Over one million people in the United States are transgender, nonbinary, or gender expansive (TGE). TGE individuals, particularly those who have pursued gender-affirming care, often need to disclose their identities in the process of seeking healthcare. Unfortunately, TGE individuals often report negative experiences with healthcare providers (HCPs). We conducted a cross-sectional online survey of 1684 TGE people assigned female or intersex at birth in the United States to evaluate the quality of their healthcare experiences. Most respondents (70.1%, n = 1180) reported at least one negative interaction with an HCP in the past year, ranging from an unsolicited harmful opinion about gender identity to physical attacks and abuse. In an adjusted logistic regression model, those who had pursued gender-affirming medical care (51.9% of the sample, n = 874) had 8.1 times the odds (95% CI: 4.1-17.1) of reporting any negative interaction with an HCP in the past year, compared to those who had not pursued gender-affirming care, and tended to report a higher number of such negative interactions. These findings suggest that HCPs are failing to create safe, high-quality care interactions for TGE populations. Improving care quality and reducing bias is crucial for improving the health and well-being of TGE people.

Background: Transgender, nonbinary, and gender-expansive (TGE) people experience pregnancy. Quantitative data about pregnancy intentions and outcomes of TGE people are needed to identify patterns in pregnancy intentions and outcomes and to inform clinicians how best to provide gender-affirming and competent pregnancy care. Aims: We sought to collect data on pregnancy intentions and outcomes among TGE people assigned female or intersex at birth in the United States. Methods: Collaboratively with a study-specific community advisory team, we designed a customizable, online survey to measure sexual and reproductive health experiences among TGE people. Eligible participants included survey respondents who identified as a man or within the umbrella of transgender, nonbinary, or gender-expansive identities; were 18 years or older; able to complete an electronic survey in English; lived in the United States; and were assigned female or intersex at birth. Participants were recruited through The PRIDE Study - a national, online, longitudinal cohort study of sexual and gender minority people - and externally via online social media postings, TGE community e-mail distribution lists, in-person TGE community events, and academic and community conferences. We conducted descriptive analyses of pregnancy-related outcomes and report frequencies overall and by racial and ethnic identity, pregnancy intention, or testosterone use. Results: Out of 1,694 eligible TGE respondents who provided reproductive history data, 210 (12%) had been pregnant. Of these, 115 (55%) had one prior pregnancy, 47 (22%) had two prior pregnancies, and 48 (23%) had three or more prior pregnancies. Of the 433 pregnancies, 169 (39%) resulted in live birth, 142 (33%) miscarried, 92 (21%) ended in abortion, two (0.5%) ended in stillbirth, two (0.5%) had an ectopic pregnancy, and seven (2%) were still pregnant; nineteen pregnancies (4%) had an unknown outcome. Among live births, 39 (23%) were delivered via cesarean section. Across all pregnancies, 233 (54%) were unintended. Fifteen pregnancies occurred after initiation of testosterone, and four pregnancies occurred while taking testosterone. Among all participants, 186 (11%) wanted a future pregnancy, and 275 (16%) were unsure; 182 (11%) felt at risk for an unintended pregnancy. Discussion: TGE people in the United States plan for pregnancy, experience pregnancy (intended and unintended) and all pregnancy outcomes, and are engaged in family building. Sexual and reproductive health clinicians and counselors should avoid assumptions about pregnancy capacity or intentions based on a patients presumed or stated gender or engagement with gender-affirming hormone therapy.

To address pervasive measurement biases in sexual and reproductive health (SRH) research, our interdisciplinary team created an affirming, customizable electronic survey to measure experiences with contraceptive use, pregnancy, and abortion for transgender and gender nonbinary people assigned female or intersex at birth and cisgender sexual minority women. Between May 2018 and April 2019, we developed a questionnaire with 328 items across 10 domains including gender identity; language used for sexual and reproductive anatomy and events; gender affirmation process history; sexual orientation and sexual activity; contraceptive use and preferences; pregnancy history and desires; abortion history and preferences; priorities for sexual and reproductive health care; family building experiences; and sociodemographic characteristics. Recognizing that the words people use for their sexual and reproductive anatomy can vary, we programmed the survey to allow participants to input the words they use to describe their bodies, and then used those customized words to replace traditional medical terms throughout the survey. This process-oriented paper aims to describe the rationale for and collaborative development of an affirming, customizable survey of the SRH needs and experiences of sexual and gender minorities, and to present summary demographic characteristics of 3,110 people who completed the survey. We also present data on usage of customizable words, and offer the full text of the survey, as well as code for programming the survey and cleaning the data, for others to use directly or as guidelines for how to measure SRH outcomes with greater sensitivity to gender diversity and a range of sexual orientations.