21. Clinicians Perform Incomplete Sexual and Reproductive Health Counseling in Trans Masculine Adolescents

Abstract

<h3>Background</h3> The current and historical emphasis of reproductive counseling and care of assigned female at birth (AFAB) trans masculine (TM) adolescents in the setting of initiating testosterone gender affirming hormone therapy (GAHT) has focused predominantly on the patients' genetic fertility potential. However fertility is only one part of AFAB TM adolescent's sexual and reproductive health (SRH), and all aspects may be impacted by testosterone GAHT (as well as gender affirming surgeries (GAS)). The study goal was to characterize the SRH evaluation patterns of AFAB TM adolescents presenting for initiation of GAHT to assess how well various aspects were being addressed. <h3>Methods</h3> This was an IRB approved retrospective cohort study of all AFAB TM patients seen for initiation of GAHT between 2010 and 2019. Inclusion criteria were having an initial visit age 15-17 (the Center for Disease Control age recommendation for discussion of SRH with adolescents). Using national medical guidelines for adolescent SRH and transgender health we identified six key measures related to SRH which should be reviewed in a patient presenting between those ages who desires GAHT (discussion of (1) GAHT impact on fertility, (2) fertility preservation (FP), (3) desire for GAS, (4) sexual activity, (5) sexual orientation (SO), and (6) human papilloma virus (HPV) vaccination). Primary outcome was identifying whether fertility measures were addressed more often than non-fertility SRH measures. <h3>Results</h3> Of the 200 patients who met inclusion criteria, only 3 (1.5%) had all 6 measures addressed. The median number addressed was 4/6 (IQR 2-5/6). The most common measure addressed was GAHT impact on fertility (95.5%, n=191), followed by GAS (74.5% n=149), SO (69.5%, n=139), sexual activity (68.5%, n=137), FP (53.5%, n=107) and HPV (5%, n=10). Every patient had at least one measure addressed. There was no difference across the study timeline regarding types of questions being asked based on year. Of the 137 where sexual activity was addressed, only 111 (81.0%) were also asked about SO. The odds of being asked about SO were 5.3 times higher if they endorsed sexual activity than if they did not (p<0.001; 95% CI 9.8-10.3). Those who desired hysterectomies were not more likely to discuss fertility preservation compared to those who did not (p=0.753). <h3>Conclusions</h3> While clinicians asked almost all TM AFAB patients about fertility prior to initiating GAHT, far fewer were asked about other aspects of SRH, indicating a biased approach to SRH counseling in TM AFAB adolescents. It is important for clinicians who are engaging in counseling regarding gender affirming care to recognize that many aspects beyond fertility can be impacted by GAHT and GAS.