ArticleLiterature Review

Contraception Across the Transmasculine Spectrum

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Abstract

The field of transgender health continues to expand rapidly, including research in the area of family planning. While much attention has been given to fertility preservation and the parenting intentions of transgender individuals, far less has been paid to pregnancy prevention and contraceptive needs of people along the transmasculine gender spectrum (transgender men and gender-nonbinary persons who were assigned female at birth). Existing research illustrates that many clinicians and transmasculine individuals falsely believe that there is no risk of pregnancy while amenorrheic. These studies also show inconsistent counseling practices provided to transmasculine persons surrounding contraception and pregnancy while falling short of providing robust clinical guidance for improvement. Clinicians report a lack of adequate training in transgender reproductive health, and consequently, many do not feel comfortable treating transgender patients. The aim of this publication is to consolidate the findings of these prior studies and build upon them to offer comprehensive clinical guidance for managing contraception in transmasculine patients. To do so, it reviews the physiologic effects of testosterone on the sex steroid axis and current understanding of why ovulation and pregnancy may still occur while amenorrheic. Gender-inclusive terminology and a suggested script for eliciting a gender-affirming sexual history are offered. Common concerns (such as the effects on gender dysphoria and gender affirmation) and side effects of available contraceptive methods are subsequently addressed and how these may have a unique impact on transmasculine persons as compared with cisgender women. Lastly, a model is provided for approaching contraceptive counseling in the transmasculine population to assist clinicians and patients in determining the need for and selection of the type of contraception. To center transmasculine voices, the development of this publication's guidelines have been led by reproductive care clinicians of transgender experience.

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... Contraception must be discussed with all people who present a risk of unplanned pregnancy. 7,[9][10][11] In Brazil, there is a higher prevalence of the use of oral pills (29.7%) by cisgender women, followed by tubal ligation (14%) and external condoms (10%). 12 Hormonal methods are divided into two groups: combined and progestogen-only contraceptives. ...
... hair. 23 Although it is not a contraceptive method, its use is associated with amenorrhea in a massive portion of TM. 9 For this reason, erroneously, 16.4 to 31% of TM believe that testosterone is a contraceptive. 7,10, 24 The presence of estrogen in contraceptive methods is one of the factors that leads TM undergoing hormonization to the use of nonhormonal methods or of progestogen alone. ...
... 7,10, 24 The presence of estrogen in contraceptive methods is one of the factors that leads TM undergoing hormonization to the use of nonhormonal methods or of progestogen alone. 9,10,25,26 Currently, there is no evidence of the influence of contraceptive use on the acquisition of secondary male characteristics. 9 There are also no studies that associate thromboembolism with combined hormonal contraception. ...
Article
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Although almost 0.7% of the Brazilian population identifies as transgender, there is currently no training for healthcare professionals to provide comprehensive care to these patients, including the discussion of reproductive planning. The use of testosterone promotes amenorrhea in the first months of use; however, this effect does not guarantee contraceptive efficacy, and, consequently, increases the risks of unplanned pregnancy. The present article is an integrative review with the objective of evaluating and organizing the approach of contraceptive counseling for the transgender population who were assigned female at birth. We used the PubMed and Embase databases for our search, as well as international guidelines on care for the transgender population. Of 88 articles, 7 were used to develop the contraceptive counseling model. The model follows the following steps: 1. Addressing the information related to the need for contraception; 2. Evaluation of contraindications to the use of contraceptive methods (hormonal and nonhormonal); and 3. Side effects and possible discomfort associated with the use of contraception. The contraceptive counseling model is composed of 18 questions that address the indications and contraindications to the use of these methods, and a flowchart to assist patients in choosing a method that suits their needs.
... While initial breakthrough bleeding is common, most patients become amenorrheic by one year of continuous use [50]. It is worth acknowledging that chest tenderness may be a side effect of these methods [51] and important to offer reassurance that total body estrogen levels do not increase, given that up to 47% of TGD patients stop using COCs because of concerns for feminizing effects [12, 40••]. ...
... Depo-Provera, depo-medroxyprogesterone acetate (DMPA), is an injectable progestin dosed every three months and is the most effective progesterone-only form of contraception. Though 60-80% of patients become amenorrheic after one year of use, breakthrough bleeding is frequent in the first 3-6 months [40,51]. Side effects include weight gain and a reversible decrease in bone density. ...
... One pregnancy occurred in a patient inconsistently taking testosterone [12••]. Given the earlier data, patients should be advised that amenorrhea alone does not indicate an inability to become pregnant [51]. Given the inconclusive data, providers should engage patients in a shared decision-making model using this information to guide contraceptive choice [54]. ...
Article
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Purpose of Review This review provides an overview of sexual and reproductive health considerations for transgender and gender-diverse (TGD) patients. Recent Findings New evidence is emerging that expands the current knowledge of TGD patient’s health needs and better informs providers to allow for more robust counseling regarding reproductive and sexual options. Summary TGD patients have a variety of sexual and reproductive health needs. Fertility preservation (FP), while underutilized, is desired and successful for TGD patients. Developing FP technologies are expanding the options we can offer patients. The effect of hormonal therapy on future fertility does not appear to be significant, but warrants further research given conflicting data. While visibility of TGD patients’ experiences with pregnancy is heightened, little is known regarding long-term pregnancy outcomes in this population. Contraceptive choice for TGD patients should be driven by patient desire to prevent pregnancy and, for patients assigned female at birth (AFAB), suppress menstruation.
... Much of the research, whether clinical/medical, experiential, or based in critical theory, explores the link between menstruation and dysphoria. While recognizing that not all trans and nonbinary people experience a sense of distress or anxiety associated with their menses, that there is a possibility for dysphoria is often framed as the impetus for clinical interventions such as menstrual suppression (Akgul et al., 2019;Krempasky et al., 2020). This possibility of distress and dysphoria is particularly salient in the literature on trans and non-binary youth, where menarche as a component of puberty is understood as being associated with significant and worsening dysphoria (Frank, 2020;Raynor, 2020). ...
... More than just the experience of cyclical menstrual bleeding, however, dysphoria may also be associated with: menstrual management and suppression techniques that require the vaginal/front hole insertion of tampons, menstrual cups or intrauterine devices (Akgul et al., 2019;Chrisler et al., 2016); the associated symptoms of cramping and breast/chest swelling, where these symptoms are made increasingly complicated for those who bind their chests (Bliss, 2018;Krempasky et al., 2020); taking medications associated with cisgender women such as combined hormonal contraceptives as well as estrogen-containing hormonal options (Krempasky et al., 2020;Pradhan & Gomez-Lobo, 2019) and purchasing and using feminized menstrual products (Bliss, 2018;Frank, 2020;Rydstr€ om, 2020). Managing menstruation in gendered public restrooms may also be triggering of gender dysphoria and distress, as these spaces can be characterized as sites of surveillance and gender policing, both in terms of their architecture and due to the watchful gaze of other users (Bliss, 2018;Chrisler et al., 2016;Fahs, 2016;Grace & Wellington, 2020;Pfeffer, 2017). ...
... More than just the experience of cyclical menstrual bleeding, however, dysphoria may also be associated with: menstrual management and suppression techniques that require the vaginal/front hole insertion of tampons, menstrual cups or intrauterine devices (Akgul et al., 2019;Chrisler et al., 2016); the associated symptoms of cramping and breast/chest swelling, where these symptoms are made increasingly complicated for those who bind their chests (Bliss, 2018;Krempasky et al., 2020); taking medications associated with cisgender women such as combined hormonal contraceptives as well as estrogen-containing hormonal options (Krempasky et al., 2020;Pradhan & Gomez-Lobo, 2019) and purchasing and using feminized menstrual products (Bliss, 2018;Frank, 2020;Rydstr€ om, 2020). Managing menstruation in gendered public restrooms may also be triggering of gender dysphoria and distress, as these spaces can be characterized as sites of surveillance and gender policing, both in terms of their architecture and due to the watchful gaze of other users (Bliss, 2018;Chrisler et al., 2016;Fahs, 2016;Grace & Wellington, 2020;Pfeffer, 2017). ...
Article
Objectives: Critical menstruation studies is a field in its nascence, marginalized within the broader area of reproductive health research. Menstruation-related research is virtually absent from trans studies, itself a marginalized field of inquiry. This article focuses on the experiences of trans and non-binary menstruators, to contribute to this burgeoning area of study. Methods: This article involves secondary data analysis of a qualitative dissertation research study on trans people's reproductive lives, health, and decision-making processes. Of the fourteen participants in the broader study, eleven discussed their perceptions of and experiences with menstruation and menstrual health. Those experiences where subjected to thematic narrative analysis, with a focus on themes that were substantively significant. Results: Participants describe experiences with amenorrhea associated with the use of testos-terone, menstrual resumption following the cessation of testosterone and for other reasons, menstruation-related dysphoria management strategies beyond medical interventions, as well as barriers to menstruation-related health care. One participant describes bloodless periods as a trans woman, a phenomenon altogether absent from the clinical and experiential literature in this field. The article explores how cisnormativity, repronormativity and transnormativ-ity informed the participants experiences of menstruation and reproductive health care. Conclusions: Contributing novel stories to the literature, this article illustrates how clinically focused research fails to attend to the experiential components of menstruation for trans and non-binary people. Expanded knowledge is beneficial to the development of gender-inclusive menstruation research, clinical interventions, healthcare environments, and activist efforts.
... 5,6 A dearth of research exists on the effects of testosterone on ovaries and ovulation and even less research exists concerning transmasculine experiences with menstruation and contraception. 7 Research in these areas is important for several reasons. Transmasculine people may engage in receptive vaginal intercourse with people with penises, which can lead to pregnancy. ...
... 8 Even for those who desire pregnancy, both contraception and menstruation can be a source of dysphoria. 7 While exogenous testosterone use often reduces or even eliminates menses, a prospective study of 32 transmasculine people found that 13 participants reported having spotting over the study period. 10 Dysphoria may possibly serve as a barrier to health care for contraception and menstruation. ...
... 11 External factors, such as discrimination by health care providers, lead to numerous additional barriers to health care for TGD people. 7,12,13 With an existing distrust of the health care system, seeking care around sensitive topics such as contraception and menstruation becomes additionally complicated. ...
Article
Purpose: A paucity of research exists concerning transmasculine experience with contraception and menstruation, despite these being possible sources of dysphoria. Understanding how transmasculine people navigate contraception and menstruation can help improve the quality of care provided for this community. This literature review consequently aims to synthesize the existing qualitative and mixed methodology literature on how transmasculine people experience and navigate contraception and menstruation. Methods: A systematically guided literature review was conducted on March 15, 2020, using CINAHL, EMBASE, Medline, PsychINFO, and Web of Science. Qualitative and mixed method studies written in English were included if (i) participants were transmasculine and older than 11 years, (ii) the research question focused on contraception and/or menstruation in the transmasculine community, and (iii) the study incorporated primary data. No publication time restrictions were placed. The analysis followed a meta-ethnographic approach, with the minority stress model and social norms theory used for guidance. Results: Five studies were found eligible for review, all published after 2015 and conducted in the United States. The majority of the total 360 participants were White and of a higher socioeconomic position. Three main thematic categories were present: (i) concerns with hormonal contraception use, including gender dysphoria and worries about interactions with testosterone; (ii) discrimination and fears around seeking health care, especially concerning the assumptions made by practitioners; and (iii) community as a positive influence, particularly for normalizing menstruation for transmasculine people. Conclusion: The data collected support the need for increased research concerning the interaction between hormonal contraception and testosterone. Reflection on assumptions, even ones made in an attempt to be supportive, can improve physician and transmasculine patient relationships. Finally, community normalization can be a powerful tool to decrease feelings of dysphoria around menstruation, and community voices should be included in all educational material concerning menstruation and contraception.
... Little is known about the effect of exogenous administration of T on fertility and lack of knowledge and awareness of the risk of pregnancies are common among transgender men as well as clinicians that care for these people [18,19]. Although data are limited, some studies report cases of unplanned pregnancies among transmen under T therapy or with previous T use [10,20]. ...
... This increase induces a negative feedback action on the hypothalamic-pituitary-gonadal (HPG) axis, with subsequent reduction of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) [15], but without complete suppression to prepubertal levels [22]. This may be the reason for breakthrough ovulation and histological findings of different stages of ovarian follicle development in transmen [18,23]. ...
... Some considerations should be made before contraceptive prescription. Most transmen want to avoid all contraceptive options that may be a source of gender dysphoria: daily or weekly medications that remind them of their gender incongruency may be uncomfortable and unacceptable [18], estrogen-containing contraceptives are perceived as contrasting compounds to the T masculinizing effect [19], contraceptive methods that require pelvic procedures, such as the vaginal ring or IUD (intrauterine device) [45], or options that may cause breast tenderness at the initiation cause concerns in this population [18]. Subdermal implants may be a good option for transmen. ...
Article
Sexual and reproductive issues are essential elements of well-being in cisgenders as well as for the transgender population. Gender-affirming hormonal treatments (GAHTs) aim to induce phenotypical changes congruent with the desired gender and subsequent reduction of gender dysphoria. While genital surgical procedures including hysterectomy and/or adenectomy cause permanent loss of ability to conceive, GAHT may induce a varying degree of reversible loss of fertility. For these reasons, transgender men and women need to be counseled concerning contraceptive options and potential effects of treatment on reproductive function before initiating GAHT. The literature reports that sexual activity with genital involvement is performed by less than half of transgender persons who have been sexually active with a partner in the past. Testosterone (T) is the most commonly used compound in transmen and usually leads to amenorrhea within 1–12 months from first administration, however cessation of menses does not mean anovulation. Some studies report cases of unintended pregnancies among transgender men under masculinizing therapy, therefore T treatment cannot be considered a contraceptive option. Currently available contraceptive options have pros and cons in transmen and scarce literature exists on their use. The effects of GAHT on fertility in transwomen are even less well known. Prolonged estrogen exposure induces sperm suppression and morphological changes of the spermatozoa, however the degree of resulting pregnancy protection is unclear. Further research to inform the contraceptive counseling in this population is mandatory.
... While taking history, using gender-inclusive language for all patients can help facilitate open and non-judgmental discussion about relevant history, particularly those related to sex and gender [33]. That way, providers would be more considerate and play an essential role in promoting sexual awareness and inclusivity. ...
... That way, providers would be more considerate and play an essential role in promoting sexual awareness and inclusivity. Examples of some questions that may come up in an encounter in a gender-neutral manner are listed in Table 1 [33]. When conducting a physical examination, providers should explicitly ask for patient permission and focus on body parts relevant to the chief complaint [34]. ...
... When conducting an organ inventory, it is important to check in with the patient to ensure that they are comfortable with the words used. Providers should refrain from using the words 'breast' and 'vagina' or 'penis' and instead use 'chest', and 'genitalia', respectively, to avoid triggering gender dysphoria in patients who are not comfortable with the aforementioned words [33]. As gender identity is distinct from sexual orientation or behavior, transgender patients' sexual orientation and sexual behaviors should not be assumed [8]. ...
Article
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Transgender persons who undergo masculinizing hormone therapy experience a wide array of dermatologic effects as they initiate and maintain testosterone therapy. Acne is one of the most common adverse effects for many transmasculine patients receiving testosterone. Acne can worsen body image and mental health, with significant impact on quality of life in transgender patients. Specific training and awareness are needed for a clinically and culturally competent encounter while providing care for the transgender patient. This article provides a practical guide for the treatment of testosterone-induced acne in transmasculine patients. Recommendations on creating a welcoming clinical setting, taking a gender-inclusive history, and conducting a patient-centered physical examination relevant to acne care are provided. Assessment of reproductive potential and the appropriate contraceptive methods before prescribing acne treatment with teratogenic potential in transmasculine patients are examined. Interactions between acne treatments with gender-affirming therapies are explored. For patients with severe or treatment-refractory acne, indications, contraindications, and barriers to isotretinoin prescription, such as the US iPLEDGE program, are examined. Multidisciplinary approaches to acne care, involving mental health, reproductive health, gender-affirming hormone therapy and surgeries, are adopted to guide isotretinoin treatment.
... The implications for clinicians are clear: sexual and reproductive health providers should avoid assumptions about pregnancy capacity or intentions based on a patient's presumed or stated gender or engagement with gender-affirming hormone therapy. The fact that nearly one in five respondents felt "at risk" of unintended pregnancy, or were unsure of their risk, emphasizes the need for improved contraceptive counseling and care delivery for these populations (Agenor et al., 2020;Bonnington et al., 2020;Boudreau & Mukerjee, 2019;Krempasky et al., 2020). Toward the other end of the family planning spectrum, that one in four respondents desired or were uncertain about future pregnancy desires underscores the need for providers to evaluate fertility plans with all patients, regardless of gender, and to offer high-quality, gender-affirming pre-conception care for those that want it. ...
... Relevant for both those desiring pregnancy and those trying to avoid pregnancy, the finding that some pregnancies occurred after starting and while using testosterone reiterates that testosterone does not completely prevent ovulation or pregnancy even if it may attenuate it by an unknown amount. (Bonnington et al., 2020;Krempasky et al., 2020;Light et al., 2014Light et al., , 2018. The potential for both potentially impaired fertility and pregnancy while using testosterone should be discussed with all patients initiating testosterone. ...
Article
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Background: Transgender, nonbinary, and gender-expansive (TGE) people experience pregnancy. Quantitative data about pregnancy intentions and outcomes of TGE people are needed to identify patterns in pregnancy intentions and outcomes and to inform clinicians how best to provide gender-affirming and competent pregnancy care. Aims: We sought to collect data on pregnancy intentions and outcomes among TGE people assigned female or intersex at birth in the United States. Methods: Collaboratively with a study-specific community advisory team, we designed a customizable, online survey to measure sexual and reproductive health experiences among TGE people. Eligible participants included survey respondents who identified as a man or within the umbrella of transgender, nonbinary, or gender-expansive identities; were 18 years or older; able to complete an electronic survey in English; lived in the United States; and were assigned female or intersex at birth. Participants were recruited through The PRIDE Study – a national, online, longitudinal cohort study of sexual and gender minority people – and externally via online social media postings, TGE community e-mail distribution lists, in-person TGE community events, and academic and community conferences. We conducted descriptive analyses of pregnancy-related outcomes and report frequencies overall and by racial and ethnic identity, pregnancy intention, or testosterone use. Results: Out of 1,694 eligible TGE respondents who provided reproductive history data, 210 (12%) had been pregnant. Of these, 115 (55%) had one prior pregnancy, 47 (22%) had two prior pregnancies, and 48 (23%) had three or more prior pregnancies. Of the 433 pregnancies, 169 (39%) resulted in live birth, 142 (33%) miscarried, 92 (21%) ended in abortion, two (0.5%) ended in stillbirth, two (0.5%) had an ectopic pregnancy, and seven (2%) were still pregnant; nineteen pregnancies (4%) had an unknown outcome. Among live births, 39 (23%) were delivered via cesarean section. Across all pregnancies, 233 (54%) were unintended. Fifteen pregnancies occurred after initiation of testosterone, and four pregnancies occurred while taking testosterone. Among all participants, 186 (11%) wanted a future pregnancy, and 275 (16%) were unsure; 182 (11%) felt “at risk” for an unintended pregnancy. Discussion: TGE people in the United States plan for pregnancy, experience pregnancy (intended and unintended) and all pregnancy outcomes, and are engaged in family building. Sexual and reproductive health clinicians and counselors should avoid assumptions about pregnancy capacity or intentions based on a patient’s presumed or stated gender or engagement with gender-affirming hormone therapy.
... 3 While testosterone suppresses ovulation at least 83% of the time, the actual risk of becoming pregnant on testosterone is unknown, and there are reports of individuals on testosterone becoming pregnant. [3][4][5][6] Because there are insufficient data to support using testosterone as a form of contraception among TM patients, TM patients not practicing abstinence should use two alternative forms of contraception. ...
... When discussing oral contraception with TM patients during iPledge enrollment, it is important to know that all forms of contraception can be safely used by TM patients on testosterone in the absence of another contraindication. 5,6 Specifically, TM patients can safely combine testosterone with combined oral contraceptives without an increase in venous thromboembolism risk. Additionally, patients on testosterone should be counseled that starting combined oral contraceptives does not appreciably increase their risk of breakthrough bleeding nor is it likely to counteract the masculinizing effects of testosterone. ...
... Gaps regarding transgender and gender nonbinary people's health and health care needs include contraceptive method preferences, the influence of gender-affirming hormone use 9 on fertility, transgender and gender non-binary people's desires for and experiences with pregnancy and experiences of abortion, and a range of other core sexual and reproductive health outcomes. [10][11][12][13] The existing literature emphasizes that many transgender and gender nonbinary people do not seek needed health care as a result of experiences with discrimination and lower quality care related directly to gender identity. 14 Transgender and gender nonbinary people are more likely than the general U.S. population to be uninsured, to experience discrimination and mistreatment in health care settings, and to be adversely affected by limited clinician knowledge or refusal to provide care. ...
... (continued ) group these recommendations according to physical aspects of care facilities (signage, services provided), patient informational materials and intake forms, and interactions between staff and patients. Our recommendations build off of guidance provided by clinicians who specialize in the care of transgender and gender nonbinary patients, [11][12][13]18 and we broaden our recommendations for clinical encounters with patients of all genders. ...
Article
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We aim to make evident that solely referencing cisgender women in the context of sexual and reproductive health-particularly pregnancy planning and care-excludes a diverse group of transgender and gender nonbinary people who have sexual and reproductive health needs and experiences that can be similar to but also unique from those of cisgender women. We call on clinicians and researchers to ensure that all points of sexual and reproductive health access, research, sources of information, and care delivery comprehensively include and are accessible to people of all genders. We describe barriers to sexual and reproductive health care and research participation unique to people of marginalized gender identities, provide examples of harm resulting from these barriers, and offer concrete suggestions for creating inclusive, accurate, and respectful care and research environments-which will lead to higher quality health care and science for people of all genders.
... 68 , 69 Testosterone is not an approved form of birth control. 70 The genital surgery literature reports generally satisfactory outcomes, with low regret, although validated instruments are yet not incorporated. 42 , 43 The most commonly reported concerns are high urethral complication rates, including strictures, fistulae, and diverticula. ...
Article
Transgender and gender diverse adolescent and young adults (AYA) may seek gender affirming surgeries (GAS) as part of their gender affirmation. A number of GAS are related to reproductive and sexual health and pediatric and adolescent gynecology (PAG) clinicians are well positioned as sexual and reproductive health experts to provide care in this area. PAG clinicians may encounter patients presenting for preoperative counseling (including discussions regarding fertility, family building, future sexual function, and choice of oophorectomy at time of hysterectomy), requesting referrals to GAS clinicians, requiring GAS aftercare, or seeking general sexual and reproductive health care who have a history of GAS. This article reviews presurgical considerations for AYA seeking GAS, types of GAS, their impact on pelvic, sexual and reproductive health, and aftercare that may involve PAG providers, with the goal of helping PAG clinicians better understand these procedures and empower them to engage collaboratively with GAS teams. With this knowledge reproductive health clinicians can have an integral role as skilled collaborators in the world of AYA GAS in partnership with GAS surgeons.
... Additionally, transmasculine young people should be counselled that although it may induce amenorrhea, testosterone does not provide reliable contraception, and, in the event of a pregnancy, is teratogenic (15,35). The need for an alternative means of effective contraception if engaging in vaginal intercourse should be emphasized (88). ...
Article
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Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being employed. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, while short-term outcomes are encouraging, longer-term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender diverse adolescents.
... Revising clinic intake forms to assess capacity and desires for pregnancy in a gender-neutral way and systematically incorporating similar questions into conversations between providers and patients may help to identify patients capable of pregnancy and prompt pregnancy options counseling. 38,39 Several studies evaluating 40 and a lack of confidence, sense of preparedness, or experience with providing care to these populations. 41e43 Therefore, clinicians should seek out training on how to provide gender-affirming sexual and reproductive healthcare for TGE patients to improve the appropriateness and quality of care. ...
... Moreover, providers should also perform an "anatomical inventory," as patients' reproductive health needs will vary based on whether they have had gender-affirming surgeries. 27 However, more formal training is needed for providers to deliver highquality sexual and reproductive healthcare for gender minority patients 12 , 25 ; only 2 in 7 obstetrician-gynecologists report being comfortable providing care for gender minorities who are assigned female (eg, female-to-male). 12 Providers can refer to recent commentaries and guidelines for more detailed recommendations on providing contraceptive counseling and reproductive healthcare for gender minorities. ...
Article
Study Objective Our objective was to describe sexual behavior and contraceptive use among assigned female cisgender and gender minority college students (i.e., those whose gender identity does not match their sex assigned at birth). Design Cross-sectional surveys administered as part of the Fall 2015 through Spring 2018 administrations of National College Health Assessment. Setting Across the United States Participants 185,289 cisgender and gender minority assigned females aged 18-25 years Main Outcome Measures Recent vaginal intercourse; Number and gender of sexual partners; Use of contraception; Use of protective barriers during vaginal intercourse. Results Both gender minority and cisgender students often reported having male sexual partners, but gender minority students were more likely to report having partners of another gender identity (e.g., women, trans women). Gender minorities were less likely than cisgender students to report having vaginal intercourse (adjusted odds ratio [AOR]: 0.86; 95% confidence interval [95%CI]: 0.80, 0.93). Gender minorities were less likely than cisgender students to report using any contraceptive methods (AOR: 0.86; 95%CI: 0.73, 1.03), and were less likely to consistently use barrier methods (AOR: 0.72; 95%CI: 0.64, 0.81), or emergency contraception (AOR: 0.56; 95%CI: 0.48, 0.65). However, gender minorities were more likely to use Tier 1 and Tier 3 contraceptive methods than cisgender women. Conclusions Providers must be trained to meet the contraceptive counseling needs of cisgender and gender minority patients. Providers should explicitly ask all patients about the sex/gender of the patients’ sexual partners and the sexual behaviors they engage in to assess sexual risk and healthcare needs.
... Revising clinic intake forms to assess capacity and desires for pregnancy in a gender-neutral way and systematically incorporating similar questions into conversations between providers and patients may help to identify patients capable of pregnancy and prompt pregnancy options counseling. 38,39 Several studies evaluating 40 and a lack of confidence, sense of preparedness, or experience with providing care to these populations. 41e43 Therefore, clinicians should seek out training on how to provide gender-affirming sexual and reproductive healthcare for TGE patients to improve the appropriateness and quality of care. ...
Article
Full-text available
Background: Transgender, nonbinary, and gender-expansive (TGE) people who were assigned female or intersex at birth experience pregnancy and have abortions. No data have been published on individual abortion experiences or preferences of this understudied population. Objective(s): To fill existing evidence gaps on the abortion experiences and preferences of TGE people in the United States to inform policies and practices to improve access to and quality of abortion care for this population. Study design: In 2019, we recruited TGE people assigned female or intersex at birth and aged 18 years and older from across the United States to participate in an online survey about sexual and reproductive health recruited through The PRIDE Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for TGE people, and respondent sociodemographic characteristics. Results: The majority of the 1,694 respondents were less than 30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all four United States Census Regions. Overall, 210 (12%) respondents had ever been pregnant; these 210 reported 421 total pregnancies, of which 92 (22%) ended in abortion. For respondents' most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (4.5%) used another method (primarily herbal). Most recent abortions took place at or before nine weeks gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion to surgical abortion three to one (n=703 versus n=217), but 514 (30%) respondents did not know which method they would prefer. Reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for TGE patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers utilize gender-neutral language, and that greater privacy be incorporated into the clinic. Conclusion(s): These data contribute significantly to the evidence base on individual experiences of and preferences for abortion care for TGE people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.
... Due to a lack of clear difference in efficacy, choice of method should be tailored to patients' preferences and goals. 27 Patients should be counseled that no method will guarantee amenorrhea and that 3 months may elapse before bleeding patterns are established, based on data from cisgender samples. 14 Finally, hysterectomies were more common in our breakthrough bleeding patients suggesting that breakthrough bleeding may be driving TGD AYA to seek surgical intervention. ...
Article
Study objective: Amenorrhea is a goal of many transgender and gender diverse adolescent and young adult (TGD AYA) patients on testosterone gender-affirming hormone therapy (T-GAHT). Breakthrough bleeding can contribute to worsening gender dysphoria. Our objective was to evaluate breakthrough bleeding in TGD AYA on T-GAHT. Design: IRB-approved retrospective cohort SETTING: : Tertiary-care children's hospital PARTICIPANTS: : TGD AYA on T-GAHT >1 year INTERVENTIONS: : None, observational MAIN OUTCOME MEASURES: : Presence of, and risk factors for, breakthrough bleeding RESULTS: : Of the 232 patients who met inclusion criteria, one quarter (n=58) had ≥1 episodes of breakthrough bleeding, defined as bleeding after >1 year on T-GAHT. In comparing patients with breakthrough bleeding to those without, there was no significant differences between age of initiation, body mass index (BMI), race/ethnicity, testosterone type used, use of additional menstrual suppression, serum testosterone, or estradiol levels. Patients with breakthrough bleeding patients were on T-GAHT longer (37.3 ± 17.0 vs. 28.5 ± 14.6 months, p=<0.001) and were more likely to have endometriosis (p=0.049). Breakthrough bleeding began at a mean of 24.3 ± 17.2 months after T-GAHT initiation. Of those with breakthrough bleeding, 46 (79.3%) had no known cause, 10 (17.2%) only bled with missed T-GAHT doses, and 2 (3.4%) only bled when withdrawing from concomitant menstrual suppression. No breakthrough bleeding management method was found to be superior. Conclusion: Breakthrough bleeding is relatively common (25%) on T-GAHT despite early amenorrhea. Most patients do not have an identifiable cause. Our data did not show superiority of any one method for managing breakthrough bleeding on T-GAHT.
... When giving counseling concerning this method it is important to discuss with the patient that although breakthrough bleeding is common in the initial months the rate of amenorrhea increases with continuous use and has been shown to be about 50% after the first year of use (18). Although the combined hormonal formulations continue to be the most popular method for suppressing menstruation for other indications, GMY may want to avoid this method due to the perceived feminizing effects of these hormones and association with an incongruent gender (19), which was the situation for case 1. It is also important to discuss the possible side effects of the medication, such as its effect on the breast tissue. ...
Article
The purpose of this case series was to evaluate menstrual suppression in sex assigned at birth female adolescents identifying as male or gender non-conforming. A retrospective chart review of 4 gender minority youth (GMY), age 14-17, was performed for gender identity history, type and success of menstrual suppression, method satisfaction, side effects and improvement in menstrual distress. Menstrual suppression was successful in 3 patients, one patient discontinued use due to side effects that caused an increase in gender dysphoria. Menstrual distress and bleeding pattern improved in the majority of GMY in this series but side effects, as well as contraindications, may limit their use. In conclusion, menstrual dysphoria can be life-threatening for GMY and it is important that clinicians consider menstrual suppression in GMY with menstrual dysphoria. This series emphasizes the importance of individualized treatment plans.
... TO THE EDITORS: We thank Dr Creinin for the correction on the amenorrhea rate of levonorgestrel (LNG) 20 (LILETTA), 1 which is 19% and not 9%, as reported in our long-acting reversible contraception comparison table. 2 Although now approved for 6 years, at the time of our electronic publication (August 5, 2019), the approved duration of use for the LNG 20 was 5 years. ...
... 10,11 For instance, although transgender and gender diverse AFAB people can experience pregnancy, 12-14 they face notable barriers to contraception, including limited access to high-quality health care, a lack of healthcare provider training and competence in transgender health, cis-and hetero-normative healthcare provider assumptions, and gender identity-related bias, stigma, and discrimination in healthcare settings in particular, and society in general. [15][16][17] Similarly, research shows that transgender and gender diverse AFAB people are also less likely to obtain regular Pap tests compared to cisgender women (i.e. AFAB individuals who identify as women in terms of gender identity) as a result of institutional discrimination in healthcare systems, a lack of healthcare provider knowledge and training, and limited access to gender-affirming care. ...
Article
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We conducted a scoping review to map the extent, range and nature of the scientific research literature on the reproductive health (RH) of transgender and gender diverse assigned female at birth and assigned male at birth persons. A research librarian conducted literature searches in Ovid MEDLINE®, Ovid Embase, the Cochrane Library, PubMed, Google Scholar, Gender Studies Database, Gender Watch, and Web of Science Core Collection. The results were limited to peer-reviewed journal articles published between 2000 and 2018 involving human participants, written in English, pertaining to RH, and including disaggregated data for transgender and gender diverse people. A total of 2197 unique citations with abstracts were identified and entered into Covidence. Two independent screeners performed a title and abstract review and selected 75 records for full-text review. The two screeners independently extracted data from 37 eligible articles, which were reviewed, collated, summarised, and analysed using a numerical summary and thematic analysis approach. The existing scientific research literature was limited in terms of RH topics, geographic locations, study designs, sampling and analytical strategies, and populations studied. Research is needed that: focuses on the full range of RH issues; includes transgender and gender diverse people from the Global South and understudied and multiply marginalised subpopulations; is guided by intersectionality; and uses intervention, implementation science, and community-based participatory research approaches. Further, programmes, practices, and policies that address the multilevel barriers to RH among transgender and gender diverse people addressed in the existing scientific literature are warranted.
... These findings are concordant with the reports in the literature indicating long-term testosterone users can still experience ovulatory events 18 and unplanned pregnancies can occur in transmasculine individuals receiving testosterone; therefore, testosterone should not be used as a contraceptive method. 19 Androgens have been shown to be important regulators of folliculogenesis and also play a role in polycystic ovary syndrome. 20 Several reports, including the present one, identified that a high percentage of transmasculine patients receiving testosterone can develop bilateral multiple cystic follicles in the ovaries, which has a striking similarity to polycystic ovary syndrome. ...
Article
Context.— Gender-affirming surgery is part of a multidisciplinary approach in gender transitioning. Deeper histologic examination may strengthen care for transmasculine individuals and increase the understanding of the influence of hormonal therapy in specific organs. Objective.— To evaluate and catalogue histologic findings of tissue obtained from gender-affirming gynecologic surgery and cervical cytology specimens. Design.— This is an institutional review board–approved retrospective study that included transmasculine individuals who underwent gender-affirming gynecologic surgery from January 2015 to June 2020. All surgical gynecologic pathology and cervical cytology slides were reviewed by 2 pathologists. Results.— Fifty-five patients were included, which represented 40 uteri, 35 bilateral ovaries, 15 vaginectomy specimens, and 24 cervical cytology results. The median age was 27 years (range, 18–56) and 94% (50 of 53) of patients were receiving testosterone for at least 1 year. Seventy-five percent (30 of 40) of endometria were inactive, while 25% (10 of 40) showed evidence of cycling. Transitional cell metaplasia was the most common finding in the cervix (17 of 40) and vagina (15 of 15), reflecting a high percentage (4 of 24) of unsatisfactory or ASC-US (atypical squamous cells of undetermined significance) cervical cytologies. Prostatic-type glands were identified in 20% (8 of 40) of cervices and 67% (10 of 15) of vaginectomy specimens. Multiple bilateral cystic follicles and evidence of follicular maturation were present in 57% (20 of 35) of cases. Four cases showed paratubal epididymis-like mesonephric remnant hypertrophy. Conclusions.— A comprehensive evaluation of tissue from gender-affirming surgery increases knowledge of the changes following androgen therapy in transmasculine individuals and may contribute to optimal patient care by raising awareness of normal histologic variations in this population.
... Clinicians should also educate themselves on how gender diversity and gender affirming care may influence pregnancy and STI risk. For example, testosterone use in transgender men cannot be relied on for contraception, even if patients are amenorrheic [7]. ...
... To-date, data on effectiveness of safer conception strategies among key populations are limited, but available data from non-key population safer conception services highlight its potential for improving viral suppression to reduce HIV transmission and promote safer pregnancy [48]. Among transgender persons, there is increasing recognition in high-income settings that culturally competent contraception, fertility preservation and planning, and pregnancy care should be incorporated into counseling and services where appropriate [49]. Given the high HIV burden among transgender women, and the high HIV-related risk of sexual assault and early sexual debut among lesbian, bi-sexual, queer-identified women and transgender men, further attention to optimization of HIV and reproductive care is warranted, particularly in LMICs [50]. ...
Article
Purpose of review: In 2020, key populations around the world still have disproportionate risks for HIV acquisition and experiencing HIV-related syndemics. This review presents current data around HIV-related syndemics among key populations globally, and on the role of intersecting stigmas in producing these syndemics in low-to-middle-income settings. Recent findings: Sex workers, sexual and gender minorities, prisoners, and people who use drugs experience high burdens of tuberculosis, sexually transmitted infections, viral hepatitis, and violence linked to heightened HIV-related risks or acquisition. Adverse sexual, reproductive, and mental health outcomes are also common and similarly amplify HIV acquisition and transmission risks, highlighting the need for psychosocial and reproductive health services for key populations. Summary: Achieving the promise of biomedical interventions to support HIV care and prevention requires action towards addressing syndemics of HIV, and the stigmas that reproduce them, among those most marginalized globally.
... We recognized that people use varied words for their sexual and reproductive anatomy, and that for some, the words used to describe their bodies may induce either gender dysphoria or feelings of empowerment-depending on how well the words align with a person's sense of their own bodies. [31,32] Consequently, we programmed the survey to allow participants to input words that they use to describe their bodies, and then have those customized words replace traditional medical terms throughout the survey. In using customizable language, we aimed to create a more personalized, understandable survey that affirmed respondents' lived experiences. ...
Article
Full-text available
To address pervasive measurement biases in sexual and reproductive health (SRH) research, our interdisciplinary team created an affirming, customizable electronic survey to measure experiences with contraceptive use, pregnancy, and abortion for transgender and gender nonbinary people assigned female or intersex at birth and cisgender sexual minority women. Between May 2018 and April 2019, we developed a questionnaire with 328 items across 10 domains including gender identity; language used for sexual and reproductive anatomy and events; gender affirmation process history; sexual orientation and sexual activity; contraceptive use and preferences; pregnancy history and desires; abortion history and preferences; priorities for sexual and reproductive health care; family building experiences; and sociodemographic characteristics. Recognizing that the words people use for their sexual and reproductive anatomy can vary, we programmed the survey to allow participants to input the words they use to describe their bodies, and then used those customized words to replace traditional medical terms throughout the survey. This process-oriented paper aims to describe the rationale for and collaborative development of an affirming, customizable survey of the SRH needs and experiences of sexual and gender minorities, and to present summary demographic characteristics of 3,110 people who completed the survey. We also present data on usage of customizable words, and offer the full text of the survey, as well as code for programming the survey and cleaning the data, for others to use directly or as guidelines for how to measure SRH outcomes with greater sensitivity to gender diversity and a range of sexual orientations.
Article
Recently, greater attention has been paid to the care of gender dysphoric and gender incongruent individuals. Gynecologists may be called upon to care for individuals who were assigned female at birth throughout or following social, medical, or surgical gender transition. Thus, gynecologists need to be aware of language regarding sex and gender, treatment typically used for the care of gender dysphoric or incongruent individuals, and aspects of well gynecologic care necessary for these individuals. This review highlights these aspects of care for transgender males to aid the general gynecologist in the care and treatment of these individuals.
Article
Simulation pedagogy and training strive to adequately educate practitioners who will care for a diverse patient population. In the pursuit of protecting patients, simulation education has included a curriculum of cultural humility , diversity, equity, and inclusion that provides patient-centered best-practice. However, the missing link is person-first language essential for optimum patient/client communication. Failing to use person-first language can negatively affect patient-provider relationships. The result can adversely lead to poor patient outcomes due to mistrust, errors, decreased satisfaction, poor adherence to treatment, wasted resources, and increased healthcare costs. The use of words and how others perceive the utilization of those words matter. It is essential to acknowledge that words matter as a symbol of respect and identity in the quest towards inclusive practices. Healthcare providers carry the burden of providing quality and safe patient care. They should incorporate training strategies such as using person-first language and evidence-based resources to support an inclusive culture of diversity, equity, and inclusion.
Article
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Purpose of Review The purpose of this narrative review is to expand routine prepregnancy counseling and anticipatory guidance to include people of all genders. Recent Findings Transgender, gender diverse, and non-binary (TGNB) individuals who were assigned female at birth may wish to parent, conceive, and carry a pregnancy, but are not included in guidelines for routine prepregnancy counseling. In addition to the topics covered in routine prepregnancy counseling, there are several unique considerations for prepregnancy care for TGNB individuals including perinatal testosterone use, gender dysphoria and distress, chest/breastfeeding, and navigation of clinical environments. Summary Research in the area of TGNB medical care continues to grow as the visibility of these communities increases. However, data are limited surrounding pregnancy and prepregnancy-related care. Therefore, we present prepregnancy medical, surgical, social, and practice of care considerations for TGNB populations in light of other known health and healthcare experiences of TGNB patients. We outline several clinical recommendations to support clinicians in providing inclusive prepregnancy care. These recommendations aim to highlight the unique needs of TGNB individuals while recognizing that each patient’s experience and goals must be individualized to them.
Article
Study Objective To study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes. Design A retrospective review Setting Boston Children’s Hospital Participants Transmasculine persons less than 26 years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1, 2020 Interventions Not applicable Main Outcome measure(s) An electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes. Results Dysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9 years ± 1.9 years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three (65.7%) were first treated with combined oral contraceptives, but 61% (14/23) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone, and 33.3% (4/12) experienced persistent symptoms. Only seven with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three were diagnosed after social transition (42.9%), with one diagnosed 20 months after initiating testosterone. Their endometriosis was treated with combined oral contraceptives, danazol or progestins; four experienced suboptimal response while on these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when utilizing testosterone. Two out of five patients with endometriosis initiated testosterone and experienced persistent symptomatology with combined testosterone and progestin therapies. Conclusion This is the first study characterizing endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation having disease confirmation. While testosterone can resolve symptoms in some, others may require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when utilizing testosterone.
Article
Transgender and non-binary people assigned female at birth (TNB/AFAB) have unintended pregnancies, but there is a dearth of information about effective pregnancy prevention care for this population. This needs assessment study aimed at discerning pregnancy prevention care best practices involved interviews of 20 healthcare providers solicited for experience providing pregnancy counseling with this group. Findings were organized via the ecological model, revealing four layers of themes. 1) Social structural level themes related to the gender binary system and other forms of oppression (racism, sexism, heterosexism); 2) the systems level theme related to access to and barriers to care; 3) provider level themes included lack of formal education, need to provide trauma-informed care, and provider discomfort or assumptions; and 4) patient-level themes included the fact that patients do not usually raise issues related to contraception and that TNB/AFAB patients have unique contraception needs. Implications of the findings are discussed.
Article
Purpose This qualitative study explores the contraceptive health-care needs of transgender and nonbinary young adults assigned female sex at birth. Methods Qualitative interviews were conducted with 20 transgender and nonbinary young adults assigned female sex at birth (ages 22–29 years), recruited via online platforms and community agencies. Semistructured interviews elicited information on participants’ gender and reproductive histories, health-care experiences, sexual practices, and contraceptive use and decision-making processes. Interviews were transcribed and coded using thematic analysis. Results Primary thematic domains centered on contraceptive experiences and needs, testosterone as contraception, and experiences with reproductive health care. Participants generally did not use hormonal contraception to prevent pregnancy; in situations where pregnancy was possible, participants relied on condoms. Some participants believed testosterone use would prevent pregnancy and subsequently did not use a contraceptive method. Participants described the lack of knowledge, among themselves and providers, of the impacts of testosterone on pregnancy risk and interactions with hormonal contraception. They described reproductive health-care experiences in which providers were unfamiliar with the needs of transgender and nonbinary patients; made assumptions about bodies, partners, and identities; and lacked adequate knowledge to provide effective contraceptive care. Conclusions Patient-centered reproductive care requires that providers be sensitive to the stress of gender-affirming care and engage with contraceptive counseling that addresses patients’ behavior, risks, and reproductive functions. In particular, providers should understand and communicate the impacts of testosterone therapy on pregnancy risk.
Article
This study aimed to discuss fertility concerns unique to the lesbian, gay, bisexual, transgender, queer, plus and single-parent-to-be populations and review special considerations regarding the evaluation and treatment of these patients relevant to the practicing reproductive medicine provider. The use of assisted reproductive technology has rapidly increased over the past 50 years. Given these trends, providers can expect a greater diversity of patients making use of these technologies. Both the lesbian, gay, bisexual, transgender, queer, plus community and single parents-to-be represent understudied and important populations who often require the use of assisted reproductive technology to build their families. The American Society for Reproductive Medicine advocates for equitable treatment of patients regardless of sexual orientation and partner status, and health care providers working in the fertility field should be comfortable and confident in assessing the needs of and providing care to these populations.
Article
The term transgender includes people whose gender identity differs from their sex assigned at birth. People identified as male at birth but possess a female gender identity are called transwomen and people identified as female at birth but experience a male gender identity are called transmen. Transgender individuals may also identify outside the binary norm. The prevalence of transgender people who seek medical treatment has dramatically increased in recent years. Transgender individuals have a higher prevalence of mental health problems, suicidality and premature mortality risk versus the general population. However, many transgender persons avoid medical care due to perceived stigma, in conjunction with transgender-specific knowledge deficits among health care providers. Integral to understanding transgender health is the concept of gender dysphoria. This refers to the internal conflict individuals experience due to incongruence between their birth sex and their self-perceived gender. For these individuals, the inconsistency causes significant internal conflict, often to the point that it interferes with functioning. To address gender dysphoria, many transgender people elect to transition to a gender role that is consistent with their gender identity. These individuals opt for medical and/or surgical interventions to do so. Medical therapy incorporates the use of cross-sex hormones to facilitate the acquisition of secondary sexual characteristics consistent with the individual’s internalized identity. Many transgender people choose to undergo gender-confirming surgeries in conjunction with hormonal therapy. Health care is transgender-affirming when it supports the patient’s inherent identity. Educating providers about this population’s unique needs can help reduce health disparities and promote respectful transgender care.
Article
Full text: https://authors.elsevier.com/a/1eC3z8yuQtYUI Double standards are widespread throughout biomedicine, especially in research on reproductive health. One of the clearest cases of double standards involves the feminine gendering of reproductive responsibility for contraception and the continued lack of highly effective, reversible methods for cisgender men. While the biomedical establishment accepts diversity and inclusion as important social values for clinical trials, their continued use of inequitable standards undermines their ability to challenge unfair social hierarchies by developing male contraception. Thus, the gender/sex bias present in contraceptive research raises the “New Demarcation Problem”: If we accept that values can and will play important roles in science, how can we nevertheless distinguish positive influences of values from more corrosive bias? I argue that biomedical researchers ought to aim their clinical trials at equity and utilize methodologies that actually achieve that aim. More specifically, I contend that we can avoid the problem of double standards by gender/sex in contraceptive research by utilizing more equitable standards. My demarcation strategy captures dynamic interplay between values and their effects, with direct policy implications for institutions conducting, funding, and evaluating clinical trials. For male contraceptive trials, this involves shifting risk assessment from an individual model to a shared model for sexual partners.
Article
Objective : To describe use of three types of longer acting contraception—intrauterine devices, subdermal contraceptives, and depot medroxyprogesterone—among transmasculine and cisgender women patients. Study Design : A repeated cross-sectional study using electronic medical records of patients, age 18 to 45, receiving care within Kaiser Permanente Northern California between 2009 and 2019. Variations in demographics, clinical characteristics and contraception method uptake were assessed using t-tests for continuous variables and chi-square tests for categorical variables for patients enrolled in 2019. A linear trend test for each group was used to assess the age-adjusted uptake of contraception methods by study year. Results : The transmasculine group was younger, with a mean age of 27.3 years (+/-7.2) versus 32.5 years (+/-7.8) years, respectively p<0.001. The transmasculine group used more tobacco, alcohol, and illicit drugs. The uptake of these contraception methods increased from 2009 to 2019 for both groups (transmasculine: 0.7% to 4.1%; cisgender: 5.6% to 6.7%) with a positive linear trend for both groups (p=0.003 and p<0.001, respectively). The change in uptake of any intrauterine device from 2009 to 2019 was greater for the transmasculine group (0.3% to 2.3% versus 3.3% to 3.5%). Etonogestrel implant uptake had a positive linear trend from 2009 to 2019 for both groups (transmasculine: 0% to 0.5%, p=0.02, and cisgender 0.1% to 1.2%, p<0.001). Conclusion : Annual uptake of these contraception methods increased significantly for both transmasculine and cisgender groups, and this increase was greater for the transmasculine patients. Uptake of these contraception methods was higher in the cisgender population.
Article
Introduction The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals. Methods TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data. Results One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD. Discussion Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.
Article
Using data from the Fall 2015 through Spring 2018 National College Health Assessment, we examined receipt of pregnancy prevention information and unintended pregnancy by gender identity among participants aged 18-25years who were assigned female at birth (n=185658). Non-binary students were more likely than cisgender students to report wanting (adjusted risk ratio [ARR]: 1.12; 95% CI: 1.08-1.16), receiving (ARR: 1.09; 95% CI: 1.04-1.13), and having an unmet need for (ARR: 1.10; 95% CI: 1.02-1.19) pregnancy prevention information from their school. Transmasculine students did not significantly differ from cisgender students for these outcomes. Non-binary and transmasculine students were as likely as cisgender students to have a past-year unintended pregnancy. Non-binary and transmasculine young people are at risk for unintended pregnancy and need access to comprehensive sexual education, reproductive health counseling, and care.
Article
Premenopausal transgender men who retain internal female reproductive organs, who use exogenous testosterone, and who are sexually active with cisgender men are often capable of conception. This article discusses the potential for fecundity in transgender men, as well as appropriate reproductive care depending on whether the patient prefers to avoid conception or to become pregnant.
Article
When working with LGBTQ+ patients who want to build families, primary care providers play a key role in increasing access to reproductive health care. There is growing demand for assisted reproductive services among LGBTQ+ individuals who do not already have their own children or do not wish to adopt. Fertility-preservation options are available for transgender patients; however, many of these treatments are inaccessible to patients because of lack of insurance coverage and high cost. Legal options for LGBTQ+ patients' reproduction vary by state. Knowledge of the laws and regulations in your own state of practice is necessary to manage expectations.
Article
There is a growing interest in the healthcare community to focus on the healthcare needs of lesbian, gay, bisexual, transgender, or genderqueer (LGBTQ) patients, particularly transgender and gender diverse (TGD) patients. TGD individuals have historically experienced rejection and mistreatment by healthcare providers yet have significant health needs, highlighting the need for providing affirming care. Medication therapy for TGD individuals involves many nuances and special considerations for managing concomitant therapies and drug interactions. Additionally, approaches to caring for TGD patients involve both medical interventions as well as social and legal processes. Pharmacists can assist and facilitate the care for TGD patients through a variety of mechanisms. This narrative review describes strategies to recognize and address many aspects of the care for TGD individuals, including destigmatizing care, affirmation strategies, and an overview of therapeutic misconceptions and concerns. Ultimately, this manuscript serves as a guide for pharmacists to care holistically for TGD patients. This article is protected by copyright. All rights reserved.
Article
Transgender and nonbinary people experience high rates of discrimination and stigma in healthcare settings, which have a deleterious effect on their health and well-being. While the preventative healthcare needs of transgender and gender nonbinary people are slowly starting to make their way into nursing curriculum, there is still a very little guidance on how to appropriately and respectfully care for this population during one of the most vulnerable interactions with the healthcare system, the perinatal period. Without exposure or education, nurses are challenged on how to provide compassionate and culturally competent care to transgender and nonbinary people. The focus of this review is to provide guidance to nurses caring for transgender and gender nonbinary people during the perinatal period. Terminology and respectful language, a discussion around the decision to parent, affirming approaches to physical examination, and care during pregnancy and the postpartum period are all discussed. By increasing the number of nurses who are trained to deliver high-quality and affirming care to transgender and nonbinary patients, challenging health inequities associated with provider discrimination can be mitigated.
Article
Background Differential sexual history assessment, whereby certain groups are more or less likely to be asked questions about their sexual behavior by a health care provider, may lead to differential sexual health care and counseling. Methods Using nationally representative data from the 2013 through 2019 waves of the National Survey of Family Growth, we examined racial/ethnic and sexual orientation identity differences in receiving a sexual history assessment from a health care provider in the last 12 months among U.S. women aged 15–44 years (N = 14,019). Results Adjusting for survey wave, Black and Latina heterosexual women; White, Black, and Latina bisexual women; and Black or Latina lesbian women had higher odds (odds ratio range, 1.47 [Latina heterosexual] to 2.71 [Black bisexual]) of having received a sexual history assessment in the last 12 months compared with White heterosexual women. All differences except for those among Black or Latina lesbian women persisted after controlling for demographic, socioeconomic, and health care factors (odds ratio range, 1.43 [Latina heterosexual] to 2.14 [Black bisexual]). Of note, Black bisexual women, about whom providers may hold biased assumptions of promiscuity rooted in both racism and biphobia, had the highest predicted probability of being asked about their sexual behavior by a provider. Conclusions Person-centered, structurally competent, and anti-oppressive practices and programs aimed at combating bias, stigma, and discrimination in the health care system and facilitating an inclusive clinic environment for all patients are needed to address differences in the provision of sexual health services and promote sexual health equity.
Article
Transgender and gender-nonbinary patients may present to primary care providers seeking gender-affirming hormone therapy. Patients who meet criteria for diagnosis of gender incongruence may start or continue hormone therapy after providing informed consent. Prescribing and monitoring of masculinizing and feminizing hormone therapy can be managed in primary care settings.
Article
Purpose of review: Long-acting reversible contraception (LARC) is comprised of highly effective methods (the subdermal implant and intrauterine devices) available to adolescents and young adults (AYAs). Professional medical societies endorse LARC use in AYAs and, more recently, have emphasized the importance of using a reproductive justice framework when providing LARC. This article reviews reproductive justice, discusses contraceptive coercion, examines bias, and highlights interventions that promote equitable reproductive healthcare. Recent findings: Research indicates that both bias and patient characteristics influence provider LARC practices. AYA access to comprehensive LARC services is limited, as counseling, provision, management, and removal are not offered at all sites providing reproductive healthcare to AYAs. Interventions aimed at addressing provider bias and knowledge, clinic policies, confidentiality concerns, insurance reimbursement, and systems of oppression can improve AYA access to equitable, comprehensive contraceptive care. Additionally, the COVID-19 pandemic has exacerbated inequities in reproductive healthcare, as well as provided unique innovations to decrease barriers, including telemedicine LARC services. Summary: Clinicians who care for AYAs should honor reproductive autonomy by approaching contraceptive services with a reproductive justice lens. This includes implementing patient-centered contraceptive counseling, increasing access to LARC, eliminating barriers to LARC removal, and committing to systemic changes to address healthcare inequities.
Article
Objective Increased research efforts over the past decade provide a more in-depth understanding of the diverse fertility desires and family planning needs of trans and gender diverse individuals assigned female at birth (TGD AFAB). Despite this increased understanding and unmet need, global health researchers and contraceptive product developers have yet to include TGD AFAB individuals and considerations of their needs in the product development process, marginalising this historically underrepresented population. The aim of this perspective is to present the case for inclusion of TGD AFAB individuals in contraceptive research. Main outcomes This perspective summarises the most recent literature characterising contraceptive access and use within TGD AFAB populations as well as the barriers to use. Furthermore, this perspective offers insight into how novel contraceptive technologies in the research and development pipeline could potentially appeal to TGD AFAB populations and recommends steps product developers can make towards being more inclusive. Conclusions With current research efforts in contraceptive product development aimed at expanding the method mix to appeal to a more diverse population of potential users, it behoves product developers to be more inclusive of TGD AFAB individuals in the development process and consider them as stakeholders of an expanded contraceptive method mix.
Article
Planned and unplanned pregnancies are occurring among transgender men. Although the literature highlights the fact that many transgender men retain their reproductive pelvic organs and desire pregnancy, there is a dearth of information on best practices and standards of care guiding perinatal care for this population. A literature review was conducted to explore the reproductive health needs of transgender men related to reproductive desires, contraception, family planning, fertility preservation, pregnancy, birth, and lactation. Findings show that pregnant and birthing transgender men are reporting feelings of invisibility, isolation, and loneliness in highly gendered perinatal care environments. A lack of gender-affirming perinatal environments and experienced providers is contributing to the avoidance of care by transgender men and further discrimination in an already marginalized population. More research attention is needed to understand the reproductive health needs of pregnant and birthing transgender men and to optimize the care they receive.
Article
Introduction Aim of this study was the evaluation of prevalence of HPV infection and resulting genital dysplasia to assess the necessity and reasonability of pap smears and HPV testing in transgender patients. HPV is the most common sexually transmitted infection and responsible for the majority of genital dysplasias and malignancies. However, few data exist about the prevalence of HPV and dysplasia in transgender people. Methods This retrospective data analysis of prospectively collected data includes all patients seen in our specialized outpatient clinic for transgender people. Gynecologic exam, colposcopy, cellular swabs and HPV typing were carried out. Primary endpoint was the prevalence of HPV and genital dysplasias in transgender patients. Secondary endpoints were the subtypes of HPV, demographic data, sexual orientation and co-morbidities in these patients. Results We investigated overall 98 patients whereof 53 were transwomen and 45 transmen. Of those, 10.2% had positive HPV tests and 10.2% dysplastic changes in the PAP and one case of invasive anal carcinoma (1.02%). Comorbidities included recurrent urinary tract infections, psychologic comorbidies and other, possibly hormone replacement related conditions. Conclusion The results underline the necessity of a routine gynecological examination including PAP and/or HPV screening and vaccinating, respectively, no matter of sexual orientation or comorbidities. Monitoring the existent anatomy may prevent invasive carcinoma requiring more invasive therapies. Moreover, concomitant pathologies are present and require long-term care of these patients almost all using hormone therapy and carrying several specific risk factors. Transgender-focused guidelines to take into account these peculiarities are needed.
Article
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Background Some transgender men retain their uterus, get pregnant, and give birth. However, societal attitudes about gender have erected barriers to openly being pregnant and giving birth as a transgender man. Little research exists regarding transgender men’s reproductive needs. Anecdotal observations suggest that social change and increasing empowerment of transgender men may result in increasing frequency and openness about pregnancy and birth. Specific needs around conception, pregnancy, and newborn care may arise from transphobia, exogenous testosterone exposure, or from having had (or desiring) gender-affirming surgery. We undertook a qualitative study to understand the needs of transgender men who had given birth. Methods We interviewed 10 transgender men who had been recruited for a recently published online cross-sectional survey of individuals (n = 41). Subjects had given birth while identifying as male. Interviews were recorded, transcribed, and systematically coded. Analysis used a priori and emergent codes to identify central themes and develop a framework for understanding participant experiences. Results Participants reported diverse experiences and values on issues including prioritization and sequencing of transition versus reproduction, empowerment in healthcare, desire for external affirmation of their gender and/or pregnancy, access to social supports, and degree of outness as male, transgender, or pregnant. We identified structural barriers that disempowered participants and describe healthcare components that felt safe and empowering. We describe how patients’ strategies, and providers’ behaviors, affected empowerment. Anticipatory guidance from providers was central in promoting security and empowerment for these individuals as patients. Conclusions Recognizing diverse experiences has implications in supporting future patients through promoting patient-centered care and increasing the experiential legibility. Institutional erasure creates barriers to transgender men getting routine perinatal care. Identifying this erasure helps shape recommendations for how providers and clinics can provide appropriate care. Specific information regarding reproduction can be helpful to patients. We provide recommendations for providers’ anticipatory guidance during the pre-transition, pre-conception, prenatal, and postpartum periods. Ways to support and bring visibility to the experience of transgender men are identified. Improving clinical visibility and affirming gender will likely enhance patient experience and may support patient-centered perinatal healthcare services. Electronic supplementary material The online version of this article (10.1186/s12884-017-1491-5) contains supplementary material, which is available to authorized users.
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The purpose of this review is to create a set of provisional criteria for Institutional Review Boards (IRBs) to refer to when assessing the ethical orientation of transgender health research proposals. We began by searching for literature on this topic using databases and the reference lists of key articles, resulting in a preliminary set of criteria. We then collaborated to develop the following nine guidelines: (1) Whenever possible, research should be grounded, from inception to dissemination, in a meaningful collaboration with community stakeholders; (2) language and framing of transgender health research should be non-stigmatizing; (3) research should be disseminated back to the community; (4) the diversity of the transgender and gender diverse (TGGD) community should be accurately reflected and sensitively reflected; (5) informed consent must be meaningful, without coercion or undue influence; (6) the protection of participant confidentiality should be paramount; (7) alternative consent procedures should be considered for TGGD minors; (8) research should align with current professional standards that refute conversion, reorientation, or reparative therapy; and (9) IRBs should guard against the temptation to avoid, limit, or delay research on this subject.
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Abstract: Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and cul
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Menstruation has long been viewed as an important aspect of women's health. However, scholars and healthcare providers have only recently begun to recognise that transgender men and people with masculine gender identities also menstruate, thus little is known about their attitudes toward and experiences with menstruation. A sample of masculine of centre and transgender individuals with a mean age of 30 years was recruited online to complete measures of attitudes toward menstruation and menstrual suppression and to answer exploratory questions about their experiences managing menstruation. Participants reported mixed attitudes toward menstruation, but generally positive attitudes toward menstrual suppression. Many participants said that they try to avoid public restrooms during menstruation because of practical and psychological concerns. Implications of our findings for the transgender health are discussed.
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Purpose: The transgender population is a small yet distinctive portion of the gynecology patient population, requiring both primary care and specialty services. Recognizing the need for increased education, the Council on Resident Education in Obstetrics and Gynecology (CREOG) developed objectives specific to the care of transgender patients. This study is to assess residency program directors' knowledge about the transgender health CREOG objectives, describe how objectives are being implemented in training programs, and identify what types of educational materials would be useful if available. Methods: In May 2014, an 11-item anonymous survey was sent through e-mail to all eligible program directors of accredited obstetrics and gynecology residency programs. The short questionnaire contained questions about program demographics, approach to training residents with regard to the CREOG objectives, and opinions on tools they would like to use to train their residents on the transgender CREOG objectives. Results: Just under half (47%) of the 86 geographically diverse respondents were from hospital-based programs. The majority reported that the transgender health objectives were important (82%); however, only 70% were familiar with the objectives themselves. Most respondents (96%) felt that providing an educational activity in their training program would be beneficial for their residents' education. Conclusions: Most program directors support the CREOG transgender health objectives and are in favor of implementing educational tools to meet the objectives, suggesting that development of new tools to meet this need would be useful. Future endeavors will be made toward build a training module to facilitate obstetrics and gynecology (Ob-Gyn) programs meeting the CREOG objectives.
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This paper reports on a qualitative study exploring the ways in which transgender adults imagine a place for parenthood in their lives, and/or the ways they have negotiated parenthood with their transgender identity. A total of 13 transgender adults (including parents and non-parents) were interviewed with respect to their thoughts and experiences about family, relationships and parenting. The study sought to understand the possibilities for parenthood that transgender people create, despite barriers imposed by restrictive laws, medical practices and cultural attitudes. Interview data showed how normative assumptions about gender and parenthood shape the way people imagined and desired parenthood. It also showed how participants re-appropriated and resisted normative cultural scripts by either re-imagining parenthood in different terms (such as step-parenthood) or by creating different family forms, such as co-parented families. Participants reported a variety of experiences with healthcare providers when it came to conversations about fertility preservation and family building.
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OBJECTIVE: To conduct a cross-sectional study of transgender men who had been pregnant and delivered after transitioning from female-to-male gender to help guide practice and further investigation. MATERIALS AND METHODS: We administered a web-based survey from March to December 2013 to inquire about demographics, hormone use, fertility, pregnancy experience, and birth outcomes. Participants were not required to have been on hormone therapy to be eligible. We used a mixed-methods approach to evaluate the quantitative and qualitative data. RESULTS: Forty-one self-described transgender men completed the survey. Before pregnancy, 61% (n=25) had used testosterone. Mean age at conception was 28 years with a standard deviation of 6.8 years. Eighty-eight percent of oocytes (n=36) came from participants' own ovaries. Half of the participants received prenatal care from a physician and 78% delivered in a hospital. Qualitative themes included low levels of health care provider awareness and knowledge about the unique needs of pregnant transgender men as well as a desire for resources to support transgender men through their pregnancy. CONCLUSION: Transgender men are achieving pregnancy after having socially, medically, or both transitioned. Themes from this study can be used to develop transgender-appropriate services and interventions that may improve the health and health care experiences of transgender men.
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Menstrual suppression to provide relief of menstrual-related symptoms or to manage medical conditions associated with menstrual morbidity or menstrual exacerbation has been used clinically since the development of steroid hormonal therapies. Options range from the extended or continuous use of combined hormonal oral contraceptives, to the use of combined hormonal patches and rings, progestins given in a variety of formulations from intramuscular injection to oral therapies to intrauterine devices, and other agents such as gonadotropin-releasing hormone (GnRH) antagonists. The agents used for menstrual suppression have variable rates of success in inducing amenorrhea, but typically have increasing rates of amenorrhea over time. Therapy may be limited by side effects, most commonly irregular, unscheduled bleeding. These therapies can benefit women's quality of life, and by stabilizing the hormonal milieu, potentially improve the course of underlying medical conditions such as diabetes or a seizure disorder. This review addresses situations in which menstrual suppression may be of benefit, and lists options which have been successful in inducing medical amenorrhea.
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To what extent do self-reported oligo-amenorrhea and hirsutism affect reproductive performance (childlessness, age at first delivery, family size and miscarriage rates)? At the age of 44, among women with both self-reported oligo-amenorrhea and hirsutism the prevalence of childlessness was not significantly different from non-symptomatic women but they had a smaller family size than non-symptomatic women. Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by oligo-amenorrhea or amenorrhea, hyperandrogenism and hirsutism and it is the most frequent cause of anovulatory infertility, but there are few studies on the reproductive capacity of women with PCOS. In our previous population-based cohort study the women with self-reported oligo-amenorrhea and hirsutism were found to have more infertility problems and smaller family size than non-symptomatic women at the age of 31. A prospective population-based cohort study. The population of the study is derived from the prospective Northern Finland Birth Cohort 1966 (NFBC1966), comprising all expected births from the year 1966 in the two northernmost provinces of Finland (n = 12 058). Of them, 5889 were females. Enrollment in this database begun at the 24th gestational week and so far data have been collected from the subjects at the ages of 1, 14 and 31 years. A postal questionnaire including questions about oligo-amenorrhea and hirsutism was sent to all women at the age of 31 (n = 5608, response rate 81%, n = 4535) and a clinical examination was performed (attendance rate 76.5%). Those who reported both hirsutism and oligo-amenorrhea were defined as women with both symptoms (n = 153). Data on pregnancies/deliveries were obtained from the Finnish Medical Birth Register (FMBR) in 2010 when the women were 44 years old. Women with both symptoms had delivered at least one child as often as non-symptomatic women [75.2 versus 79.0%, adjusted odds ratio (OR) 0.86, 95% confidence intervals (CI) 0.57-1.30], were of similar age [mean (SD)] at first delivery [27.7 (4.81) versus 27.3 (4.71)] and had similar incidence of miscarriages. However, non-symptomatic women had more often ≥2 deliveries (61.6 versus 52.9%, adjusted OR 0.70, 95% CI 0.49-1.00, P = 0.048) and had larger family size [mean (SD)] [2.4 (1.4) versus 1.9 (0.8), P < 0.001]. Women with both symptoms had been treated more often for infertility than non-symptomatic women (6.1 versus 2.4%, adjusted OR 2.74, 95% CI 1.14-6.60, P = 0.024). The diagnosis of oligo-amenorrhea and hirsutism was based on a questionnaire, suggesting a risk of information bias in reporting the symptoms. However, we have previously shown that self-reported oligo-amenorrhea and hirsutism can distinguish most women with the typical profile of PCOS. Only the women who had delivered at least once were recorded in the FMBR, thus excluding from the study those who had experienced miscarriages and/or infertility treatments but did not have a live birth. This feature could potentially decrease the differences in incidence of miscarriages and/or infertility treatment between symptomatic and non-symptomatic subjects. This is one of the few studies, in which the impact of self-reported oligo-amenorrhea and hirsutism on lifetime reproductive success can be measured. Our results suggest that even at more advanced age, women with both symptoms do not quite match the parity of healthy non-symptomatic women, and that infertility treatment does not always restore normal reproductive capacity in these women. Obese women with both symptoms had the worst prognostic as regards reproduction, which emphasizes the importance of life intervention and preventive politics against obesity in this group of women. This work was supported by grants from the Finnish Medical Society Duodecim, the North Ostrobothnia Regional Fund, the Academy of Finland, University Hospital Oulu, Biocenter, University of Oulu, Finland, the European Commission and the Medical Research Council, UK, the National Institute for Health Research (NIHR). None of the authors has any conflict of interest to declare.
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The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
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This consensus statement is an executive summary of several papers resulting from a 2009 consensus process comprising nine work groups and 37 members of the World Professional Association for Transgender Health (WPATH). The purpose of this group was to put forth recommendations for the upcoming revision of the DSM with respect to the Gender Identity Disorder diagnoses. The consensus process was collaborative, interdisciplinary, and evidence based. A majority (but not all) of the participants believed that a diagnosis related to Gender Identity Disorder should remain in the DSM, and many advocated changes in name, diagnostic criteria, and placement within the DSM. The proposed name is Gender Dysphoria, and the diagnostic criteria should be distress based. Placement should be outside the chapter on Sexual Disorders and possibly within Psychiatric Disorders Related to a Medical Condition. If there were to be a diagnostic category for childhood, there should also be separate categories for adults and adolescents. A Not Otherwise Specified category should be retained, and Disorders of Sex Development should not be an exclusionary criterion for Gender Dysphoria.
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Hirsutism, defined by the presence of excessive terminal hair in androgen-sensitive areas of the female body, is one of the most common disorders in women during reproductive age. We conducted a systematic review and critical assessment of the available evidence pertaining to the epidemiology, pathophysiology, diagnosis and management of hirsutism. The prevalence of hirsutism is ~10% in most populations, with the important exception of Far-East Asian women who present hirsutism less frequently. Although usually caused by relatively benign functional conditions, with the polycystic ovary syndrome leading the list of the most frequent etiologies, hirsutism may be the presenting symptom of a life-threatening tumor requiring immediate intervention. Following evidence-based diagnostic and treatment strategies that address not only the amelioration of hirsutism but also the treatment of the underlying etiology is essential for the proper management of affected women, especially considering that hirsutism is, in most cases, a chronic disorder needing long-term follow-up. Accordingly, we provide evidence-based guidelines for the etiological diagnosis and for the management of this frequent medical complaint.
Article
Background: As part of transition, transmasculine persons often use testosterone gender-affirming hormone therapy; however, there is limited data on its long-term effects. The impact of exogenous testosterone on uterine pathology remains unclear. While testosterone achieves amenorrhea in the majority of this population, persistence of abnormal uterine bleeding can be difficult to manage. Excess androgens in cisgender females are associated with pathologic uterine processes such as polycystic ovary syndrome, endometrial hyperplasia, or cancer. There are no guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population. Objective: The aim of this study was to describe the characteristics of uterine pathology after the initiation of testosterone in transmasculine persons. Materials and methods: A retrospective, multicenter case series was performed. Uterine pathology reports of transmasculine persons who received testosterone and subsequently underwent hysterectomy were reviewed. The endometrial phase and endometrial thickness were recorded. Results: A total of 94 subjects met search criteria. The mean age of participants was 30 ± 8.6 years, and the mean interval from initiation of testosterone to hysterectomy was 36.7 ± 36.6 months. Active endometrium was found in the majority of patients (n = 65; 69.1%). One patient had complex hyperplasia without atypia. There were no cases of endometrial cancer. Conclusion: Despite amenorrhea in the majority of transmasculine persons on testosterone, endometrial activity persists with predominantly proliferative endometrium on histopathology. Individualized counseling for abnormal uterine bleeding is encouraged in this patient population.
Article
In this article, we consider the impact of gendered language on our ability to provide inclusive care and to address health disparities experienced by transgender and non-binary people. We posit that while obstetrician gynecologists and others trained in women's health are already well-positioned to extend care to this population, we can improve this care through simple adjustments in the framing and language we use.
Article
Objectives: Female-to-male (FTM) transgender men (affirmed males) can experience planned and unplanned pregnancy during and after testosterone therapy. We conducted an exploratory study to understand current contraceptive practices and fertility desires among transgender men during and after transitioning. Study design: Self-identified transgender and transmasculine individuals assigned female at birth, ages 18-45, completed an anonymous online survey derived from standardized family planning surveys. We recruited participants from LGBT health centers, online listservs, and online groups for transgender men and used a mixed-methods analysis to evaluate quantitative and qualitative data. Results: Of the one hundred and ninety-seven participants included in the study, the median age was 30years old, most respondents were white, and 86% were taking masculinizing hormones (testosterone). Of the 60 pregnancies reported, 10 (17%) pregnancies occurred after stopping testosterone, 1 (1.6%) while taking testosterone irregularly, and 5 of 7 abortions occurred in participants who had been using testosterone in the past. Over half of the respondents desired at least one child, and a quarter reported fears of not getting pregnant. The majority of participants reporting using contraception (n=110, 60.1%), with condoms and pills used most commonly (n=90, 49.2% and n=62, 33.9% respectively). Methods of contraception used did not differ between testosterone users and non-users, except for hormonal IUDs (20% testosterone versus 7% non-testosterone). Thirty participants (16.4%) believed that testosterone was a form of contraception, and 10 (5.5%) participants reported that their healthcare providers advised testosterone as contraception. Conclusion: Transgender men use contraception and can experience pregnancy and abortion, even after transitioning socially and hormonally. Transgender men need counseling and care regarding reproductive health, including contraceptive and conception counseling. Implications: Providers should be aware that transgender men may desire pregnancy and use contraception; This study highlights the need for further research regarding fertility, fertility desires, and optimal contraception among transgender men.
Article
Background: Little research documents the self-identified reproductive health priorities and health care experiences of lesbian, gay, bisexual, transgender, queer (LGBTQ)-identified individuals who may be in need of services. Methods: We conducted in-depth interviews with a diverse sample of 39 female-assigned-at-birth individuals (ages 18-44) who also identified as lesbian, bisexual, queer, and/or genderqueer, or transmasculine. Interviews were primarily conducted in person in the Bay Area of California, and Baltimore, Maryland, with 11 conducted remotely with participants in other U.S. Locations: We asked participants about their current reproductive health care needs, topics they felt researchers should pursue, and past reproductive health care experiences. Data were analyzed using a framework method, incorporating deductive and inductive thematic analysis techniques. Results: Reproductive health care needs among participants varied widely and included treatment of polycystic ovary syndrome and irregular menses, gender-affirming hysterectomies, and fertility assistance. Many faced challenges getting their needs met. Themes related to these challenges cross-cutting across identity groups included primary focus on fertility, provider lack of LGBTQ health competency relevant to reproductive health priorities and treatment, and discriminatory comments and treatment. Across themes and identity groups, participants highlighted that sexual activity and reproduction were central topics in reproductive health care settings. These topics facilitated identity disclosures to providers, but also enhanced vulnerability to discrimination. Conclusions: Reproductive health priorities of LGBTQ individuals include needs similar to cisgender and heterosexual groups (e.g., abortion, contraception, PCOS) as well as unique needs (e.g., gender affirming hysterectomies, inclusive safer sex guidance) and challenges in pursuing care. Future reproductive health research should pursue health care concerns prioritized by LGBTQ populations.
Article
Objective: Existing transgender treatment guidelines suggest that for transmasculine treatment, there is a possible need for estrogen-lowering strategies adjunct to testosterone therapy. Further, guidelines advocate consideration of prophylactic female reproductive tissue surgeries for transgender men to avoid the possibility of estrogen-related health risks. Despite the paucity of objective data, some transgender men seek conversion inhibitors. We sought to determine estradiol levels in transgender men treated with testosterone therapy and the change in those levels with treatment, if any. Methods: Estradiol levels were extracted from the electronic medical records of 34 anonymized transgender men treated with testosterone therapy at the Endocrinology Clinic at Boston Medical Center. Data were sufficient to observe 6 years of follow up. Results: With increased testosterone levels in transgender men, a significant decrease in estradiol levels was noted. There was a significant negative correlation between testosterone levels and body mass index, which may serve to explain part of the mechanism for the fall in estradiol levels. Even though the fall in estradiol levels was significant statistically, the actual levels remained within the normal male range, even with 6 years of follow-up. Conclusion: These data suggest that when exogenous testosterone is used to achieve normal serum male testosterone levels for transgender men, it is converted to normal male levels of estradiol, with some decline in those estradiol levels that might be attributable to a fall in fat mass. There appears to be no role for aromatase conversion inhibitors or other estrogen-reducing strategies in transgender men. Abbreviation: BMI = body mass index.
Article
Study objective: This study sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder. DESIGN, SETTING, PARTICIPANT, INTERVENTION, AND MAIN OUTCOME MEASURES: Retrospective chart review of adolescent <21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information included demographics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into two categories based on the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared. Results: 73 subjects tested for a bleeding disorder. Of the subjects completing testing, 34 (46%) were diagnosed with a bleeding disorders. 39 (54%) subjects had heavy menstrual bleeding due to other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without bleeding disorder. When comparing hormone therapy success, the levonorgestrel IUD (LNG-IUD) (89%) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10mg/day (83%), and the transdermal patch (80%). All subjects using both tranexamic acid and hormonal therapy had 100% achievement of menstrual suppression. Conclusion: A high frequency of bleeding disorder was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. While combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option.
Article
Purpose: Little is known about the reproductive desires of transgender and gender-nonconforming (TGNC) adolescents who may seek gender-affirming medical care that leads to infertility. The current study addressed this gap by examining attitudes toward fertility and family formation in a diverse sample of TGNC youth. Method: An online survey about sexual/reproductive health in sexual and gender minority (SGM) adolescents ages 14-17 years was conducted from September to October 2016. Results: A total of 156 TGNC adolescents (Mage = 16.1 years; 83.3% assigned female at birth; 58.3% youth of color) responded. Overall, 70.5% of TGNC adolescents were interested in adoption and 35.9% in biological parenthood; more gender-nonconforming youth (43.8%) than transgender youth (25.8%) expressed interest in biological fertility. Discussions with health-care providers about fertility and reproductive health were uncommon-only 20.5% of youth had discussed fertility in general and only 13.5% had discussed effects of hormones on fertility. However, 60.9% of respondents were interested in learning more about their fertility and family building options. Key themes emerging from qualitative comments included concerns related to fertility/reproductive health (e.g., stigma of SGM parenthood, effect of gender-affirming treatments on fertility), and the need for additional reproductive health information both tailored to their individual experience and for SGM individuals more generally. Discussion: TGNC adolescents expressed interest in multiple family building options, including adoption and biological parenthood, and identified a need for more information about these options. Thus, clinicians working with adolescents should be aware of the unique fertility and reproductive health needs of TGNC youth.
Article
Background: The subdermal contraceptive implant and the 52-mg levonorgestrel intrauterine device are currently Food and Drug Administration approved for 3 and 5 years of use, respectively. Limited available data suggested both of these methods are effective beyond that time. Demonstration of prolonged effectiveness will improve the cost-effectiveness of the device, and potentially patient continuation and satisfaction. Objective: We sought to evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device in women using the method for 2 years beyond the current Food and Drug Administration-approved duration. Study design: We initiated this ongoing prospective cohort study in January 2012. We are enrolling women using the contraceptive implant or 52-mg levonorgestrel intrauterine device for a minimum of 3 and 5 years, respectively (started intrauterine device in ≥2007 or implant in ≥2009). Demographic and reproductive health histories, as well as objective body mass index, were collected. Implant users were offered periodic venipuncture for analysis of serum etonogestrel levels. The primary outcome, unintended pregnancy rate, was calculated per 100 woman-years. We analyzed baseline demographic characteristics using χ(2) test and Fisher exact test, and compared serum etonogestrel levels stratified by body mass index using the Kruskal-Wallis test. Results: Implant users (n = 291) have contributed 444.0 woman-years of follow-up. There have been no documented pregnancies in implant users during the 2 years of postexpiration follow-up. Calculated failure rates in the fourth and fifth years for the implant are calculated as 0 (1-sided 97.5% confidence interval, 0-1.48) per 100 woman-years at 4 years and 0 (1-sided 97.5% confidence interval, 0-2.65) per 100 woman-years at 5 years. Among 496 levonorgestrel intrauterine device users, 696.9 woman-years of follow-up have been completed. Two pregnancies have been reported. The failure rate in the sixth year of use of the levonorgestrel intrauterine device is calculated as 0.25 (95% confidence interval, 0.04-1.42) per 100 woman-years; failure rate during the seventh year is 0.43 (95% confidence interval, 0.08-2.39) per 100 woman-years. Among implant users with serum etonogestrel results, the median etonogestrel level was 207.7 pg/mL (range 63.8-802.6 pg/mL) at the time of method expiration, 166.1 pg/mL (range 67.9 25.0-470.5 pg/mL) at the end of the fourth year, and 153.0 pg/mL (range 72.1-538.8 pg/mL) at the end of the fifth year. Median etonogestrel levels were compared by body mass index at each time point and a statistical difference was noted at the end of 4 years of use with overweight women having the highest serum etonogestrel (195.9; range 25.0-450.5 pg/mL) when compared to normal (178.9; range 87.0-463.7 pg/mL) and obese (137.9; range 66.0-470.5 pg/mL) women (P = .04). Conclusion: This study indicates that the contraceptive implant and 52-mg hormonal intrauterine device continue to be highly effective for at least 2 additional years of use. Serum etonogestrel evaluation demonstrates median levels remain above the ovulation threshold of 90 pg/mL for women in all body mass index classes.
Article
Clinicians, including hematologists,are more frequently encountering transgender individuals in practice; however,most lack training on the management and complications of transgender medicine. Hormonal therapy forms the backbone of medical interventions for patients undergoing gender transition. While supplementing an individual's intrinsic sex hormone is associated with a variety of hematologic complications including increased rates of venous thrombosis, cardiovascular events, erthyrocytosis, and malignancy, the risks of supplementing with opposing sex hormones are not well understood. Data on the hematologic complications of these therapies are accumulating but remain limited, and clinicians have little experience with their management. This review highlights the current interventions available in transgender medicine andrelated potential hematologic complications, and it suggests simple, evidence-based management going forward. This article is protected by copyright. All rights reserved.
Article
Background: Health communication and interpersonal skills are increasingly emphasized in the measurement of health care quality, yet there is limited research on the association of interpersonal care with health outcomes. As approximately 50% of pregnancies in the United States are unintended, whether interpersonal communication influences contraceptive use is of public health importance. Objective: The aim of this study was to determine whether the quality of interpersonal care during contraceptive counseling is associated with contraceptive use over time. Study design: The Patient-Provider Communication about Contraception study is a prospective cohort study of 348 English-speaking women seen for contraceptive care, conducted between 2009 and 2012 in the San Francisco Bay Area. Quality of communication was assessed using a patient-reported interpersonal quality in family planning care measure based on the dimensions of patient-centered care. In addition, the clinical visit was audio recorded and its content coded according to the validated Four Habits Coding Scheme to assess interpersonal communication behaviors of clinicians. The outcome measures were 6-month continuation of the selected contraceptive method and use of a highly or moderately effective method at 6 months. Results were analyzed using mixed effect logistic regression models controlling for patient demographics, the clinic and the provider at which the visit occurred, and the method selected. Results: Patient participants had a mean age of 26.8 years (SD 6.9 years); 46% were white, 26% Latina, and 28% black. Almost two-thirds of participants had an income of <200% of the Federal Poverty Level. Most of the women (73%) were making visits to a provider whom they had not seen before. Of the patient participants, 41% were still using their chosen contraceptive method at 6-month follow-up. Patients who reported high interpersonal quality of family planning care were more likely to maintain use of their chosen contraceptive method (adjusted odds ratio [aOR], 1.8; 95% CI, 1.1-3.0) and to be using a highly or moderately effective method at 6 months (aOR, 2.0; 95% CI, 1.2-3.5). In addition, 2 of the Four Habits were associated with contraceptive continuation; "invests in the beginning" (aOR, 2.3; 95% CI, 1.2-4.3) and "elicits the patient's perspective" (aOR, 1.8; 95% CI, 1.0-3.2). Conclusion: Our study provides evidence that the quality of interpersonal care, measured using both patient report and observation of provider behaviors, influences contraceptive use. These results provide support for ongoing attention to interpersonal communication as an important aspect of health care quality. The associations of establishing rapport and eliciting the patient perspective with contraceptive continuation are suggestive of areas of focus for provider communication skills training for contraceptive care.
Article
Purpose of review: We provide an update of bone health in trans persons on cross-sex hormonal therapy. This drastic hormonal reversal will have direct but also indirect effects on bone, through body composition changes. Recent findings: Recent evidence suggests that trans women, even before the start of any hormonal intervention, already have a lower bone mass, a higher frequency of osteoporosis, and a smaller bone size vs. natal men. During cross-sex hormonal treatment, bone mass was maintained or gained in trans women. In trans men, bone metabolism seemed to increase during short-term testosterone therapy, but no major changes have been found in bone density. On long-term testosterone therapy, larger cortical bone size was observed in trans men vs. natal women. Summary: Follow-up of bone health and osteoporosis prevention in trans persons is important. We advise active assessment of osteoporosis risk factors including the (previous) use of hormonal therapy. Based on this risk profile and the intended therapy, bone densitometry may be indicated. Long-term use of antiandrogens or gonadotropin-releasing hormone agonists alone should be monitored as trans women may have low bone mass, even prior to treatment. Therapy compliance with the cross-sex hormones is of major concern, especially after gonadectomy. Large-scaled, multicenter, and long-term research is needed to determine a well tolerated dosage of cross-sex hormonal treatment, also in elderly trans persons.
Article
Background: Medical school and residency curricula are lacking in content on the care of the transgender patient. As a result, many providers do not have enough experience and knowledge to adequately care for this patient population. The aim of this study was to assess gynecologists' preferences and knowledge base with regard to transgender healthcare. Methods: This was a cross-sectional survey of obstetrics and gynecology (OBGYN) providers. An anonymous survey was sent via electronic mail to nine academic OBGYN departments across the United States. Survey questions were designed to assess provider experience and practice environment, education about transgender health practices, personal experience with transgender patients, and knowledge base regarding current recommendations for the care of gender minority patients. Results: Of the 352 providers who received the survey, 141 responded, for a 40.1% response rate. Of the respondents, 61.7% (87 of 141) were generalist OBGYNs, and 86% (117 of 136) practiced in an academic institution; 80% (113 of 141) did not receive training in residency on the care of transgender patients. Time in practice was not associated with having learned about transgender care. Only 35.3% and 29% were comfortable caring for male-to-female and female-to-male transsexual patients, respectively; and, 88.7% and 80.4% were willing to perform screening Pap smears on female-to-male transsexual patients and routine breast examinations on male-to-female patients, respectively. Eighty-two of 138 providers (59.4%) did not know the recommendations for breast cancer screening in male-to-female patients. Conclusions: Efforts should be made to educate trainees on the important aspects of transgender care, and comprehensive guidelines should be published for practicing providers.
Article
Introduction: Like members of any other population, transgender and gender variant people--individuals whose gender identity varies from the traditional norm or from the sex they were assigned at birth--often seek parenthood. Little is known about the decision making and experiences of these individuals, including male-identified and gender-variant natal females who wish to achieve parenthood by carrying a pregnancy. This pilot qualitative study used grounded theory methodology to explore the conception, pregnancy, and birth experiences of this population of parents. Methods: A grounded theory methodology was used to guide data collection and analysis. Eight male-identified or gender-variant gestational parents participated in the study. Data collection included individual 60-minute to 90-minute interviews conducted by recorded online video calls, as well as a self-administered online demographic survey. Data were collected from September 2011 through May 2012. Data saturation was achieved at 6 interviews, after which 2 more interviews were conducted. The interviews were transcribed verbatim, and a constant comparative method was used to analyze the interview transcripts. Results: Loneliness was the overarching theme that permeated participants' experiences, social interactions, and emotional responses during every stage of achieving biologic parenthood. Within this context of loneliness, participants described complex internal and external processes of navigating identity. Navigating identity encapsulated 2 subthemes: undergoing internal struggles and engaging with the external world. The preconception period was identified as participants' time of greatest distress and least involvement with health care. Discussion: The findings of this study suggest that culturally-sensitive preconception counseling could be beneficial for transgender and gender-variant individuals. The grounded theory produced by this pilot investigation also provides insights that will be useful to health care providers and others working with male-identified and gender-variant prospective parents.
Article
In recent years, resistance to the cultural, political, and legal barriers facing trans people has gained greater attention. As trans resistance grows, we will increasingly see trans people making demands for access to education. In this two-part essay, I offer tips for addressing obstacles to trans students’ classroom participation and for avoiding unintentional exclusionary practices. In the first part, I suggest guidelines for referring to students by their preferred names and pronouns. In the second, I address people who talk about bodies, within and outside classrooms, suggesting ways to avoid implying that gender is defined by body parts. + Do not call the roll or otherwise read the roster aloud until you have given students a chance to state what they prefer to be called, in case the roster represents a prior name. + Allow students to self-identify the name they go by and what pronouns they prefer. Do not make assumptions based on the class roster or the student’s appearance. A great way to accomplish this is to pass around a seating chart or sign-in sheet and ask them to indicate these items in writing—as well as whether they prefer Mr. or Ms. in contexts using that formality, like law schools—and then use it when you call on them or refer to them in class. In smaller groups, you can do a go-around on the first day where people state what name and pronoun they would like to be called in class. + If you are aware of a student’s former name that they do not use, either because you knew them before they changed it or because it is on the roster, do not use it or reveal it to others. Well meaning comments like “I knew Gina when she was Bill,” even if meant supportively, reveal what might feel like personal information to the student, and unnecessarily draw attention to their trans identity. If they want to share their former name or trans history or identity with others, they can do so, but others should not share those for them. + Set a tone of respect. At the beginning of each semester when establishing the guidelines for class (do not surf the internet while in class, do the reading, be punctual) include something like: “It is important that this classroom be a respectful environment where everyone can participate comfortably. One part of respectful behavior is that everyone should be referred to by what they go by. This includes pronouncing people’s names correctly and referring to them by the pronouns they prefer.” Add in whatever guidelines for respect that you see as important, but make sure to include pronoun usage since people are often unaware of the issue. I present at the end of this section a pronoun etiquette sheet that you can use if you want to give students more information on the issue. Keep in mind that some students, even at the graduate level, do not seem to know what a pronoun is and you may need to use an example by saying something like, “For example, I prefer to be referred to as ‘he/him.’” + If you make a mistake about someone’s pronoun, correct yourself. Going on as if it did not happen is actually less respectful than making the correction. This also saves the person who was misidentified from having to correct an incorrect pronoun assumption that has now been planted in the minds of classmates or anyone else who heard the mistake. It is essential, especially as teachers, that we model respectful behavior. + Whether in office hours, when speaking with students in groups, or when speaking with faculty and staff, when someone else makes a pronoun mistake, correct them. It is polite to provide a correction, whether or not the person whose pronoun was misused is present, in order to avoid future mistakes and in order to correct the mistaken assumption that might now have been planted in the minds of any other participants in the conversation who heard the mistake. Allowing the mistake to go uncorrected ensures future uncomfortable interactions for...
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This paper reports on findings from a qualitative interview-based study of women’s experiences and perceptions of menstrual suppression using a diverse sample of 12 women from Vancouver, Canada. The study used open-ended, in-depth interviews to ask women questions related to the following overarching research question: How do Canadian women perceive and experience menstrual suppression? Of the 12 women, six had experience with menstrual suppression, while six had never suppressed their periods. The six women who suppressed their periods cited convenience, pain management, and feeling more positively about their bodies as their reasons for suppression. The six women who had not suppressed their cycles cited fears about compromising their health, worries about altering the “natural” menstrual cycle, and an uneasiness with pharmaceutical products in general as rationales for rejecting menstrual suppression. Ultimately, the findings reveal that there are many considerations and factors involved in women’s decisions about menstrual frequency. While many of the women appreciated the appeal of menstrual suppression, the long-term risks and health uncertainties deterred many of them from reducing their menstrual frequency. The findings are discussed in relation to medical literature which encourages women to suppress their menses, as well as sociological theorizing about menstrual culture within a Foucauldian framework of discipline and control.
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The American Congress of Obstetricians and Gynecologists (ACOG) has endorsed intrauterine devices (IUDs) as first-line contraceptive choices for both nulliparous and parous adolescents. The committee opinion did address some of the practical elements of IUD use in adolescents, but because these practical concerns may be barriers to use for both teens and clinicians, this review is devoted to "practical tips," based on the available literature as well as the author's clinical experience. Counseling, informed consent, techniques of pain management, and preventive guidance about possible side effects are addressed in an effort to promote successful use of this long-acting reversible contraception (LARC) option.
Article
To evaluate an integrated analysis of bleeding patterns associated with use of the subdermal contraceptive implant Implanon (etonogestrel, Organon, part of Schering-Plough) and to provide physician guidance to optimize patient counselling. Data from 11 clinical trials were reviewed (N = 923). Assessments included bleeding-spotting records, dysmenorrhoea, and patient-perceived reasons for discontinuation. Bleeding patterns were analysed via reference period (RP) analyses. Implanon use was associated with the following bleeding irregularities: amenorrhoea (22.2%) and infrequent (33.6%), frequent (6.7%), and/or prolonged bleeding (17.7%). In 75% of RPs, bleeding-spotting days were fewer than or comparable to those observed during the natural cycle, but they occurred at unpredictable intervals. The bleeding pattern experienced during the initial phase predicted future patterns for the majority of women. The group of women with favourable bleeding patterns during the first three months tended to continue with this pattern throughout the first two years of use, whereas the group with unfavourable initial patterns had at least a 50% chance that the pattern would improve. Only 11.3% of patients discontinued owing to bleeding irregularities, mainly because of prolonged flow and frequent irregular bleeding. Most women (77%) who had baseline dysmenorrhoea experienced complete resolution of symptoms. Implanon use is associated with an unpredictable bleeding pattern, which includes amenorrhoea and infrequent, frequent, and/or prolonged bleeding. The bleeding pattern experienced during the first three months is broadly predictive of future bleeding patterns for many women. Effective preinsertion counselling on the possible changes in bleeding patterns may improve continuation rates.
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Abstract unintended pregnancy may worsen the condition and carry even greater risk of adverse pregnancy outcomes, including maternal and perinatal death. Although safe and highly effective contraceptive methods are available to prevent unintended pregnancy, there may be concerns about the safety of contraceptive methods among women with medical conditions. The Centers for Disease Control and Prevention (CDC) has recently developed the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, which provides evidence-based recommendations for the safety of contraceptive use among women with medical conditions. Most women, even those with medical conditions, can safely use most methods of contraception.
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While there is a large body of evidence on the effectiveness of Pap smears for cervical cancer screening and on screening for cervical gonorrhea and Chlamydia, there is sparse evidence to support other portions of the pelvic examination and little guidance on examination logistics. Maximizing comfort should be the goal; lubrication use and careful speculum selection and insertion can ease this intrusive procedure. This is particularly important in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia. We review the evidence and provide guidance to minimize physical and psychological discomfort with pelvic examination.