Abstract
Purpose: This study was designed to enhance health care providers' abilities to engage transgender men and trans-masculine non-binary individuals (TMNBI) in sexual and reproductive health care conversations by identifying preferences for provider communication and terminology related to sexual and reproductive anatomy and associated examinations.
Methods: From May to July 2017, we conducted a cross-sectional online survey with a convenience sample of TMNBI (N = 1788) in the United States. We examined participants' provider communication experiences and preferences related to sexual and reproductive anatomy, and preferred terminology for sexual and reproductive anatomy and associated examinations. Communication experiences/preferences and preferred terminology were assessed by gender identity and gender-affirming medical interventions (hormones and/or surgery).
Results: Most participants had regular access to health care (81.3%); of those, 83% received care from a provider knowledgeable in transgender health. Only 26.9% of participants reported that a provider had ever asked about preferred language for their genitalia/anatomy. The majority of the sample (77.7%) wanted a provider to ask directly for preferred language and 65% wanted a provider to use medical terminology, rather than slang when talking about their body. Participants provided varied responses for their preferred terminology related to sexual and reproductive anatomy and associated examinations.
Conclusions: These data underscore the importance of medical providers asking for and then using TMNBI' preferred language during sexual and reproductive health conversations and examinations, rather than assuming that all TMNBI use the same language. Asking for and using TMNBI' preferred language may improve gender-affirming sexual and reproductive health care and increase patient engagement and retention among these individuals.
Keywords: gender-affirming health care, patient–provider communication, sexual and reproductive health, transgender men
Introduction
Transgender men and trans-masculine non-binary individuals (TMNBI) (i.e., individuals who identify along the trans-masculine spectrum and were assigned female at birth) have received limited attention in transgender health research. To date, much of the literature specific to TMNBI has focused on gynecological care,1–5 fertility and pregnancy,6–9 sexual health,10–14 and testosterone management,15–17 and consistently demonstrates that TMNBI often struggle to receive comprehensive medical care that is respectful of, and responsive to, their needs, experiences, and preferences.14,18–22
There are several barriers to competent care for TMNBI. The first is a lack of basic provider education and training in transgender health. Studies of medical education indicate that the vast majority of schools provide five or fewer hours of instruction related to lesbian, gay, bisexual, and transgender (LGBT) health,23 with less than a third providing any education related to hormone therapy or gender-affirming surgery.24 Providers at all levels report that insufficient training and limited exposure to transgender and non-binary (TGNB) patients impact their ability to provide appropriate medical care to this community.25–28 A recent review of attempts to integrate education on transgender issues into medical school curricula indicates that most consist of one-time interventions to improve awareness or attitudes, without any in-depth clinical practice focus.29
Second, several incorrect assumptions about the sexual behavior and sexual health needs of TMNBI have limited their access to comprehensive health care. The majority of federally funded research on transgender health has focused on HIV prevention, ignoring TMNBI because they are assumed not to be at risk for HIV.11,30–32 Many providers also assume that TMNBI do not need reproductive health care, and ignore both contraception and fertility needs in this population.14,33,34 Both of these assumptions stand in contrast to data indicating that TMNBI claim a variety of sexual identities and engage in sexual behavior with individuals of all genders.13,35–37 The lack of valid and reliable assessment tools for engaging TMNBI in conversations about their sexual and reproductive health prevents providers from understanding the vital needs of this patient population.12–14,38,39
Third, TMNBI experience persistent discrimination and mistreatment in health care settings. Previous research has shown that TMNBI experience barriers to health care regardless of whether they are seeking preventive, routine, emergency, or transition-related care.40,41 Experiences of discrimination often result from lack of provider knowledge or training related to working with TGNB individuals and/or provider-level transphobia,2,3,5,40,42,43 which may lead to disengagement in care among TMNBI that can have significant negative impacts on their health.25–27,29,44,45
Although these barriers are important, missing from conversations about competent and affirming health care for TMNBI is an understanding of patients' experiences of and preferences for engaging in conversations about their sexual and reproductive anatomy and sexual health. Little data have been collected from TMNBI regarding the language they use for their own bodies or the ways in which they would like their providers to engage them in health conversations.38,46 This study was designed to enhance health care providers' abilities to engage TMNB patients in sexual and reproductive health care conversations by identifying preferences for provider interactions and terminology related to sexual and reproductive anatomy and associated examinations among TMNBI with varying gender identities and engagement in gender-affirming medical interventions.
Methods
From May to July 2017, we conducted a cross-sectional survey of TMNBI in the United States. The survey recruited “transgender men and non-binary individuals of transmasculine experience,” and was developed and implemented by a majority transgender-identified research team and was the second phase of a mixed methods project to understand the range of sexual behaviors, identities, and sexual and reproductive health needs of TMNBI. The majority of measures were specifically designed for the survey based on findings from 30 in-depth semistructured qualitative interviews (Phase I) conducted with a sample of TMNBI. Study participation involved completion of a 45-minute self-administered online survey.
The survey was advertised on social media platforms (i.e., Facebook, Twitter, and Tumblr) and through e-mail to transgender community leaders. Snowball sampling on social media and word of mouth were also critical to sample recruitment. During the 3-month recruitment period, there were 519 shares by participants on Facebook, 479 retweets on Twitter, and 953 reblogs on Tumblr. The Facebook page for the project had 719 users.
To be eligible for participation, individuals were ≥18 years of age, assigned female at birth, identified with a gender identity other than their sex assigned at birth and on the trans-masculine spectrum, and had the option to enter a raffle to win 1 of 10 $100 Visa gift cards. Study procedures were approved by the Hunter College of the City University of New York Human Research Protection Program Office. Before survey completion, informed consent was given through an online consent form by checking “yes” to study participation.
Sample
Overall, 2404 individuals attempted the survey with 2386 (99.3%) meeting eligibility criteria. Due to the length of the survey and the fact that participants were entered into a raffle as opposed to receiving direct payment, no surveys were deleted for suspect responding (e.g., survey attempts from automated Internet bots and multiple survey attempts from participants).47 We removed participants from this analysis if they lived outside the United States (n = 207) or did not complete the questions related to patient/provider communication and preferred terminology that were the focus of this study (n = 391), leaving a final analytic sample of 1788.
Measures
To determine health care access, participants were asked if they currently had a regular place to go for medical care (yes/no). LGBT-focused health centers may be a critical point of entry to gender-affirming medical care for the TGNB community. To better understand whether participants with regular access to health care received care at an LGBT-focused health center, we asked participants to indicate whether they received their regular health care at an LGBT health center (yes/no). Participants who indicated having a regular place to go for medical care were asked whether their provider was knowledgeable and competent in transgender health (yes/no).
Participants were asked to indicate (yes/no) to whether they were currently taking testosterone and if they have had (i) top surgery, (ii) hysterectomy, (iii) oophorectomy, or (iv) genital surgery (metoidioplasty and/or phalloplasty). Participants who had genital surgery were asked if they had a vaginectomy. A binary variable—any gender-affirming medical intervention (hormones and/or any surgery)—was also created.
Participants were asked three questions to assess their provider communication experiences and preferences related to sexual and reproductive anatomy. They were also asked to indicate what terminology they would like a health care provider to use for chest/breast and gynecological examinations. Survey questions and response options for these measures are documented in Table 1.
Table 1.
Survey Questions and Response Options for Patient–Provider Communication and Preferred Terminology
| Variables | Survey questions | Response options and sample write-in responses |
|---|---|---|
| Provider communication (Anatomy) | ||
| Asked your preferred language for body parts | Has a medical provider ever asked what language you prefer to use for your genitalia/body parts? | 1 = Yes; 0 = No |
| Ask me what words I prefer to use for my body parts | Would you like a health care provider to ask you directly what words you use for your genitalia/body parts? | 1 = Yes; 0 = No |
| Use medical terminology as opposed to slang when talking about body | When a health care provider talks to you about your body, would you like them to use medical or more common/slang terminology? | 1 = Medical terminology; 0 = common/slang |
| Preferred terminology (Examinations) | ||
| Chest/breast examination | What would you like a doctor or health care provider to call a chest/breast examination? | 1 = Top exam; 2 = Chest exam; 3 = Chest tissue examination; 4 = A term not listed here (please specify) |
| Gynecological examination | What would you like a doctor or health care provider to call a gynecological examination? | 1 = Gynecological/GYN examination; 2 = Pelvic examination; 3 = Bottom examination; 4 = Pap or pap test; 5 = A term not listed here (please specify) |
| Preferred terminology (Anatomy) | The next series of questions addresses what language you would like a doctor or medical provider to use when talking about your specific body parts/genitalia. We will ask you to write-in the word(s) you would like a doctor or medical provider to use when talking about these parts. You may skip this section entirely or at any point during this section you may skip to the next question. | This language was used to introduce participants to the series of questions regarding their preferred terminology |
| Chest/breasts | Some people have breast tissue over the pectoral muscle, while others do not. Does your chest have breast tissue that would have grown during your first puberty or has the tissue been surgically removed or never grown during your first puberty? | 1 = Has breast tissue; 0 = No breast tissue (either surgically removed or never grew) |
| What word(s) do you want a doctor or medical provider to use to describe your chest? (please use text box) | ||
| Female-identified terminology | Sample write-in responses from participants | Breasts, breast tissue |
| Male-identified terminology | Male chest, breast tissue from gynecomastia | |
| Gender-neutral terminology | Chest, chest area, top, top half, upper area, torso | |
| External and internal sex organs | Some bodies have the following external and internal sex organs. We have included medical terms for these organs to make sure you understand any question you may answer about them later. | |
| These are external and internal sex organs some people have. Please tell us what word(s) you would like a doctor or medical provider to use to describe the following body parts | ||
| Clitoris | ||
| Female-identified terminology | Sample write-in responses from participants | Clitoris, clitoral tissue, birth female part |
| Male-identified terminology | Natal penis, natal/neo phallus, micro/small penis | |
| Gender-neutral terminology | Genitals, anatomy, body part, external genitals | |
| Phallus | Sample write-in responses from participants | Phallus, penis, surgically constructed phallus |
| Male-identified terminology | ||
| Vaginal opening | ||
| Female-identified terminology | Sample write-in responses from participants | Female anatomy, vagina, vaginal opening/area/canal |
| Male-identified terminology | Scrotum, behind balls | |
| Gender-neutral terminology | Front area, front hole, opening, frontal canal/cavity, second hole, outer opening | |
| Ovaries/gonads | ||
| Female-identified terminology | Sample write-in responses from participants | Ovaries, female organs, female reproductive parts |
| Male-identified terminology | Testes, testicles | |
| Gender-neutral terminology | Internal gonads, internal sex organs, reproductive organs | |
| Uterus | ||
| Female-identified terminology | Sample write-in responses from participants | Uterus, female organ, birth female organ, womb |
| Male-identified terminology | Prostate | |
| Gender-neutral terminology | Internal genitals/organ/sex organ, pelvic organ, reproductive area/organ/part | |
Text boxes were provided for participants to write in the word(s) they prefer a provider to use when talking about their sexual and reproductive anatomy. Table 1 presents the specific survey questions and associated prompts used for data collection. Written-in responses were coded into three categories: (i) female-identified terminology, (ii) male-identified terminology, and (iii) gender-neutral terminology. We provide examples of participants' written-in responses for these three categories in Table 1. A fourth category was created for participants who wrote in that they do not refer to or have a word to describe these parts. Participants who reported having a vaginectomy or hysterectomy and oophorectomy were not prompted to provide a written response for vaginal opening or ovaries and uterus, respectively.
To ascertain gender identity, participants were shown an array of choices, which included, male/man, transgender male/man, transsexual male/man, FTM (female-to-male), non-binary, gender non-conforming, genderqueer, or a gender not listed in the survey (open-ended text response). For this analysis, participants were coded as either binary (i.e., identified as male/man, transgender male/man, transsexual male/man, or FTM) or non-binary (i.e., identified as non-binary, gender non-conforming, genderqueer, or wrote in a response to “a gender not listed in the survey”).
Demographic characteristics included age, race/ethnicity, geographic region, area (urban/rural/suburban),48 education, income, employment, and health insurance status. A binary variable for age (1 = 18–29; 0 = 30+) was created for use in the multivariate logistic regression model to account for the lack of significant difference in bivariate analyses, between participants 18–29 years of age and 30 years of age and older.
Data analysis
All analyses were conducted using IBM SPSS Statistics, version 25.0 (IBM Corp., Armonk, NY). Data were analyzed using a chi-square test, with Bonferroni correction (adjusted p-value <0.001).49 First, bivariate analyses were conducted to examine demographic predictors associated with the three outcome variables measuring access to regular health care, access to an LGBT health center, and access to a provider who is knowledgeable and competent in transgender health. We then used multivariable logistic regression to obtain adjusted odds ratios in predicting each health care-related outcome variable. Demographic variables were included in multivariate models if they were significantly associated with each outcome variable at p < 0.001 in bivariate analyses.
Next, we examined communication experiences with providers, preferences for provider communication when discussing body parts, and preferred terminology for sexual and reproductive anatomy and associated examinations. Third, analyses were repeated to assess differences by gender identity and gender-affirming medical intervention.
Results
Sociodemographic and other characteristics of the sample are presented in Table 2. Participants ranged in age from 18 to 69 (mean = 28.15, standard deviation = 8.83), with 40% younger than 25, 29% identified as a person of color, and 32% identified as trans-masculine non-binary. Participants lived in all 50 states and were well distributed across the country, with almost a quarter (24%) living in a rural area. Slightly over 21% of the sample reported being publicly insured (Medicaid/Medicare), and 71.6% reported having private insurance, with 7.2% reporting no insurance. Almost two-thirds (68.1%) reported a binary gender identity, 67.8% current testosterone use, and 43.3% had some form of gender-affirming surgery.
Table 2.
Sample Characteristics and Gender-Affirming Health Care Access
| Total N = 1788 |
Regular access to health care (n = 1454, 81.3%) |
p | Access to an LGBT Health Center (n = 537, 30%) |
p | Access to trans-competent provider (n = 1214, 67.9%) |
p | |
|---|---|---|---|---|---|---|---|
| N (%) | n (%) | n (%) | n (%) | ||||
| Demographics | |||||||
| Age | |||||||
| 18–24 | 701(39.2) | 517 (73.8)a | <0.001 | 156 (22.3)a | <0.001 | 385 (54.9)a | <0.001 |
| 25–29 | 495 (27.7) | 394 (79.6)a | 158 (31.9)ab | 339 (68.5)b | |||
| 30–44 | 484 (27.0) | 436 (90.1)b | 191 (39.5)b | 395 (81.6)c | |||
| 45+ | 108 (6.0) | 107 (99.1)b | 32 (29.6)ab | 95 (88.0)c | |||
| Region | |||||||
| Northeast | 521 (29.1) | 445 (85.4)a | <0.001 | 234 (44.9)a | <0.001 | 388 (74.5)a | <0.001 |
| Midwest | 324 (18.1) | 268 (82.7)ab | 102 (31.5)b | 215 (66.4)ab | |||
| South | 455 (25.4) | 329 (72.3)b | 91 (20.0)b | 246 (54.1)b | |||
| West | 488 (27.3) | 412 (84.4)a | 110 (22.5)b | 365 (74.8)a | |||
| Area | |||||||
| Urban | 1085 (60.7) | 891 (82.1) | 0.552 | 383 (35.3)a | <0.001 | 775 (71.4)a | <0.001 |
| Rural | 431 (24.1) | 346 (80.3) | 66 (15.3)b | 262 (60.8)b | |||
| Suburban | 272 (15.2) | 217 (79.8) | 88 (32.4)a | 177 (65.1)b | |||
| Race/Ethnicity | |||||||
| African American/Black | 131 (7.3) | 111 (84.7) | 0.043 | 37 (28.2) | 0.786 | 96 (73.3) | 0.033 |
| Latinx/Hispanic | 174 (9.7) | 134 (77.0) | 56 (32.2) | 106 (60.9) | |||
| White Non-Hispanic | 1262 (70.6) | 1042 (82.6) | 381 (30.2) | 875 (69.3) | |||
| Asian/Pacific Islander | 77 (4.3) | 56 (72.7) | 25 (32.5) | 49 (63.6) | |||
| Multiracial | 144 (8.1) | 111 (77.1) | 38 (26.4) | 88 (61.1) | |||
| Education | |||||||
| High school or less | 266 (14.9) | 183 (68.8)a | <0.001 | 56 (21.1)a | <0.001 | 134 (50.4)a | <0.001 |
| Some college or 2-year degree | 644 (36.0) | 508 (78.9)a | 172 (26.7)ab | 398 (61.8)a | |||
| Bachelor's degree or more | 878 (49.1) | 763 (86.9)b | 309 (35.2)b | 682 (77.6)b | |||
| Income | |||||||
| <$24,999 | 764 (42.7) | 566 (74.1)a | <0.001 | 213 (27.9) | 0.089 | 467 (61.1)a | <0.001 |
| $25,000–$49,999 | 468 (26.2) | 390 (83.3)b | 138 (29.5) | 313 (66.9)a | |||
| $50,000+ | 556 (31.1) | 498 (89.6)b | 186 (33.5) | 434 (78.1)b | |||
| Employment | |||||||
| In the workforce | 1294 (72.4) | 1070 (82.7) | 0.016 | 429 (33.2) | <0.001 | 921 (71.2) | <0.001 |
| Not in the workforce | 494 (27.6) | 384 (77.7) | 108 (21.9) | 293 (59.3) | |||
| Health Insurance | |||||||
| Private | 1280 (71.6) | 1075 (84.0)a | <0.001 | 385 (30.1) | 0.010 | 901 (70.4)a | <0.001 |
| Public | 379 (21.2) | 327 (86.3)a | 127 (33.5) | 269 (71.0)a | |||
| Uninsured | 129 (7.2) | 52 (40.3)b | 25 (19.4) | 44 (34.1)b | |||
| Gender identity | |||||||
| Binary | 1218 (68.1) | 1027 (84.3) | <0.001 | 383 (31.4) | 0.057 | 896 (73.6) | <0.001 |
| Non-binary | 570 (31.9) | 427 (74.9) | 154 (27.0) | 318 (55.8) | |||
| Gender-affirming medical intervention | |||||||
| Currently taking testosterone | |||||||
| Yes | 1212 (67.8) | 1097 (90.5) | <0.001 | 486 (40.1) | <0.001 | 1023 (84.4) | <0.001 |
| No | 576 (32.2) | 357 (62.0) | 51 (8.9) | 191 (33.2) | |||
| Has had top surgery | |||||||
| Yes | 722 (40.4) | 627 (86.8) | <0.001 | 253 (35.0) | <0.001 | 566 (78.4) | <0.001 |
| No | 1066 (59.6) | 827 (77.6) | 284 (26.6) | 648 (60.8) | |||
| Has had a hysterectomy and oophorectomy | |||||||
| Yes | 278 (15.5) | 254 (91.4) | <0.001 | 95 (34.2) | 0.101 | 228 (82.0) | <0.001 |
| No | 1510 (84.5) | 1200 (79.5) | 442 (29.3) | 986 (65.3) | |||
| Has had genital surgery | |||||||
| Yes | 53 (3.0) | 48 (90.6) | 0.080 | 15 (28.3) | 0.780 | 40 (75.5) | 0.231 |
| No | 1735 (97.0) | 1406 (81.0) | 552 (31.8) | 1174 (67.7) | |||
| Any medical intervention | |||||||
| Yes | 1370 (76.6) | 1204 (87.9) | <0.001 | 507 (37.0) | <0.001 | 1090 (79.6) | <0.001 |
| No | 418 (23.4) | 250 (59.8) | 30 (7.2) | 124 (29.7) | |||
Percentages are calculated by row. p-Values refer to the omnibus chi-square with Bonferroni correction; abcsuperscripts are used to denote differences in paired comparisons. Percentages with differing superscripts within columns are significantly different at p < 0.001.
LGBT, Lesbian, Gay, Bisexual, and Transgender.
Most participants had regular access to health care (81.3%) and of these participants, 83% received care from a medical provider knowledgeable and competent in transgender health. As demonstrated in Table 2, age (30 or older), gender identity (binary), geographic region (Northeast, Midwest, West), and socioeconomic position (bachelor's degree or higher, income ≥$50,000, and having health insurance) were significantly associated with having regular access to health care. Regular access to health care was also associated with having had any gender-affirming medical intervention (hormones and/or surgery). In the multivariate model (Table 3), regular access to health care remained significantly associated with all predictor variables, except education (bachelor's degree or more).
Table 3.
Factors Associated with Gender-Affirming Health Care Access
| Regular access to health care (n = 1454, 81.3%) |
p | Access to an LGBT health center (n = 537, 30%) |
p | Access to trans-competent provider (n = 1214, 67.9%) |
p | |
|---|---|---|---|---|---|---|
| AORa(95% CI) | AORa(95% CI) | AORa(95% CI) | ||||
| Demographics | ||||||
| Age | ||||||
| 18–29 | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | |||
| 30+ | 1.91 (1.32–2.76) | 0.001 | 1.26 (0.99–1.60) | 0.051 | 1.66 (1.24–2.22) | 0.001 |
| Region | ||||||
| Northeast | 1.48 (1.03–2.14) | 0.034 | 2.99 (2.20–4.07) | <0.001 | 1.89 (1.37–2.60) | <0.001 |
| Midwest | 1.51 (1.02–2.25) | 0.040 | 2.01 (1.41–2.85) | <0.001 | 1.60 (1.13–2.27) | 0.008 |
| South | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | |||
| West | 1.49 (1.03–2.14) | 0.032 | 1.09 (0.78–1.51) | 0.626 | 2.19 (1.58–3.04) | <0.001 |
| Area | ||||||
| Urban | 2.59 (1.90–3.52) | <0.001 | 1.28 (0.96–1.69) | 0.092 | ||
| Rural | 1.00 (ref) | 1.00 (ref) | ||||
| Suburban | 2.53 (1.70–3.76) | <0.001 | 1.32 (0.90–1.94) | 0.897 | ||
| Education | ||||||
| High school or less | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | |||
| Some college or 2-year degree | 1.18 (0.82–1.70) | 0.384 | 0.92 (0.63–1.395) | 0.690 | 1.05 (0.75–1.49) | 0.767 |
| Bachelor's degree or more | 1.24 (0.83–1.93) | 0.296 | 0.86 (0.62–1.35) | 0.429 | 1.49 (1.03–2.15) | 0.035 |
| Income | ||||||
| <$24,999 | 1.00 (ref) | 1.00 (ref) | ||||
| $25,000–$49,999 | 1.60 (1.14–2.25) | 0.007 | 0.99 (0.73–1.34) | 0.970 | ||
| $50,000+ | 2.06 (1.42–3.00) | <0.001 | 1.39 (1.01–1.93) | 0.050 | ||
| Employment | ||||||
| In the workforce | 1.29 (0.99–1.69) | 0.062 | 1.12 (0.86–1.46) | 0.412 | ||
| Not in the workforce | 1.00 (ref) | 1.00 (ref) | ||||
| Health insurance | ||||||
| Private | 5.75 (3.72–8.89) | <0.001 | 3.32 (2.12–5.19) | <0.001 | ||
| Public | 9.13 (5.50–15.15) | <0.001 | 4.01 (2.45–6.57) | <0.001 | ||
| Uninsured | 1.00 (ref) | 1.00 (ref) | ||||
| Gender identity | ||||||
| Binary | 1.61 (1.22–2.13) | 0.001 | 2.00 (1.56–2.57) | <0.001 | ||
| Non-binary | 1.00 (ref) | 1.00 (ref) | ||||
| Any gender-affirming medical intervention (hormones and/or surgery) | ||||||
| Yes | 3.45 (2.58–4.61) | <0.001 | 6.75 (4.51–10.09) | <0.001 | 6.22 (4.75–8.14) | <0.001 |
| No | 1.00 (ref) | 1.00 (ref) | 1.00 (ref) | |||
The model controlled for factors significantly associated with each outcome at the bivariate level. p-Values are significant at p < 0.05.
AOR, adjusted odds ratio; CI, confidence interval.
Receiving care from a transgender-competent provider (Table 2) was significantly associated with age (30 years or older), geographic region (Northeast, Midwest, West), living in an urban area, education (bachelor's degree or more), income ($50,000+), being employed, having health insurance (private or public), a binary gender identity, and having had some form of gender-affirming medical intervention. In the multivariate model (Table 3), receiving care from a transgender-competent medical provider remained significantly associated with all predictor variables except geographic area (urban, rural, and suburban), education (some college or 2-year degree), income, and employment.
Provider communication experiences (anatomy)
As shown in Table 4, only 26.9% of participants reported ever having a medical provider ask for their preferred language for sexual and reproductive anatomy. Having a provider ask for preferred terminology was significantly associated with a binary gender identity (Table 4), current testosterone use, and having had some form of gender-affirming surgical intervention (Table 5). The majority of the sample (77.7%) wanted a medical provider to ask directly for their preferred language and 65% reported wanting a health care provider to use medical terminology as opposed to slang when talking about their body; there were no significant differences associated with each outcome by gender identity and gender-affirming medical intervention.
Table 4.
Patient–Provider Communication Experiences and Preferences for Terminology Related to Sexual and Reproductive Anatomy and Associated Examinations by Gender Identity
| Total sample |
Gender identity |
p | ||
|---|---|---|---|---|
| n (%) |
Binary |
Non-binary |
||
| n = 1788 | (n = 1218, 68.1%) | (n = 570, 31.9%) | ||
| Experiences—has a medical provider ever… | ||||
| Asked for your preferred language for body parts | 481 (26.9) | 365 (30.0) | 116 (20.4) | <0.001 |
| Preferences | ||||
| Ask me what words I prefer to use for my body parts | 1390 (77.7) | 927 (76.1) | 463 (81.2) | 0.015 |
| Use medical terminology as opposed to slang when talking about body | 1169 (65.4) | 781 (64.1) | 388 (68.1) | 0.102 |
| Preferred terminology (Examinations) | ||||
| Chest/breast examination | ||||
| Top examination | 129 (7.2) | 90 (7.4) | 39 (6.8) | 0.213 |
| Chest tissue examination | 229 (12.8) | 147 (12.1) | 82 (14.4) | |
| Chest examination | 1382 (77.3) | 943 (77.4) | 439 (77.0) | |
| Do not have a word | 48 (2.7) | 38 (3.1) | 10 (1.8) | |
| Gynecological examination | ||||
| GYN examination | 268 (15.0) | 162 (13.3)a | 106 (18.6)a | <0.001 |
| Pelvic examination | 788 (44.1) | 490 (40.2)a | 298 (52.3)b | |
| Bottom examination | 136 (7.6) | 109 (8.9)a | 27 (4.7)a | |
| Pap test | 165 (9.2) | 112 (9.2)a | 53 (9.3)a | |
| Do not have a word | 142 (7.9) | 118 (9.7)a | 24 (4.2)b | |
| Has had hysterectomy and oophorectomy and/or genital surgery | 289 (16.2) | 227 (18.6)a | 62 (10.9)b | |
| Preferred terminology (Anatomy) | ||||
| Chest/breasts | ||||
| Female-identified terminology | 209 (11.7) | 93 (7.6)a | 116 (20.4)b | <0.001 |
| Male-identified terminology | 44 (2.5) | 38 (3.1)a | 6 (1.1)a | |
| Gender-neutral terminology | 1455 (81.4) | 1037 (85.1)a | 418 (73.3)b | |
| Do not refer to it or have a word | 80 (4.5) | 50 (4.1)a | 30 (5.3)a | |
| Clitoris | ||||
| Female-identified terminology | 770 (43.1) | 431 (35.4)a | 339 (59.5)b | <0.001 |
| Male-identified terminology | 701 (39.2) | 573 (47.0)a | 128 (22.5)b | |
| Gender-neutral terminology | 33 (1.8) | 21 (1.7)a | 12 (2.1)a | |
| Do not refer to it or have a word | 231 (12.9) | 147 (12.1)a | 84 (14.7)a | |
| Phallus | ||||
| Male identified terminology | 53 (3.0) | 46 (3.8) | 7 (1.2) | 0.003 |
| Vaginal opening | ||||
| Female-identified terminology | 787 (44.0) | 477 (39.2)a | 310 (54.4)b | <0.001 |
| Male-identified terminology | 49 (2.7) | 39 (3.2)a | 10 (1.8)a | |
| Gender-neutral terminology | 518 (29.0) | 391 (32.1)a | 127 (22.3)b | |
| Do not refer to it or have a word | 406 (22.7) | 285 (23.4)a | 121 (21.2)a | |
| Has had a vaginectomy | 28 (1.6) | 26 (2.1)a | 2 (0.4)a | |
| Ovaries/gonads | ||||
| Female-identified terminology | 1015 (56.8) | 640 (52.5)a | 375 (65.8)b | <0.001 |
| Male-identified terminology | 68 (3.8) | 47 (3.9)a | 21 (3.7)a | |
| Gender-neutral terminology | 63 (3.5) | 52 (4.3)a | 11 (1.9)a | |
| Do not refer to it or have a word | 364 (20.4) | 259 (21.3)a | 105 (18.4)a | |
| Has had an oophorectomy | 278 (15.5) | 220 (18.1)a | 58 (10.2)b | |
| Uterus | ||||
| Female-identified terminology | 1050 (58.7) | 666 (54.7)a | 384 (67.4)b | <0.001 |
| Male-identified terminology | 79 (4.4) | 64 (5.3)a | 15 (2.6)a | |
| Gender-neutral terminology | 24 (1.3) | 18 (1.5)a | 6 (1.1)a | |
| Do not refer to it or have a word | 357 (20.0) | 250 (20.5)a | 107 (18.8)a | |
| Has had a hysterectomy | 278 (15.5) | 220 (18.1)a | 58 (10.2)b | |
Percentages are calculated by column. p-Values refer to the omnibus chi-square with Bonferroni correction; absuperscripts are used to denote differences in paired comparisons. Percentages with differing superscripts within rows are significantly different at p < 0.001.
Data for clitoris and phallus are presented separately for the gender identity analyses.
Table 5.
Patient–Provider Communication Experiences and Preferences for Terminology Related to Sexual and Reproductive Anatomy and Associated Examinations by Gender-Affirming Medical Intervention
| On testosterone |
p | Top surgery |
p | Hysterectomy and oophorectomy and/or genital surgery |
p | ||||
|---|---|---|---|---|---|---|---|---|---|
| Yes |
No |
Yes |
No |
Yes |
No |
||||
| (n = 1212, 67.9%) |
(n = 576, 32.2%) |
(n = 722; 40.4%) |
(n = 1066; 59.6%) |
(n = 289; 16.2%) |
(n = 1499; 83.8%) |
||||
| n (%) | n (%) | n (%) | n (%) | n (%) | n (%) | ||||
| Experiences—has a provider ever | |||||||||
| Asked for your preferred language for body parts | 415 (34.2) | 66 (11.5) | <0.001 | 234 (32.4) | 247 (23.2) | <0.001 | 107 (37.0) | 374 (24.9) | <0.001 |
| Preferences | |||||||||
| Ask me what words I prefer to use for my body parts | 951 (78.5) | 439 (76.2) | 0.285 | 579 (80.2) | 811 (76.1) | 0.040 | 229 (79.2) | 1161 (77.4) | 0.504 |
| Use medical terminology as opposed to slang when talking about body | 767 (63.3) | 402 (69.8) | 0.007 | 471 (65.2) | 698 (65.5) | 0.916 | 178 (61.6) | 991 (66.1) | 0.139 |
| Preferred terminology (Examinations) | |||||||||
| Chest/breast examination | |||||||||
| Top examination | 65 (5.4)a | 64 (11.1)b | <0.001 | 33 (4.6)a | 96 (9.0)b | 0.001 | 17 (5.9) | 112 (7.5) | 0.141 |
| Chest examination | 964 (79.5)a | 418 (72.6)a | 584 (80.9)a | 798 (74.9)b | 219 (75.8) | 1163 (77.6) | |||
| Chest tissue examination | 150 (12.4)a | 79 (13.7)a | 83 (11.5)a | 146 (13.7)a | 40 (13.8) | 189 (12.6) | |||
| Do not have a word | 33 (2.7)a | 15 (2.6)a | 22 (3.0)a | 26 (2.4)a | 13 (4.5) | 35 (2.3) | |||
| Gynecological examination | |||||||||
| GYN examination | 151 (12.5)a | 117 (20.3)b | <0.001 | 75 (10.4)a | 193 (18.1)b | <0.001 | |||
| Pelvic examination | 488 (40.3)a | 300 (52.1)b | 273 (37.8)a | 515 (48.3)b | |||||
| Bottom examination | 91 (7.5)a | 45 (7.8)a | 35 (4.8)a | 101 (9.5)b | |||||
| Pap test | 114 (9.4)a | 51 (8.9)a | 54 (7.5)a | 111 (10.4)a | |||||
| Do not have a word | 114 (9.4)a | 28 (4.9)b | 49 (6.8)a | 93 (8.7)b | |||||
| Has had hysterectomy and oophorectomy and/or genital surgery | 254 (21.0)a | 35 (6.1)b | 236 (32.7)a | 53 (5.0)b | |||||
| Preferred terminology (Anatomy) | |||||||||
| Chest/breasts | |||||||||
| Female-identified terminology | 91 (7.5)a | 118 (20.5)b | <0.001 | 35 (4.8)a | 174 (16.3)b | <0.001 | 15 (5.2) | 194 (12.9) | 0.002 |
| Male-identified terminology | 29 (2.4)a | 15 (2.6)a | 7 (1.0)a | 37 (3.5)b | 6 (2.1) | 38 (2.5) | |||
| Gender-neutral terminology | 1050 (86.6)a | 405 (70.3)b | 648 (89.8)a | 807 (75.7)b | 256 (88.6) | 1199 (80.0) | |||
| Do not refer to it or have a word | 42 (3.5)a | 38 (6.6)a | 32 (4.4)a | 48 (4.5)a | 12 (4.2) | 68 (4.5) | |||
| Clitoris or phallus | |||||||||
| Female-identified terminology | 399 (32.9)a | 371 (64.4)b | <0.001 | 259 (35.9)a | 511 (47.9)b | <0.001 | 75 (26.0)a | 695 (46.4)b | <0.001 |
| Male-identified terminology | 651 (53.7)a | 103 (17.9)b | 353 (48.9)a | 401 (37.6)b | 174 (60.2)a | 580 (38.7)b | |||
| Gender neutral terminology | 20 (1.7)a | 13 (2.3)a | 17 (2.4)a | 16 (1.5)a | 3 (1.0)a | 30 (2.0)a | |||
| Do not refer to it or have a word | 142 (11.7)a | 89 (15.5)a | 93 (12.9)a | 138 (12.9)a | 37 (12.8)a | 194 (12.9)a | |||
| Vaginal opening | |||||||||
| Female-identified terminology | 455 (37.5)a | 332 (57.6)b | <0.001 | 287 (39.8)a | 500 (46.9)a | <0.001 | 89 (30.8)a | 698 (46.6)b | <0.001 |
| Male-identified terminology | 38 (3.1)a | 11 (1.9)a | 17 (2.4)a | 32 (3.0)a | 7 (2.4)a | 42 (2.8)a | |||
| Gender-neutral terminology | 409 (33.7)a | 109 (18.9)b | 228 (31.6)a | 290 (27.2)a | 90 (31.1)a | 428 (28.5)a | |||
| Do not refer to it or have a word | 282 (23.3)a | 124 (21.5)a | 166 (23.0)a | 240 (22.5)a | 75 (26.0)a | 331 (22.1)a | |||
| Has had a vaginectomy | 28 (2.3)a | 0 (0) | 24 (3.3)a | 4 (0.4)b | 28 (9.7)a | 0 (0) | |||
| Ovaries/gonads | |||||||||
| Female-identified terminology | 625 (51.6)a | 390 (67.7)b | <0.001 | 324 (44.9)a | 691 (64.8)b | <0.001 | |||
| Male-identified terminology | 42 (3.5)a | 26 (4.5)a | 19 (2.6)a | 49 (4.6)a | |||||
| Gender-neutral terminology | 41 (3.4)a | 22 (3.8)a | 16 (2.2)a | 47 (4.4)a | |||||
| Do not refer to it or have a word | 254 (21.0)a | 110 (19.1)a | 128 (17.7)a | 236 (22.1)a | |||||
| Has had an oophorectomy | 250 (20.6)a | 28 (4.9)b | 235 (32.5)a | 43 (4.0)b | |||||
| Uterus | |||||||||
| Female-identified terminology | 647 (53.4)a | 403 (70.0)b | <0.001 | 331 (45.8)a | 719 (67.4)b | <0.001 | |||
| Male-identified terminology | 52 (4.3)a | 27 (4.7)a | 22 (3.0)a | 57 (5.3)a | |||||
| Gender-neutral terminology | 14 (1.2)a | 10 (1.7)a | 4 (0.6)a | 20 (1.9)a | |||||
| Do not refer to it or have a word | 249 (20.5)a | 108 (18.8)a | 129 (17.9)a | 228 (21.4)a | |||||
| Had had a hysterectomy | 250 (20.6)a | 28 (4.9)b | 235 (32.5)a | 43 (4.0)b | |||||
Percentages are calculated by column. p-Values refer to the omnibus chi-square with Bonferroni correction; absuperscripts are used to denote differences in paired comparisons. Percentages with differing superscripts within rows are significantly different at p < 0.001.
Preferred terminology (anatomy)
Participants' preferred terminology for sexual and reproductive anatomy and differences in preferences by gender identity and gender-affirming medical intervention are presented in Tables 4 and 5.
Chest/breasts
Most participants (81.4%) preferred gender-neutral terminology (e.g., chest) for chest/breasts. A binary gender identity, current testosterone use, or having had top surgery was significantly associated with a preference for gender-neutral terminology. Approximately 12% of participants preferred female-identified terminology (e.g., breasts) for their chest. A preference for female-identified language was associated with a trans-masculine non-binary gender identity, no current testosterone use, and not having had top surgery.
Clitoris or phallus
Overall, 43.1% of participants preferred female-identified terminology (e.g., clitoris) and 39.2% preferred male-identified terminology (e.g., penis and phallus). Participants who identified as trans-masculine non-binary and had no gender-affirming medical intervention were more likely to prefer female-identified terminology. In contrast, a binary gender identity, current testosterone use, and having had some form of gender-affirming surgery were significantly associated with a preference for male-identified terminology.
Vaginal opening
Close to half (44%) of participants preferred female-identified language (e.g., vaginal opening or vagina), 29% preferred gender-neutral terminology (e.g., front hole or opening), and 22.7% did not refer to or have a word for their vaginal opening. A trans-masculine non-binary gender identity and no gender-affirming medical intervention were associated with female-identified terminology. In contrast, gender-neutral terminology was associated with a binary gender identity and current testosterone use.
Ovaries/gonads and uterus
Approximately 60% of the sample preferred female-identified language to describe their ovaries/gonads (56.8%) and uterus (58.7%). A small percentage preferred male-identified terminology for ovaries/gonads (e.g., brovaries; 3.8%) or uterus (e.g., duderus; 4.4%), and 20% reported that they did not refer to or have a word for their reproductive organs. Preference for female-identified language was associated with a trans-masculine non-binary gender identity, no testosterone use, and not having had top surgery.
Preferred terminology (exams)
Overall, 77.3% of participants preferred that the term “chest exam” be used by a medical provider when discussing a chest/breast examination (Table 4). When discussing gynecological exams, 44.1% of participants preferred “pelvic exam.” A trans-masculine non-binary gender identity, no testosterone use, and no top surgery were significantly associated with preference for “pelvic exam” (Tables 4 and 5).
Discussion
To our knowledge, this is one of the first studies to ask TMNBI about preferred language for their sexual and reproductive anatomy and associated examinations. Most studies on transgender health focus on the negative consequences of health care discrimination or document the lack of medical education training for doctors, nurses, and other health professionals in transgender health.29,40,42–45 In contrast, our findings suggest the importance of creating more inclusive gender-affirming health care services that meet the needs of all TMNBI, not just those seeking medical interventions.
Gender-affirming health care is often focused on binary individuals and is considered synonymous with prescribing hormones and access to gender-affirming surgery.50 In contrast, our sample included a large percentage of individuals who identify as trans-masculine non-binary, and who may or may not be engaging in these interventions. These data challenge the field of transgender health to adopt a more integrated, patient-centered health care model, in which gender-affirming health care represents an overarching clinical practice that respects the gender diversity among TMNBI and supports the various gender transition pathways (e.g., social, medical, and legal) an individual may choose.
This study was designed to enhance health care providers' abilities to engage TMNB patients in sexual and reproductive health care conversations by identifying preferences for provider interactions and terminology related to sexual and reproductive anatomy and associated examinations among TMNBI with varying gender identities and engagement in gender-affirming medical interventions. These findings provide concrete examples to assist providers when initiating and navigating conversations with TMNBI about their sexual and reproductive health. Our sample provided varied words to describe their anatomy and associated examinations. These data underscore the importance of medical providers asking for and then using TMNBIs' preferred language during sexual and reproductive health conversations and examinations, rather than assuming that all TMNBI use the same language.
It is important to note that these conversations are necessary even in practice settings that are considered LGBT friendly; only 27% of our sample reported ever having a provider ask them about their preferred terminology, even though 83% of those with regular access to health care reported having a provider who is knowledgeable about and competent in transgender health.
Our study findings indicate that there is tremendous potential for enhancing provider communication, by teaching providers to ask for and use their TMNB patients' preferred language. Although a large percentage of our sample reported wanting a provider to ask about their preferred language, almost one-quarter of respondents stated that they did not want a provider to ask. It is possible that these participants prefer providers to use the medical terminology associated with their anatomy or they do not refer to or have words to describe their body parts. Additional research in clinical settings is needed to better understand these differences and to test whether asking for and using TMNBIs' preferred language is associated with enhanced gender-affirming patient–provider communication.
It is important to note that a large proportion of participants reported not referring to or having a word to describe their vaginal opening, ovaries/gonads, or uterus. These data are potentially concerning, as they suggest erasure in an aspect of sexual and reproductive health care that could be potentially critical to this population. As noted, only 15% of the sample reported having a hysterectomy and oophorectomy.
Allowing TMNBI to discuss their reproductive organs as part of sexual and reproductive health care conversations with their provider is critical to the overall health of this population. These data underscore the importance of providers finding terminology with which to communicate to their TGNB patients about their bodies and health. Future research is needed to develop and test clinical assessment tools that are both sensitive to and relevant to the bodies and sexual and reproductive needs of TMNBI.
Limitations
A major strength of this study is the fact that it is a large-scale, national sample of TMNBI that is relatively demographically diverse. We believe that our success in recruitment was due, in large part, to the efforts of our transgender-led research team, who designed a survey instrument that many participants described as “affirming” and led to wide distribution and sharing within various trans-masculine social networks across the country. At the same time, several limitations are important to consider when interpreting these findings.
First, this sample is a convenience sample of individuals who completed a self-report survey on the Internet. Participants were recruited solely online through social media platforms and peer networks. This may have introduced selection bias, in that TMNBI who heard of the study and/or opted to participate may be different than those who did not participate or do not participate in online surveys.
For example, participation required access to an Internet-connected device, 45 minutes of personal time to complete the survey in its entirety, and a willingness to complete the study without guaranteed compensation (i.e., entrance into a raffle), which may have skewed our sample toward TMNBI of higher socioeconomic status, with health insurance, who are highly engaged in gender-affirming medical care. Future research should be conducted to review and potentially replicate study findings related to preference for and use of preferred terminology with less homogenous samples of TMNBI, especially those that contain higher percentages of older TMNBI (≥40 years of age), individuals of lower socioeconomic status, and those with limited access to or less engagement in gender-affirming medical care.
Second, we do not have any information on whether asking for and using TMNBIs' preferred language over time will result in enhanced patient–provider communication and overall health care access and utilization. Future research must include the collection of more specific, longitudinal data on this population to better understand the relationship between patient-provider communication in the provision and receipt of gender-affirming medical care and health-related outcomes.
Third, 18% (391 of 2179) of participants were not included in the analysis because they did not respond to the predictor and/or outcome variables used in our model. Participants with missing data were not demographically different from the analytic sample; however, they were more likely to have skipped all questions pertaining to preferred terminology in bivariate analyses. To address the issue of missingness, research strategies are needed to ensure that survey questions accurately reflect all TMNBI, do not assume or require a level of comfortability discussing sexual and reproductive anatomy and health, and are acceptable enough to ensure full participation.
Fourth, all measures included in this analysis were developed specifically for this survey. Lack of validated measures could have resulted in misclassification of information and non-comparability of data to other studies that have standardized instruments. Future research must focus on the development of new, adaptation of existing, and testing of clinical assessment tools to enhance patient–provider communication and the overall provision of gender-affirming medical care.
Finally, research has documented that TGNB people of color are at high risk for negative social, emotional, and physical health outcomes due to multiple and intersecting forms of discrimination (e.g., racism, classism, and transphobia).40 Given the relative homogeneity of our sample, extra attention needs to be paid to increase participation and involvement in research among TGNB people of color. It is critical to design research projects and data collection strategies that increase the potential for proportionate participation.
Conclusion
This study was designed to provide analyses with direct implications for improving provider communication related to the sexual and reproductive health of TMNBI by asking patients about their experiences with and preferences for these interactions. The take-home messages from these data are threefold. First, the majority of TMNBI (73.1%) are not being asked by their providers about their preferred language for their body parts, and they want to be asked. It is possible that some providers think that asking TMNBI about preferred language is rude or presumptuous; in contrast, these data indicate that such conversations would be welcomed by patients.
Second, the majority of patients prefer their provider to use medical terminology as opposed to slang when talking about their body. This finding is important both because it may put some providers at ease during these discussions and because it points out that most TMNBI want their health concerns taken seriously during medical encounters (as opposed to providers using terms like “brovaries” or “duderus”). Gender-neutral terminology can be taught to providers to increase their options for having respectful conversations with patients.
Third, variation in TMNBI preferences for terminology highlights the importance of talking openly with TMNBI about their preferences during health care interactions, rather than assuming that all TMNBI use the same language. Integrating the practice of asking for and then using TMNBIs' preferred language in health care may improve gender-affirming sexual and reproductive health care and increase patient engagement and retention, which can reduce negative health outcomes and increase the overall health and well-being of TMNBI.
Acknowledgments
The authors gratefully acknowledge the contributions of Charles Solidum, Brandyn Gallagher, Eugene Matthews, and all the individuals who gave their time and energy to participate in this study.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This research was supported by Grant R01AA022067-04S1 from the National Institute on Alcohol Abuse and Alcoholism (S.A.G., Principal Investigator).
References
- 1. Seay J, Ranck A, Weiss R, et al. : Understanding transgender men's experiences with and preferences for cervical cancer screening: A rapid assessment survey. LGBT Health 2017;4:304–309 [DOI] [PubMed] [Google Scholar]
- 2. Peitzmeier SM, Khullar K, Reisner SL, Potter J: Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med 2014;47:808–812 [DOI] [PubMed] [Google Scholar]
- 3. Peitzmeier SM, Reisner SL, Harigopal P, Potter J: Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: Implications for cervical cancer screening. J Gen Intern Med 2014;29:778–784 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Harris M, Kondel L, Dorsen C: Pelvic pain in transgender men taking testosterone. Nurse Pract 2017;42:1–5 [DOI] [PubMed] [Google Scholar]
- 5. Agénor M, White Hughto JM, Peitzmeier SM, et al. : Gender identity disparities in Pap test use in a sample of binary and non-binary transmasculine adults. J Gen Intern Med 2018;33:1015–1022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Armuand G, Dhejne C, Olofsson JI, Rodriguez-Wallberg KA: Transgender men's experiences of fertility preservation: A qualitative study. Hum Reprod 2017;32:383–390 [DOI] [PubMed] [Google Scholar]
- 7. Hoffkling A, Obedin-Maliver J, Sevelius J: From erasure to opportunity: A qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth 2017;17:332. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL: Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol 2014;124:1120–1127 [DOI] [PubMed] [Google Scholar]
- 9. Maxwell S, Noyes N, Keefe D, et al. : Pregnancy outcomes after fertility preservation in transgender men. Obstet Gynecol 2017;129:1031–1034 [DOI] [PubMed] [Google Scholar]
- 10. Cipres D, Seidman D, Cloniger C, 3rd, et al.: Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception 2017;95:186–189 [DOI] [PubMed] [Google Scholar]
- 11. Lemons A, Beer L, Finlayson T, et al. : Characteristics of HIV-positive transgender men receiving medical care: United States, 2009–2014. Am J Public Health 2018;108:128–130 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Reisner SL, Hughto JM, Pardee DJ, et al. : LifeSkills for men (LS4M): Pilot evaluation of a gender-affirmative HIV and STI prevention intervention for young adult transgender men who have sex with men. J Urban Health 2016;93:189–205 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Scheim AI, Santos GM, Arreola S, et al. : Inequities in access to HIV prevention services for transgender men: Results of a global survey of men who have sex with men. J Int AIDS Soc 2016;19:20779. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Stephenson R, Riley E, Rogers E, et al. : The sexual health of transgender men: A scoping review. J Sex Res 2017;54:424–445 [DOI] [PubMed] [Google Scholar]
- 15. Irwig MS: Clinical dilemmas in the management of transgender men. Curr Opin Endocrinol Diabetes Obes 2017;24:233–239 [DOI] [PubMed] [Google Scholar]
- 16. Irwig MS: Testosterone therapy for transgender men. Lancet Diabetes Endocrinol 2017;5:301–311 [DOI] [PubMed] [Google Scholar]
- 17. Velho I, Fighera TM, Ziegelmann PK, Spritzer PM: Effects of testosterone therapy on BMI, blood pressure, and laboratory profile of transgender men: A systematic review. Andrology 2017;5:881–888 [DOI] [PubMed] [Google Scholar]
- 18. Reisner SL, Gamarel KE, Dunham E, et al. : Female-to-male transmasculine adult health: A mixed-methods community-based needs assessment. J Am Psychiatr Nurses Assoc 2013;19:293–303 [DOI] [PubMed] [Google Scholar]
- 19. Reisner SL, Perkovich B, Mimiaga MJ: A mixed methods study of the sexual health needs of New England transmen who have sex with nontransgender men. AIDS Patient Care STDS 2010;24:501–513 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Rowniak S, Chesla C, Rose CD, Holzemer WL: Transmen: The HIV risk of gay identity. AIDS Educ Prev 2011;23:508–520 [DOI] [PubMed] [Google Scholar]
- 21. Rowniak S, Chesla C: Coming out for a third time: Transmen, sexual orientation, and identity. Arch Sex Behav 2013;42:449–461 [DOI] [PubMed] [Google Scholar]
- 22. Sevelius J: “There's no pamphlet for the kind of sex I have”: HIV-related risk factors and protective behaviors among transgender men who have sex with nontransgender men. J Assoc Nurses AIDS Care 2009;20:398–410 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. : Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA 2011;306:971–977 [DOI] [PubMed] [Google Scholar]
- 24. White W, Brenman S, Paradis E, et al. : Lesbian, gay, bisexual, and transgender patient care: Medical students' preparedness and comfort. Teach Learn Med 2015;27:254–263 [DOI] [PubMed] [Google Scholar]
- 25. Korpaisarn S, Safer JD: Gaps in transgender medical education among healthcare providers: A major barrier to care for transgender persons. Rev Endocr Metab Disord 2018;19:271–275 [DOI] [PubMed] [Google Scholar]
- 26. Morrison SD, Wilson SC, Smith JR: Are we adequately preparing our trainees to care for transgender patients? J Grad Med Educ 2017;9:258. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Safer JD, Pearce EN: A simple curriculum content change increased medical student comfort with transgender medicine. Endocr Pract 2013;19:633–637 [DOI] [PubMed] [Google Scholar]
- 28. Braun HM, Garcia-Grossman IR, Quiñones-Rivera A, Deutsch MB: Outcome and impact evaluation of a transgender health course for health profession students. LGBT Health 2017;4:55–61 [DOI] [PubMed] [Google Scholar]
- 29. Dubin SN, Nolan IT, Streed CG Jr, et al. : Transgender health care: Improving medical students' and residents' training and awareness. Adv Med Educ Pract 2018;9:377–391 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. McFarland W, Wilson EC, Raymond HF: HIV prevalence, sexual partners, sexual behavior and HIV acquisition risk among trans men, San Francisco, 2014. AIDS Behav 2017;21:3346–3352 [DOI] [PubMed] [Google Scholar]
- 31. Poteat T, Malik M, Scheim A, Elliott A: HIV prevention among transgender populations: Knowledge gaps and evidence for action. Cur HIV/AIDS Rep 2017;14:141–152 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Clark H, Babu AS, Wiewel EW, et al. : Diagnosed HIV infection in transgender adults and adolescents: Results from the National HIV Surveillance System, 2009–2014. AIDS Behav 2017;21:2774–2783 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Light A, Wang LF, Zeymo A, Gomez-Lobo V: Family planning and contraception use in transgender men. Contraception 2018;98:266–269 [DOI] [PubMed] [Google Scholar]
- 34. Fein LA, Zaw C, Wong A, et al. : Reproductive health care knowledge, needs, and access among transgender men: A mixed methods study. Obstet Gynecol 2019;133:192S–193S [Google Scholar]
- 35. Reisner SL, Moore CS, Asquith A, et al. : High risk and low uptake of pre-exposure prophylaxis to prevent HIV acquisition in a national online sample of transgender men who have sex with men in the United States. J Int AIDS Soc 2019;22:e25391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Golub SA, Fikslin RA, Starbuck L, Klein A: High rates of PrEP eligibility but low rates of PrEP access among a national sample of transmasculine individuals. J Acquir Immune Defic Syndr 2019;82:e1–e7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Scheim AI, Adam BD, Marshall Z: Gay, bisexual, and queer trans men navigating sexual fields. Sexualities 2019;22:566–586 [Google Scholar]
- 38. Stroumsa D, Wu JP: Welcoming transgender and nonbinary patients: Expanding the language of “women's health.” Am J Obstet Gynecol 2018;219:585.e1–e585.e5 [DOI] [PubMed]
- 39. Dharma C, Scheim AI, Bauer GR: Exploratory factor analysis of two sexual health scales for transgender people: Trans-specific condom/barrier negotiation self-efficacy (T-Barrier) and trans-specific sexual body image worries (T-Worries). Arch Sex Behav 2019;48:1563–1572 [DOI] [PubMed] [Google Scholar]
- 40. James SE, Herman JL, Rankin S, et al. : The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality, 2016 [Google Scholar]
- 41. Grant JM, Mottet LA, Tanis J, et al. : Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011 [Google Scholar]
- 42. Seelman KL, Miller JF, Fawcett ZER, Cline L: Do transgender men have equal access to health care and engagement in preventive health behaviors compared to cisgender adults? Soc Work Health Care 2018;57:502–525 [DOI] [PubMed] [Google Scholar]
- 43. Stroumsa D, Shires DA, Richardson CR, et al. : Transphobia rather than education predicts provider knowledge of transgender health care. Med Educ 2019;53:398–407 [DOI] [PubMed] [Google Scholar]
- 44. Shires DA, Jaffee K: Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health Soc Work 2015;40:134–141 [DOI] [PubMed] [Google Scholar]
- 45. Shires DA, Stroumsa D, Jaffee KD, Woodford MR: Primary care clinicians' willingness to care for transgender patients. Ann Fam Med 2018;16:555–558 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46. Eyssel J, Koehler A, Dekker A, et al. : Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey. PLoS One 2017;12:e0183014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47. Miner MH, Bockting WO, Romine RS, Raman S: Conducting Internet research with the transgender population: Reaching broad samples and collecting valid data. Soc Sci Comput Rev 2012;30:202–211 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48. Ingram DD, Franco SJ: 2013. NCHS urban-rural classification scheme for counties. Vital Health Stat 2 2014:1–73 [PubMed]
- 49. Abdi H: The Bonferonni and Šidák corrections for multiple comparisons. In: Encyclopedia of Measurement and Statistics. Edited by Salkind NJ. Thousand Oaks, CA: SAGE Publications, Inc., 2007, pp 103–107 [Google Scholar]
- 50. Reisner SL, Bradford J, Hopwood R, et al. : Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. J Urban Health 2015;92:584–592 [DOI] [PMC free article] [PubMed] [Google Scholar]