Expanding the Boundaries of Sexual & Reproductive Health Care

Taken from the March/April 2013 issue of the Women's Health Activist Newsletter.

Trans men are individuals who were assigned a female sex at birth but who identify as male. Many people have heard of Thomas Beatie, a trans man who self-identified as the world’s first “Pregnant Man” after he decided to become pregnant when his wife was found to be infertile. Beatie and his then-wife have described the painful and extended process of seeking care during Beatie’s pregnancy, and how some providers refused to treat the couple.i

In 1999 another trans man, Robert Eads, died of complications from metastasized ovarian cancer.1 In his 40s, Eads had sexual reassignment surgery to physically transition from female to male. As a post-menopausal woman prior to transition, Eads was told that it was unnecessary to remove his uterus and ovaries as part of the reassignment.ii Unaware of his need for regular gynecological cancer screenings, Eads suffered from an unidentified illness for over a year, until the Medical College of Georgia accepted him as a patient in 1997 and diagnosed his cancer. While ovarian cancer is notoriously deadly and hard to diagnose and treat, the year-long delay in diagnosis hampered Eads' chance of survival and negatively affected his quality of life.

Regrettably, Beatie’s and Eads’ stories both illustrate providers’ discrimination and the pervasive lack of knowledge about trans men’s needs for routine sexual and reproductive health care. Their experiences highlight the need for comprehensive education on trans men’s sexual and reproductive health for health care providers and the general public. In particular, women’s health care providers must support the needs of transgender men and gender non-conforming female-bodied individuals — or this population will continue to be underserved and at-risk for poor health outcomes.

Who Are Trans Men?

First, some background. According to the World Health Organization, sex refers to the “biological and physiological characteristics that define men and women,” while gender describes the “socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women.”iii The American Psychological Association defines “transgender” as “an umbrella term for persons whose gender identity, gender expression, and/or behavior does not conform to that typically associated with the sex to which they were assigned at birth.”iv (In contrast, a cisgender individual’s gender identity aligns with the sex assigned at birth.)

Trans men were assigned a female sex at birth but have a male gender identity. These individuals may describe themselves as trans men, female-to-male transgender individuals, males, or a range of other identifiers. Trans men are not a homogenous group and are not defined by what medical procedures they have or haven’t had. Trans men may seek a variety of medical procedures if they decide to undergo sexual reassignment surgery, including hormone therapy (e.g., androgen therapy) and reconstructive surgery (e.g., double mastectomy with nipple and areola reconstruction).v But, some who identify as trans men do not use hormones, have surgery, or seek other physical changes to their appearance as part of their transition, and only shift clothing and/or pronouns to signify their transition.

Trans Men’s Health Needs

Regardless of the medical procedures they have, most trans men are at-risk for women’s health problems, such as ovarian, cervical and uterine cancers – before, during and after transition. The American College of Obstetricians and Gynecologists (ACOG) has stated that basic preventative services, such as sexually transmitted infection (STI) tests, comprehensive contraceptive counseling, and cancer screening, does not require “specific expertise in transgender care.” Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers clearly describes trans men’s need for comprehensive services before, during, and after transition. It recommends that, in general, “screening should continue until the patient no longer has the screened organ” (emphasis added).v

The Guide stresses the importance of educating trans men who retain their uterus about the signs of endometrial cancers, and notes, “any patient with a uterus/cervix should ideally have yearly pelvic exams with Pap smears…even if a Pap smear is not required ACOG still recommends yearly pelvic exams for any adult female-bodied person. This need for screening should be emphasized to trans men who have historically been reticent to seek out appropriate gynecologic care.”v The Guide notes that long-term androgen treatment and testosterone therapy — which aid the physical transition from one sex to another — are linked with high rates of Polycystic Ovarian Syndrome (PCOS), which is associated with an increased risk of endometrial and breast cancers as well as decreased fertility.v Similar guidance about screening mammograms should be followed when treating trans men who have not had bilateral mastectomies.

Family planning is another potential area of need, since many trans men have cisgender male sexual partners. Trans men who have not had a hysterectomy can become pregnant and will benefit from access to stigma-free contraception and abortion services.vi Yet, clinical guidance on this population’s health care needs is usually silent about family planning and abortion counseling and services.

Addressing Barriers to Care

Barriers to sexual and reproductive health services for transgender individuals are created when there is a disconnect between what providers and health care workers perceive the individual’s needs to be, and the individual’s actual needs. One way to address this barrier is to ensure providers have the resources needed to provide quality, respectful services to transgender-spectrum and gender-nonconforming patients. And, providers must ensure that all patients’ needs are heard and addressed. Too many trans men and other gender-nonconforming individuals face overwhelming levels of discrimination and marginalization throughout their lives, including discrimination when seeking health care.

The National Gay and Lesbian Task Force and the National Center for Transgender Equality’s National Transgender Discrimination Survey (NTDS) describes this population’s appalling health outcomes, including “much higher rates of HIV infection, smoking, drug and alcohol use[,] and suicide attempts than the general population.”vii  The survey found that 63 percent of “participants had experienced a serious act of discrimination — events that would have a major impact on a person’s quality of life and ability to sustain themselves financially or emotionally.”vii

In a ground-breaking report on lesbian, gay, bisexual and transgender (LGBT) health issues, the Institute of Medicine (IOM) noted the significant barriers to care faced by transgender individuals, which include providers refusing treatment and verbally abusing their patients.viii The NTDS found that 28 percent of the respondents had experienced harassment in a doctor’s office; 19 percent had been denied medical care; and 2 percent had been physically attacked in a doctor’s office.vii Respondents were most likely to be refused care in doctor’s offices and hospitals (24 percent), followed by Emergency Departments (13 percent), and mental health clinics (11 percent).vii Those whose gender presentation closely matched their assigned sex were less likely to report having been refused care. Dishearteningly, the likelihood of discrimination increased when medical providers were aware of the patient’s transgender status.”vii

Providers need to be better informed about, and more accepting of, transgender patients’ sexual and reproductive health care needs. About 62 percent of trans men NTDS respondents reported “having to teach their medical care providers about transgender care.”vii Most trans men who have sex with men (95 percent) reported getting inadequate information from providers about their overall sexual health.viiProviders need to communicate with their female-born transgender patients about the full range of preventative screenings, tests, and precautions needed to maintain their sexual and reproductive health.

Transgender individuals also face economic barriers that hamper their ability to get needed health care. Trans men have high rates of unemployment and, when employed, report workplace abuse and harassment, being forced to present as the wrong gender, and physical assault. Respondents reported being less likely to be covered by private or employer-based insurance; 19 percent had no insurance coverage.vii

Further, even in cases where trans men are insured, complications may arise for gender-specific services. For example, a trans man who takes hormones and has legally changed gender from female to male might be denied coverage for a Pap smear, which is covered only as part of a woman’s wellness visit. Although the Affordable Care Act prevents discrimination based on transgender or gender-nonconforming status by Federally funded programs and organizations, it does not fundamentally ensure that all needed services are covered and/or offered to these individuals.

Where Do We Go From Here?

In 2011 ACOG’s Committee on Health Care for Underserved Women published an opinion noting that, “Lack of awareness, knowledge, and sensitivity in health care communities eventually leads to inadequate access to, underutilization of, and disparities within the health care system for this population.ix The fact that transgender issues are being discussed by key officials, health care associations, and policy-making entities demonstrates a significant cultural sea change on this issue. Much more must be done, however, to ensure that health care providers and insurance companies are able and willing to provide necessary health care services to all who need them, regardless of their gender expression and identity. Doctor’s offices, Emergency Departments, labor and delivery rooms, and clinics must be safe spaces for individuals of anygender presentation, and services must be offered based on a person’s need rather than their appearance.

E. Cameron Hartofelis is a MA/MPH candidate in Communication Studies and Maternal and Child Health at the University of North Carolina at Chapel Hill. Her work focuses on the reduction of disparities in access to sexual and reproductive healthcare in the United States.

Anu Manchikanti Gomez, PhD, MSc is a Research Scientist at the Center for Research and Education on Gender and Sexuality at San Francisco State University and a NWHN Board Member.

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[1] A health clinic named in Eads’ honor has been integrated as part of the yearly Southern Comfort conference, which attends to the needs of transgender (particularly trans-masculine) individuals.

[i] Currah P, "Expecting Bodies: The Pregnant Man and Transgender Exclusion from the Employment Non-Discrimination Act," WSQ: Women's Studies Quarterly 2008; 36(3): 330-336.

[ii] Southern Comfort, DVD, directed by Kate Davis (2001; New Wave Films), Film.
[iii] World Health Organization (WHO), What do we mean by ‘sex’ and ‘gender’?,http://www.who.int/gender/whatisgender/en/, 2012.
[iv] American Psychological Association (APA), Answers to Your Questions About Transgender People, Gender Identity, and Gender Expression, Washington, DC: APA, 2011. Available online at: http://www.apa.org/topics/sexuality/transgender.aspx.
[v] Gorton R, Buth J, Spade D, Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers, San Francisco: Lyon-Martin Women's Health Services, 2005.
[vi] National Center for Transgender Equality (NCTE), Transgender Sexual and Reproductive Health: Unmet Needs and Barriers to Care, Washington DC: NCTE, 2012.
[vii] Grant JM, Mottet LA, Tanis J, et al., Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, Washington DC: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011,p. 72
[viii] Institute of Medicine (IOM), The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, Washington DC: National Academy Press, 2011, p. 62.
[ix] The American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women, “Health Care for Transgender Individuals,” Obstetrics and Gynecology 2011; 118: 1454-8.