As a supplement to the main blog post which details the research and development process behind our Co-ParentPad, Georgie and Hannah have pulled together an up-to-date summary of the main discussions, developments and research which impact upon the accessibility of health and social care services for LGBTQI+ people in the world today.  We’ll endeavour to keep this blog post under regular rolling review, and will keep the date of any subsequent updates listed at the foot of the page.

Over the last 5-10 years, accessibility of health and social care services by LGBTQI+ people has become more publicly discussed and researched, highlighting many disparities for LGBTQI+ people in the world today.  One of the many areas of disparity is in relation to experiences of gynaecological, reproductive, fertility, conception and perinatal care and services.

The recent focus on addressing LGBTQI+ inequalities in health and social care access in the UK has been thanks to the consistent international campaigning of LGBTQI+ organisations and high-profile LGBTQI+ individuals and allies, as well as members of the LGBTQI+ community sharing and discussing their experiences more openly, via social media, films and documentaries.

The UK LGBTQI+ research, evidence and information landscape has therefore been changing rapidly throughout the time that the C0-ParentPad has been in development.  We’ve therefore needed to not only explore as much as possible of the existing shared experiences, information and research in the international public domain, but also keep up with the ongoing discussions, news and emerging information and research, too.

Some of the main developments that we’ve been monitoring are as follows…

Consultation on the reform of the Gender Recognition Act 2004

In July 2018, the UK Government published a consultation paper relating to reform of the Gender Recognition Act (GRA) 2004 in England and Wales, which threw trans and non-binary issues into the political spotlight. The consultation focused on the process for achieving legal recognition of an individual’s gender. One option on which views were sought was the removal of the requirement for a medical diagnosis, which drew a lot of negative attention towards the trans and non-binary community.

In the consultation paper, the Government stated that it wanted to make it easier for transgender people to achieve legal recognition. It also said that many transgender people feel that the current process is “overly intrusive, humiliating and administratively burdensome” [Ref 1 – p21], arguing that, “by requiring a diagnostic psychiatric report, the process perpetuates the outdated and false assumption that being trans is a mental illness” [Ref 1 – p21]. The Government also acknowledged that concerns were being raised about the potential implications of reform on the exceptions in the Equality Act 2010, associated with gender reassignment discrimination.

Following this, in September 2020, Liz Truss – then the Minister for Women and Equalities – made a ministerial statement and the Government Equalities Office published an Analysis Report of Consultation Responses by researchers at Nottingham Trent University.

Based on the consultation results, the statement shared that the Government had decided not to change the criteria in the GRA for legal recognition of gender, meaning that a system based upon self-declaration was not going to be introduced.  Liz Truss stated that “it is Government’s view that the balance struck in [the GRA] is correct, in that there are proper checks and balances in the system and also support for people who want to change their legal sex” [Ref 2]. The Government also confirmed, where it is a proportionate means of meeting a legitimate aim, that it would still be possible to exclude transgender people from single-sex services.

Whilst this was a disappointing outcome for the trans and non-binary community, the report did affirm the need to improve the process and experience transgender people have when applying for a Gender Recognition Certificate (GRC) (the official document which “shows that the holder has satisfied the criteria for legal recognition in their acquired gender… [so that] the holder’s gender becomes the acquired gender for all purposes” [Ref 1 – p7]), in order to make it “kinder and more straightforward” [Ref 2]. The Government still proposed changes to the GRC process that they believed would address the main concerns which transgender and non-binary people had expressed, and also said that it intended to improve access to healthcare for transgender people, who had reported that waiting lists at NHS gender clinics were too long.

References:

1. Reform of the Gender Recognition Act – Government Consultation: July 2018
2. Written Ministerial Statement: Response to the Gender Recognition Act (2004) Consultation: September 2020

ITEMS Research Project

In September 2020, the LGBT Foundation announced the commencement of a ground-breaking research project called the ITEMS (Improving Trans Experiences of Maternity Services) Project.  Commissioned by the Voluntary, Community and Social Enterprise Health and Wellbeing Alliance (VCSE HWA) and to be delivered in partnership with a steering group, the unique research project’s aim was to gain an insight into trans and non-binary experiences of perinatal services and to put forward recommendations for improvement.

Following the reporting of the Project’s initial findings at the TPATH Conference in July 2021 (see below), the final report was published in April 2022.

The survey had received 121 eligible responses, making it one of the largest studies of trans pregnancy, and the largest ever outside of the US. It has added to the growing evidence that the number of trans and non-binary people who become pregnant appears to be increasing and, given that the NHS does not consistently record trans or non-binary status in perinatal services (or, indeed, in any of its services), it is a unique and ground-breaking study of this community’s experiences.

The ITEMS report picks up on six key points relating to trans and non-binary people’s experiences of perinatal care, and makes a series of recommendations for all perinatal care providers, and the healthcare system in general, to act upon, which is in the early stages of implementation.  These core recommendations are:

1. Production of targeted information and support for trans and non-binary pregnant and birthing parents, which should be available in a range of formats. This targeted information should include:
   • support with planning the place of birth;
   • the availability of continuity of carer and the benefits of this;
   • choices around feeding; and
   • support with mental health during and after pregnancy.
2. Prioritising the use of inclusive language for each service user.
3. Proactively identifying and removing barriers faced by the trans and non-binary community when accessing maternity, neonatal and perinatal services, and communicating these improvements.
4. Provision of holistic and personalised care, which recognises and is tailored to address the specific health and wellbeing needs, for trans and non-binary people.  This should include a personalised care support plan (PCSP).
5. Proactive discussion by services with regards to taking a trauma-informed approach with trans and non-binary service users, explaining the support that is available.
6. Provision of and investment in training – that has been designed and delivered by trans and non-binary-led organisations or individuals – for every midwife and other clinician involved in perinatal care, to help support them in delivering gender-inclusive care.  There should also be training for service managers, commissioners and policymakers on the specific needs of trans and non-binary people accessing maternity, neonatal and perinatal services, and how they can work to address those needs within their professional capacity.

References:

1. LGBT Foundation News announcement re ITEMS research project launch: October 2020
2. LGBT Foundation News announcement re ITEMS research project report: April 2022
3. Trans + Non Binary Experiences of Maternity Services – Survey findings, report and recommendations: 2022

Gender Inclusion Policies and Gender Inclusive Language

In terms of language guidance for maternity services, the BMA has suggested the use of the phrase ‘pregnant people’ rather than ‘expectant mothers’, to recognise the fact that not all who have been pregnant or have given birth will identify as women [Ref 1 – p11].

In 2021, the Brighton & Sussex University Hospitals NHS Trust publicly announced and shared their gender inclusion policy in maternity care, which gives clear guidance to pregnancy care professions on how to care for LGBTQI+ service users. Their intention was to broaden “the language we use and… to support people who identify in a different way to feel the service includes and represents them.”  They acknowledged that the “vast majority of midwifery service users are women and we already have language in place they are comfortable with“, noting that this “is not changing, and we will continue to call them pregnant women and talk about breast feeding” but at the same time would add “to the language we use, and that people are comfortable with… [so as to ensure] we are providing individual care for every person.” [Ref 3 – p2].

Their Mission Statement document contains a helpful guide setting out suggestions for previous and new terms and examples, such as using the phrase ‘maternal or parental’ in place of simply ‘maternal’, and ‘mother or birthing parent’ to replace ‘mother’. They also provide suggestions of alternative ways to describe/refer to the co-parent or second biological parent, proposing ‘parent or co-parent’ rather than ‘father’ [Ref 3 – pp16-17].

The Trust’s Gender Inclusion Team continues to offer specialist care to LGBTQI+ parents and provides support and training to other medical professionals on how to care for LGBTQI+ people appropriately.

This concept of using a ‘gender additive’ approach to language was noted in a research paper published in the British Journal of Midwifery in April 2022, which examined 130 maternity websites for gender-inclusive language.  The websites were rated as being ‘fully inclusive’, ‘inclusive’ or ‘not inclusive’, with only 2.3% found to be ‘fully inclusive’.  69.2% were found to be using generally inclusive language, which adhered to the NHS Digital style guide, with the remaining 28.5% being found to use language that was not inclusive – such as referring to patients and/or maternity staff using she/her pronouns, and describing patients as ‘ladies’.

References:

1. BMA – A guide to effective communication: inclusive language in the workplace: 2016
2. University Hospitals Sussex NHS Foundation Trust Gender inclusion webpage
3. Gender Inclusive Language in Perinatal Services – Mission Statement and Rationale: December 2020
4. Gender inclusive language on public-facing maternity services websites in England: April 2022
5. NHS Digital – Content Style Guide: Inclusive content: Sex, gender and sexuality: September 2021

First International TPATH Conference

The Transgender Professional Association for Transgender Health (TPATH) held their first international conference – created by and for transgender people – at the end of July 2021. This interdisciplinary conference was organised with the intention of “creating opportunities for transgender and non-binary professionals engaged in transgender health, rights and activism to share their research and work“.

At this inaugural conference, a team from ITEMS presented the project’s initial findings.

Other information, media and academic research 

The good news is that there’s a growing body of research papers and research teams specialising into LGBTQI+ experiences of all aspects of fertility, conception and perinatal care and services.  Some of these include:

• Dr Mari Greenfield – a post-doctoral academic researcher in maternity care at King’s College London, as well as being a doula and birth activist – continues to publish papers on aspects of the perinatal experiences of LGBTQI+ people. She has also brought together, for the first time, academic and medical research about LGBTQI+ people’s experiences of conception, pregnancy, birth and the postnatal period in the form of a podcast. In each episode of Pride in Birth, Mari speaks with different researchers to discover what aspect of LGBTQI+ pregnancy they were researching, how they went about that research, and what they learnt;
• The Trans Pregnancy project at Leeds University: this project aims to explore the feelings, experiences and health care needs of transmasculine people (including trans men and non-binary individuals) who wish to or become pregnant.  Their website includes links to their published policy reviews and blog posts, as well as links to academic articles that their team have had published. There are also links to short films and trailers for documentaries about trans people, childbirth and parenthood, and other related academic research;
• The website of the breastfeeding support organisation, La Leche League GB, includes a specific webpage which provides Support for Transgender and Non-binary Parents. This page collates a whole range of information and links to other resources to support trans men, trans women and non-binary individuals who choose to breastfeed or chestfeed their babies;

In terms of media, some of the original families who were trailblazers in publicly documenting their LGBTQI+ parenthood journeys have since expanded their families and continued to champion trans and non-binary parent voices in 2021 and 2022. Freddy McConnell, whose 2019 ‘Seahorse‘ film which documented his experience of conceiving and being pregnant with his first child, gave birth to his second child in January 2022 and continues to write about LGBTQI+ parenting and legal issues, and Jake and Hannah Graf, who featured in the documentary ‘Our Baby: A Modern Miracle‘, have also recently welcomed their second child and continue to campaign together in support of trans and non-binary people (especially in relation to considering family planning as part of the current gender-affirming treatment or surgery process).

Similarly, research and general awareness raising is growing in terms of same-sex parents’ experiences of perinatal mental ill health. Whilst a lot of this is coming from other countries – especially the US – information can also be found via UK sources, including:

• an interview with Peter McGraith on the PaNDAS (PND Awareness and Support) Foundation website, discussing his experience of becoming a gay dad, including reflections on mental health struggles;
• an article by Katherine Walker in the NCT journal from March 2017 – What issues do lesbian co-mothers face in their transition to parenthood? – which not only considers the ways in which the perinatal experience might differ for same-sex couples preparing for birth and new parenthood, but also contains a list of resources and references for further reading;
• a dedicated webpage on the Mind mental health charity’s website – Postnatal depression and perinatal mental health – which considers the potential for partners to also experience mental health problems during the perinatal period;
• an article on the Institute of Health Visiting’s website, LGBTQ+ parent families and perinatal mental health, from June 2021; and
• of course, the growing number of LGBTQI+ organisations who include information, advice and/or support in relation to becoming a parent – such as the LGBT Foundation and LGBT Mummies.

All of these – and many more – are of course helping to raise awareness, broaden understanding and lead to change in practice, and we’re keen to continue our support of this in terms of ensuring that LGBTQI+ non-birthing parents have access to the same levels of help, advice and information as male dads in a heterosexual relationship now have.

Dates of review of this blog:

First published: 24 Feb 2022