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.

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.

Last year when CRUK launched the campaign for 'people with cervixes' to widespread criticism. A person who was transgender similarly voiced their belief that their experience of being misgendered at the GP was far worse than the prospect of dying of cancer.

www.dailymail.co.uk/news/article-5847585/Cancer-Research-UK-swaps-woman-campaign-avoid-offending-transgender-people.html

A few months ago someone started a thread on here about how one of the NHS patient record systems had a field for sex, and another field for gender ID. And it turned out that staff were ignoring the sex field and putting the person's biological sex in the gender ID field. Can anyone remember any more details?

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

Exactly, and it doesn't help when the news media talks about "pregnant man", that is just ideological gobbledegook.

I wouldn't be surprised, Ali1ce. From the little I've read, standards of obstetric care in the US can be very poor. Interesting to read they have far fewer midwives, significantly fewer autopsies in cases of maternal death, no national standards.

www.scientificamerican.com/article/the-u-s-needs-more-midwives-for-better-maternity-care/?redirect=1

www.nationalgeographic.com/culture/2018/12/maternal-mortality-usa-health-motherhood/

www.propublica.org/article/why-giving-birth-is-safer-in-britain-than-in-the-u-s

www.propublica.org/article/why-giving-birth-is-safer-in-britain-than-in-the-u-s

We have no idea what the ER looked like that day. Ever been to an ER on Friday night? Or right after work hours during flu season? In an area of significant poverty (where people use the ER as their primary care doctor)? During a cold snap in a cold climate where people gather there just to stay warm as they are homeless?

Cases are triaged when one presents themselves at ER, usually by a nurse/clerk sitting at a desk dealing with a line of people. Depending on the urgency they can tell by the information provided, you can be waiting a while. If you are ambulatory, often you go to a “second” stage triage at some point. Where you wait some more. If any other more urgent/emergency situations come in while you are waiting, you are going to be waiting longer.

This trans man’s records said they were male. They said they were “transgender” to the hospital staff, not “I am female who likes to be called male”.

They said they took a pregnancy test but doubted it (and pregnancy tests in late stage pregnancy rarely are positive so that is interesting itself). A test was ordered anyway. The journal notes they were obese so a pregnancy would not be immediately obvious. I can tell you a couple stories of obese women who did not know they were pregnant until they were in labour because a lot of the other symptoms were passed off as gas, etc and the baby was close to the back/carrying high in the torso and so physically it was not apparent.

Trans women rarely “pass” but trans men more often do - or at least cause some uncertainty - because testosterone is a hell of a drug - it can shift fat distribution, cause male pattern baldness, deepen voice - all permanent changes. Even after stopping it.

To busy ER staff, saying “I am transgender” means little - if their charts say male and they are showing the effects of testosterone, they could just as easily think that means a man who “identifies” as a woman (and we know some trans women who like to say they can get periods so why would they talking a pregnancy test be different?)

This is why SEX is important. Sex. Not gender feels.

Note I posted twice as I reported my first post as I realized after I posted I used a term not allowed on here (gets hard when different sites allow different terms!)

www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system

That's the one I was looking for. I read it a couple of years ago. Too much focus on the baby, not enough on the mother. Sounds familiar at all from the news this week?

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.

Well no, it wasn’t that clear cut though was it?

A suspected pregnancy from somebody reporting that they were male and did not have menses so no time scale and a questionable diagnosis. A pregnancy test was done to confirm - that would be the appropriate action for that being reported. It certainly wasn’t ignored.

Large abdomen on a visibly obese person is not de facto a symptom of anything.

The patient had a history of hypertension and was off meds so no immediate reason to flag that as an additional concern and abdomen pain can have numerous causes.

Of course in hindsight it’s obvious that it was a female in labour but HCP’s don’t deduce from the pricking of their thumbs, they deduce by information and confusing, patchy information will lead to delays/mistakes in diagnosis.

That said I agree about the lack of health care for the poor. Had this individual had health insurance (or free at point of use medical care) they likely would have been able to access care that would have saved their baby and it’s appalling that a baby’s life was lost in part due to money.

Koala I think we all agree that anyone who is of the female sex should be treated as having female sex issues.

Problem arise when document state that the person isn’t female but male.
That you are in a high pressure environment but you also insist that no HCP will make any assumption on the sex of the person depending in their gender/presentation (because of course, it’s totally logical for someone with a deep voice and a beard to say they are pregnant)
That everyone is so worried about saying the wrong thing that they might well not dare asking for the SEX of the person for fear of ending up in Court (see the case about the broken arm and someone daring asking for that information - even though it’s clear that it was for their own safety)

We could of course just never assume that we have a Male or female SEX person in front us and ask every cis man I’d they have a uterus, take hormones etc... I’m sure this will be very helpful as 1- it will make intake so much longer and complicated and 2- I can’t see (cis) men agreeing to be basically ask if they are in fact women.....

Since there have been transwomen demanding access to female gynaecology services, such as cervical smears, it's not beyond the bounds of imagination that a transwoman might want to think they are pregnant as part of their whole belief-system, and might demand medical attention for such, when in fact they have wind or similar.

Yes this case went dramatically and tragically wrong but in the current climate, it's not that surprising.

It is a case where it really doesn't help that 'transgender' includes gender-fluid, non-binary and cross dressers now.

So a medical record stating male and a male-presenting person saying that they are transgender gives no reliable information that they are actually of the female sex.

The person who identifies as transgender could be a male person who cross-dresses, a male person who identifies as a non-binary woman, or indeed a female person who is pregnant.

Gregor Murray, the Dundee Councillor who was suspended yesterday, identifies as transgender. He is male and states that he is non-binary. If he went to hospital with stomach pains, should the staff there give him a pregnancy test? Because male on the medical record and a non-binary identity could actually mean that the person is a pregnant woman.

I don't think this is primarily about underfunded health care. I can see the same thing happening in a well-funded ER.

The whole point of triage is a system to relatively quickly sort patients. And the whole hospital is a set of interlocking systems.

Human error is always a factor, and more of a factor in this kind of complex system, so systems should be designed in a way that minimise this possibility. This is a well-studied area, there is a lot of best practise information about how to do this - by creating overlapping elements in the system, by making sure accurate information is there, etc. But there will often be tension between speed and more information and more layers or care. Both are important.

All this stuff people are saying about "clarify what sex the person was assigned at birth" "second guess the medical record" is bad practise in terms of reducing systemic error and in terms of speed. They obscure what is going on, they add more layers of mental sorting for nurses who also now need to be kept up to date in training on the fads in language, they add more time asking questions, they add more holes where a problem can slip through.

On a systemic level this has to result in more problems. And not just for trans patients but for the ones who have to go through all this extra processing in case they are trans and someone hasn't realised it.

'embrace their genitals to engage in a healthy sex life'

You can do this without piv sex FYI.
The word 'healthy' is pretty loaded tbh within a heteronormative context.

Haven't read the entire thread, but as an American I want to chime in to say: our ER's are always full of crazy people. That's life in America. When I've been to ER, I've been around people saying all kinds of things, once a man waving a gun, many homeless people, but really, frankly: a lot of mentally ill people. They end up in the ER because they have nowhere else to go.

My guess is that the nurse privileged the records saying "male" over anything the patient was saying because she's used to patients saying all kinds of things and it wouldn't be at all unheard of to have a disoriented or disturbed male patient telling her the problem was that he was pregnant.

Healthcare in the US is VERY tied to electronic records, which have been touted as ideal solutions to every problem (they're not.) When I see a physician, they're rarely looking at me, they're so busy looking into a screen and typing.

We have horrible health care in the US unless you're wealthy, and ALL ER care is a mess. I'm sure the triage nurse is horrified by not having recognized the patient is female. But the record said "male" and the record rules everything.

So I had my post deleted because I said TIF?

That wasn’t intended as a slur incidentally. Would “female who identifies as trans” been acceptable? Considering this individual’s femaleness and trans identity were at the core of this tragedy, I genuinely didn’t see the problem with using that descriptor.

Female transperson is usually ok.

The FWR pinned guidelines explain about TIM/TIF these terms have not been allowed for some time along with 'cis' 'terf' etc

It really isn’t actually that easy to tell whether someone pregnant by looking at them or by examining them even if they present as obviously female. Mistakes happen all the time. It’s rare but absolutely not unheard of for women who aren’t even pregnant to be sent off to maternity triage by emergency department staff or for women with a term pregnancy to be admitted onto a general ward because no one including herself has realised she is pregnant. Mistakes happen.

Of course this only makes it all the more important for information about a persons sex to be recorded accurately and to have words to describe important medical facts about people instead of a load of made up nonsense.

I do agree that there are plenty of people who think it is misgendering to ask about biological sex. I also noticed in the media responses to Caster Semenya that there are a lot of people whose grasp of biology is very limited.

This is exactly the sort of example which shows why asking someone about their recorded sex at birth is not transphobic.

The article recommended recording both sex and gender in medical records. Surely this something everyone can agree on? Even if one does not believe in the concept of gender, one should recognise that others do and that respecting their sense of self is important to help people follow any treatments they are prescribed.

I can't remember whether it was Maria Miller or penny Mordaunt who promised a trans health campaign. As well as training for health care staff, this also needs to be about health education for trans people.

I will say that in my area, it looks like they are planning to record both sex and gender identity on health records. I have a relative who is running the program that is supposed to get our whole health region onto one electronic record system - and it really is a massive undertaking and I wonder how necessary really - and this is one thing they have looked at.

Essentially the medical people have said to the transgender community that it really is medically necessary to have both, and they seem to understand and be happy with that. I am of the view that gender identity, as a concept, is kind of a problem, but OTOH I am glad that including sex is agreed upon as important here.

Haworthia

Yes it is not a permitted term on here. I had to self report myself above as I used it; I also post where that is not only an allowed term but the preferred term so mistakes - especially if I am typing in a rush! - happen sometimes!

it looks like they are planning to record both sex and gender identity on health records.

I feel for the admin clerk who is going to have to write in when they ask for my gender: “is a set of sex based stereotypes that ought to be abolished”. Not sure the line will leave enough room.

Of course, they will probably just shorten that to ‘non-binary’

Feministcat

From what I have heard, they are only going to have something like M and F for gender anyway, which to me seems odd. I have a few family members who are fairly high up administratively in health, and I've pointed out to them that what they are planning would be totally inadequate now to represent the gender rainbow, who knows what might be expected in a few years time.

They were non-plussed, I think because they really just think it's an irrelevancy anyway. They all have to go to conferences and stuff on treating transgender patients, but I have real doubts about who is really on board with it all ideologically.

^
"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.^

6500 chromosomes are expressed differently according to sex. This will affect how medical conditions present between the sexes and how the sexes react to drugs. We absolutely need sex as observed at birth to be recorded on medical records.

How these 6500 chromosomes are expressed in people with disorders of sexual development needs further research. This research is made less likely by the trans movement's attempts to erase sex as irrelevant.

^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.^

Clearly, these people have the privilege of having never been seriously ill. I find smear tests outright traumatic because of sexual assault history, to the point that I have to book the test in the morning and book the whole day off work (from my holiday entitlement, when it's anything but a holiday) to recover. I still attend them because I'd rather relive my rape every couple of years and need a day of crying and baths to cope, than die of cervical cancer. Having been misgendered several times, I can state with some confidence that the smear test is far worse.