From Transition to Reproduction: A Narrative Review of Evolving Evidence in Transgender Obstetrics and Gynecology.

Information on the general health of transgender and gender diverse (TGD) individuals continues to be lacking. To bridge this gap, the National Institute of Health in Italy together with the National Office against Racial Discriminations, clinical centres, and TGD organizations carried out a cross-sectional study to define the sociodemographic profile, health-related behaviours, and experiences of healthcare access in Italian TGD adult population. A national survey was conducted by Computer-Assisted Web Interviewing (CAWI) technique. Collected data were compared within the TGD subgroups and between TGD people and the Italian general population (IGP). TGD respondents were 959: 65% assigned female at birth (AFAB) and 35% assigned male at birth (AMAB). 91.8% and 8.2% were binary and non-binary TGD respondents, respectively. More than 20% of the TGD population reported to be unemployed with the highest rate detectable in AMAB and non-binary people. Cigarette smoking and binge drinking were higher in the TGD population compared with IGP (p < 0.05), affecting TGD subgroups differently. A significant lower percentage of AFAB TGD people reported having had screening for cervical and breast cancer in comparison with AFAB IGP (p < 0.0001, in both cases). Over 40% was the percentage of AFAB and non-binary TGD people accessing healthcare who felt discriminated against because of their gender identity. Our results are a first step towards a better understanding of the health needs of TGD people in Italy in order to plan the best policy choices for a more inclusive public health.

Knowledge regarding the effects and side effects of gender-affirming hormone therapy (GAHT) in adults is rapidly growing, partly through international research networks such as the European Network for the Investigation of Gender Incongruence (ENIGI). However, data on the effects of puberty suppression (PS) and GAHT in transgender and gender diverse (TGD) youth are limited, although these data are of crucial importance, given the controversies surrounding this treatment. We sought to present a detailed overview of the design of the ENIGI Adolescents study protocol, including the first baseline data. The ENIGI Adolescents study is an ongoing multicenter prospective cohort study. This study protocol was developed by 3 European centers that provide endocrine care for TGD adolescents and were already part of the ENIGI collaboration: Amsterdam, Ghent, and Florence. Study outcomes include physical effects and side effects, laboratory parameters, bone mineral density, anthropometric characteristics, attitudes toward fertility and fertility preservation, and psychological well-being, which are measured in the study participants during PS and GAHT, up to 3years after the start of GAHT. Between November 2021 and May 2023, 172 TGD adolescents were included in the ENIGI Adolescents protocol, of whom 51 were assigned male at birth (AMAB) and 121 were assigned female at birth (AFAB); 3 AFAB participants reported a nonbinary gender identification. A total of 76 participants were included at the start of PS, at a median (IQR) age of 13.7 (12.9-16.5)years in AMAB and 13.5 (12.4-16.1)years in AFAB individuals. The remaining 96 participants were included at start of GAHT, at a median (IQR) age of 15.9 (15.1-17.4)years in AFAB and 16.0(15.1-16.8)years in AMAB individuals. At the time of this report the study was open for inclusion and follow-up measurements were ongoing. In response to the rising demand for gender-affirming treatment among TGD youth, this ongoing study is fulfilling the need for prospective data on the effects and safety of PS and GAHT, thus providing a foundation for evidence-based healthcare decisions. This study has a strong multicenter, prospective design that allows for systematic data collection. The use of clinical and self-reported data offers a broad range of outcomes to evaluate. Nevertheless, the burden of additional measurements and questionnaires may lead to withdrawal or lower response rates. Few participants with a non-binary gender identity have been included. With the ENIGI Adolescents study we aim to create a comprehensive dataset that we can use for a wide range of studies to address current controversies and uncertainties and to improve healthcare for TGD adolescents.

Current studies show that about half of transgender and gender-diverse (TGD) people wish to have children in the future. TGD patients who pursue gender-affirmation interventions must be aware of the impact that various treatments can have on fertility, as gender-affirming care through medical or surgical treatment can limit or alter reproductive potential. Many medical professional societies encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation (FP) as early as possible, though patients may not be aware of all the family formation methods available. There is a significant need for a tool that thoroughly details not only the various opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option. A fertility decision-aid would allow for a more robust informed consent process and shared decision-making for all individuals pursuing gender-affirming care.

Background:Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for HPV and cervical cancer screening. Self-sampling options may expand access to HPV testing for TGD people AFAB.Methods:We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at-home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression.Results:The majority of the 101 participants who completed the study reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. About 70% of participants who reported negative experiences with either self-swab were still willing to use that swab in the future.Conclusions:TGD AFAB individuals were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for cancer screening could expand access to HPV screening for TGD AFAB populations.

Purpose: Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face numerous barriers to preventive care, including for cervical cancer screening. At-home human papillomavirus (HPV) testing may expand access to cervical cancer screening for TGD people AFAB. This study assessed the perceptions of TGD individuals AFAB who self-collected cervicovaginal and anal samples. Methods: We recruited TGD individuals AFAB to collect cervicovaginal and anal specimens at home using self-sampling for HPV testing, and individuals reported their perceptions of self-sampling. Associations between demographic and health characteristics and each of comfort of use, ease of use, and willingness to use self-sampling were estimated using robust Poisson regression. Results: Of 137 consenting participants, 101 completed the sample collection and the surveys. The majority of participants reported that the cervicovaginal self-swab was not uncomfortable (68.3%) and not difficult to use (86.1%), and nearly all (96.0%) were willing to use the swab in the future. Fewer participants found the anal swab to not be uncomfortable (47.5%), but most participants still found the anal swab to not be difficult to use (70.2%) and were willing to use the swab in the future (89.1%). Participants were more willing to use either swab if they had not seen a medical professional in the past year. Conclusions: TGD individuals AFAB were willing to use and preferred self-sampling methods for cervicovaginal and anal HPV testing. Developing clinically approved self-sampling options for HPV testing could expand access to cancer screening for TGD populations.

Transgender and gender diverse (TGD) people are disproportionately impacted by various health issues and associated risk factors, but little is known about differences in these outcomes between gender identities within the TGD population. This study characterized the health of a diverse sample of TGD youth and young adults. Data were taken from the baseline visit of two longitudinal studies in the Chicago area, RADAR (N = 1079, M age = 20.8years) and FAB 400 (N = 488, M age = 19.57years), which are cohorts of young sexual and gender minorities assigned male at birth (AMAB) and assigned female at birth (AFAB), respectively. There was a combined sample of 214 TGD (128 AFAB, 86 AMAB) individuals across cohorts. We examined differences between gender identities in self-reported health and related psychosocial variables, and compared TGD youth and their cisgender sexual minority peers from their cohort of origin on all variables. Among TGD youth, we found high rates of depression and suicidality (ideation, plan, attempt), violence (trauma, victimization, childhood sexual abuse), and substance use (cigarette, alcohol, illicit drug use). With the exception of depression, transgender women and non-binary AMAB youth reported worse health outcomes than transgender men and non-binary AFAB youth. Non-binary AMAB youth reported the highest rates of certain outcomes, including traumatic experiences and suicidal ideation. TGD youth generally reported worse outcomes than cisgender sexual minority youth; these differences were less pronounced among AFAB youth. Findings point to the diversity of experiences within the TGD population and critical needs for intervention approaches to mitigate health disparities.

Purpose:The human papillomavirus (HPV) causes cervicovaginal, oral, and anogenital cancer, and cervical cancer screening options include HPV testing of a clinician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face many barriers to preventive care, including cancer screening. Self-sampling options may increase access and participation in HPV testing and cancer screening. This study estimated the prevalence of HPV in self-collected cervicovaginal, oral, and anal samples from Midwestern TGD individuals AFAB.Methods:We recruited TGD individuals AFAB for an observational study, mailing them materials to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for high-risk (HR; 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) and other HPV genotypes (6, 11, 66, 68, 73, 90) using a polymerase chain reaction mass array test. Prevalence ratios for HPV infection at each site as a function of participant characteristics were estimated in log-binomial models.Results:Out of 137 consenting participants, 102 completed sample collection. Among those with valid tests, 8.8% (HR = 6.6%; HPV 16/18 = 3.3%) were positive for oral HPV, 30.5% (HR = 26.8%; HPV 16/18 = 9.7%) for cervicovaginal HPV, and 39.6% (HR = 33.3%; HPV 16/18 = 8.3%) for anal HPV. A larger fraction of oral (71.4%) than anal infections (50.0%) were concordant with a cervicovaginal infection of the same type.Conclusions:We detected HR cervicovaginal, oral, and anal HPV in TGD people AFAB. It is essential that we reduce barriers to cancer screening for TGD populations, such as through the development of a clinically approved self-screening HPV test.

Introduction:HPV causes oral, cervicovaginal, and anogenital cancer, and cervical cancer screening options include HPV testing of a physician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face discrimination and stigma in many healthcare settings; are believed to be a lower risk for cervical cancer by many physicians; are less likely to be up to date on preventive health care services such as pelvic health exams; and are more likely to have inadequate results from screening tests. Self-sampling options may increase access and participation in HPV testing and cancer screening.Methods:We recruited 137 TGD individuals AFAB for an observational study, mailing them a kit to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for HPV genotypes 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73 and 90 using a PCR mass array test.Results:102 participants completed the study. Among those with valid tests, 8.8% were positive for oral HPV, 30.5% were positive for cervicovaginal HPV, and 39.6% were positive for anal HPV. A large fraction of anal (50.0%) and oral (71.4%) infections were concordant with a cervicovaginal infection of the same type.Conclusions:HPV infection in TGD people AFAB may be just as high, if not higher, than in cisgender women. It is essential that we reduce barriers to cancer screening for TGD populations, such as through the development of a clinically approved self-screening HPV test.

Purpose: This study examined the perspectives of transgender and gender diverse (TGD) people on fertility preservation and future biological family building at the initiation of gender-affirming hormone therapy (GAHT), aiming to enhance counseling practices and support informed decision-making. Method: This international multicenter questionnaire study was conducted as part of the European Network for the Investigation of Gender Incongruence across four outpatient clinics in four countries. Participants completed a fertility questionnaire at the initiation of GAHT from January 2017 to June 2023. Results: Of 661 participants, 58% were assigned female at birth (AFAB) and 42% assigned male at birth (AMAB). Most received information on GAHT’s effects on fertility (78%), with 36% expressing a (future) desire for parenthood, biologically or otherwise. Cryopreservation rates for people AFAB were 7% and 24% for people AMAB. The most common reason for not freezing gametes was not finding it necessary, in both people AFAB and AMAB. Conclusions: Our study shows that many TGD individuals desire to parent children. However, they do not always consider a biological relation a necessity. This partly explains the low uptake of fertility preservation.

Childhood Abuse Among Transgender Youth: A Trauma-Informed Approach.

Many transgender and gender diverse (TGD) people want to have biologically related children. This review summarizes and discusses the options for fertility treatment and preservation in TGD adults and adolescents, with an emphasis on gender-affirming hormone therapy in the context of fertility treatment, clinical management strategies to minimize gender dysphoria during treatment and major factors in future use of cryopreserved gametes. Years of growing research demonstrate that TGD people desire fertility counseling and family building; however, social and medical factors can impact future fertility options. Fortunately, TGD individuals have many viable options for family building using their own gametes and/or reproductive organs. However, the nuanced ways in which different gender-affirming treatments affect reproduction, the interplay with nontreatment-related infertility factors and mitigation of likely dysphoria triggers are all critical to actual utilization. This review focuses on fertility treatment and preservation options for TGD patients and highlights these influential social and medical factors. Fertility treatments may be associated with worsening gender dysphoria in TGD people, and an affirming clinical environment and conscientious provider approach is paramount to treatment success. However, reducing gender dysphoria can also require specific changes to medically assisted reproduction and sperm collection protocols, some of which carry the potential for diminished outcomes or unknown effects. Adolescents undergoing fertility preservation treatments may need more support or additional protocol modifications, and outcomes may be poorer in this age group compared with adults. Testicular and ovarian tissue cryopreservation may present a fertility preservation option for prepubertal TGD children; however, in vitro gamete maturation remains experimental in this situation.

Purpose: The purpose of this study was to assess the future family building desires of assigned female at birth (AFAB) transgender and gender diverse (TGD) adolescents initiating hormone therapy, and to characterize the individuals interested in adoption. Methods: This was a retrospective chart review of AFAB TGD adolescents ages 15-17 years old initiating testosterone gender-affirming hormone therapy between 2010 and 2019, analyzing interest in adoption, demographics, and gender-affirming care. Results: Of 195 AFAB TGD adolescents asked about family planning goals, 58% (n = 113) indicated desire for adoption in their future, and 13.3% (n = 26) had no desire for children. There was no difference between those who did and did not want to adopt in terms of age at time of first visit (p = 0.22), or race distribution (p = 0.45); however, straight-identified patients were more likely to desire adoption (p = 0.02) than people with other sexual orientations. Fifty-nine percent (n = 110) of those who did not have a history of adoption and/or experience with the child welfare system desired adoption, compared with 22% (n = 2) of those with a history (odds ratio, 5.14; 95% confidence interval, 1.04-25.39; p = 0.05). Conclusion: Some AFAB TGD adolescents endorse adoption as their desired pathway to parenthood. Clinicians should be sensitive to the complexities of parenthood desires of AFAB TGD patients and have resources to direct patients to more information. Further research is needed to better understand why many AFAB TGD adolescents desire adoption, how this changes with age, and the barriers they face in achieving their goals.

The growing and interdisciplinary field of transgender health.

Objectives Transgender and gender diverse (TGD) individuals face numerous challenges in their daily lives, including a higher prevalence of mental health issues and lower quality of life (QoL) levels compared to cisgender individuals. A common intervention shown to have a positive effect on mental well-being and QoL of TGD individuals is gender-affirming hormone therapy (GAHT). However, the short- and long-term outcomes of GAHT on mental health and QoL are not yet fully explored. Therefore, this study aimed to investigate QoL both in individuals assigned male at birth (AMAB) and individuals assigned female at birth (AFAB) receiving GAHT, and control groups not receiving GAHT. Additionally, this study aimed to investigate the relationship between sex hormone levels and QoL outcomes. Methods This study used a cross-sectional design. TGD individuals were recruited from the Centre for Gender Identity, Aalborg University Hospital. The WHOQOL-BREF questionnaire was used to investigate four QoL domains. MANOVA and post-hoc t-tests were performed to analyse QoL domain scores between the GAHT- and control groups. Additionally, linear regression analyses were performed to examine the relationship between QoL scores and levels of oestradiol and testosterone for AMAB and AFAB individuals, respectively. Results 360 individuals were included in the study. Individuals receiving GAHT had significantly higher QoL scores than controls for both the AMAB (p = 0.005) and AFAB (p = 0.021) group, with the largest differences observed in the psychological domain (D2). AFAB individuals had significantly higher QoL scores than AMAB individuals in both the GAHT and control groups (p = 0.010; p = 0.042, respectively), with a notable difference in the social domain (D3) within the GAHT group. No significant linear relationship was found between sex hormone levels and QoL scores. Conclusions TGD individuals receiving GAHT had significantly higher QoL than those not receiving GAHT. Also, a higher QoL was found for individuals AFAB compared to individuals AMAB. This study highlights the advantages of offering GAHT to TGD individuals and differences based on assigned sex at birth. However, future longitudinal studies are crucial to investigate the short- and long-term effects of GAHT. Conflicts of Interest None.

We aimed to investigate how adults, who started gender-affirming hormone treatment during adolescence, reflect on their reproductive decisions. We recruited transgender and gender-diverse (TGD) people who visited our gender identity clinic and commenced medical treatment in adolescence at least 9 years ago. We collected data through an online survey. The cohort consisted of 89 participants (66 TGD people assigned female at birth (AFAB) and 23 TGD people assigned male at birth (AMAB) with a mean age of 32.4 years (range 25.5-51.2) at the time of study, and 15.6 years (range 11.5-20.6) at the start of medical treatment. All participants initiated medical treatment before 2014, when laws requiring sterilization for legal gender recognition were still in place, and only 30% of participants reported to have received information about fertility preservation, which none of them pursued. In addition, 96% of participants underwent gonadectomy and thus became permanently infertile, which was troublesome for 27%. With today's knowledge, 44% of TGD people AFAB and 35% of TGD people born AMAB would pursue fertility preservation. The percentage of participants with a (future) desire for children increased from 34% at the start of medical treatment (at adolescent age) to 56% at the time of this study (at adult age), of whom 23% had currently started a family. It is important to inform transgender adolescents about the effect of medical treatment on fertility and the options for fertility preservation since many may develop a desire for (biological) children when they reach adulthood.