Tag Archives: Dear Dr Pate

Got a question? I’ll do my best to answer. Please note that it may take me several months to formally reply given my crazy resident schedule. When published, I will remove all personal identifiers to maintain your privacy.

We do NOT want to cut your beautiful baby boy!

IMG_5505Dear Dr Pate,

I’m a third-year medical student who is strongly considering going into OBGYN. Unfortunately, I’ve been really dismayed to discover how common it is for OBGYN residency programs to require their residents to perform circumcisions. I’ve begun to worry that my moral opposition to circumcision might be incompatible with going into OBGYN. I don’t want to get into a situation where I might be fired if I don’t perform circumcisions because I would rather get fired–and if that’s the case then why go into that field in the first place. I started to google about the topic and your blog was one of the first to come up.

Do you have any advice for a student in my situation? Should I try to seek out OBGYN residency programs that don’t require residents to circumcise? Should I just match into OBGYN and then refuse once I already have the job (can I be fired for that?).

Thanks,
MS3


Dear MS3,

Thanks for writing! I find it so refreshing to hear more and more from students, such as yourself, who desire to refrain from performing circumcision. Clearly you are not alone but tradition is deeply engrained in culture and deviation therefrom is considered illogical and threatening. If you are interested in OB/GYN, don’t worry about circumcisions. I wouldn’t even bother mentioning it in your interviews — it falls under the same legal protection as beliefs about abortion.

I encourage you to check out my post — Do medical students have to assist circumcisions? There are links to resources available to you. Hold you head high! Where there is a will there is a way. You don’t have to compromise yourself.

Some will tell you that refraining will limit your career opportunities. It is true that some jobs will try to push you. You can take either approach — put it out there so that potential problems will fall away before you become too invested or discuss it after the fact and assert your rights.

I chose to be proud and loud throughout my process; I stirred controversy and rocked the boat. This did result in expected consequences and more than a few blows to my ego however it was the right path for me. At least one attending physician and another resident refuse to do circumcisions because of my example. And that, for me, made the pain and suffering worth it.

And I have not been pushed aside by all employers as I was warned. One recruiter even told me that I didn’t have a chance landing a job in a major city. I dropped him like a rock. Instead I have joined a phenomenal group practice in a very coveted location just 20 minutes north of Manhattan.

So my advice to you is this: Follow the path that feels right for you and do not fear the obstacles that you will find. Be true to yourself and work hard and your path will continue to unfold before you. Keep your eyes on that path and drop the rocks!

Sincerely,
James Pate, MD
http://JamesPateMD.com

Care of the prematurely retracted foreskin

Dear Dr Pate,

I’ve read some of your (awesome) posts and have a random question I’m hoping you can answer! :) I know of a mom whose son was forcibly retracted when he was 7 months old. Unfortunately, she was told that after that point, she needed to continue doing it, which she did for another year following that incident. Now she knows that was wrong. The problem is that he’s fully retractible now (even though not “naturally” so), and she doesn’t know if she should continue asking him to retract himself to clean it (as she would a naturally retractible child), or not. He’s only 2 years old, and resistant to doing so. I’m inclined to say leave it alone and that just soaking in the bath will be good enough, but wanted to double-check. If he doesn’t retract to clean, would it encourage adhesions or infection?


Dear KD,

Thank you for your kind comments and your excellent question! I am inclined to tell her to leave it alone as well given that kiddos do not have the same amount of body secretions as teens and adults. Likewise, I can’t image that other cultures around the world pay even a 10th of the interest in either the excision or maintenance of the foreskin as we do in the U.S. Do little girls really need to be taught anything more to wash briefly in the tub? The same should apply to little boys. However, I am not a pediatrician so I asked my colleagues for their opinions which follow below. Best of luck to the little tyke and thanks again for writing.

Sincerely,

James Pate, MD
http://jamespatemd.com


I agree with you and would have advised the same. If he is resistant to retraction, I would leave it alone. It may re-adhere, but I would imagine that it will detach over time without undue intervention despite the earlier forcible retraction. If not, he can use steroid cream if indicated. I don’t see it becoming infected.

On the other hand he may become more amenable to retraction and cleaning in the coming months which would make it a non-issue. He may be objecting because he’s two years old. But I see no reason to compel him to do something he doesn’t want to do at this time.
―Dr Paula Brinkley, pediatrician


I just wanted to assure you that your advice was just right! We need not retract the eyelid to wash under it, and mucous membrane will keep adjacent tissues from adhering one to the other. In most non-circumcising countries, from what men have told me, they often are taught little and generally figure out hygiene on their own. If they are told something, it’s usually around puberty, probably when secondary sex hormones are produced.

We don’t teach girls to pull their prepuce back to wash under it and we don’t put Q-tips or anything else into their vaginas to wash them. The body is self-cleaning. And, little boys need a normal sense of unconcerned boyhood. The baby’s objections to having his foreskin messed with is the message to which everyone should listen.

There are three great articles that you might find helpful at http://www.nocirc.org/articles. They are:

―Marilyn Milos, RN, Executive Director, National Organization of Circumcision Information Resource Centers (NOCIRC)


In my opinion, you don’t have to be a pediatrician to answer this question – most pediatricians don’t know anything about taking care of the foreskin anyway! – so I’m going to offer my own take on this.

There are no controlled studies on correct care of the intact penis, so the best we have to go on is a good understanding of the structure and development of the foreskin, plus common sense.

The few studies that I know of that looked at retractability, foreskin hygiene, and outcomes are so methodologically problematic and ignorant of the natural development of the foreskin as to be completely worthless guides (Kalcev 1964, Krueger and Osborn, 1986).

Most of the “literature” on care of the intact penis are merely opinion pieces. One would hope that this “opinion” would be based on a solid knowledge of the development of the intact penis, and/or extensive experience in conservative care of the intact penis, but unfortunately this is not the case, as we all know, and there is a lot of mistaken and potentially harmful advice given.

“I did an inservice on care of the intact penis 6+ years ago where I dug up as much literature on it as I could (17 articles, 2 of which were from CIRP and NOCIRC). I am attaching a summary of some of the advice from these handouts that I posted at Mothering.com some years back, plus some additional quotes that support the idea of “leave it alone”.

Here’s the general consensus from these handouts:

  • If the FS is non-retractable, no matter how old the boy is, all that need be done is to wash off the outside. PERIOD.
  • Once the FS is retractable AND the boy is developmentally able (generally have the motor dexterity and ability to follow instructions by about age 4-5), he can be taught to retract, rinse, replace. [Note, this makes the idea of requesting a 2 year old to retract and clean himself seem pretty pointless.]

Sources that specifically mention frequency suggest:

  • In childhood: this rinsing might be done say only “occasionally”
  • By puberty: more “regular”, or “daily” rinsing is suggested

Although some older articles will recommend that parents retract the child (based, I believe on a preconception of the foreskin as problematic, and ignorance of the natural development of the intact penis), most do NOT say this, and a number do support the idea of leaving it alone (see my Mothering post attachment). In fact there is one great quote from Canadian pediatric urologist Peter Anderson stating that “there’s no evidence there’s any need to clean under the foreskin before puberty.”

Remember that the foreskin is designed to keep the ooky stuff out (tight outlet in childhood, sphincter-like action of the peripenic muscle), and that it is flushed outward multiple times a day with sterile urine, thus keeping itself clean.

As a John Geisheker likes to point out, “Our primate predecessors were unlikely to head down to a nearby river every day to scrub their children’s genitals. Nature would quickly eliminate those who needed such care. Only those tough enough to not require genital cleansing would have survived. We are those survivors. … Mid-19th century English-speaking boys and girls did not suddenly require aggressive genital hygiene when their ancestors, for hundreds of generations, survived nicely on benign neglect.”

If this 2-year-old is resistant to having his foreskin retracted, by all means, leave it alone! It is unnecessary from a hygiene point of view, and could be more psychologically distressing than its worth. He will discover the joys of retracting himself when he’s ready and interested himself. In the meantime, it is quite possible that just playing with his penis in clean tub water might be all the cleaning needed. Since the average age to full retractability is somewhere are age 10, I would encourage this young mom to sit back, respect her son’s own time table and emotional boundaries, and just let nature take its course.

―Gillian Longley RN, BSN, MSS, Colorado NOCIRC


Rather than re-invent the wheel and write a longish, potentially unwelcome, or over-obvious email, I am attaching several articles we at DOC wrote for Psychology Today magazine on this very issue.

The short answer, (which I suspect you know instinctively), is that urine is sterile and the boy-child is ‘washed’ at each urination. The notion that intact (not C’d) boys need special hygiene is an invented one of Anglophone origin, its sources easily traced to the mid 19th century, a time of great anxiety about masturbation (even among toddlers) as a source of disease. This was before Koch (1879) and others identified pathogens.

In evolutionary terms, the notion that boys need special genital hygiene makes no sense. Our primate ancestors were likely far more concerned with foraging for food and finding a safe place to sleep each night. There was no time or motive to scrub the genitalia of their offspring (and my primatologist neighbor tells me no such behavior has ever been seen in the wild).

We are their descendants who never needed any such care. The infant vulva and infant penis, like the infant eyes and mouth, are self-defending and self-cleaning. It could hardly be otherwise.

―John V. Geisheker, J.D., LL.M. Executive Director, General Counsel, Doctors Opposing Circumcision (D.O.C.)

Do medical students have to assist circumcisions?

Dear Dr Pate,

I am a 2nd year medical student that will be starting rotations soon. Coming across your website, I noticed you were an intactivist OB/Gyn. I am also an intactivist and realize there will be many procirc doctors with crazy mindsets. It is expected that there will be issues with doctors when I refuse to help with this operation.

Do you have any advice for me at this point?
Do you get a lot of resistance to your views and how do you deal with it?

I read through your blog briefly, there are some interesting things contained there. Thank You!


Dear P,

Thanks for writing! You absolutely have the right to refuse to participate in any way of the circumcision process including offering the procedure to new parents when you round on patients, discussing it with interested parents who bring up the topic, consenting parents for the procedure, observing and performing circumcisions. Check out the pamphlet Conscientious Objection to the Performance of Non-therapeutic Circumcision of Children: A guidance for healthcare providers from Doctors Opposing Circumcision. You will likely get some flack, but it is absolutely worth it. I have blogged quite a bit about experiences with my residency program regarding the subject. Senior residents in particular were not happy with my stance given that they then “had to do my work”. Whatever. No one can make you do anything you are morally opposed to. Check out the links on my website for information about intactivist organizations. There are a LOT of resources for you and for the parents you will come in contact with. Thanks for your willingness to stand up for personal autonomy and “do no harm.” Feel free to write again at anytime. Good luck!

Sincerely,

James Pate, MD
http://jamespatemd.com

Am I intersexed?

Dear Dr Pate,

I was born with a DSD. Is penoscrotal hypospadias with severe chordee an intersex condition? Am I intersexed?


Dear J,

Your questions are more difficult to answer than one would think. The term “intersex” has changed in meaning over time, more so among doctors than perhaps many who consider themselves to be intersex. From a medical point of view, your condition would not necessarily have been considered an intersex disorder in the past. However, an international consensus reclassified disorders with either abnormal sex chromosomes (ie XO, XXY) or atypical genitalia under the umbrella term “disorders of sex development” (DSD) in 2006. Given that hypospadias is a condition where development of male external genitalia is halted prematurely, this is indeed a DSD. The term “intersex” however is no longer considered to be a contemporary medical word and has been replaced by DSD.

Adults who consider themselves to be intersex generally have a history of ambiguous genitalia, may or may not have been subjected to “normalizing” genital surgeries in infancy and/or childhood, but do not feel that they fit neatly into the binary boxes of male or female. They usually feel that if surgery occurred that it was undesired and destructive. Their gender identity may be the same as their sex of rearing, opposite, a combination, or something else. Adults who identify as intersex are generally offended by the new medical nomenclature “DSD”; they do not feel that their sex is disordered but rather a natural occurrence within the human spectrum. They are also quick to point out that they are not transgender or transsexual and do not feel that they are a part of those communities. Unlike the trans communities, they feel that their gender identities match(ed) their bodies, though they may not match their surgically altered bodies nor the sex of rearing that was chosen for them. The intersex community is still rather small given the shame, embarrassment and mistreatment individuals were subjected to while growing up as well as the continued ignorance of society regarding their existence.

People that continue to be born with chromosome abnormalities and/or varying degrees of genital ambiguity may feel that they are either truly male or truly female with a DSD medical condition, not intersexed. On the other hand, if their gender identity is the opposite of their sex of rearing then they may consider themselves to be trans. Others feel more comfortable with an intersex identity. Thus the matter of what is considered an intersex condition and who considers themselves to be intersex remains quite murky.

There are intersex groups that exist online and occasionally meet in person. If you are interested in chatting with others like you I would recommend checking out Organisation Intersex International (OII). They are “devoted to systemic change to end the fear, shame, secrecy and stigma experienced by children and adults through the practice of non-consensual normalisation treatments for people born with atypical anatomy, and the arbitrary assignment of a particular gender without an informed consultation with the individual concerned.”

Hope this helps and good luck to you. Happy holidays!

Sincerely,

James Pate, MD
http://jamespatemd.com/

Testosterone and autism

Dear Dr Pate,

My name is M, a cisgender gay man, and I am married to Y, a transgender gay man. Y has currently stopped his testosterone shots after 3 years, and we are planning a pregnancy in the near future.

I came across your name in your blog, and in several posts made by transman who are in a similar position to me and my partner. I was hoping you could assist us with our major  questions, since we live in Israel, and most MD’s, OBGYN’s and other medical personnel here do not have any experience with transman fertility and pregnancy.

Since Y’s period has returned very quickly (after only one month without testosterone), our major concern at this time is on the prospect of having a healthy baby after 3 years of high-dosage testosterone treatment (250mg every 2/3 weeks). We have come across several stories of transman who got pregnant after using testosterone for some time, and there seems to be a high percentage of autistic children born that way (3/4 out of 8 stories we found, with the rest all under 3 years old – so we assume no conclusive diagnosis could be reached). In addition, we could not find any information about the effects testosterone usage has on the ova, and the chances it could cause mutations or other problems (since Y did not have a period for almost 3 years).

Do you have any information regarding these issues that we bring to our doctors for consultation? Any assistance would be appreciated, since we are currently considering giving up on the pregnancy because of that…

Thank you very much for your help :)


Dear M,

Thank you for your excellent questions. Congratulations also on your plans to become fathers. Being a father changes you for the better and I am so grateful to be one myself.

I have identified the the following questions from your letter:

  1. What is the prospect of having a healthy baby after 3 years of high-dosage testosterone treatment?
  2. Is there an increased risk of having an autistic child as a result of prior testosterone use?
  3. What are the effects of testosterone on the ova (egg cells in the ovaries)? Can it cause mutations or other negative problems?

Your question about the relationship between testosterone and autism is complicated in that the diagnostic criteria has changed over time, its cause is unknown and there is no published data on transmen who father children much less those who father autistic children. That said, I have scoured the literature and will do my best to answer your questions to the limits of current scientific findings. I will do this in two ways. In “Short & Sweet” I will answer your questions as succinctly as possible and “Nitty Gritty” will probably give you more info than you care to know. All references will follow below. Thanks again for writing and good luck to you as you plan to enlarge your family.

Sincerely,

James Pate, MD
http://jamespatemd.com/


SHORT & SWEET

1. What is the prospect of having a healthy baby after 3 years of high-dosage testosterone treatment?

The most important determinants in whether or not you will have a healthy baby are the age of the ovaries, genetic predispositions, drug exposures and healthy living.

DNA is packaged into chromosomes of which humans have 46, 23 from each parent. Each chromosome has thousands of genes which form the blueprint for making and sustaining life. Unlike sperm, eggs have a long shelf life and do not get replaced when they run out. Babies with ovaries already have all the eggs their body will ever have. As they age their eggs age too and the risk for chromosomal errors continues to climb. The most common chromosome error is Down Syndrome and is a result of having an extra chromosome #21. While the risk for having a child with Down Syndrome is only 1 in 1667 for a 20 year-old, this risk rises to 1 in 385 for a 35 year-old and 1 in 106 for a 40 year-old.

We all have 2 copies of our genes. Many of us carry mutant copies that are compensated by having paired normal genes that can do all the work necessary. Individuals with 2 mutant genes will have disease, such as Tay-Sachs, cystic fibrosis or sickle cell anemia. These disorders are called recessive because you must have 2 bad genes for disease to be present. Some genes are so essential that you need to have 2 working copies to prevent disease. These disorders are called dominant because you only need 1 bad gene to have the disease. Examples of this are Huntington Disease and neurofibromatosis. The best way to find out if you have an increased risk of having a child with a genetic disease is to see a genetic counselor who will help you to review your family tree and calculate your unique risk.

Drugs including alcohol, nicotine, street drugs and pharmaceutical drugs can all impact the health of a developing baby. As much of the fetal organ formation occurs within the first 3 months of pregnancy, it is very important to stop smoking, drinking and using recreational drugs prior to becoming pregnant. You should also start taking a prenatal vitamin with extra folate (aka folic acid) and review your medications with your doctor.

Both testosterone and estrogen are present in all humans in varying amounts. They are very similar structurally and can be readily converted from one to the other by a single enzyme, aromatase. Depending on which type of testosterone you are using, it can take as long as 6 weeks for your body to get rid of it.  The major risk to a pregnancy with elevated levels of androgens like testosterone is the masculinization of a baby’s female external genitalia and brain with potential social, sexual and gender identity consequences. The effect on males appears to be blunted as male fetuses are able to compensate and maintain their total testosterone exposure within normal limits. In conclusion, testosterone should be discontinued at least 6 weeks prior to pregnancy in order to prevent its negative effects on a potentially female fetus.

2. Is there an increased risk of having an autistic child as a result of prior testosterone use?

The cause of autism remains unknown and there is no evidence to suggest that prior testosterone use increases your risk for having a child with autism. However, there have been some interesting findings that may implicate continuous exposure of elevated testosterone levels as a factor in its development.

First of all, let’s review some facts about autism. Autism is a clinical diagnosis given to a child after evaluation by a physician if s/he meets criteria however there is no blood or genetic test to confirm or refute a diagnosis. The definition of autism has changed over time and is now felt to be a part of spectrum. Current thinking is to place the typical female brain on one end of the spectrum, the typical male brain in the middle, Asperger syndrome next and autism on the other end. Thus autism can be thought of as an “extreme male brain” disorder. Evidence to support this includes the fact that autism effects 4 boys to every girl and Asperger syndrome is 8 to 1. Additionally women with congenital adrenal hyperplasia, who were exposed to elevated prenatal levels of androgens, have increased autistic traits. However, high levels of prenatal testosterone alone does NOT invariably result in autism.

3. What are the effects of testosterone on the ova (egg cells in the ovaries)? Can it cause mutations or other negative problems?

Testosterone is not known to cause mutations in egg cells. High levels of circulating androgens have been associated with polycystic ovarian syndrome (PCOS), infertility and cancers of the breast, ovary and uterus.


NITTY GRITTY

Autism spectrum disorders (ASD)

  • Prevalence is 1 in 100 to 200 people.
  • The typical female has a strong desire to empathize (to identify and respond appropriately to another person’s emotions and thoughts).
  • The typical male has a strong desire to systemize (to analyze and construct rule-based systems).
  • Individuals with ASD have a stronger desire to systemize than to empathize.
  • Autism
    • Impaired communication.
    • Impaired reciprocal social interaction and formation of social relationships.
    • Repetitive stereotyped patterns of behaviors and unusually narrow interests.
    • Diagnosis is difficult to make before 18 months of age and is usually made after age 3.
    • Sex ratio of 4:1 (male to female).
    • Worldwide prevalence is 4 to 58.7 per 10,000.
    • Between 6-10% of children with autism have a medical condition that may have led to autism. Medical conditions associated with autism are epilepsy, fragile X syndrome, tuberous sclerosis, cerebral palsy, phenylketonuria, neurofibromatosis, Down syndrome, congenital rubella and hearing and visual impairments.
    • Compared to the general population, women with autism have higher rates of PCOS, male-pattern body hair growth, bisexuality or asexuality, delayed onset of menses, irregular and painful menses, severe acne, tomboyism, gender identity disorder, transsexualism and family history of cancers of the breast, ovary, uterus and prostate.
  • Asperger syndrome
    • Introduced as a diagnosis in 1992.
    • Has normal IQ and does not have delayed language development.
    • Sex ratio of 9:1 (male to female).

Prenatal testosterone

  • Gestational week 6: the Sry gene on the Y chromosome initiates testicular differentiation of the fetal gonad.
  • Gestational week 8: Leydig cells of the testis are capable of testosterone synthesis.
  • Testosterone surges occur between weeks 8-24 of gestation (males 249 ng/dL and females 29 ng/dL) and between 0-6 months after birth (males 200 ng/dL) suggesting that these are the critical periods of hormonal influence. Testosterone surges again for males during puberty with levels 200-300 ng/dL.
  • In the brain
    • Affects the anatomy of the brain including the hypothalamus, limbic system and neocortex.
    • Permanently inhibits the growth of certain areas of the left hemisphere and facilitates the growth of the same areas in the right hemisphere in the developing fetus.
    • The human bed nucleus of the stria terminalis (BSTc) is sexually dimorphic in size and neuron number (larger in women than men). MTF individuals have BSTc comparable to cis-gendered females while FTMs compare with cis-gendered males.
  • 2D:4D finger ratio
    • Defined as the length of the 2nd digit (the pointer finger) divided by the length of the 4th digit (the ring finger). Measurements can be made from photocopies of the palm measuring from the proximal crease of the base of the finger to the fingertip.
    • It was recognized as sexually dimorphic (lower in men than in women) as early as the year 1888 and is purported to be a maker for prenatal androgen exposure.
    • Development of the bones of the hand are governed by the Hox/Homeobox genes which respond to androgens like testosterone. This process begins as early as the 9th week of gestation and becomes more marked with time. Relative finger growth may not be complete until adolescence.
    • Increased androgen exposure results in elongation of the 4th digit relative to the 2nd digit and thus a lower 2D:4D ratio.
    • Children with Asperger syndrome and autism have lower 2D:4D ratios than average, so thus families with lower 2D:4D ratios may have an increased risk for children with autism. However, high levels of prenatal testosterone does NOT invariably result in autism.
  • Polycystic ovarian syndrome (PCOS)
    • Associated with irregular or absent menstrual cycles, male-pattern body hair growth and hair loss, insulin resistance, diabetes and hypertension.
    • Affects 5-10% of women and is the most common endocrine disorder among women of reproductive age.
    • Animal studies have shown that prenatal exposure of excess androgens results in PCOS, insulin resistance (pre-diabetes) and hypertension.
    • Testosterone levels in umbilical vein blood of female infants born to mothers with PCOS are raised to male levels. Thus PCOS pregnancies have a hyperandrogenic in-utero environment.
    • FTM individuals have rates of PCOS twice as high as the general population.
    • Women with autism have higher rates of PCOS than the average population.
  • Congenital adrenal hyperplasia (CAH)
    • A genetic disorder that causes excess adrenal androgen production and results in varying degrees of virilization of external genitalia.
    • Incidence is 1 in 14,500 live births.
    • In general, girls exposed to high levels of prenatal androgens show
      • Male-typical childhood play including preference for boys’ toys.
      • Traits of autism including low measures of empathy and need for intimacy.
      • Male-typical interests as adolescents.
      • Little interest in infants, marriage, motherhood, “feminine” appearance.
      • Masculinization of performance in spatial orientation, visualization, targeting, personality and cognitive abilities.
      • 1/3 are lesbian, bisexual or queer.
      • 3-5% indicate a desire to live as males.
    • In general, CAH males
      • Resemble other males with respect to play patterns and interests.
      • Have normal prenatal androgen levels by inhibition of androgen production from the testes.
  • Complete androgen insensitivity syndrome (CAIS)
    • X-linked disorder (only affects genetic males).
    • Lack functional androgen receptors.
    • Genetic males are phenotypically female.
    • Share the same sex-typed behaviors, gender identity and sexual orientation as genetic women.
    • Prevalence is 1 in 20,000 to 1 in 60,000 live genetic male births.
  • Genetic males with congenital ambiguous genitalia
    • May be surgically assigned to female sex at birth.
    • Have more male-typical play patterns and interests than control girls.
    • Girls with prenatal exposure to synthetic sex hormones
    • More likely to exhibit male-typical childhood play, behavior and interests.
    • More likely to report use of physical aggression in conflict situations.

Discrimination against LGBTQI parenting

  • There is no evidence to suggest that LGBTQI individuals are inherently incompetent to parent nor is there evidence of harm to offspring.
  • In 2006 the American Society for Reproductive Medicine (ASRM) issued an ethics advisory that urged its members to not discriminate against patients by sexual orientation.
  • In 2008 the California Supreme Court found that a fertility clinic had violated the state’s anti-discrimination law by refusing to inseminate a lesbian patient.
  • The American Medical Association (AMA) rejects health insurance discrimination based on gender identity and recommends that insurers cover the treatment of Gender Identity Disorder (GID).

What to expect from your providers

  • Proper noun and pronoun usage (ie “dad” not “mom”, “what are your plans for feeding the baby?” not “will you breastfeed?”).
  • A review of privacy issues and/or creation of a formal policies when warranted
  • No information provided over the phone.
  • Written medical records kept in the patient’s room.
  • Aliases for patient and baby if requested.
  • The public relations dept should be the media’s only contact.
  • Security officer to prevent unauthorized entry or to provide escort services.
  • Additional staffing if needed.
  • Transfer family to another unit if desired.
  • Lactation support for either parent if desired.

Possible future reproductive technologies for LGBTQI individuals

  • Male pregnancy could theoretically occur if the embryo implants on the intestine as this has indeed occurred in a few women.
  • Researchers have transplanted vagina-uterus-ovary units in rats however there has not been a successful similar transplant in humans.

REFERENCES

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  • Auyeung B. Baron-Cohen S. Ashwin E. Knickmeyer R. Taylor K. Hackett G. Hines M. Fetal testosterone predicts sexually differentiated childhood behavior in girls and in boys. Psychological Science. 20(2):144-8, 2009 Feb.
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  • Manning JT. Baron-Cohen S. Wheelwright S. Sanders G. The 2nd to 4th digit ratio and autism. Developmental Medicine & Child Neurology. 43(3):160-4, 2001 Mar.
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