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. 1 6/15/2017 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. 2 6/15/2017 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 3 6/15/2017 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 4 6/15/2017 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 5 6/15/2017 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… 6 National Committee Recognize This… Transgender identity is a spectrum Barriers to care are significant Appropriate referrals & safe environment are key Okay, so what do I need to What is the population prevalence of A. 1in 100 B. 1 in 200 - 300 transgender people in the U.S.? C. 1 in 500 – 1,000 Quiz Time know? D. 1 in 2,000 – 3,000 E. 1 in 10,000 – 30,000 F. None of the above 6/15/2017 1 “Transition” has 3 components 74% 2 4% 1 i n 1 0 0 7% 1 i n 2 0 0 - 3 0 0 7% Social 1 i n 5 0 0 – 1 , 0 0 0 3% 1 i n 2 , 0 0 0 – 3 , 0 0 0 4% 3 1 i n 1 0 , 0 0 0 – 3 0 , 0 0 0 N o n e o f t h e a b o v e Medical Surgical 7 6/15/2017 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 8 6/15/2017 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 9 6/15/2017 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.