Unmet Reproductive Health Needs of Transgender and Gender Diverse People in Hawai‘i: A Qualitative Needs Assessment

Abstract

The purpose of this study was to assess the reproductive health experiences of transgender and gender diverse people in Hawai‘i, identify reproductive health needs that were unmet, and explore opportunities for addressing those needs. This was a qualitative, semi-structured individual interview study. Adults who identified as transgender or gender diverse were interviewed about their experiences accessing reproductive health services, their needs, and their ideas about clinical settings in which to receive reproductive health care services. Interviews were conducted until thematic saturation was reached. Six trans men, 6 trans women, and 4 people who identified as non-binary or genderqueer were interviewed. Negative experiences in health care settings, particularly when seeking reproductive health care services, were common. Participants often had multiple providers and gender-affirming care was often accessed separately from other health care services. Desires for fertility and pregnancy varied widely between participants but were often not addressed at the initiation of gender-affirming care. Finding trans-friendly providers was notably difficult and participants often relied on friends and other members of the transgender community for guidance. Obstetrics and gynecology clinics present a potential opportunity for access to reproductive health services although their gendered environment was concerning for some participants. Transgender and gender diverse people in Hawai‘i have access to some reproductive health services but experience stigma in certain settings. There is a need for ongoing improvement in reproductive health care services in Hawai‘i to improve access for transgender and gender nonconforming people in Hawai‘i.

Introduction

Transgender and gender diverse (TGD) people experience significant barriers to comprehensive health care and subsequently experience significant adverse health outcomes in the United States.^1–3 Despite increased efforts to educate medical professionals on approaching TGD patients with sensitivity to their lived experience, health care needs, and efforts to improve health insurance coverage for gender-affirming care, there remain disparities in health care access for TGD people.^4–6 Reproductive health and the implications of gender-affirming hormone therapy and surgical care are particularly important to take into consideration for TGD people who may be considering pregnancy or childbearing in the future.⁷

There are approximately 7800 transgender people in Hawai‘i, making up 0.7% of the population.⁸ In 2013, researchers at the University of Hawai‘i at Manoa School of Social Work conducted an in-depth needs assessment of the lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) communities of Hawai‘i.⁹ This study found that the LGBTQI community faced many challenges in receiving health care, including stigma and discrimination in health care settings and inconsistent insurance coverage.⁹ TGD people in Hawai‘i reported the lowest rates of perceived wellness, highest rates of being uninsured, the lowest access to a regular primary care provider, and higher rates of discrimination in health care settings compared to other members of the LGBTQI community.⁸ Based on their findings, researchers called for additional work to understand and address the specific challenges for TGD people in Hawai‘i. A survey of obstetrician-gynecologists (OB/GYNs) in Hawai‘i indicated that OB/GYNs are comfortable providing sexual and reproductive health services to TGD people but are less familiar with gender-affirming care such as hormone therapy or requirements for gender-affirming surgery.¹⁰ The aim of this study was to identify the unmet reproductive health needs of TGD people living in Hawai‘i through a community-based needs assessment and to understand the potential for reproductive health service provision in obstetrics and gynecology clinics and other clinical settings.

Materials and Methods

This study was a qualitative reproductive health needs assessment to identify the unmet reproductive health needs of TGD adults living in Hawai‘i using a community-based participatory research approach. Researchers at the University of Hawai‘i John A. Burns School of Medicine partnered with the Kua‘ana Project at the Hawai‘i Health and Harm Reduction Center to design the research instruments, recruit study participants, contextualize results, and disseminate study findings. The Kua‘ana Project is a non-profit organization in Honolulu that provides social services, support, and HIV and hepatitis education and testing for the TGD community of Hawai‘i. The Kua‘ana Project is closely connected to the O‘ahu transgender community and all of the staff of the Kua‘ana Project identify as transgender. Structured interview questions were developed for TGD people in Hawai‘i aimed at understanding their sources of reproductive health care, insurance coverage, access to gender affirming care, discrimination from reproductive health care providers, fragmentation of health care, parenting intentions, and ideal settings for reproductive health care delivery. The University of Hawai‘i research team developed the interview questions collaboratively based on the reproductive health care subjects to be explored. The interview guides were evaluated internally for clarity, conversational flow, and TGD community relevancy by the Kua‘ana Project team and community partners. Interview guides were modified in an ongoing process to explore emerging themes. Interviews were conducted until thematic saturation was reached.

The University of Hawai‘i research team all identify as people of color, with 3 cis identified people and 1 trans identified person. The Kua‘ana Project team members both identify as trans people of color. Interviewers were from the University of Hawai‘i and included 2 cis identified people and 1 trans identified person; 2 are OB/GYNs and 1 is a nurse. All interviewers have experience and training in qualitative interviewing.

Participants were recruited using fliers and case manager referrals at Kua‘ana Project, online advertising on Craigslist, and referrals from other TGD clinics in O‘ahu.

People were eligible to participate in the study if they identified as transgender, intersex, genderqueer, gender diverse, gender non-binary, or any other TGD identity; were 18 years or older; lived in Hawai‘i; and were willing to complete a demographic survey and 20–30 minute phone interview in English. A trained research assistant screened all potential participants for study eligibility over the phone. If they met inclusion criteria, participants were scheduled for a phone interview with researchers and sent a link to complete the demographic questionnaire online. Demographic characteristics of participants were obtained separately from interviews in order to de-identify interview responses and protect confidentiality of sexual health information. Demographic data were collected and managed using REDCap software (Vanderbilt University, Nashville, TN). Study participation was voluntary. Participants were compensated with a $25 electronic gift card for their participation.

Informed consent was obtained verbally from participants prior to starting the interview. Interviews were conducted via telephone and audio-recorded with participants’ permission. The interviewers did not have prior clinical or research relationships with the participants. Study participants were recruited and interviews conducted from December 2017 – December 2019 until thematic saturation was reached. Interview recordings were transcribed by study staff. All personal identifying information was removed from the transcripts.

Researchers met regularly during the recruitment phase to evaluate emerging themes and ensure continued clarity of the interview questions. A codebook was created and updated using a grounded theory approach through an iterative process of content analysis throughout the recruitment period. Once thematic saturation was reached, 2 researchers (SR and GM) conducted line-by-line coding of transcripts using Atlas.ti software, version 8.4.4 (Atlas.ti Scientific Software Development Gmbh, Berlin, Germany). Discrepancies in coding were discussed and resolved by mutual discussion.

This study was approved by the University of Hawai‘i at Mānoa Institutional Review Board (2017-00309).

Results

Eighteen TGD people in Hawai‘i were screened for study participation and 16 people completed the semi-structured phone interviews. Seven people identified as trans masculine, 6 people identified as trans feminine, and 3 people identified as non-binary or mixed gender. Participant ages ranged from 20 to 58 years old, with a median age of 30 years old. Most participants lived alone or with a roommate, but 2 participants reported having unstable housing or being houseless. Many respondents had received some form of gender affirming care, most commonly hormonal treatment. All participants answering the demographic survey were located on the island of O‘ahu.

From the interviews 5 major themes were identified: (1) negative experiences in health care settings are common, (2) gender-affirming care is often accessed separately from other health care services, (3) A welcoming health care environment and health care providers who are open to caring for TGD people are important to TGD people, (4) desires for fertility or pregnancy are variable, but often are not addressed at the initiation of gender-affirming care, and (5) obstetrics and gynecology clinics present a potential opportunity for access to reproductive health services for TGD people.

Theme 1: Negative Experiences in Health Care Settings are Common

Almost all participants reported either having negative experiences in the health care system themselves, witnessing friends or partners have negative health care experiences, or knowledge of TGD community members with negative experiences (Table 1). Misgendering was the most common negative experience that participants reported, although experiences ranged from inexperience of providers to outright refusal of care. Misgendering occurred both on an interpersonal level but also at an institutional level.

Table 1.

Negative Experiences in Health Care Settings Are Common—Theme 1

Subtheme	Quote
Misgendering	“I’d go for a hospital visit and right away they’d get my pronouns wrong because, all my medical records, even though I legally changed my name and everything and my pronoun marker on my ID, the hospital refuses to change it. Every time I go to the hospital, for anything, it depends on who I get. But if they see it says miss, and I’m obviously presenting as a male, it depends on what they feel like doing that day.” – 26-year old trans man
Limitations of binary health systems	“They’ll make statements like… they’re talking about women and I feel like they’re including me in that group when they’re talking and I know that that’s a little bit more nuanced and more difficult for health care providers to do, but it’s kind of like, don’t tell me what women’s experiences on this thing are ‘cause I’m not one of them, I don’t know.” – 35-year old trans man
Negative experiences with health care providers	“For instance, the last gynecologist that I saw that actually made me decide to put a pause on going to see gynecologists was a doctor… I thought would be friendly but I shared something about my identity and her reaction was so… I don’t even know how to describe it, but it made me feel so uncared for and unwanted in that environment that I didn’t go back.” – 30-year old non-binary person

ID = identification

Participants acknowledged the limitations of the current medical establishment with respect to the binary setup of health care services for cisgender men or cisgender women, and the assumptions that providers, particularly providers of reproductive health services, often make about sexual partners, behaviors, pregnancy risk, and menstrual experiences.

Negative experiences with the health care system contributed to anxieties about future health care experiences and an overall reluctance to seek care within the medical establishment. In particular, having a provider who demonstrated obvious inexperience with transgenderbodies or reacted negatively to gender identity disclosure was particularly concerning for participants.

Theme 2: Gender-affirming Care is Often Accessed Separately from Other Health Care Services

Most participants reported having multiple different providers for various health care needs (Table 2). Participants who were receiving gender-affirming health care services often received these from a provider who was not their primary care provider, resulting in additional appointments and complexity in coordination of care.

Table 2.

Gender-Affirming Care Is Often Accessed Separately from Other Health Care Services—Theme 2

Subtheme	Quote
Fragmented care	“So I have 3 different providers for all that different stuff because my PCP does not want to handle my hormone treatment because he does not feel capable of handling the hormone treatment, he doesn’t want to do gynecology. My gynecologist doesn’t feel capable of handling my hormone treatment. And I also because I have a severe clotting disorder, see a specialist for my clotting disorder. And so it’s very complicated.” – 50-year old trans man
Gender-affirming care and other medical diagnoses	“I was actually asked from my doctor, you know, ‘cause my kidneys were doing really bad. He was like, ‘Are you eating a lot of fatty food, what’s going on?’ And he actually said, ‘Are you going through hormone therapy?’ And I go, ‘Maybe.’ And he asked me more about it and where am I getting it from and he highly suggests that I don’t do it… As stubborn as I am, I’ll lose a kidney [laughing] to gain a vagina” – 28-year old trans woman
Integrated care	“Well, my primary care provider is an inclusive LGBT clinic. So, it was very easy for me to disclose [my gender identity], that’s the reason why I went there in the first place.” – 25-year old trans man
Gender-affirming surgical care	“I had called about 4 or 5 doctors that specialized with breast augmentation and 1 of them actually had told me that he will not accept transgender patients whatsoever. And his reasoning was it was too hard because they still have masculine or male tissue and it would be… much more work than he would want to do to create the pocket, to insert the implant. And the rest were like, “We do, we can, but we don’t know how, we can’t promise how it’s gonna come out, we don’t, we’ve done 1 or 2, we don’t really see a lot of transgender clients.” And it was just kind of very awkward but for me I like to be upfront with them because I want them to know what they’re getting into especially if you’re cutting into me.” – 30-year old trans woman

PCP = primary care provider. LGBT = lesbian, gay, bisexual, transgender

Gender-affirming care was particularly difficult to access for people with other medical conditions. Health care providers in other specialties who provided treatment for other medical conditions were often reluctant to discuss gender-affirming therapies and cautioned participants about the risks of gender-affirming hormone therapy in conjunction with the treatment of their chronic medical conditions. Participants expressed difficulty communicating with some of their health care providers about their desire to pursue gender-affirming care.

A few participants received their gender-affirming care and their primary care and preventive services from the same provider or clinic. For those who had this experience, they reported high satisfaction with their health care, particularly with respect to being able to be open with their provider about their gender identity and their health care needs.

Surgical care was notably difficult to access, and participants who had gender-affirming surgeries reported difficulty finding a surgeon who was comfortable with gender-affirming surgeries. Primary care providers had limited knowledge of surgeons in the community, and participants who sought surgical services often relied on word-of-mouth from other TGD people or on internet searches to find surgeons.

Theme 3: A Welcoming Health Care Environment and Health Care Providers Who are Open to Caring for TGD People are Important to TGD People

Although most participants were currently receiving some form of medical care, many noted that their providers had limited knowledge of other TGD-friendly providers to whom participants could be referred for medical, surgical, or specialty care (Table 3). Participants often relied on their friends or other members of the TGD community to find TGD-friendly health care professionals for their other health care needs. Concern about stigma was an important driving factor in trying to identify TGD-friendly providers through community connections.

Table 3.

A Welcoming Health Care Environment and Health Care Providers Who Are Open to Caring for Transgender and Gender Diverse (TGD) People Are Important to TGD People – Theme 3

Subtheme	Quote
Reliance on social networks to find providers	“Okay, you gotta go and find a new primary care doctor. Okay, you don’t know which ones are what you call ‘LGBT friendly,’ you see. You start asking around like, ‘Oh have you ever heard if he or she is nice?’ It’s a gamble, and you know some doctors, they might not treat you too well or they might give you a stink eye look or you can feel the chemistry and stuff like that.” – 44-year old transwoman
A provider’s attitude is more important than the clinical setting	“I would much rather go to a place that I know is affirmative of who I am, even if it’s a little corridor. If I know that’s the spot that I go to, to get those same things but the space and people and services are inclusive of me, I’m good. Just give me a room.” - 30-year old non-binary person
Gender identity closure prior to appointments is important	“When I called to look for a new OB/GYN I specifically called and asked each OB/GYN’s office. I want an OB/GYN who is willing to work with a transgender man who may go through transitioning with bottom surgery. And I will not work with an OB/GYN who will not do that.” – 50-year old transman
Hopeful about resources for future generations	“I try to be a good role model for other trans girls. And I mean I see it getting even younger, you know? And the resources they need, the information they need, the components they need that they try to find, it’s really hard, you know.” – 28-year old transwoman

OB/GYN = obstetrician-gynecologist

Providers who were friendly and welcoming were typically viewed very positively by participants, even if they noted that the providers may have limited knowledge in TGD-specific care. Some participants also noted that while the physical clinic surroundings may be important to creating a welcoming environment, that the most important part was being able to access care at all.

Disclosing their gender identity to a provider’s office prior to seeking care was a common method for some participants to determine whether the provider they were attempting to see was experienced with caring for TGD people or open to providing care to them. This was particularly important for participants who were already receiving gender-affirming care or who had plans to receive gender-affirming care in the near future.

Despite the many obstacles to finding health care providers or services, many TGD people were hopeful for the future of health care for themselves and their communities. They expressed resiliency and a sense of optimism about the future of TGD health care. Despite facing personal difficulties in seeking care, participants were eager to improve health care and provider education and experience for the future generations of TGD people.

Theme 4: Desires for Fertility or Pregnancy are Variable, but Often are Not Addressed at the Initiation of Gender-affirming Care

Participants expressed a wide spectrum of desires for fertility, pregnancy, and parenting (Table 4). The desire for fertility or pregnancy was intimately tied to participants’ goals for gender-affirming care and the timing of their care, particularly gender-affirming surgeries. Fertility concerns in relation to gender-affirming care were particularly common for transmen, whose decisions around hysterectomy or oophorectomy would definitively impact their future childbearing potential.

Table 4.

Desires for Fertility or Pregnancy Are Variable, but Often Are Not Addressed at the Initiation of Gender-Affirming Care—Theme 4

Subtheme	Quote
Fertility concerns related to gender-affirming care	“[I discussed fertility] with my OB/GYN, yeah, but that was pre-transition. I didn’t even know if I wanted to be pregnant in the future, but I did feel like it was important for me to preserve my uterus health or, you know, reproductive health, so that maybe in the future that, maybe I do decide to bear a child, I wouldn’t worry about that in the future because the birth control that helped regulate my periods would help my reproductive health.” – 25-year old transman
Stigma and assumptions about parenting and childbearing goals	“I think that because there’s a stigma attached to being trans, not many people think that we want to reproduce. So they just push it aside and are kind of like, ‘Well if you can’t do it the traditional way then that’s it.’… And that’s like a big thing that prevents trans people from seeing that they can have a family. You know, people are like, ‘Well if you get rid of the parts then what’s the use?’ But… I mean, give them an option.” – 26-year old transman
Desires for pregnancy, parenting, and childbearing can change	“I didn’t think it was necessary [to discuss future pregnancy with my medical providers] because I didn’t think it was something that I would consider and as time goes on, given my relationships, and getting older and trying to figure out what I want to do with my future I’m starting to consider the possibility that I might want to have a child.” – 22-year old transman
Gendered language around pregnancy	“There’s a lot of conversation that’s based around womanhood for pregnancy and childbearing which… is mostly for like cis womanhood or the occasional emphasis on the transman but what I find very irritating is a lot of people don’t mention a transwoman. Especially when transwomen have a huge stake in reproductive services. I- I just feel like the industry around pregnancy [is] like another barrier for a lot of trans people to be marginalized.” – 21-year old transman

Participants perceived that the assumption that people undergoing gender-affirming care were not interested in childbearing was prevalent among health care providers. Moreover, participants also reported that at the initiation of gender-affirming therapy they assumed they would not want to pursue pregnancy or childbearing in the future. The cost of gamete preservation and storage was also a deterrent for participants, many of whom were already incurring significant medical costs for their gender-affirming care.

For some participants, their desire to be pregnant or to be a parent changed over time, with new relationships, or with age. While they may not have considered childbearing or parenting when initiating their gender-affirming care, they uncovered a desire for pregnancy or parenting over time. For participants who had had gender-affirming surgeries that resulted in sterilization, such as hysterectomies or oophorectomies, options for parenting were more limited. Others who were unable to be pregnant or bear children themselves identified numerous creative ways, such as different modes of adoption, to fulfill their desires to parent.

With respect to pregnancy specifically, participants noted that the culture of pregnancy and pregnancy care, which is focused on the cisgender female body and experience, can be alienating to TGD people and that these assumptions and narrow definitions contributed to the marginalization of TGD people in pregnancy-related health care. Participants who were considering pregnancy expressed reluctance to receive care through the standard medical establishment due to these concerns.

Theme 5. Obstetrics and Gynecology Clinics Present a Potential Opportunity for Access to Reproductive Health Services for TGD People

Participants had received reproductive health services in a variety of places ranging from their primary care providers to specialists such as OB/GYNs to reproductive health clinics (Table 5). Experiences with reproductive health services varied. The specific focus on reproductive health services was often viewed as a positive factor in obstetrics and gynecology clinical spaces.

Table 5.

Obstetrics and Gynecology Clinics Present a Potential Opportunity for Access to Reproductive Health Services for Transgender and Gender Diverse People – Theme 5

Subtheme	Quote
Specialized in reproductive health	“There’s a feeling of emotional and physical safety that I feel that I really do enjoy about OB/GYN spaces that I am in. I do enjoy that it is a space that is specific to concentrating on my reproductive health. Like I’m there to work on this part of myself and I like that. I value health in my body so much and reproductive organs are so vital and having a space to go think about that and nurture that part of myself.” – 30-year old non-binary person
Affirmation of female identity (for trans women)	“I portray myself as a woman and being a transgender woman I feel like I look like a woman but I still have my insecurities… If it’s just a clinic for women, like OB/GYNs, of course I would feel totally at home and comfortable going to do my check ups… When I first started [going to an OB/GYN office for care] and I didn’t change my name, and they’re calling out, ‘Michael, Michael?’a And I’m getting up and I’m wearing a dress, it’s very shameful, and embarrassing. People are looking like, there’s a few looking like, ‘Oh maybe she called her last name first, Michael.’ No but really my name is Michael, you know?” – 28-year old transwoman
Scrutiny from other patients (for trans men)	“I wouldn’t want people to be seeing me waiting in the waiting room. They would be looking at me like, ‘What is this guy doing here?’ because I don’t look like a girl. And they’re going to be staring at me and most of those ladies take their kids there too and that’s really uncomfortable as well. Because the kids are going to be like, ‘Mommy, is that a guy or is that a lady?’ I know it’s not their fault they don’t know. Still, it just gets on my nerves.” – 36-year old non-binary person
Improvements towards inclusive spaces	“I know that a lot of medical facilities have different kinds of posters on the walls with different information. If there was something there identifying the office as an inclusive space. Maybe put up little flags, flag stickers, stuff like that. Make it known walking in that it was a safe space.” – 22-year old transman
Integrated multidisciplinary networks	“For me, the ideal set up would be… where they actually have like a full staff, whether it’s a mixture of the OB/GYN, the psych department for mental health, as well as individual specialists, as well as a GP. Like having it all centrally located and then maybe, if they don’t then they have a list of names that are connected in the community. Like a connected network of LGBT health care providers that are… comfortable working with LGBT [people].” – 30-year old transwoman

GP = general practitioner

^aNames have been changed to protect the identity of participants

For many participants, particularly those who identified as transwomen and described themselves as presenting as very feminine, obstetrics and gynecology clinics were viewed as spaces that were affirming of their feminine identity. Issues with use of the wrong name (deadnaming, which is the act of referring to a transgender or gender diverse person by a name they were given in the past but with which they no longer identify) or staff lack of knowledge of a participant’s new name resulted in uncomfortable encounters for participants.

Conversely, those who identified as trans men found obstetrics and gynecology clinic spaces to be exclusionary and expressed concern about scrutiny from staff and other patients, particularly if their appearance was more masculine.

Despite the fact that many viewed obstetrics and gynecology clinics as a necessary entity in the provision of reproductive health services, there were numerous suggestions for ways to improve these clinical spaces to make them more comfortable and more welcoming to TGD people. These ranged from having gender-neutral bathrooms and inclusive signs in waiting rooms, to having clinics specifically stating their openness to caring for both cis and TGD clients.

When asked to describe their ideal clinic in which to receive care, participants most commonly discussed the need for comprehensive care in a single location. Having providers who were experienced with TGD care or who identified as TGD themselves was also important to participants as it indicated that providers may have had their own personal experiences with gender-affirming care. The availability of other services such as mental health care, voice therapy, and referral options for other TGD-friendly providers in the community was also important in an ideal clinic model.

Discussion

The participants in the current study had a wide variety of reproductive health experiences with the health care system. Overall, most were able to access some care, although the care they received was sometimes from providers who were not experienced with TGD care, or did not take their gender identity and unique needs into consideration. Some experiences were uncomfortable, particularly in clinical spaces that focused on gender-specific care.

Fertility, pregnancy, and desires for future childbearing were often not addressed as part of reproductive health care for TGD people. TGD people may not be aware of the impact that gender-affirming care, particularly gender-affirming hormone therapy, can have on fertility and desires for pregnancy or parenting may change over time. Major professional organizations recommend that the desire for fertility or gamete preservation be addressed prior to initiating gender-affirming hormone therapy.^11,12 Gamete preservation and storage is also often prohibitively costly and may not be covered by all insurance companies, thus there is an ongoing need for advocacy in this area to ensure access to comprehensive reproductive health services.

Although the American College of Obstetricians and Gynecologists recommends that care for TGD people is within the scope of practice for OB/GYNs, many are inexperienced or not comfortable with providing services to a TGD population.^10,13 In addition, the cisgender female-oriented language, clinical spaces, and assumptions inherent in obstetrics and gynecology care can be uncomfortable and alienating for TGD people. This was particularly noted to be true for language around pregnancy and pregnant bodies.

These results indicate that there is a need for improved integration of services and improved referral systems within the medical community in Hawai‘i so that TGD people can access the care that they need. Gender-affirming surgical care is particularly challenging to access in Hawai‘i due to a lack of experienced providers and this was highlighted by multiple participants. Targeted recruitment of providers with experience in gender-affirming surgery or support of training in gender-affirming surgery during general medical education are strategies that can improve access to surgical options in a local setting. Providers’ attitudes towards TGD people, particularly in being friendly, welcoming, and respecting names and pronouns, were highly important to participants, and often noted to be more important than providers’ experience in TGD health care. Addressing TGD care throughout the process of medical training through workshops, lectures, and direct patient care may lead to more health care providers who are open to providing care for TGD populations in the future.

The major strength of this study is its community-oriented nature. This study was a collaborative effort between community organizations and health care providers who serve the TGD population to establish trust with the community during recruitment, and a variety of different recruitment methods were used. A diverse group of transgender male, transgender female, and non-binary people were interviewed to reflect the spectrum of gender identity and of people who may present for reproductive health services. People were also asked about their ideal clinic to foster consideration of health care possibilities that may not exist currently within the health care system.

This study is limited by selection bias as participants volunteered to discuss their experience with prior care, and thus selected for people who were comfortable talking about these experiences. All of the participants lived on O‘ahu, the island in the state of Hawai‘i with the highest level of health care services and number of providers. Although there are some gender-affirming services on other islands, the unique geographic barriers in Hawai‘i make it more difficult for people to access care that requires flying to other islands. Participants on other islands in the state may not have the same experience with accessing health care services, including reproductive health services, as those on O‘ahu.

Conclusions

TGD people in Hawai‘i are able to access some reproductive health services, but do not always receive counseling about fertility and pregnancy prior to gender-affirming hormone therapy. Access to care is often fragmented and people often rely on their community to find TGD-friendly providers. While obstetrics and gynecology clinics are potential places for TGD people to receive reproductive health services, additional work is needed on the part of providers and clinic staff to create inclusive spaces and to provide skilled care for the TGD community.

Glossary

Abbreviations

ID

identification

GP

general practitioner

LGBT

lesbian, gay, bisexual, transgender

LGBTQI

lesbian, gay, bisexual, transgender, queer, and intersex

OB/GYN

obstetrician-gynecologist

PCP

primary care provider

TGD

transgender and gender diverse

Conflict of Interest

None of the authors identify a conflict of interest.

Funding

This study was funded through the generosity of the Lakshmi Devi and Devraj Sharma Fund.