Abstract

This study aims to analyze the experiences of a transgender man during the gestational-puerperal period and the perspective of obstetric nurses in training based on the dynamics and organization of obstetric healthcare in a hospital setting. This qualitative study is based on a case study approach, employing interviews and direct observations to collect data. The analysis was based on the theoretical and normative framework of the Nursing Process, the Theory of Caring, and the theoretical/critical perspective of transfeminism. The results are organized into six categories: Transgender man in the context of pregnancy, childbirth, and postpartum; partnership and parental dimensions; dilemmas faced by the pregnant couple; impressions recorded by the nursing professional; understanding of the case through a theoretical and epistemological lens; implications for healthcare professionals. We underscore the need to promote spaces for continuing education among healthcare professionals and to reformulate legislation in a way that enables the development of public policies based on respect for diversity and equitable care, recognizing the transgender population’s specificities in the contexts of pregnancy, childbirth, and postpartum.

Key words:
Parenting; Paternity; Transgender Persons; Sexual and Gender Minorities; Outcome assessment in Healthcare

Introduction

This study was developed from the organization of care and health practices dedicated to trans men and their partners in the context of parenting during the pregnancy-puerperal period. The “parenting” concept transcends the borders of biological ties and broadens the idea of family to include families of people of different gender identities¹1 Besse M, Lampe NM, Mann ES. Experiences with Achieving Pregnancy and Giving Birth Among Transgender Men: A Narrative Literature Review. Yale J Biol Med 2020; 93(4):517-528.. The “transparenting” term emerged in this context, which involves families made up of trans people and challenges cisheteronormative standards, promoting greater diversity in the parenting conception and experience²2 Monaco S. Different in Diversity: An Intersectional Reading of LGBT Parenting. Culture Studi Soc 2022; 7(2):234-252..

The “trans” term refers to the transgender population, encompassing people with gender identities and expressions different from those assigned at birth³3 Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Basar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health 2022; 23(S1):S1-S259.. Thus, gender transition involves several heterogeneous and non-linear factors in which self-identification plays a central role but does not necessarily involve behavioral, legal, or bodily changes.

In Brazil, health protocols for trans people are generally based on pathologizing perspectives, which do not reflect the complexity of individual experiences⁴4 Simakawa VV. Por inflexões decoloniais de corpos e identidades de gênero inconformes: uma análise autoetnográfica da cisgeneridade como normatividade [dissertação]. Salvador: Universidade Federal da Bahia; 2015.. In this context, the “paternal pregnancy” concept underscores the possibility of trans men becoming fathers through pregnancy⁵5 Peçanha LMB. Ressignificar e empoderar o corpo: Homem trans grávido e os desafios da adequação. In: Seminário Internacional Desfazendo Gênero. 2ª ed. Salvador: Anais UFBA; 2015. p. 1-5.^,66 Peçanha LMB, Neves BDA. Memórias transmasculinas: Das reflexões nacionais ao movimento de homens trans carioca. In: Seminário Internacional Desfazendo Gênero. 5ª ed. Salvador: Anais UFBA; 2021.. This term is based on the theoretical/critical and epistemological perspective of transmasculinity transfeminism, which emerged to encompass the demands and specificities of trans men and transmasculine people within transfeminism⁷7 Leonardo MBP, Anne AM, Jaqueline GJ. Transfeminismo das transmasculinidades: diálogos sobre direitos sexuais e reprodutivos de homens trans brasileiros. Rev Bras Estud Homocultura 2023; 6(19):90-104.. Therefore, trans men pregnancy challenges traditional masculinity and femininity notions, with profound implications for motherhood and fatherhood conceptions⁸8 Monteiro AA. Homens que engravidam: um estudo etnográfico sobre parentalidades trans e reprodução [dissertação]. Salvador: Universidade Federal da Bahia; 2018..

The theoretical and normative framework of the Nursing Process was used regarding the analysis for solving the problems highlighted in the case, defined by the Federal Nursing Council as “a method that guides the nurse’s critical thinking and clinical judgment, directing the nursing team to care for the individual, family, community, and special groups”⁹9 Brasil. Conselho Federal de Enfermagem (COFEN). Resolução nº 736 de 17 de janeiro de 2024. Dispõe sobre a implementação do Processo de Enfermagem em todo contexto socioambiental onde ocorre o cuidado de enfermagem. Diário Oficial da União 2024; 23 jan.. The Nursing Process framework was also used because it is considered a powerful strategy for clinical teaching and strengthening the use of a standardized language in health¹⁰10 Freitas MIP, Carmona EV. Estudo de caso como estratégia de ensino do Processo de Enfermagem e do uso de linguagem padronizada. Rev Bras Enferm 2011; 64(6):1157-11560..

In this context, we applied the assumptions of the Theory of Caring proposed by Kristen Swanson, developed in 1988 on the American scene using the inductive method, which has been widely used in obstetric practice, mainly by Nursing professionals, focusing on caring processes as interventions to be implemented in Nursing¹¹11 Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991; 40(3):161-166.

12 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. IMAGE 1993; 25(4):352-357.^-1313 Oliveira TC, Silva ALL, Oliveira JFS, Pereira EAT, Trezza MCSF. A assistência de enfermagem obstétrica à luz da teoria dos cuidados de Kristen Swanson. Enferm Foco 2018; 9(2):3-6..

This theoretical framework can support the construction of a relationship between professional and patient, organizing care, and advocates stages for reflection on care and its dimensions: “know”, “be with”, “do for”, “enable”, and “keep the belief”¹³13 Oliveira TC, Silva ALL, Oliveira JFS, Pereira EAT, Trezza MCSF. A assistência de enfermagem obstétrica à luz da teoria dos cuidados de Kristen Swanson. Enferm Foco 2018; 9(2):3-6.. This practice is consistent with and essential for promoting inclusive care that respects the complexities of pregnancy, childbirth, and the puerperium for trans men¹⁴14 Rosa DF, Carvalho MVF, Pereira NR, Rocha NT, Neves VR, Rosa AS. Nursing Care for the transgender population: genders from the perspective of professional practice. Rev Bras Enferm 2019; 72:299-306..

This study aims to analyze the experiences of a trans man during the pregnancy and puerperal period and the perspective of obstetric nurses in training based on the dynamics and organization of obstetric healthcare in a hospital environment, providing insight into the healthcare needs and barriers faced by pregnant trans men and underscores the importance of respecting individual experiences in the healthcare environment.

Methods

This qualitative, narrative, and reflective case study of everyday professional experiences involves an in-depth investigation of real life and contexts that deserve attention¹⁵15 Andrade SR, Ruoff AB, Piccoli T, Schmitt MD, Ferreira SA, Xavier ACA. O estudo de caso como método de pesquisa em enfermagem: uma revisão integrativa. Texto Contexto Enferm 2017; 26(4):e5360016.^,1616 Yin RK. Case Study Research and Applications: Design and Methods. 6ª ed. Thousand Oaks: Sage Publications; 2018..

It was conducted in a capital city in the Brazilian Northeast, where the trajectory of an adult trans man during the pregnancy and puerperal period was followed in public health services (outpatient, hospital, and specialized care).

The participant was intentionally recruited based on the inclusion criteria of being an adult trans man who experienced pregnancy and prenatal care with their partner. No exclusion criteria were applied as this was a single case study.

The research team comprised transgender and cisgender people with Nursing Obstetric Residency, Master’s and Ph.D. in Social Sciences, Anthropology, Nursing, Physical Education, and Law. Part of the team directly accessed the participant, returning the collected material to them for appraisal.

Data production involved different methodological strategies for triangulating data sources, gaining a more comprehensive understanding of the event, and locating data consistency and validity: 1. Field notes recorded from the residency training experiences (conducted in a coordinated fashion and guided by a roadmap); 2. Completing an analytical matrix (study planning, project development by determining the model, the stages, and the required instruments); and 3. Validation, sharing the data collection/analysis, and construction of the study¹⁶16 Yin RK. Case Study Research and Applications: Design and Methods. 6ª ed. Thousand Oaks: Sage Publications; 2018..

Data collection was followed by an instructional roadmap for preparing the clinical case study (Case identification, formulating the guiding questions, a summary of problems identified, theoretical basis, alternatives or proposals, actions implemented or recommended, and case discussion)¹⁷17 Galdeano LE, Rossi LA, Zago MMF. Roteiro instrucional para a elaboração de um estudo de caso clínico. Rev LatinoAm Enferm 2003; 11(3):371-375..

Subsequently, we adopted a structured form (sociodemographic, identity, work, and health questions - gynecological, obstetric, and puerperal aspects) and open-ended questions targeting the experiences of the pregnancy-puerperal period, parenthood/parenting, and the affective-marital relationship. Moreover, an in-depth interview (couple dynamics and parenting) was conducted in two stages, using the audiovisual resource on the WhatsApp application. The thematic categories were then derived through data saturation, considering the occurrence, convergence, and complementarity regarding reflexivity.

The participant was approached during a collaborative activity on transparenting (a group of trans men, health services, activists, universities, and civil society representatives). The participant was informed and invited to participate in the study. The Informed Consent Form was applied, and consent was granted. Subsequently, the collection procedures were scheduled, guaranteeing autonomy, convenience, and confidentiality.

The audios lasted 110 minutes, were transcribed verbatim, and processed using NVIVO12 software, which allowed the generation of theoretical codes (nodes), streamlining the data coding process. No images were employed to analyze the data. This procedure was organized by two researchers to systematize the data, grouping it by units of meaning concerning standardization by thematic content based on the establishment of a corpus of analysis.

Data were submitted to Thematic Content Analysis, as proposed by Bardin¹⁸18 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016. to identify emerging themes and patterns: Trans men in the context of pregnancy, childbirth, and the puerperium; partnership and parental dimensions; the pregnant couple’s dilemmas; impressions recorded by the nursing professional; understanding the case from a theoretical and epistemological lens; implications for health professionals.

The results were analyzed from the theoretical and normative framework of the Nursing Process, the Theory of Caring proposed by Kristen Swanson, and the theoretical/critical perspective of transfeminism¹¹11 Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991; 40(3):161-166.

12 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. IMAGE 1993; 25(4):352-357.^-1313 Oliveira TC, Silva ALL, Oliveira JFS, Pereira EAT, Trezza MCSF. A assistência de enfermagem obstétrica à luz da teoria dos cuidados de Kristen Swanson. Enferm Foco 2018; 9(2):3-6.. Strategies such as peer review (researchers who developed the study), review by transgenderism and health experts, study participants’ analysis, and the research team’s reflexivity were adopted to guarantee the generated data’s (study results) credibility. In this sense, the transferability of the results was addressed through a detailed description of the case study’s context and the participants. The detailed information recording, methodological procedures, and research decisions ensured the study’s reliability.

Ethical aspects were complied with at all stages of the study. The Research Ethics Committee approved the project under CAAE 11851619.2.0000.5531 and Opinion No. 3.960.330. The Brazilian legislation in force for the development of human research and the recommendations issued by the National Research Ethics Committee for conducting case studies were respected. Generic descriptions of the participants have been used to preserve their image, integrity, and anonymity. No additional information was included in the case in order to ensure its veracity, reliability, and internal validity, preserving the sociocultural sensitivity of the investigated experience.

Results and discussions

The results of this research were structured from the description of the guiding questions formulated, outlined by the summary of the survey of problems, changes identified, the theoretical framework, presenting alternatives, and proposing actions to be implemented or recommended in order to streamline the case’s conduct, structured in six thematic categories.

Thematic Category 1: The case - A trans man in the context of pregnancy, childbirth, and puerperium

This category presents data from the case study of a transgender man in the context of pregnancy, childbirth, and the puerperium, which expressed events experienced in hospital care. It points to previous clinical contexts resulting from the therapeutic trajectory in Primary and Specialized Care health services, specifically an outpatient clinic for transgender people. Data include sociodemographic, general health, gynecological, and obstetric characteristics, diagnostic tests performed, clinical manifestations experienced during the pregnancy-puerperal period, including mental health (Chart 1).

This context highlights the urgent need to integrate mental health care into the gestational care of transgender people, given the substantial influence of the pregnancy-puerperal period on physical and emotional health. Moreover, the decision to terminate the pregnancy due to mental health issues emphasizes respect for the life of the pregnant woman and the medical intervention when necessary to ensure the well-being of both parties. In short, this case illustrates the complexity of pregnancy care for transgender people and underscores the need for sensitive and inclusive approaches to healthcare during this period⁵5 Peçanha LMB. Ressignificar e empoderar o corpo: Homem trans grávido e os desafios da adequação. In: Seminário Internacional Desfazendo Gênero. 2ª ed. Salvador: Anais UFBA; 2015. p. 1-5..

The pregnancy experienced by a transgender man undermines and challenges the preconceived idea that this process is intrinsically associated with femininity. Beyond the biological conventions traditionally associated with the designations “father” and “mother”, parenting encompasses diverse approaches to caring and identifying within the binary parental structure. Each trans man plays the parental role that best aligns with his journey⁸8 Monteiro AA. Homens que engravidam: um estudo etnográfico sobre parentalidades trans e reprodução [dissertação]. Salvador: Universidade Federal da Bahia; 2018..

Thematic Category 2: The case - the partnership and parental dimensions

This category explains the relationship with the partner, a cisgender woman, according to the participant. The results pointed to a parental perception limited to the condition of companion and not co-participant, active throughout pregnancy, childbirth, and the puerperium in the hospital context. The report allowed for the identification of the participant’s dissatisfaction with the daily care routine and interactions with health professionals regarding recognizing the pregnant couple’s parenting. Information on the patient - a pregnant trans man and the father of the newborn - was recorded in the parturient field of the Live Birth Declaration, which was at odds with the parturient father’s wishes, and the mother/partner did not have her data entered on the declaration (Chart 2).

In Category 2, we can see that the legal weaknesses associated with transparenting create obstacles to the civil registration of the gestated child and, consequently, to receiving social benefits, which weaken the child’s rights since the lack of documentation prevents the infant from accessing health services, such as vaccinations, visits to monitor growth and development, and education, such as nurseries. However, the Manual of Instructions for Completing the Live Birth Declaration states that only the full name of the parturient who gestated the child should be included, regardless of their gender identity¹⁹19 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise Epidemiológica e Vigilância de Doenças Não Transmissíveis. Declaração de Nascido Vivo: manual de instruções para preenchimento. 4ª ed. Brasília: MS; 2022..

Decree No. 8,727, of 2016, “provides for the use of the social name and the recognition of the gender identity of transvestites and transsexuals within the direct, autarchic and foundational federal public administration”. Article 1 explains the social name as the “designation by which the transvestite or transsexual person identifies and is socially recognized;” and gender identity as the “dimension of an individual’s identity that concerns how they relate to representations of masculinity and femininity and how this translates into their social practice, without being necessarily related to the gender assigned at birth”, and these rights are essential for the individual’s dignity. Once the patient has changed their name and gender on their documents, they can change their registration²⁰20 Brasil. Decreto nº 8.727, de 28 de abril de 2016. Dispõe sobre o uso do nome social e o reconhecimento da identidade de gênero de pessoas travestis e transexuais no âmbito da administração pública federal direta, autárquica e fundacional. Diário Oficial da União 2016; 28 abr..

Thematic Category 3: Discussing the case - the pregnant couple’s dilemmas

The discussion of the case is described in this category, which points to the pregnant couple’s dilemmas regarding the care context vis-à-vis parenting and healthcare (Chart 3).

In Category 3, the story shows the couple’s lack of financial resources and their choice of home insemination to realize their parental project. Brazil has unequal access to reproductive technologies, which is because access to assisted reproduction in clinics for the population, especially LGBTQIANP+ people, faces several barriers, such as the high cost of private procedures, the public health system’s limited supply, the concentration of clinics in urban areas, and the presence of a cis-heterocentric clinical environment.

In this complex context, home insemination emerges as a self-insemination practice performed outside of assisted reproduction clinics²¹21 Mariana GF, Marlene T. Inseminação caseira como possibilidade de lesboparentalidades no Brasil. Rev Encuentros Latinoam 2021; 5(2):180-201.. It is a tool and strategy for reproductive autonomy that allows trans men and transmasculine people to realize their parental projects²²22 Monteiro AA, McCallum C. Paternidades Trans: uma análise etnográfica das experiências parentais de um homem trans em Salvador, Bahia. Rev Bras Estud Homocultura 2023; 6 (20):30-59..

Faced with this conflict over the expectations created during the pregnancy and puerperal period, which may not align with the reality experienced, emotional changes and challenges that lead to gender dysphoria emerge. We should underscore the importance of the support network, especially the partner’s involvement during the pregnancy and puerperal period, along with family and close friends who can offer positive support²³23 Charter R, Ussheret JM, Perz J, Robinson K. The transgender parent: experiences and constructions of pregnancy and parenthood for transgendermen in australia. Int J Transgend 2018; 19(1):64-77..

Moreover, the findings of this study pointed to transphobia among health professionals. This event is characterized by historical and cultural denial through fear, discomfort, hatred, and stigmatization of how a trans person constructs their gender identity. Veiled or materialized violence causes suffering in this population, imposing barriers that prevent approaching them and providing them with healthcare. The presence of a trans man in the health service breaks with the ideological binary discourse, such as the idea that only cisgender women can get pregnant because the uterus is only female²⁴24 Zerbinati JP, Bruns MAT. Transfobia: contextos de negatividade, violência e resistência. PERI 2019; 2(11):195-216..

Law No. 7,716, of 1989, which “defines crimes resulting from the prejudice of race or skin color”, in its Article 1, states that “Crimes resulting from discrimination or prejudice of race, skin color, ethnicity, religion or national origin shall be punished under this Law”. It extends its protection to several types of intolerance, even if it does not directly mention discrimination on the grounds of sexual orientation and gender identity, but this law²⁵25 Brasil. Lei nº 7.716, de 5 de janeiro de 1989. Define os crimes resultantes de preconceito de raça ou de cor. Diário Oficial da União 1989; 5 jan. can cover them.

The reflections raised from the experience of the case highlight the high relevance of understanding the complexities of gender identity and the mental health of trans people. This case emphasizes the urgency of improving the quality of care provided to trans patients, especially within the Unified Health System (SUS), which involves the continuous training of staff regarding gender issues and requires developing protocols, ensuring that the rights and health of all patients are respected.

Thematic Category 4: Contextualizing the case - impressions recorded by the nursing professional

The data in this category show the impressions recorded by nursing professionals in the context of Obstetric Nursing residency training regarding the contextualization of the assisted case. We identified the difficulties and challenges and the perceptions of the care team regarding the conduct adopted, dilemmas experienced, and the need to review professional health practices in the obstetric hospital context for the care of trans men in the pregnancy-puerperal period, with notes to reflect on and build new care settings for the production of health care in the public service (Chart 4).

Furthermore, in Category 4, it is essential to reflect on breastfeeding, marked by periods of emotional distress. It is the height of discomfort with the body, as it is perceived as one of women’s emblematic social roles²⁶26 García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* Pregnancy and Lactation: A Literature Review from a Nursing Perspective. Int J Environ Res Public Health 2019; 17(1):44.. It is essential to consider other feeding options for the children of trans men who choose not to breastfeed, such as the use of human milk banks, milk formulas, and the induction of lactation by their partners. Health professionals should provide information during prenatal care appointments about the alternatives available without putting pressure on individuals and respecting their autonomy²⁷27 MacDonald T, Noel-Weiss J, West D. Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth 2016; 16:106..

Milk production is facilitated through a procedure that covers three distinct stages: hormonal preparation of the breast tissue, prolactin promotion, and hormonal weaning with breast expression²⁶26 García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* Pregnancy and Lactation: A Literature Review from a Nursing Perspective. Int J Environ Res Public Health 2019; 17(1):44.^,2828 Ferri RL, Rosen-Carole CB, Jackson J, Carreno-Rijo E, Greenberg KB. ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients. Breastfeeding Med 2020; 15(5):284-293.. The Lactation Induction technique expands the opportunity for non-biological mothers to breastfeed their children, thus benefiting a diversity of families, including those made up of adopters, transgender people, and lesbian couples. It helps to ensure that more children have access to human milk’s nutritional, emotional, and affective benefits, promoting their proper growth and development²⁹29 Fernandes LCR, Sanfelice CFDO, Carmona EV. Indução da lactação em mulheres nuligestas: relato de experiência. Esc Anna Nery 2022; 26:e20210056.. Lactation induction requires time and effort, an assessment of health and psychosocial conditions to guarantee the health of the individual wishing to induce lactation and the baby who will be breastfed.

Reflecting the context of childbirth, the hospital-centric setting is centered on the medical figure, and the parturient is disqualified and unable to decide whether she would like a cesarean section or not, due to the attitude of health professionals²2 Monaco S. Different in Diversity: An Intersectional Reading of LGBT Parenting. Culture Studi Soc 2022; 7(2):234-252.. This situation causes suffering for the patient, who requires guidance on delivery routes and the use of non-pharmacological methods for pain relief. In this sense, disrespect for autonomy is obstetric violence.

Obstetric violence includes disrespect, physical, verbal, and psychological abuse, negligence during childbirth, unconsented procedures, and preventing the presence of a companion³⁰30 Organização Mundial da Saúde (OMS). Prevenção e eliminação de abusos, desrespeito e maus-tratos durante o parto em instituições de saúde. Genebra: OMS; 2014.^,3131 Bahia. Lei nº 2.228, de 4 de junho de 2018. Dispõe sobre a implantação de medidas de informação e proteção à saúde e parturiente contra a violência obstétrica no município de Vitória da Conquista. Prefeitura Municipal de Vitória da Conquista; 2018.. In Vitória da Conquista, Bahia, Law No. 2,228, of 2018, which characterizes obstetric violence as the appropriation of women’s bodies and reproductive processes, does not include trans men in childbirth, showing a gap in the legal protection of this population segment in the healthcare context³¹31 Bahia. Lei nº 2.228, de 4 de junho de 2018. Dispõe sobre a implantação de medidas de informação e proteção à saúde e parturiente contra a violência obstétrica no município de Vitória da Conquista. Prefeitura Municipal de Vitória da Conquista; 2018..

In this case, the trans man who gave birth had conflicts with the bodily changes resulting from the pregnancy, the way he established his body and masculine identity, and the interactions with the health professionals who followed him up, which culminated in an intense psychological distress episode, a risk to the health and life of the trans man, his child, and the people around him. The bodily changes associated with pregnancy can be challenging and emotionally complicated to address for some trans men who are pregnant, especially for those who wish to masculinize their bodies through hormonal and surgical interventions. The way trans men and transmasculine people perceive and construct their bodies is particular, whether or not it is affected during pregnancy. Choices carry emotional, social, and physical implications linked to how gender experiences are established and how discrimination is addressed³²32 Hoffkling A, Obedin-Maliver J, Sevelius J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth 2017; 17(Supl. 2):332..

The analysis of this case highlights gaps in the training of health teams in caring for transgender people during the pregnancy-puerperium period, highlighting the Obstetric Nursing Residency context. The failure to promote continuing education spaces for health professionals, especially in the field of gynecology and obstetrics, results in practices that compromise the quality of care, contributing to the reproduction of obstetric care performed under the cisheteronormativity rationale, where trans men’s specificities are concealed in the several settings. It is, therefore, crucial to include topics such as “prenatal care, delivery, birth, and puerperium of trans men” during the training of health professionals in order to prepare these people for person-centered care approaches that consider the sociocultural particularities of transmasculinities³³33 Pereira DMR, Araújo EC, Silva ATCSG, Abreu PD, Calazans JCC, Silva LLSB. Evidências científicas sobre experiências de homens transexuais grávidos. Texto Contexto Enferm 2022; 31:e20210347..

Thematic Category 5: Understanding the case - adopting a theoretical and epistemological lens

The understanding of the case explained in this category was anchored in the Theory of Caring, based on the interrelationship with transfeminist epistemology, to think about the production of Nursing and Health professional care in the pregnancy-puerperal period of trans men and their parental relationship (Chart 5).

Thematic Category 6: Critical analysis of the case - implications for health professionals

In Categories 5 and 6, Swanson’s Theory of Caring/Caregiving lens supported the care developed within the family in its diverse relational configurations. It helps to understand the care processes around what is expected of a pregnant person and the social roles to be assigned to men and women since it considers the element of “keeping the belief” - both in people and their abilities¹¹11 Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991; 40(3):161-166..

Nursing care is essential, centered on the relationship of affection, the development of the professional and the person being cared for, and accountability and involvement¹¹11 Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991; 40(3):161-166.^,1212 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. IMAGE 1993; 25(4):352-357.. Recognizing homoparental health needs from the viewpoint of care, considering interpersonal relationships, is indispensable for recognizing sexual and gender diversity in family configurations and attention to the specificities of pregnant trans men and their partners, in which caring finds an essential place, especially when expressed and practiced effectively in an interpersonal way.

In this sense, it is recommended to create care devices in the services that guarantee the safety and protection of homoparental families in health services, empowering and strengthening the teams of health professionals and workers. In a perspective of making care transpersonal, to be permeated by different means of communication, feelings, harmonization of the mind, body, and spirit of the person being cared for in these spaces, overcoming medical-centric models, which give restrictive emphasis to protocols, control, rigor, objectivity, and high technological incorporation, disregarding the humanistic dimension and the sense of care as a valuable attribute for humanity¹¹11 Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991; 40(3):161-166.^,1212 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. IMAGE 1993; 25(4):352-357..

The metaparadigm of the Theory of Caring understands “Nursing” as care based on the person’s well-being in clinical and cultural terms. The “Person” is seen as a unique being who can constantly evolve and whose uniqueness can be expressed through thoughts, emotions, and behaviors; “Health” is considered a subjective, significant experience that can be associated with the human being integrity and totality. Finally, the “Environment” encompasses a situational level transcending the physical dimension¹¹11 Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991; 40(3):161-166.. Thus, we call on health professionals to “get to know” the human experience of transgenderism, to reframe the care logic and production, and to review the meanings and senses of affective-sexual relationships, family, and parenting.

The transfeminism perspective can build other types of masculinities that differ from hegemonic masculinity³⁴34 Connell RW, Messerschmidt JW. Masculinidade hegemônica: repensando o conceito. Rev Estud Fem 2013; 21(1):241-82. and dialogue with feminism precisely because they have common agendas, such as the fight against machismo, misogyny, obstetric violence, and the fight for the right to the body. In this sense, transmasculine identities subvert normative discourses, giving visibility to other possibilities for constructing what it means to be a man³⁵35 Santana B. Pensando as transmasculinidades negras. In: Restier H, Souza RM, organizadores. Diálogos contemporâneos sobre homens negros e masculinidades. São Paulo: Ciclo Contínuo Editorial; 2019. p. 95-104.. These masculinities find space to tension and debate central issues such as pregnancy, childbirth, the puerperium, and the health of this population⁷7 Leonardo MBP, Anne AM, Jaqueline GJ. Transfeminismo das transmasculinidades: diálogos sobre direitos sexuais e reprodutivos de homens trans brasileiros. Rev Bras Estud Homocultura 2023; 6(19):90-104. within the field of transfeminisms of transmasculinities.

The mismatch between current Brazilian legislation and the experiences of trans men during pregnancy and childbirth creates a gap in the protection of rights and the guarantee of quality care. Therefore, implementing institutional protocols ensures that trans patients receive timely and adequate care.

Conclusion

Transgender people’s pregnancy is a reality that needs to be recognized and incorporated into the organization of services. It requires investing in the promotion of continuing education spaces for health professionals aimed at understanding and respecting gender diversity and family configurations. Transgender individuals must be involved in organizing the care they wish to receive in order to prioritize the bioethical principle of autonomy in making decisions about their health.

There is a need to rethink professional training curricula to adequately prepare health professionals to provide care that is more inclusive and sensitive to diverse gender identities, with theoretical and practical experiences that enable their specificities in care and the development of skills that meet the unique demands of transgender patients. Thus, the implementation of continuing education programs on care for transgender people in the context of pregnancy, childbirth, and the puerperium is essential as it could enable a more inclusive organizational culture.

Furthermore, there are still significant gaps in scientific output addressing trans men’s transparency and obstetric trajectory. There is a need to produce new studies that address issues relating to sexual and reproductive rights, prenatal care, breastfeeding, and care during labor and birth based on the experiences of trans men, reflecting on the intersecting cisheteronormativity and the representations of transparency in the context of healthcare.

References

Publication Dates

History