased after the pregnancy. As a result, my psychological problems deteriorated during pregnancy. Everything was fine as long as my belly didn't grow. Then it changed, my body didn't stay the same, and I started “doing stupid things”, like trying to hurt myself, punching my belly and thinking about killing myself. I had to be hospitalized because of this [...] while I was in the hospital for prenatal care, I went through new difficulties, such as being called "she" or "mother" all the time by the health professionals [...] I also warned the staff that I didn't want to breastfeed and that I had some discomfort with my body, especially the parts that might refer to the feminine. This really affected me because I’m not her, I'm not the mother: I'm the father.

Care processes	Theoretical interpretations	Epistemological implications
Keep the belief	Believe that it is possible to be cared for with respect	Consider the diversity of bodies and possible identities for care in the production of scientific knowledge
Know	Seek information on the experience of trans men during pregnancy, childbirth, and the puerperium	Review cisheteronormativity, making multiple identities visible
Be with	Share planned care and responsibilities between users and professionals	Inclusive practice considering empirical knowledge from experience
Do for	Perform with respect, preserving individuality	Respect for fundamental rights, human rights and human dignity
Enable/Empower	Guide and generate possibilities centered on the other	Pedagogical-therapeutic care process centered on the subject based on transgenderism
Care processes	Problems	Implications for practice
Keep the belief	Delegitimization of the culture of self-care and parenting and the transgender experience	Visibility of the unique and challenging experiences, encouragement of self-care, and recognition of the parental rights of transgender people
Know	Attitudinal and technical weaknesses in the clinical management of trans men’s pregnancies	Commitment to continuing health education activities to raise awareness of gender identity issues and create inclusive and respectful care environments
Be with	Ethical dilemmas in the actions of health professionals in respecting autonomy and instruction, even in the face of judicialization and the preservation and protection of mental health	Supporting trans men in making decisions about childbirth and the puerperium and evaluating the termination of pregnancy protocol in situations of psychological distress and life-threatening risk
Do for	Care plans that follow the heteronormative pattern for cis women do not include the partner and do not think about the needs and specificities of the pregnant couple	Drawing up an extended and individualized care plan to avoid repetitive and unnecessary approaches
Enable/Empower	A training plan that is not attentive to occurrences, has gaps, and does not match the profile of the population served	Create dynamic learning possibilities and strategies in the hospital environment, including emerging demands.

[1] Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Brasil

Brasil

Trans men and paternal pregnancy: experiences during the pregnancy-puerperal period

Abstract