Reproductive health risks and clinician practices with gender diverse adolescents and young adults

4.1 Strategies for improving reproductive health counseling practices

As outlined above, comprehensive reproductive health counseling for TGD AYAs should include discussions about: youths’ reproductive health goals; contraception use and safer sex practices; implications of gender-affirming hormonal and surgical interventions on fertility, sexual function and satisfaction; relationship safety and exposure to risks (eg sex work), violence and trauma; and preventive care to preserve reproductive health. Additionally, clinicians need to be sensitive to the specific needs and elevated reproductive health risks of TGD AYA with multiple minoritized identities.

With a steadily increasing number of TGD youth seeking hormonal interventions at earlier ages,6, 81 these discussions are becoming more clinically and ethically complex. Beyond structural barriers such as cost, clinicians must address the AYA’s competing demands (ie urgency to start treatment) and developmental factors, in addition to family dynamics (eg discordance between AYAs’ and parents’ perspectives) and access barriers.65, 82, 83 Additionally, clinicians are often tasked with providing education about topics AYAs do not view as important, such as contraceptive options, or that they are not well trained to address, such as sexual and other interpersonal violence.84-86 Given the numerous challenges and the sensitive nature of these topics, clinicians must be both knowledgeable and skilled at building rapport and trust with TGD AYAs.87 For example, inquiring about chosen names and pronouns, using preferred terms for body parts and reproductive anatomy, approaching physical exams/procedures with caution and, as warranted, employing trauma sensitive approaches, are all necessary aspects of reproductive health encounters with TGD AYAs.

Recent research shows communication skills and confidence in reproductive health counseling are suboptimal for clinicians who provide care to TGD AYAs.88, 89 Web-based training in reproductive health with other populations (eg oncology) demonstrates efficacy for improving communication skills and confidence in counseling, and for reaching clinicians in rural or under-resourced areas who may have difficulty accessing desired reproductive health training.88, 90-92 Enhancing reproductive health counseling with TGD AYAs would improve the quality and sensitivity of care, reduce mistrust, increase satisfaction with health services and safety for youth, and optimize TGD AYA reproductive health outcomes. These programs should be geared toward a heterogeneous group of clinicians, as both medical (eg physicians, nurse practitioners) and mental health (eg psychologists, social workers) clinicians, play important roles in the reproductive health care of all AYAs.91, 92

Specific training needs may vary between groups—medical providers may have more knowledge in some domains (eg implications of medical/surgical interventions on fertility) whereas mental health providers may be more comfortable exploring patient priorities, taking into account cultural, social, developmental, and mental health considerations. However, certain topics such as health literacy are important for both provider groups. If clinicians use language that does not make sense to the patient this can create mistrust and contribute to non-adherence to treatment plans.93 Patient educational materials should be tested and assessed for health literacy by the demographic groups for which they are intended.

Communication training for medical and mental health clinicians can be enhanced by using talking points and scripts. Talking points may be helpful for initiating conversations on a topic that may be uncomfortable for both the clinician and patient, and could ensure consistency of messages across patients. Table 1 provides a list of objectives and talking points related to reproductive health topics.94 Counseling approaches should consider that many TGD AYAs may be highly anxious, traumatized, dysphoric and (at least initially) distrustful during these conversations, and eager to proceed with medical intervention.95 At the same time, TGD AYAs often have high levels of resilience.96 A multi-disciplinary approach should be used to approach these discussions prior to initiation of medical interventions, and on an ongoing basis thereafter. In addition to addressing fertility, contraception, sexual function and STI prevention, any training on reproductive health counseling targeting TGD AYAs should include training on cultural sensitivity, as well as safety screening and counseling related to sexual assault, violence in interpersonal relationships, and referrals for self-protection and advocacy (eg domestic violence advocacy programs geared toward the needs of TGD AYAs). In summary, enriched communication training for clinicians is necessary to provide a skilled workforce for the TGD AYA population.

TABLE 1. Recommended Reproductive Health Talking Points (adapted from Santa Maria et al) Topic Talking points Strategies Private consultation Request time alone with minors to discuss sexual health topics privately “I would like to have a few moments with you alone. Would that be okay?” Assure the youth that information will not be shared with the parent unless specifically required by law, such as in the case of abuse or suicidal ideation Sexual orientation Inquire about sexual orientation, Provide local resources for counseling and peer support “Are you sexually attracted to men, women, transgender people or neither?” Gender Identity Inquire about how the youth identifies with regard to gender. Inquire about pronouns and offer your own

“I’m Dr. Smith, my pronouns are she/her—what are your pronouns?”

“Do you identify as a man? Woman? Transgender” non-binary? Genderqueer/gender fluid or something else?”

HPV vaccination Recommend HPV vaccination and support completion of the series “Have you started the HPV vaccine series to protect against various cancers and diseases caused by HPV?” Fertility

Identify if potential infertility is a concern

Provider referrals to reproductive endocrinology

“Have you thought about having a biological child in the future? Do you know how hormones may affect your ability to create a pregnancy?” High-risk sexual situations Discuss anticipation of high-risk sexual situations, refusal and negotiation skills, role of alcohol and drugs in sexual behavior, and setting and maintaining personal boundaries Role-play scenarios such as parties, going out with friends who use drugs or alcohol, someone wanting to go farther sexually than you do. “Who can you go to where you work or live if you don't feel safe?” Healthy relationships, dating violence, safety and trauma

Inquire about coercive sex, dating violence, healthy relationships, safety at home and school, and sexual abuse. Inquire about whether past victimization experiences interfere with current sexual comfort and/or current well-being

Provide education about and information regarding sexual assault and interpersonal violence services, as well as trauma interventions as needed

“Have you ever been hit, punched, slapped, made fun of, teased, or pressured where you work or where you live?

“Have you ever engaged in unwanted sexual activity?”

Condom and contraceptive use Educate on the efficacy and correct use of various contraceptive methods and on the need for another method with condom use. Discuss pregnancy and other risks of sexual activity. Support informed decision making and access to condoms and contraceptives “Would you like to become pregnant in the next year?” Respond accordingly with pregnancy prevention counseling (see www.onekeyquestion.org) STI/HIV testing Discuss recommendations for STI and HIV screening for sexually actives and the importance of partner testing and treatment if results are positive. Assess high-risk adolescents for the appropriateness of PrEP and PEP “Have you had sex? Have you been sexually active with a person with a penis? Or a vagina? Have you had sex with a new partner? Have you and your partner been tested for HIV and STIs?” Role-play discussing testing with a future sexual partner. “How many times did you have vaginal or anal sex where a condom wasn't used? How many of your partners were HIV positive?” Abbreviations: HPV, human papillomavirus; PEP, post-exposure prophylaxis; PrEP, pre-exposure prophylaxis; STI, sexually transmitted infection. 4.2 Priorities for future research

Clinical research is needed to better understand reproductive health goals and risks in TGD AYAs across ages and developmental stages. Perspectives of parents/caregivers (for adolescents) and partners should also be examined. The exponentially greater health risks associated with multiple minoritized identities requires research to identify the reproductive health experiences and barriers for members of the TGD AYA community who are most marginalized. These studies may be more difficult to undertake given that TGD AYA facing the most barriers to healthcare may be harder to recruit as much of this research takes place in academic clinic settings. Researchers have highlighted the need for intersectional frameworks to account for health inequities in transgender populations. For instance, the Intersectionality for Transgender Health Justice (ITHJ) framework specifies steps to guide researchers seeking to study transgender health to understand and disrupt power structures impeding adequate health care.17

There is great need to expand patient focused research on improving our understanding of issues of well-being surgical outcomes at different stages of transition for TGD AYAs. For example, transgender men who begin pubertal suppression at early stages of puberty may feel less need for follow-up mastectomies, or require less invasive mastectomies than those who do not take pubertal suppression. However, while there are advantages to early intervention, the limited phallic growth associated with puberty blockers in transgender women has implications for vaginoplasty, if desired at a later point, due to reduced penile growth and occasionally insufficient tissue to perform this feminizing surgery. Instead, additional tissue may be required from another part of the body, often intestinal tissue. Due to these complexities, counseling about potential impacts of pubertal suppression on future aspects of gender-affirming medical care should account for various considerations and outcomes.97 There is a dearth of understanding about the extent to which each type of gender-affirming treatment and the timing of the treatments by age positively or negatively affects sexual practices and satisfaction.

In addition to patient focused research, research with the clinical community is critically needed to understand: (1) best modalities for mental health and medical provider training; and (2) documentation of practice improvements based on trainings. Evidence-based strategies are needed to facilitate developmentally, culturally and trauma sensitive counseling practices among TGD AYAs to mitigate potential distress and regret, including those that may be associated with fertility loss after treatment. While regret and distress are well documented in other AYA populations (eg those with cancer),98-102 we cannot assume TGD AYAs will have the same perspectives. Research with older adults who have transitioned is needed to determine if these negative feelings may be anticipated by TGD AYA youth in the future, to better inform counseling practices across the care continuum.

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