'The empowerment of childbearing women can co-exist with supportive care for trans people.'
At the beginning of January 2018, I thought about all the inspirational birth world people I’m in contact with.
I wanted to have a pool of encouraging, motivational interviews on Midwife Diaries which also had 'nuts and bolts' strategies for the midwifery community to draw on.
I developed some questions to send out to those women and men who I know have stories to tell and ideas to add to midwifery's cultural bloodstream.
The response has been amazing. I have some brilliant advice sitting in my inbox and I'm enjoying the meeting of minds that happens when I get to post these interviews.
Today I'm sharing an interview from Nathan Welch, a transgender midwife and total lovely. I'm fascinated with the care needed for transgender people in the maternity services - if we can be supportive, it shows we're empathetic and capable of nuanced care.
I've been pestering Nathan for months to do an interview because I know how many lessons he has to share.
I also have people in my life who I adore who are gay and I'm passionate about getting it right for the LGBTQ community.
I bet you are too so now it's Nathan's turn to talk!
My name is Nathan Daniel Welch, I'm 24 and I work in East Sussex Healthcare NHS Trust in an obstetric led unit.
I'm married to an incredibly supportive man, we are daddies to two amazing girls and my husband stays at home with them while I work hard in midwifery. He has always known who I am and making it public has only made us stronger. We're proud, queer and very settled, we spend most of our free time gaming, being creative and are major geeks.
I've been qualified as a midwife for a year and have been working full time, my whole career is in front of me and I have many ideas about what it may include but I'm mainly just excited to see where it takes me. I love midwifery and my passion burns ever brighter.
Do you have any media to share which will help us understand being a trans person? Are there any resources you think that midwives specifically should look at?
Sadly there are not many published resources out there. There is a huge trans youtube community. Here is a wonderful, deeply emotive video of a trans man's experience carrying and birthing his child in this society.
Could you tell us a bit about your journey as a transgender person? What would you like people to know?
My journey has been a long and steady road of self discovery in a safe, nurtured, open and LGBTQ+ friendly environment. After many years of ups and downs, feeling uncomfortable or frustrated but not knowing why, over compensating or dissasociating, I came to realise that I am trans.
When I look back I can see it manifesting from as early as seven years old. I am finally becoming more comfortable in the world and more motivated to become my most authentic self. I spent a long time living a double life, but now all those bits and pieces are coming together to make one whole person.
I identify as quite an effeminate, mostly gay/queer man, but still without a doubt a man. My documents have all been changed, including with the NMC, the most important one of all! My medical transition will be starting within a few weeks.
What would you most like student midwives and midwives to know about being trans? From both a staff and a caring for clients point of view?
There's a debate that comes up regularly regarding whether or not the language used in midwifery is too gender specific. I want to share my thoughts on this:
The word midwife means 'with women' because for as long as women have been birthing, their power and unique inner strength has been supported by midwives. Midwifery has served an integral role to support the voice of women in a patriarchal world and the fight for equality and will continue to do so.
Trans people (men, women and folk outside the binary) ought not seek to take away or threaten this deep truth. Every trans sibling I've asked agrees with me that these terms are rooted in midwifery for a reason and do not need to be changed to support the trans people who use maternity services.
The empowerment of childbearing women can continue and co-exist with supportive and empowering care for trans people accessing the service.
Every health care professional needs to be aware that they may care for a trans person at any time and have an understanding that you cannot know a person's gender by looking at them, so that they are ready to be accepting and give the best possible care.
Sadly some or many trans people who might not be 'out' yet, might not feel able or safe to disclose but if you notice someone appears sensitive to certain language or perhaps more androgynous in clothing or behaviour, simply reaching out and asking about pronouns someone prefers can be a lifeline and really help a trans person open up to you.
Ideally we would have a question about gender identity during booking appointments, even a more comprehensive check box list or a space to write in one's gender on the notes would help enormously, we have hope for the future!
If someone discloses to you that their gender identity differs from how they appear OR if you care for someone who has clearly commenced medical transition already then please (with consent) document it clearly anywhere that might flag it quickly to other professionals. This will help that professional enter the communication already aware of the client's identity/preferred name and pronouns. There is nothing worse for a trans person than having to come out over and over again.
Lastly when you meet a trans person, particularly while working but also in your personal life, remember that it's not their job to be your teacher on the subject. Remember that they are there to be cared for and they might not be ready to answer lots of questions about being trans. There is a huge amount of information on google about trans people and transition if you need/want to know more.
*Note from Ellie: this is an important point.
To learn more see here for Laura Godfrey Isaac's post on All4Maternity.com.
There's also a brilliant blog on the subject from Shawn Walker (RM, PhD) here.
What is poor advice you've heard being given about caring for trans people?
Something less understood in all medical fields is childbearing after medical transition has already commenced. Unfortunately there is next to no research available but there are a few key things from anecdotal evidence that I can share.
Disclaimer: someone identifying as male or non-binary and using he/him or they/them pronouns is common before or without any medical intervention and their identity is valid and should be respected regardless of their outer appearance.
Medical transition for people with reproductive organs capable of childbearing, usually with the goal to masculinise or appear more androgynous can include the following: taking testosterone, having 'top surgery' or a mastectomy to remove breast tissue and make the chest appear masculine and 'bottom OR lower surgery' which is complex and can take several years to complete.
Trans people who have been on testosterone for years and have grown full facial hair and appear outwardly male are able to come off testosterone, allow their menstrual cycles to return and conceive, carry and birth a healthy baby. And they have, many times.
It is VERY important that they are no longer taking testosterone while pregnant, accidental conception can happen and testosterone is teratogenic (harmful to the fetus); they must immediately discontinue testosterone and have medical gender specialist counselling.
Trans people may be pre or post top surgery when they decide to carry a child. If they're pre top surgery they may or may not plan to breastfeed like any other new parent, however extra sensitivity is required here.
Some trans people prefer to refer to their breasts as any number of nicknames, if in doubt, ask. Exampe, "How would you like me to refer to your chest when discussing infant feeding?"
Lower surgery - it is rarer but still possible that a trans person may have had gender confirmation surgery on their genitals before choosing to carry a child. In these circumstances a referral to a consultant may be necessary to discuss the options but it is likely that an elective caesarean section will need to be seriously considered. They may still be able to birth through their genitals but there might be a risk that surgery results will be permanently altered. This is a very basic overview of the medical side of what you may encounter when caring for a transgender person.
What is something unusual you do as a midwife – is there something a bit odd you do or love which really helps in practice?
I believe in a team effort when it comes to supporting birth! I think I get the birth partners involved in caring for and supporting the birther more than some and throw a healthy amount of humour in there when it's appropriate.
Examples include teaching the basics of the physiological process the birther is going through to the partner(s) and the signs that change and progress is happening that I am picking up on.
Another example is I'll share about what I'm looking at on the CTG or listening to with the sonicaid. I have noticed that for some people a bit of understanding or knowing the reason why I am offering something or acting a certain way goes a long way in helping them feel secure. It strengthens the trusting relationship and reminds ME to always offer informed choice for everything and anything.
On the flip side, I think I am exquisite in holding the sacred silence and I will happily gently remind birth partners when silence is needed.
Basically, I pride myself in being clear and honest in the birth space.
In the last five years, what is one realisation about midwifery that has improved your practice or life as a midwife?
Whoa, that's a big question; I think it is the profound belief in myself that I can and do make a difference as a midwife. I have known since my early teens that midwifery is in my soul but as I went through my training there were many things that were hard for me to watch and be involved in, things that I felt were not in the best interests of the family being cared for, I really struggled with this. I was concerned that as a qualified midwife I would have to do these things and that I was naive in hoping that I could be the change and make a real difference. Thankfully, I was wrong. Sure sometimes tough decisions have to be made with the birther but on the whole, even in a busy obstetric led unit, I am able to uphold the values that make me proud of my practice and always provide sensitive, informed, choice based, person centred care.
If you could put a giant billboard up on every labour ward or work place for midwives worldwide, with a big message for every member of staff, what would it say?
One of my favourite midwifery sayings is "One of the most dangerous attitudes in midwifery is 'that's the way we've always done it.' " Midwifery needs to be as adaptable and malleable as the people it serves.
Is there anything else you think we should be asking?
Terminology and gendered language can be difficult for a trans person to navigate. Particularly anatomical and medical words for body parts can trigger gender dysphoria (being uncomfortable/upset/disassociating with one's body or social situations). There are many alternate words that trans people use to avoid these triggering words. If you are caring for someone who you know is trans identifying in some way the best thing to do if you're unsure and it is relevant is simply ask "What words do you use to refer to your anatomy, so I can get it right?" This will make a trans person feel respected and validated and will avoid a nasty dose of dysphoria at an already vulnerable time.
Thank you Nathan for your personal experience here and your considered approach based in true understanding of the challenges.
Once you've read this, Nathan and I would love to hear your thoughts:
- What was the most important thing you learnt from Nathan here and how can you apply it in practice?
Identifying this will help you remember and will also help others learn (ever noticed how much blog comments can stick with you? Some of my favourite breakthrough learning has happened this way!)
HUGE thanks to Nathan for sharing really quite private personal experience and profession knowledge here. And thanks to you for caring and reading.
The best bit of midwifery for me is always the empathy, I’m like ‘c’mon, tell me what it’s like to be you, give me the goods’. Basically I’m nosy but I like to think it’s from a good place, that connection is what I’m after.
It’s part of the midwife/client relationship that prompts such good satisfaction and outcomes.
Much Love, Ellie x