Society of Family Planning clinical recommendations: Contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth

Hormonal contraceptives and behavior: Updating the potent state of the nascent science

Hundreds of millions of people worldwide use hormonal contraceptives (HCs), which have been an essential part of women's reproductive health care for decades. Throughout that time, however, research on the neural and behavioral consequences of HCs was minimal and plagued by poor methodology. HC effects - and users - were assumed to be homogenous. Fortunately, there has been a recent upswell in the number and quality of investigations, affording tentative conclusions about the roles of HCs in spatial cognition and mental health, particularly depression. Thus, this paper leverages findings from the past few years to highlight the heterogeneous aspects of use that seem to matter for behavior - ranging from variation in hormonal contraceptive formulations and routes of administration to individual differences among users linked to age and reproductive health history. This paper closes with five tips for future research that will help capture and clarify heterogeneity in potential relations between HCs and behavior, namely data collection, regional access, lifespan factors, gender, and collaboration. HCs are sociopolitically provocative and research on their potential behavioral neuroendocrine impacts is becoming increasingly popular. It is, therefore, imperative for scientists to conduct replicable and robust empirical investigations, and to communicate findings with the nuance that the heterogeneity among users and effects requires.

Gynecologic Care for Sexual and Gender Minority Patients

Sexual and gender minority (SGM) people, including lesbian, gay, bisexual, transgender, and queer individuals, are a diverse population with a wide spectrum of gynecologic needs. Institutionalized cisheteronormativity, stigmatization, lack of provider training, and fear of discrimination contribute to health disparities in this patient population. In this article, we review key topics in the gynecologic care of SGM patients and provide strategies to enable gynecologists to provide SGM people with equitable and inclusive full spectrum reproductive health care.

Lived Experience of Acne and Acne Treatment in Transgender Patients

Importance

While acne is common in transgender and gender-diverse people and is associated with gender-affirming hormone therapy, little research has examined these factors and their impact in gender minority groups.

Objective

To examine the lived experiences of acne and acne treatment in transgender and gender-diverse participants.

Design, Setting, and Participants

This mixed-methods analysis was conducted at a multidisciplinary gender center at a public safety-net hospital and endocrinology and dermatology clinics at a tertiary academic center from January 4, 2021, to April 7, 2022, using semistructured interviews and surveys. Participants were transgender or gender-diverse adults who had received gender-affirming hormone therapy. Data analysis was performed from November 11, 2021, to March 31, 2023.

Exposure

Current diagnosis of acne.

Main Outcomes and Measures

Interviews exploring the experience of acne and acne treatment were audio recorded, transcribed verbatim, coded using minority stress theory and the socioecological model, and analyzed using thematic analysis. Themes were triangulated with survey data on gender, self-reported acne severity, skin-specific quality-of-life impact, and treatment experience.

Results

A total of 32 participants were included in the study (mean [range] age, 32 [18-57] years; 17 transgender men, 11 transgender women, and 4 nonbinary participants). Ten participants (31%) self-rated their skin as currently clear or almost clear, 11 (34%) reported mild acne, and 11 (34%) had moderate to severe acne. Participants described experiences of rejection and bullying related to acne and admitted avoiding social interactions in which they anticipated acne-related discrimination, which led to feelings of depression and anxiety. Acne worsened body appearance dissatisfaction. Transgender women reported acne interfering with feminine gender expression. Transgender men often normalized acne development, sometimes viewing acne positively as an early sign of testosterone action. Most participants tried over-the-counter acne treatments and commonly sought acne treatment advice from physicians, peers, online forums, and social media. Barriers to acne treatments included cost, lack of multidisciplinary care, mistrust toward the health care system, and lack of transgender-specific acne care education.

Conclusions and Relevance

In this mixed-methods study, transgender and gender-diverse individuals reported experiencing acne-related stigma and facing barriers to acne treatment. Multilevel changes, such as developing strategies to reduce acne stigma, providing transgender-specific acne care education, facilitating multidisciplinary acne care, and expanding transgender-friendly clinical environments, are recommended to reduce the impact of acne in transgender individuals.

Assessing comprehension of the Parenting/Pregnancy Attitudes, Timing, and How Important (PATH) questions through cognitive interviewing

OBJECTIVES

PATH, "Parenting/Pregnancy Attitudes, Timing, and How Important," is a method for providers to engage in a person-centered discussion about reproductive desires. This study sought to assess patient understanding of and receptivity to PATH questions.

STUDY DESIGN

Cognitive interviews were conducted with young adult (aged 18-29 years) patients at a federally qualified health center in New York (n = 10).

RESULTS

Participants demonstrated clear comprehension and comfort with the PATH questions.

IMPLICATIONS

These data provide needed person-driven support for the Centers for Disease Control and Prevention and the Society of Family Planning's recommendation to implement PATH questions as a patient-centered method for discussing an individual's reproductive desires.

Evidence-based sexual healthcare for the LGBTQIA2+ patient across the lifespan

ABSTRACT

People who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, two-spirit, or other minority sexual and gender identities (LGBTQIA2+) often avoid seeking healthcare due to social discrimination and stigma. Clinical education in LGBTQIA2+-affirming care is essential but often lacking across disciplines. Provider acceptance, awareness of personal biases, and understanding of microaggressions affecting LGBTQIA2+ people can improve access, outcomes, and survival for this population. Expertise in caring for LGBTQIA2+ people in rural and suburban communities, for people who are transgender, and for people who have undergone or are in the process of undergoing gender-affirming surgeries is essential to offer best-practice healthcare.

Incidence and Factors Associated With Acne in Transgender Adolescents on Testosterone: A Retrospective Cohort Study

OBJECTIVE

This retrospective cohort study aimed to assess incidence and predictors of acne among transgender adolescents receiving testosterone.

METHODS

We analyzed records of patients aged <18 years, assigned female at birth, seen at Children's Healthcare of Atlanta Pediatric Endocrinology clinic for testosterone initiation between January 1, 2016, and January 1, 2019, with at least 1-year follow-up documented. Bivariable analyses to determine the association of clinical and demographic factors with new acne diagnosis were performed.

RESULTS

Of 60 patients, 46 (77%) did not have baseline acne, but of those 46 patients, 25 (54%) developed acne within 1 year of testosterone initiation. Overall incidence proportion was 70% at 2 years; patients who used progestin prior to or during follow-up were more likely to develop acne than nonusers (92% vs 33%, P <.001).

CONCLUSION

Transgender adolescents starting testosterone, particularly those taking progestin, should be monitored for acne development and treated proactively by hormone providers and dermatologists.

Menstrual Suppression in Adolescent and Young Adult Transgender Males

OBJECTIVE

To describe time to cessation of menses in adolescent and young adult transgender males with testosterone and/or other hormonal therapies DESIGN: Retrospective chart review SETTING: Tertiary children's hospital PARTICIPANTS: Patients, aged 10-24, who began gender-affirming hormonal therapy between January 2013 and January 2019 (n = 220) INTERVENTION(S): None MAIN OUTCOME MEASURE(S): Time to cessation of menses RESULTS: Most patients identified as transgender male or transmasculine (211/220, 95.9%), with an average age of 15.8 (±1.9) years. Approximately 53.6% (118/220) of patients reported regular menstrual cycles; 18.2% (40/220) reported irregular cycles. Median time to cessation of menses for all patients was 182 days. Patients treated with testosterone alone (n = 105) reported a median time to cessation of menses of 151 days. Patients who concurrently began testosterone and norethindrone acetate (NETA) (n = 5) had a median time to cessation of menses of 188 days, compared with 168 days for those on testosterone and depot medroxyprogesterone acetate (DMPA, n = 15). In 15 patients who began testosterone, a progestin therapy was later added to induce menstrual suppression, and the median time to cessation of menses was 168 days (+DMPA, n = 4) or 56 days (+NETA, n = 11). Patients treated with NETA (n = 14) or depot leuprolide (n = 11) reported a median time to cessation of menses of 78 days or 77 days, respectively. Considerable variability in prescribing patterns was noted in the remaining 36.4% of patients (n = 80).

CONCLUSION

Patients used a variety of different hormonal regimens for menstrual suppression. Less than half achieved cessation of menses within 6 months. NETA and depot leuprolide users reported the most rapid cessation of menses.

Breaking the Binary: How Clinicians Can Ensure Everyone Receives High Quality Reproductive Health Services

The gender binary has historically defined the study and practice of reproductive and sexual healthcare. However, the male and female binary categorization of sex does not adequately define patients seeking reproductive and sexual health. Comprehensive sexual healthcare should consider diverse gender identity and non-heteronormative sexual practices, family planning, sexually transmitted infections, cancer prevention, and sexual function. Recent research suggests clinicians do not feel prepared to provide care for sexual and gender minority (SGM) patients. In this narrative review, we focus on reproductive and sexual health within the scope of obstetric and gynecologic (OB/GYN) clinical practice. We used traditional medical subject headings to summarize data from publications in peer-reviewed journals published in the last 10 years and identified barriers, facilitators and best practices for de-gendering reproductive healthcare. Following a roughly chronological care path across the lifespan, we categorized findings into the following topics: Early Care for SGM, Sexual Health, Family Planning, and Care Later in Life for SGM. We include recommendations for creating a welcoming environment, SGM inclusive training for clinicians and staff, and best practices for individualized counseling. We review suggested practices related to service delivery and clinical considerations in the provision of sexual and reproductive health care for gender and sexual minority patients.

Society of Family Planning Clinical Recommendation: Emergency contraception

Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.

Recap of the sixth international symposium on intrauterine devices and systems for women's health

Due to the COVID-19 pandemic, the Sixth International Symposium on Intrauterine Devices and Systems for Women's Health was held as a series of seven 2-hour webinars between May 28, 2020, and June 22, 2021. This Symposium featured 48 different presenters and moderators covering a wide range of topics to highlight new IUD issues and update general IUD knowledge, just as it was done in previous symposia dating back to 1962 [1-5]. A total of 1346 people attended remotely to observe the events live. In this article, we share summaries of the presentations from the sixth symposium. These summaries, provided by the presenters, are meant to archive the symposium. This article gives the reader an overview of the topics and identifies the sessions' moderators and speakers charged with providing the content. Those interested in further detail, references, and information about the speakers can find more information on the conference website: www.iud2020.com. After the summaries, we share ideas for future IUD research and programmatic needs, as provided by Symposium's presenters and organizers. The authors' summaries are personal opinions and do not necessarily reflect the perspectives of the Symposium's organizers or the medical community at large. The Symposium was recorded and the sessions are available for viewing free of charge at the website, www.iud2020.comor on YouTube. As of July 2022, approximately 1700 visitors have viewed the recordings.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Contraceptive Counseling for the Transgender Patient Assigned Female at Birth

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.

Values and preferences for contraception: A global systematic review

OBJECTIVE

To identify and synthesize original research on contraceptive user values, preferences, views, and concerns about specific family planning methods, as well as perspectives from health workers.

STUDY DESIGN

We conducted a systematic review of global contraceptive user values and preferences. We searched 10 electronic databases for qualitative and quantitative studies published from 2005 to 2020 and extracted data in duplicate using standard forms.

RESULTS

Overall, 423 original research articles from 93 countries among various groups of end-users and health workers in all 6 World Health Organization regions and all 4 World Bank income classification categories met inclusion criteria. Of these, 250 (59%) articles were from high-income countries, mostly from the United States of America (n = 139), the United Kingdom (n = 29), and Australia (n = 23). Quantitative methods were used in 269 articles, most often cross-sectional surveys (n = 190). Qualitative interviews were used in 116 articles and focus group discussions in 69 articles. The most commonly reported themes included side effects, effectiveness, and ease/frequency/duration of use. Interference in sex and partner relations, menstrual effects, reversibility, counseling/interactions with health workers, cost/availability, autonomy, and discreet use were also important. Users generally reported satisfaction with (and more accurate knowledge about) the methods they were using.

CONCLUSIONS

Contraceptive users have diverse values and preferences, although there is consistency in core themes across settings. Despite the large body of literature identified and relevance to person-centered care, varied reporting of findings limited robust synthesis and quantification of the review results.

Dimensional Analysis of Shared Decision Making in Contraceptive Counseling

OBJECTIVE

To conduct a dimensional analysis to identify conceptual gaps around shared decision making (SDM) in reproductive health care and to refine the conceptual definition of SDM as related to contraceptive counseling.

DATA SOURCES

We identified source data through systematic searches of the CINAHL and PubMed databases.

STUDY SELECTION

We included peer-reviewed research and nonresearch articles that addressed contraceptive counseling for pregnancy prevention in the United States. We did not consider date of publication as an inclusion criterion. We included 35 articles in the final review.

DATA EXTRACTION

Using dimensional analysis, we extracted data to clarify the definition of SDM as a socially constructed concept that varies by perspective and context.

DATA SYNTHESIS

Data synthesis enabled us to compare SDM from patient and provider perspectives and to identify four primary dimensions of SDM that varied by context: Patient Preferences, Relationship, Provider Bias, and Clinical Suitability.

CONCLUSION

The four dimensions we identified illustrate the complexity and depth of SDM in contraceptive counseling encounters and broaden the definition of SDM to more than an encounter in which decision making incorporates clinician expertise and patient participation. We identified several assumptions that indicate the need for improved understanding that SDM is not a universal concept across perspectives and contexts. Most researchers in the included articles addressed the Patient Preferences dimension. Fewer considered the patient-provider relationship, the effect of provider bias, and the effect of specific clinical circumstances on SDM. We propose a conceptual map and model that can be used to refine the concepts that inform SDM and guide providers and researchers. Future research is needed to address the remaining gaps.

Perinatal considerations for care of transgender and nonbinary people: a narrative review

PURPOSE OF REVIEW

The visibility of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities, specifically the transgender and nonbinary (TGNB) communities, continues to grow. However, there is little description, much less guidance toward optimizing, the pregnancy-related care of TGNB people. The overarching goal of this paper is to provide guidance that aids in reimagining obstetrics to include people of all genders.

RECENT FINDINGS

This article will review current literature and provide recommendations specific to the hospital birthing environment to help address the lack of knowledge regarding pregnancy-related care of TGNB individuals. This care is further divided into three main times: (1) preconception, antepartum care, and triage, (2) intrapartum, and (3) postpartum. We also discuss considerations for the general medical care of TGNB individuals.

SUMMARY

Understanding facilitators and barriers to gender affirming pregnancy-related care of TGNB individuals are first steps toward providing a respectful, affirming, and evidence-based environment for all patients, especially TGNB individuals. Here we provide context, discussion, and resources for providers and TGNB patients navigating pregnancy-related care. Lastly, this review challenges researchers and clinicians with future directions for the care of TGNB individuals in this continually expanding field.

Leveraging Administrative Claims to Understand Disparities in Gender Minority Health: Contraceptive Use Patterns Among Transgender and Nonbinary People

Purpose: Transgender people face disparities in access to reproductive and sexual health services; however, differences in receipt of contraceptive services have not been quantified. We compare contraceptive patterns between cisgender women and trans masculine people in insurance claims databases. Methods: We analyzed 2014-2018 Truven MarketScan data, using diagnostic and procedural codes to identify sex assigned at birth, and existing coding methodology to identify transgender and nonbinary people. We compared contraceptive patterns between cisgender women and trans masculine people aged 15-49 in Medicaid and commercial databases. Results: We identified 4700 people in the commercial and 1628 people in the Medicaid databases as trans masculine. Trans masculine people were prescribed fewer oral contraceptive pills (Medicaid: 17.44%, commercial: 16.62%) compared to cisgender women (Medicaid: 24.96%, commercial: 27.85%), less long-acting reversible contraception (LARC) use (Medicaid: 7.62%, commercial: 7.49% vs. Medicaid: 12.79%, commercial: 8.51%), had more hysterectomies (Medicaid: 5.77%, commercial: 8.45% vs. Medicaid: 2.15%, commercial: 2.48%), and less evidence of any contraception (Medicaid: 34.21%, commercial: 32.28% vs. Medicaid: 46.80%, commercial: 39.81%). Hysterectomies and LARC use varied by insurance type. Conclusion: We found significant differences in contraceptive patterns between trans masculine people and cisgender women. Data suggest potential differences in hysterectomy occurrences by trans masculine people, and long-acting reversible contraceptive use by cisgender women, in Medicaid versus commercial insurance cohorts. Appropriate counseling, insurance coverage, and removal of structural barriers are needed to ensure adequate access to contraception methods for people of all genders-regardless of whether they are being employed for contraception, menstrual management, or gender affirmation.

Changes in the Sexual Behavior of Partners in Each Trimester of Pregnancy in Otwock in Polish Couples

The aim of this study was to improve knowledge regarding pregnant couples by assessing changes in their sexual behavior, the reasons for the frequency and forms of intercourse, and the self-sexuality of partners in each trimester of pregnancy. As a result, 100 couples were qualified to take part in the final study, with 100 men and 100 women examined at intervals equivalent to the trimesters of pregnancy. These women (n = 100) and men (n = 100) were partners. Each of the studied couples was assessed in the trimesters of pregnancy. A prospective examination was conducted based on the observation of the same people, which were heterosexual couples, throughout pregnancy. The data used in the study was obtained using Davies’ Sexual Satisfaction Scale (DSSS), as well as an original survey on the sexuality of people during pregnancy (SARSS). The survey allowed us to obtain sociodemographic (metrics) information along with information regarding the sexual activity, satisfaction, and sexual attraction of the partners. All questionnaire questions were answered in paper form. There was a statistically significant drop in sexual intercourse from the first trimester in the second and third trimesters. The frequency of masturbation increased in men and decreased in women. The most common cause of sexual abstinence during the pregnancy was cited as fear for the fetus by all genders. A statistical analysis indicated that the average overall scores of the DSSS for the examined women in the first trimester of pregnancy were statistically significantly higher than in the two subsequent trimesters (p < 0.05). Sexual satisfaction, measured through both DSSS and SARSS, was also strongly correlated with the level of satisfaction in the assessment of the partner relationship and with the sense of one’s own attractiveness (p < 0.05). Changes in sexual behavior and sexual problems are often exposed or worsened during a first pregnancy and can have negative impacts on a person and the future of relationships. Medical staff should be trained in the assessment of sexual difficulties in people during pregnancy, in order to conduct reliable education and increase the awareness of couples regarding sexual and reproductive health.

Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines

Background

Hormonal treatments and surgical interventions practiced with the aim to affirm gender identity in transgender and gender diverse patients may impact their future reproductive ability, family building, and family planning options. Whereas it is recommended by international guidelines to discuss the potential risks of infertility and to present fertility preservation (FP) options to transgender individuals and their families prior to initiating any of these treatments, many barriers still remain. Further, transgender and gender diverse individuals often experience barriers to accessing contraception, abortion, pre-conception care, and comprehensive perinatal care.

Aims

In this review we summarize the current literature on reproductive healthcare issues reported in transgender people including fertility issues, fertility preservation (FP), contraception, pregnancy and lactation and perinatal health.

Methods

A narrative literature search of major databases (Pubmed, Medline, PsycInfo, Google Scholar, Web of Science) was conducted. Given the paucity and heterogeneity of studies, summative review tactics were not available. The literature was critically reviewed by international experts in the field with focus on the impact of gender-affirming medical interventions on future fertility, current FP options and reproductive health issues in transgender people.

Results

The current literature supports that transgender and gender diverse individuals may wish to have genetically related children in the future, rendering the issue of FP relevant to this patient group. The cryopreservation of mature gametes is an efficacious option for FP for post-pubertal adolescents and adults. It is recommended to discuss these options at time of planning for gender-affirming hormonal therapy (GAHT) or engaging with other gender-affirming procedures that can limit future fertility. Discontinuation of GAHT may allow individuals to undergo FP later, but data are limited and there is the concern of symptoms and consequences of stopping GAHT. For pre-pubertal and early pubertal children, FP options are limited to the cryopreservation of gonadal tissue. At present the tissue can become functional only after re-transplantation, which might be undesirable by transgender individuals in the future. Preconception counseling, prenatal surveillance, perinatal support, contraceptive, and pregnancy termination related healthcare need to be meaningfully adapted for this patient population, and many knowledge gaps remain.

Discussion

Specialized FP reproductive healthcare for transgender and gender diverse individuals is in early evolution. Research should be conducted to examine effects of medical interventions on fertility, timing of FP, gamete preservation and outcome of the fertility treatments. Strategies to inform and educate transgender and gender diverse patients can lead to optimization of reproductive care and counseling and decision making of FP for this population.

Family-building and parenting considerations for people with cystic fibrosis

As people with cystic fibrosis (CF) live longer and healthier lives, increasing numbers are considering the full range of reproductive options for their futures, including parenthood, pregnancy, or pregnancy prevention. As the face of CF changes, the CF care model must adapt to meet the reproductive health needs of both parents and nonparents with CF. This article summarizes the reproductive goals and family-building concerns faced by people with CF, including fertility, pregnancy, and alternative paths to parenthood, the impact of parenthood on mental and physical health, and important future research.

Pregnancy prevention and unintended pregnancy across gender identity: a cross-sectional study of college students

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.

Beyond the Binary: Sexual and Reproductive Health Considerations for Transgender and Gender Expansive Adolescents

Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.

Trans-affirming care: An integrative review and concept analysis

BACKGROUND

Contemporary healthcare exists within a cisnormative landscape which underpins the erasure of trans persons in healthcare, health research, and health education, and results in negative experiences and poorer outcomes. Further, nurses report feeling inadequately prepared to provide affirming care to trans patients, with little guidance available to inform their practice.

OBJECTIVE

To explore the conceptual understanding of trans-affirming care as it pertains to nursing, and to provide recommendations for trans-affirming nursing care at the systemic, organizational, and individual level.

METHODS

A systematic search of the literature was completed using standard review processes. Two reviewers independently applied a two-step study selection procedure to identify eligible citations. Walker and Avant's concept analysis method was used to analyze the extracted data to determine antecedents, defining attributes, empirical referents, and consequences.

RESULTS

Of the 5914 studies, 136 met criteria, representing a variety of clinical settings. The antecedents identified were depathologization of gender variance and cultural humility. The defining attributes were patient-led care, trans-affirming culture, and trans-competent providers. The consequences were improved psychological and physical health outcomes.

CONCLUSIONS

Trans persons and communities are becoming more visible in society, as are their testimonials about their substandard treatment within healthcare systems. Nurses need to respond to these health inequities with self-reflection, advocacy, and education. At the center of this work is the concept of trans-affirming care, which is a philosophy of care specific to trans persons. Tweetable abstract: This article offers an evidence-informed definition of trans-affirming care and recommendations for how it can be operationalized by nurses.

Sexual Behavior and Contraceptive Use Among Cisgender and Gender Minority College Students Who Were Assigned Female at Birth

STUDY OBJECTIVE

Our objective was to describe sexual behavior and contraceptive use among assigned female cisgender and gender minority college students (ie, 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 the National College Health Assessment.

SETTING

Colleges across the United States.

PARTICIPANTS

A total of 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 (eg, 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 in which they engage, to assess sexual risk and healthcare needs.

Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States

Background

Transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth experience pregnancy and have abortions. Scarce data have been published on individual abortion experiences or preferences of this understudied population.

Objective

This study aimed to fill existing evidence gaps on the abortion experiences and preferences of transgender, nonbinary, and gender-expansive 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 transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth at the age of ≥18 years from across the United States to participate in an online survey about sexual and reproductive health recruited through The Population Research in Identities and Disparities for Equality 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 transgender, nonbinary, and gender-expansive people, and respondent sociodemographic characteristics.

Results

Most of the 1694 respondents were <30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all 4 United States Census Regions. Overall, 210 respondents (12%) had ever been pregnant; these 210 reported 433 total pregnancies, of which 92 (21%) ended in abortion. For respondents’ most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (5%) were another method (primarily herbal). Most recent abortions took place at ≤9 weeks’ gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion over surgical abortion in a 3:1 ratio (n=703 vs n=217), but 514 respondents (30%) did not know which method they would prefer. The 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 transgender, nonbinary, and gender-expansive patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers use gender-neutral language, and that greater privacy be incorporated into the clinic.

Conclusion

These data contribute substantially to the evidence base on individual experiences of and preferences for abortion care for transgender, nonbinary, and gender-expansive people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.

The female condom: What do Australian women say?

BACKGROUND

The female condom is a barrier method for the prevention of sexually transmissible infections and unintended pregnancy. Uptake of this method remains low in Australia, although little research has been undertaken to explore this.

METHODS

An interventional cross-sectional study was undertaken in 2019 to explore the views and experiences of women in New South Wales. After trying the female condom, they were invited to complete an online survey and/or structured interview. Training in the use of the female condom was not provided. This paper reports on qualitative findings from open-ended survey responses and interviews.

RESULTS

In total, 284 participants completed the survey and 20 participated in an interview. Most were aware of the female condom prior to participating in the study, but few had used it previously. Four broad themes were identified from the data: (i) accessibility of the female condom, including cost and availability, (ii) supporting choice in different circumstances, (iii) aspects of empowerment and control and (iv) use of gendered language.

CONCLUSIONS

The female condom may be an acceptable option for many women in Australia. To support the choice of method and promote uptake, it will be important to increase the accessibility of the female condom by raising awareness and addressing the issues of cost and availability. Further exploration of issues regarding inclusive language and messaging in health promotion campaigns and marketing is warranted to ensure that this product is accessible for all people who may wish to use it, regardless of gender or sexuality. Similar research could be undertaken with men/partners and members of the LGBTQ+ community to explore their perspectives of the female condom. SO WHAT?: To support contraceptive choice and promote the uptake of the female condom for those who desire this method, it will be important to address the issues of cost and availability. Accessibility will also be enhanced through the consideration of inclusive language and messaging in health promotion campaigns and marketing of the female condom.

Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey

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.

Adolescents and long-acting reversible contraceptives: beyond the basics

PURPOSE OF REVIEW

The current article explores some of the more complex subtopics concerning adolescents and long-acting reversible contraceptives (LARC).

RECENT FINDINGS

Recent research has highlighted ways in which LARC provision can be optimized in adolescents and has identified gaps in adolescent LARC access and utilization.

SUMMARY

Contraceptive counseling for adolescents should be patient-centered, not necessarily LARC-first, to avoid coercion. There are increasing applications for the noncontraceptive benefits of LARC for several unique patient populations and medical conditions.