Diana M. Tordoff

Background: Testosterone gender-affirming hormone therapy frequently results in genital atrophy among transmasculine individuals. Low-dose topical genital estrogen is currently recommended for transmasculine individuals experiencing dyspareunia and vaginitis, but its effectiveness has not been assessed among those using testosterone. The objective of this study was to describe the lived experience of genital atrophy and the acceptability of available treatments in this population. Methods: We conducted in-depth one-on-one interviews with 28 transmasculine adults using testosterone, recruited through PRIDEnet, an established national LGBTQIA+ community-engagement network. Participants were asked questions related to their lived experiences of genital atrophy, including symptom recognition, experiences seeking care, and treatment preferences using a structured interview guide. Transcribed interviews were analyzed using qualitative thematic analysis and content analysis. Results: Nearly all participants (93%) had heard of genital atrophy and 64% had ever experienced it in their lifetimes (46% in the past year). Symptoms ranged from transient dryness and discomfort during penetrative sex to chronic pain affecting walking, sitting, urination, and daily functioning. Most participants (79%) had heard of topical genital estrogen; 43% had ever used it, and most reported symptomatic relief. Cream was the most commonly prescribed but least preferred formulation due to messiness, dysphoria associated with genital contact, and interference with sexual activity; suppository tablets and the genital ring were most preferred. Concerns about systemic estrogen absorption and interference with testosterone were pervasive. Participants encountered significant treatment barriers including providers who lacked knowledge of genital atrophy in transmasculine patients, minimized or dismissed symptoms, or refused to prescribe topical genital estrogen. Insurance denials, formulation restrictions, and negative pharmacy interactions represented additional barriers. Conclusion: The provider knowledge gaps and systemic barriers documented in this study underscore that improving genitourinary health outcomes for transmasculine individuals will require concurrent advances in medical education, insurance policy, and clinical evidence. Clinicians should proactively counsel transmasculine patients about genital atrophy at testosterone initiation and discuss all available treatment formulations with explicit attention to gender dysphoria, systemic absorption concerns, and insurance constraints. Provider education on the genitourinary effects of testosterone and the diagnosis and treatment of genital atrophy must improve across clinical training programs. Clinical trials evaluating the efficacy, systemic absorption, and acceptability of all available treatment options — including topical estrogen formulations, dehydroepiandrosterone, and ospemifene — among transmasculine individuals using testosterone are urgently needed.

Introduction: Sexual and gender minority (SGM) individuals assigned male at birth (AMAB) remain underrepresented in family‐building research despite facing unique barriers to having children, especially when they are single or in partnerships where neither person can carry a pregnancy. This qualitative study examined the family‐building experiences of cisgender sexual minority men, transgender women, and nonbinary people AMAB. Methods: We conducted 10 asynchronous online focus groups with 56 participants (23 parents, 33 prospective parents) across three gender groups (22 cisgender sexual minority men, 18 nonbinary people AMAB, 16 transgender women) at different phases of their family‐building journey. Participants answered a series of writing prompts related to parenthood, family‐building, and raising children. Data were analyzed using template analysis to identify cross‐cutting and group‐specific themes. Results: Participants had used or were considering a diversity of methods to have children, including sexual activity, medically assisted reproduction, surrogacy, adoption, and fostering. Participants' preferences for and the accessibility of each of these methods were influenced by intersecting issues of identity, systemic inequities, and cultural belonging. Financial constraints were pervasive, as were concerns related to legal parentage and discrimination. Race and ethnicity profoundly shaped participants' decisions, including preferences for race‐concordant gamete donors and experiences of discrimination within fertility and adoption settings. Conclusion: Our findings reflect the diversity of family‐building goals and priorities within SGM communities and underscore the importance of inclusive reproductive health services. This comparative examination of family‐building among cisgender men, transgender women, and nonbinary individuals AMAB revealed both shared and unique barriers to parenthood.

Background: Sexual and gender minority adults are increasingly growing their families and having children, yet there is limited information on the lactation experiences of sexual and gender minority parents. Method: Using data from The PRIDE Study, a national cohort of sexual and gender minority adults in the United States, we examined patterns and correlates of lifetime breast/chestfeeding among sexual minority (i.e., lesbian, bisexual, queer) cisgender women, transgender women, transgender men, and gender diverse individuals who were parents. Results: Our analysis included 1,562 parents aged 19–83 years with a median of two children (IQR 1–3). Among this population, 941 (60.2%) were sexual minority cisgender women, 232 (14.9%) transgender women, 199 (12.7%) transgender men, and 190 (12.2%) gender diverse parents assigned female at birth. Among 962 parents who had ever carried a pregnancy and delivered a child, sexual minority cisgender women were most likely to have ever breast/chestfed (91.7%), followed by gender diverse parents (88.8%) and transgender men (83.3%). No other demographic factors were associated with ever breast/chestfeeding. Few participants (6.7%) had ever breast/chestfed a child from another person’s pregnancy. Ever having delivered a child and having an increasing number of children were associated with ever breast/chestfeeding a child from another person’s pregnancy. In addition, seven (3%) transgender women had ever breast/chestfed a child. Conclusions: In our cohort, rates of lifetime breast/chestfeeding were high among sexual and gender minority parents who had ever carried a pregnancy. Breast/chestfeeding provides important health and infant–parent bonding benefits in families where one or more parents has the interest in and capacity for lactation. Co-lactation and/or lactation induction may be particularly beneficial for sexual and gender minority families.

STUDY QUESTION: What methods are used by sexual and gender minority (SGM) parents to build their families? SUMMARY ANSWER: SGM parents used diverse methods to build their families, which varied both by gender identity and age. WHAT IS KNOWN ALREADY: Despite experiencing significant barriers to becoming parents, 63% of SGM adults aged 18–35 years old are considering having children or expanding their family. Data on US same-sex couples demonstrate that although most same-sex parents (68%) are genetically related to their children, they are more likely to adopt, foster, and be step-parents compared with different-sex couples. STUDY DESIGN, SIZE, DURATION: Cross-sectional analysis of 2018–2020 data from The PRIDE Study, a community-engaged longitudinal cohort study of SGM adults living in the USA. This analysis included 2122 SGM parents with 4712 children (median of 2 children per parent). PARTICIPANTS/MATERIALS, SETTING, METHODS: Primary exposures were SGM subgroups (cisgender sexual minority men, cisgender sexual minority women, gender diverse people assigned female at birth [AFAB], gender diverse people assigned male at birth [AMAB], transgender men, and transgender women) and age cohorts (18–39, 40–54, and 55 and older). The primary outcome was method of family building, grouped into three overarching categories defined as (1) pregnancy from sexual activity, (2) pregnancy without sexual activity (e.g. use of donor gametes, surrogacy), and (3) a method other than pregnancy (e.g. adoption, fostering, step-parenting). We used logistic regression models to evaluate differences in methods of family building used by SGM subgroup and age groups. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, 56% of SGM adults became parents through pregnancy from sexual activity, 14% became parents through pregnancy without sexual activity, and 28% became parents from a method other than pregnancy. Transgender women, gender diverse parents, and cisgender men had a higher odds of using pregnancy through sexual activity to become parents and were less likely to become parents using pregnancy without sexual activity compared with cisgender women. Conversely, transgender men were less likely to use pregnancy through sexual activity (aOR 0.57, 95% CI 0.44, 0.73) and over twice as likely to use methods other than pregnancy (aOR 2.39, 95% CI 1.86, 3.06) compared to cisgender women. Parents aged 18–39 and 40–54 years old were twice as likely to use pregnancy without sexual activity compared with parents aged 55+ years old (Age 18–39: aOR 2.16, 95% CI: 1.55, 2.99; Age 40–54: aOR 1.92, 95% CI: 1.39, 2.66). LIMITATIONS, REASON FOR CAUTION: Our convenience sample was predominantly White. We are unable to infer information about the preferred methods or attempted but unsuccessful methods of family building. WIDER IMPLICATIONS OF THE FINDINGS: The number of SGM parents is likely to grow, given that younger generations are more likely to identify as SGM, desire children, and have access to medically assisted reproduction. Clinicians must be aware of the diversity of methods SGM parents used to become parents and the financial, legal, and institutional barriers that SGM people navigate when building their families. STUDY FUNDING/COMPETING INTEREST(S): Funding for this work was provided by the Stanford Maternal and Child Health Research Institute Seed Grant program to J.O.M. and S.L. and the Stanford University School of Medicine Department of Obstetrics and Gynecology. Research reported in this article was partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Award [award number PPRN-1501-26848] to M.R.L. The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee, or the National Institutes of Health. J.O.M. was partially supported by the National Institute of Diabetes, Digestive, and Kidney Disorders [grant number K12DK111028]. A.F. was partially supported by the National Institute on Drug Abuse [grant number K23DA039800]. The funding sponsors had no role in study design; the data collection, analysis, and interpretation of data; the writing of the report; the decision to submit the article for publication; or the preparation of the manuscript. Dr Obedin-Maliver has received grants and consultation fees from Ibis Reproductive Health, Hims and Hers Health Inc., Folx Health Inc., Sage Therapeutics and Upstream Inc. on topics unrelated to this work. Dr Lunn received consultation fees from Hims and Hers Health Inc., Folx Health Inc., Otsuka Pharmaceutical Development and Commercialization, Inc., and the American Dental Association on topics unrelated to this work. All other authors have no conflicts of interest to report. TRIAL REGISTRATION NUMBER: None.

Inclusive measures of gender are critical for health equity research. This study compared the reliability and applications of 2 different approaches for measuring gender in response to emerging community concerns regarding the potential harms of asking about sex assigned at birth (SAAB) within transgender and gender diverse (TGD) populations. Using data from a 2021 survey of LGBTQ+ people in Washington state, we compared approaches for measuring gender via a 2-step question that collected data on (1) current gender and SAAB vs (2) current gender and transgender self-identification. Among 2275 LGBTQ+ participants aged 9-81 years, 63% were cisgender, 35% TGD, and 2% were not categorized. There was near perfect agreement between the 2 methods in their ability to identify TGD participants (percent agreement = 99.7%, unweighted Cohen’s Kappa = 0.99). Among gender diverse participants, stratification by SAAB revealed differences in sexual health outcomes, while stratification by transgender self-identification revealed differences in access to gender-affirming care and lifetime experiences of discrimination. Ascertaining SAAB may be most useful for identifying sexual health disparities, while transgender self-identification may better illuminate healthcare needs and social determinants of health among TGD people. Researchers and public health practitioners should critically consider the acceptability and relevance of SAAB questions to their research goals.

Background: There are limited data on pelvic pain among transgender men and gender diverse people, and the impact of testosterone on pelvic pain is poorly understood.Objective: Characterize the prevalence and correlates of chronic pelvic pain (CPP) among transgender men and gender diverse people and examine the association between testosterone use and CPP.Materials and methods: We used 2020–2022 data from The Population Research in Identity and Disparities for Equality (PRIDE) Study, an online prospective cohort study of sexual and gender minority adults in the United States, to conduct complementary cross‐sectional and longitudinal analyses. Our primary outcome was self‐reported CPP lasting 3 months or longer measured using the Michigan Body Map.Results: Among 2579 transgender men and gender diverse people assigned female at birth included in our sample, 457 (18%) reported CPP. CPP correlates included: inflammatory bowel disease, irritable bowel syndrome (IBS), kidney stones, pelvic inflammatory disease, polycystic ovary syndrome (PCOS), uterine fibroids, current hormonal intrauterine device use, prior pregnancy, vaginal delivery, hysterectomy, and oophorectomy. Individuals with CPP reported a high prevalence of IBS (37%), PCOS (20%), uterine fibroids (9%), post‐traumatic stress disorder (51%), and severe depression and anxiety symptoms (42% and 25%, respectively). Current testosterone use was associated with a 21% lower prevalence of CPP (adjusted prevalence ratio (aPR) 0.79, 95% confidence interval [CI]: 0.65–0.96). In longitudinal analyses (N = 79), 15 (19%) participants reported any CPP after initiating testosterone: eight (56%) of whom reported CPP prior to testosterone initiation, and seven (47%) who reported new‐onset CPP.Discussion and conclusions: The relationship between CPP and testosterone is complex. Although testosterone use was associated with a lower prevalence of CPP, some transgender and gender diverse individuals experienced new‐onset pelvic pain after testosterone initiation. Given the significant impact that CPP can have on mental health and quality of life, future research must examine the role of testosterone in specific underlying etiologies of CPP and identify potential therapies.