 and now I think it is over to Eva. So I will mute myself and Eva take it away. Hello. Thank you Linda. It's really lovely to be here at the Virtual International Day of the Midwife. I've gone to a couple of the sessions now and it's a really wonderful event and it's really wonderful to be here. So thank you. So I'm going to be talking about meeting the needs of LGBTQ parents during pregnancy and when they're meeting their baby. There we go. So this is a little bit about me. I trained as a midwife in Ireland and I qualified into 2014. After that I moved to England and I worked in another big hospital here for 18 months. For the last 10 months I have had some time off and I have been looking at working as an independent midwife which is a bit of a different story here in the UK at the moment and as well as that I have been researching more about midwifery care and perinatal care for the LGBTQ community. I am a member of that community myself and I'm an ally and so that makes me a lot more interested in this work. It's a particular interest to me because me and my partner at some point in the future will be going through the maternity system and so it makes me more fascinated to know what that experience is like. Also I have a particular interest in supporting trans parents through the childbirth process. I became more interested in this and it was prompted more by speaking to trans and non-binary friends and just thinking more about the rest of that community and what pregnancy might be like for someone who's transgender or even for someone who identifies as non-binary and how we use gendered language so much around birth. That's where my interest comes in this and where my passion comes from and that's why I'm giving this presentation. One of the things I wanted to do just at the beginning of this presentation is put up a poll just to find out the people who are listening, what your experience is in looking after anyone from the LGBTQ community. I think hopefully Linda will be able to put up those questions from the poll. There we go. So have you cared for a same-sex couple as a midwife or a doula or however you work in the birth community? That's nice to see there's a mix anyway. The next question is about whether you've cared for any transgender people as part of your midwifery practice. That might have been a parent who was pregnant or a partner or a family member. The final question was about how confident you feel in caring for LGBTQ families. That's something that comes up a lot for healthcare professionals if they're not feeling confident in that care and that's felt by the people that they're caring for. I thought that would be interesting to hear. Lovely. Thank you Linda for doing that and that's nice to get some participation and see what you guys have done. So just this is what I'm going to talk about during the presentation. I'm going to talk about identities and labels. Some people find it confusing in the LGBTQ community. What do the different letters stand for? What does it mean if someone says that they're transgender or something else? So I'll just go through that. I'm going to look at the experiences that these families in accessing healthcare and care during pregnancy. And then I'm going to talk a little bit about different conception options. What it is like to be pregnant for people from the LGBT community and different feeding options that they might consider and that you might be helping with. And at the end or throughout the presentation hopefully I'll give you some practical information and tools so that you feel confident in your care and just more information around it. And most of all make sure your practice is respectful and acknowledging the unique experience that LGBTQ parents have when they're receiving perinatal care. And I would love to have questions and have feedback on your experiences. That'll be brilliant. So just to start with identifying as LGBTQ. So just those letters there stand for lesbian, gay, bisexual, transgender and the Q stands for either queer or questioning. And then there's other identities that might include asexual or intersex or pansexual. And in a minute I'll put up a slide that has a description of each letter underneath. The word queer, more people are using that now. I know originally the meaning of the word is like strange or unusual and people find it very strange that people might use that to identify themselves and it's used to be used as a derogatory word in some places maybe it still is. But people from the community are starting to reclaim that and use that for themselves. So and the word queer is an umbrella term that can be used to refer to everyone who is in these gender identity and sexual orientation minorities. Transgender will include people who don't identify with the gender they were assigned at birth whether that's male or female or it might be intersex as well. This includes those who don't identify as one gender or another so in a gender binary so that might be referred to as someone who's non-binary gender non-conforming or gender queer. So just for this next slide it's a little bit hazy but hopefully we'll be able to make out some of it. It's just a good description of each of the letters and what they mean. I think over the years the letters have there's been more letters added on and I think some people get confused as to what they might mean. Some of them like asexual and pansexual might be less relevant to you as a midwife or working with childbearing people because those aren't things necessarily you'll know about someone but knowing you know the difference obviously between lesbian and gay and transgender I think those ones are really important to be aware of and also intersex and that's someone who's sexual anatomy or chromosomes don't fit with the traditional markers of female or male so they might have been born with genitals that don't fit into one or the other and they might have been brought up as either female or male depending on where they were born and society. Next slide this is a bit more about gender identity. When we identify as cisgender that's when you identify with the gender you were assigned when you were born so when I was born you know my parents told you've got a girl and that's identified as female and I still identify as female now so that would be meaning that I'm cisgender. Transgender or non-binary is where someone is assigned one gender at birth but through the period of their life at some point they realize that that's not how they identify that's not how they identify themselves. And I just ran down there the different terms for people who might not have seen them before or just were confused about them. When someone trans describes themselves as a trans man or transgender they were assigned female at birth but identify as male and they might have transitioned I'll talk a little bit about that in a minute to present us as male. The trans woman is then obviously the opposite so assigned male at birth but identifies female. Non-binary is I think I said a little bit about that before so someone who doesn't identify clearly with either being male or female they don't feel that they fit into either of those binary terms but they feel more that they just fit as themselves without either of those labels on them and some people actually feel that it's more fluid that they go between them and what all of this what I'm trying to say with all of this is that there's a spectrum to gender it's not just about being male female but there's more of a fluidity to it and just on the note of transitioning and people being transgender at the bottom now I found it really interesting in the survey from 2015 that one in two transgender people receive hormonal treatment but more people wanted it and only one in four transgender people have hands up transition related surgery. I think the perception often in culture is that when someone transitions that they have surgery to change their whole body to become their identity to fit with their identity of male or female but actually that isn't reflected in people's experience. This is a little bit about gender pronouns so the gender pronouns that are usually used in our society are he and she and that fits with the binary of being male or female but then some people will identify without those gender neutral people that I was talking about who identify without being one or the other might use other pronouns so such as they z there's a couple of examples there but when you go looking actually people use all sorts of pronouns that you know whatever feels right for them and what's really important if you're unsure that you speak to someone you ask them so you're not misgendering them and it can be something as simple as saying my name's Eva I use she her pronouns what pronouns should I use for you. I found I've got some information here about what the LGBTQs experience of health care is and what I found I've got that quote at the top because I just felt that it was very telling about the medical system and society so the health care system is a reflection of society that the prejudices stereotypes and discrimination contained within the large larger social system are mirrored within medical professions so I think that's really important especially as there's people around the world listening that if you look at your society you'll get an idea of how the medical professional medical professionals might also hold similar prejudices and stereotypes and discrimination discrimination is experienced by LGBT community quite often and it's very real some examples there are that there's no acknowledgement of a relationship so you might have a couple sitting there but a doctor who keeps just calling someone's partner their friend so just not acknowledging that relationship and another example is by asking inappropriate questions that are irrelevant to their care so if they find that someone is gay that they might start asking questions about their sexual relationships when it's irrelevant to the actual reason they came to their to the care provider or in the terms of the trans community just misgendering so using incorrect name and gender and if you just think about if someone started using the incorrect gender pronoun for you if you were at your gpu surgery or if you were out shopping how that would feel and just how horrible that would feel for you if someone was completely disrespecting your identity LGBTQ people are more likely to avoid health care usually due to the fear of discrimination some examples are cervical screening because that's such an intimate thing that's for cisgender people as well as transgender people so trans men because if they've transitioned and they still retain their uterus and their cervix they still need cervical screening um but they might feel a lot of fear going for that treatment um mental health services similarly and LGBTQ people have a lot higher um cases of mental health illness and yet they're less likely to access mental health services the other thing that I found in my research is that health care professionals often feel unskilled and nervous to discuss sexuality and care for LGBTQ patients um that they find that a difficult thing to discuss once sexuality or gender comes up and therefore people are there's the potential there for people to not get the care that they they need because their doctor is feeling unsure about how to deliver that care however they have found that there's studies to show that when health care professionals have some education around um the community that their confidence increases and there was one study where they brought medical students um to do medical histories with LGBTQ patients and they looked at their confidence before and afterwards and once the medical students had gone through that taking a history from a queer person afterwards their confidence increased because they realized actually it's just the same as delivering care to anyone else so some of the barriers to accessing care I talked a little bit about that already the fear of being disrespected or mistreated as an LGBTQ person um there's a lot of reluctance to come out to their health care providers um due to concern of potential reception or how how their health care providers might take that whether they're going to realize that actually their GP is very homophobic and doesn't want to provide the care that they deserve and also that there's a lack of knowledge um potential lack of knowledge from the health care professionals um one study I was reading found um that was a study about lesbian and bisexual women found that half of them went out to their GP which can just if you think about what that might mean if they were you know if they're going for routine appointments and their GP is talking about contraception that might not really be relevant to them or they're just not acknowledging the unique um social structure that they're in and the culture that they're in um so that's that's a really important point um the discrimination experienced by transgender people varies um from something like verbal harassment and refusal of treatment which is obviously very significant um to having ed having to educate their health care professionals in order to receive appropriate care so that might be that their doctor that they're seeing or whatever health care professional they're seeing does not know the recommended treatment for someone who's from the transgender community and in order for that person to receive appropriate care they need to tell them they need to bring in the guidelines and teach them which if you think about you know if you're going to your your health care professionals you're looking for support and you're looking for their medical advice you don't want to be going to teach them to tell them um how to care for you. Cost can be a significant barrier to health care in countries where you have to pay for health care so in England the NHS covers the majority of health care but in the US I found that um cost is a really significant barrier for LGBTQ people accessing health care um and one thing that kept coming up was discrimination from health insurance um there was a few different examples um some were where people get health insurance through their um employers and but they weren't recognized that their same-sex partner is entitled to the partner benefits of their health insurance or where um someone who's transitioned um it needs health care such as a service called the smear test um but they wouldn't provide that because on the health insurance documents they're listed as male so they won't grant cover for something that would be considered female health care treatment and at the bottom there I said that transgender men were more likely to report discrimination in medical care and more likely to avoid care and that I put that there because it's relevant if we're going to see someone who's transgender um as a um a midwife or a doula it's it's going to be a transgender man who's pregnant and it's just really important to recognize that they're more likely to report discrimination and may not have attended some health care which might be recommended. Then we come to LGBTQ people as parents and they have been parents for many years um recently it has become more um seen in society as as our cultures have changed and become more accepting of the queer community um and as laws have changed so you know things like decriminalization of homosexuality which there's still many countries where it is a criminal offense um but that that's changing um or the legalization of same sex marriage which creates a lot more opportunity for people um to be seen as a family um I have those statistics there I thought it was just interesting to see what kind of from statistic statistics point of view um LGBTQ people as parents um advancement of medical possibilities has made it more possible for people to become families where they might not have been before um things like being able to use donated sperm to become pregnant um using surrogates um IVF um egg sharing or egg donation schemes um and something that is often used um against things like legalizing same sex marriage is that for a child to be a good child you know a healthy child that they need to have a mother and father um but something that's been shown again and again in parenting studies that children from same sex parents or different families do just as well as children from families with a mum and a dad or other makeup of parents so I said I was going to talk a little bit about the difference conceiving options um this is something that often um queer parents say that they get asked very inappropriately that might be from colleagues in work asking oh well how did you get pregnant um so I think it's just important to know when is it relevant to know that and as medical professionals it often is relevant to the care that you're providing um the options for people conceiving depends on their individual circumstances who's in their their family to make a baby um which genetic material do they have access to so if it's to cisgender women if they have two uteruses well where are we going to go to get some sperm because for every family that's well for making any baby that's what you need you're going to need an egg and some sperm um and who will just date and birth that baby so if that's one of the partners if the if one of the partners have got a uterus and that ability to to get pregnant um or if it's um a couple that don't are they going to find a surrogate or how might they do that um so I've talked about a couple of different options there um you might have a sperm donation that could be from a known sperm um a known donor um or an anonymous donor or you can get egg donation the same way um surrogacy so that's where someone else is carrying the pregnancy there's um some same sex couples where it's to women who have um ovaries and eggs they might decide to get pregnant with each other's eggs um as a different option so they both feel like they're more involved in that process um there's cases where two women have both got pregnant at the same time in a family so there's just different ways that it might work for different families um when trans people go through the medical process of transitioning so whether that's getting hormones or surgery um they should be offered the option of freezing their sperm or eggs prior to the medical transition if they want to that's something they choose to do so should they down the road want to have children and use their own genetics that they'd be able to do that um they might not be offered it but that they should be hopefully um hormonal treatments such as testosterone in trans men does not prevent pregnancy whether that's planned or unplanned um if if a man is taking testosterone he can get pregnant by accident um but he can also get pregnant planned so some trans men can and do choose to carry pregnancies um if they were planning a pregnancy it would be best to seek medical support um because it's often it's recommended that they would stop taking testosterone um for a few months prior to it and then their um periods the menstruation will return and then they should be they'll be able to try and get pregnant um and I just have a few points at the bottom there of when is it medically when is it relevant to know so you know when you're taking um a history at a booking you'd want to know for for future is like his genetic history of the newborn um and it might be part of building a relationship if you know if you've got a continuity of carer it you might want to have that relationship where you know the family and they might want to share that with you to build that relationship pregnancy is a very gendered experience in our culture it's all about being a new mom um maternity clothing maternity leave um and for some people that is really special to them and that's exactly what they want um but for some women and for then for trans men it's not this big female um birthing goddess experience that some people have that it's just really important to to look at that um and a tailor individually to couples that you're caring for um if you're caring for someone who identifies as gender non-binary then tailor that to them don't keep calling them mum ask them what they would would like to be referred to as um and that goes as well for when you're talking about someone who's pregnant and asking them is it a boy or a girl some people don't find out but some people also that's not a really important thing to them um especially if they are trans or or identify as non-binary it it's really making a very gendered experience something that same-sex couples often get asked and which is very sad is being asked well who is the mum who's the real mum when actually if there's two parents in a family they're both the parents no matter if they're genetically related or who gave birth or how they that baby came into their family they're both the parents um or you wouldn't say that to a heterosexual couple who were adopting a baby or using a donated egg or donated sperm um and that's often when some of the studies that look at lesbian couples experience of midwifery care they talk about in antenatal classes where the antenatal teacher or the midwife is referring to the mum and the dads or the husbands um and it's just tailoring your care so that it meets the people who are in your class and there's some really easy adjustments you can make which i'm gonna um put in any in a few slides and then if um if someone is transgender or non-binary or even if they're cisgender female being pregnant can give you a lot of body and gender dysphoria which is where there's a marked incongruence between one's experience or express gender and their assigned gender so when you're pregnant it can bring up a lot of things about your body um being the female body that's giving birth and whether does that actually fit with your identity um and there's a very good um research article that I've just written down the bottom um by mcdonald et al um which has been recently published about um trans experience of being pregnant and of um of feeding i'm gonna come on to feeding now um for feeding there's essentially the same options as for any parent however lgbtq parents might have a larger range of options um they might choose for one or both of the parents to nurse um for the non gestational parent they might choose to induce lactation so that both parents can share that responsibility and that experience um or they might choose to feed express human milk or formula via a bottle um induced lactation is possible for cisgendered women and transgendered women um it's a process of going through using medications to use the pill and another set of medication and herbs along with expressing regularly um and it's something called the newman goldfab protocol um which you can research and that's something that's really good to know about if you are caring for a couple that might be interested in that so you can support them with it chest feeding or nursing is um chest feeding is another term that um trans men and non binary people have um started using instead of breastfeeding if they don't call their um chest their breasts or they might have had chest surgery um so that they have it's been contoured to be more to be like a male chest they might want to call it chest feeding or nursing instead um and they might choose to chest feed um after pregnancy or they might induce it um if they're the gestational parent they might choose to chest feed um if they have had surgery that may affect their ability or or supply depending on the surgery method but it's hard to know before that the baby's actually born and to know what might be there um but they might choose to use um a supplementary nursing system um to help with supply and also adoptive parents can induce lactation and use the same method um and families will appreciate support from someone who has the knowledge or who's willing to learn and support this family non-judgmentally and not give them funny looks and wonder what they're doing this is just a little bit about using a supplementary nursing system so you might have seen this before um so people might use it if they've got low supply um for a variety of reasons but it's a really good tool to be used um but um families who are feeding in different ways for example a parent who's induced lactation so they can feed as well as their partner or someone who's adopted who's adopting a baby so I've got a couple of slides about what we can do um at the top there there's a quote from Grant that says the medical professional medical establishment should fully integrate transgender sensitive care into its professional standards I think there is a move towards that now um recently the British Medical Association put some new guidelines in around um terms to use they suggested using pregnant people instead of pregnant women where relevant where it's where it was relevant to the care you're providing um it's really important to be aware that the LGBT people um may have accessed less healthcare um even when it was recommended and I've talked about cervical screening so just be aware that they might have had less access to healthcare that they'll feel more nervous perhaps and have fear around accessing especially perinatal care so around the birth I've called that perinatal care rather than maternity care just to include transgender and non-binary people due to fear of discrimination a lack of understanding regarding their family and their identity and they're more likely to have experienced poor mental health and be more vulnerable to mental health challenges that's really important obviously as part of birth and the postnatal period either can I just step in for a minute um can I give you a warning that we should be winding up soon if we're going to have any question time yes I'm about two slides away I think oh that's brilliant that's fine thank you okay um some really easy things to do would be to change language on forms and in paperwork so it's more inclusive so rather than having um mother and father on a form just change that language um have some more adaptable forms so people can write in what is relevant to them and as well as that making leaflets and websites and teaching tools more inclusive um things like antenatal classes as an individual language is really important so I talked about asking people about their pronouns and their identity using the name and pronouns that they tell you they want you to use using parent instead of mother or father um only talking to them about clinically relevant things so start asking about things that aren't relevant to that care that you're giving and maybe start challenging your own assumptions and understanding of what family is and the definition of gender be an advocate and an ally to your colleagues and clients and if you're not sure it's really important to find support and refer to other people and research things um people will really appreciate that and finally I just had a few examples of um language that we can change um something like what words do you prefer to be used for body parts for transgender people they might not want their chest to be called their breasts just ask them so just let you read through a few of them and yes I'm happy to take questions that's great Eva thank you very much um there are a few questions already in the chat box perhaps you might like to select from there let's have a look is it often that both parents are breast or chest feeding the baby um that's something that you can see um people are making the choice on I've read um a few accounts of parents where um the non gestational parent decides to induce lactation um whether they've given birth before or not um so that both parents can um can choose to breastfeed or chest feed their baby are there any other questions there's one about um I'm interested to know if your research shows that their care is more likely to be medicalized um I haven't I'm not sure it's I it's not something that I've come across um as yet I suppose that's coming from the assumption that if they've had surgery it might complicate matters if um yeah okay so if someone um is a transgender male and they have if they um have had surgery there's different types of surgery so there's what some people refer to as top surgery um which is where they would change the the presentation of their chest um and then there's what some people refer to as bottom surgeries that's the genital right reproductive organs if someone was choosing to be pregnant it's very unlikely they would have had any genital or um reproductive heart surgery so it shouldn't affect it in that way do we have any more questions I have to agree with some of the comments that have been made that this is fascinating um I you've opened my eyes to many things and I'm beginning to be care um think I'll have to design a whole new language and yet as a people person and a good person a person that communicate with people and having several same-sex parent friends I thought I was doing I knew what I was doing so to speak but now I don't know anything everyone's always trying their best and I think that's what's really important that people are trying their best and asking and just thinking about things before you say them um I think there is a lot of things that people are unfamiliar with like someone who's transgender becoming pregnant um I think that's something that is very new to people and it's very challenging to people's kind of presumptions and and known experience of what birth and pregnancy is um I think that is a challenge for people yeah but they're just parents and they just need and I think it's all to do with speaking to people and communicating and Jane midwife is the term for any sex isn't it because it means with woman so there shouldn't be an issue there with how you are called um unless someone who is giving birth doesn't identify as a woman I guess oh right oh gosh now you see that's another thing yeah it's it is uh yeah it's something to think about I I still call myself a midwife but yeah I guess that's something that you know people will understand very easily as well if you describe yourself as a midwife but that doesn't necessarily mean that's what we should be doing yes very good question there from Olu Olu Femi who's saying is there any training for any professional specifically about the treatment of lgbtq um not that I found I've been looking and I I haven't found anything yet one thing that um I'm in the process of doing actually is um setting up a website that will it's going to be specifically around transgender people um because there's so there's so much lacking there when I was trying to research about transgender people becoming pregnant there's so there's just a complete lack of information both for the people who who want to become pregnant and for medical professionals um so I'm in the process of setting up a website which will hopefully be up in the next few months just with as much research as I can find around the issues um so if you want to know if you want to be updated on that I'm happy if you want to contact me and I will send you out an email when I have it up that's excellent thank you any further questions that's brilliant Jane has just put a link up I will have a look at that thank you Jane there you go there's a new one new question I guess it depends um um Emmy it depends on the midwives abilities to prescribe specific medications um they might know the right people to prescribe the medication um and it depends on their experience I think a lot of midwives don't have that experience but if you find someone who's willing to help I think it's a bit about researching and finding someone either who does have the experience and knowledge or who's willing to go out of their way to help you find it um I would have said that the midwife looking after these people um would have a duty to um assist in this way and if they don't know how to or whatever they'd be up to them to find a contact or have some education themselves yeah absolutely some people that um would be good people as well to get involved is lactation consultants um they might have um some good experience or knowledge around induced lactation as well especially if they've worked with adoptive parents who uh adoptive parents have been using induced lactation for quite a while um and that's who the the protocols were originally designed for was um parents who are adopting and want to be able to breastfeed well yes and we're we've known about that and had experience with that for many years so um no midwife can know everything and every midwife should know how to find out what they don't know or how to refer on to people who are who do know what they're talking about so you know um I I suppose that's where I'm coming from with the thought that all midwives should be able to help and should be expected to help also yeah yeah and just yeah helping whichever families they're looking after exactly individualised care I said that so often today exactly yeah yeah it's so important so have we any more questions because we should be winding up now in order to set up for the next session I think we might have one left oh yes Eva what is your email um let me just type it in there there you go and I'll just put my website as well that's fabulous and of course this is recorded and you can access the recording from our website once we get it sorted need to do that um sometimes don't have enough arms and things to type away well you're doing amazing work thank you fabulous okay then I think I'm going to wind up there and say thank you very much for a really interesting presentation Eva um certainly made me think and I'm sure it's made lots of other people think as well so it's your thank you for having me it's brilliant to be a part of it yes you could bring something else back next year yeah so have we got and we've had the summary so you're okay okay okay so I'm just going to bring this particular session to a close stop