Reproduction in Transgender and Nonbinary Individuals

Description:

There are approximately 1.4 million trans-identified individuals in the US alone, many of whom will undergo gender-affirming medical or surgical interventions to better align their appearance with their gender identity. Multiple major medical societies recommend fertility preservation counseling prior to starting any gender-affirming therapies, but data are limited on the reproductive effects of common gender-affirming hormone regimens. The burden of fertility counseling falls to the hormone providers and surgeons that are encountering these patients, many of whom will not have had adequate training or resources to provide evidence-based recommendations and options. Additionally, many reproductive health care providers are not trained in how to care for gender minorities.

The purpose of this book is to be a reference for clinicians and researchers in the field of transgender medicine, to provide up-to-date data and resources to properly counsel transgender and nonbinary patients about the reproductive consequences of gender-affirming interventions and their options for family-building, and to educate providers about appropriate and culturally competent reproductive health care. Effects of masculinizing and feminizing hormone therapy, as well as the fertility preservation options available, are discussed in detail for both adults and youth. In addition to these medical considerations, both psychosocial, legal and ethical considerations are highlighted for a more well-rounded presentation. A final chapter describes how to create a welcome and accepting clinical environment.
Such a reference does not currently exist, leading to the propagation of misinformation and encouraging patients to seek nonmedical sources, such as social media, for their information. Reproduction in Transgender and Nonbinary Individuals fills in this gap as a timely text for reproductive endocrinologists, surgeons and all clinical staff working with this population.

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Table of contents :

Contents
Chapter 1: Introduction to the Demographics and Reproductive Health Needs of Transgender and Nonbinary People
References
Chapter 2: Overview of Gender-Affirming Therapy
Introduction
Initiation of Hormone Therapy
Masculinizing Therapies
Hormone Therapies
Medications and Regimens (Table 2.1)
Expected Physical Changes
Surveillance (Table 2.2)
Risks (Table 2.3)
Surgical Treatment Options
Surgical Procedures
Perioperative Medication Management
Feminizing Therapies
Hormone Therapies
Medications and Regimens (Table 2.1)
Expected Physical Changes
Surveillance (Table 2.2)
Risks (Table 2.3)
Surgical Treatment Options
Surgical Procedures
Perioperative Medication Management
Management of TGNB Youth
Fully Reversible Interventions: Puberty Suppression
Partially Reversible Interventions: Hormone Therapy
Irreversible Interventions: Surgery
Conclusion
References
Chapter 3: Effects of Masculinizing Therapy on Reproductive Capacity
Introduction
Impact of Testosterone on the Ovaries
Impact of Testosterone on the Uterus
Impact of Testosterone on the Fallopian Tubes
Pregnancies After Testosterone Therapy
Assisted Reproductive Technology Outcomes After Testosterone
Animal Models for Gender-Affirming Testosterone
Unanswered Questions
References
Chapter 4: Fertility and Fertility Preservation in Transmasculine Individuals
Introduction
Gender-Affirming Treatment and Fertility
Fertility Preservation in the Post-pubertal Transmasculine Individual
Fertility Preservation in the Pre-pubertal Transmasculine Individual
Conclusion
References
Chapter 5: Fertility and Fertility Preservation for Transfeminine Adults
Introduction
Transfeminine People Are Interested in Building Genetically Related Families
Obstacles to Family Building
Biologic Impacts of Gender-Affirming Treatments
Psychological Considerations
Partner Considerations
Fertility Preservation Options
Reasons to Cryopreserve Sperm
Methods for Sperm Collection
Other Considerations for Sperm Cryopreservation
Assisted Reproduction
Intrauterine Insemination
In Vitro Fertilization
Family Building Options for Transfeminine People
Approach for Transfeminine People with Testes, a Penis, and the Ability to Ejaculate (Table 5.1)
Approach for Transfeminine People Who Do Not Have Testes or a Penis but Cryopreserved Sperm (Table 5.1)
Approach for the Single Transfeminine Individual (Table 5.1)
Success Rates with Reproductive Options for Transfeminine People
Conclusion
References
Chapter 6: Obstetric, Antenatal, and Postpartum Care for Transgender and Nonbinary People
Introduction
Guiding Principles of Care
Prior Negative Healthcare Experiences
Minority Stress
Trauma-Informed Care
Language
Abortion Care
Preconception
Testosterone
Achieving Pregnancy
Preconception Screening
Cancer and STI Screening
Pap Smears
Substance Use
Intimate Partner Violence
Housing and Food Security
Prenatal Vitamins
BMI and Health Weight Gain
Identity and Mental Health
Disclosure
Antepartum Considerations
Pelvic Exams
Pregnancy Outcomes
Delivery
Location of Delivery
Mode of Delivery
Analgesia
Support
Postpartum
Lactation
Induction of Lactation in Transfeminine People
Restarting GAH
Postpartum Depression
Contraception
Summary
References
Chapter 7: Fertility Preservation in Transgender and Non-binary Youth
Introduction
Medical Considerations
Psychosocial Considerations
Ethical and Legal Considerations
Summary and Clinical Recommendations
References
Chapter 8: Non-procreative Reproductive Issues and Sexual Function in Transmasculine Individuals
Gynecologic History and Physical Considerations in the Transmasculine Patient
Changes in Genital and Reproductive Anatomy and Physiology on Testosterone
Changes to the Uterus on Testosterone
Changes to the Ovaries on Testosterone
Changes to the Vulva and Vagina on Testosterone
Changes to the Urinary System on Testosterone
Gynecologic Considerations in Gender-Affirming Genital and Reproductive Surgeries
Hysterectomies in Transmasculine Patients
Metoidioplasty and Phalloplasty
Chest Care in the Transmasculine Patient
Human Papillomavirus and Cervical Cancer Screening in Transmasculine Patients
Sexually Transmitted Infections in Transmasculine Patients
Contraception Counseling and Transmasculine Patients
Genital Bleeding Workup and Management in Transmasculine Patients on Testosterone
Testosterone-Specific Considerations in Genital Bleeding
Evaluation and Management of Testosterone-Specific Considerations of Bleeding
Vulvovaginal Atrophy
Pelvic Pain in Transmasculine Patients
Psychological and Social Considerations in Pelvic Pain in Transmasculine Patients
Testosterone-Related Considerations in Pelvic Pain in Transmasculine Patients
Masculinizing Genital Affirmation Surgery Considerations in Pelvic Pain in Transmasculine patients
Evaluation and Management Considerations of Pelvic Pain in Transmasculine Patients
Conclusion
References
Chapter 9: Non-procreative Reproductive Issues and Sexual Function in Transfeminine Individuals
Overview of Sexual Function
Sexual Activity and Orientation in Transfeminine Individuals
Important Considerations
Assessing Sexual Desire and Function
Psychological Health
Sexually Transmitted Infections
Pre-treatment
Sexual Desire
Sexual Function
Hormone Therapy
Sexual Desire
Sexual Function
Surgery
Satisfaction
Future Directions
Conclusion
References
Chapter 10: Psychosocial Aspects of Reproduction in Transgender and Non-binary Individuals
Introduction
Barriers to Medical Care
Barriers to Competent Reproductive Care
Parenthood Desires
Problems with and Solutions to the Current Medical System
Conclusions
References
Chapter 11: Legal Considerations
Legislation
Modifications to State and Federal Identification
The Challenges of Inconsistent Legal Identification
Birth Certificates and Gender Markers
The ACA and Health Care Insurance
Expanding Access
Prohibition of Discrimination and Health Care Insurance Management
Conclusion
Chapter 12: Ethical Considerations for Transgender and Non-Binary Reproduction
Definitions of Infertility
Marginalization in the Practice of Fertility Medicine
Cost of Fertility Treatment
Decision-Making despite Uncertainty
Fertility Preservation Decision-Making in TGNB Youth
Conclusion
References
Chapter 13: Creating Inclusive, Gender Affirming Clinical Environments
Background
Affirming Language
Handling Mistakes
Hiring and Non-Discrimination Policies
Staff Training/Staff Considerations
Cultivating a Gender Affirming Clinic Culture
Critical Components of Ongoing Staff Training
Foundations of Gender
The Gender Affirmative Clinical Model
Nongendered Language
Exploring Provider Bias
Gender Inclusive Clinic Spaces
Policies and Procedures
Gender Affirming Systems Audit List
Creating Inclusive Clinical Spaces
Clinic Entrance
Waiting Room and Other Clinic Spaces
Restrooms
Telehealth
Electron ic Health Records
Overview
Demographic Data Collection
SOGI(E): Sexual Orientation, Gender Identity (Gender Expression)
Affirming Patient Encounters
Inclusive Histories, Review of Systems, Body Inventory
Beyond SOGI: Sexual Histories
Physical Exam
Billing and Insurance Issues
Marketing
Moving Forward
Appendix 1: Resources for Developing Gender Affirming Clinical Environments
Appendix 2: Training and Other Resources for Providers
Appendix 3: Books for Patients in the Waiting and Clinic Rooms
Appendix 4: Pamphlets and Patient Education Handouts for the Waiting and Clinic Rooms
Appendix 5: Billing and Insurance Resources
References
Index