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This chapter focuses on the reproductive and obstetric aspects of health that are specific to transgender and gender diverse (TGD) populations. Sexual health, including prevention of HIV and sexually transmitted infections (STIs), is covered elsewhere in this book (see Chapter 16, “Screening and Prevention of HIV and Sexually Transmitted Infections” and Chapter 17, “Treatment of HIV and Sexually Transmitted Infections”). This chapter also discusses legal and financial aspects of family building for TGD individuals and provides resources for patients who are exploring ways to build a family.


The term reproductive health refers to the condition of the human reproductive systems during all life stages. The World Health Organization (WHO) expands this definition to include “complete physical, mental and social well-being, and not merely the absence of disease or infirmity” and states that reproductive health implies that “people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so.”1 Reproductive health care includes contraception counseling, screening for and treatment of STIs, cancer screening, and discussion of a reproductive plan. For those who wish to become pregnant, prepregnancy counseling provides the opportunity to achieve optimal health before pregnancy and address modifiable risk factors to improve obstetric outcomes.2 For TGD individuals, additional reproductive health issues may include education about how gender-affirming hormone therapy (GAHT) and surgeries may affect fertility and reproductive planning and consequent fertility treatment and preservation. Many of these services, especially those related to preventive health care, can be provided by clinicians who do not have specific expertise in TGD care. Other services, such as GAHT and gender-affirming surgery, may be best managed in consultation with experts who specialize in the care and treatment of TGD individuals.3


Many TGD people report barriers to accessing reproductive health care while at the same time acknowledging their need for such health care and their interest in addressing various reproductive health concerns, including cervical cancer screening, STI testing and prevention, and contraception. TGD patients seek information about gender-affirming care, including the impact of GAHT on pregnancy, how to preserve future fertility when pursuing gender-affirming treatments, and the use of GAHT following gender-affirming surgery.4

Barriers to reproductive care include structural barriers, such as the failure of health insurance plans to cover mental health services and gender-affirming care. Social and economic marginalizations constitute another barrier to consistent, quality health care. Discrimination and stigma often discourage TGD individuals from seeking professional health care due to the lack of education and acceptance among health care professionals about TGD health needs. In one study, TGD people assigned female sex at birth (AFAB) point to the association of reproductive health care with “women’s health” as a major barrier to addressing reproductive ...

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