- Email: [email protected]
Nonbinary Adolescents
Journal of Adolescent Health 66 (2020) 372e374
www.jahonline.org Adolescent health brief
Reproductive Attitudes and Behaviors Among Transgender/ Nonbinary Adolescents Leena Nahata, M.D. a, b, c, *, Diane Chen, Ph.D. d, e, Gwendolyn P. Quinn, Ph.D. f, Meika Travis, M.S. c, Connor Grannis c, Eric Nelson, Ph.D. a, c, and Amy C. Tishelman, Ph.D. g a
The Ohio State University College of Medicine, Columbus, Ohio Division of Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio c Center for Biobehavioral Health, Abigail Wexner Research Institute, Columbus, Ohio d Potocsnak Family Division of Adolescent and Young Adult Medicine, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois e Departments of Psychiatry and Behavioral Sciences and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois f Departments of Obstetrics and Gynecology and Population Health, Division of Medical Ethics, New York University School of Medicine, New York, New York g Departments of Psychiatry and Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts b
Article history: Received July 10, 2019; Accepted September 10, 2019 Keywords: Transgender; Adolescents; Reproductive health; Contraception; Fertility; Counseling
A B S T R A C T
Purpose: The aim of the study was to examine reproductive health attitudes and behaviors related to contraception use, provider counseling, parenthood goals, and fertility preservation (FP) in TNB adolescents. Methods: A 24-item survey was administered to 44 TNB adolescents aged 12e19 years. Results: Contraceptive use was variable even among the 46% who reported sexual activity. Half denied or were unsure if they had been offered options from their provider to prevent sexually transmitted infections, and more than one third denied or were unsure about the offer of pregnancy prevention options. Importantly, the majority did not desire more information about contraceptive options. Few used FP, although many thought their feelings about parenthood may change in the future. Conclusions: TNB adolescents are at risk for sexually transmitted infections, unplanned pregnancies, and future infertility, yet many do not desire more information about contraception or FP. Tailored counseling strategies should be developed and researched to protect this vulnerable group of youth. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Reproductive health (RH) has unique implications for transgender and nonbinary (TNB) adolescents. TNB adults demonstrate misconceptions about pregnancy risks (e.g., believing gender-affirming hormones always prevent pregnancy) [1]. Conflicts of interest: No conflicts of interest or sources of funding to report. * Address correspondence to: Leena Nahata, M.D., Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. E-mail address: [email protected] (L. Nahata). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.09.008
IMPLICATIONS AND CONTRIBUTION
Transgender/nonbinary adolescents are at high risk for adverse reproductive health outcomes because of unsafe sexual practices and potential future infertility. Providers are challenged to offer culturally relevant reproductive health counseling to transgender/nonbinary adolescents who may not be interested in more information. Tailored communication strategies may reduce risk.
One study showed 26% of TNB adolescents had unintentional pregnancies, versus 12% in cisgender adolescents [2]. TNB youth also experience disproportionate rates of sexually transmitted infections (STIs) [3]. Moreover, hormonal/surgical interventions initiated in adolescence also risk impairing future fertility [4,5]. Although many TNB adults desire biological children, TNB adolescents rarely preserve fertility [5]. However, little is currently known about RH attitudes/behaviors among TNB youth.
L. Nahata et al. / Journal of Adolescent Health 66 (2020) 372e374
373
survey completions (81% response rate). Adolescents were predominantly assigned female at birth; mean age was 16.3 years, and 91% identified as transgender (Table 1). The majority identified as gay (n ¼ 10, 23%), bisexual (n ¼ 9, 21%), or heterosexual (n ¼ 8, 18%), and 10 (22%) preferred not to answer. More than half said “yes” or “unsure” about the possibility of their sexual orientation changing in the future (Table 1). Thirty-four (77%) participants reported engaging in a romantic relationship currently or within the past year; 20 (45%) reported current/history of sexual contact with another person. Half denied or were unsure if they had been offered contraceptive options from their health care provider to prevent STIs, and more than one-third denied or were unsure if they had been offered pregnancy prevention options (Table 1). More than half reported “never” using contraception (n ¼ 25); the majority did not desire more information about contraceptive options (Table 1). Of the 20 participants who reported sexual contact with another person, the majority were satisfied with the amount of information their provider offered regarding contraceptive options (n ¼ 15, 75%); half reported “always” using contraception, and the majority indicated their providers offered options to prevent STIs and pregnancy (n ¼ 16, 80%; n ¼ 17, 85%, respectively). Older participants were significantly more likely to have been in a relationship (p ¼ .024), sexually active (p ¼ .007), be offered contraception to prevent pregnancy (p ¼ .045), and use contraception (p ¼ .039). Most participants knew hormonal treatments could negatively impact fertility, and FP options were available (Table 1). The majority learned about FP options from a health care provider (n ¼ 30, 68%), and 3 (7%) attempted FP. “Not caring to have” a biological child, followed by feeling “too young” to consider it were, respectively, the most common reasons for declining FP (Figure 1). More than half of participants wanted to adopt a child in the future (Table 1). The majority agreed their parents wanted them to have a child or were unsure; more than half did not know if their parents would prefer a biological grandchild and
Adolescents and sexual/gender minorities were recently identified as at risk for “experiencing inequities in accessing RH services” [6]. The American Academy of Pediatrics recommends counseling adolescents on contraception for pregnancy/STI prevention [7], with recent RH guidance specific to the TNB population [4]. Regarding TNB youth, minimal research exists on RH counseling practices, contraception-related attitudes/behaviors, and reasons for declining fertility preservation (FP). The goals of this study were to examine (1) attitudes toward contraception and fertility/parenthood; and (2) self-reported counseling experiences, contraception, and FP in TNB adolescents presenting to a large Midwest pediatric academic center for gender-related care. Methods The study team developed a 24-item survey (informed by a recent fertility questionnaire [8]), examining gender identity/ sexual orientation; contraception counseling and utilization; attitudes toward fertility/parenthood; and FP counseling, attempts, and reasons for decline. TNB adolescents (aged 12e 19 years) completed the survey during gender-related clinic visits (all established patients with 3þ visits in the program), as part of a larger institutional review boardeapproved study examining biopsychosocial outcomes. Parents/caregivers and youth aged 18e19 years provided informed consent; minors provided assent. Current hormonal therapy status was obtained from the electronic medical record. Descriptive statistics characterized the sample. Results Seventy-nine potential participants were identified from clinic rosters; 25 were deemed physically or psychiatrically unable to participate based on the parent protocol (which included a magnetic resonance imaging). Ten declined, resulting in 44 Table 1 Subject Characteristics and Reproductive Health Attitudes and Behaviors Subject characteristics
Domain question Behavior change My gender identity may change in the future My sexual orientation may change in the future Contraception HCP offered contraceptive options to prevent STIs HCP offered contraceptive options to prevent pregnancy I wish HCP talked to me more about contraceptive options Parenthood I am aware that hormonal treatments may cause problems with the ability to have a biological child I am aware there are options to preserve my genetic material to have a biological child in the future I wish my HCP talked to me about fertility I want to adopt in the future My parents want me to have a child My parents would prefer a biological grandchild My feelings about having children may change in the future
Age m, SD
AFAB, % (n)
Testosterone, % (n)
Estradiol, % (n)
GnRHa, % (n)
No treatment, % (n)
16.30, 1.84
81.81% (36)
43.18% (19)
15.91% (7)
9.09% (4)
34.09% (15)
“Yes,” % (n)
“No,” % (n)
“Don’t know,” % (n)
“Prefer not to answer,” % (n)
2.27 (1) 15.91 (7)
84.09 (37) 43.18 (19)
11.36 (5) 40.91 (18)
d d
43.18 (19) 59.09 (26)
20.45 (9) 18.18 (8)
29.55 (13) 18.18 (8)
2.27 (1) 2.27 (1)
6.82 (3)
56.82 (25)
29.55 (13)
4.55 (2)
93.18 (41)
4.55 (2)
2.27 (1)
d
95.45 (42)
2.27 (1)
2.27 (1)
d
13.64 52.27 45.45 13.64 29.55
(6) (23) (20) (6) (13)
72.73 22.73 9.09 31.82 36.36
(32) (10) (4) (14) (16)
9.09 25.00 45.45 54.55 34.09
(4) (11) (20) (24) (15)
4.55 (2) d d d d
AFAB ¼ assigned female at birth; GnRHa ¼ gonadotropin releasing hormone agonist; HCP ¼ health care providers; SD ¼ standard deviation.
374
L. Nahata et al. / Journal of Adolescent Health 66 (2020) 372e374
REASONS FOR NOT ATTEMPTING FERTILITY PRESERVATION TOO YOUNG
27.27
NOT ON HORMONES
11.36
NO ONE TOLD ME
6.82
DON’T KNOW ENOUGH
11.36
COULDN'T AFFORD
15.91
DIDN'T WANT TO DELAY TX
27.27
WILL WAIT UNTIL TRANSITION
9.09
DON'T WANT TO BE A PARENT
25.00
DON'T WANT TO HAVE BIOL CHILD
56.82
MEDICAL PROCEDURE TOO HARD
6.82 0.00
10.00
20.00
30.00
40.00
50.00
60.00
Figure 1. Percentage of respondents endorsing each reason for not attempting fertility preservation.
said their feelings about having children may change in the future or were unsure (Table 1).
Discussion These data reveal important information about TNB adolescents’ RH. Although many reported romantic/sexual involvement, contraception counseling practices and utilization were inconsistent. Even among sexually active adolescents, only half consistently used contraception. The majority did not want more contraceptive information, consistent with research with cisgender at-risk adolescent populations [9]. Most TNB adolescents endorsed receiving fertility counseling; few attempted FP, and lack of desire for biological children was the most common reason. Although nearly one third of adolescents felt “too young” to consider FP, responses suggest these youth may not be discussing reproductive goals with their parents. Studies in cisgender youth facing gonadotoxic treatments (e.g., for cancer) differ in that more of these adolescents report a desire for biological children, yet similarly face challenges considering future parenthood, and may disagree with their parents regarding reproductive goals [9,10]. Although TNB adolescents in our study were aware future parenthood goals could change (similar to prior research [8]), the implications for their FP decisions and the extent to which such feelings are unique to TNB youth are important areas for future investigation. Despite study limitations (single site, adapted instrument not fully validated, parent study restrictions), results suggest counseling for STI/pregnancy prevention and future parenthood is inconsistent, and/or TNB adolescents’ recall of counseling is weak. This is significant since TNB individuals are at high risk for HIV and other STIs [2]. Speculatively, counseling may occur in a hurried/abrupt way or be offered in a developmentally or culturally insensitive manner. Providers may encounter difficulties counseling TNB youth about the possibility of reduced fertility while simultaneously emphasizing the importance of contraception [11]. Some TNB adolescents may feel aspects of RH discussions are inapplicable to them based on sexual orientation and/or current parenting goals.
Providers may need unique strategies for counseling sometimes disinterested youth on important RH issues. Further research should examine whether TNB youth have similar misperceptions as TNB adults about the need for pregnancy prevention and whether there is regret about lack of FP; future studies should also assess counseling about pre-exposure prophylaxis/HIV. Additional research on best practices for RH counsel of TNB youth can help inform innovative, culturally relevant, and effective standardized models of counseling to protect this vulnerable group from adverse RH outcomes and their associated psychosocial sequelae.
References [1] Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception 2018;98:266e9. [2] Veale J, Watson RJ, Adjei J, Saewyc E. Prevalence of pregnancy involvement among Canadian transgender youth and its relation to mental health, sexual health, and gender identity. Int J Transgend 2016;17:107e13. [3] Reisner SL, Jadwin-Cakmak L, Sava L, et al. Situated vulnerabilities, sexual risk, and sexually transmitted infections’ diagnoses in a sample of transgender youth in the United States. AIDS Patient Care STDs 2019;33: 120e30. [4] Safer JD, Tangpricha V. Care of the transgender patient. Ann Intern Med Jul 2 2019;171:ITC1e16. [5] Nahata L, Chen D, Moravek MB, et al. Understudied and under-reported: Fertility issues in transgender youthda narrative review. J Pediatr 2019; 205:265e71. [6] Governor’s Interagency Council on Health Disparities. 2019. Available at: https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName¼ LiteratureReviewReproductiveHealthAccess_SSB6219_FINAL_1.1.2019_42 423dd8-5280-4cc5-bb55-2220637ba6a5.pdf. Accessed January 31, 2020. [7] American Academy of Pediatrics Committee on Adolescence; Blythe MJ, Diaz A. Contraception and adolescents. Pediatrics 2007;120:1135e48. [8] Strang JF, Jarin J, Call D, et al. Transgender youth fertility attitudes questionnaire: Measure development in nonautistic and autistic transgender youth and their parents. J Adolesc Health 2017;62:128e35. [9] Nahata L, Caltabellotta NM, Ball K, et al. Desire for parenthood and reproductive health knowledge in adolescents and young adults with sickle cell disease and their caregivers. Pediatr Blood Cancer 2018;65. [10] Quinn GP, Knapp C, Murphy D, et al. Congruence of reproductive concerns among adolescents with cancer and parents: Pilot testing an adapted instrument. Pediatrics 2012;129:e930e936. [11] Tishelman AC, Sutter ME, Chen D, et al. Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: Qualitative responses to an international survey. J Assist Reprod Genet 2019;36:579e88.
www.jahonline.org Adolescent health brief
Reproductive Attitudes and Behaviors Among Transgender/ Nonbinary Adolescents Leena Nahata, M.D. a, b, c, *, Diane Chen, Ph.D. d, e, Gwendolyn P. Quinn, Ph.D. f, Meika Travis, M.S. c, Connor Grannis c, Eric Nelson, Ph.D. a, c, and Amy C. Tishelman, Ph.D. g a
The Ohio State University College of Medicine, Columbus, Ohio Division of Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio c Center for Biobehavioral Health, Abigail Wexner Research Institute, Columbus, Ohio d Potocsnak Family Division of Adolescent and Young Adult Medicine, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois e Departments of Psychiatry and Behavioral Sciences and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois f Departments of Obstetrics and Gynecology and Population Health, Division of Medical Ethics, New York University School of Medicine, New York, New York g Departments of Psychiatry and Endocrinology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts b
Article history: Received July 10, 2019; Accepted September 10, 2019 Keywords: Transgender; Adolescents; Reproductive health; Contraception; Fertility; Counseling
A B S T R A C T
Purpose: The aim of the study was to examine reproductive health attitudes and behaviors related to contraception use, provider counseling, parenthood goals, and fertility preservation (FP) in TNB adolescents. Methods: A 24-item survey was administered to 44 TNB adolescents aged 12e19 years. Results: Contraceptive use was variable even among the 46% who reported sexual activity. Half denied or were unsure if they had been offered options from their provider to prevent sexually transmitted infections, and more than one third denied or were unsure about the offer of pregnancy prevention options. Importantly, the majority did not desire more information about contraceptive options. Few used FP, although many thought their feelings about parenthood may change in the future. Conclusions: TNB adolescents are at risk for sexually transmitted infections, unplanned pregnancies, and future infertility, yet many do not desire more information about contraception or FP. Tailored counseling strategies should be developed and researched to protect this vulnerable group of youth. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Reproductive health (RH) has unique implications for transgender and nonbinary (TNB) adolescents. TNB adults demonstrate misconceptions about pregnancy risks (e.g., believing gender-affirming hormones always prevent pregnancy) [1]. Conflicts of interest: No conflicts of interest or sources of funding to report. * Address correspondence to: Leena Nahata, M.D., Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205. E-mail address: [email protected] (L. Nahata). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.09.008
IMPLICATIONS AND CONTRIBUTION
Transgender/nonbinary adolescents are at high risk for adverse reproductive health outcomes because of unsafe sexual practices and potential future infertility. Providers are challenged to offer culturally relevant reproductive health counseling to transgender/nonbinary adolescents who may not be interested in more information. Tailored communication strategies may reduce risk.
One study showed 26% of TNB adolescents had unintentional pregnancies, versus 12% in cisgender adolescents [2]. TNB youth also experience disproportionate rates of sexually transmitted infections (STIs) [3]. Moreover, hormonal/surgical interventions initiated in adolescence also risk impairing future fertility [4,5]. Although many TNB adults desire biological children, TNB adolescents rarely preserve fertility [5]. However, little is currently known about RH attitudes/behaviors among TNB youth.
L. Nahata et al. / Journal of Adolescent Health 66 (2020) 372e374
373
survey completions (81% response rate). Adolescents were predominantly assigned female at birth; mean age was 16.3 years, and 91% identified as transgender (Table 1). The majority identified as gay (n ¼ 10, 23%), bisexual (n ¼ 9, 21%), or heterosexual (n ¼ 8, 18%), and 10 (22%) preferred not to answer. More than half said “yes” or “unsure” about the possibility of their sexual orientation changing in the future (Table 1). Thirty-four (77%) participants reported engaging in a romantic relationship currently or within the past year; 20 (45%) reported current/history of sexual contact with another person. Half denied or were unsure if they had been offered contraceptive options from their health care provider to prevent STIs, and more than one-third denied or were unsure if they had been offered pregnancy prevention options (Table 1). More than half reported “never” using contraception (n ¼ 25); the majority did not desire more information about contraceptive options (Table 1). Of the 20 participants who reported sexual contact with another person, the majority were satisfied with the amount of information their provider offered regarding contraceptive options (n ¼ 15, 75%); half reported “always” using contraception, and the majority indicated their providers offered options to prevent STIs and pregnancy (n ¼ 16, 80%; n ¼ 17, 85%, respectively). Older participants were significantly more likely to have been in a relationship (p ¼ .024), sexually active (p ¼ .007), be offered contraception to prevent pregnancy (p ¼ .045), and use contraception (p ¼ .039). Most participants knew hormonal treatments could negatively impact fertility, and FP options were available (Table 1). The majority learned about FP options from a health care provider (n ¼ 30, 68%), and 3 (7%) attempted FP. “Not caring to have” a biological child, followed by feeling “too young” to consider it were, respectively, the most common reasons for declining FP (Figure 1). More than half of participants wanted to adopt a child in the future (Table 1). The majority agreed their parents wanted them to have a child or were unsure; more than half did not know if their parents would prefer a biological grandchild and
Adolescents and sexual/gender minorities were recently identified as at risk for “experiencing inequities in accessing RH services” [6]. The American Academy of Pediatrics recommends counseling adolescents on contraception for pregnancy/STI prevention [7], with recent RH guidance specific to the TNB population [4]. Regarding TNB youth, minimal research exists on RH counseling practices, contraception-related attitudes/behaviors, and reasons for declining fertility preservation (FP). The goals of this study were to examine (1) attitudes toward contraception and fertility/parenthood; and (2) self-reported counseling experiences, contraception, and FP in TNB adolescents presenting to a large Midwest pediatric academic center for gender-related care. Methods The study team developed a 24-item survey (informed by a recent fertility questionnaire [8]), examining gender identity/ sexual orientation; contraception counseling and utilization; attitudes toward fertility/parenthood; and FP counseling, attempts, and reasons for decline. TNB adolescents (aged 12e 19 years) completed the survey during gender-related clinic visits (all established patients with 3þ visits in the program), as part of a larger institutional review boardeapproved study examining biopsychosocial outcomes. Parents/caregivers and youth aged 18e19 years provided informed consent; minors provided assent. Current hormonal therapy status was obtained from the electronic medical record. Descriptive statistics characterized the sample. Results Seventy-nine potential participants were identified from clinic rosters; 25 were deemed physically or psychiatrically unable to participate based on the parent protocol (which included a magnetic resonance imaging). Ten declined, resulting in 44 Table 1 Subject Characteristics and Reproductive Health Attitudes and Behaviors Subject characteristics
Domain question Behavior change My gender identity may change in the future My sexual orientation may change in the future Contraception HCP offered contraceptive options to prevent STIs HCP offered contraceptive options to prevent pregnancy I wish HCP talked to me more about contraceptive options Parenthood I am aware that hormonal treatments may cause problems with the ability to have a biological child I am aware there are options to preserve my genetic material to have a biological child in the future I wish my HCP talked to me about fertility I want to adopt in the future My parents want me to have a child My parents would prefer a biological grandchild My feelings about having children may change in the future
Age m, SD
AFAB, % (n)
Testosterone, % (n)
Estradiol, % (n)
GnRHa, % (n)
No treatment, % (n)
16.30, 1.84
81.81% (36)
43.18% (19)
15.91% (7)
9.09% (4)
34.09% (15)
“Yes,” % (n)
“No,” % (n)
“Don’t know,” % (n)
“Prefer not to answer,” % (n)
2.27 (1) 15.91 (7)
84.09 (37) 43.18 (19)
11.36 (5) 40.91 (18)
d d
43.18 (19) 59.09 (26)
20.45 (9) 18.18 (8)
29.55 (13) 18.18 (8)
2.27 (1) 2.27 (1)
6.82 (3)
56.82 (25)
29.55 (13)
4.55 (2)
93.18 (41)
4.55 (2)
2.27 (1)
d
95.45 (42)
2.27 (1)
2.27 (1)
d
13.64 52.27 45.45 13.64 29.55
(6) (23) (20) (6) (13)
72.73 22.73 9.09 31.82 36.36
(32) (10) (4) (14) (16)
9.09 25.00 45.45 54.55 34.09
(4) (11) (20) (24) (15)
4.55 (2) d d d d
AFAB ¼ assigned female at birth; GnRHa ¼ gonadotropin releasing hormone agonist; HCP ¼ health care providers; SD ¼ standard deviation.
374
L. Nahata et al. / Journal of Adolescent Health 66 (2020) 372e374
REASONS FOR NOT ATTEMPTING FERTILITY PRESERVATION TOO YOUNG
27.27
NOT ON HORMONES
11.36
NO ONE TOLD ME
6.82
DON’T KNOW ENOUGH
11.36
COULDN'T AFFORD
15.91
DIDN'T WANT TO DELAY TX
27.27
WILL WAIT UNTIL TRANSITION
9.09
DON'T WANT TO BE A PARENT
25.00
DON'T WANT TO HAVE BIOL CHILD
56.82
MEDICAL PROCEDURE TOO HARD
6.82 0.00
10.00
20.00
30.00
40.00
50.00
60.00
Figure 1. Percentage of respondents endorsing each reason for not attempting fertility preservation.
said their feelings about having children may change in the future or were unsure (Table 1).
Discussion These data reveal important information about TNB adolescents’ RH. Although many reported romantic/sexual involvement, contraception counseling practices and utilization were inconsistent. Even among sexually active adolescents, only half consistently used contraception. The majority did not want more contraceptive information, consistent with research with cisgender at-risk adolescent populations [9]. Most TNB adolescents endorsed receiving fertility counseling; few attempted FP, and lack of desire for biological children was the most common reason. Although nearly one third of adolescents felt “too young” to consider FP, responses suggest these youth may not be discussing reproductive goals with their parents. Studies in cisgender youth facing gonadotoxic treatments (e.g., for cancer) differ in that more of these adolescents report a desire for biological children, yet similarly face challenges considering future parenthood, and may disagree with their parents regarding reproductive goals [9,10]. Although TNB adolescents in our study were aware future parenthood goals could change (similar to prior research [8]), the implications for their FP decisions and the extent to which such feelings are unique to TNB youth are important areas for future investigation. Despite study limitations (single site, adapted instrument not fully validated, parent study restrictions), results suggest counseling for STI/pregnancy prevention and future parenthood is inconsistent, and/or TNB adolescents’ recall of counseling is weak. This is significant since TNB individuals are at high risk for HIV and other STIs [2]. Speculatively, counseling may occur in a hurried/abrupt way or be offered in a developmentally or culturally insensitive manner. Providers may encounter difficulties counseling TNB youth about the possibility of reduced fertility while simultaneously emphasizing the importance of contraception [11]. Some TNB adolescents may feel aspects of RH discussions are inapplicable to them based on sexual orientation and/or current parenting goals.
Providers may need unique strategies for counseling sometimes disinterested youth on important RH issues. Further research should examine whether TNB youth have similar misperceptions as TNB adults about the need for pregnancy prevention and whether there is regret about lack of FP; future studies should also assess counseling about pre-exposure prophylaxis/HIV. Additional research on best practices for RH counsel of TNB youth can help inform innovative, culturally relevant, and effective standardized models of counseling to protect this vulnerable group from adverse RH outcomes and their associated psychosocial sequelae.
References [1] Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception 2018;98:266e9. [2] Veale J, Watson RJ, Adjei J, Saewyc E. Prevalence of pregnancy involvement among Canadian transgender youth and its relation to mental health, sexual health, and gender identity. Int J Transgend 2016;17:107e13. [3] Reisner SL, Jadwin-Cakmak L, Sava L, et al. Situated vulnerabilities, sexual risk, and sexually transmitted infections’ diagnoses in a sample of transgender youth in the United States. AIDS Patient Care STDs 2019;33: 120e30. [4] Safer JD, Tangpricha V. Care of the transgender patient. Ann Intern Med Jul 2 2019;171:ITC1e16. [5] Nahata L, Chen D, Moravek MB, et al. Understudied and under-reported: Fertility issues in transgender youthda narrative review. J Pediatr 2019; 205:265e71. [6] Governor’s Interagency Council on Health Disparities. 2019. Available at: https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName¼ LiteratureReviewReproductiveHealthAccess_SSB6219_FINAL_1.1.2019_42 423dd8-5280-4cc5-bb55-2220637ba6a5.pdf. Accessed January 31, 2020. [7] American Academy of Pediatrics Committee on Adolescence; Blythe MJ, Diaz A. Contraception and adolescents. Pediatrics 2007;120:1135e48. [8] Strang JF, Jarin J, Call D, et al. Transgender youth fertility attitudes questionnaire: Measure development in nonautistic and autistic transgender youth and their parents. J Adolesc Health 2017;62:128e35. [9] Nahata L, Caltabellotta NM, Ball K, et al. Desire for parenthood and reproductive health knowledge in adolescents and young adults with sickle cell disease and their caregivers. Pediatr Blood Cancer 2018;65. [10] Quinn GP, Knapp C, Murphy D, et al. Congruence of reproductive concerns among adolescents with cancer and parents: Pilot testing an adapted instrument. Pediatrics 2012;129:e930e936. [11] Tishelman AC, Sutter ME, Chen D, et al. Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: Qualitative responses to an international survey. J Assist Reprod Genet 2019;36:579e88.