Characterizing sexual and reproductive health needs, experiences, and disparities in care access among transgender, nonbinary, and gender expansive communities in the United States

Abstract

Transgender, nonbinary and gender expansive (henceforth, trans) communities are disproportionately burdened with higher rates of negative sexual and reproductive health (SRH) outcomes and gaps in healthcare engagement. Gender affirmation has been shown to be associated with improved health outcomes for trans populations, including SRH care access and outcomes. To improve our understanding of this relationship, we used three different approaches and SRH content areas. First, we applied a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) intersectional analysis using the 2015 U.S. Transgender Survey (USTS) to quantify intersectional inequities by exploring heterogeneity in HIV testing in relation to gender affirmation and relevant social identities. Dimensions of social strata were operationalized via self-reported measures of age, gender identity, ethnoracial group, and medical/legal affirmation. Second, using electronic health record and computer-assisted self-interview data from transmasculine patients attending the municipal sexual health clinic in Washington, we compared differences in pregnancy prevention and contraception service utilization by gender identity and testosterone use and assessed correlates of contraceptive use and desire for a pregnancy test among patients at risk for pregnancy. Third, we implemented a community-engaged approach that addressed gaps in trans-inclusive sexual health knowledge educational tools by co-developing and content validating sexual health knowledge measures for trans youth. These measures can be utilized to support future research examining both content and quality of sexual health education for trans youth. We found significant heterogeneity in SRH care utilization across multiple dimensions of identities and experiences, SRH care needs in relation to gender affirmation, and a need for relevant SRH measures for trans populations. Our findings underscore the importance of trans-inclusive SRH care to address multilevel stigma and marginalization in SRH care.