Motivators and Barriers to Accessing Sexual Health Care Services for Transgender/Genderqueer Individuals Assigned Female Sex at Birth

Strategies to Optimize Cervical Cancer Screening Rates Among Transgender and Gender-Diverse People Assigned Female at Birth

Self-sampling for primary HPV detection for cervical cancer screening is now FDA-approved. Many persons interested in cervical cancer screening are eager to opt out of the invasive speculum exam and opt into the self-sampling. There is no limitation on which persons can choose self-sampling. Transgender, nonbinary, and gender-diverse assigned female at birth (TGD AFAB) people experience barriers such as gender dysphoria and discomfort with sensitive exams. They may find more comfort with this equivalent method of screening. However, no clinical guidelines describe the best practices to increase screening among this underserved population. Much community work needs to occur to make the language of screening gender-affirming for all participants. Solutions to currently invasive follow-up exams after abnormal screens need to be communicated in language directed by the TGD AFAB community.

"Just for pregnant women, not for you": a qualitative evaluation of the sexual and reproductive healthcare experiences of transgender and gender diverse cancer survivors

PURPOSE

To identify opportunities to improve sexual and reproductive health (SRH) care for transgender and gender diverse (TGD) cancer survivors by describing (1) challenges experienced when navigating SRH care and (2) strategies to help overcome these challenges.

METHODS

We enrolled a purposive sample of 17 adult TGD cancer survivors and 5 co-survivors. We aimed for a diverse sample across cancer experience, age, racial/ethnic background, sexual orientation, and gender identity. We conducted 90-min individual interviews via videoconference and used reflexive thematic analysis, guided by a focus on three social determinants of health.

RESULTS

Themes describing challenges were as follows: (1) Cancer treatment's impact on sexual health was insufficiently addressed by cancer care providers; (2) fertility-related information and conversations were complicated by gendered expectations and ultimately did not meet survivors' needs; (3) feeling excluded and uncared-for in healthcare settings due to gendered language and lack of supportive services that met their needs; and (4) TGD survivors commonly reported high financial burden, negatively impacting their access to care. Strategies to overcome these challenges were (1) a solid social support network that can be integrated into the care team to meet the unique SRH needs of TGD survivors and (2) gender-affirming healthcare providers and environments to address SRH care needs and concerns.

CONCLUSIONS

TGD survivors and co-survivors desire improved access to gender-affirming SRH care in cancer survivorship.

IMPLICATIONS FOR CANCER SURVIVORS

Key opportunities to improve gender-affirming SRH care in cancer survivorship include fostering and engaging TGD survivors' support networks and implementing system-level changes in cancer care settings.

Transgender and non-binary peoples experiences of cervical cancer screening: A scoping review

AIM(S)

To synthesise the literature about transgender and non-binary people's experiences of cervical cancer screening and identify ways to improve screening.

BACKGROUND

Transgender people often face barriers to accessing health services including cervical screening, where transgender people have a lower uptake than cisgender women.

DESIGN

A scoping review was undertaken following the Arksey and O'Malley (2005) framework and the PRISMA-ScR checklist. Following database searching of Medline via PubMed, Web of Science, Scopus and CINHAL, 23 papers published between 2008 and 2003 were included. Papers were included if they shared trans and non-binary people's experiences of cervical screening and were written in English. There were no date or geographical data restrictions due to the paucity of research.

RESULTS

Transgender people experience barriers to cervical screening including gender dysphoria, a history of sexual trauma, and mistrust in health professionals or health services, which can result in having negative experiences of screening or avoiding screening. Health professionals can help to create a positive experience by informing themselves about best practices for trans+ health.

CONCLUSION

Changes are required to improve transgender people's experiences and uptake of cervical screening. Improving medical education about trans health and updating health systems would help to combat issues discussed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Having an understanding of the reasons why accessing health services can be more difficult for transgender people will help health professionals to provide appropriate care for transgender patients. This paper details this in the context of cervical cancer screening and can be applied to other areas of healthcare.

REPORTING METHOD

We have adhered to relevant EQUATOR guidelines and used the PRISMA-ScR reporting method. No Patient or Public Contribution.

Gender-Affirming Hormone Therapy and Cervical Cancer Screening Rates in Transgender Men and Nonbinary People: A Cross-Sectional Study from a Boston Community Health Center

Purpose: Clinical monitoring for patients receiving gender-affirming hormone therapy (GAHT) has the potential to facilitate their receipt of preventive health services. We aimed to determine whether GAHT is associated with increased utilization of cervical cancer screening among transgender men (TM) and nonbinary persons assigned female at birth (NB-AFAB). Methods: We conducted a cross-sectional observational study of a single community health center in Boston. Persons of all gender identities eligible for cervical cancer screening during 2008-2019 were assessed. The outcome of interest was receipt of cervical cancer screening based on U.S. Preventive Services Task Force recommendations. We compared the proportion of persons who received cervical cancer screening by prescription of GAHT. Results: We identified 13,267 eligible persons. This cohort included 10,547 (79.5%) cisgender women, 1547 (11.7%) TM, and 1173 (8.8%) NB-AFAB persons. Among all persons eligible for cervical cancer screening, TM and NB-AFAB persons were less likely to receive screening than cisgender women (56.2% and 56.1% vs. 60.5% respectively; odds ratio [OR] = 0.84; 95% confidence interval [CI] = 0.75-0.93; OR = 0.84; 95% CI = 0.74-0.94, respectively). Among TM, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (57.9% vs. 48.2%, OR = 1.47; 95% CI = 1.14-1.92). Among NB-AFAB adults, those prescribed testosterone were more likely to receive cervical cancer screening than those not prescribed testosterone (61.9% vs. 51.5%, OR = 1.53; 95% CI = 1.21-1.93). Conclusions: The benefits of engagement in care to access GAHT may extend beyond the hormonal intervention to preventive health services.

Characteristics of Clinicians Caring for Transgender Men and Nonbinary Individuals and Guideline Concordance of Clinicians' Cervical Cancer Screening Counseling for Cisgender Individuals Versus Transgender Men and Nonbinary Individuals with a Cervix

Purpose: We examined characteristics of clinicians caring for transgender men and nonbinary (TMNB) individuals and guideline concordance of clinicians' cervical cancer screening recommendations. Methods: Using a survey of clinicians who performed ≥10 cervical cancer screenings in 2019, we studied characteristics of clinicians who do versus do not report caring for TMNB individuals and guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women. Results: In our sample (N = 492), 49.2% reported caring for TMNB individuals, and 25.4% reported performing cervical cancer screening for TMNB individuals with a cervix. Differences in guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women (45.8% vs. 50% concordant) were not statistically significant. Conclusion: Sizable proportions of clinicians cared for and performed cervical cancer screening for TMNB individuals. Research is needed to better understand clinicians' identified knowledge deficits to develop interventions (e.g., clinician trainings) to improve gender-affirming cervical cancer prevention.

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.

Promoting equitable sexual health communication among patients with minoritized racial/ethnic, sexual orientation, and gender identities: Strategies, challenges, and opportunities

People assigned female at birth (AFAB) with minoritized racial/ethnic, sexual orientation, and gender identities experience notable barriers to high-quality sexual healthcare. In confronting these barriers, patient-provider communication can be a crucial factor, influencing patients' experiences and access to relevant sexual health information and services by determining the quality of care. However, research that investigates this communication among AFAB patients with minoritized social positions is scarce, indicating a research gap regarding the perspectives and roles of healthcare providers in addressing such barriers to care for minoritized patients. Thus, we conducted a qualitative research study, using individual in-depth interviews, to explore the multi-level factors that influence providers' attitudes, knowledge, and skills regarding sexual health communication with AFAB patients with minoritized racial/ethnic, sexual orientation, and gender identities. Interpreting study findings within frameworks of person-centered care, intersectionality, and structural competency, we identified three cross-cutting themes. We found that providers frequently drew on their prior professional training, personal lived experiences, and population-level health disparities data when engaging in sexual health communication with minoritized AFAB patients. Participants reported minimal explicit training in anti-racist and lesbian, gay, bisexual, transgender, and queer (LGBTQ+)-competent care as a significant barrier to engaging in equitable sexual health communication with minoritized AFAB patients, which was exacerbated by many providers' lack of shared social positions and lived experiences with these patients. Providers also frequently applied population-level data to individual patients when formulating counseling and recommendations, which may undermine person-centered sexual health communication. Our findings suggest that critical anti-racist and LGBTQ+-competent provider training is urgently needed, and that health professional education and institutions must be transformed to better reflect and consider the experiences of patients with minoritized racial/ethnic, sexual orientation, and gender identities.

Use of gender-inclusive language in genetic counseling to optimize patient care

Providing welcoming, inclusive, and culturally competent care is essential for genetic counselors (GCs) to serve the needs of all patients, including transgender and nonbinary (TGNB) individuals. Inclusive language creates welcoming healthcare spaces and improves health outcomes for TGNB individuals. Training on gender-affirming healthcare can increase knowledge, comfort, and self-efficacy working with TGNB patients. Using a mixed-method survey, this study assessed 65 GCs' gender-inclusive communication practices and elucidated reasons for discomfort using language to determine how language builds trust and fosters patient-provider relationships, ascertain differences between specialties, and identify potential gaps in education and professional development. This study found that approximately one-third of GCs are comfortable using gender-inclusive language and just over half regularly use it with patients. Most GCs do not share their pronouns or ask patients theirs, which was not correlated with comfort levels or frequency of using gender-inclusive language. There were no significant differences based on specialty. Thematic analysis of open responses revealed GCs used gendered language to promote shared language and for clarity, some mentioning sex assigned at birth was relevant for risk assessment. Most felt the impact of gendered language depended on the patient's perspective. Twenty-five percent noted gendered language was familiar for most patients and 40% recognized negative impacts on TGNB individuals. Most GCs desired more gender-inclusivity training even though >95% had some type previously. Those who had gender-inclusivity training in their genetic counseling program were more comfortable using gender-inclusive language and were more likely to share their pronouns with patients. This study adds to the growing body of literature demonstrating GCs' desire for more gender-inclusivity education and highlights the potential importance of having this education integrated into genetic counseling training programs. GCs should continue to incorporate gender-inclusive language into their practice in concordance with the tenants of the Reciprocal Engagement Model.

Treatment Goals of Adolescents and Young Adults for Gender Dysphoria

OBJECTIVES

With this study, we aim to describe transgender and nonbinary adolescents and young adults' stated gender treatment goals at the time of initial presentation to medical care.

METHODS

This is a retrospective chart review of transgender and nonbinary patients aged 10 to 24 seeking specific gender-affirming health care. Charts were reviewed for specifically stated goals of future hormonal or surgical care for gender and analyzed by the experienced or asserted gender (man, woman, nonbinary, eclectic) of participants.

RESULTS

In total, 176 patient encounters were reviewed. Of these, 71% were assigned female at birth. Most participants experienced a masculine gender (46.6%), identified as white (65.3%), and had private health insurance (73.3%). Most patients had a goal of initiating hormone therapy (97.4%) and eventual surgery (87.1%). Of those who had a surgical goal, most (87.5%) desired surgery of the chest or breast, and a minority (29.3%) desired eventual genital surgery. The second-largest gender group was patients who either declined to state an asserted gender or felt unable to describe their gender experience (eclectic, 23.3%), and this group's treatment goals did not mirror any other group's goals.

CONCLUSIONS

At the time of initial presentation to medical care for gender-specific needs, many adolescents are capable of asserting specific treatment goals. Most do not desire genital surgery. A large minority of patients decline to state an asserted gender or feel unable to assert a specific gender, and this population appears distinct from more traditional genders in terms of treatment goals.

Interaction among health workers and trans men: Findings from a qualitative study in Chile

PURPOSE

To explore trans men's access and use of healthcare services in Chile, based on the experiences of the trans men themselves, as well as of healthcare professionals.

METHODS

A qualitative study with an ethnographic approach was carried out with 30 participants: 14 trans men and 16 healthcare professionals. Semi-structured one-on-one interviews with open-ended questions were used to collect the data. A thematic analysis was carried out with the NVivo Software.

RESULTS

Three main themes were identified: (1) failures in the recognition of trans identity, (2) challenges with patient-centered care, and (3) use of other ("non-trans") health services.

CONCLUSIONS

The results suggest that not all transition processes are the same, individuals seek different ways; therefore, it is necessary to consider different body types and identities when planning programs and care for men in transition. Moreover, the accompaniment provided during the gender transition process should contemplate emotional and mental support.

CLINICAL RELEVANCE

The study outlines the need for all healthcare professionals to have training and knowledge about the transgender population, regardless of whether they are part of the teams supporting gender transition processes. The role of nurses and the contributions that can be made from nursing discipline in this research field are fundamental.

Health disparities in one of the world's most progressive countries: a scoping review of mental health and substance use among sexual and gender minority people in the Netherlands

BACKGROUND

Evidence from many parts of the world shows that sexual and gender minority (SGM) people have poorer health than their cisgender heterosexual counterparts. Minority stressors, particularly stigma and discrimination, have been identified as major contributors to sexual orientation- and gender identity-related health disparities, particularly negative mental health and behavioral health outcomes. To better understand factors that contribute to these disparities, we conducted a scoping review of SGM mental health and substance use research in the Netherlands-a country with a long-standing reputation as a pioneer in SGM equality.

METHODS

Using Joanna Briggs Institute guidelines and the PRISMA-ScR protocol, we searched seven databases to identify studies published between 2010 and 2022 that focused on substance use and/or mental health of SGM youth and adults in the Netherlands.

RESULTS

Although there was some evidence that SGM people in the Netherlands report fewer substance use and mental health concerns than those in less progressive countries, with very few exceptions studies found poorer outcomes among SGM participants than cisgender, heterosexual participants. However, this observation must be considered cautiously given major gaps in the literature. For example, only one study focused exclusively on adult sexual minority women, two focused on older SGM adults, and very little attention was given to nonbinary individuals. Most studies used non-probability samples that were quite homogenous. Many studies, especially those with youth, assessed sexual orientation based on sexual attraction; some studies of adults operationalized SGM status as having a same-sex partner. Importantly, we found no studies that directly assessed associations between structural-level stigma and health outcomes. Studies were mostly focused at the individual level and on health problems; very little attention was given to strengths or resilience.

CONCLUSIONS

Findings of persistent health disparities-despite the relatively long history of SGM supportive policies in the Netherlands-highlight the need for more research and greater attention to population groups that have been underrepresented. Such research would not only provide guidance on strategies to improve the health of SGM people in the Netherlands, but also in other countries that are seeking to reduce health inequities. Addressing SGM health disparities in the Netherlands and elsewhere is complex and requires a multifaceted approach that addresses individual, interpersonal and structural factors.

Cervicovaginal Papanicolaou tests in transgender men: Cytomorphologic alterations, interpretation considerations, and clinical implications

BACKGROUND

The transgender population faces unique psychosocial and physical obstacles to cervical cancer screening. Additionally, most individuals undergo masculinizing testosterone hormone therapy, and the physiologic changes can cause cytomorphologic alterations that may mimic lesions. Although the literature on cervicovaginal cytology is growing in this patient population, it is still limited.

METHODS

The pathology information system was queried for all Papanicolaou (Pap) tests from transgender men from January 2013 to February 2023. The original diagnostic categories were catalogued. Cases were reviewed to evaluate the cytomorphologic alterations. Clinical data were also sought, including whether the sample was self-collected. Two comparison groups were established: one was a postpartum atrophic group and the other was an all-comer group.

RESULTS

A total of 51 cases from 43 individuals were identified, with a mean age of 31 years. Approximately a third of cases (18 of 51; 35%) were self-collected. The abnormal rate was low, with 5.9% of cases rendered atypical squamous cells of undetermined significance on original review and no lesions identified. The Pap unsatisfactory rate according to original reports was 3.9%. This increased to 13.7% when the cases were rereviewed, which was significantly higher than the all-comer comparison group. The unsatisfactory rate did not correlate with self-collection. Atrophy was a prevalent cytomorphologic alteration, with the vast majority of cases (92%) showing at least mild atrophy. Small blue cells and transitional cell metaplasia were seen in many cases (53% and 43%, respectively).

CONCLUSIONS

There are clinical and morphologic considerations that are distinct to the transgender patient population. Laboratory personnel and diagnosticians need to be aware of these in order to optimize patient care.

Developing medical professionalism in care of gender nonconforming patients: Reflections of second-year medical students after a curricular experience with gender nonconforming people and allies

INTRODUCTION

Negative healthcare experiences persist for gender nonconforming individuals. Clinician-related factors, including lack of comfort with gender nonconforming persons and unexamined personal biases, present barriers to equitable and affirming healthcare. We explored the effects of contact with gender nonconforming individuals in preclinical medical education through a structured curricular intervention designed to build medical and humanistic knowledge and stimulate the development of medical professionalism surrounding the care of gender nonconforming individuals.

METHODS

A curricular module (didactic prework, time-synchronous online panel discussion, and post-event written reflection) was implemented in a second-year preclinical course in a large multi-campus Midwestern medical school. The module was based on pedagogical foundations of contact theory and reflective writing. Post-event written reflections were investigated using thematic analysis.

RESULTS

Analysis of 355 written reflections revealed three major themes (moments of insight, topics of confusion, connections to professional identity formation) and eight sub-themes. The findings demonstrated emerging gender professionalism and the importance of contact in professional development.

DISCUSSION

Contact with gender nonconforming people and the use of written reflections can encourage self-examination and foster professional identity formation among preclinical medical students. Modeling gender-affirming approaches may help counteract negative cultural messages about gender nonconforming people, aiding development of inclusive future physicians.

Clinical Performance of Cobas 6800 for the Detection of High-Risk Human Papillomavirus in Urine Samples

Testing for high-risk human papillomavirus (HPV) as part of primary cervical cancer screening has become more common recently. The Cobas 6800, an FDA-approved cervical screening platform, detects 14 high-risk HPVs, including HPV16 and HPV18. However, this test is limited to only women, which leads to low screening rates in trans men and other non-binary people. The cervical screening of trans men and other genders, especially those lying on the female-to-male spectrum, is equally important. Furthermore, cisgender males, particularly homosexuals, are also prone to chronic HPV infections and serve as HPV carriers, transmitting it to women and other men through sexual contact. Another limitation of the test is its invasive specimen collection, which induces discomfort and genital dysphoria. Therefore, there is a need for an innovative, less invasive method that would allow the sampling process to be more comfortable. In this study, we assess the performance of the Cobas 6800 for high-risk HPV detection in urine samples spiked with HPV16, HPV18, and HPV68. The limit of detection (LOD) was calculated using a dilution series (1.25-10,000 copies/mL) over a course of three days. Furthermore, the clinical validation was performed by calculating sensitivity, specificity, and accuracy. The limit of detection ranged from 50-1000 copies/mL depending upon the genotype. Moreover, the urine test demonstrated a high clinical sensitivity of 93%, 94%, and 90% for HPV16, HPV18, and HPV68, with 100% specificity. The overall percent agreement was calculated to be 95% for both HPV16 and HPV18, and 93% for HPV68. The high concordance, reproducibility, and clinical performance of the current assay suggest that the urine-based HPV test fulfills the requirements for its use in primary cervical screening. Moreover, it has the potential to be used for mass screening to not only identify high-risk individuals, but also to monitor vaccine effectiveness.

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

Participation, barriers, and facilitators of cancer screening among LGBTQ+ populations: A review of the literature

The LGBTQ+ community is at higher risk of certain cancers but is less likely to participate in screening programs or engage with preventive healthcare. Despite this, the barriers and facilitators to cancer screening are not well understood in this population. We conducted a literature review of research related to LGBTQ+ participation in cancer screening, as well as barriers and facilitators to participation. Following abstract and full-text screening, 50 studies were included in the final synthesis. Compared to their heterosexual counterparts, lesbian and bisexual women were less likely to participate in cervical cancer screening and mammography, but gay and bisexual men were more likely to participate in anal and colorectal cancer screening. Transgender individuals had lower rates of screening than cisgender individuals for all cancer types. Barriers to participation were found at the individual-, provider-, and administrator-level, and good communication with a healthcare provider was the strongest facilitator. These results provide reasonable first steps toward improving participation rates for LGBTQ+ populations in cancer screening. Patient-centered approaches should draw on core guiding principles to inform the provision of care, including anticipating LGBTQ+ patients, improving knowledge about care for these patients, and confronting individually-held biases that may affect care, in order to improve care experiences and participation rates in preventive services.

The Use of Nursing Theory to Support Sexual and Reproductive Health Care Education in Nursing Curricula

BACKGROUND

Inclusive sexual and reproductive health care (SRH) content is limited in nursing curricula, resulting in nurses who lack education to provide complex SRH services to marginalized patients, especially sexual and gender minorities (SGM).

METHOD

The 10 Caritas Processes, the framework of Watson's Theory of Caring, were evaluated for being integral components of SRH. This theory is used to advocate for SGM-inclusive SRH content in nursing curricula.

RESULTS

The interpretation of Caritas Processes 2, 4, and 7 provide theoretical support for SGM-inclusive SRH content. Specific strategies to modify and improve nursing curricula are described.

CONCLUSION

There is a need to incorporate inclusive SRH education into nursing curricula to normalize evidence-based SRH for diverse, marginalized patient populations. By emphasizing the caring intentions necessary for nursing professionals, Watson's Theory of Caring is an appropriate framework to guide the development of SGM-relevant SRH content in nursing education. [J Nurs Educ. 2023;62(2):69-74.].

Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians

In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women's Health Organization overturned Roe v. Wade, removing almost 50 years of precedent and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive health care, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.

Sexual healthcare experiences of nonbinary young adults

Nonbinary young adults (who do not identify with a binary male or female identity and may hold diverse gender identities, including genderqueer, nonbinary and agender) may have unique and unmet sexual healthcare needs compared to binary transgender and cisgender people. However, there is limited knowledge about the sexual health and healthcare needs of nonbinary young adults. We conducted 19 semi-structured, in-depth interviews between August and November 2018 with nonbinary people aged 18-30 years in New England. Interview topics included experiences accessing sexual healthcare and engaging in sexual activity. Interviews were transcribed and transcripts were analysed using inductive and deductive thematic analysis. Three main themes were identified. First, participants described barriers to accessing high-quality sexual healthcare at both the interpersonal and institutional level. Second, participants employed strategies to meet their sexual healthcare needs despite encountering barriers. Third, participants articulated the ways nonbinary gender identities affect sexual relationships, with implications for sexual health. These findings underscore the need for research and advocacy - in collaboration with nonbinary persons themselves - to develop best practices to meet the sexual healthcare needs and advance the sexual health of nonbinary young people.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I 2 measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I 2=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I 2=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

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.

Current Management of Locally Advanced and Metastatic Cervical Cancer in the United States

Despite decreases in incidence in the twentieth century, cervical cancer continues to be a highly morbid disease in the United States. For those diagnosed with locally advanced disease, single-agent cisplatin-based chemotherapy concurrent with radiation remains the mainstay of treatment. For patients with metastatic, progressive, and recurrent disease, treatment typically consists of combination chemotherapy and incorporation of bevacizumab, and recent data show benefits with the addition of upfront immunotherapy in women whose cancer expresses programmed death ligand-1. The physical sequelae of locally advanced cervical cancer treatments stem largely from irradiation of the pelvis, and treatment of these is aimed at identifying reversible or treatable causes of symptoms and palliating those with irreversible causes. From a psychologic standpoint, patients with cervical cancer face the stigma of having a preventable cancer caused by a sexually transmitted infection and the ramifications of sexual dysfunction. Clinicians must invite honest dialogue to be able to address specific survivorship issues.

Healthcare Providers' Pregnancy Prevention Counseling of Trans and Non-Binary Assigned Female at Birth (TNB/AFAB) Patients

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.

Sexual experience, relationships, and factors associated with sexual and romantic satisfaction in the first Australian Trans & Gender Diverse Sexual Health Survey

Background: Sexual and romantic satisfaction are important aspects of sexual health and wellbeing, but they have not been thoroughly investigated among transgender and gender diverse ('trans') people in Australia. Aims: To address this gap and improve sexual health and wellbeing, we assessed the sexual behavior and relationships of a national sample of trans people in Australia, and factors associated with sexual and romantic satisfaction. Methods: We conducted a national survey of trans people from Australia in October-November 2018. Results: The sample included 1,613 trans participants, of whom 353 (21.9%) were men, 397 (24.6%) were women and 863 (53.5%) were non-binary. Over 70% of the sample had been sexually active in the previous year, and 56.9% were in a relationship, but only 32.4% were satisfied with the sexual aspects and 47.1% with the romantic aspects of their lives. Sexual satisfaction was associated with younger age, being asexual, having more trans friends, more frequent sex, and using illicit drugs in the context of sexual activity. Anxiety or fear about sex was associated with less sexual satisfaction, as was being in an open relationship. Romantic satisfaction was associated with younger age, having non-binary partners, and being in a current relationship (particularly a monogamous one). Recent distress, anxiety, or fear about sex were associated with less romantic satisfaction. Conclusion: Participants reported a broad range of sexual relationships, but low levels of satisfaction with the sexual and romantic aspects of their lives. The findings underscore the importance of supportive partners, access to social support and peer networks of trans people, as well as access to mental health support and sex-positive, trans affirming counseling in sexual health services.

"Making a Way Out of No Way:" Understanding the Sexual and Reproductive Health Care Experiences of Transmasculine Young Adults of Color in the United States

Research focusing on the specific and unique sexual and reproductive health care experiences of transmasculine young adults of color are extremely scarce. We conducted five focus group discussions with 19 Black, Latinx, Asian, Native, and other transmasculine individuals of color aged 18-25 years in the greater Boston area. Using thematic analysis, we found that transmasculine young adults of color experienced cissexism, heterosexism, and racism in accessing and utilizing sexual and reproductive health services. These multiple forms of discrimination undermined participants' receipt of high-quality sexual and reproductive health information and care from competent health care providers who shared their lived experiences. Participants relied on support from their lesbian, gay, bisexual, transgender, and queer peers to obtain needed sexual and reproductive health resources and minimize harm during clinical encounters. Multilevel interventions are needed to promote access to person-centered and structurally competent sexual and reproductive health care among transmasculine young adults of color.

Changes in Utilization of Birth Control and PrEP During COVID-19 in the USA: A Mixed-Method Analysis

In the USA, the COVID-19 pandemic has created challenges beyond the direct consequences of the infection. Because of shifting resources in response to need, many domains within the healthcare sector unrelated to COVID-19 have had interrupted abilities to provide care. In the current study, we focus on preventative sexual health care during the pandemic. In a sample of 511 (mean age = 27.7) people, we examined quantitative data regarding continuation and discontinuation of birth control and PrEP during the pandemic, along with qualitative data illustrating the underlying reasons for participants' (dis)continuation. Results showed that most (92.5%) of birth control users reported continuation of their birth control, with the predominant reasons reported being use for health reasons, long-acting reversible contraceptive use, access to remote healthcare services, and increased vigilance over pregnancy prevention. Conversely, around half (52.6%) of PrEP-using participants reported already discontinuing or planning to discontinue their PrEP regimen. Temporary abstinence and concerns about accessing in-person health care were the predominant reasons for PrEP discontinuation. These results have implications for both researchers and sexual healthcare providers. Disruptions to preventative sexual health care should be considered in ongoing research about patient needs, and healthcare providers may wish to consider particular challenges faced by PrEP users concerning re-start and continuation.

Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

BACKGROUND

Transgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.

METHODS

In 2019, we recruited participants for an online survey about sexual and reproductive health. Eligible participants were TGE people assigned female or intersex at birth, 18 years and older, from across the United States, and recruited through The PRIDE Study or via online and in-person postings.

RESULTS

Of 1694 TGE participants, 76 people (36% of those ever pregnant) reported considering trying to end a pregnancy on their own without clinical supervision, and a subset of these (n=40; 19% of those ever pregnant) reported attempting to do so. Methods fell into four broad categories: herbs (n=15, 38%), physical trauma (n=10, 25%), vitamin C (n=8, 20%) and substance use (n=7, 18%). Reasons given for abortion without clinical supervision ranged from perceived efficiency and desire for privacy, to structural issues including a lack of health insurance coverage, legal restrictions, denials of or mistreatment within clinical care, and cost.

CONCLUSIONS

These data highlight a high proportion of sampled TGE people who have attempted abortion without clinical supervision. This could reflect formidable barriers to facility-based abortion care as well as a strong desire for privacy and autonomy in the abortion process. Efforts are needed to connect TGE people with information on safe and effective methods of self-managed abortion and to dismantle barriers to clinical abortion care so that TGE people may freely choose a safe, effective abortion in either setting.

Automated STI/HIV risk assessments: Testing an online clinical algorithm in Ottawa, Canada

Despite the ongoing transmission of sexually transmitted infections (STIs) and HIV, many people became unable to access testing due to COVID-19. To address this, we created a mail-out HIV self-test kit, which could be delivered without restrictions in our region. The uptake and feedback from this project made us realize that comprehensive STI testing was being sought. To ensure testing occurred correctly-that is, it would be targeted at the persons most affected by STIs/HIV-we automated clinical decision-making. We built this model based on a 2-by-2 matrix that plots the risk of STI/HIV transmission and risk of STI/HIV exposure. The intercept of these two measures classifies a person as low, medium, or high risk. After automating this logic, 16 expert clinicians in STI/HIV care tested this system with over 400 test patient cases and refined the algorithm until it yielded the exact outcomes that these clinicians would offer patients based on guidelines. Findings of interest are that the scale of the y-axis is exponential, in that risk factors for exposure do not climb cumulatively but do so according to a quadratic equation. This helps ensure that testing services are targeted at those who are most inequitably burdened by these infections.

Bridging Barriers to Cervical Cancer Screening in Transgender Men: A Scoping Review

Estimates of high-risk human papillomavirus (HPV) infection and susceptibility to HPV-related cancer in transgender men (TM) are comparable to prevalence rates found in cisgender women. Regular and thorough screening for cervical cancer is equally as crucial for TM as for cisgender women; however, despite continued risk for cervical cancer in TM and associated recommendations for screening, studies indicate disparities in rates of cervical cancer screening (CCS) in TM compared to cisgender women. The current scoping review explores TM’s knowledge and experiences of CCS and barriers to screening uptake in this population. A range of barriers were identified including the need for health-care services to provide care for TM within the context of a nonbinary approach to gender identity and health. Findings synthesized from relevant research studies (n = 15; published 2008–2019) are presented, and recommendations are drawn from these findings to inform primary health-care providers’ clinical practice and care of TM.

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.

Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case-Based Scoping Review

Research shows an overrepresentation of trans people in vulnerable socioeconomic situations, primarily due to experiences of discrimination. At the same time, rural or suburban living areas often lack specialized trans-related health care, which a majority of trans people rely on to some extent. Taken together, the lack of both socioeconomic resources and access to trans-related health care can exacerbate health-related distress and impairment for trans people. We illustrate this problem using case vignettes of trans people from rural and suburban areas in (Northern) Germany. They are currently participating in an e-health intervention and randomized controlled trial (RCT) called i²TransHealth, whose case vignettes provided the impetus for the scoping review. The scoping review analyzes the impact of place of residence and its intersection with barriers to accessing trans-related health care. PubMed and Web of Science Data bases were searched for relevant studies using a search strategy related to trans people and remote, rural, or suburban residences. 33 studies were selected after full-text screening and supplemented via reference list checks and study team expertise by 12 articles addressing the living conditions of remotely living trans people and describing requirements for trans-related health care. The literature on trans people living remotely reveals intersections of trans mental health with age, race, gender expression, geographic location, community size, socioeconomic status, discrimination experiences, and attitudes towards health care providers. Several structural health care barriers are identified. The role of health care professionals (HCPs) for remotely living trans people is discussed. There is no need assuming that rural life for trans people is inevitably worse for health and well-being than urban life. Nevertheless, some clear barriers and health disparities exist for trans people in remote settings. Empowering trans groups and diversity-sensitive education of remote communities in private and institutional settings are needed for respectful inclusion of trans people. Facilitating access to trans-related health care, such as through video-based e-health programs with HCPs, can improve both the health and socioeconomic situation of trans people.

Stakeholder Perceptions and Experiences Regarding Access to Contraception and Abortion for Transgender, Non-Binary, and Gender-Expansive Individuals Assigned Female at Birth in the U.S

Sexual and reproductive health (SRH) care often excludes the needs and experiences of transgender, non-binary, and gender-expansive (TGE) individuals. This study aimed to collect diverse stakeholder perspectives on barriers and facilitators to contraception and abortion for TGE individuals assigned female at birth (AFAB), assess knowledge and attitudes about unintended pregnancy prevention in these populations, and identify recommendations for improving SRH services for people of all genders. Between October 2017 and January 2018, we conducted 27 in-depth interviews with SRH stakeholders, including five TGE individuals who had obtained contraception or abortion care, and 22 clinicians, researchers, and advocates experienced in transgender healthcare. We iteratively developed a codebook and conducted thematic analysis to capture the spectrum of perspectives across interviews. Stakeholders reported a range of barriers to contraception and abortion access for TGE people AFAB, including inability to afford services, lack of gender-affirming clinicians, difficulty obtaining insurance coverage, and misconceptions about fertility and unplanned pregnancy risk. Deterrents to care-seeking included gendered healthcare environments, misgendering, and discrimination. Stakeholders described provider knowledge gaps and a perceived lack of medical education relevant to the SRH needs of TGE people. Recommendations included using gender-inclusive language and gender-affirming patient education materials and improving provider training on gender-affirming SRH care. Stakeholders identified substantial barriers to high-quality contraception and abortion care for TGE AFAB people in the U.S. They recommended specific interventions at the provider and institutional levels to improve experiences with care for TGE people and ensure broader access to gender-affirming SRH services.

Improving Cervical Screening in Trans and Gender-Diverse People

BACKGROUND

Trans and gender-diverse people with a cervix experience difficulties accessing cervical cancer screening because of structural, interpersonal, and individual barriers.

OBJECTIVE

The aim of this study was to explore issues with cervical cancer screening participation, awareness, and healthcare provider recommendation for trans and gender-diverse people.

METHODS

A national Australian survey was conducted in 2018 to 2019. Participants included 196 trans and gender-diverse people with a cervix. Data were analyzed using descriptive and multiple regression analyses. Two awareness items related to cervical cancer screening, healthcare provider recommendation, and cervical cancer screening participation were assessed. Four variables associated with cervical cancer screening were included in the regression: age, healthcare provider recommendation, like for body, and gender.

RESULTS

The sample was young; half (52.6%) were aged 20 to 24 years. Almost half (44.6%) had never had a healthcare provider recommend cervical cancer screening to them. Around half (48.0%) had never participated, with 21.9% reporting that they are regular screeners. More than a quarter (27.5%) of people who had screening had an abnormal result. The most common reasons for not participating in screening were that it is emotionally traumatic for them (55.3%) and inability to find a healthcare provider with whom they are comfortable (38.3%).

CONCLUSIONS

Trans and gender-diverse Australians with a cervix are unlikely to be regular participants in cervical cancer screening. To continue reducing cervical cancer rates, healthcare providers must address underscreening in this community.

IMPLICATIONS FOR PRACTICE

Gender diversity training needs to be provided to healthcare providers. In addition, healthcare providers need to promote participation in cervical screening in this trans and gender-diverse community.

Barriers and facilitators to cervical cancer screening among transgender men and non-binary people with a cervix: A systematic narrative review

Cervical cancer mortality in the United Kingdom (UK) has decreased over the last decade, largely due to uptake of cervical cancer screening. However, only those with a female gender marker on their health records are invited, creating a significant barrier to gender minorities accessing screening. We undertook a systematic review to synthesise published literature on cervical cancer screening among eligible gender minorities, aiming to identify barriers and facilitators that might inform changes in UK policy and clinical practice. We conducted a broad search across Medline, Embase, PsycInfo and Global Health databases to 3rd January 2020 and included any original, peer-reviewed research, published in the English language that reported on cervical cancer screening among gender minorities assigned female at birth (AFAB). Twenty-seven studies were critically appraised and included in the final synthesis, which identified significant disparities in cervical cancer screening uptake between gender minorities AFAB and cis women. It revealed a lack of knowledge surrounding the relationship between gender minority status and cervical cancer risk among both service users and providers and highlighted significant barriers to access for gender minorities AFAB. Cervical cancer screening was not universally associated with dysphoria among gender minorities AFAB and we recommend that providers explore patients' preferences around screening, while avoiding assumptions. Providers should be proficient in examination techniques that maximise patient autonomy and minimise gender dysphoria or pain. Self-swabs for high-risk HPV may provide a more acceptable, evidence-based, alternative to Pap smears but there remains a need for further UK-specific research, to inform changes in policy.