Contraception across the transmasculine spectrum.

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

Desire for Gender-Affirming Surgery in a Sample of Transgender and Gender Diverse Individuals in Late Adolescence Assigned Female at Birth.

OBJECTIVE: To describe choices of transgender and gender diverse (TGD) late adolescents assigned female at birth regarding gender-affirming surgery (GAS). METHODS: Participants aged 18-21 completed an online survey that included demographic characteristics, surgical history, desire for GAS, and barriers to care. RESULTS: Two hundred and sixty surveys were completed. Forty-three (16.7%) respondents had undergone GAS. Of those who had not, 178 (83%) planned to do so in the future, and 15 (7%) reported no desire to undergo GAS. One hundred and sixteen (54%) had not due to financial reasons, 54 (25%) due to insurance difficulties, and 28 (13%) because they were unable to find a surgeon. CONCLUSION: TGD late adolescents assigned female at birth have varying desires for future GAS that align with their gender expression. They also face many barriers to care. It is important for health care providers to be aware of the unique desires of TGD adolescents, not assume any particular surgical path for gender affirmation, and acknowledge the barriers experienced.

Success in Accessing Fertility Preservation Appointments for Egg-Producing Transgender and Gender-Diverse Patients: A Mystery Caller Study.

Purpose: This study aimed to evaluate access to fertility preservation appointments for egg-producing transgender and gender-diverse patients. Methods: Fertility clinics nationwide were identified through the 2018 National Assisted Reproductive Technology Surveillance System dataset of the Centers for Disease Control and Prevention. Using a mystery caller approach with a standardized, community-developed script, three researchers called 456 clinics between July and December 2020 identifying themselves as a transgender man seeking oocyte cryopreservation. Information was collected regarding access to fertility preservation for the caller. Univariate and multivariable logistic regression analysis were used to compare call outcomes by geographic region and clinic demographics. Results: Of 369 clinics included in the final analysis, 90.2% of clinics offered an initial appointment. A clinic that offered an appointment was four times more likely to be located on the West Coast (95% confidence interval [CI] 1.33-12.7; p = 0.014). Notably, endorsement of prior experience caring for transgender patients was most strongly associated with an appointment being offered (odds ratio = 7.31; 95% CI: 3.44-15.5; p < 0.001). Themes across some calls included a lack of knowledge about transgender identities and care models (e.g., requiring a letter of support) leading to additional steps (e.g., having to explain anatomy or being transferred to another staff member) before accessing an appointment. Conclusion: The majority of clinics offered an initial appointment to a caller identifying as a transgender man seeking oocyte cryopreservation, suggesting access to an initial appointment is not a major barrier.

Prevalence of Vulvar Pain and Dyspareunia in Trans Masculine Individuals.

Purpose: The prevalence of vulvar pain and dyspareunia has not been studied in trans masculine individuals. The aim of this study was to determine the prevalence of self-reported vulvar pain symptoms and dyspareunia in this population and investigate its relationship to gender-affirming hormone therapy with testosterone. Methods: Trans masculine individuals of ages 18-64 years participated in a voluntary online survey including questions about demographics, hormone therapy, and whether they experienced vulvar pain symptoms. The study was conducted between May 2017 and October 2018. Descriptive statistics were used to analyze the data. Results: A total of 782 trans masculine individuals completed the survey. The mean age was 27 years (standard deviation 8.6). The majority was White (661/778, 85.0%) and had private health insurance (517/781, 66.2%). Testosterone use was reported by 468 of 782 (59.8%) individuals, and 566 of 672 (84.2%) individuals had been sexually active in their lifetime. Unintentional pain with sexual intercourse was experienced by 372 of 605 (61.5%) participants. A total of 236 of 399 (59.1%) individuals utilized testosterone compared with 136 of 206 (66.0%) individuals who did not (p = 0.11). Of survey respondents, 68 of 710 (9.6%) individuals reported vulvar pain symptoms, and 42 of 452 (9.3%) individuals were on testosterone compared with 26 of 258 (10.1%) individuals not on testosterone (p = 0.79). Of all participants experiencing vulvar pain symptoms, 42 of 68 (61.8%) individuals were on testosterone. Conclusion: In this study, trans masculine individuals had a higher prevalence of dyspareunia than the general population, whereas the prevalence of vulvar pain was similar to that reported in cisgender women. The use of testosterone did not appear to increase the risk of developing unintentional pain with intercourse or vulvar pain symptoms.

The Intrauterine Device Experience Among Transgender and Gender-Diverse Individuals Assigned Female at Birth.

INTRODUCTION: The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals. METHODS: TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data. RESULTS: One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD. DISCUSSION: Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.