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.

Why on earth are medical records saying "male" when someone isn't?

Of course it should be prominently on your notes that you wish to be addressed as male and details of all the medications etc that you are taking will be there. But surely it is vital that medical records contain the facts of your biology.

Incorrect use of language leads to confusion. Had the medical records indicated that they were female then it is highly likely that a report of pregnancy would have been treated differently, regardless of the persons presentation.

This is sadly what happens when you purposely obscure reality.

Medical records need to be biologically accurate. Gender preferences could be added as an addendum in order to treat people sensitively but confusing HCP’s with inaccurate details has and will again lead to avoidable tragedy’s.

It sounds like it was a combination of factors. When you’re pregnant it’s best to present to Maternity (not ED) but if you’d had no ante natal care (and weren’t even sure you were pregnant) how would you know?

Transmen often do look just like any other man, if the record said “male” the HCP might have thought he was a man transitioning to female (agree with PP - it’s not intuitive).

A female sex person feels that in their head they are male, and they are having PIV sex with their boyfriend.

And we're still not allowed to consider that gender dysphoria could be a mental health condition not being born in the wrong body?

This is what happens when you castigate HCPs for treating trans people appropriately.

Remember Pink News frothing at the mouth when a trans man presented with a broken arm because they were asked if they were on hormones or could be pregnant?

"broken arms are not a gender issue" - erm, yes they are, mate, cos your medication can make you osteoporotic and you need an x ray so they need to know if you might be pregnant.

Pretending that you can change sex is causing problems. This is a really sad situation.

I can't read the article because of ad blocker (which I have to have because of MN!)

from the summary you have posted, I can see how confusion would occur. if the staff thought the patient was a man who peed himself, why would they then have any idea that it was actually a pregnant woman? I can't see any information to see how far along the pregnancy was.

this has been one of my major bugbears all along - medical records shouldn't be altered.

I have read the article Kesstrel abd it does read as if the triaging nurse ordered a pregnancy test on the basis that the patient was a transgender woman so it was bound to be negative. Several hours later the physician took a more detailed history.

I also looked at the declaration of interests. The author is certainly interested in women's repreductive health - not sure about anything else.

As Gabrielle says, the article recommends that biological sex and gender identity and legal sex are recorded (assume the latter relates to US legislation).

Still seems like poor care to me rather than a lack of disclosure from the patient.

I'm guessing here, but could it be that when medical records first went electronic they were designed with certain required fields, one being Male/Female, or perhaps Male/Female/Intersex, no mention of gender identity, maybe not easy to add extra fields. But now we have a small but growing number of people who have a clear bio sex but because they identify as trans or nonbinary they have changed all their documentation to something different from their bio sex. Instead of reworking medical records to allow people to have their gender identity included alongside bio sex, healthcare providers have simply allowed patients to get their bio sex record changed. This may perhaps all have happened at a relatively lowly admin level with little thought to the medical consequences.

sackrifice I'll concede that I don't know enough about what happened to make a judgement about it either way.

manchester that's an awful thing to say.

I don’t think it’s unknown for actual women to turn up to a hospital in early labour and for it not to be immediately realised.

Why are people having issues with Transmen having PIV sex?

While there are a lot who end up having dysphoria around not owning a penis, there are also plenty who are able to transition, present and live as a male, but still embrace their genitals to engage in a healthy sex life with their partners.

If people are too stupid to understand that, then things like this will continue to happen.

Anyone is entitled to have any kind of (consenting) sex they want - but what’s that got to do with the triage process?

Nettie - yes, you are right, have now looked at the article, the nurse did order pregnancy test. What a sad story.

Regarding the doctor's views, this is her twitter:

twitter.com/dstroumsa?lang=en

For those who have been wondering about a transman having PIV sex: I've been reading a lot of destransitioner stuff, and I think a lot of these young people are so desperate for someone to love them that they will make that kind of compromise even if conflicted over it. Alternatively, a transman in this position could subconsciously be moving in the direction of detransitioning. Or they never really had dysphoria, but just hated what presenting as a woman means in this society, and prefer to think of themselves as gay men. Lots of possibilities.

I'm not too stupid to understand it, KoalaTea, I'm just struggling to grasp what gender dysphoria means in practice if someone who identifies as the opposite to their birth sex continues to have heterosexual sex involving the genitalia they have as a result of being that bio sex, especially when that sex is not just recreational but also results in the birth of a child.

It might help if people had stopped being so fucking twee about labelling sex where it occurs, preferring to use "gender" instead (not the same thing).

Female sex, male gender - no problem. Biology identified on records, biological imperatives noted, medical exams accordingly.

Koala "If people are too stupid to understand that, then things like this will continue to happen"

I'm afraid I'm going to stick my neck out and say that there's enough for medical professionals to be dealing with, especially in A&E, without having to work their way round words that encompass all the complexity of human habits.

for medical purposes, the staff need to know the sex of the person they are dealing with. That's part of how they triage. They shouldn't have to factor in anyone's gender ID.

if the patient said clearly to the doctors "I'm pregnant" I agree that the doctors should have realised/considered they were dealing with a biological female though.

Biological sex and preferred gender should both be included in my opinion to try and clear up any confusion that may occur. You cannot change your sex, and there are several sex related issues that can occur for someone presenting as a different gender. We are so busy being PC and 'woke' that we are unintentionally therefore failing some people.

why would preferred gender be needed? If it's just for pronouns, I would really rather doctors be left to get on with their work than have to flap about this kind of thing.

Thanks for twitter link Kesstrel.

I think this report is a very sad way to highlight the need for recording sex and gender. Re the horrid deleted comment, the article does say how distressed the patient was and a stillbirth is a terrible thing to wish on anybody. Article also says person is now on the coil because, despite having a phobia about menstruation, he is more affected by the fear of becoming pregnant again. Agree with Gabrielle that this sounds more than a inner feeling of being a man which is easily resolved by taking cross sex hormones.

It is worth signing up to read the NEJM article. I think it is really helpful at highlighting when sex matters and how easy it is to assume every trans person is a trans woman.

Thanks kess for the doctor’s Twitter - interesting. She liked this tweet-thread... the gist seems to be that you only ask for bio sex if “medically necessary...” (and “not for a broken arm”) - otherwise just ask for pronouns.

.

if the patient said clearly to the doctors "I'm pregnant" I agree that the doctors should have realised/considered they were dealing with a biological female though

Except in this case they didn’t clearly say they were pregnant. They said they had done a test, the results of which they were questioning.

The HCP did the appropriate thing which was to order a test to confirm or rule out that possibility without having to do an invasive examination on a person who was otherwise stable. Had they been in full receipt of all the accurate info, communicated in clear language then I’m sure they would have taken a different course of action.

Asking people in highly complex and pressurized situations to “guess” the appropriate course of action by what is obvious only in hind sight is deeply unfair and dangerous.

Or they assumed it was a male who identifies as a female. And therefore not an 'actual' pregnancy.

I wonder if this was the confusion.

The medical notes saying male almost certainly didn’t help.

We were sent to a consultant in last pg, we wanted a second HB. He spent a good 10 minutes arguing with us that our 2-year-old son was 8 because he insisted that’s what my medical notes said. We were parents we knew how old our children were, but his notes took precedence . When DH finally got through to him turned out he’d read the notes wrong.

The notes were more important than a patient saying no that's wrong.

A family member had it recently – the notes were wrong or read wrong and the medication changed on that basis and fact they had medicine they’d been prior with them – oh no notes say different.

Kittens okay but even saying "I've done a test" - surely they should consider they might be dealing with a biological female?

I realise they can't take anything for granted but isn't this highlighting even more that medical records should be factual?

to be clear, I don't wish to criticise the medical staff here. I think they are in a horrible position generally - adding all this into it makes certain situations almost impossible to navigate.