EXECUTIVE SUMMARY

Clinicians should learn more about transgender and gender-diverse patients to better inform their care of these populations.

  • Transgender people have diverse needs. Clinicians should always ask what they want and how they prefer to be called.
  • Ask about the patients’ reproductive history and medications that help with their transition.
  • Learn about words transgender populations prefer, and words that are micro-misgendering and harmful.

Family planning clinicians and obstetrician/gynecologists likely will see transgender or gender-diverse patients seeking contraceptive care. It is a good idea to learn how to best advise and care for these populations.

The first step is for clinicians to apply to transgender patients the same competence they have in speaking to cisgender people (patients who were assigned female gender at birth and identify as females).

“When I talk to gynecologists who are new to this, I remind them of the competence they already have in talking to cisgender people, and tell them they can apply this to trans folks,” says Frances W. Grimstad, MD, MS, faculty in the division of gynecology, department of surgery at Boston Children’s Hospital, and instructor of surgery at Harvard Medical School. Grimstad specializes in transgender reproductive healthcare, focusing on adolescents and youth. “There is no reason to be worried,” she adds.

Reproductive health services for transgender or gender-diverse patients is more about taking care of those individuals than it is about providing specific health services to a transgender patients. “If you can walk into a room and confidently list all the pluses and minuses for a cis patient, you can do it for trans patients,” Grimstad explains.

“Transgender people are different, and have had different experiences than cisgender people by nature of the fact of walking around in a world that is gendered and assuming people are this gender,” says Juno Obedin-Maliver, MD, MPH, MAS, assistant professor in the department of obstetrics and gynecology at Stanford University School of Medicine. She also is the co-director of the PRIDE Study.

“Every transgender and gender-diverse person is different from one another,” Obedin-Maliver says. “We would not say we met one woman and now know all women, but physicians might think that because they have met one transgender man they now know how to take care of them.”

While a patient’s experience and needs are different, reproductive health providers can improve their care of transgender patients by changing their preconceptions about gender and the language they use with patients who are not cisgender.

Grimstad, Obedin-Maliver, and other researchers and clinicians who work with transgender patients offer these additional tips:

• Find out what the patient wants. Transgender and gender-diverse patients have diverse needs and desires with contraception and reproductive health. For instance, there is not one simple solution that will work for every transgender man.

Grimstad sees patients who are taking both testosterone and estrogen-containing contraception. Some were using the contraception before they began testosterone, and they used estrogen birth control to stop their menstruation. “Then, they took testosterone and continued with contraception,” Grimstad says.

Some patients might use estrogen contraception to suppress menstruation while they wait a couple of years for the testosterone to stop their periods, she explains. Some patients might prefer to avoid estrogen and use progestin-only hormone contraceptives.

“I’ve only had one patient in my career ask for a nonhormonal contraceptive,” Grimstad says. “Most people want the added benefit of stopping their periods, which the copper IUD [intrauterine device] can’t do.”

The most important thing a reproductive health clinician can do is to ask patients about their goals with reproductive health, she says. “What are their goals right now, and what do they think their goals might be in the future?” she asks. “I have patients, ages 17 to 19, who have long known that one of their goals is to have genital surgery, and they are already seeing a genital surgeon. Part of the surgery for transgender men involves removal of the uterus and having a penis developed.”

For these patients, their goal might be to avoid pelvic exams and insertion of an IUD. They might prefer birth control pills or a contraceptive shot every few months.

“For a patient who has tried the shot, but struggled with regular bleeding and has no desire to remove their uterus, we might discuss placing an IUD while they are under sedation,” Grimstad says. “With sedation, trans patients do not have to be awake and experience the pelvic exam, which may be dysphoric or painful and discomfort them.”

Some transgender people do not want to think about that part of their body because they do not think of a vagina as being part of their body.

“Think about what the patient knows and feels about their current, short-term, and long-term reproductive health goals,” Grimstad says.

• Consider the person’s past reproductive history. Clinicians should ask about the patient’s contraceptive use, pregnancy, abortion, and other reproductive health issues, using language that is affirming and respectful of the patient’s preferred words. Obedin-Maliver and co-researchers developed an affirming and customizable electronic survey that can be used with transgender and gender nonbinary people. The questionnaire includes 328 items across 10 domains that include gender identity, language to describe reproductive and sexual anatomy, gender affirmation process history, sexual orientation, sexual activity, contraceptive use, and more.1

Transgender and gender-diverse patients’ reproductive history could include prepubescent treatment that helped them with their transition plan. For instance, transgender men might use blockers such as GnRH agonists, which are a group of drugs that treat endometriosis. They also prevent testicles and ovaries from making sex hormones by blocking other hormones. (For more information, visit: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gnrh-agonist.)

For transgender patients, use of these blockers can be their first stage of transition. GnRH agonists pause puberty and can cause temporary menopause in older adults, Grimstad explains.

“Blockers are used for treating endometriosis and to stop precocious puberty by pausing it until they’re older,” she explains. For instance, when used in a very young person who has identified as male since age 2, it can stop puberty until the person is ready to use normal hormones, she adds.

“It allows them to grow, develop, and determine hormones later in life,” Grimstad says. “Blockers are fully reversible and can be used for a couple of years to buy time in terms of the person’s maturity and understanding.”

Clinicians should ask if patients have used blockers. If patients take these when they are very young, they might have a pre-puberty uterus. This means they might not be able to have an IUD and will need another type of contraceptive, Grimstad explains.

Clinicians also should ask about patients’ menstruation, including length and pain levels. If they have a history of heavy or painful periods, they might respond differently to different contraceptives, Grimstad explains.

• Ask patients which words they use to describe themselves and their bodies. Providers should ask patients which pronouns they use, what name they prefer to be called, and how they describe themselves. Increasingly, providers are putting their own preferred pronouns with their titles and contact information in emails, such as “she, her, hers.” Some gender-diverse people might prefer neutral pronouns: they, their, themselves. These preferences should be included in the patient’s charts, and staff should make sure they call out the patient’s preferred name.

“Collect information on the patient’s gender identity, sex assigned at birth, and correct pronouns, and have it reviewed and updated, as necessary,” says Adam Bonnington, MD, associate position and volunteer clinical faculty in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “There has to be a system in place to allow that information to be known by everyone in the clinical setting and to mirror language that patients use for different body parts.”

Also, it is important to understand that a transgender patient’s preferred name and legal name could be different, which would mean the insurance information will have a name different from what the clinic staff call the patient, Obedin-Maliver says.

“There are a lot of reasons why people may not change their insurance name,” she says. “For example, someone may get their insurance through work, and the person is not out [about being transgender] at work.”

Or the person might want to get pregnant soon, and the insurance policy will not cover pregnancy for a man, Obedin-Maliver adds.

“Instead of fighting that battle, they say ‘Let’s keep the name and marker the way it is even if that’s not how I live my day-to-day life,’” she explains. “Have a conversation with the patient and ask what name the insurance is under and what name the person should be called in the clinic.”

Most electronic medical records include a field for a patient’s nickname or preferred name, as well as the legal name.

• Train staff to avoid misgendering. Clinicians and clinic staff should avoid microaggressions, including misgendering their patients by referring to them with the wrong names, pronouns, or gender. If they make a mistake, they should apologize and correct the mistake. (More information is available at: https://www.naswoh.org/page/transadvocacy/Advocating-for-Transgender-Clients.htm.)

To a transgender or gender-diverse person, misgendering can be compared to a bee sting, an analogy that Grimstad once heard from a trans leader. “You get stung once a year, you say it hurts, and you get over it,” she explains. “But think about how it would feel if you walk through your day and you get stung by a bee and then you go to a bus stop and get stung, and then you open your emails and get stung by three more bees.”

The stinging pain builds up and does not go away. Each micro-misgendering is small and isolated, but when they occur once a person wakes up and continue through the day, they hurt.

“The patient is not responding to that one bee sting in the clinic, but they’ve been stung 40 times today, and so they’re responding to that,” Grimstad says.

REFERENCE

  1. Moseson H, Lunn MR, Katz A, et al. Development of an affirming and customizable electronic survey of sexual and reproductive health experiences for transgender and gender nonbinary people. PLoS One 2020;15:e0232154.