Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Iman K. Berrahou

Abstract

Many transgender and gender diverse (TGD) individuals have contraceptive needs. Contraceptive counseling in this population is often nuanced due to the diverse experiences and healthcare goals of TGD individuals. Testosterone therapy is an important component of gender affirming care for some transgender and gender diverse (TGD) individuals. A common misconception among patients and providers is the role of testosterone in pregnancy prevention. Testosterone is not an effective form of contraception due to its inconsistent suppression of ovulation. Previous studies have shown that some patients who use testosterone for contraception do so based on guidance from their healthcare provider. Therefore, this study aimed to evaluate providers’ education, knowledge, experience, and perception regarding contraceptive counseling for TGD patients. By gaining a deeper understanding of providers' current practices and knowledge gaps, this study aims to identify strategies to improve counseling and ensure more accurate contraceptive guidance for TGD patients.The study was granted an exemption from Yale University’s Institutional Review Board. Licensed US healthcare providers with experience providing contraceptive counseling were eligible to complete the study survey. The survey collected provider demographic information, their prior education on providing care for TGD patients, and information about their clinical practice. We assessed (1) contraception-related knowledge, (2) provider confidence providing contraceptive counseling to TGD patients, (3) perceptions of barriers that limited effective contraceptive counseling for TGD patients, and (4) practice behaviors regarding counseling of reproductive health topics. Surveys were collected anonymously through Qualtrics. Participants were recruited through professional networks and email distribution across multiple academic institutions. Forty-seven complete survey responses were collected from providers nationwide. Most respondents were physicians (91.5%) with the majority practicing in the Northeast (37%) and Midwest (39.1%). Diverse gender identity and sexual orientation were represented among respondents, with 32.6% identifying as a sexual or gender minority. Most practiced at academic institutions with resident trainees (76.6%). Respondents varied in the number of TGD patients seen per month, with 59.6% reporting fewer than five, 23.4% seeing five to ten, and 17% seeing more than ten TGD patients per month. Our respondents had a median of 2.5% (IQR 1-8.86%) TGD patients in their practice. Providers who care for significantly higher proportions of TGD patients were more likely to work in non-academic settings (p=0.011), identify as a sexual or gender minority (p<0.001), have received over 11 hours of formal TGD health education (p=0.049), and work in practices with formal staff training on TGD care (p=0.015). Nearly 30% of respondents had no TGD health education during their medical training. However, 46.8% reported 1-5 hours of formal education on TGD health during training. Providers practicing less than 10 years reported statistically more TGD health education during training than more experienced providers (p<0.002). Most respondents (91.5%) had additional TGD health education since completing their medical education, most frequently from colleagues (80.9%), medical journals or publications (72.3%), professional meetings or conferences (66%), and TGD patients (63.8%). Overall contraceptive-related knowledge was high– with respondents averaging 5.89 (SD=0.983) correct responses to the 7 knowledge-assessment questions. Providers who saw five or more TGD patients per month had significantly higher cumulative knowledge scores (mean=6.47, SD=0.772) than providers with fewer TGD patients (mean=5.5, SD=0.923); p<0.001. There was no significant difference in cumulative knowledge score by provider education, years in practice, practice environment, or identity. Despite respondents’ high knowledge scores, 27.6% lacked confidence in their ability to counsel TGD patients on their contraceptive options and 34% lacked confidence in their ability educate patients on testosterone’s impact on reproductive potential. Significantly higher confidence was associated with providers who saw five or more TGD patients each month (p<0.001), identified as a sexual or gender minority (p=0.033), or used diverse educational resources to learn more about TGD healthcare (p<0.001). Providers most frequently reported TGD patients not seeking gynecologic care as a barrier to providing contraceptive counseling (72.4%). Compared to their cisgender patients, 14.9% of providers were less likely to discuss fertility desires and family planning goals and 6.4% were less likely to discuss contraceptive options with TGD patients. Our national survey results suggest a shift in medical training to include more TGD health education, however significant gaps still exist. Our study found that providers who care for a higher number of TGD patients had significantly greater knowledge scores and confidence in counseling. Therefore, increasing exposure to TGD patients during clinical training is key to preparing the next generation of providers to deliver informed and inclusive care. Additionally, our study highlighted significant barriers to contraceptive counseling for TGD patients, including a lack of provider confidence, disparities in provider practices, and the common belief that TGD patients are reluctant to seek gynecologic care. Therefore, practices should develop a gender inclusive environment with appropriate materials and staff training to improve TGD patients’ comfort in seeking care and increase opportunities to provide contraceptive counseling.

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