Experiences of progestin-only pill users in the United States and attitudes toward over-the-counter access.

CONTEXT: Removing the prescription requirement and making oral contraceptive pills available over the counter (OTC) could increase contraceptive access in the United States. Despite current efforts to make a progestin-only pill (POP) available OTC, there are no qualitative data exploring the experiences of POP users and their perspectives on making POPs available OTC. METHODS: We conducted six online, asynchronous focus group discussions with 36 POP users between July and November 2020. We stratified focus group discussion placement based on three reasons for POP use: breastfeeding, having a contraindication to estrogen (for a reason other than breastfeeding), and for any other reason. We thematically analyzed these data using inductive and deductive coding. RESULTS: The majority of participants described their overall POP experience as positive, mostly because they experienced minor or no side effects and thought the pill was effective. Participants overwhelmingly supported OTC availability of POPs and expressed interest in purchasing an OTC POP. Over one-third of participants had very limited knowledge or held inaccurate assumptions about POPs before they started using this method and many stressed the need to disseminate accurate information and resources about POPs to the public. CONCLUSIONS: Most focus group discussion participants were satisfied with POPs and supported OTC access. While misconceptions and concerns about POPs should be addressed, an OTC POP has the potential to be a safe, effective, and convenient contraceptive option in the United States.

Healthcare Providers' Pregnancy Prevention Counseling of Trans and Non-Binary Assigned Female at Birth (TNB/AFAB) Patients.

Transgender and non-binary people assigned female at birth (TNB/AFAB) have unintended pregnancies, but there is a dearth of information about effective pregnancy prevention care for this population. This needs assessment study aimed at discerning pregnancy prevention care best practices involved interviews of 20 healthcare providers solicited for experience providing pregnancy counseling with this group. Findings were organized via the ecological model, revealing four layers of themes. 1) Social structural level themes related to the gender binary system and other forms of oppression (racism, sexism, heterosexism); 2) the systems level theme related to access to and barriers to care; 3) provider level themes included lack of formal education, need to provide trauma-informed care, and provider discomfort or assumptions; and 4) patient-level themes included the fact that patients do not usually raise issues related to contraception and that TNB/AFAB patients have unique contraception needs. Implications of the findings are discussed.

Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey.

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 patient's presumed or stated gender or engagement with gender-affirming hormone therapy.

Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States.

BACKGROUND: Transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth experience pregnancy and have abortions. Scarce data have been published on individual abortion experiences or preferences of this understudied population. OBJECTIVE: This study aimed to fill existing evidence gaps on the abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States to inform policies and practices to improve access to and quality of abortion care for this population. STUDY DESIGN: In 2019, we recruited transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth at the age of ≥18 years from across the United States to participate in an online survey about sexual and reproductive health recruited through The Population Research in Identities and Disparities for Equality Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for transgender, nonbinary, and gender-expansive people, and respondent sociodemographic characteristics. RESULTS: Most of the 1694 respondents were <30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all 4 United States Census Regions. Overall, 210 respondents (12%) had ever been pregnant; these 210 reported 433 total pregnancies, of which 92 (21%) ended in abortion. For respondents' most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (5%) were another method (primarily herbal). Most recent abortions took place at ≤9 weeks' gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion over surgical abortion in a 3:1 ratio (n=703 vs n=217), but 514 respondents (30%) did not know which method they would prefer. The reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for transgender, nonbinary, and gender-expansive patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers use gender-neutral language, and that greater privacy be incorporated into the clinic. CONCLUSION: These data contribute substantially to the evidence base on individual experiences of and preferences for abortion care for transgender, nonbinary, and gender-expansive people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.