Contraception Care for Transmasculine Individuals on Testosterone Therapy

Contraception and fertility‐associated advisement is needed for any individual with a uterus who is engaging in sexual activity with reproductive potential. As greater awareness spreads regarding the health care needs of transgender, nonbinary, and gender‐nonconforming individuals, the research on evidence‐based care for these populations lags behind. Many clinicians may not be well versed in the best practices to support the sexual and reproductive well‐being of individuals who are taking gender‐affirming hormone therapy. This article reviews the use of contraception for individuals who are on testosterone gender‐affirming hormone therapy. Each contraceptive method is individually considered for the risks and benefits that are unique to this population.     

Fertility care for persons considering gender transition

Referrals to the gender identity development service and gender identity clinics are increasing. Gender affirming medical interventions can adversely impact on fertility potential of the individual. Discussion about possible impact of various treatments such as GnRH agonists and cross over hormones (oestrogen or testosterone) and surgery of genitalia and reproductive organs should be discussed. Opportunity should be provided to discuss options for fertility preservation and assisted decision-making. It should be appreciated that transgender individuals have an increased incidence of mental health problems and barriers to care.Oocyte and sperm cryopreservation provide options for biological parenthood.     

Medical Options for Care of Gender Diverse and Transgender Youth

Increasing numbers of transgender and gender diverse (TGD) youth are presenting for medical care, including seeking more information and access to services from gynecologic and reproductive health experts. Such experts are well positioned to provide affirming, comprehensive services, including education, hormonal interventions, menstrual management, contraception, and various gynecological procedures. Early medical guidance and support for the TGD community has been associated with long-term positive emotional and physical health outcomes. In this article medical interventions that reproductive health experts can offer to their TGD patients are discussed.     

Nurse‐Midwives in Federally Funded Health Centers: Understanding Federal Program Requirements and Benefits

Midwives are working in federally funded health centers in increasing numbers. Health centers provide primary and preventive health care to almost 20 million people and are located in every US state and territory. While health centers serve the entire community, they also serve as a safety net for low‐income and uninsured individuals. In 2010, 93% of health center patients had incomes below 200% of the Federal Poverty Guidelines, and 38% were uninsured. Health centers, including community health centers, migrant health centers, health care for the homeless programs, and public housing primary care programs, receive grant funding and enjoy other benefits due to status as federal grantees and designation as federally qualified health centers. Clinicians working in health centers are also eligible for financial and professional benefits because of their willingness to serve vulnerable populations and work in underserved areas. Midwives, midwifery students, and faculty working in, or interacting with, health centers need to be aware of the regulations that health centers must comply with in order to qualify for and maintain federal funding. This article provides an overview of health center regulations and policies affecting midwives, including health center program requirements, scope of project policy, provider credentialing and privileging, Federal Tort Claims Act malpractice coverage, the 340B Drug Pricing Program, and National Health Service Corps scholarship and loan repayment programs.     

Committee Opinion no. 512: health care for transgender individuals

Transgender individuals face harassment, discrimination, and rejection within our society. Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population. Although the care for these patients is often managed by a specialty team, obstetrician–gynecologists should be prepared to assist or refer transgender individuals with routine treatment and screening as well as hormonal and surgical therapies. The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity and urges public and private health insurance plans to cover the treatment of gender identity disorder.     

Gynecologic Care for Transgender Adults

Purpose of the Review

Transgender 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 Findings

Though 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.

Summary

We 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.

     

The challenge of addressing gender in reproductive health programmes examples from Indonesia

In 1994, ICPD stressed gender equity as a precondition for health and development while affirming the need to address women's subordination in reproductive health programmes. However, those responsible for implementing these broad goals still struggle with how to operationalise gender-aware approaches. Starting from the assumption that gender equity and women's empowerment are necessary to achieving women's reproductive health and using examples from Indonesia, this paper focuses on the ways in which reproductive health programmes view gender inequity. It questions the capacity of existing intervention paradigms to counter gender disparities and promote women's emancipation. It discusses the problems of a women-centred approach, of focusing on men in order to support women, and of reifying the family to the detriment of its individual members. Finally, it suggests that new, alternative approaches for interventions should be sought which transcend individual actors and uphold a focus on relationships.     

ACOG committee opinion, number 312, August 2005: healthcare for homeless women

Homelessness is a considerable social and health problem in the United States with far-reaching effects on the health of homeless women. Homeless women are at higher risk for injury and illness and are less likely to obtain needed health care than women who are not homeless. It is critical to undertake efforts to prevent homelessness. Until this can be accomplished, community-based services targeted specifically to this population that provide both health care and support services are essential. Health care providers can help address the needs of the homeless by identifying their own patients who may be homeless, treating their health problems, offering preventive care, and working with the community to improve the full range of resources available to these individuals.     

Infertility and the environment: the medical context

Approximately 10 to 15% of the population experiences infertility. Although 85 to 90% of couples or individuals who experience infertility have a diagnosis for their infertility, underlying causes of infertility rarely are found. Extensive literature reporting adverse effects of environmental contaminants on wildlife and laboratory animal reproductive tract development, and reproductive function and epidemiologic studies with humans, suggests that many environmental chemicals and heavy metals may contribute to infertility. This article introduces the medical context in which infertility patients are evaluated and lays the foundation for health care professional and patient conversations, and medical education regarding environmental contaminants and human reproductive health for the future.     

Partial Treatment Requests and Underlying Motives of Applicants for Gender Affirming Interventions

IntroductionHistorically, only individuals with a cross‐gender identity who wanted to receive a full treatment, were eligible for “complete sex reassignment” consisting of feminizing/masculinizing hormone treatment and several surgical interventions including genital surgery (full treatment). Currently, it is unclear what motives underlie a request for hormones only or surgery only or a combination of hormones and surgery (e.g., a mastectomy), but no genital surgery (partial treatment).AimsThe aims of this study were (i) to describe treatment requests of applicants at a specialized gender identity clinic in the Netherlands; and (ii) to explore the motives underlying a partial treatment request, including the role of (non‐binary) gender identity.MethodsInformation was collected on all 386 adults who applied for treatment at the Center of Expertise on Gender Dysphoria of the VU University Medical Center in Amsterdam, the Netherlands, in the year 2013. Treatment requests were available for 360 individuals: 233 natal men (64.7%) and 127 natal women (35.3%). Treatment requests were systematically collected during assessment. Individuals were classified as either desiring a full or partial treatment. The motives behind a partial treatment request were collected and categorized as well.ResultsThe majority of applicants at our gender identity clinic requested full treatment. Among those who requested partial treatment, the most reported underlying motive was surgical risks/outcomes. Only a small number of applicants requested partial treatment to bring their body into alignment with their non‐binary gender identity.ConclusionIt becomes clear that partial treatment is requested by a substantial number of applicants. This emphasizes the need for gender identity clinics to provide information about the medical possibilities and limitations, and careful introduction and evaluation of non‐standard treatment options. Beek TF, Kreukels BPC, Cohen‐Kettenis PT, and Steensma TD. Partial treatment requests and underlying motives of applicants for gender affirming interventions. J Sex Med 2015;12:2201–2205.     

Reproductive Health Considerations in Sexual and/or Gender Minority Adolescents

Disparities exist in the area of reproductive health for lesbian, gay, bisexual (LGB), and transgender and gender nonconforming (TGNC) adolescents compared with cisgender, heterosexual adolescents, particularly related to pregnancy and pregnancy risk factors. Review of the literature indicates an estimated increased risk of adolescent pregnancy involvement between 2 and 10 times higher for LGB youth compared with heterosexual youth. This might be explained by a broad spectrum of sexual health risks experienced, including an earlier age of sexual debut, exposure to sexual abuse, and a higher number of sexual partners. TGNC youth face conflict with their gender identity and potentially their sexual orientation. It is likely that their experience is similar to cisgender LGB adolescents as it pertains to reproductive health considerations. TGNC adolescents additionally confront the added challenge of fertility preservation. Health care providers play an important role in identifying and addressing these risk factors to improve the health of LGB and TGNC adolescents. Unfortunately, whether implicit or explicit, bias among health care providers exists and affects patient care. We believe it is the responsibility of health care providers to be informed about the increased needs of these patients and to provide appropriate risk-reducing management while using inclusive and sensitive history-taking and language.     

Changing Concepts of Women’s Health—What does this mean for Obstetrics and Gynaecology?

Over the past decade, increased attention has focused on the topic of women’s health. Traditionally, women’s health was considered to encompass only reproductive health and health care. Currently, however, women’s health is defined as involving women’s social, cultural, spiritual, emotional and physical well-being, and is influenced by social, political and economic factors, as well as by a woman’s biology. Therefore, in providing health care to women, one must address not only their biology and their reproductive functions but also the broader determinants of health and in particular the critical role of gender as a determinant of health. The health priorities women themselves identify, their own perceptions of their health and well-being and the diversity of women are all key components of optimal care for women. While obstetricians and gynaecologists have played a leading role in improving reproductive and gynaecologic care and outcomes, they must identify, acknowledge and address the multiple factors which influence the health and illness of their patients. Together with other physicians and health professionals, obstetricians and gynaecologists through their clinical work, their educational activities and their research must integrate and apply this broader understanding of women’s health if they are to provide appropriate holistic care to their women patients.     

Educational Strategies to Help Students Provide Respectful Sexual and Reproductive Health Care for Lesbian,Gay, Bisexual,and Transgender Persons

Graduate medical, nursing, and midwifery curricula often have limited amounts of time to focus on issues related to cultural competency in clinical practice, and respectful sexual and reproductive health care for all individuals in particular. Respectful health care that addresses sexual and reproductive concerns is a right for everyone, including those who self‐identify as lesbian, gay, bisexual, or transgender (LGBT). LGBT persons have unique reproductive health care needs as well as increased risks for poor health outcomes. Both the World Health Organization and Healthy People 2020 identified the poor health of LGBT persons as an area for improvement. A lack of educational resources as well as few student clinical experiences with an LGBT population may be barriers to providing respectful sexual and reproductive health care to LGBT persons. This article offers didactic educational strategies for midwifery and graduate nursing education programs that may result in reducing barriers to the provision of respectful sexual and reproductive health care for LGBT clients. Specific ideas for implementation are discussed in detail. In addition to what is presented here, other educational strategies and clinical experiences may help to support students for caring for LGBT persons prior to entrance into clinical practice.     

Desistance,Self‐treatment,or Substitution: Decisions about Cannabis Use During Pregnancy

Cannabis is the most commonly used drug during pregnancy in the United States and Canada, and the American College of Obstetricians and Gynecologists recommends that all pregnant individuals be screened for cannabis use and counseled regarding potential adverse health impacts of use. However, those considering or using cannabis during pregnancy report experiencing stigma and lack of information from health care providers and, thus, frequently rely on friends, family, and the internet for information. This article describes 3 types of decisions individuals may be making about cannabis use during pregnancy and suggests approaches health care providers may take to minimize judgment and provide optimal support for informed cannabis use decisions among pregnant individuals. Desistance decisions involve consideration of whether and how to reduce or stop using during pregnancy. Self‐treatment decisions are made by those exploring cannabis to help alleviate troublesome symptoms such as nausea or anxiety. Substitution decisions entail weighing whether to use cannabis instead of another substance with greater perceived harms. Health care providers should be able to recognize the various types of cannabis use decisions that are being made in pregnancy and be ready to have a supportive conversation to provide current and evidence‐based information to individuals making desistance, self‐treatment, and substitution decisions. Individuals making desistance decisions may require support with potential adverse consequences such as withdrawal or return of symptoms for which cannabis was being used, as well as potentially navigating social situations during which cannabis use is expected. Those making self‐treatment decisions should be helped to fully explore treatment options for their symptoms, including evidence on risks and benefits. Regarding substitution decisions, health care providers should endeavor to help pregnant individuals understand the available evidence regarding risks and benefits of available options and be open to revisiting the topic over time.     

Infusing Diversity and Equity Into Clinical Teaching: Training the Trainers

Clinical instructors in health care disciplines are charged with engaging students in experiential learning wherein respect and cultural sensitivity is applied. This article reports on the results of 3 diversity workshops conducted for clinical preceptors and field instructors from various disciplines. The workshops were developed in response to students’ growing concerns that their academic learning experiences were negatively affected by dissatisfying management of differences between students, faculty, and preceptors with respect to ethno‐racial group membership, socioeconomic level, and degree of privilege and power. The workshops included a didactic session that presented basic principles of social and health equity followed by small‐group reflection about various ethical and moral dilemmas that were presented in clinical education scenarios. Examples of discrimination on a variety of levels were addressed in these workshops, including race, ethnicity, immigration status, sexual orientation, religion, body size and appearance, ability, age, socioeconomic class, religious faith, and gender. The group exercises and discussion from these sessions provided valuable insight and approaches to difficult but common areas of discomfiture encountered in the clinical teaching setting. This article presents the findings from participants of these diversity workshops in order to encourage the application of equity principles into clinical teaching in midwifery and other health care education contexts.     

A girl thing: perceptions concerning the word "hymen" among young Swedish women and men

Introduction: This study investigated, from a gender perspective, perceptions concerning the word “hymen” among students in a Swedish senior high school. Methods: Students answered an open‐ended question: What do you think about when you hear the word hymen? The answers were analyzed by using content analysis. Results: In total, 198 students, aged 17 to 18 years, answered the question. The theme “a fragile biological structure in the female body” described how the vast majority of the girls and 57% of the boys associated the hymen with a thin membrane that breaks during first vaginal intercourse. The theme “a symbol and manifestation of feminine virginity” described the symbolic meanings of having or not having a hymen. The theme “questioning the existence of the hymen” revealed the doubts that some had about its existence. Discussion: Most of the students associated the hymen with a breakable membrane. This is problematic. It may lead to misunderstandings about virginity or about bleeding during sexual intercourse. Changing these views about the hymen is important to correct such misunderstanding but may be a significant challenge. In modern medical discourse, in health care, and in popular speech, there are few discussions about the hymen as a social construct, indicating that more gender research concerning hymen‐related issues is needed.