Juno Obedin-Maliver

Transgender men and pregnancy

Transgender people have experienced significant advances in societal acceptance despite experiencing continued stigma and discrimination. While it can still be difficult to access quality health care, and there is a great deal to be done to create affirming health care organizations, there is growing interest around the United States in advancing transgender health. The focus of this commentary is to provide guidance to clinicians caring for transgender men or other gender nonconforming people who are contemplating, carrying, or have completed a pregnancy. Terms transgender and gender nonconforming specifically refer to those whose gender identity (e.g., being a man) differs from their female sex assigned at birth. Many, if not most transgender men retain their female reproductive organs and retain the capacity to have children. Review of their experience demonstrates the need for preconception counseling that includes discussion of stopping testosterone while trying to conceive and during pregnancy, and anticipating increasing experiences of gender dysphoria during and after pregnancy. The clinical aspects of delivery itself fall within the realm of routine obstetrical care, although further research is needed into how mode and environment of delivery may affect gender dysphoria. Postpartum considerations include discussion of options for chest (breast) feeding, and how and when to reinitiate testosterone. A positive perinatal experience begins from the moment transgender men first present for care and depends on comprehensive affirmation of gender diversity.

Sexual and gender minority identity disclosure during undergraduate medical education: "in the closet" in medical school.

Purpose To assess identity disclosure among sexual and gender minority (SGM) students pursuing undergraduate medical training in the United States and Canada. Method From 2009 to 2010, a survey was made available to all medical students enrolled in the 176 MD- and DO-granting medical schools in the United States and Canada. Respondents were asked about their sexual and gender identity, whether they were “out” (i.e., had publicly disclosed their identity), and, if they were not, their reasons for concealing their identity. The authors used a mixed-methods approach and analyzed quantitative and qualitative survey data. Results Of 5,812 completed responses (of 101,473 eligible respondents; response rate 5.7%), 920 (15.8%) students from 152 (of 176; 86.4%) institutions identified as SGMs. Of the 912 sexual minorities, 269 (29.5%) concealed their sexual identity in medical school. Factors associated with sexual identity concealment included sexual minority identity other than lesbian or gay, male gender, East Asian race, and medical school enrollment in the South or Central regions of North America. The most common reasons for concealing one’s sexual identity were “nobody’s business“ (165/269; 61.3%), fear of discrimination in medical school (117/269; 43.5%), and social or cultural norms (110/269; 40.9%). Of the 35 gender minorities, 21 (60.0%) concealed their gender identity, citing fear of discrimination in medical school (9/21; 42.9%) and lack of support (9/21; 42.9%). Conclusions SGM students continue to conceal their identity during undergraduate medical training. Medical institutions should adopt targeted policies and programs to better support these individuals.

Feasibility of Vaginal Hysterectomy for Female-to-male Transgender Men

OBJECTIVE To describe the hysterectomy data among a cohort of transgender men and nontransgender (ie, cisgender) women with a particular goal to evaluate the feasibility of vaginal hysterectomy among transgender men. METHODS This cohort study includes all hysterectomies performed for benign indications on transgender men and cisgender women at a single academic county hospital from 2000 to 2012. Hysterectomy cases and patient gender were identified by billing records and confirmed by review of medical records. Primary study outcome was the hysterectomy route among transgender men compared with cisgender women. We also examined risk factors and operative outcomes. Student two-sided t tests, χ analysis, and descriptive statistics are presented; sensitivity analyses using regression techniques were performed. RESULTS Hysterectomies for benign gynecologic procedures were performed in 883 people: 33 on transgender men and 850 on cisgender women. Transgender men were younger, had fewer pregnancies and deliveries, and smaller uteri. The leading indication for hysterectomy differed significantly: pain (85%) was most common among transgender men (compared with 22% in cisgender women; P<.001), whereas leiomyomas (64%) was most common for cisgender women (compared with 21% in transgender men; P<.001). Vaginal hysterectomies were performed in 24% transgender men and 42% of cisgender women. Estimated blood loss was less among transgender men (P=.002), but when uterine size and route of hysterectomy were considered, the difference between gender groups was no longer significant. There was no difference in patients experiencing complications between the groups. CONCLUSION Transgender men and cisgender women have different preoperative characteristics and surgical indications. Vaginal hysterectomies have been successfully completed among transgender men. Because vaginal hysterectomy is a viable procedure for this population, it should be considered in surgical planning for transgender men.

Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.

PURPOSE Although many transgender men may be able to conceive, their reproductive health needs are understudied. METHODS We retrospectively reviewed charts of transgender men presenting to a clinic for sex workers to describe the proportion at risk for pregnancy, pregnancy intentions, and contraceptive use. RESULTS Of 26 transgender men identified, half were at risk for pregnancy. Most desired to avoid pregnancy but used only condoms or no contraception. Two individuals desired pregnancy, were taking testosterone (a teratogen), and not using contraception. CONCLUSION Further research is needed to explore how to best provide family planning services including preconception and contraception care to transgender men.

Vaginal Hysterectomy as a Viable Option for Female-to-Male Transgender Men

INTRODUCTION: According to the 2011 Institute of Medicine Report and emphasized by the American College of Obstetricians and Gynecologists Committee Opinion, transgender individuals encounter significant healthcare barriers. The American College of Obstetricians and Gynecologists charges obstetrician–gynecologists to help eliminate these barriers to care by creating nondiscriminatory practices and assisting with transitioning. This includes supporting social, medical, and surgical aspects of the gender affirmation process. Obstetrician–gynecologists are able, without additional training, to perform hysterectomies for transgender men, and total vaginal hysterectomies are the least morbid and most cost-effective form of hysterectomy. METHODS: We present data from a retrospective chart review of all hysterectomies performed for benign indications at a single urban county hospital from 2000 to 2012. Primary area of interest is a case series of hysterectomies performed on female-to-male transgender men. RESULTS: A total of 948 hysterectomies were performed for benign indications. Of those, 34 were for female-to-male transgender men. Compared with women with carcinoma in situ (CIS), female-to-male transgender men were younger, had fewer pregnancies and deliveries, had smaller uteri, had lower body mass index, were usually on testosterone before surgery, and were more likely to have concurrent oophorectomies. The primary indication for hysterectomy for female-to-male transgender men was pain (53%) compared with bleeding (46%) for women with CIS. Total vaginal hysterectomies were performed in 24% of female-to-male transgender men compared with 39% of women with CIS. There was no difference in complication or conversation rates between the two groups. CONCLUSION: Total vaginal hysterectomy is a safe, viable, and cost-effective option to consider for female-to-male transgender men and gender affirmation surgery and encourage obstetrician–gynecologists to consider total vaginal hysterectomy as a minimally invasive option in serving female-to-male transgender men to encourage nondiscrimination and augment access to care.

Gynecologic Care for Transgender Adults

Purpose of the ReviewTransgender people need both routine gynecological and reproductive health care and services specific to gender-affirming processes. However, there is little evidence to guide their routine gynecological and reproductive health care, and data suggests that 33% of transgender people avoid routine health care due to persistent discrimination and disrespect. Here we systematically approach the care of transmasculine and transfeminine people for practicing obstetrician-gynecologists (OBGYNs) with an eye towards enhancing knowledge and enhancing respectful care.Recent FindingsThough hampered by a paucity of high-quality data specific to transgender people, topics covered in the review include routine health care maintenance; including cancer screening, assessment of sexually transmitted infections, and contraception; as well as issues specific to transgender individuals such as to use of gender-affirming hormones and care surrounding gender-affirming surgeries. Additionally, we incorporate perspectives to support cultural humility and provider preparedness towards promoting patient comfort in seeking and obtaining care.SummaryWe aim to demonstrate that though there are some clinical topics specific to transgender people and their health care that warrant enhanced training and resources, obstetrician-gynecologists (OBGYNs) are actually well-poised to support the care of this population. Bringing awareness of the needs of transgender people to OBGYNs will help decrease the well-documented care gap for this underserved population.

From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers

BackgroundSome transgender men retain their uterus, get pregnant, and give birth. However, societal attitudes about gender have erected barriers to openly being pregnant and giving birth as a transgender man. Little research exists regarding transgender men’s reproductive needs. Anecdotal observations suggest that social change and increasing empowerment of transgender men may result in increasing frequency and openness about pregnancy and birth. Specific needs around conception, pregnancy, and newborn care may arise from transphobia, exogenous testosterone exposure, or from having had (or desiring) gender-affirming surgery. We undertook a qualitative study to understand the needs of transgender men who had given birth.MethodsWe interviewed 10 transgender men who had been recruited for a recently published online cross-sectional survey of individuals (n = 41). Subjects had given birth while identifying as male. Interviews were recorded, transcribed, and systematically coded. Analysis used a priori and emergent codes to identify central themes and develop a framework for understanding participant experiences.ResultsParticipants reported diverse experiences and values on issues including prioritization and sequencing of transition versus reproduction, empowerment in healthcare, desire for external affirmation of their gender and/or pregnancy, access to social supports, and degree of outness as male, transgender, or pregnant. We identified structural barriers that disempowered participants and describe healthcare components that felt safe and empowering. We describe how patients’ strategies, and providers’ behaviors, affected empowerment. Anticipatory guidance from providers was central in promoting security and empowerment for these individuals as patients.ConclusionsRecognizing diverse experiences has implications in supporting future patients through promoting patient-centered care and increasing the experiential legibility. Institutional erasure creates barriers to transgender men getting routine perinatal care. Identifying this erasure helps shape recommendations for how providers and clinics can provide appropriate care. Specific information regarding reproduction can be helpful to patients. We provide recommendations for providers’ anticipatory guidance during the pre-transition, pre-conception, prenatal, and postpartum periods. Ways to support and bring visibility to the experience of transgender men are identified. Improving clinical visibility and affirming gender will likely enhance patient experience and may support patient-centered perinatal healthcare services.

The new era of precision population health: insights for the All of Us Research Program and beyond

Although precision medicine has made advances in individualized patient treatments, there needs to be continued attention on tailored population health and prevention strategies (often termed “precision population health”). As we continue to link datasets and use “big data” approaches in medicine, inclusion of diverse populations and a focus on disparities reduction are key components within a precision population health framework. Specific recommendations from the All of Us Research Program and the Precision Public Health Summit provide examples for moving this field forward.

Time to Change: Supporting Sexual and Gender Minority People—An Underserved, Understudied Cancer Risk Population

Juno Obedin-Maliver, MD, MPH, MAS, is an Assistant Professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at the University of California, San Francisco. She also serves as the Chief of Gynecology at the San Francisco Veterans Affairs Medical Center. Academically she focuses on promoting the health and well-being of sexual and gender minorities, which include but are not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ) people. Dr. ObedinMaliver is the Co-Director of The PRIDE Study (pridestudy.org), an online prospective longitudinal cohort of sexual and gender minority individuals based at University of California, San Francisco.

Estimating the Prevalence of Sexual Minority Adolescents

The Viewpoint by Dr Zaza and colleagues1 on US lesbian, gay, or bisexual (ie, sexual minority) high school students and their health-related behaviors represents “an important starting point” by describing understudied communities at risk for poor health. However, there are limitations in the Youth Risk Behavior Surveys (YRBS) worthy of comment.