Interest in over-the-counter progestin-only pills among transgender, nonbinary, and gender-expansive individuals in the United States.

BACKGROUND: In July 2023, the US Food and Drug Administration approved the first nonprescription oral contraceptive, a progestin-only pill, in the United States. Transgender, nonbinary, and gender-expansive people assigned female or intersex at birth face substantial contraceptive access barriers and may benefit from over-the-counter oral contraceptive access. However, no previous research has explored their perspectives on this topic. OBJECTIVE: This study aimed to measure interest in over-the-counter progestin-only pill use among transgender, nonbinary, and gender-expansive individuals assigned female or intersex at birth. STUDY DESIGN: We conducted an online, cross-sectional survey from May to September 2019 (before the US Food and Drug Administration approval of a progestin-only pill) among a convenience sample of transgender, nonbinary, and gender-expansive people assigned female or intersex at birth who were aged 18 to 49 years from across the United States. Using descriptive statistics and logistic regression analyses, we estimated interest in over-the-counter progestin-only pill use (our outcome) overall and by sociodemographic and reproductive health characteristics (our exposures). We evaluated separate logistic regression models for each exposure. In each model, we included the minimally sufficient adjustment set to control for confounding pathways between the exposure and outcome. For the model for age, we ran a univariable logistic regression model; for all other exposures, we ran multivariable logistic regression models. RESULTS: Among 1415 participants in our sample (median age, 26 years), 45.0% (636/1415; 95% confidence interval, 42.3-47.6) were interested in over-the-counter progestin-only pill use. In separate logistic regression models for each exposure, there were higher odds of interest among participants who were aged 18 to 24 years (odds ratio, 1.67; 95% confidence interval, 1.33-2.10; vs those aged 25-34 years), those who were uninsured (adjusted odds ratio, 1.91; 95% confidence interval, 1.24-2.93; vs insured), those who currently used oral contraceptives (adjusted odds ratio, 1.69; 95% confidence interval, 1.17-2.44; vs non-users), had ≤high school degree (adjusted odds ratio, 3.02; 95% confidence interval, 1.94-4.71; vs college degree), had ever used progestin-only pills (adjusted odds ratio, 2.32; 95% confidence interval, 1.70-3.17; vs never users), and who wanted to avoid estrogen generally (adjusted odds ratio, 1.32; 95% confidence interval, 1.04-1.67; vs those who did not want to avoid estrogen generally) or specifically because they viewed it as a feminizing hormone (adjusted odds ratio, 1.72; 95% confidence interval, 1.36-2.19; vs those who did not want to avoid estrogen because they viewed it as a feminizing hormone). There were lower odds of interest among participants with a graduate or professional degree (adjusted odds ratio, 0.70; 95% confidence interval, 0.51-0.96; vs college degree), those who were sterilized (adjusted odds ratio, 0.31; 95% confidence interval, 0.12-0.79; vs not sterilized), and those who had ever used testosterone for gender affirmation (adjusted odds ratio, 0.72; 95% confidence interval, 0.57-0.90; vs never users). CONCLUSION: Transgender, nonbinary, and gender-expansive individuals were interested in over-the-counter progestin-only pill use, and its availability has the potential to improve contraceptive access for this population.

Accounting for Misclassification and Selection Bias in Estimating Effectiveness of Self-managed Medication Abortion.

BACKGROUND: Studies on the effectiveness of self-managed medication abortion may suffer from misclassification and selection bias due to self-reported outcomes and loss of follow-up. Monte Carlo sensitivity analysis can estimate self-managed abortion effectiveness accounting for these potential biases. METHODS: We conducted a Monte Carlo sensitivity analysis based on data from the Studying Accompaniment model Feasibility and Effectiveness Study (the SAFE Study), to generate bias-adjusted estimates of the effectiveness of self-managed abortion with accompaniment group support. Between July 2019 and April 2020, we enrolled a total of 1051 callers who contacted accompaniment groups in Argentina and Nigeria for self-managed abortion information; 961 took abortion medications and completed at least one follow-up. Using these data, we calculated measures of effectiveness adjusted for ineligibility, misclassification, and selection bias across 50,000 simulations with bias parameters drawn from pre-specified Beta distributions in R. RESULTS: After accounting for the potential influence of various sources of bias, bias-adjusted estimates of effectiveness were similar to observed estimates, conditional on chosen bias parameters: 92.68% (95% simulation interval: 87.80%, 95.74%) for mifepristone in combination with misoprostol (versus 93.7% in the observed data) and 98.47% (95% simulation interval: 96.79%, 99.39%) for misoprostol alone (versus 99.3% in the observed data). CONCLUSIONS: After adjustment for multiple potential sources of bias, estimates of self-managed medication abortion effectiveness remain high. Monte Carlo sensitivity analysis may be useful in studies measuring an epidemiologic proportion (i.e., effectiveness, prevalence, cumulative incidence) while accounting for possible selection or misclassification bias.

Abortion-Related Laws and Concurrent Patterns in Abortion Incidence in Indiana, 2010-2019.

Objectives. To analyze abortion incidence in Indiana concurrent with changes in abortion-related laws. Methods. Using publicly available data, we created a timeline of abortion-related laws in Indiana, calculated abortion rates by geography, and described changes in abortion occurrence coincident with changes in abortion-related laws between 2010 and 2019. Results. Between 2010 and 2019, Indiana's legislature passed 14 abortion-restricting laws, and 4 of 10 abortion-providing clinics closed. The Indiana abortion rate decreased from 7.8 abortions per 1000 women aged 15 to 44 years in 2010 to 5.9 in 2019. At all time points, the abortion rate was 58% to 71% of the Midwestern rate and 48% to 55% of the national rate. By 2019, nearly 1 in 3 (29%) Indiana residents who obtained abortion care did so outside the state. Conclusions. Access to abortion in Indiana over the past decade was low, required increases in interstate travel to obtain care, and co-occurred with the passage of numerous abortion restrictions. Public Health Implications. These findings preview unequal abortion access and increases in interstate travel as state-level restrictions and bans go into effect across the country. (Am J Public Health. 2023;113(4):429-437. https://doi.org/10.2105/AJPH.2022.307196).

The pleasure, joy and positive emotional experiences of abortion accompaniment after 17 weeks' gestation.

Research documents how abortion can be emotionally difficult and stigmatising, but generally has not considered whether and how involvement in abortion may be a source of positive emotions, including pleasure, belonging and even joy. The absence of explorations that start from the possibility of abortion pleasure and joy represents an epistemic foreclosure. Moreover, it highlights how social science literature has tended to emphasise the negative aspects of abortion care in ways that produce or amplify normative negative associations. In this paper, we investigate the positive emotions, pleasure and joy of abortion involvement by drawing on interviews conducted in 2019 with 28 abortion accompaniers in Argentina, Chile, and Ecuador about their experiences accompanying abortions after 17 weeks' gestation. Abortion accompaniment is a response to unsafe and/or inaccessible abortion whereby volunteer activists guide abortion seekers through a medication abortion. Interviewees described how the practice of accompaniment generated positive emotions by building a feminist community, shared intimacy among women, and witnessing aborting people claim their strength. Importantly, these positive emotional experiences of involvement with abortion were not distinct from the broader marginalisation of abortion but were, instead, rooted in its marginalisation.

What constitutes a good healthcare experience for unintended pregnancy? A qualitative study among young people in California.

Little is known about young people's experiences accessing healthcare for unintended pregnancy in the USA. To address this gap, we conducted in-depth interviews with 25 young people in California who had experienced at least one unintended pregnancy at or before 25 years of age. Participants were asked about their interactions with healthcare providers during the pregnancy, their thoughts on the determinants of their perceived quality of care, and the ways in which their healthcare experience could have been improved. Thematic analysis was used to organise information within and across interview transcripts. Two important determinants of participants' satisfaction with their healthcare experience were identified during analysis: (1) receiving comprehensive information about their pregnancy options and what to expect from each, and (2) having an empathetic, non-judgemental provider. Regarding abortion, participants described an unmet need for accurate information and frequent stigmatising experiences with dismissive and judgemental care providers. These findings highlight the importance of providing comprehensive, non-judgemental pregnancy options counselling to all pregnant people, regardless of age and desired pregnancy outcome; and reinforce the need for providers to consider ways in which their own bias may influence the quality of care they provide.

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.

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.

Self-managed medication abortion outcomes: results from a prospective pilot study.

BACKGROUND: To evaluate the feasibility of conducting a prospective study to measure self-managed medication abortion outcomes, and to collect preliminary data on safety and effectiveness of self-managed medication abortion, we recruited callers to accompaniment groups (volunteer networks that provide counselling through the out-of-clinic medication abortion process by trained counselors over the phone or in-person). METHODS: In 2019, we enrolled callers to three abortion accompaniment groups in three countries into a prospective study on the safety and effectiveness of self-managed medication abortion with accompaniment support. Participants completed up to five interview-administered questionnaires from baseline through 6-weeks after taking the pills. Primary outcomes included: (1) the number of participants enrolled in a 30-day period, (2) the proportion that had a complete abortion; and (3) the proportion who experienced any warning signs of potential or actual complications. RESULTS: Over the 30-day recruitment period, we enrolled 227 participants (95% of those invited), and retained 204 participants (90%) for at least one study follow-up visit. At the 1-week follow-up, two participants (1%) reported a miscarriage prior to taking the pills, and 202 participants (89% of those enrolled and 99% of those who participated in the 1-week survey) had obtained and taken the medications. Three weeks after taking the medications, 192 (95%) participants reported feeling that their abortion was complete. Three (1.5%) received a surgical intervention, two (1%) received antibiotics, and five (3%) received other medications. Participants did not report any major adverse events. CONCLUSION: These results establish the feasibility of conducting prospective studies of self-managed medication abortion in legally restrictive settings. Further, the high effectiveness of self-managed medication abortion with accompaniment support reported here is consistent with high levels of effectiveness reported in prior studies. Trial registration ISRCTN95769543.

Reducing underreporting of stigmatized pregnancy outcomes: results from a mixed-methods study of self-managed abortion in Texas using the list-experiment method.

BACKGROUND: Accurately measuring stigmatized experiences is a challenge across reproductive health research. In this study, we tested a novel method - the list experiment - that aims to reduce underreporting of sensitive events by asking participants to report how many of a list of experiences they have had, not which ones. We applied the list experiment to measure "self-managed abortion" - any attempt by a person to end a pregnancy on one's own, outside of a clinical setting - a phenomenon that may be underreported in surveys due to a desire to avoid judgement. METHODS: We administered a double list experiment on self-managed abortion to a Texas-wide representative sample of 790 women of reproductive age in 2015. Participants were asked how many of a list of health experiences they had experienced; self-managed abortion was randomly added as an item to half of the lists. A difference in the average number of items reported by participants between lists with and without self-managed abortion provided a population level estimate of self-managed abortion. In 2017, we conducted cognitive interviews with women of reproductive age in four states to understand how women (1) interpreted the list experiment question format, and (2) interpreted the list item on prior experiences attempting to self-manage an abortion. RESULTS: Results from this list experiment estimated that 8% of women of reproductive age in Texas have ever self-managed an abortion. This number was higher than expected, thus, the researchers conducted cognitive interviews to better understand how people interpreted the list experiment on self-managed abortion. Some women interpreted "on your own" to mean "without the knowledge of friends or family", as opposed to "without medical assistance", as intended. CONCLUSION: The list experiment may have reduced under-reporting of self-managed abortion; however, the specific phrasing of the list item may also have unintentionally increased reporting of abortion experiences not considered "self-managed." High participation in and comprehension of the list experiment, however, suggests that this method is worthy of further exploration as tool for measuring stigmatized experiences.

Contextualizing medication abortion in seven African nations: A literature review.

We conducted a comprehensive literature review on abortion in seven African countries to synthesize and analyze the landscape of abortion-related scientific knowledge, with the aim of informing abortion-access related research and programs in the region. We find that that abortion is common, despite legal restrictions, and often occurs outside of the formal health care system. Use of medication abortion was reported to be low, potentially due to legal restrictions and insufficient provider training across the continent. Creative interventions that could improve people's knowledge of and access to safe medication abortion were identified and described.

Multivariable regression analysis of list experiment data on abortion: results from a large, randomly-selected population based study in Liberia.

BACKGROUND: The list experiment is a promising measurement tool for eliciting truthful responses to stigmatized or sensitive health behaviors. However, investigators may be hesitant to adopt the method due to previously untestable assumptions and the perceived inability to conduct multivariable analysis. With a recently developed statistical test that can detect the presence of a design effect - the absence of which is a central assumption of the list experiment method - we sought to test the validity of a list experiment conducted on self-reported abortion in Liberia. We also aim to introduce recently developed multivariable regression estimators for the analysis of list experiment data, to explore relationships between respondent characteristics and having had an abortion - an important component of understanding the experiences of women who have abortions. METHODS: To test the null hypothesis of no design effect in the Liberian list experiment data, we calculated the percentage of each respondent "type," characterized by response to the control items, and compared these percentages across treatment and control groups with a Bonferroni-adjusted alpha criterion. We then implemented two least squares and two maximum likelihood models (four total), each representing different bias-variance trade-offs, to estimate the association between respondent characteristics and abortion. RESULTS: We find no clear evidence of a design effect in list experiment data from Liberia (p = 0.18), affirming the first key assumption of the method. Multivariable analyses suggest a negative association between education and history of abortion. The retrospective nature of measuring lifetime experience of abortion, however, complicates interpretation of results, as the timing and safety of a respondent's abortion may have influenced her ability to pursue an education. CONCLUSION: Our work demonstrates that multivariable analyses, as well as statistical testing of a key design assumption, are possible with list experiment data, although with important limitations when considering lifetime measures. We outline how to implement this methodology with list experiment data in future research.

The List Experiment for Measuring Abortion: What We Know and What We Need.

Measuring abortion incidence and prevalence is often difficult because of under-reporting and other biases, complicated research designs, and other issues. Recently, family planning researchers have introduced a new method called the list experiment, adopted from political science and economics, to measure abortion. Three completed studies and at least four studies currently underway use this method to measure abortion in several countries. We discuss the lessons learned from completed studies, when the list experiment may and may not be appropriate, and open questions regarding the use of the list experiment for abortion research. This method has the potential to improve measures of abortion prevalence and incidence, which could translate to better-informed interventions to increase abortion access and reduce unmet need for family planning. Future research should further clarify the advantages and limitations of the list experiment for measuring abortion.

Bone mineral density and mammographic density in Mexican women.

BACKGROUND: Bone mineral density (BMD) is a putative marker for lifetime exposure to estrogen. Studies that have explored whether BMD is a determinant of mammographic density (MD) have observed inconsistent results. Therefore,we examined this potential association in a sample of women (n = 1,516) from the clinical sub-cohort in the Mexican teachers' cohort (n = 115,315). METHODS: We used multivariable linear regression to assess the association between quartiles of BMD and percent MD, as well as total dense and non-dense area of the breast, stratified by menopausal status. We also examined the associations by body mass index (BMI) (< 30 kg/m(2), ≥ 30 kg/m(2)). RESULTS: Overall, there was no association between BMD and MD among premenopausal women. However, when we stratified by BMI, there was a modest inverse association between BMD and percent MD (difference between extreme quartiles = -2.8, 95 % CI -5.9, 0.27, p trend = 0.04) among women with BMI < 30 kg/m(2), but a positive association among obese women (comparable difference = 5.1, 95 % CI 0.02, 10.1, p trend = 0.03;p interaction < 0.01). Among postmenopausal women, BMD and percent MD were positively associated after adjustment for BMI (p trend < 0.01). Postmenopausal women in the highest two quartiles of BMD had 4­5 % point higher percent MD compared to women in the lowest quartile. The association did not differ by BMI in postmenopausal women (p interaction = 0.76). CONCLUSION: Among obese premenopausal women as well as postmenopausal women, BMD was positively associated with percent MD. Among leaner premenopausal women, BMD and percent MD were modestly inversely associated. These findings support the hypothesis that cumulative exposure to estrogen (as measured by BMD) may influence MD.

Systematic Motorcycle Management and Health Care Delivery: A Field Trial.

OBJECTIVES: We investigated whether managed transportation improves outreach-based health service delivery to rural village populations. METHODS: We examined systematic transportation management in a small-cluster interrupted time series field trial. In 8 districts in Southern Zambia, we followed health workers at 116 health facilities from September 2011 to March 2014. The primary outcome was the average number of outreach trips per health worker per week. Secondary outcomes were health worker productivity, motorcycle performance, and geographical coverage. RESULTS: Systematic fleet management resulted in an increase of 0.9 (SD = 1.0) trips to rural villages per health worker per week (P < .001), village-level health worker productivity by 20.5 (SD = 5.9) patient visits, 10.2 (SD = 1.5) measles immunizations, and 5.2 (SD = 5.4) child growth assessments per health worker per week. Motorcycle uptime increased by 3.5 days per week (P < .001), use by 1.5 days per week (P < .001), and mean distance by 9.3 kilometers per trip (P < .001). Geographical coverage of health outreach increased in experimental (P < .001) but not control districts. CONCLUSIONS: Systematic motorcycle management improves basic health care delivery to rural villages in resource-poor environments through increased health worker productivity and greater geographical coverage.

'How shall we survive': a qualitative study of women's experiences following denial of menstrual regulation (MR) services in Bangladesh.

BACKGROUND: About one quarter of women in Bangladesh are denied menstrual regulation (MR) due to advanced gestation [J Fam Plann Reprod Health Care 41(3):161-163, 2015, Issues Brief (Alan Guttmacher Inst) (3):1-8, 2012]. Little is known about barriers to MR services, and whether women denied MR seek abortion elsewhere, self-induce, or continue the pregnancy. METHODS: After obtaining authorization from four health facilities in Bangladesh, we recruited eligible and interested women in to the study and requested informed consent for study participation. We conducted in-depth interviews with 20 women denied MR from four facilities in four districts in Bangladesh. Interviews were translated and transcribed, and the transcripts were analyzed by two researchers through an iterative process using a qualitative content analysis approach. RESULTS: Of those interviewed, 12 women sought abortion elsewhere and eight of these women were successful; four women who sought subsequent services were denied again. Two of the eight women who subsequently terminated their pregnancies suffered from complications. None of the participants were aware of the legal gestational limit for government-approved MR services. Given that all participants were initially denied services because they were beyond the legal gestational limit for MR and there were no reported risks to any of the mothers' health, we presume that the eight terminations performed subsequently were done illegally. CONCLUSIONS: Barriers to seeking safe MR services need to be addressed to reduce utilization of potentially unsafe alternative abortion services and to improve women's health and well being in Bangladesh. Findings from this study indicate a need to raise awareness about legal MR services; provide information to women on where, how and when they can access these services; train more MR providers; improve the quality and safety of second trimester services; and strengthen campaigns to educate women about contraception and pregnancy risk throughout the reproductive lifespan to prevent unintended pregnancies.

How Effective Is Misoprostol Alone for Medication Abortion?

AbstractWith recent severe restrictions to abortion accessibility in the United States and a pending Supreme Court case challenging the Food and Drug Administration's approval of mifepristone, evidence-based strategies to protect and expand access to abortion care are needed. Two safe and effective regimens for medication abortion are widely used globally - misoprostol-only and misoprostol in combination with mifepristone. However, misoprostol-only regimens are rarely used in the United States. In 2023, the National Abortion Federation and the Society of Family Planning updated their recommended protocol for misoprostol-only for medication abortion to 800 µg of misoprostol administered buccally, sublingually, or vaginally every 3 hours for three or more doses. To characterize the data supporting this specific regimen, this article reviews the relevant literature to address the question of how effective misoprostol-only is for medication abortion. The authors conclude that the updated misoprostol regimen is highly effective and a potential strategy for expanding access to abortion.

Family building and pregnancy experiences of cisgender sexual minority women.

BACKGROUND: Although 10% to 20% of cisgender women aged 18 to 40 years have a sexual minority identity (eg, bisexual, lesbian, and queer), there is limited research on the family building and pregnancy experiences of sexual minority cisgender women. Improving our understanding of the family building and pregnancy experiences of cisgender sexual minority women is critical for improving the perinatal health of this population. OBJECTIVE: This study aimed to compare the mode of family building, past pregnancy experiences, and future pregnancy intentions among cisgender sexual minority women by sexual orientation. STUDY DESIGN: This is an observational study which was conducted using cross-sectional data collected in 2019 from a national sample of 1369 cisgender sexual minority women aged 18 to 45 years. RESULTS: Most participants (n=794, 58%) endorsed multiple sexual orientations, most commonly queer (n=641, 47%), lesbian (n=640, 47%), and/or bisexual (n=583, 43%). There were 243 (18%) cisgender sexual minority women who were parents. Pregnancy was used by 74% (181/243) of women to build their families. Among participants who used pregnancy, 60% (108/181) became pregnant through sexual activity with another parent of the child, whereas 27% (64/243) of women used donor sperm. An additional 10% (n=24) became parents through second-parent adoption, 10% (n=25) through adoption, and 14% (n=35) through step-parenting. Bisexual women more often used sexual activity to become parents (61/100, 61%) compared with queer (40/89, 45%) and lesbian women (40/130, 31%). In contrast, lesbian (50/130, 39%) and queer (25/89, 27%) women more often used donor sperm to become parents compared with bisexual women (11/100, 11%). Among the 266 (19%) cisgender sexual minority women who had ever been pregnant, there were 545 pregnancies (mean, 2.05 pregnancies per woman). Among those pregnancies, 59% (n=327) resulted in live birth, 23% (n=126) resulted in miscarriage, 15% (n=83) resulted in abortion, and 2% (n=9) resulted in ectopic pregnancy. A quarter of women had future pregnancy intentions, with no differences by sexual orientation. Overall, few participants (16%) reported that all of their healthcare providers were aware of their sexual orientation. CONCLUSION: Cisgender sexual minority women primarily built their families through pregnancy and a quarter have future pregnancy desires. In addition, there were important differences in family building methods used by sexual orientation. Providers should be aware of the pregnancy and family-building patterns, plans, and needs of cisgender sexual minority women.

Pathways to parenthood among transgender men and gender diverse people assigned female or intersex at birth in the United States: analysis of a Cross-Sectional 2019 Survey.

Objective: To assess pathways to parenthood, pregnancy outcomes, future pregnancy desire, and fertility counseling experiences among a cross-sectional sample of transgender men and gender diverse individuals assigned female or intersex at birth in the United States. Methods: Participants were recruited from The Population Research in Identity and Disparities for Equality (PRIDE) Study and the general public. Eligible participants for this analysis were able to read and understand English, assigned female or intersex at birth, US residents, 18+ years old, and identified as transgender, nonbinary, or gender diverse. We analyzed responses to close-ended survey questions, overall and stratified by gender identity, race/ethnicity, and testosterone use. We also qualitatively assessed open-text responses on fertility counseling. Results: Among the 1694 participants, median age was 27 years (range: 18-72), 12% had ever been pregnant, and 12% were parents. Carrying a pregnancy where the individual was the egg source (36%) was the most common pathway to parenthood. Individuals with an exclusively binary gender identity (ie, transgender man or man) more often reported becoming parents through adoption than individuals with gender diverse identities (19% vs 12%). A third of individuals did not receive fertility counseling prior to initiating testosterone; individuals who exclusively reported nonbinary identities were recommended to investigate fertility preservation options less often (36%) compared to transgender men (50%). Conclusion: Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption. Clinicians should avoid making assumptions about reproductive desires in these populations based on gender identities or testosterone use and should provide consistent fertility counseling prior to and after hormone initiation.