Men, trans/masculine, and non-binary people negotiating conception: Normative resistance and inventive pragmatism

Locating Men in Sexual and Reproductive Health, Rights, and Justice: Past, Present, Futures

Since the International Conference on Population and Development in 1994, global policies, and agenda-setting milestones have emphasized that universal sexual and reproductive health and rights (SRHR) are unattainable without the meaningful engagement and inclusion of men. Despite this, the field of SRHR continues to struggle with how and in what ways men can and should be included in research, programs, and policies. In this commentary, we argue that the programmatic focus of SRHR limits the capacity to produce the data and evidence needed to inform gender transformational change. For men to be meaningfully engaged with by SRHR, researchers need an analytic lens that can capture the manifestations and outcomes of gender and power. We consider the conceptual complementarities between two theoretical frameworks: hegemonic masculinities and Reproductive Justice. We contend that bringing together these conceptual approaches to men and SRHR offers an analytic framework to iterate and innovate approaches to research. Such changes will allow for a greater interrogation of gender and power and the production of data and evidence necessary to grapple with the ongoing injustices that curtail people's sexual and reproductive freedoms.

The road to equity: A scoping review of the evidence and practices on abortion policies and services in Sweden

OBJECTIVE

The aims of this study are to i) map and synthesize scientific evidence on abortion policies and service provision and delivery developments in Sweden and ii) identify potential facilitators and barriers to equitable abortion services nationally.

METHODS

A scoping review of peer-reviewed papers (n = 51) and grey literature (n = 23) published 1975-2024 was conducted. The PRISMA-ScR protocol for scoping reviews was followed. Seventy-four (n = 74) documents were included, and a qualitative synthesis was used to summarize, analyze, and assess the body of evidence identified.

RESULTS

Divergence in clinical guidelines was found and indicates inconsistencies in service delivery. Although there is strong evidence supporting midwife's role in delivering medication abortion, it has not been fully implemented and differs between and within regions. The Swedish abortion legislation prevents the implementation of midwives being key providers of medication abortion and self-managed home abortions in whole, thereby hampering access. The gap analysis show that although abortion services have been well researched, the experiences of migrants are scarcely addressed, and those of LGBTQI + people and persons with disabilities are absent.

CONCLUSION

Significant progress has been made in advancing access to equitable abortion services through legislative developments, medical innovations and the expansion of midwifery-led medication abortion services. However, some barriers remain including variability in service delivery and there is a research gap from an intersectional perspective. To better inform policy and practice, future research could apply a reproductive justice lens to explore how ethnicity, gender, disability and sexuality intersect and shape access to and experience of abortion services.

Improving the experience of health services for trans and gender-diverse young people and their families: an exploratory qualitative study

Background

In the United Kingdom, trans young people find themselves at the centre of political storms and debate regarding their access to health care and treatment. This research was carried out against a backdrop of increasing evidence of repeated failings in health care for trans people. Compounding this, trans young people face lengthy waiting lists when seeking specialist gender services and problems with the referral process. In order to cope and thrive, online resources and spaces have become increasingly important for trans young people. Finding good-quality resources and information can be difficult for young people and families.

Objectives

Our aim was to improve the care and support of gender-diverse youth, and their families, through identifying improvements to National Health Service care and services. Within this overall aim, our objectives were to gain a better understanding of the experiences of trans youth, family members and health professionals; and to develop and evaluate sections of the Healthtalk website on young people and parent/carer experiences.

Methods

The primary method of data collection was qualitative in-depth interviews conducted between 2019 and 2021. In total, 91 interviews were conducted with 50 young people (42 aged 13-24 years and 10 aged 25-35 years), 19 family members (parents/carers) and 20 health professionals working with trans patients. We evaluated the resources with young people and families who have experience of being on the waiting list for specialist gender services.

Results

From interviews with health professionals, we identified four key domains that prevent trans and gender-diverse young people receiving good-quality care. These were structural, educational, cultural and social, and technical barriers. Parents/carers' healthcare experiences were marked by multiple challenges. These occurred at all stages of the pathway and range from getting a referral to specialist gender services, lack of support during waiting times through to sometimes unclear and lengthy assessment processes, which many experience as gatekeeping of gender-affirming care. The majority of the young people in our sample felt the current healthcare system does not cater for the diversity of trans identities and needs. A linear, one-dimensional, conception of gender identity informs services. This is restrictive and does not reflect the plurality and fluidity of experiences. Young people we spoke with generally perceived National Health Service services as built around a culture of pathologisation, gatekeeping and trans hostility, resulting in a general level of mistrust. The research supported the development of two sections of the Healthtalk website concerning young people and parent/carer experiences.

Conclusions

We make five recommendations: (1) better and empowered decision-making for trans young people; (2) recognising and catering for gender diversity in health care; (3) a 'systems change' intervention approach that goes beyond training for individual health practitioners; (4) a restructured service based upon informed consent; and (5) a positive role for the National Health Service in public debate, challenging misinformation. These findings have wider applicability to other settings/services such as education and social work.

Limitations

This research was not a service evaluation and did not evaluate current practice in Gender Identity Development Service or Gender Identity Clinics. The research was conducted in a rapidly changing field where specialist gender services for children and adolescents are undergoing significant changes based on the Cass review recommendations, which might render some service-specific information out of date.

Future work

An evaluation in partnership with trans organisations to assess the reorganisation of specialist services. Research on homeless trans youth, sibling and grandparent experiences, and trans youth in care/care leavers.

Study registration

This study is registered on ISRCTN Registry ISRCTN26256441.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/51/07) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 4. See the NIHR Funding and Awards website for further award information.

Barriers and opportunities for health service access among fathers: A review of empirical evidence

ISSUE ADDRESSED

Engagement with health supports benefits the whole family, yet few health services report successful engagement of fathers. Our aim was to describe available evidence on barriers and opportunities relevant to health system access for fathers.

METHODS

Scoping reviews were conducted seeking empirical evidence from (1) Australian studies and (2) international literature reviews.

RESULTS

A total of 52 Australian studies and 44 international reviews were included. The most commonly reported barriers were at the health service level, related to an exclusionary health service focus on mothers. These included both 'surface' factors (e.g., appointment times limited to traditional employment hours) and 'deep' factors, in which health service policies perpetuate traditional gender norms of mothers as 'caregivers' and fathers as 'supporters' or 'providers'. Such barriers were reported consistently, including but not limited to fathers from First Nations or culturally diverse backgrounds, those at risk of poor mental health, experiencing perinatal loss or other adverse pregnancy and birth events, and caring for children with illness, neurodevelopmental or behavioural problems. Opportunities for father engagement include offering father-specific resources and support, facilitating health professionals' confidence and training in working with fathers, and 'gateway consultations', including engaging fathers via appointments for mothers or infants. Ideally, top-down policies should support fathers as infant caregivers in a family-based approach.

CONCLUSIONS

Although barriers and opportunities exist at individual and cultural levels, health services hold the key to improved engagement of fathers. SO WHAT?: Evidence-based, innovative strategies, informed by fathers' needs and healthy masculinities, are needed to engage fathers in health services.

Men's involvement in women's abortion-related care: a scoping review of evidence from low- and middle-income countries

Men's involvement in abortion is significant, intersecting across the individual, community and macro factors that shape abortion-related care pathways. This scoping review maps the evidence from low- and middle-income countries relating to male involvement, including male abortion providers, in abortion trajectories. Five databases were searched, using search terms, to yield 7493 items published in English between 01.01.2010 and 20.12.2019. 37 items met the inclusion criteria for items relating to male involvement in women's abortion trajectories and were synthesised using an abortion-related care-seeking framework. The majority of studies were conducted in sub-Saharan Africa and were qualitative. Evidence indicated that male involvement was significant, shaping the ability for a woman or girl to disclose her pregnancy or abortion decision. Men as partners were particularly influential, controlling resources necessary for abortion access and providing or withdrawing support for abortions. Denial or rejection of paternity was a critical juncture in many women's abortion trajectories. Men's involvement in abortion trajectories can be both direct and indirect. Contextual realities can make involving men in abortions a necessity, rather than a choice. The impact of male (lack of) involvement undermines the autonomy of a woman or girl to seek an abortion and shapes the conditions under which abortion-seekers are able to access care. This scoping review demonstrates the need for better understanding of the mechanisms, causes and intensions behind male involvement, centring the abortion seeker within this.

"Recommendations for Communication in Gender Affirming Surgical Care"

SUMMARY

The surgical treatment of gender incongruence with gender affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women, as well as those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to our own mistakes during patient care. Based on the lessons learned from these experiences, we provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.

Setting a research agenda in trans health: An expert assessment of priorities and issues by trans and nonbinary researchers

Background

This article is by a group of trans and nonbinary researchers and experts in the field of trans health who have conducted an analysis of trans health research needs.

Aims

To highlight topics that need further research and to outline key considerations for those conducting research in our field.

Methods

The first author conducted semi-structured interviews with all coauthors, and these were used to create a first draft of this manuscript. This draft was circulated to all authors, with edits made until consensus was reached among the authors.

Results

More comprehensive long-term research that centers trans people's experiences is needed on the risks and benefits of gender affirming hormones and surgeries. The trans health research field also needs to have a broader focus beyond medical transition or gender affirmation, including general health and routine healthcare; trans people's lives without, before, and after medical gender affirmation; and sexuality, fertility, and reproductive healthcare needs. More research is also needed on social determinants of health, including ways to make healthcare settings and other environments safer and more supportive; social and legal gender recognition; the needs of trans people who are most marginalized; and the ways in which healing happens within trans communities. The second part of this article highlights key considerations for researchers, the foremost being acknowledging trans community expertise and centering trans community members' input into research design and interpretation of findings, in advisory and/or researcher roles. Ethical considerations include maximizing benefits and minimizing harms (beneficence) and transparency and accountability to trans communities. Finally, we note the importance of conferences, grant funding, working with students, and multidisciplinary teams.

Discussion

This article outlines topics and issues needing further consideration to make the field of trans health research more responsive to the needs of trans people. This work is limited by our authorship group being mostly White, all being Anglophone, and residing in the Global North.

Fertility preservation and fertility treatment in transgender adolescents and adults in a Swedish region, 2013-2018

STUDY QUESTION

In a transgender population referred for fertility consultation, which factors influence the decision to cryopreserve oocytes and sperm?

SUMMARY ANSWER

Previous hormonal treatment, gender affirmation surgery and sexual orientation were associated with the decision to undergo fertility preservation and transgender women underwent fertility preservation more frequently than transgender men.

WHAT IS KNOWN ALREADY

It is well-known internationally that fertility preservation and fertility treatment are increasingly requested by transgender men and women. Factors affecting their decisions as well as treatment differences between transgender women and transgender men have been reported, but many studies have had low participation rates and small sample sizes.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study, conducted during 2013–2018, included 78 transgender women (assigned male at birth and referred for sperm cryopreservation) and 164 transgender men (assigned female at birth referred for oocyte cryopreservation).

PARTICIPANTS/MATERIALS, SETTING, METHODS

In 2013, the previous requirement for sterilization before completion of a legal gender change was removed in Sweden. All fertile-aged transgender men and transgender women referred to a tertiary care centre for consultation concerning fertility preservation, fertility treatment or hysterectomy were identified from administrative systems. Demographic, medical and treatment data were extracted from electronic medical records and from an ART database. Logistic regression was applied to analyse factors affecting the decision to cryopreserve gametes among transgender men and transgender women.

MAIN RESULTS AND THE ROLE OF CHANCE

A majority of transgender men (69.5%) and transgender women (82%), wanted to become parents. Fertility preservation was less frequent in transgender men than in transgender women (26.2% versus 75.6%, respectively). No individuals among those primarily referred for hysterectomy opted for cryopreservation of oocytes. Among transgender men, young age, no previous hormonal treatment and stating homosexual orientation were independent factors associated with the decision to cryopreserve oocytes. Among transgender women, the decision to undergo gender affirmation surgery and stating heterosexual orientation were independent factors associated with a decision to refrain from fertility preservation. Fertility treatments, using IUI or IVF with donor sperm, were mainly performed in partners of transgender men. Ten live births were reported in the group of transgender men and two for transgender women.

LIMITATIONS, REASONS FOR CAUTION

The main limitation is the retrospective nature of the study, with missing data for many variables. The short study period and the study population being too young to permit observation of long-term outcomes of fertility preservation and fertility treatments are reasons for caution.

WIDER IMPLICATIONS OF THE FINDINGS

Our results confirm that fertility preservation has been requested by transgender people since the change in Swedish legislation in 2013. Information about aspects of fertility early in the transition process is important, since hormonal and surgical treatments may have a large impact on the decision to undergo fertility preservation. It is important to train fertility clinic staff to identify and handle the specific obstacles, as well as address the need for information and support that transgender people may have when planning for fertility preservation, fertility treatment and pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by a grant from the Swedish state, under the ALF agreement between the Swedish government and the county councils (ALFGBG-720291), and by Hjalmar Svensson’s Research Foundation. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

"Mom and dad = cis woman + cis man" and the stigmatization of trans parents: an empirical test of norm-centered stigma theory

Background: Empirical research on transgender individuals and their families is growing but investigations of attitudes toward trans parents are sparse. This gap is especially important to address because transgender parents face unique strains due to their violations of hetero-cis-normativity and the "Mom and Dad = Cis Woman + Cis Man" stereotype. Methods: Using a sample of adults aged 18-64 stratified by U.S. census categories of age, gender, race/ethnicity and census region collected from online panelists (N = 2,948), this study provides an intersectional investigation of Norm-Centered Stigma Theory (NCST) with hetero-cis-normativity (a system of norms, privilege, and oppression that situates heterosexual cisgender people above all others) as the centralized overarching concept that helps us to understand negativity directed toward transgender parents. Specifically, social power axes including gender identity (cisgender woman, cisgender man, nonbinary; trans people were excluded from the current study), sexual identity (heterosexual, lesbian, gay, bisexual), and interactions among these axes of social power are investigated. Results: Findings indicate that hetero-cis-normativity is strongly related to negativity toward trans mothers and fathers and that there is overall greater stigma toward trans dads when compared to trans moms. In addition, gender, sexual identity, and interactions among these experiences of social power have complex relationships with the stigmatization of trans parents. Conclusion: Results provide support for the use of Norm-Centered Stigma Theory to help us best understand the constellation of hostilities directed toward trans people and their families.

New horizons in trans and non-binary health care: Bridging identity affirmation with chronicity management in sexual and reproductive services

BACKGROUND

Transgender and non-binary people experience erasure, stigma, and discrimination in sexual and reproductive health care. Previous research shows worse sexual and reproductive health outcomes and higher rates of chronicity for trans and non-binary populations as compared to cisgender populations. Historically such outcomes have been framed as separate issues.

AIMS

To describe methodological approaches for exploring gaps in the sexual and reproductive health care of transgender and non-binary people, and explore intersections between chronic disease management and gender-affirming care.

METHODS

We critically reviewed methods for studying sexual and reproductive care and chronic condition management among trans and non-binary populations. We focus on two themes: unmet needs and response strategies.

RESULTS

We summarize findings and opportunities in existing research about service needs in trans and non-binary care. Key barriers to effective sexual and reproductive care for trans and non-binary people include persistent medical myths about trans people and bodies, siloization of different domains of health and associated services, lack of research on how chronic disease treatments interact with transition related care, and lack of active communication between providers and patients about individual care needs and goals.

DISCUSSION

We recommend methodologically diverse research with trans and non-binary populations capturing: (1) erasure, stigma, and discrimination in sexual and reproductive health care settings; (2) individual, interpersonal, and structural factors catalyzing chronicity; and (3) the impact of sexual and reproductive health disparities on chronic disease outcomes.

A qualitative study examining transgender people's attitudes towards having a child to whom they are genetically related and pursuing fertility treatments in Greece

BACKGROUND

Advances in biomedical technologies permit transgender individuals not only to achieve gender transition but also to experience parenthood. Little is known about this topic in Greece, which, although a traditionally conservative country, is changing at the legal level towards a greater recognition of transgender people's rights. This study aimed to investigate transgender people's attitudes towards having a child to whom they are genetically related and pursuing fertility treatments in Greece.

METHODS

This is a prospective qualitative study conducted with adult individuals who identified as transgender men or transgender women between April 2019 and March 2020. Individual in-depth qualitative interviews were conducted with 12 participants. The interviews were carried out in person and were digitally recorded and transcribed verbatim. We performed a thematic analysis of the data.

RESULTS

The thematic data analysis resulted in the identification of themes that represent key barriers to pursuing fertility preservation or the use of assisted reproductive technology. Six major themes were clearly present in the findings (lack of adequate information and counseling, worsening gender dysphoria, increased discrimination against transgender people due to the rise of extreme far-right populism, low parental self-efficacy, high costs, and a less-than-perfect legal framework). Moreover, diverse cases were examined, and minor themes, such as the symbolic value of the uterus and pregnancy, the relationship between the type of gender transition and willingness to pursue fertility treatments, and transgender people's adherence to heteronormative patterns in the context of reproduction, were identified. Various reasons for transgender people's differing degrees of desire for parenthood were identified.

CONCLUSION

Our findings demonstrated contextual factors as well as factors related to transgender people themselves as barriers to pursuing transgender parenthood. Most aspects of our findings are consistent with those of previous research. However, some aspects of our findings (regarding aggressive behaviors and economic instability) are specific to the context of Greece, which is characterized by the rise of extreme far-right populism due to the decade-long Greek economic crisis and a deeply conservative traditionalist background. In that regard, the participants highlighted the (perceived as) less-than-perfect Greek legislation on transgender people's rights as a barrier to transgender (biological) parenthood.