Reproductive Needs of Transgender Men

6/15/2017

Disclosures Reproductive Needs of Transgender Men

I have consulted for Sage Therapeutics about post- Juno Obedin-Maliver, MD, MPH, MAS partum depression treatment and care pathways. University of California, San Francisco Assistant Professor (UCSF and SFVAMC) Co-Director, The PRIDE Study Founder, Stanford University LGBT Medical Education Research Group

Antepartum & Intrapartum Management San Francisco, CA 15 June 2017

Today’s Objectives Today’s Plan • Terminology • Why is this important? • Understand the difference between sex, gender, sexual orientation, • What do I need to know? gender identity, and gender expression. • Resources • Understand some of the reproductive health needs for transgender men Resources lwn6au5 • Build a framework for providing sensitive and competent peripartum http://tinyurl.com/ health care for transgender patients.

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Gender vs. Sex

Are we talking, gender? A day in theOr life of 5M Sex? prenatal… Terminology

Right?

Gender vs. Sex Gender vs. Sex

Are we talking, gender? Are we talking, gender? A day in theOr life of 5M A day in theOr life of 5M Sex? Sex? prenatal… prenatal…

Sex: But what if the The biological and physiological characteristics that define males and females. family gets Gender: The socially constructed roles, behaviors, activities, and attributes that a given society Laverne instead considers appropriate for men and women.

of Jessie? “Male” and “female” are sex categories, while “man” and “woman” are gender categories.

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Gender vs. Sex Gender vs. Sex

“ “ ““Sex is what’s in your genes/jeans. ““Gender identity is who you go to bed as. ” ” Gender identity is what’s between your ears. ”” Sexual orientation is who you go to bed with.””

GenderThe Alphabet Identity Soupvs. Sex Transgender: an Umbrella

Lesbian Gay Transgender (Trans*) is an umbrella term… Bisexual For persons whose gender identity, gender expression, or behavior does not conform…to Transgender that typically associated with the sex to which they were assigned at birth. http://transhealth.ucsf.edu/tra Queer ns?page=guidelines- … and others terminology Use people’s affirmed gender

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Transgender: an Umbrella Terminology Transgender (Trans*) is an umbrella term… • Transition: The process of “gender transition” or “gender affirmation” may include social, medical, and/or surgical processes. Use people’s affirmed gender • Transgender man/ trans man (FTM): • Putting it together! (Sexual orientation and GI) a man who was assigned female sex at birth. • Lesbian (Transgender/Cisgender) Woman • Straight (Transgender/Cisgender) Man • Transgender woman/ trans woman (MTF): a woman who was assigned male sex at birth. • Bisexual (Cisgender/Transgender) Woman

• Genderqueer: someone who identifies outside of the gender binary of man and woman may have either sex assigned at birth.

Terminology: Principles for Use Quiz Time The following are features that correspond • No single definition with a person’s sex assigned at birth: • Vary geographically, A. Clothing, hair, make-up 100% individually, & over time! B. Reproductive organs • Avoid seeking or attaching C. Vocal intonation labels to people. D. Desire to carry a child E. “Opposite” gender attraction 0% 0% 0% 0%

s n g a t i o n r a c h i l d a c m a k e - u p e o r y a r a t t r i r , c t i v c r h a o ASK patients & use THEIR language ! t d e Vocal intonatione i n g , r g e n h s i ” o t R e p r o d u D e C l p p o s i t e Primary Care Protocol for Transgender Patient Care, Center of Excellence for Transgender Health, “O University of California, San Francisco, Department of Family & Community Medicine, April 2011

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LGBT ADULT Population Estimates

Massachusetts I’m busy, what does this have BRFSS 0.5% transgender to do with me?

Gates GJ. How many people are lesbian, gay, bisexual, transgender? UCLA School of Law, 2011.

Patients Want LGBT-Specific Care Providers Don’t Ask About SOGI

When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against Sobecki et al. J Sex Med. 2012;9:1285–1294. LGBT People and People with HIV (New York: Lambda Legal, 2010). Available at www.lambdalegal.org/health-care-report

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Don’t be that doctor. Some MEN need OBGYN health care!

Southern Comfort: A documentary about the life of Robert Eads a trans man who died of ovarian cancer.

Trans MEN’s repro health care needs Trans women need repro health care too! Obstetrics: they get pregnant Obstetrics: uterus transplants are on the horizon Family Planning: undesired pregnancies Family Planning: semen analysis, Gynecology: they still have vaginas, uteri cryopreservation etc. Gynecology: they have neo-vaginas, and REI: PCOS, needing assisted need support and mammos reproduction REI: back to family planning Urogynecology: genital reconstruction, general urogyn Urogynecology: often involved in reconstruction RID: STIs, HIV RID: high rates of STIs, HIV Oncology: sadly cancer too… Oncology: they get cancer too…

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National Committee Recognize This… Quiz Time What is the population prevalence of transgender people in the U.S.?

A. 1in 100 B. 1 in 200 - 300

C. 1 in 500 – 1,000 74% D. 1 in 2,000 – 3,000 E. 1 in 10,000 – 30,000 Transgender identity is a spectrum F. None of the above 7% 7% Barriers to care are significant 4% 3% 4%

0 0 0 0 0 0 v e 3 0 0 0 , 0 - 3 1 i n 1 0 0 – 0 – 1 , e a b o n 2 0 0 0 – 3 0 , 0 0 h Appropriate referrals & safe environment are key i 5 0 f t 1 i n , 0 o 1 i n 2 , 0 0 0 e 1 1 i n 1 0 N o n

“Transition” has 3 components 1 Social Okay, so what do I need to know? 2 Medical

3 Surgical

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Beyond surviving…thriving. Beyond surviving…thriving.

TIME My Brother’s Pregnancy and the The Next Frontier in Fertility Treatment. Making of a New American Family. Sarah Elizabeth Richards. September12, 2016 January 12, 2014.

“Pregnancies like Evan’s – will stretch our cultural perceptions of gender “Over the past 15 years, activists have fought to compel insurers to cover norms even further….But what is you were born into a female body, know transgender-related health care.... you are a man and still want to participate in the traditionally exclusive rite of What’s been left out of the spotlight: having babies.” womanhood? What kind of man are you then?

Transgender Parenting Transgender & GNC Research Participants VERY limited data mostly from National Transgender who Have Children/ Are Parents Discrimination Survey (NTDS) (2011) Ranges: • Parenting increases with age • Overall: • 82% in those 55 and older 15-26% • 38% in those younger than 55 • • In NTDS in each of the following were parents: Trans Women: • 52% trans women 23-69% • 17% trans men • Trans Men: • 20% GNC 0-35% • Trans people can and have lost their rights through • GNC: transition (Daly v. Daly, Nevada) • Only 6 states prohibit gender identity discrimination in 20-69%

adoption / fostering Stotzer. Transgender Parenting: Review of Existing Research. Williams Institute, 2014. Stotzer, RL, et al. Transgender Parenting: A Review of Existing Research. Williams Institute, 2014

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What about parenting desires? Reminder: Ingredients for a Baby

Study Goal: Provide info on reproductive wishes of What it takes to make a baby: transsexual men after SRS (FTM)

Single-center, cross-sectional, 50 FTM after testosterone & SRS (gender affirming surgery) • 64% in a relationship • 22% had children • N = 8 female partner, donor sperm • N = 3 gave birth before T & SRS • Egg • 54% desired to have children • Sperm • (Egg & sperm get together) • 37.5% would have frozen eggs • Uterus • (Time & Hormones) Wierckx K, Van Caenegem E, Pennings G, Elaut E, Dedecker D, Van de Peer F, et al. Reproductive wish in transsexual men. Hum Reprod 2012;27:483–7. What Makes a Baby. Cory Silverberg and Fiona Smyth.

What about contraception/conception? What about contraception/conception? Conclusion: Transgender men have different gender Study goal: Understand contraceptive use among partners & family building options & needs transgender men “at risk” for pregnancy. 26 transgender men studied at San Francisco Clinic • 50% using testosterone (13/26) • Among those on T, 69% amenorrheic (9/13) ~~ • 50% “at risk” for pregnancy (13/26) – have uterus + sex with cisgender man or transgender woman • 85% wanted to avoid pregnancy • 42% no contraceptive method (11/26) 28%+

Bauer 2013 Cipres et al. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception. 2016

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What about pregnancy? (1) What about pregnancy? (2) Study goal: Understand FTM who had been Study goal: Understand FTM who had been pregnant and delivered after transition. pregnant and delivered after transition. • 50% has MD prenatal care Online, cross-sectional, international • 78% delivered in hospital 41 FTM (social and medical transition) • 61% used testosterone prior to pregnancy • C/s (25% requested) • 72% resumption menses within 6 mos • 36% in testosterone group • 84% used their own oocytes • 19% in no testosterone group • 24% unplanned pregnancy • 50% chest (breast) fed (40% with prior T, 69% no T)

Light et al. Transgender Men who Experienced Pregnancy After Female-To Male Gender Transitioning. AJOG, 2014. Light et al. Transgender Men who Experienced Pregnancy After Female-To Male Gender Transitioning. AJOG, 2014.

What about pregnancy? (3) What about pregnancy? (4) Goal: Understand FTM who had been pregnant and Goal: Understand FTM who had been pregnant and delivered after transition. delivered after transition.

“Lonely, because I was the only one” The experience with pregnancy: “I found my gender dysphoria lessened significantly .” “I was just a carrier . I always knew I'd be the baby’s dad .” “Heavy time, having a baby, not passing as male, all the changes and society telling me to just be happy” What do you want providers to know: “The way they treat their patients is going to lead to people not seeking medical care .” “Began to show symptoms of postpartum depression long “OB/GYN offices rarely have restrooms labeled for 'men' .” “Even just basic stuff like knowing what pronouns to use would be good.” before anyone discussed symptoms to watch for” “I was personally turned away by several doctors .”

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What about the experiences of pregnancy? What about the experiences of pregnancy? Study: Perinatal Experiences of Male & Gender Variant Perinatal Experiences of Male & Gender Variant Gestational Gestational Parents: It’s How We Could Have a Family Parents: It’s How We Could Have a Family

8 Interviews male/gender variant gestational parents - Pregnancy as “most viable way” to make a “Even though I really hated the idea that I had to be seen as family -- 2 said: “I was my own surrogate” a woman in some places by some people to be pregnant, I - Internal & External struggles really liked the idea of bringing life into this world and being - Loneliness a part of that. … - Contextualizing pregnancy & miscarriage And I couldn’t do it any other way.” - Unable to locate relevant information

Ellis. Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family. J of Midwifery & Women’s Health. 2014 Ellis. Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family. J of Midwifery & Women’s Health. 2014

What about the experiences of pregnancy? What about the experiences of pregnancy? Perinatal Experiences of Male & Gender Variant Gestational Perinatal Experiences of Male & Gender Variant Gestational Parents: It’s How We Could Have a Family Parents: It’s How We Could Have a Family Strategies: - Training for all staff Simple interventions: - Documenting preferred name and pronouns clearly in • “[A]re you interested in becoming a parent someday?” the chart - Offering scheduling accommodations or alternate waiting areas • “[H]ave you thought about how you would like to become - Proactively discussing privacy issues a parent?” - Anticipatory discussion about labor/housing - Continuity of care - Calling ahead to referrals Ellis. Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family. J of Midwifery & Women’s Health. 2014 Ellis. Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family. J of Midwifery & Women’s Health. 2014

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CA is ahead of the curve Quiz Time Who are transgender men partnering with sexually?

80% A. Cisgender men B. Cisgender women C. Transgender men D. Transgender women 15% 2% 3% E. Genderqueer people 0% 0% “Gender is no barrier to applying for Medi-Cal Pregnancy Services” n n n l e v e m e m e o p e r a b o F. All of the above d r p e s g e n Cisgender m e g e n d e r w o n ender w om en r a g A ll of the C i s T T r a n s G e n d e r q u e e

What about chest (breast) feeding? What about chest (breast) feeding? Study Goal: Transmasculine individuals’ experiences Study Goal: Transmasculine individuals’ experiences with lactation, chestfeeding, & gender identity with lactation, chestfeeding, & gender identity

Qualitative Study, n=22 I don’ t think that I could have navigated this entire - 41% (9/22) chest surgery prior to conception process [pregnancy] without having had top surgery. - 27% (6/22) surgery after pregnancy [Oren] - 23% (5/22) wanted in future To get top surgery you kind of have to talk about - 16 chest fed (4 didn’t, 2 pregnant / SAB) it as if you never want to get pregnant, right, to - 56% (9/16) no dysphoria with chest-feeding the surgeon. …I don’ t think there was a way to talk to - Chests = dysphoria for many, but some delay him about getting surgery without having a - Language = key: (avoidMacDonald she/mom/breasts) et al. BMC Pregnancy and Childbirth (2016) 16:106 DOI 10.1186/s12884-016-0907-y conventional narrativeMacDonald et aboutal. BMC Pregnancy it. and Childbirth[Felix] (2016) 16:106 DOI 10.1186/s12884-016-0907-y

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Considerations in the clinical encounter SignalingGender ApproachabilityIdentity vs. Sex Establishing rapport: How can you signal to LGBTQ people that you are a safe • Use - Patient’s own language person with whom they can disclosure and or discuss sexual • Use - Preferred vs. given names orientation, gender identity? • Use - Gender neutral terminology • Ask - About identity & pronouns: Consider in your practice: ey/em/eir; he/him/his; ne/nem/nirs; she/her/hers; What happens when patients come in the door? ve/ver/vis; xe/xem/xyr ze(or zie)/hir; ze(or What happens behind closed doors? zie)/zir; it/its; they/them/their; (others) What happens between the doors? It’s okay to make mistakes, be humble and honest! What happens to open doors?

* Making Your Clinic LGBTQ Friendly * Get Involved Change the Landscape 1. Board and Senior Management are Actively Engaged 2. Policies Reflect the Needs of LGBTQ People •National, online, longitudinal cohort 3. All Staff Receive Training on Culturally Affirming LGBT Care study 4. Processes & Forms Reflect the Diversity of LGBT People & their Relationships •Web Based Platform 5. Data is Collected on Sexual Orientation & Gender Identity Population •Designed for and by LGBTQ people 6. All Patients Receive Routine Sexual Health Histories Research in •State-of-the-art participant Clinical Care and Services Incorporate LGBT Health Care Needs 7. Identity and management system 8. The Physical Environment Welcomes and Includes LGBT People Disparities for • 9. LGBT Staff are Recruited and Retained 5800+ participants since May 2, Equality 2017 10.Outreach Efforts Engage LGBT People in Your Community

See the webinar from The Fenway Institute:

National LGBT Health Education Center – Fenway Institute: Harvey Makadon - Webinar: 10 Things: Providing an Inclusive and Affirmative www.pridestudy.org Health Care Environment for LGBT People

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Conclusions Thank You! • Transgender men and their reproductive health needs are diverse, but not insurmountable Juno Obedin-Maliver, MD, MPH, MAS • Understanding the difference between sex, [email protected] gender, and gender transition are critical to good care. Resources • There are reproductive health implications to gender transition, but more data is needed. http://tinyurl.com/lwn6au5 • You know the medicine, simple changes to care for transgender people help! Check us out at www.pridestudy.org !