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.

"
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."

SEX NOT GENDER - lives literally depend on this information. It is not literal violence to get SEX based medical treatment.

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

It looks like they did re-ordered the pg test - so they must have considered it - perhaps it just got bit confused in busy work environment.

Yes Gederfreelass, that’s what I’m saying. If the records had clearly stated Female then a report of a positive pregnancy test would have been flagged immediately.

Asking an HCP to decode gender jargon and guess the appropriate course of action is deeply unfair to them and dangerous for the patient.

Definitely sex must be known, there was a young transman I believe who very tragically died from kidney complications, as the HCP understood him to be (biologically) male and treated him accordingly.

It’s only anecdotal but this seems to impact on transmen moreso than transwomen, hopefully they can adjust medical records / triage protocols so the risk is minimised.

and the nurse just didn't really grasp what was going on
Well surely that's the issue there.

Man walks in, says I'm pregnant.
Nurse asks him to repeat himself
He does
She asks if he means a partner etc,he says no I'm trans
She doesn't understand so she asks him to clarify
He explains he was born female
Patient is treated for pregnancy.

Alternatively massively overly busy a and e, nurse hears man is pregnant, calsl someone to look at them, obstetrics comes looking for woman, can't see one and leaves. Nurse is over stretched and trying to chase obstetrics again. It's too late

I think the upshot of this case is that if self describing as trans you need to establish -

• what sex the patient was at birth (including intersex)
• what gender they currently identify as
• if undergoing gender reassignment - at what stage they are in the process.

Several hours later, an emergency physician came to evaluate him.

This IS a failure of care due to the hospital assuming "male" means "male" quite understandably.

If the treatment that was done "several hours later" had been done on admission, the baby might have been saved.

The journal article is clearer than the newspaper report, but as none of us was there, it is still really hard to know what happened. The patient seems to have told the nurse he'd done a positive pregnancy test but then expressed doubt as to whether it was accurate. If that's true, you'd hope that the nurse would have then picked up on that and immediately ordered an examination to see if the patient was pregnant - but we can't know what was going through the nurse's mind. If what you see in front of you is an overweight man with abdominal pains, then "this person might be in labour" is not necessarily the first thing you'd think.

If someone hasn't had any antenatal care at all, and isn't even sure they're pregnant, then they are inevitably going to be more at risk than someone who has been monitored throughout pregnancy.

The other question I'd like answered is: what impact might this person's medication have had on the developing foetus, if any?

Its not rocket science, its about doing a proper job with the patient you're presented with.. basic paying fucking attention.

If a patient presents with severe abdominal pain at an 8/9 level, states they're transgender and taken a positive pregnancy test, then it takes all of 5 seconds to ask what gender they were assigned at birth!

ANY one with female biological sex with those symptoms should be triaged as an emergency.

Its simple bloody negligence on the part of the ER staff.

This is where playing with language becomes dangerous. ‘Assigned at birth’ is a nonsense. This person was recognised and noted as Female at birth and that is the sex they continue to have, throughout their life. They may present as Male but their recorded sex should continue to be Female.

This is particularly important in medicine, not just for the obvious such as this case shows, but because presentation of stroke, heart attack, reaction to medication and many more all differ by SEX not gender.

Biological sex must be recorded on all medical records, with a seperate category for 'gender', if different. In addition, transgender people must take responsibility and be honest with medical staff. There is no way round this, and how sad that a baby died as a result of confusion.

If a patient presents with severe abdominal pain at an 8/9 level, states they're transgender and taken a positive pregnancy test, then it takes all of 5 seconds to ask what gender they were assigned at birth!

How dare a medical professional question my gender?
Off with her head!
Pile on from the TRAs.
Medical professional gets the sack.

The TRAs have made it impossible to ask the question. It's just not worth the additional hassle of never working in the medical professional again if they dare ask the question.

I'm not exactly sure how it works in the US but in the UK the confusion over sex could easily happen.

When you present to hospital here, we have no access to your actual medical records. They are all paper files (apart from maybe clinic letters, etc which are stored electronically but only by the department that wrote them, and are not accessible to every doctor) which are stored in the medical records department. When you're admitted I'll request these, but it can take days to actually get them.

In the meantime, I have to rely on the history I take from you. Which assumes you're telling me the whole story. If the paramedics notes said male, it would be because the patient said they were male.

As for this story, there are many reasons why an apparently male patient who confirmed they were male, would claim to be pregnant. The foremost of these is NOT that they're actually female. Psychosis or delirium for example are considerably more common than transgenderism. Any medical professional would eventually come to the correct conclusion but you'd rule out the more obvious stuff first, which would cause a delay. Sounds like it didn't take that long for the correct diagnosis to be made here, but that that short delay proved fatal to the baby.

In a world where the patient's own truth is considered more important than scientific facts, there will always be tragedies like this

I know doctors who were not aware you could change the sex on your medical notes. If they are faced with an androgynous looking person who can only answer questions with nonsense like "identify," "I was assigned..." they would assume the notes were accurate and defer to them "oh, okay, male then."

These lovely conversations where the exact questions could be asked to correctly understand the situation are both unrealistic in an A&E environment and have the benefit of hindsight and exposure to the language on this board. Loads of patients are confused, below average intelligence, on strong painkillers etc. not the clear messengers implied by PPs.

All medical notes are upsetting, they catalogue the worst things that have happened to you. "I see you have breast cancer," "I see you have had repeated miscarriages," "so you lost your leg in a car accident ..." it is insane we have decided a wrong pronoun is more upsetting than being reminded of a horrible experience. The integrity of medical notes matters, really, really matters. Stick gender identity in with religion, by all means, make sure medication is listed but keep sex accurate.

It's also a side effect of campaigning for dysphoric thinking not to be considered a medical condition. If it said "male," but gender dysphoria was diagnosed and sitting at the top of the notes, that would be better than just "male," not as accurate as "female," but at least a clue.

Why can’t hospitals access medical records online?! Patients can now access their medical records online.

then it takes all of 5 seconds to ask what gender they were assigned at birth!

No human being in the history of human existence has ever had a gender assigned at birth. Avoiding confusing language like this is paramount to appropriate healthcare.

The other question I'd like answered is: what impact might this person's medication have had on the developing foetus, if any?

Royalcorgi The article explains the person stopped taking hormone treatment because they had no insurance so they weren’t taking any medication when they got pregnant. I don’t know enough to be able to comment if there would be any long term effects if someone subsequently became pregnant. The person also had untreated high blood pressure which is of course another risk factor.

In a world where the patient's own truth is considered more important than scientific facts, there will always be tragedies like this

This^ The whole TRA movement is utterly fucked up - their religious beliefs are going to kill more and more people.

Why can’t hospitals access medical records online?! Patients can now access their medical records online.
I can access my GP records but the paeds clinic still takes a paper history every time we take DS to outpatients. I'm pretty sure that doesn't yet go online.

That Lila person's thread that's screenshotted above is instructive. The replies are all around how very distressing it is to be misgendered, to have pronouns assumed or have to explain.
Being dead or having your baby die seems to be neither here nor there.

Time to have TWO sections. One for [birth] SEX and one for GENDER.

This.

It's not a Trans story, It's a fund-decent-healthcare-for-poor-people story.

It took place in a US ER, rather than a more appropriate setting, because the patient had lost their healthcare insurance along with their job.

The patient may have had male on their records, but told staff they were transgender and had had a postitive pregnancy test.

So we have a pregnancy, a swollen abdomen, high blood pressure + abdominal pain. Red flags for pre-eclampsia amongst other things. I cannot defend the HCP involved here at all.

Because we as feminists are sick of being accused of transphobia because we hold gender critical beliefs, we shouldn't forget either that Transphobia does exist and can be especially marked amongst those with strong religious beliefs. I am not saying that is what happened in this case, but I would be interested to know if there were any homophobic/transphobic issues at play here.

In a world where the patient's own truth is considered more important than scientific facts, there will always be tragedies like this

Yes, this.

Isn't it also true that a man/male who has certain health conditions could get a positive pregnancy result?

This issue was raised in a rather irreverent youtube segment when a man who says he is as a woman presented to Planned Parenthood for the morning after pill & women's health advice. The point to to illustrate how women's health services are required to affirm.

-the key issue is that so many vulnerable people have not been fully advised of their sex-specific health needs & may be significantly disadvantaged as a consequence.

Health care professionals need patients to provide as much accurate pertinent information as is possible, especially in critical situations.

Establishing sex is a key part of triage.

Why can’t hospitals access medical records online?! Patients can now access their medical records online.

It's because it's technically quite complicated to link up GP records with the records from the various hospital departments, most of which would have had their own separate, paper-based systems. Years ago there was an attempt to create a nationwide digital patient record system in the NHS and it was eventually abandoned as costs and complexity spiralled.

Quite a few hospitals are now implementing EPRs (electronic patient records) but it's by no means universal. And some are hooking up with GP systems, but again, that's fairly patchy. What we don't have is a single health record for every patient that contains all their health information.