Man loses his pregnancy, world loses its senses
Sam’s story
It was Sylvia’s* tenth patient that day. According to the patient’s records, he was 32 years old and his medical history included use of anti-hypertensives along with testosterone, both of which had been discontinued after his insurance coverage expired. He had been brought in by his boyfriend who told the nurse that Sam* had been in quite severe pain for the last eight hours or so, somewhere in the region of his lower abdomen.
Sam added that he was a “transgender man,” and that he hadn’t had a period for a few years. He also mentioned that he’d taken a home pregnancy test before coming to the hospital, which was positive, but he wasn’t sure whether to believe it or not. He added that he had “peed himself” that morning.
Sylvia, somewhat confused, took his vitals. His blood pressure was high (185/84 mm Hg) but he seemed stable and the bouts of pain appeared manageable. She categorized him as nonurgent. Just to be on the safe side, she took a few blood samples including an hCG (pregnancy) test.
A few hours passed.
Finally, the emergency physician arrived, along with the hCG results—positive. She noted that Sam was obese, and wondered whether this “man” might be suffering with early pregnancy complications. A physical exam then revealed that this was no early pregnancy—the evaluation now changed to one of hypertension in late pregnancy with possible rupture of membranes which suggested the likelihood of labor, preeclampsia, or even placental abruption.
Sam was now categorized as an emergency, but it was too late. A sonogram showed unclear fetal cardiac activity. An internal exam showed cord prolapse and no one, least of all Sam, knew how long things had been that way. He was transferred to the operating room for an emergency C-section. The baby was stillborn.
Medicine is no longer an exact science
Sam’s story was featured in an article titled, “The Power and Limits of Classification — A 32-Year-Old Man with Abdominal Pain” which was published in the New England Journal of Medicine in 2019, authored by several Ob/Gyns and an anthropologist from the University of Michigan, Ann Arbor. The article isn’t really about Sam. It just uses her case to support the authors’ argument that classification is no longer simple (or binary). It’s now “complex.” And medicine is no longer an exact science. It’s “social.”
Classification is at the heart of both medicine and social interactions (indeed, medicine is a social practice).
ER medicine done the old-fashioned way, the article writes, involves taking a patient and asking a series of yes/no questions, the answers to which determine the action taken:
The diagnostic process includes attributing signs and symptoms to disease categories, which in turn prompt action. Classification is essential because it simplifies complex physiological phenomena into dichotomous questions: Does the patient have a given disease? Does the patient have risk factors? Does the patient need to see a specialist? Classification is particularly important for triage, in which degrees of urgency and thus order of treatment are assigned.
Instead, medicine should be moving into an all-new, multi-polar future, the researchers say.
Post-truth medicine
This is because binary questions don’t work for non-binary patients, or so claim the authors. Since “the triage nurse did not fully absorb the fact that [Sam] did not fit clearly into a binary classification system with mutually exclusive male and female categories,” accurate assessment was delayed.
In fact, the only “male” aspect of Sam cited here was her claim that she was male. Possibly she had a beard and mustache too—the article doesn’t mention this. So what did the authors want the nurse to do? Ask Sam to describe her reproductive organs?
No. Apparently, they wanted her to use “pregnancy algorithms.”
Despite communicating that he was transgender, Sam was not evaluated using pregnancy algorithms.
The authors don’t specify what these “pregnancy algorithms” actually are. But they compare them with the nurse’s “implicit assumptions about who can be pregnant.”
Having no clear classificatory framework for making sense of a patient like Sam, the nurse deployed implicit assumptions about who can be pregnant, attributed his high blood pressure to untreated chronic hypertension, and classified his case as nonurgent.
They then add that if Sam had presented as a “cisgender woman” and listed all her symptoms, she would immediately have been “evaluated more urgently for pregnancy-related problems.” Her description of incontinence would have been more quickly interpreted as ruptured membranes, and it is possible that the baby’s life might have been saved.
Nowhere is it even suggested that Sam herself might have done a better job of understanding and explaining her symptoms and seeking accurate medical care, if she had fully accepted her female self.
Triage by robot
The next clue as to where the article’s authors are coming from is a reference to the writings of Michel Foucault:
We often assume that classificatory systems have consistent principles for sorting items into mutually exclusive categories that comprehensively describe the aspect of the world they are trying to capture. Social theorists have shown that, in practice, classification systems never correspond perfectly to the complex world they purport to describe...
The solution, the authors implicitly suggest, is to replace the human classification process with classification by computer—AI triage.
... humans do not perform classification in the dry, abstract way a computer does: our classification process involves perception, which is in turn influenced by expectation and experience, and much of this process is unconscious...
Since human nurses and doctors have human perceptions, many of which are unconscious, they are irredeemably flawed, according to this outlook. Only computers, with no preconceived (binary) notions about gender or sex or binaries, can be trusted to triage patients accurately.
Non-binary medicine for all
The authors then move on to claim that “non-binary” methods of practicing medicine would benefit everyone, not just people like Sam.
Awareness of the limitations of implicit classification in patient management can improve care not only for transgender patients, but for all patients who fall through classificatory “cracks.” For instance, excessive reliance on the category of “race” may lead us to miss a diagnosis of cystic fibrosis in a multiracial child with recurrent respiratory problems. Elderly patients might not be diagnosed with sexually transmitted infections because they are assumed not to be sexually active.
The fact that they don’t cite a single real-world example of a multiracial child or an elderly person being misdiagnosed due to unconscious and implicit bias doesn’t detract from their findings, they apparently believe.
What on earth is ‘identity-affirming prenatal care’?
The authors also dismiss out-of-hand any insinuation that Sam’s problems could have been solved by her medical records stating that she was female.
The ability to change one’s legal sex marker can be crucial for transgender people in many areas of their lives, including safety, health insurance, employment, housing, and restroom use. Hence, the issues raised in this case cannot be resolved by preventing transgender people from changing their sex on legal documentation or in their medical chart.
For Sam and other “transgender men,” apparently, being officially defined as male is crucial. Therefore, the authors write, nurses should ask questions such as, “Does the person have a uterus?” or “Is the person receiving hormones?” They also recommend three separate intake categories to replace the standard male/female:
Charting sex at birth, gender identity, and legal sex as three separate categories on formal documentation can enable nuanced and appropriate care...
Sam should also have been offered “identity-affirming prenatal care,” they write. (Something like, “Don’t worry! All this pregnancy and birth stuff doesn’t mean you’re not a man...” ?)
It takes a village to birth a child (no father and mother needed)
Sam’s story ends with her discharge from hospital with a copper IUD to prevent future pregnancies. She is described as “heartbroken” at the loss of the baby “though [she] had not planned or expected” it, and as having fallen into a major depression, along with dysphoria at resuming menstruation—however, she opted not to resume testosterone treatment, as her menses reassured her that she wasn’t pregnant.
The story of unfortunate “transmen” didn’t stop in 2019, however. A recent article written by a self described “coalition of midwives, midwifery students, trans, queer, gender diverse, and cisgender professionals” continues the progressive push toward the entire restructuring of perinatal care. Today, woke theorists are actually claiming that the two-parent family is a “recent development” in history and that “community and extended family” are more important for childbearing than the two parents themselves:
The notion of childbearing having a necessary or logical belonging within the nuclear two-parent family initiated by heterosexual couples whose gender has a normative relationship with their sex assigned at birth is a recent development in our human history, and one still inconsistently observed around the globe.
Indeed, community and extended family are often as, if not more important.
Binary = Deadly
The authors describe attempts to push back and insist that there are only two sexes/genders as a “conservative counter-resistance.” They ascribe the outcomes of cases such as Sam’s to a “myopic focus on sexed language” and write that “harmful stereotypes and biases ... can cause significant harm and death...”
Such failure to recognize the complexities and intersectionality of people as individuals not only contravenes the principle of non-maleficence, but arguably situates perinatal staff as agents of harm rather than agents of care... Evidently, where perinatal services are rigidly gendered, worse health outcomes occur...
Those who persist in calling women “women,” and men “men,” are accused of using language to “discriminate, abuse, police, marginalize, disrupt, and destabilize individuals and communities, and incorrectly infer pathology.”
They add that such people “disregard the reality that bodies change continuously, and considerable variation exists within the categories of both sex and gender, neither of which are binary.”
Instead, they write,
... biological sex and gender [should be understood] as neither binary nor immutable...
And they predict that this will eventually come about, comparing attitudes toward “trans” people to those toward left-handed people:
... the number of people in the Global North identifying as gender diverse is increasing, much like the numbers of left-handed people did when society became more inclusive of such populations...
Don’t blame the rapist, blame ‘colonialism’
The authors also dismiss women’s concerns that female-only spaces are being invaded by men by blaming not men themselves for male-against-female violence, but rather “patriarchal and colonial influences.”
The sexed language argument understands women to be facing the threat of erasure, not by the patriarchy, but by gender-diverse people. It employs a scarcity narrative, wherein the safety of cisgender women cannot be shared with gender diverse people, rather than recognizing that both groups are oppressed by the same patriarchal and colonial influences that remain starkly present in the inequity of perinatal services and outcomes...
The misunderstanding is furthermore that masculine violence is reduced to male biology, rather than being reproduced through colonial and patriarchal gender binaries.
By definition, they say, there is really no such thing as a “transwoman” perpetrating sexual violence against a female, because only “cisgender men” do that. Unfortunately, there is no reliable test to differentiate between “cisgender men” and men dressed up as women and claiming to be “transwomen,” nor is there much hope for people like Sam in a world gone mad.
*not their real name
