Medical uncertainty and reproduction of the “normal”

Written by Various on July 26, 2023. Posted in Current News

Sex hormones are often misunderstood as the dimorphic chemical building blocks of gender

The lessons that we can learn from medical authorities’ work to manage and regulate access and use of such hormones, however, suggests that the case is much more complicated.

Indeed, there is much to learn about gender, medicine, and biological and social reproduction if we are willing to ask different questions.

We find that the medical science around the potential effects of gestational parent testosterone therapy on fetal development in-utero or infant secondary exposure during the postpartum period (e.g., via chestfeeding/breastfeeding) remains nascent at best (Oberhelman-Eaton et al., 2021).

Previous research repeatedly demonstrates how ambiguity and uncertainty is associated with authority-(re)establishing practices that may either intentionally or inadvertently involve stigma, discrimination, and poor care (Doan & Grace, 2022; Freeman, 2015; Poteat et al., 2013; shuster, 2019, 2021) and gendered precautionary practices that work toward avoiding potential risk through protecting embryos, fetuses, children, and families above all else (MacKendrick, 2018; Waggoner, 2017).

In this context of medical ambiguity and uncertainty in the hyper-gendered context of pregnancy and lactation care, both health care providers and trans patients engaged in precautionary approaches that prioritized potential fetal and infant health and wellbeing (and imaginaries concerning future offspring’s normative development) over adult trans patient health (particularly mental health) and wellbeing in the present.

Health care providers also worked to dispense health care recommendations and edicts in ways that (re)established their expertise and authority. These precautionary and expertise/authority-(re)establishing approaches had the result of shoring up social constructions around binary conceptualizations of sex and sex hormones and was driven, in their explanations, by a focus on attempting to (re)produce normative bodies and people.

Considering the co-occurring uncertainty and epistemic authority of medical providers working with trans pregnant clients, who have primary control over dispensing prescriptions for hormone treatments and advice on their use in the context of pregnancy, is imperative when examining processes whereby trans people make decisions that weigh their own mental health and well-being against the potential health and well-being of their offspring.

Importantly, these processes do not occur within a social vacuum. As shuster (2019: 196) notes: “Underpinning trans medicine is the inescapable fact that providers are working within gender-specific medicine.

Gender normative expression becomes a lens through which providers make distinctions of ‘good’ and ‘bad’ patients.” As such, part of being a “good” pregnant or chestfeeding/breastfeeding patient, as a trans person, is suspending use of testosterone, even if it may involve significant negative consequences for one’s own mental health and well-being.

Part of being a “good” doctor, too, involves rule-following and precaution in the context of medical practice in order to meet expectations of professionalism.

As Timmermans and Almeling (2009:26) write:

“Any actual course of action should thus be viewed and studied as a locally situated accomplishment: rules are not simply pre-set abstractions but become part of working professionally.”

Indeed, few medical professionals receive comprehensive training on trans pregnancy care and are left to rely, instead, on standards and norms created with other groups or within other bureaucratized systems, underlining the importance of attending to interpersonal negotiations and structural competency in medical education and health care institutional contexts involving trans patients (Cruz, 2014; Kirkland, 2021; White Hughto, Reisner, & Pachankis, 2015; Willging et al., 2019).

The precautionary focus on the normative development of trans people’s offspring was shared among both patients and their providers.

The logics guiding current medical advice around precautionary testosterone cessation in pregnancy involve potentially troubling assessments of the sorts of risks testosterone exposure in the prenatal and postpartum environments may pose for later child and adult development: namely, potentially heightened likelihoods of autism, obesity, intersex conditions, being lesbian and/or trans.

In this way, precautionary practices of protecting the offspring of trans people become, paradoxically, a method of social control through safeguarding against reproduction of some of the very same characteristics held by some trans parents themselves.

It also raises the specter of panoptics of the womb and epistemic injustice as it simultaneously reflects elevation of the epistemic authority of medical professionals and erosion of the epistemic privilege of trans gestational parents (Freeman, 2015).

We also find that, despite relatively standard precautionary medical advice for trans people to stop or pause testosterone administration prior to conception, during the gestational period, and across the duration of chestfeeding/breastfeeding, there remains little empirical evidence guiding this advisement, particularly in the context of testosterone microdosing.

As shuster (2016, p. 321) notes:

“Much of trans medicine has been built on the assumption of binary genders …

[T]rans people’s understandings of their selves and bodies have become more fluid, and ‘cross’-gender transitioning is not always the ultimate goal.”

Indeed, future medical research might approach continuation of testosterone during pregnancy among trans people not as a binary yes/no question or a topic to approach for the purpose of developing one-size-fits-all medical standardization (Timmermans & Almeling, 2009), but one that investigates the potential impacts (on trans patients and their offspring) of continuing various dosages of testosterone across pregnancy.

In an interesting shift, the aforementioned “recommendations” against use of testosterone during pregnancy and chestfeeding in the current WPATH Standards of Care (Coleman et al., 2022) reflect a marked softening in language from the previous edition published a decade ago, which stated that “absolute contraindications to testosterone therapy include pregnancy” (Coleman et al., 2022, p. 45).

We can understand medicine’s refusal to consider the possibility of trans people continuing testosterone during pregnancy to be a striking example of what Paine (2018) has described as embodied disruption, “how patients’ embodied nonconformity to binary medical constructs disrupts ordinary medical interactions, and how provider reactions prevent GNC [gender non-conforming] patients from meeting their health needs” (p. 357).

We argue that health care providers’ precaution-focused labor in this highly-gendered context of pregnancy care seems driven largely by their concerns about producing normative offspring rather than non-normative gestating patients themselves (see also Waggoner, 2017).

Our work also reveals that these practices of biological and social (re)production are not solely the domain of women or those who are pregnant.

Drawing upon sociological theorizing around social control, normativity, risk, and precaution, in this work we further consider just what is at stake as health care providers and trans people interface, in the context of pregnancy, to make decisions around testosterone administration and use.

This case provides an opportunity to consider how these medically managed and often highly consequential decision-making processes emerge in a highly-gendered context of pregnancy care steeped in incomplete and conflicting empirical medical evidence.

Of particular focus in this work is the question: Which needs and whose well-being are protected (and challenged) as these decisions are made, and to what potential personal and social consequences?

Through working to consider alternate possibilities for current medical practices around the recommendation to precautionarily pause testosterone during pregnancy, there may be opportunities to develop health care practices for trans people that better meet their mental and physical health care needs using more tailored approaches.

Indeed, similar considerations have already been made when determining whether and how to use potentially-teratogenic medications to treat various physical and mental health issues among those who are pregnant (Angelotta & Wisner, 2017; Given et al., 2018).

As Timmermans and Almeling note:

“The point is not to presume stable and universal health care goals but to document who aims for what kind of outcomes under which circumstances and then to examine what kinds of actions are made possible to reach these goals” (2009:27).

This work aims to make room for further consideration of testosterone therapy during pregnancy for trans people, with a call to more fully consider their mental and physical health alongside predominant precautionary approaches for safeguarding the normativity of their offspring.

Doing so attends not only to the social control functions of working to prevent non-normative bodies and people, and the artificial binarization of sex and gender in medicine and society, but also that between mental and physical health as it insists upon increased attention to the mental health concerns and well-being experienced by trans people before, during, and after pregnancy.

Editor’s note: this is just the conclusion of the paper. To see the entire (very long) document, click here sciencedirect.com

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