Gynecologists will encounter more and more transgender and non-binary patients within their practice. Providing inclusive and thorough gynecological care will become increasingly necessary.
Roughly 1.6 million people in the United States, ages 13 and older, identify as transgender according to a report by the Williams Institute. OB/GYN clinicians should expect to encounter an increasing number of transgender and non-binary patients and be prepared to address both their mental health and reproductive health. Gynecologists and their colleagues should take an informed approach to creating a practice that provides inclusive services for better transgender reproductive health.
Understanding the Spectrum of Transgender and Non-Binary Identities
Learning the language of transgender and non-binary patients provides a foundation for understanding. It can improve communication and increase trust with this patient group.
- Gender identity: This is the inner sense of a person's gender (such as male, female, or non-binary).
- Transgender: This term describes people with a gender identity different from their gender assigned at birth. "Trans" is shorthand for this term. Transmasculine describes a person assigned female at birth but who identifies as male. Transfeminine describes a person assigned male at birth but who identifies as female.
- Non-binary: A non-binary person does not identify as exclusively male or exclusively female, so their gender identity falls outside of the traditional binary notions of gender.
- Cisgender: A person whose gender identity is the same as their gender assigned at birth.
- Gender expression: These are the social and physical representations of gender, such as dress, hairstyle, mannerisms, vocalisms, behaviors, pronoun use, and name.
- Gender affirmation: These are changes a trans person makes to affirm their gender identity. They may include forms of gender expression and physical changes that result from gender-affirming hormone therapy or surgery.
People with a uterus, ovaries, and breasts should still receive regular gynecological care and screenings. However, gynecological visits may trigger gender dysphoria, traumatic responses, depression, or a host of other mental health concerns. That's why it's important to recognize the complementary roles of mental health and reproductive health. OB/GYN staff are instrumental in creating a positive and welcoming healthcare experience for transgender and non-binary patients. A focus on respect and communication can build an environment of trust that encourages patients to seek the care they need.
Hormone Therapy and Reproductive Health
Most people seeking hormone replacement therapy (HRT) are cisgender menopausal women. However, OB/GYN practices may also encounter non-binary and transgender patients also seeking hormone therapy. For these patients, hormone therapy may affect transgender reproductive health.
The Mayo Clinic notes that masculinizing hormone therapy is used by trans men and non-binary people seeking gender-affirming care that will result in physical changes brought on by male hormones. This therapy may lead to infertility as well as drying and thinning of the vaginal lining. If these patients hope to one day have biological children, they may want to explore egg freezing, embryo freezing, and ovarian tissue preservation prior to starting therapy. Additionally, these patients will likely need to maintain recommended breast and cervical cancer screenings and monitor their bone density.
The Mayo Clinic describes feminizing hormone therapy as gender-affirming care that results in the physical changes brought on by female hormones, which would be used by trans women and non-binary people seeking female secondary sex characteristics. This therapy may lead to infertility. If these patients want to have biological children, they may need to consider sperm banking prior to starting the therapy. These patients may also need to follow recommendations for breast and prostate cancer screenings, and will also need to monitor their bone density.
Fertility Preservation Options
Gender-affirming care may affect transgender reproductive health. The physical changes that result from this care can impact fertility. The most recent World Professional Association for Transgender Health (WPATH) standards of care advise that healthcare professionals discuss infertility risk and fertility preservation options with trans patients before initiating hormone therapy or surgery, as well as the effects of therapies that may not be reversible. Fertility preservation options include sperm banking, egg freezing, and embryo freezing.
Though it is ideal to use fertility preservation options before hormone therapy, patients may also want to know that hormone therapy can be paused. The long-term effects of testosterone therapy on ovarian function are not definitive, but a recent study found that after a year of testosterone therapy, ovarian function was preserved to a degree that could allow reproduction.
Fertility preservation options for trans men include egg and embryo freezing and ovarian tissue cryopreservation. Frozen eggs and embryos can be used later to establish a pregnancy in the patient, the patient's partner, or a gestational carrier or surrogate. Frozen ovarian tissue would be retransplanted into the patient. The lifespan of frozen tissue is shortened, so it needs to be transplanted when the patient is ready to conceive.
Fertility preservation options for trans women include sperm banking. The patient provides ejaculated sperm which is then cryopreserved. When the patient is ready to conceive, the sperm can be implanted in the patient's partner or gestational carrier.
As with cisgender patients, the success of conception and fertility treatments may be affected by patient age, weight, other health conditions, and substance use and abuse.
Gender-Affirming Surgeries and Reproductive Health
Some transgender patients may elect to only transition socially, which means choosing non-medical gender expressions such as name and pronoun changes or hairstyle and dress changes. Others may opt for medical gender affirmations including hormone therapy or surgery.
For trans men, gender-affirming surgical options include mastectomy with chest reconstruction, metoidioplasty, or phalloplasty. They may also choose to have a hysterectomy, vaginectomy, and oophorectomy. It's also possible for patients to do a combination of these surgeries. For example, a trans man may choose to retain a uterus and ovaries, but also have a phalloplasty. For trans women, gender-affirming surgeries include breast augmentation, orchiectomy, scrotectomy, vaginoplasty, and vulvoplasty. Again, these patients may choose a combination of surgeries.
OB/GYNs should collaborate with the patient's care team, which may include plastic surgeons, endocrinologists, mental health professionals, and primary care providers, to ensure seamless care for the patient before and after gender-affirming surgeries. As with hormone therapy, it will be important to have discussions about fertility and fertility preservation options before surgery takes place.
Mental Health and Emotional Well-Being
However, trans and non-binary people sometimes experience discrimination, harassment, and gender dysphoria, all of which can affect mental health. The 2015 U.S. Transgender Survey paints a disturbing picture of the mental health concerns faced by transgender and gender-diverse people. The survey of more than 27,000 transgender individuals found that 40% of respondents have attempted suicide in their lifetime, which is nine times the suicide rate of the U.S. population (4.6%). One-third (33%) of respondents who saw a healthcare provider had at least one negative experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. Nearly one-quarter (23%) reported that they did not seek the healthcare they needed in the year prior to completing the survey due to fear of being mistreated as a transgender person.
Gynecologists with transgender and non-binary patients should understand the interplay between mental health and reproductive health in this patient population. Staff at OB/GYN practices should be educated in ways to support and respect these patients. Practices can refer to the WPATH standards of care for advice on how to ensure their facility can properly assist transgender and non-binary patients in accessing safe and effective healthcare. These practices can also share local and national resources that transgender patients can access for assistance with mental health. The Human Rights Campaign lists a number of resources. The National Center for Transgender Equality also provides mental health resources, as well as legal, insurance, healthcare, immigration, employment, nutrition, housing, veteran, and advocacy resources.
To create an environment of trust, OB/GYN clinicians will need to educate themselves about both the mental health and reproductive health needs of transgender and non-binary people. By staying informed, they can close the gap on the healthcare disparities experienced by this community.
