Attitudes and experiences of health care professionals when caring for transgender men undergoing fertility preservation by egg freezing: a qualitative study

Creating a direction

While the lectures from experts within psychiatry gave a medical understanding of the diagnosis, and what it may imply for the treatment in connection with FP, the lectures by representatives for transgender people gave an understanding of the transgender men’s experience of living with gender dysphoria. The HCPs described how the new knowledge helped them to understand the complexity of the diagnosis combined with the special needs arising with it. By gaining understanding, they felt that they were better prepared and could anticipate what to expect:

It is good to know how they [feel] because we don’t know how this patient group think. “Okay, they find this and that offensive. I had no idea about that!” And then we can adapt and strive to respect it as well. (HCP P12)

Even though the preparations mostly gave a positive direction, the lectures about the special needs in the patient group sometimes created apprehension even before meeting the patients, and after being told what to do or not to do some felt that their professional knowledge was being questioned. In knowing about potential pitfalls, the need to use certain language and to adapt to certain needs, some HCPs felt dismayed and even felt that it would have been better not to know about the special needs for fear of making an error:

The woman [from the LGBTQ organization] told us about what to expected, which made us quite horrified, I can say. Because it was so much you weren’t supposed to say, so many words one couldn’t use, and there were so many things we had to think about. So I think we felt quite nervous . . . it felt like “This will be tough.” (HCP P10)

The HCPs described how the formation of a smaller project group condensed knowledge, experience, situational awareness, and insight. This was especially important, as the patient group was relatively small by limiting the number of HCPs patients encountered, they created a sense of security for patients:

They become the specialists. [Do you think it’s good for the patients that there are only few who have the responsibility?] I think so. They meet the rest of us when the treatment starts and it’s time to take out the eggs or via the phone and everything, but . . . Yes, I do think that it’s an advantage. [. . .] It’s hard for everyone to get all education and to go to all the courses. (HCP P6)

However, having a small project group was not uniquely positive, where some of the HCPs outside of the group felt excluded and that they had limited knowledge of what was going on. This sometimes created a problem as it was not always feasible to assign a specifically designated gynecologist or midwife to a patient coming for a visit, as the patient group grew quickly and more professionals became involved in their care.

Identifying learning needs

Over time, the HCPs identified learning needs that only became evident when they had met and cared for the transgender men. They felt that they had limited knowledge about the group’s situation when it came to mental health, such as problems with self-harm and suicidal behavior:

They have much higher . . . [. . .] suicidal tendencies and self-harm behaviours and things like that. It has become much more tangible [after meeting them at the clinic]. It might not change anything, but it would have been nice to have known about it in some way. (HCP P10)

The HCPs also called for practical knowledge about how to work with the group, such as what alternative words to use, or special needs in connection with FP. Most described how they had little knowledge about the next step following FP as they only had vague knowledge about the transgender men’s reproductive choices and legal rights. This made them feel inadequate when the transgender men asked questions about it. Also, many described how they felt uncertain about the need of FP for transgender men as a group, as they did not know how they could have any use for the frozen gametes:

I wonder how they’re intended to have children. In which constellation, it will happen. It’s very unclear, I think. Can it become a reality? [Do you want to know more so you can answer questions?] No, I think it’s more for my own sake [. . .] to be able to relate to this particular group. (HCP P1)

Reactions toward the group

The understanding of the patients’ situation gained by the accommodation of new knowledge, were often followed by feelings of empathy when meeting the patient group. The HCPs theoretical knowledge about transgender individuals’ situation in society and about gender dysphoria in general gave them an understanding of why some transgender men reacted as they did, when, for example, a wrong pronoun was used or when they underwent examination by transvaginal ultrasound.

I understand that it feels awkward to come here and do this, you know. Because clearly it’s really tough to get here and to awaken something they don’t want to acknowledge. (HCP P11)

The HCPs also described how the work with the transgender men had forced them to see what cis-normative and binary assumption they harbored, and mostly the HCPs described this as something being positive and refreshing. It had led to a reformulation of earlier knowledge and preconceptions:

It was an eye-opener in the beginning . . . that on some forms it was written “woman” and on other forms “man.” I think it was quite good, to be awakened. “Why is this so?” (HCP P11)

However, others expressed ambivalence toward the group. They found the new patient group as alien as the transgender men’s gender expressions were difficult to understand and made them feel uncomfortable. They understood that the transgender men had special needs but found it hard to handle the demands that were set as they sometimes found them unnecessary and needless, such as demanding gender-neutral toilets or paper forms:

They’re born in the wrong body, I can understand that. But one cannot both want something and at the same time not wanting it. [. . .] The person I talked with didn’t want to be reminded of being a woman [. . .] but the most important thing in life was to save these gametes in order to use them later. It was weird. (HCP P8)

The perceived strangeness of the new patient group combined with the limited knowledge about needs and expectations also gave rise to a fear of doing wrong, and they described how negative encounters had reinforced these fears, which in turn led to them trying to avoid the patient group.

He thought I was rude. [. . .] And I started to think about what I had said that was so sensitive. [. . .] And I remember how sad I was. . . it was like getting a cold shower. So in the end I became terrified to meet them. (HCP P2)

Seeking understanding

The HCPs were aware of their shortcomings and worked actively to improve their care of transgender men. However, they sought understanding of their shortcomings by pointing out that they were unexperienced, still had a lot to learn regarding gender dysphoria and the needs following it:

I don’t expect them to understand, but it can be really difficult for us who haven’t changed our sex . . . [. . .] You don’t do it out of spite [use the wrong words]. And it’s not because you think you can say things because you always have done so . . . it’s more about that one really don’t have the knowledge or experience. (HCP P8)

The HCPs also sought understanding for sometimes using the wrong name or pronoun. They explained that it was especially hard to say the right thing when they did not experience the patient’s gender expression as masculine. However, even if the patient had what they read as a more masculine gender expression, it was easy to slip and to use the pronoun she when the transgender men were in situations that the HCP perceived as feminine, such as when the transgender men were lying in the examination chair in lithotomy position or during transvaginal ultrasounds:

It’s sensitive what you call them [. . .] If they haven’t changed their appearance, and have so far only decided to change their sex but still looks feminine, it’s easy to slip and say something that’s not gender neutral. (HCP P13)

The HCPs described how they spontaneously talked with other colleagues about their experiences of the new patient group. Nevertheless, some called for more organized meetings as they felt a need for discussing negative experiences of caring for the patient group. However, unspoken demands on professionalism hindered them from talking with their colleagues about their qualms when caring for the patients as they were afraid of being judged:

I didn’t dare to tell about it [that I found the group difficult]. And I felt that I might be alone thinking like this, “Maybe it’s something wrong with me.” [. . .] So I raised this issue [. . .] and it turned out that everyone had pretty much the same experience. And it was such a relief. [. . .] I just needed to hear someone else say “Yes, but that’s not strange that you feel so.” [. . .] Actually, it was so little that was needed. (HCP P8)

Adjusting examinations

In the clinical work with transgender patients, some of the HCPs stated that they did not change any routines when it came to the examinations. They described that they were always careful and responsive to all patients and did not feel that the transgender men had different needs. Others, however, described how they perceived the transgender men being tense and more worried than other patients. The HCP knew that some transgender men had never undergone pelvic examinations before, and some had never had receptive/penetrating sex. Also, the knowledge about possible gender dysphoria motivated them to act differently when caring for the transgender men. Some discussed the examination beforehand in order to obtain information about the patients’ preferences, for example if they wanted the HCP to show on the monitor during the transvaginal ultrasound or not:

I thought it was easier to learn from patients. Actually, saying to them “I don’t really know what you want me to say, but let’s figure it out together.” That one is honest towards the patient. (HCP P11)

However, most HCPs described a silent responsiveness as they worked toward being extra sensitive to the patient’s reactions and signals during the examinations. They covered the transgender man’s genital area in order to guard their integrity, slowed down the examination if the patient became tense, and prepared each movement by telling the man about it:

I have been caring for a few [transgender men] at the surgery [in connection with retrieval of oocytes], and it’s been distressing for them. One feels that they need extra support and extra privacy. . . I mean, you’re supposed to treat all patients [carefully], and we do that of course, but you are extra careful. (HCP P1)

Rethinking communication

A challenging part that was described in the encounter with the transgender men was the communication. The encounters made the HCPs aware of the gendered language and symbols that were used at the clinic, and they were forced to change already settled way in how to communicate about the procedures following FP. Some transgender men felt uncomfortable with gendered words and the HCPs tried to find new ways to communicate about the procedures, for example, by trying to find alternative words, such as gametes or bleeding instead of eggs and menstruation. However, as many of the words are not replaceable some of the HCPs described a restraining behavior in the way that they sometimes held back in their communication, as they were afraid of using the wrong words or the wrong pronoun:

I do not think it’s been more difficult [to do the examinations]. But one doesn’t talk so much in the meantime. [Do you think you talk less with them than you do with your regular patients?] Yes, I think so. [. . .] One is afraid that one would use the wrong words, and then it is better that you don’t say as much. (HCP P6)

An alternative way to handle the issue was to listen to the patient and hear what words the patients used. If the patients’ them-self used gendered words such as egg they also used the words, otherwise they used gender-neutral words such as gametes. Importantly, the clinic also adapted the electronic medical records system to enable identification of transgender patients. Through this HCPs involved in the care could be informed about the persons preferred name or if special attention was needed:

We ask “What name do you use?” And then we write it down, unless the midwives haven’t written it already. “Wants to be called . . .” and the name they have chosen. [. . .] By doing so you show respect. (HCP P12)

Also, paper forms given to patients caused problems in the beginning, as the clinic only had had cisgender patients previously and the forms were color coded—blue for cryopreservation of sperm and pink for cryopreservation oocytes. As the transgender men were scheduled to cryopreserve oocytes, they were given pink papers developed for this purpose. Before the clinic changed the color to green, some of the transgender men protested as they felt that the clinic wanted to assign them as females, as pink often symbolize femininity in many cultures:

They must experience this a much tougher than our usual patients, and they have probably been very nervous about coming here. And then we comes and hand out pink paper [. . .] One might think ‘Why, the color of the paper doesn’t matter!’ But they really do [feel that that it matters]. (HCP P3)

Another administrative problem that arose regarding communication was data systems connected to the FP procedures. The transgender men who came to the clinic to undergo FP were at different points in their transitions and sometimes they had already undergone change of legal sex. The Swedish personal identity numbers are binary and indicate a male or female sex in one of its digits. This raised problems when the cryopreserved oocytes should be registered—the electronic medical record system did not allow a male personal identity number to be tied with the registration of cryopreserved oocytes:

In the beginning we had problems with how to freeze eggs with a male personal identification number as only female numbers functioned in the system. Now we have changed it so that you can leave eggs with any personal identification number [. . .] It works, maybe not completely without hitches as the system is not perfect yet, but we constantly get suggestions for improvements. (HCP P12)