Dreadfully sad case reported of a transman whose medical records said 'male' with tragic consequences

[GabrielleNelson]

This is a tragic case involving stillbirth. From the report I've just read in the Washington Post, that might have happened anyway, but the report suggests there were delays in treatment and confusion because the patient records said 'male'. The patient said 'I'm transgender' but the implications don't seem to have registered.

www.washingtonpost.com/national/health-science/blurred-lines-a-pregnant-mans-tragedy-tests-gender-notions/2019/05/15/00463b30-7755-11e9-a7bf-c8a43b84ee31_story.html?utm_term=.ee047038899f

Sequence of events:
Patient starts taking cross-hormones and medication for high blood pressure (not sure if the two are related)
Patient loses insurance (in the US), stops taking all medication but menstruation doesn't resume
Patient becomes pregnant, not clear from the news report how early patient realised this, but my hunch is only when abdominal pains started, so no antenatal care
Patient goes to emergency room and reports positive pregnancy test, says 'I have peed myself' which nurse fails to realise means the waters have broken, nurse does not triage patient as an emergency
Hours pass, doctor sees patient, realises belatedly that patient is in labour, discovers fetal heartbeat is very weak, cord has prolapsed into vagina, EMCS, baby is stillborn.

The Washington Post's take on this is that health services need to up their game. Transgender people often run into problems getting gender-specific health care such as cervical cancer screening, birth control and prostate cancer screenings. They mean sex-specific, as (interestingly) all five comments below the line point out.

“He was rightly classified as a man” in the medical records and appears masculine, Stroumsa said. “But that classification threw us off from considering his actual medical needs.” ..... Transgender men, who are considered female at birth but who identify as male, may or may not be using masculinizing hormones or have had surgical alterations, such as womb removal. Considered female! Observed as female, surely.

Transmen shouldn't be classified as men in medical records. By all means add a field for gender presentation, but if a patient clearly recorded as of the female sex arrived at A&E looking obese, hadn't had a period for a long time, suffering serious abdominal pains, mentioning that she'd 'peed herself', I'm pretty sure it wouldn't take several hours before anyone thought to check whether she was in labour.

I think it sounds like very poor healthcare and think blaming the transman for their stillbirth, when hcps knew about the pregnancy, is terrible.

Have you not heard of the USA? Healthcare isn't free out there. how is it blaming the 'transman' for their still birth when only women can get pregnant? If you twist reality then and demand people obey, what the fuck is a person to do?

Treat you like a woman, and risk losing your job.
Treat you like a man and risk losing a life.

That is the reality for HCPs these days. If their decision was to treat this person as they wanted to be treated, like a man, then that was their decision to make.

This is very sad, maybe medical documents need to be changed. Maybe birth gender could be included? Also maybe if a transgender man has kept their female reproductive organs it would be useful to include that also.
As being transgender is more accepted and more people transition this situation will appear. Women have given birth without knowing they were pregnant, this could happen to those who are transgender. But the healthcare workers in this case clearly were either overworked or not doing their jobs correctly.
Hopefully this tragic event will prevent this happening again.

Maybe birth gender could be included? Also maybe if a transgender man has kept their female reproductive organs it would be useful to include that also.

BIRTH SEX. And 'until you die sex'. As you cannot change sex.

And yes of course this needs to be 'included'.

How awful. My first thought was how a woman - in this case an anatomical woman identifying as a man - is once again a casualty of these lies.

I imagine the hcps were confused and saw “overweight bloke identifying as a woman”.

So bloody awful.

#SexMatters.

Healthcare for the uninsured in America is not great, and probably treats a lot of people with mental illness.

If the healthcare professionals didn't understand that this person had female reproductive organs then they could have filed it under 'Delusional'. Possibly even worse 'Delusional male that wants nurses to give them a cervical exam' in a wax my balls style.

Your birth sex should never be removed from your medical records.

Transgender or not the nurse knew he was pregnant and ordered a test. It’s gross negligence that resulted in a babies death and blaming confusion on gender due to medical records is just crappy. It sounds to me like a ridiculous way of shifting all blame. If she had no idea he was pregnant and he didn’t know then I would understand thinking the condition wasn’t serious as you may mistake signs for something else but when you know someone is pregnant you do the checks!

I don’t think emergency health care for uninsured people in the US is known to be much good generally.
Just wondering what the implications of the proposed ban on abortion in Alabama might be for trans men unfortunate enough to get pregnant in that state. As a man, would an abortion be OK? Many people on the political right who don’t support women’s rights are happy enough with the trans agenda...

Frankly, I'd want to read the actual article in the medical journal before making any deductions about exactly what this patient said on arrival. The Post article is very unclear on that.

The article in the medical journal is behind a paywall but it starts:

A 32-year-old transgender man, presenting with severe lower abdominal pain and hypertension, is classified as a man who hasn’t taken his blood-pressure medications. When examined several hours later, he’s found to be pregnant

I guess ordering a test doesn't guarantee that the results were back in a timely manner. There isn't exactly a timeline in the article, so it could have gone

A pregnant man -> oh I'll order a test just in case -> time passes -> holy shit he's pregnant -> too late handover to consultant.

www.nejm.org/doi/full/10.1056/NEJMp1811491 The Power and Limits of Classification — A 32-Year-Old Man with Abdominal Pain

This is the article the newspaper report is based on, in this week's issue of the New England Journal of Medicine. Extracts follow. The main focus of the article is on the importance of getting all relevant information into medical records so that right from the start HCPs can classify patients in a useful way, and it does say that bio sex should be there alongside gender identity. Unarguable, surely.

Sam, a 32-year-old man, was brought to the emergency department by his boyfriend. Sam reported an 8-hour history of severe (8 out of 10), intermittent lower abdominal pain. In triage, he had a blood pressure of 185/84 mm Hg and a heart rate of 67 beats per minute. The triage nurse noted that he was an obese man who appeared comfortable between bouts of pain. Sam told the nurse that he was a transgender man. His electronic medical record (EMR) indicated that he was male. He had previously used testosterone, as well as antihypertensives, both of which he had discontinued because he’d lost his insurance coverage. It had been several years since he last menstruated. He had taken a home pregnancy test that morning and got a positive result, but he wondered whether it was a false positive. He added that he had “peed himself” that morning.

The triage nurse assessed him to be a man with abdominal pain who had not taken his prescribed blood-pressure medications. Determining that his condition was stable, she triaged him to nonurgent assessment. .....Several hours later, an emergency physician came to evaluate him. She noted the positive results of the serum hCG test and took a more detailed history, considering possible early pregnancy complications. On examination, she noted that his abdomen was not only obese but also gravid. The evaluation had changed: the patient had severe abdominal pain, possible ruptured membranes, and hypertension in advanced pregnancy, which suggested possible labor, placental abruption, or preeclampsia — urgent conditions presenting a potential emergency.

...................

After discharge from the hospital, Sam reestablished care. He resumed antihypertensive treatment and requested the placement of a copper IUD. Though he had not planned or expected the pregnancy, he was heartbroken at the loss of his baby and had a major depressive episode. Despite having significant dysphoria related to menstruation, he has not resumed testosterone treatment, since he prefers to have continued menses that reassure him that he is not pregnant.

How does a HCP even start to have a clarifying conversation in these circumstances without laying themselves open to career ending accusations of transphobia. When the words "pregnant", "vagina" and "period" are potentially triggering and not to be used.

Lay people and presumably a lot of medical care staff get easily confused between transman and Transgender male.

Me! The only place I hear anything about trans, terfs, gender vs sex, etc is right here on Mumsnet. I've learnt a lot but STILL when I read transwoman I have to ask myself is that M2F or F2M? Every time. Because it's counter-intuitive, I think, i.e. transwoman is actually male. I know that on here you're all very familiar with the terms but nobody I know irl is.

HCPs have to be able to talk frankly even when what they're saying is unwelcome. Plenty of women have had to be told they were pregnant, or even in labour, when that was the last thing they wanted to hear. Anyone who is physically capable of becoming pregnant might have to be told that news.

Sam told the nurse that he was a transgender man. His electronic medical record (EMR) indicated that he was male.
She would've heard 'man' and read 'male' and thought for sure that he was a bloke.

Oh for goodness sake sackrifice, the patient said they were transgender and pregnant on arrival. Any health care professional who is too thick to process that information sufficiently in order to decide on care is a SHIT hcp. Your comment sounds like you're saying 'ner ner na ner ner'

Agree

I didn't think a pg test would be positive so late on in pregnancy?
And why is a transman having PIV sex?

Thanks!

Sam, a 32-year-old man, was brought to the emergency department by his boyfriend. Sam reported an 8-hour history of severe (8 out of 10), intermittent lower abdominal pain. In triage, he had a blood pressure of 185/84 mm Hg and a heart rate of 67 beats per minute. The triage nurse noted that he was an obese man who appeared comfortable between bouts of pain. Sam told the nurse that he was a transgender man.
His electronic medical record (EMR) indicated that he was male.
He had previously used testosterone, as well as antihypertensives, both of which he had discontinued because he’d lost his insurance coverage. It had been several years since he last menstruated. He had taken a home pregnancy test that morning and got a positive result, but he wondered whether it was a false positive.
He added that he had “peed himself” that morning.

My concern is that the unbolded bits aren't clearly attributed to anything he said on arrival or anything in his medical record. I would like to be certain that they were in fact known to the triaging nurse.

I don't know, kesstrel. I signed up for three free articles just with an email address, but I'm not an HCP or a trained scientist, so I don't know if there's a convention here that allows the reader to assume that everything stated in that intro is drawn from the case notes.

Manchester that’s an awful thing to say - there is no reason the babe’s parents would not have been loving and wonderful parents. Sam is clearly grieving the loss, like any of us would - I’m almost in tears and have no connection, it’s sad however you look at it.

newt, this is the part that is totally beyond my comprehension. I would have assumed that if you have such bad gender dysphoria that you can't stand being identified as female and want to change the external appearance of your body, PIV sex with a man would have been out of the question, ditto pregnancy and childbirth, as these are such female things to do. But seemingly not.

Oh, I didn't think of signing up! I'll have a look later, thanks. Perhaps I'm wrong to be so wary, but the doctor who wrote the article is a gender activist, and we have seen examples of disingenuous reporting from medical personnel before. It could certainly be that the nurse was incompetent or badly trained, of course, but it would be interesting to know the nurse's account of this incident.

The update is more clear. From the OP it sounded as if the nurse had simply failed to realise ‘peeing’ was the waters breaking.

But from the update it does sounds more like the nurse didn’t twig he was pregnant.

We certainly have. That article about the transwoman feeding a baby was an appalling piece of work. Raised so many obvious questions to anyone who'd actually breastfed a baby, but left them all unanswered.