Midwives of the Revolution

Explorations, analysis, and reflections on women's health, midwifery, and politics from a feminist, marxist lens


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Trans-Affirming Midwifery, Always

Dear readers,

If you are an ACNM (American College of Nurse Midwifery) member, please access and sign the open letter supporting the provision of trans health as a core competency for nurse midwives by clicking the link below.

The letter captures so many sentiments I share about why trans healthcare should be absolutely integrated into nurse midwifery from the beginning. Let’s stop ghettoizing any reproductive healthcare (including miscarriage management, elective abortions, basic assisted reproductive therapies for LGBT clients) — and in this moment, especially trans affirming care — and respond to the fact that queer and trans midwives and clients are demanding an expansion of core care that is appropriate and respectful. And let’s please root out the gender essentialism and transphobia in the midwifery community and the current ACNM leadership! Thank you to all the wonderful folks who put together this letter and who have been working so hard to advance an intersectional feminist leadership in midwifery. Our side will prevail.

-A proud signer to this letter and member of The Queer and Transgender Midwives Association (QTMA)

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As ACNM members, we submit this letter to raise our concerns about the ACNM Board of Directors’ (BOD) recent actions in making decisions about access to care for transgender and gender non-conforming (TGNC) people in closed session and without any mechanism for transparency or accountability. We submit this letter on Transgender Day of Remembrance in the spirit of honoring the lives of those we have lost to transphobia, and fighting for the rights of those who continue to survive. We are publishing this letter publicly so that midwives and midwifery students can sign on in solidarity.

We are alarmed to learn that at their October 2018 Board meeting, the newly-elected BOD 1) failed to approve proposed revisions to the ACNM Position Statement on care of TGNC people, and 2) failed to uphold the March 2018 decision of the previous BOD, which had confirmed that the midwifery core competencies as they currently stand already include gender affirming hormone therapy for TGNC people. Instead, the BOD rejected the Position Statement, stating that “neither hormone therapy or care of natal men [sic] is a core competency.”

These actions were motivated by concerns regarding midwifery care of transgender women and non-binary people assigned male at birth (referenced by the BOD as “natal men”), and are in direct opposition to the recommendations of the Gender Equity Task Force (GETF) Chair and the Core Competencies Committee Chair. No midwives who identify as TGNC or who provide care to TGNC communities participated in the closed discussions related to these motions.

Frustratingly, the BOD is able to withhold the detailed minutes of their discussion per protocol that only open session minutes are released publicly. The BOD included only very vague information on this discussion in the open session minutes. This is particularly concerning given that these BOD decisions have significant implications for work currently underway by the GETF and a number of ACNM committees. In reviewing the available open session notes, it is notable that the only topics from open session that were moved to closed session were related to midwifery care of TGNC people.

With this letter, we intend to alert the BOD and ACNM’s membership of:

  1. The presence of the many current and future midwives who stand in support of transgender, non-binary, gender-diverse and intersex people;
  2. The importance of midwifery care for these communities;
  3. The ethical implications of the BOD’s lack of transparency; and
  4. The practice implications of these decisions on us all.

The BOD’s actions are very concerning in that they create an impression that gender affirming hormone therapy – widely recognized as straightforward and lifesaving care – is not appropriate for new-to-practice midwives. This creates a barrier to increasing the number of providers equipped to provide this care, a development that is very problematic given the significant and well-documented health disparities experienced by TGNC communities. It is important to remember that midwives – including new midwives – are well versed in many forms of hormone therapy (such as for contraception and for management of menopausal symptoms), and that these other therapies are uncontested in their inclusion in the core competencies. Therefore, the BOD’s exclusion of  only gender affirming hormone therapy specifically and unethically targets TGNC people.

While we cannot presume to know the exact intent of BOD members participating in these decisions, the impact is clear. These decisions are transphobic; they send a message that the current BOD does not view transgender women as “real women” simply because some transgender women have a penis; otherwise they would be deemed inherently appropriate for midwifery care under the ACNM vision of “a midwife for every woman.” Importantly, midwives are able to care for people with penises when it comes to circumcision, as part of expanded midwifery practice. Thus, these motions are clearly not an issue of scope, but of what ACNM leadership finds uncomfortable politically or personally.

The BOD did not specifically state concerns regarding midwifery care of transgender men and non-binary people assigned female at birth. In more neutral circumstances this could be perceived as reassuring or benign. However, in the context of the BOD’s actions it raises concern that the BOD perceives transgender men as “women” regardless of their gender identity, simply because some of these individuals may have breasts, ovaries, a uterus, and a vagina. This negates the true selves and humanity of these individuals, and tarnishes the value of midwifery care by filtering care provision through a lens of transphobia.

Biological determinism, the act of reducing a person’s identity to their body parts, is inhumane, abhorrent, and unconscionable. This is the first time the BOD has attempted to make any distinctions between TGNC individuals based on anatomy. Previous BODs have intentionally described TGNC care inclusively, recognizing that gender is a spectrum and that anatomical distinctions reinforce biological determinism. Our peers in allied professions which have historically defined their scope of practice as “care of women” (Obstetricians/Gynecologists and Women’s Health Nurse Practitioners) have long affirmed that care of all TGNC people – including transgender women – is important and within their scope. Our own prior BOD did the same in March of this year. Yet the current BOD has decided to change course entirely, in a move that favors biological determinism and is particularly foreboding given the current political climate.

Within the past month, the Department of Health and Human Services released a memo stating that it is planning to require that gender be identified as a biological condition determined by genitalia at birth. Immediately, over 2,600 experts in the field, including both scientists and care providers, published a response, stating that to define someone by genitalia is “not only fundamentally inconsistent with science, but also with ethical practices, human rights, and basic dignity.” Why are we, as a profession, reversing our prior well-thought-out decisions and joining in a widespread assault on the rights, bodies, and health of transgender and non-binary people? Why have we sided with anti-science and transphobic positions by defining who midwives can take care of based on their genitals alone?

This position places midwives in the inappropriate position of acting as “gender police” tasked with determining who is “woman enough” to receive midwifery care, and leaves the many midwives already providing sexual and reproductive healthcare to gender diverse patients in professional and licensure limbo. Given research that indicates people of color are more likely to identify as TGNC than their white counterparts, limiting access to care for TGNC people also serves to further the already significant health disparities experienced by communities of color.

The truth is that midwives take care of people, not body parts, and that body parts are not inherently gendered. As midwives we pride ourselves on treating the whole person. We care holistically, we believe what people tell us, and we meet patients where they are. These BOD decisions are ethically in conflict with core midwifery values. Instead of providing guidance for clinicians, they require that we choose between practicing midwifery, and participating in a political decision by our professional organization that privileges bigotry and ignorance over the people harmed by that bigotry. They violate midwifery’s ethical obligations as care providers and reinforce the systemic oppressions already experienced by TGNC and intersex people. They use midwifery as a tool to amplify harm rather than increase equity. That is not acceptable.

We will not stand by as this BOD makes decisions that dehumanize the patient populations we are honored to serve. We will not stand by as this BOD makes decisions that dehumanize our own midwife colleagues who are TGNC or intersex.

We ask the BOD to do the following:

  1. Commit to holding all future discussion of this issue in open session;
  2. Reinstate the March 2018 decision that care of TGNC individuals and provision of gender affirming hormone affirmation therapy falls within entry midwifery care as outlined in the Core Competency document Section V.C.
  3. Approve the revised Position Statement and revised Core Competencies documents as submitted by the GETF to the BOD for the October 2018 meeting, without the addition of restrictions on the care of transgender women or the provision of gender affirming hormone therapy
  4. Charge the GETF and other relevant ACNM Volunteer Committees to work collaboratively to review and update the Midwifery Scope of Practice document to include care for TGNC individuals.
  5. Publicly acknowledge the damage that has been done by the BOD’s recent actions, and outline a plan for accountability in the future, including BOD and DOME additional training in gender diversity and impact on health disparities.
  6. Use respectful and inclusive language when referring to TGNC individuals and communities in all communications and public documents; guided by ACNM’s Issue Brief on “Use of Culturally-Appropriate Terminology for Gender-Diverse Populations
  7. Charge the Ethics Committee to review public documents that have potentially political implications.

We, as individuals deeply committed to increasing healthcare access to TGNC populations, hope that you will join us as we continue to strive towards a more inclusive path for midwifery. These signatures below affirm and signify the gravity of the harm we feel these decisions have brought forth by excluding vulnerable individuals from midwifery care.

We invite you to consider taking the following steps:

  1. Signing this letter in support of inclusion of midwifery care for all bodies;
  2. Sharing this letter with peers, friends, colleagues, and students;
  3. Educating people about affirming language and engaging in conversations in a way that supports all people;
  4. Sending a personalized letter to a regional representative or the BOD;
  5. Running for office, and/or intentionally supporting the leadership of TGNC midwives in regional and national leadership roles, so that we have a Volunteer structure that understands TGNC issues;
  6. Sending a letter to your current midwifery Director or the Director at your Alma Mater, with copies to DOME, to advocate for the inclusion of this education in midwifery programs.

For midwives and midwifery students who are TGNC and LGBQ identified: The Queer and Transgender Midwives Association (QTMA) is dedicated to supporting and representing LGBTQIA2S+ midwives and student midwives as they train and grow as providers and people. QTMA provides educational opportunities, advocacy, community and tools for their members, all grounded in an intersectional ideology and framework. It envisions a world where all LGBTQIA2S+ midwives and student midwives have the resources and representation they need to thrive in practice and in their community. QTMA is fiscally sponsored by the birth justice organization, Elephant Circle. Interested folks can connect with QTMA on their Facebook page or by emailing QTmidwives@gmail.com.

Sincerely,

Stephanie Tillman (she/her), CNM, University of Illinois, Region IV – Chair, ACNM Gender Equity Task Force

Simon Adriane Ellis (they/them, he/him), CNM, Kaiser Permanente Washington, Region VII – Member, ACNM Gender Equity Task Force

Noelene K. Jeffers, (she/her), CNM, Region II, Member, ACNM Gender Equity Task Force

Margaret Haviland (she/her), CNM, WHNP-BC, Kernodle Clinic, Region III, Member – ACNM Gender Equity Task Force

Signey Olson (she/her), CNM, WHNP-BC, Columbia Fertility Associates, Region II – Member, ACNM Gender Equity Task Force

Lily Dalke (she/her), CM, LM, Planned Parenthood NYC, Region I – Member, ACNM Gender Equity Task Force; Member, ACNM Core Competencies Committee

Nikole Gettings (she/her), CNM, Region III- Member, ACNM Gender Equity Task Force

Anne Gibeau (she/her/hers), CNM, PhD, Director of Midwifery – Midwifery Practice, Jacobi Medical Center, Region 1, New York State Association of Licensed Midwives – Downstate Region Representative; Member – ACNM Gender Equity Task Force

Máiri Breen Rothman (she/her), CNM, MSN, FACNM, Director, M.A.M.A.S., Inc., Region II; Member – ACNM Gender Equity Task Force

Meghan Eagen-Torkko (she/her), PhD, CNM, ARNP, University of Washington Bothell and Public Health Seattle-King County, Region VII — Member, ACNM Ethics Committee

Lee Roosevelt (she/her), PhD, MPH, CNM, University of Michigan, Region IV

Jenny Nelson, (she/her), CNM, Region I

Jennifer M. Demma (she/her) MSN, APRN-CNM, Family Tree Clinic, Region V

Rob Reed (they/them), CNM, ARNP, IBCLC, Swedish Medical Center, ACNM Region VII – WA ACNM Affiliate Vice President

https://docs.google.com/document/d/1jS9Mxdkh45ROZR38H0yXYVI2Bxh05v6aZhCy0u0m57A/edit?usp=sharing

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Clinical Resources for Providers & Patients

One of my major roles as a provider is to counsel patients about their health and link them with resources. I also spend a great deal of time educating myself about women’s health, since being a clinician requires lifelong learning — especially evident at the beginning of my career. I have compiled a pretty sweet resources list that I wanted to share, featuring legit, evidence-based sources that I trust.

I’ve arranged it by subject area and include a bit of info about its intended use. Enjoy, and please provide me with feedback — what works, what could be added, what’s maybe not so good.

Holistic Approaches Women’s Preventive Health & Primary Care

From the website: “Bright Futures for Women’s Health and Wellness implements and evaluates culturally competent, evidence-based consumer, provider, and community tools for women across their lifespan. Bright Futures for Women’s Health and Wellness materials help women of all ages achieve better physical, emotional, social, and spiritual health by encouraging healthy practices.” That side Includes resources on physical activity, nutrition, emotional wellness, and maternal wellness.

This is a great handout for patients developed by the Western Australian government’s public health department on sleep hygiene that I use often.

I post this visual aid developed by the Harvard Medical School in my exam rooms, to demonstrate a healthy food plate. It’s improved over the FDA’s food pyramid.

A good complement is this schematic of the Healthy Mind Platter, to demonstrate mental activities essential to mental health promotion.

Say what you will about the US Preventive Services Task Force (USPFT) — their resources are incredibly useful. This source walks you through the organization’s screening, counseling, and preventive medication recommendations.

This government site includes resources for patients and clinicians, including continuing medical education (CME) that midwives, other APNs, and docs might find useful. Topics include: CancerDiabetesGenitourinary ConditionsGynecologyHeart and Blood Vessel ConditionsMental HealthMuscle, Bone, and Joint Conditions, & Pregnancy and Childbirth

I really don’t know much about this organization, but what I’ve seen looks pretty great: Integrative Medicine for the Underserved provides community and resource-sharing for folks interested in this area.

Reproductive Health

CARDEAI recently learned about CARDEA by participating in an excellent series of CME events about providing care for transgender clients. They have lots of resources and offer training on a variety of topics you can peruse here. They seem to focus on reproductive health and “wraparound” services.

For STI prevention, treatment, and counseling, the CDC is tops. I have read the CDC’s STD Treatment Guidelines front to back more than once. If you provide any reproductive health services, it’s a must read. This is a library of resources straight from the CDC.

After you’ve done the CDC thing, I encourage you to hang out with the American Sexual Health Association. Their Herpes Resource Center is fantastic, but their overall positivASHAe and holistic approach to sexual health shines through everything they do. I’ve not used them, but they have brochures on STIs and other sexual health topics you can order for your clinic that look pretty good. And an intriguing book they recently published: Creating a Sexually Healthy Nation. Yes, please.

The National Chlamydia Coalition is seriously dedicated to our most common bacterial STI, chlamydia!

There isn’t any current medical consensus on the breast self-exam (BSE), but I still teach and encourage it, as it promotes awareness of the woman’s body. Here’s a link to a good teaching tool for the BSE.

I like this handout on kegel (pelvic floor or vaginal) exercises. Yay, vag workouts!

This is a comprehensive guide to female sexual health and wellness that everyone should read! It covers everything and is basically a course on female sexuality. Woot! Thanks again, ARHP!

General Clinical Practice

This Health Literacy Universal Precautions toolkit “offers primary care practices a way to assess their services for health literacy considerations, raise awareness of the entire staff, and work on specific areas.”

Cervical Cytology & Pathology (AKA Pap Stuff)

ASCCP_HeaderGraphicThe medical world hasn’t entirely caught up yet, but the American Society for Colposcopy & Cervical Pathology released its consensus guidelines on pap screening and followup a couple years ago. Hang out at their website to get the backstory and summary of screening and management guidelines.

OK, so this resource for clinics on managing HPV did get some funding from some pharmaceutical giants, but provides guidance on HPV management on a wide variety of issues/from different angles.

Family Planning & Abortion

For contraceptive prescribing, always start with the CDC. Here’s their Selected Practice Recommendations on Contraceptive Use. And don’t forget the Medical Eligibility Criteria.

My favorite new thing from the CDC. Highly recommended reading on providing comprehensive family planning services.

I am a proud member of the Association of Reproductive Health Professionals (ARHP)! Here is a page full of their patient fact sheets and patient resources on family planning.

The You Decide Toolkit is also from ARHP and “is designed to help health care providers better understand and speak to the risks and benefits of hormonal contraception.

The mama of all abortion resources is the National Abortion Federation. Their site can connect you with all the info you could ever want — from medical to political to funding issues.

RHAPThe Reproductive Health Access Project “seeks to ensure that women and teens at every socioeconomic level can readily obtain birth control and abortion from their own primary care clinician.” Their site has invaluable resources, from contraception info to miscarriage management to tools to help primary pare providers integrate comprehensive reproductive healthcare into their practice.

Backline, Connect & Breathe, and Exhale are all terrific organizations dedicated to providing options counseling and pro-choice, affirming post-abortion counseling.

Bedsider is a pretty hip, patient-centered site for helping people find the right birth control method.

It may not be the best place to work, but Planned Parenthood is still the best and biggest organization nationally providing evidence-based family planning services. Their site has lots of great health info.

The University of Chicago recently unveiled the guide Accessing Abortion in Illinois, which provides a very holistic approach “to help health and social service providers advise pregnant persons who may be seeking abortion care in Illinois.” Rad!

Pre-Conception & Fertility Promotion

CDC at it again — here’s a pretty old but still useful guide on improving preconception care as a public health concern.

Loads of stuff on planning pregnancy. March of Dimes has this stuff on their website on pregnancy planning, but no great stuff you can print (or integrate into your electronic medical record handouts).

I don’t know much about this organization, but Attain Fertility seems to have some good stuff for helping people get pregnant and info on IVF and fertility treatments.

I found this resource list that seems pretty comprehensive, including transgender parenting, same sex parents, and single parenting by choice. Nice!

Before & BeyondBefore, Between, and Beyond is “the national preconception curriculum and resource guide for clinicians.”

Every Woman California is a public health initiative in that state with resources on preconception heath that may be useful to folks in other areas.

Pregnancy

More goodness from the CDC. Links to pre-conception, contraception, pregnancy itselfpostpartum, and even basic infertility care and resources.

And from a different government agency (why are there so many?) through US Department of Health & Human Services, there’s this resource, with same topic areas covering pregnancy.

Childbirth ConnectionChildbirth Connection has almost 100 year old roots in being a resource for mamas in the US. This site is at a higher literacy level than many of my patients, so I mainly use this for my own reference on pregnancy, prenatal care, labor and birth issues, postpartum, and lactation. Others may find its utility as a direct patient resource. Fantastic, pro-woman, pro-midwifery organization and site.

Mother To Baby has a great collection of patient handouts on medication use in pregnancy that I frequently use. English & Spanish! They will also personally answer your clinical questions about drugs in pregnancy for stuff that’s not on the website. They also have evidence-based fact sheets on illicit drug use in pregnancy, but so far only cover three.

This is a patient worksheet you can use at the 6 week postpartum checkup, brought to you by our friends over at ARHP.

Woah! This app looks pretty cool — for mamas to trace embryonic and fetal development.

Some Sites for Continuing Medical Education

ARHQ sponsors some great, free, evidence-based CME activities on disease prevention and care management that you can find here.

More goodies from ARHP can be found in these Clinical Minute activities on family planning issues. They also have great webinars that may draw from their annual Reproductive Health conference content. As if that wasn’t enough, they also have CORE for additional repro health curricula.

Before, Between, & Beyond has CME on preconception topics.

Medications

I often use GoodRx.com to find drug discounts and coupons for uninsured patients. The site can text or email the coupon to the patient. You just have to find out which pharmacy they want to use.

Target and Walmart both have cheap generic medications available. If patient is uninsured, try to prescribe drugs off these lists and explain why you recommend filling the script at those stores.

ARHPedia_logoARHPedia (sound familiar?) is another source through ARHP: “the comprehensive source for resources on pharmaceutical products,” including coupons/samples/vouchers, patient education, patient assistance, and more.