Introduction

Despite increased transparency and decreased stigma around sexual and reproductive health, health disparities and critical gaps in medical and patient knowledge persist. These obstacles have both direct and indirect physical, mental, and social effects on patients seeking care. Eliminating disparities and improving the quality of sexual and reproductive health care require evidence-based, inclusive research and clinical practice. Our hope for this issue is to provide an update on reproductive and sexual health research that reflects recent healthcare advancements towards greater inclusion of sexual and gender minorities. Additionally, we aim to highlight the need for improved treatment of long-recognized but understudied reproductive health concerns. This issue encompasses numerous fields of research on sexual and reproductive health, including contraception, LGBTQ+ mental and physical well-being, and infertility, and additionally include current and historical perspectives from experts on New Haven community health efforts.

The early 1980s saw the emergence of an entirely new disease, and with it, widespread uncertainty and misinformation about its causes and transmission. This disease is now known as acquired immunodeficiency syndrome (AIDS) and is caused by human immunodeficiency virus (HIV). During this time, healthcare professionals and social workers navigated uncertainty and limited information to establish appropriate systems of care for those affected. In a Special Editorial, Dr. Warren Andiman provides a personal account of the rise of the New Haven pediatric AIDS epidemic in the 1980s and its ultimate resolution through the combined efforts of a team of clinicians, scientists, and social workers. Still, however, there remains no cure for HIV infection. Although antiretroviral therapy effectively controls HIV replication in actively infected cells, it fails to eradicate infection due to the persistence of the virus in latently infected cells. Ventura reviews the current state of research on the biology of HIV and its pathogenesis. He additionally highlights cure strategies that focus on eliminating the HIV latent reservoir, including broadly neutralizing antibody immunotherapy and latency reversing agents. By targeting the HIV reservoir, such therapies hold promise in permanently controlling HIV infection without the need for ongoing treatment.

Our issue also features an interview with New Haven community leader, Beatrice Codianni. Codianni is an accomplished activist and founder of the Sex Workers & Allies Network (SWAN). In the interview, she provides a candid account of her experience with incarceration and survival sex work. Furthermore, she shares some of the common challenges that sex workers face in accessing basic resources like healthcare and housing. Healthcare-induced trauma, stigma, gender-based violence, and harassment by police, amongst other factors, contribute to the marginalization of sex workers and interfere with access to necessary services. Codianni founded SWAN in order to better connect people to basic resources and provide access to harm reduction services through community organizing and street outreach. SWAN is committed to the rights, safety, dignity, and wellbeing of those doing survival sex work. Since its founding, SWAN has continuously grown its partnerships with organizations throughout Yale and New Haven in order to provide more programming and services to support those who are unhoused and/or doing survival sex work.

Despite increased awareness and acceptance of individuals belonging to sexual and gender minority groups, LGBTQ+ communities continue to face poorer mental and physical health outcomes compared to cis-heterosexual individuals. Studies consistently show that LGBTQ+ individuals are at disproportionate risk of developing mental health disorders [1,2]. In their review, Nieder et al. discuss strategies for providing inclusive mental health care. Establishing LGBTQ+ mental health equity requires the acknowledgement that LGBTQ+ individuals “face challenges that may or may not be specific to the LGBT spectrum.” In other words, patients’ multiple identities should inform mental health care. Nieder and colleagues further advocate for the use of a shared decision-making continuum as a way of driving towards patient-centered mental health care and allowing shared decision making to take different forms depending on patient needs.

Our issue also aims to shed light on advances and new perspectives in transgender and gender non-binary reproductive medicine. Recent advancements in gender transition therapies and surgeries raise questions regarding the validation of these surgical techniques, as well as potential long-term effects and barriers in the patient-provider relationship. Mainstream assumptions regarding pregnancy and birth can stigmatize and create complex environments for transgender men who are pregnant or giving birth. Besse and colleagues offer a comprehensive review of the state of transgender medicine and a thorough examination of the gaps in literature regarding pregnancy and birth outcomes among transgender men. Presumptions about who can get pregnant and give birth compromise the quality of care for transgender individuals, including the dismissal of pain and misdiagnoses. The authors identified major themes in their narrative literature review, including preconception planning, the medicalization of transgender pregnancies, differential access or barriers to care, balancing gender identity and cis-normative ideas of pregnancy, the need for inclusion of transgender men in clinics, and obstetric/gynecological practices.

Drs. Nolan and Cheung bring attention to the field of perioperative use of estradiol therapy for trans people undergoing feminizing hormone therapy in their review. Similar to Besse et al., these authors tackle a field of medical research that is both new and understudied. Nolan and Cheung highlight the current state of research and the need for further prospective trials regarding the use, given that most estimates of risk are based on menopausal hormone therapy studies. The authors caution the lack of evidence supporting discontinuation of perioperative estradiol therapy due to potential thrombotic risk.

Improving transgender health and provider-patient interactions do not end with gender affirming surgery and can take multiple modalities for each patient, sometimes including transplant surgeries. The first baby born via uterine transplant occurred in 2017 in the US, marking a significant advancement in allowing people who may not have otherwise been able to carry and give birth to their child, the opportunity to have this experience [3]. Both living and deceased uterine donors have been transplanted with success. Given the ethical implications of using a living donor, Bruno and Arora explore the significance of using deceased uterus donations and the broader bioethics surrounding the uterine donation process. Successful examples of uterine transplants, and examination of ethical donations, offer a new hope for transgender individuals to experience live birth.

Our issue also offers numerous manuscripts that examine common but understudied reproductive health concerns, including endometriosis, infertility, male contraceptive methods, and sudden infant death syndrome (SIDS). Endometriosis was first described at the end of the 19th century and affects 1 in 10 women of reproductive age [4,5]. Despite this, endometriosis remains underfunded and poorly understood. Garcia-Fernandez and García-Velasco review our current understanding on the pathogenesis of endometriosis and how endometriosis may impair fertility. Indeed, infertility is common amongst patients with endometriosis and there is concern for reduced ovarian function following surgical treatment. The authors therefore stress the importance of endometriosis treatment that also takes patient pregnancy intentions into consideration.

Polonio and colleagues review the most recent literature on ovarian aging in both mice models and humans with ovarian failure, with a particular focus on telomere attrition. Telomere attrition causes multiple changes to mice fertility, including decreased litter size and difficulty conceiving. The authors postulate that telomere attrition could be linked to reproductive senescence and conclude that new approaches, such as telomere activation in the ovary, should be a focus of future research. Studies by both Garcia-Fernandez and García-Velasco and Polonio et al. reflect the need for physicians and researchers to address women’s needs and desires to have children outside of what has traditionally been considered the optimal window of fertility.

Our issue also features a review article on male contraceptive methods. Gender equity in family planning services is central to equal reproductive responsibility. However, there is presently a lack of effective and reversible methods of male contraception. Abbe et al. provide an overview of the mechanisms and clinical development of various hormonal and non-hormonal male contraceptive methods. Hormonal contraceptive methods primarily interfere with spermatogenesis, while non-hormonal methods interfere with the sperm release. Although further clinical development is necessary, current studies on hormonal methods report higher contraceptive efficacy rates than condoms, producing optimism for a new form of male contraceptive.

SIDS is one of the top causes of infant mortality in the US [6]. While the cause of SIDS is unknown, studies have identified risk factors associated with preventable actions. Appropriate medical knowledge and communication of evidence-based risk-reduction strategies are thus integral to preventing SIDS. Fernandes et al. investigate knowledge of SIDS amongst Portuguese parents and healthcare providers via a self-administered questionnaire. About one-third of parents surveyed never heard of SIDS. Additionally, although all surveyed healthcare professionals were aware of SIDS, the majority reported moderate (46.9%) and low or very low (31.9%) confidence in discussing SIDS-related issues, and varied in their recommendations to patients about the safest sleep position. This study highlights the need for improved patient and clinician education about SIDS.

The reviews, perspectives, and original research featured in this issue reflect the numerous important recent advancements in sexual and reproductive health, producing optimism for future researchers, physicians, and patients. These articles also underscore the need for continued research to better understand and meet the health needs of women and minority populations. Many experts in this issue have devoted their work to investigating and addressing unmet needs in subpopulations receiving sexual or reproductive healthcare. We hope that the manuscripts included in this issue contribute to the growing field of literature, as well as inspire continued research on understudied areas of sexual and reproductive health.