This is the tragic story of Sam, a transgender man who went to the ER with classic indications of labor but suffered a stillbirth when the hospital refused to believe that he was pregnant.
In Wednesday’s New England Journal of Medicine in an article titled “The Power and Limits of Classification — A 32-Year-Old Man with Abdominal Pain,” it was revealed that ‘Sam’ in an undisclosed time and location, lost his baby due to the hospital’s delay in proper care.
“Sam reported an 8-hour history of severe (8 out of 10), intermittent lower abdominal pain. In triage, he had a blood pressure of 185/84 mm Hg and a heart rate of 67 beats per minute. The triage nurse noted that he was an obese man who appeared comfortable between bouts of pain. Sam told the nurse that he was a transgender man.”
By all accounts, Sam presents exceptionally well as a cisgender male.
“The triage nurse assessed him to be a man with abdominal pain who had not taken his prescribed blood-pressure medications. Determining that his condition was stable, she triaged him to nonurgent assessment. “
Several hours later the staff returned with his ultrasound and the serum hCG test giving undeniable evidence of pregnancy. Combined with his uncontrollable urge to urinate, convulsions and dilation, all conditions he was admitted with, they concluded he was in the final stages of childbirth.
But by then it was too late for Sam’s baby.
PodCast Interview with Dr. Daphna Stroumsa on the limitations of classification systems in health care and their potential effects on patients.
‘The point is not what’s happened to this particular individual but this is an example of what happens to transgender people interacting with the health care system,’ said the lead author, Dr. Daphna Stroumsa of the University of Michigan, Ann Arbor.
‘He was rightly classified as a man’ in the medical records and appears masculine, Stroumsa said. ‘But that classification threw us off from considering his actual medical needs.’
The New England Journal of Medicine article continues.
“In Sam’s evaluation, the triage nurse did not fully absorb the fact that he did not fit clearly into a binary classification system with mutually exclusive male and female categories. Though she had respectful intentions and nominally acknowledged the possibility of pregnancy by ordering a serum hCG test, she did not incorporate that possibility into the differential diagnosis in a way that would affect ensuing classifications and triage decision making. Despite communicating that he was transgender, Sam was not evaluated using pregnancy algorithms. Having no clear classificatory framework for making sense of a patient like Sam, the nurse deployed implicit assumptions about who can be pregnant[ ].”
“A cisgender woman (a woman whose gender identity corresponds to the sex she was assigned at birth) presenting similarly — with a remote or unknown last menstrual period, positive home pregnancy test, severe abdominal pain, hypertension, and large-volume clear discharge — would almost surely have been triaged and evaluated more urgently for pregnancy-related problems. If the woman was in early pregnancy, practitioners would have considered an ectopic pregnancy; beyond 20 weeks of pregnancy, the patient would have been directed to urgent obstetric evaluation for possible labor, rupture of membranes, placental abruption, and severe preeclampsia. Such evaluation would also have included assessment of the fetal heart rate. Sam should have received the same treatment. Instead, it was only after significant delay that a practitioner took a more detailed history and conducted a physical exam, revealing that Sam was in labor, with a cord prolapse. Earlier evaluation might have resulted in detection of the cord prolapse in time to prevent fetal death.”