LGBTQIA Inclusive Pregnancy And Birth Care

Today's guest post is written by Lex Londino, MSN, MSPH, CNM. I am happy to have a resource on IBP that addresses a common question I see from birthworkers, which is how to make their practices more inclusive for LGBTQIA people. Lex currently has an inclusive online childbirth class, which can help fill a gap for those seeking acceptance and understanding and not finding such a childbirth class within their own communities. Enjoy their blog post!

Pregnancy and birth care professionals fulfill a wide range of roles and functions in the lives of the people and families we serve. However, as a whole, our goal is to provide compassionate, respectful, culturally appropriate care to all of our clients. For massage therapists, chiropractors, doulas, midwives, doctors, nurses, lactation consultants, childbirth educators, and all other pregnancy/birth/postpartum professionals this goal can be difficult because there are few, if any, guidelines to providing support that is LGBTQIA inclusive. Most of the resources available to birthworkers are not centered on the lived experience, identity, and needs of people whose gender identity and sexual orientation fall outside of heteronormative mainstream definitions of sex and gender.

Wait . . . what?

If you're confused already, don't worry! I will provide some definitions and descriptions in a moment. But first I want to delve a little into why it's so important to keep reading. Many people who identify on the LGBTQIA spectrum find it difficult to find pregnancy and birth care that is inclusive and accepting.

Negative encounters can occur anytime a pregnant person starts looking for care and support—from interacting with a website to calling or emailing for more information, to filling out paperwork, to showing up for a class, office visit, or facility tour, and finally to giving birth and transitioning into parenthood. Negative or insensitive interactions could happen with a receptionist, nurse, case manager, medical assistant, security guard, doctor, nurse, doula, midwife, or other health care professional. Some LGBTQIA people are refused care because of their gender identity and/or sexual orientation.

Jokes, slurs, or insensitive criticisms about appearance or behavior are common experiences that LGBTQIA people have to navigate when accessing health care. In some cases, problems arise from simple oversights or mistakes made by well-meaning professionals who lack an understanding of how to interact with LGBTQIA people.

Many LGBTQIA people have experienced stigma and discrimination throughout their lives, therefore even seemingly innocuous mistakes can bring up past negative experiences. These feelings can affect their willingness to seek out health care. Birthworkers must communicate with knowledge and understanding about the needs, identities, and barriers to care that many LGBTQIA people experience so that this vulnerable community receives the services it needs. This concerns all birthworkers whose mission and goal are to provide quality care to pregnant people and their families. Before moving on to providing some tips for how pregnancy and birth care professionals can provide inclusive care, below are some definitions of important terminology.

LGBTQIA—What do all those letters mean?

First of all, it's important to clarify the terms biological sex, sexual orientation, gender identity, and gender expression.

Biological sex is a medical term referring to the chromosomal, hormonal, and anatomical characteristics used to categorize individuals as female, male, or intersex. Interestingly, even people who try their best to use inclusive language make the common mistake of thinking of biological sex in terms of a female/male binary. In reality, biological sex is a spectrum with a variety of combinations of chromosomes, hormones, and primary/secondary sex characteristics.

Sexual orientation refers to the type of sexual, romantic, and emotional attraction an individual has the capacity to feel.

Gender identity is the internal perception/awareness of a person's gender. Common identity labels include boy, girl, man, woman, genderqueer, trans, and more. Gender identity describes how a person feels, not how they express themselves outwardly.

Gender expression is the external display of a person's inner gender identity. This can be manifested through clothing, mannerisms, demeanor, behavior, and other factors, generally on a spectrum of feminine to masculine.

If you're having trouble keeping this all sorted in your head, here's a simple tool:

• Biological sex is a medical term to describe a constellation of physical, hormonal, and chromosomal characteristics—male, female, or intersex.
• Sexual orientation is who a person wants to go to bed with.
• Gender identity is who a person goes to bed as.
• Gender expression is what a person wears to bed.

So, let's get into what all those letters mean in LGBTQIA. There's a mix of sexual orientations and gender identities in the LGBTQIA acronym.

LG&B stands for lesbian, gay, and bisexual and refer to sexual orientation. People who identify as lesbian, gay, or bisexual can have a mix of gender identities and expressions.

T stands for transgender and refers to people whose gender identity is different than the one assigned at birth based on biological sex. This includes people assigned male at birth and people assigned female at birth who identify as the opposite gender or who identify as non-binary or gender non-conforming. Trans people can be straight, gay, bisexual, queer, or any other sexual orientation.

Q stands for queer and is an umbrella term to refer to people who don't identify as straight. The term queer encompasses a spectrum of identities including lesbian, gay, bisexual, transgender, same-gender-loving, questioning, asexual, genderqueer, non-labeling, polyamorous, pansexual, and anyone else who does not strictly identify as heterosexual and/or cisgender. Due to its history as a demeaning slur, the word queer is not embraced by all members of the non-straight community. If someone self-identifies as queer, feel free to use this term to describe them. When in doubt, refrain from using this term and ask what term they prefer.

I stands for intersex and is a general term used for a variety of conditions in which a person is born with reproductive or sexual anatomy that doesn't fit the "typical" definitions of female or male. These differences encompass chromosomes, gonads, hormones, internal sex organs, and genitals. Hermaphrodite is an outdated term that is now considered derogatory—don't use this term. As mentioned previously, biological sex is a spectrum or continuum with numerous possibilities and combinations of physical attributes, hormones, and chromosomes. The frequency of individuals born with "atypical" anatomy and characteristics, and therefore labeled intersex, is hard to quantify because there is no singular definition for what constitutes "typical." The Intersex Society of North America states: "If you ask experts at medical centers how often a child is born so noticeably atypical in terms of genitalia that a specialist in sex differentiation is called in, the number comes out to about 1 in 1500 to 1 in 2000 births. But a lot more people than that are born with subtler forms of sex anatomy variations, some of which won’t show up until later in life." Link here.

A stands for asexual and refers to people who have little or no sexual attraction to others and/or a lack of interest in sexual relationships/behavior.  Asexuality exists on a continuum from experiencing no sexual attraction or desire for sex, to those who experience low levels, to sexual attraction only under specific conditions.

There are multiples other letters that could be added to the LGBTQIA acronym making it endless, and therefore unusable. Other identities and expressions include genderqueer, polyamorous, genderfluid, pansexual, androgynous, demisexual, gender non-conforming, non-binary, two spirit, and many others. If you would like to read more, here's a link to a comprehensive list of LGBTQIA+ terms and definitions.

HOW TO MAKE YOUR BIRTH BUSINESS INCLUSIVE

So, now let's talk about how you can make your birth business more inclusive of LGBTQIA people! One of the main things to keep in mind is that there is no one right way that will meet everyone's needs. The LGBTQIA community is as varied and diverse as any other cultural group on earth and its members have wide-ranging needs and identities. Keep an open mind and heart and educate yourself as much as you can. Take the time to seek out resources and information BEFORE you meet with LGBTQIA clients! Don't make your clients do all the work. Once you have educated yourself as much as possible, ask specific questions of your clients about their individual needs, make note of their responses, and implement those policies in ongoing care plans.

1. ASK, DON'T ASSUME!

Just because someone “looks like” a particular gender doesn’t mean they identify that way. Ask them what name and pronoun they use, note their name and pronouns on intake and medical history forms—and use them consistently. Similarly, don't assume what a person's sexual orientation is. If you're not sure what term to use to describe them, ask! Many (but not all!) LGBTQIA people have complicated relationships with their body. Asking them what terms they prefer to be used for their body and/or body parts, and then using those terms, can help them feel empowered and affirmed.

2. USE INCLUSIVE LANGUAGE

Pull up your five favorite websites for pregnant and birthing people and focus on what terms are used to describe these people. Most likely you will see words such as "pregnant mom, birthing woman, new mother, powerful goddess, breastfeeding mother, expectant father, husband" and others that explicitly refer to people with certain gender identities, role expectations, and relationship models. These terms only apply to pregnant people who identify as women and mothers, partners who identify as men and fathers, and couples who are married. This leaves out a broad range of LGBTQIA people who don't fit into those categories. In order to be inclusive of the LGBTQIA community, I encourage you to use language that is inclusive of all experiences and identities. For example, you can use the terms expectant, laboring, birthing, or gestational parent to describe and name the person who is pregnant and giving birth. Use of the words woman, mother, or mom can be minimized for a couple of reasons. First, lesbian non-gestational parents may identify with the title of mom or mother as well so it is not inclusive to limit the use of mom or mother to just the birthing parent. Secondly, trans men, genderqueer, or non-binary parents may not identify with titles like mom or mother, so use of the non-gendered term parent acknowledges birthing people who don't identify as women. Rather than using gendered, couple-focused terms for partners/spouses, use of the inclusive term partner or birth partner can be used to describe the person supporting the birthing parent through pregnancy and birth. This person may be a life partner or spouse, but may also be a friend, family member, doula, or other role. The neutral word partner acknowledges all types of relationships and roles as legitimate support people and parents. Neutral terms such as lactation or baby feeding can be used rather than breastfeeding to include people who don't identify with the term breastfeeding. Pay attention to the words and language you use on your website, social media, intake and chart forms, brochures, and informational handouts. Simple changes to language and terminology can go a long way towards helping potential and actual clients feel welcomed, respected, and included.

3. RESPECT THE PRIVACY AND AUTONOMY OF LGBTQIA PEOPLE

Ensure that your clients are treated professionally and compassionately by respecting their privacy and autonomy. As mentioned in #1, you can and should ask questions pertaining to the care you are providing (such as "what pronouns do you use?”) but don't ask unnecessary questions about their bodies, genitals, or relationships. DO NOT ask questions or make comments about your clients' sexual orientation or gender identity that have nothing to do with the care you are providing (such as "what is it like being trans?" or "how can you identify as a man if you're pregnant?" or "how did you decide which one of you would get pregnant?"). If you are a health care provider (midwife, doctor, nurse, etc.) you may need to ask specific questions about anatomy and physiology, but if you are a non-medical birthworker (childbirth educator, doula, massage therapist, etc.) don't ask questions or make comments about your clients' bodies and/or genitals. If you provide direct medical/midwifery/nursing care remember that many LGBTQIA people may have been harassed, shamed, and even assaulted in health care offices, so ask permission before touching them and give them clear information about any procedures you need to perform. Focus on providing safe, responsive, affirming treatment.

4. HELP LGBTQIA PEOPLE FEEL REPRESENTED, WELCOMED, AND INCLUDED

Think about how your literature, pictures, promotional materials, information, posts, tweets, videos, etc. make LGBTQIA people feel? Take stock of what messages you are conveying online on your website, social media, advertising campaigns, blog posts, and bios, and include images and text that let LGBTQIA people know you welcome them and their families. Also take a look at what information and images are present in your waiting room, reception area, bathroom, care areas, and in literature, brochures, handouts, etc. Seeing their lives represented and affirmed goes a long way towards making LGBTQIA people feel comfortable.

5. EDUCATE YOURSELF, LISTEN, AND BE OPEN TO CORRECTION

You will make mistakes! That's ok. It's more important to be committed to being respectful and open-minded than to being perfect. Read books, take trainings, watch webinars, seek out resources and information, and ask questions. There are many websites, blogs, and articles that specifically provide information and suggestions for making public spaces and health care-related businesses more LGBTQIA inclusive. See below for a list of resources that will get you started! Be open to learning and know that you will make mistakes or stumble on your words. Refer back to #1 if you're not sure how someone identifies. Ask questions, but remember that your clients are not your personal educators. It is your responsibility as a birthworker to educate yourself first. If your client corrects you on terminology or language, respectfully acknowledge your mistake and make a concerted effort to remember this in the future. Your client shouldn't have to continuously remind you that they prefer the term "gestational parent" rather than "pregnant mom."

Gender and sexual diversity have existed throughout history and all over the world. Wherever there are narrowly defined and rigidly enforced definitions of gender identity and sexual orientation, individuals existing outside of those norms face health disparities, marginalization, and barriers to quality health care. Even those who vary only slightly from the norm can become targets of disapproval and shame. This does not have to be the case. Through a thoughtful consideration of the uniqueness and validity of every person’s experience and needs, birthworkers can develop greater acceptance for all. Not only will this create greater inclusion for individuals who challenge gender and sexuality norms, it will create space for all individuals to more fully explore and celebrate who they are.

FURTHER READING AND EXPLORATION

Websites

Birth for Every Body (check here for a list of resources, websites, and information about trainings and continuing education for birthworkers)

Family Equality Council (connecting, supporting, and representing all families, especially queer ones)

GLMA: Health Professionals Advancing LGBT Equality

Gayby Baby (told from the perspective of the kids, Gayby Baby is an intimate account of four children and their families)

Healthcare Equality Index (HEI) (national LGBTQ benchmarking tool that evaluates healthcare facilities’ policies and practices related to the equity and inclusion of their LGBTQ patients, visitors, and employees)

It’s Conceivable (providing clear, no-frills pregnancy and parenting information to the GLBTQ community)

Lesbian Dad: Notes from the Crossroads of Mother and Father

Milk Junkies

Mombian: Sustenance for Lesbian Moms

My Trans Health (ensuring that all trans and gender nonconforming people receive culturally competent service)

The Next Family (digital lifestyle destination and online resource for modern families, gay dads, lesbian moms, adoptive parents, and multi-racial families)

Our Family Coalition (advancing equity for LGBTQ families with children through support, education, and advocacy)

Path2Parenthood (information for lesbian, gay, straight, and single people wanting to have children)

Proud Parenting

Q Spaces (a free website for LGBTQ folks to find, rate, and review health and wellness providers on LGBTQ-friendliness, competency, and overall care)

Queer Mama (vlog about lesbian conception, pregnancy, and motherhood)

Rad Remedy (connecting trans, gender non-conforming, intersex, and queer folks to accurate, safe, respectful, and comprehensive care in order to improve individual and community health)

The Rainbow Babies (providing general information on many aspects of GLBT pregnancies and parenting)

A Womb of Their Own (follow the stories of a group of masculine-of-center-identified people as they establish and celebrate their own unique gender, develop their definition of family, grow a baby in their bodies, and birth, chestfeed, and parent their children)

Books

Breastfeeding Without Birthing, by Alyssa Schnell

Buying Dad: One Woman’s Search for the Perfect Sperm Donor, by Harlyn Aizley

Confessions of the Other Mother: Non-Biological Lesbian Moms Tell All, edited by Harlyn Aizley

The New Essential Guide to Lesbian Conception, Pregnancy, and Birth, by Stephanie Brill

Mommies, Daddies, Donors, Surrogates: Answering Tough Questions and Building Strong Families, by Diane Ehrensaft

The Complete Lesbian and Gay Parenting Guide, by Arlene Istar Le

Where’s the Mother: Stories from a Transgender Dad, by Trevor McDonald

Waiting in the Wings: Portrait of a Gay Motherhood, by Cherrie Moraga

The Ultimate Guide to Pregnancy for Lesbians: How to Stay Sane and Care for Yourself from Pre-conception through Birth, by Rachel Pepper

Pregnant Butch: Nine Long Months Spent in Drag, by A.K. Summers

Lex Londino, MSN, MSPH, CNM, is a registered nurse, certified nurse midwife, and OBGYN nurse practitioner. Lex began working with birthing families in 1999 as a doula and childbirth educator, went on to complete nursing and midwifery education, and eventually owned and operated an independent homebirth midwifery service in upstate New York for over 5 years. Lex has trained and worked in a variety of clinical settings, including community and tertiary care hospitals, high-risk obstetrics, birth centers, ambulatory care, emergency department, short-stay surgical, endocrinology, home-based care, and sexual/reproductive health clinics.

Lex completed a master's program in Social and Behavioral Interventions in the International Health Department at Johns Hopkins Bloomberg School of Public Health in Baltimore, MD in May 2020. Lex has interest and experience in health disparities at the intersections of race, gender, and sexuality. Lex has engaged with these intersections via quantitative, qualitative, and mixed research methods, as well as through programming, policy, and practice. In addition, Lex is interested in evaluating health outcomes in individuals with HIV infection and improving HIV/AIDS health outcomes among key populations.

Lex identifies as non-binary and uses they/them/theirs pronouns. In their spare time, Lex enjoys cooking, reading, roller skating, sewing, growing and tending plants, and spending time with their partner, children, and cats.