User:Maralogan/sandbox

LGBTQ+ motherhood
LGBTQ+ or queer motherhood refers to the unique experiences of "parenting adults who identify themselves on a spectrum of gender and sexual identities."

Trans Motherhood
Transgender motherhood refers to the parenting relationship between a trans woman and her child. Like cis women, trans women can have biological or non-biological children, but what sets trans motherhood apart is the unique barriers many trans women face in becoming mothers.

Many trans parents utilize adoption or surrogacy as ways to have children, and research shows that trans individuals want to become parents at the "same rates as other LGBTQ+ people." Trans parents face the same issues as other queer parents (i.e. "cisgender sexual minorities") when trying to adopt, but often to a more extreme degree. Adoption agencies often refuse to work with trans and queer parents or are reluctant to do so.

Trans men may have biological children, and if they have not had a hysterectom y they may also carry and give birth to children. There is still much that is unknown about pregnancy for trans men, specifically around testosterone use during pregnancy. However, successful pregnancies and births have occurred for trans men who stopped testosterone during pregnancy, and for those who continued testosterone use as normal. There is currently no global medical consensus on testosterone use during pregnancy for trans men.

As pregnant men, an experience that is typically conceived of as "female," trans men may face additional discrimination socially, medically, and legally. "Mainstream assumptions of pregnancy and childbirth are often associated with cisgender (i.e. non-transgender) women’s experiences," and a lack of trans health education means medical professionals may be unaccustomed to and unprepared for supporting pregnant trans patients, contributing to the "discrimination, stigma, and erasure" trans individuals frequently face in medical settings.

Depending on the country, trans men may be legally listed as "mother" on their child's birth certificate because of their role as the birthing parent. The title of "mother" may be kept so the birthing parent can benefit from the legal and medical protections associated with biological motherhood, but in many cases trans men feel uncomfortable with the title because of its gendering as female. Trans men may then petition for legal recognization as the "father," "parent," or "gestational parent" of their child. In cases where their petitions are denied trans men may be a "father in life, but a mother under the law." However, there is a growing legal movement to recognize non-binary gender on birth certficates, and make legal forms of identification more gender-inclusive.

Trans women may also have biological children with a partner by utilizing their sperm to fertilize an egg and form an embryo. If they produce viable sperm—often not possible while taking estrogen because of the hormone's harmful effect on sperm production—this conception can occur through intercourse. However, many trans women choose to preserve fertility by "freezing" sperm through cryopreservation before or early on in their transition process, which can later be utilized by a "female partner or gestational carrier." Even with a biological conception of a child, trans parents may face stigma or discomfort from their healthcare provider, who are frequently not given comprehensive LGBTQ+ health education during medical school or residency. Trans women are also frequently not informed of their options to preserve fertility by healthcare providers, as a 2018 survey reported 51% of trans women wished they had preserved fertility, but only 3% actually did, while 97% believed fertility should be discussed prior to transition.

For trans women there is currently no accessible way to carry a child. However, research is being done on uterus transplants which could potentially allow trans women to carry and give birth to children through Caesarean section. As of March 2021 over 60 uterus transplants have been performed, with more than 18 women giving birth successfully post-transplant. Currently the procedure has only been performed on genetic females, karyotype=XX, and there is concern from the trans community about resistance to making the procedure available for trans women on religious and social grounds.

Representations of trans motherhood are becoming more prevalent in media, and can be found in books like "Detransition, Baby" and "The Argonauts", as well as TV shows like Transparent.

Potential topics:

 * OB/GY: Add section on LGBTQ+ friendly/inclusive care training for OB residents
 * OR add info on training in other countries
 * OR add info on OB/GYN certification in general
 * Healthcare & the LGBT Community: Add section on "importance of LGBTQ+ friendly providers"
 * OR under "healthcare education" add a section on OB/GYN training
 * Reproductive rights: Add LGBTQ+ Reproductive Rights section
 * Under issues add:
 * Healthcare Provider Bias
 * Access to health services

Potential sources:

United States
According to the American Board of Obstetrics and Gynecology (ABOG), which is responsible for issuing OB-GYN certifications in the United States, the first step to OB-GYN certification is completing medical school to receive an MD or DO degree. From there doctors must complete a four-year OB-GYN residency program approved by the Accreditation Council for Graduate Medical Education (ACGME). For the 2021 Electronic Residency Application Service (ERAS) match, there were 277 OB-GYN residency programs accepting applicants.

In their fourth year of residency, with an affidavit prom their director to confirm program completion, OB-GYN residents can choose whether to begin the board certification process by applying to take the ABOG Qualifying Exam, which is a written test. If residents pass the Qualifying Exam, demonstrating they possess the knowledge and skills to potentially become certified OB-GYNs, they are then eligible to sit for the oral Certification Exam. Prior to the Certification Exam, residents must also gather a list of patient cases they've worked on throughout their residency in order to demonstrate their competence and experience in OB-GYN patient care.

Residents then sit for the three-hour oral exam at ABOG's test center, and if they pass the exam they become "board certified" OB-GYNs. Since 2013 at least 82% of all Certifying Exam examinees have passed.

After completing medical school, one must complete a four-year residency program to be eligible to sit for boards.

For the ERAS match in 2017, there were 238 participating programs accepting applicants.

This adds up to 11–14 years of education and practical experience. The first 7–9 years are general medical training.

Experienced OB-GYN professionals can seek certifications in sub-specialty areas, including maternal and fetal medicine. See Fellowship (medicine).

United Kingdom
All doctors must first complete medical school and obtain a MBBS or equivalent certification. This portion typically takes five years. Following this, they are eligible for provisional registration with the General Medical Council.

Then they must complete a two years of foundation training. After the first year of training is complete, trainees are eligible for full registration with the General Medical Council. After the foundation training is complete applicants take the Part 1 MRCOG examination administered by the Royal College of Obstetricians and Gynaecologists. There are an additional seven years of training after this, and two more exams (Part 2 and Part 3 MRCOG exams) which adds up to nine years total minimum in training, although some trainees may take longer.

Inclusive approaches to care
There is no global standard, or national U.S. standard, for OB-GYN curricula, during or after residency. Hospitals and universities implement their care and provider education with different priorities in mind, some institutions focusing on following the requirements from their governing body while others go beyond the set standards to set a precedent with the care they offer.

However, the American College of Obstetrics and Gynecology (ACOG) encourages OB-GYN care providers to offer care that is inclusive to all individuals, in the context of providing a safe space for lesbian and bisexual women, and transgender and gender diverse individuals. ACOG shares this reccomendation through a series of Committee Opinions, the latest of which are #525 and #823, published 2012 and 2021 respectively. ACOG's first comment on the need for LGBTQ+ inclusive care from OB-GYNs came in 2011 through Committee Opinion #512, "Healthcare for Transgender Individuals", which has since been withdrawn and replaced by 2021 opinion #823.

ACOG recommends that OB-GYNs should:


 * Be a resource for both patients and families with health-oriented information on sexual orientation and gender issues
 * Provide gender-affirming surgeries if possible, and treat these procedures as medically necessary for patients with gender dysphoria
 * In the process of gender transition, fertility and parenting desires should be discussed early on, and patients should be offered all available information
 * Preventative screening procedures should be offered based on anatomical structures present, not gender identity
 * Create a structurally inclusive environment by making their offices "inviting to all individuals who need obstetric or gynecologic health care"
 * Educate all care providers and office personnel about LGBTQ+ health, including the use of inclusive language and the unique needs of LGBTQ+ patients
 * Post a nondiscrimination policy for the office in the reception area
 * Offer comprehensive patient education specific to LGBTQ+ individuals, like clarifying that gender hormone therapy is not a form of birth control

The need for LGBTQ+ affirming OB-GYNs
Transgender, nonbinary people, and lesbian or bisexual women frequently face additional challenges—including structural and overt discrimination, accessing insurance coverage stigma, and cisnormativity—when attempting to access gynecologic and reproductive healthcare services and providers. Obstetrics and gynecology is a field thought of as traditionally serving women because of it's focus on the female reproductive system, leading care providers to make assumptions about patients' gender identity and expression in "women's health clinics" when many transgender or nonbinary patients may also seek care from OB-GYNs. Additionally, LGBTQ+ patients are at risk for and experience unique health conditions which care providers may not be prepared to address—i.e. the providers lack cultural competence—without LGBTQ+ specific healthcare training.

Interactions with care providers who are not prepared or knowledgable enough to offer comprehensive and effective care can compound the "negative and traumatic experiences that many nonbinary and transgender people have had when accessing care", and drive them away from seeking necessary healthcare in the future. Even if transgender or nonbinary patients haven't had a personally negative of traumatic experience, collective trauma can also play into a fear of medical settings and providers. This results in nearly 25% of transgender or nonbinary people reporting avoidance of healthcare services out of fear of being mistreated for their gender. Care typically offered by OB-GYNs, like pelvic exams and procedures, can be "particularly difficult or traumatic" for transgender and nonbinary patients, which the provider can offset by engaging a trauma-informed care approach to exams.

More research is gradually being done to establish the need for an LGBTQ+ healthcare curriculum for all medical students, residents, and doctors. Multiple researchers have also suggested that obstetrics & gynecology is the ideal field for this education to initially be implemented, since the nature of OB-GYN work ties it more directly to gender than other medical specialties. OB-GYNs also historically have more cultural competency training around gender based issues.

Some common services LGBTQ+ folks may seek from OB-GYNs include:


 * Preventive services such as PAP smears
 * Contraceptive counseling
 * Treatment for gynecologic conditions
 * Support for family planning
 * Risk/harm reduction
 * Gender affirming surgeries like hysterectomies and oophorectomies

If providers are not educated on LGBTQ+ healthcare they won't be aware of some of the health risks LGBTQ+ patients may be more vulnerable too, placing their patients at greater risk. Common chronic diseases the LGBTQ+ population is at risk for:


 * Chronic anovulation and polycystic ovarian syndrome
 * Sexually transmitted infections including human papilloma virus (HPV) and human immunodeficiency virus (HIV) infections
 * Intimate partner violence
 * Substance abuse
 * Cancer (anal, breast, cervical, colon, endometrial and oropharyngeal)

Teaching LGBTQ+ healthcare
Most OB-GYN programs have a flexible curriculum that offers learning in a variety of contexts, including small group discussions, case study discussions, and structured patient exams. The multifaceted nature of this teaching structure makes it easier for programs to begin initiating LGBTQ+ healthcare instruction in informal voluntary contexts, while simultaneously advocating for long-term structural change that would incorporate LGBTQ+ healthcare into all OB-GYN and medical school curricula.

When initially instituting a LGBTQ+ healthcare curricula for OB-GYN residents or professionals, the Association of Professors of Gynecology and Obstetrics' (APGO) Undergraduate Medical Education Committee (UMEC) recommends that topics like patient education, screening standards, and common chronic diseases in the LGBTQ+ population are prioritized to ensure comprehensive and effective care for LGBTQ+ patients.

In Residency
APGO's UMCE poses that academic health centers are in an ideal position to drive the "curricular change that is needed to remove health disparities" for all patient populations in the LGBTQ+ community.

Although not a requirement within the ACGME's standards for American OB-GYN residency programs curriculum, LGBTQ+ healthcare education is established in some OB-GYN residency programs throughout America. A web-based survey of approximately 100 Illinois OB-GYN residents a survey study found that 62% of their programs had spent 1-5 hours in the past year educating residents about lesbian and bisexual health, and 63% of the their programs had spent 1-5 hours in the past year educating residents about transgender health.

APGO's UMEC identifies the third year of residency or "clerkship" as an ideal time to institute education if it hasn't already occurred, and ideally to reinforce competencies with LGBTQ+ patients through clinical experiences.

To Established OB-GYNs
In addition to instituting new educational policies for current and future OB-GYN residents, many programs are also looking to educate OB-GYNs that are already certified.

For example, the University of Michigan OB-GYN program utilizes what they name "Continuing Medical Education" to instruct their OB-GYN care providers on the nuances of caring for transgender patients. Daphna Strousma, MD, MPH, is responsible for instituting and developing UM's transgender healthcare curriculum—"Improving Care for Transgender & Non-Binary Individuals"—in coordination with Michigan Medicine and the Council on Resident Education in Obstetrics and Gynecology (CREOG). The curriculum is offered to UM's OB-GYNs through a series of video modules covering the following topics:


 * 1) Gender Identity and Care of Transgender and Gender Non-Conforming Patients
 * 2) Preventative Care for Transgender and Gender Non-Conforming Patients
 * 3) Gender Affirming Treatment & Transition Related Care
 * 4) Addressing Common Gynecologic Issues Among Transgender Patients
 * 5) Health Records, Billing, Insurance, and Legal Documents in Transgender Medicine

Challenges to instituting inclusive care
Although the ACOG has called upon OB-GYN care providers to provide gender-affirming and inclusive care for all individuals, that doesn't mean there hasn't been resistance, particularly because there is no formal legislation mandating the inclusion of LGBTQ+ healthcare in OB-GYN curricula.

Many OB-GYN providers do not currently feel comfortable offering care to LGBTQ+ patients, either because of their personal beliefs or due to a lack of education on LGBTQ+ healthcare. One study of approximately 100 Illinois OB-GYN residents found that 50% of residents felt unprepared to care for lesbian or bisexual patients, and 76% of residents felt unprepared to offer care to transgender patients. The two main areas the residents identified as preventing the implementation of LGBTQ+ healthcare training were curricular crowding, 85%, and lack of experienced faculty, 91%. However, 92% of residents wanted to receive more education on how to offer care to LGBTQ+ patients.