ConQual Summary of Findings

Introduction

With an intensified focus on patient-centered and culturally competent care, it is important to acknowledge populations that may live a more marginalized life. Although the transgender community is gaining visibility and acceptance in the overall population, barriers still exist in seeking health care. Often these barriers are intensified when the care being sought is gender-based, such as gynecological care or prostate examinations.

Transgender is an umbrella term used to describe individuals whose gender identity differs from society's male/female binary understanding of gender and their birth (assigned) sex. For example, a transgender man is assigned the sex female at birth, yet he identifies as male on the spectrum of gender identity. Unlike sex designation, gender can be thought of as a spectrum of masculine to feminine, and individuals can fall at different points on the spectrum at different times in their lives.

As the transgender population becomes more visible and vocal, more individuals are finding the courage to identify themselves as transgender. This has led to more accurate estimations of the size of the population. In 2016, a Williams Institute survey found an estimated 0.6% or 1.4 million people in the United States identified as transgender. This number is double that of prior estimates.2 In 2016, Winter et al.3 investigated international studies to estimate the global prevalence of the transgender population. They found studies indicating that the prevalence of persons who identify as transgender was 0.5% in the United States and the United Kingdom, 0.6% in Belgium, 0.9% in the Netherlands, and 1.2% in New Zealand. As knowledge about the size of the transgender population improves, there is a growing urgency to focus on recognizing and eliminating the barriers to care that continue to exist.

In a recent survey-based study on over 6000 transgender respondents, 19% had been refused medical care, 25% delayed seeking medical care, 28% postponed needed medical care when sick or injured, and 33% delayed or did not seek preventive care as a result of previous discrimination or disrespect. Perhaps the most concerning of these findings is that 2% of respondents reported having been physically assaulted in a doctor's office or hospital.4

It is clearly identified within the existing literature that fear of mistreatment and discrimination is an ongoing concern among the transgender community. It is this fear that has historically led the transgender individual to avoid seeking needed care.5-9 Jaffee et al.10 identified that in a sample of 3486 transgender participants, 30.8% delayed or did not seek needed care due to discrimination. This avoidance of the healthcare system is only part of a multifactorial environment of marginalization that can lead to health disparities among this population.11 In a separate study of transgender men, Shires and Jaffee12 found that 41.8% reported verbal harassment, physical assault, or denial of equal treatment in doctors' offices.

Also cited in the literature is the frequent need for transgender individuals to educate their providers on how best to care for them. Jaffee et al.10 identified that transgender individuals who needed to educate their providers were four times more likely to delay needed care. In a 2015 study, Unger13 found that 80% of gynecologists had received no training in residency around how to care for transgender individuals and that only 29% were comfortable caring for female-to-male patients. In a qualitative study of nursing faculty and students, Echezona-Johnson14 found that respondents were not knowledgeable about the obstetrical health issues of lesbian, gay, bisexual, and transgender (LGBT) persons. This study further found that many of the respondents were uncomfortable including LGBT needs in the curriculum due to religious beliefs, with one respondent stating, "The lifestyle is not clear to me. I have limited information about the population[horizontal ellipsis] I can understand and even teach about the gays, the lesbians and even the bisexuals, but the transgender lifestyle is an abomination practice - we do not need to promote the lifestyle by teaching it to our students - I know everyone is now making a big deal about it."14^(p.142) This study further evaluated LGBT content within course materials, finding 0.14% of textbook lines and 0.16% of lecture note lines contained LGBT content.

Transgender persons face systematic difficulties in accessing care as well. Sex designation on birth certificates, gender designation on government-issued identification, and gender designation on insurance cards all prove problematic for transgender men. These difficulties are again compounded when the care being sought is gender-based, such as gynecological examinations. If routine screening examinations are neglected, transgender men may face health risks or be forced to access emergency care for gynecological concerns.

Transgender individuals frequently point to unnecessary genital examinations by providers as a reason for avoiding medical care.4-6,15-18 The reality that these types of examinations are often needed also prompts many transgender men to avoid preventive care as a result of past discrimination.19-24 When transgender men do seek preventive care, they must often contend with a provider and staff who are poorly educated and ill-prepared to care for such a specialized clientele.8,14,25-27

Compassionate, culturally competent care requires a deeper understanding of the special needs of the transgender individual. This understanding can be gained through listening to the voices of those experiencing care as it exists today. The objective of this review was to gain further understanding of the experiences of transgender men when seeking gynecological and reproductive health care in both the community and acute care settings. The goal of this review is for frontline clinicians and policy makers to use the knowledge to inform and impact care experiences for the transgender man in seeking care locally as well as globally.

A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or in-process systematic reviews on the topic were identified.

Review question

What are the experiences of transgender men in seeking gynecological, fertility, and/or reproductive health care in all healthcare settings globally?

Inclusion criteria

Participants

This review considered all studies that included natal females who identified as transgender men, gender non-binary, gender expressive, or gender queer. Puberty may necessitate gaining access to gynecological care for the first time. On average, natal females experience menarche between 12 to 14 years of age.28 In an attempt to gain understanding of these experiences, an age range of 12 years through adulthood was selected.

Phenomena of interest

This review considered studies that explored the experiences of transgender men seeking gynecological care, obstetrical care, fertility care, or reproductive care, including their perspectives, narratives, and/or reflections during the care experience. The healthcare experience included interactions with care providers such as registered nurses, advanced practice nurses, physicians, or physician assistants as well as office, clinic or hospital registration staff, and social workers. Studies that focused on the aforementioned healthcare provider's perceptions of providing care were excluded.

Context

This review considered qualitative studies that explored the experiences with care that take place in community-based clinics, gynecological health clinics, physician offices, emergency departments, or urgent care centers (if seeking care for gynecological conditions), and obstetrical labor and delivery units of hospitals.

Types of studies

This review includes studies that focused on the experiences of transgender men while seeking gynecological, reproductive, or fertility-related care in which researchers had collected and analyzed qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and feminist research.

Methods

This systematic review was conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.29 The review was conducted in accordance with an a priori protocol.30

Search strategy

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized. An initial limited search of PubMed and CINAHL was undertaken followed by analysis of the text words obtained in the title and abstract, and the index terms used to describe the articles. A second search using all identified keywords and index terms was undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles was searched for additional studies. A full search strategy is detailed in Appendix I. The search strategy, including all identified keywords and index terms, was adapted for each included information source. Truncation and wild cards were utilized to ensure international and regional differences in spelling for search terms were captured in the search results. A nursing library scientist was consulted throughout the search phase of the review to ensure the best possible results were identified. Searches were conducted between November 2018 and January 2019.

Studies published in English were included. Studies published from 1979 to the present were included as 1979 was the year of the first publication of World Professional Association of Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (formerly the Benjamin Standards of Care).31

Information sources

The databases searched included CINAHL Complete (EBSCO), PubMed, PsycINFO (EBSCO), PsycArticles (EBSCO), ScienceDirect All Subscribed Content (Elsevier), and Web of Science. Sources of unpublished studies and gray literature searched included Google Scholar, MedNar, and ProQuest Dissertations and Theses.

Study selection

Following the search, all identified citations were collated and uploaded into EndNote X9 (Clarivate Analytics, PA, USA) via Web of Science and duplicates removed. Titles and abstracts were then screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies were retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations was assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that did not meet the inclusion criteria were recorded and are reported in Appendix II. Any disagreements that arose between the reviewers at each stage of the study selection process were resolved through discussion, with no need for a third reviewer. The results of the search are reported in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.32

Assessment of methodological quality

Eligible studies were critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Assessment and Review instrument contained in and accessed via JBI SUMARI.33 All studies, regardless of the results of their methodological quality, underwent data extraction and synthesis (where possible). The results of the critical appraisal are reported in narrative form and in a table.

Data extraction

Qualitative data were extracted from studies included in the review by two independent reviewers using the standardized tool in JBI SUMARI.33 The data extracted included specific details about the populations, context, culture, geographical location, study methods, and the phenomena of interest relevant to the review objective. Findings, and their illustrations, were extracted and assigned a level of credibility (Table 1). Any disagreement that arose between the reviewers was resolved through discussion.

Table 1 JBI levels of credibility for qualitative studies

Data synthesis

Qualitative research findings were pooled using JBI SUMARI and the meta-aggregation approach.33 This involved the synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories were then subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. The ConQual approach to assessing the dependability and credibility of each synthesized finding was then applied.1

Both members of the review team collaboratively studied the extracted findings and grouped them into draft categories based on similarity in meaning. The draft categories and their associated findings were re-examined individually, then discussed cooperatively and refined over a period of two weeks. The synthesized findings were drafted by the primary author and discussed with the second author to confirm and further revise as needed.

Assessing confidence in the findings

The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.1 The Summary of Findings includes the major elements of the review and details how the ConQual score was developed. Included in the Summary of Findings are the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review has been presented, along with the type of research informing it, scores for dependability and credibility, and the overall ConQual score.

Results

Study inclusion

A comprehensive search of the literature was conducted from November 2018 through January 2019. The search yielded 2217 possible articles, and 10 were identified through other sources. After removing duplicates, 2153 titles remained. These 2153 articles were assessed for relevance using their titles and abstracts. From this, 74 were deemed potentially relevant and full-text articles were retrieved where possible. Following full-text assessment, 48 studies were excluded for various reasons (see Appendix II). The search strategy of this review sought sensitivity over specificity of studies to assess. Because little research has been completed with transgender men exclusively, it was known that a vast number of studies would need to be assessed to identify inclusion of transgender men in the sample. As a result of this, many of the assessed articles were excluded on full reading because they either did not include transgender men in the sample or because there was no discussion of gynecological or reproductive health care for transgender men. Following full-text assessment, 26 studies remained. These reports were appraised for quality using the standardized JBI Critical Appraisal Checklist for Qualitative Research via JBI SUMARI, and findings of those appraisals are discussed within a subsequent portion of this review. As per the approved protocol for this review, no studies were excluded due to methodological quality. Figure 1 presents the PRISMA flow diagram of study selection and inclusion below.32

Figure 1. Search results and study selection and inclusion process

Methodological quality

All included articles were appraised separately by both reviewers. Overall quality of the included results ranged from low (3/10) to high (10/10). Six studies yielded a low score for quality (3/10 [two studies34,35], 4/10 [one study23], and 5/10 [three studies20,36,37]); five studies resulted in a moderate-quality score (6/10 [two studies38,39] and 7/10 [three studies40-42]); and 15 received a high score of eight or more "yes" answers (8/10 [five studies27,43-46], 9/10 [one study47], and 10/10 [nine studies48-56]). No disagreements between reviewers arose in the appraisal process. The appraisal results of the 26 included articles can be found in Table 2.

Table 2 Critical appraisal of eligible studies

It is common within reports of qualitative data to exclude information sought within the appraisal tool in favor of brevity in reporting. The reviewers determined that Q8 (Are participants, and their voices, adequately represented?) and Q10 (Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?) in the JBI critical appraisal checklist were crucial to the integrity of this review. Therefore, these questions required a "yes" answer for the study to be included in the review.

The appraisal questions that scored the lowest among the included articles were Q6 (Is there a statement locating the research culturally or theoretically?) and Q7 (Is the influence of the researcher on the research, and vice-versa, addressed?) with overall scores of 59% and 48%, respectively. This is problematic for the dependability of the studies that do not address these questions.23,28,34,35,38-47 Within qualitative research, the integrity of data is contingent on acknowledgement of the researchers' previous experiences and preconceived notions (either through recognition of researcher impact on results or through bracketing). It is crucial the researcher recognize the impact they have on the research and vice-versa. When researching vulnerable populations such as transgender men, a power differential may be perceived by participants. This has the potential to influence results. Without acknowledgement of the researchers' perspective on the results, minimization of bias cannot be assumed to have occurred.

Also absent or unclear in 41% of reports was congruity between the stated philosophical perspective and the research methodology (Q1). Many of the articles appraised had no discussion of the philosophical perspective that drove the research.20,23,34-41 This is often not discussed within published qualitative research articles as a result of the need for succinctness. This question was answered clearly and appropriately in all but one of the included dissertations or theses.36

The congruity between the research methods and the stated research methodology is appraised in questions 2 to 5. If the authors select to not take publication space to discuss their research methodology (eg, phenomenology, ethnography, grounded theory), it results in a "no" or "unclear" answer to these questions. The reviewers determined that 74% to 78% of included studies scored a "yes" for questions 2 to 5 (Q3 and Q5: 74%; Q2 and Q4: 78%).

The reviewers also determined that Q9 (Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body?) was found in 25 of the 26 included studies. This question speaks to the importance of reporting ethical approval by the researchers. This is an often-vital component that is omitted from research reports. The studies included within this review, however, deemed it important enough to be included in research reports.

It cannot be assumed that any exclusions in reports are exclusively due to publishing page limits; however, they are common omissions from qualitative reports.

Characteristics of included studies

The 26 included studies were published between 2006 and 2018. Nineteen were published research articles while seven were unpublished dissertations. These studies were conducted in five different countries: United States (17),20,23,34-37,39,40,44,45,47,50,51,55,56 Canada (four),42,46,48,49 Sweden (two)41,43 Australia (two),28,38 with one study conducted in both Australia and New Zealand.54 The data collection of the included studies was conducted primarily through in-depth interviews. Eighteen studies utilized in-person, one-on-one interviews.23,28,34-36,40-46,48,49,51,52,55,56 Three utilized online interviews.36,47,50 One used either online or in-person interviews.38 One researcher conducted phone interviews.20 Two of the included studies utilized focus groups for data collection.39,42 One study was conducted using a photo-voice technique that combines photos taken by participants with narrative responses to gain understanding of participant experiences.42 One researcher utilized an open-ended-question survey distributed online.54

The total sample size was 874 participants. Participants ranged in age from 18 to 75 years. As there is limited research specifically investigating the experiences of transgender men, specificity could not be sought. As a result, studies varied in their inclusion criteria. As discussed earlier, specificity could not be sought in the search strategy for this review. Studies included in this review sampled the following demographics: lesbian, gay, bisexual, transgender, and queer participants; transgender men; transgender individuals; lesbian or bisexual women and transgender men; transgender or gender-queer individuals assigned female at birth; and transgender community members and allies. Characteristics of included studies can be found in Appendix III.

Review findings

All 26 studies addressed the views and opinions of transgender men seeking gynecological or reproductive health care. The review objectives were considered fully to enable construction of a meta-synthesis (Tables 3-7). The analysis yielded a total of 86 research findings of which 95% (n = 82) were assessed as unequivocal (U), while 5% (n = 4) were assessed as credible (C). No illustrations were assessed as unsupported. See Appendix IV for the findings from each study. The 86 findings were grouped into 14 categories, which were aggregated into five synthesized findings.

Table 3 Synthesized finding 1: negotiating the binary system

Table 4 Synthesized finding 2: navigating the cis-normative world

Table 5 Synthesized finding 3: healthcare access adaptive behaviors

Table 6 Synthesized finding 4: verbal and nonverbal discrimination

Table 7 Synthesized finding 5: provider knowledge and trustworthiness

Synthesized finding 1: Negotiating the binary system

The first synthesized finding is negotiating the binary system: Incongruence between masculine identity and the female need for gynecological care forces transgender men to negotiate within the confines of a binary healthcare system. The strictly binary system requires that patients be either male or female, which leads to denial of coverage and negative impacts on health.

It is well documented within the literature that transgender individuals face barriers when accessing any type of health care. This is particularly troublesome when the care being sought is of a gendered nature. The current healthcare system is structured in a strictly binary manner so that transgender men must negotiate for their gynecological and reproductive care. The binary system requires that patients be either male or female and current reimbursement systems do not allow for any gender variability. This requirement of strict adherence to the male/female binary necessitates that transgender men negotiate within this system to access the care they need.

This synthesized finding comprises two categories and eight findings.

Category 1.1: Denial of coverage

Transgender men must weigh the benefit of seeking gynecological and reproductive care against the risk of potentially being outed to employers as transgender or being denied coverage for the care. As they negotiate within the system, they must decide whether it is more important to maintain their female status with insurers and risk being outed to employers, or if they prefer their healthcare documents to reflect their masculine identity, which would lead them to either avoid gynecological care or pay for care out of pocket.

"Those who had fully transitioned to living as men could not get employer-provided insurance coverage for gynecological care without risking disclosure of their transgender status and thus risking the loss of their insurance or possibly even their jobs. 'Do you come out at work, or do you come out to your insurance company? Do you call them up and say there's been a mistake, or do you just pay for your gyn stuff out of pocket and hope nothing's ever wrong? I know that was always a big issue."'45^(p.8)

"The system of healthcare really has, in some ways, it's not set up to help transgender people. And so knowing that, like, I can't change my legal sex, because I still need to get Paps. And that's the one part that still tied to my old identity is, and that's the only reason that I can't do it is that it's tied to my healthcare. And so um, I think it's, it's those thought processes that actually make getting Paps harder, because it again reinforces how there's, it's kind of institutional discrimination that happens against trans people, and how we're not visible and how we're not seen."56^(p.2143)

Category 1.2: The system

The need to negotiate within the binary system has led transgender men to attempt to manipulate that system when accessing gynecological care by hoping or waiting for abnormal gynecological examinations in an attempt to gain coverage for desired hysterectomies. Negotiating within the binary system drives transgender men to acquiesce to gender norms in order to gain desired reproductive services. Working within or playing the binary system requires transgender men to risk their health in order to obtain necessary or needed care.

"I thought, whatever they call me I just want their help. And if they want me to be female, I don't think I'm gonna say anything [or] if they want to call me the wrong name... the priority is having a kid."50^(p.1370)

"Another FtM participant described what he did to make it work in order the get the hysterectomy he sought: 'I waited because I knew I was transgender. I wanted a hysterectomy but I knew my insurance would not cover it. Waited, I did, I had an abnormal Pap smear prior to me getting cervical cancer. I waited. I waited and I did not go back for any kind of Pap smear. I did not go back in for any pelvic exams, I waited 6 years until... I knew, I knew that I was, at the point where I probably had cancer or the beginnings of cancer and I should go in. And it was just something that came over my body that I knew that okay, I pushed it far enough, I should go in, and I did and I was just at that point where [it] was CIN3 (e.g., cervical intraepithelial neoplasia)... But also I knew that since it had been far enough, my insurance covered my hysterectomy."'46^(p.421)

Synthesized finding 2: Navigating the cis-normative world

The second synthesized finding is navigating the cis-normative world: Spaces and resources of gynecological care are often geared only toward non-transgender, heterosexual women. These care experiences leave transgender men feeling excluded, alienated, invisible, and under-informed about their gynecological and reproductive care.

As with all health care, the care environment plays a major role in patient access and outcomes. This is a particularly important aspect of gendered care such as gynecological and reproductive care. The environment of care for gynecological and reproductive health caters almost exclusively to heterosexual, cis-gender women. All aspects of the care environment are tailored toward femininity and cis-gender and heterosexuality. This includes sexual history questionnaires that assume heterosexuality, spaces and apparel that assume femininity, and educational and informational resources that exclude the unique needs of transgender men. The exclusively cis and heteronormative care environment leaves transgender men feeling excluded, alienated, invisible and under-informed about their gynecological healthcare needs.

This synthesized finding comprises three categories and 18 findings.

Category 2.1: Institutional erasure

When administering gynecological health care, obtaining an accurate sexual history is of great importance. In many gynecological care settings, intake forms and history data intake lack inclusion of transgender men and their unique sexual histories and experiences. This can result in invalid and inappropriate assumptions by healthcare providers regarding health and risk behaviors. Using forms and history-taking procedures that are inclusive can improve both the experience and the relationship between transgender men and their healthcare providers.

"Whenever health professionals throughout most of my life have asked me if I am sexually active, they mean are you currently having a penis in your vagina, because in the end, they don't actually care about my sexual health. They care about... am I at risk of becoming pregnant, do I want to become pregnant, or do I have a risk of getting a sexually transmitted infection from a penis?"23^(p.354)

"They ask 'are you sexually active?' yes 'do you use birth control?' Well, no. And then, immediately, the assumption is that I'm female, so I'm having sex and being penetrated by a penis in my vagina and it's unprotected so there's all of this risk involved with that, which is true, but that's not the type of sex I'm having. And, and, but they're already making that assumption. And so now I have to say, 'Oh, you know, I don't have vaginal penetration by a penis,' and some are like, 'Huh? What do you mean? Like how are you having sex then?' You know, and that's this ... and nobody again has ever said that out loud, but like their facial expressions, their body language said this."53^(p.65)

"At the Planned Parenthood in Massachusetts... they had really inclusive forms that really separated everything instead of trying to minimize and wasn't always gender specific... it was amazing and there were actually questions that I could answer."49^(p.38)

Category 2.2: Information and educational resources

When accessing gynecological care, transgender men find that most educational resources and information available to them are specific to heterosexual, cis-gender women. They find that their unique needs are not addressed within the literature and information available to patients. They find that their clinicians and providers are also not sharing individualized information with them with regard to their specific gynecological and reproductive needs. This leads to feelings of exclusion and invisibility, and can have a negative impact on health outcomes.

"What is missing is all that concerns everyday health like going to have a test how to get a good gynecologist how to get that not all that which is exotic and only about transgender people but all the other stuff the stuff that everybody needs"51^(p.3519)

"Began to show symptoms of postpartum depression long before anyone discussed symptoms to watch for... Began researching and working through postpartum depression issues independently; found no professional with familiarity with 'trans/genderqueer' gestational parents"38^(p.1124)

"This is the conclusion people come to about gynecological healthcare and FTMs. It is a very dangerous conclusion, because biologically I am still female and I haven't had a hysterectomy, I haven't had any lower surgery whatsoever. So from that point of view, I very much need gynecological healthcare, particularly in light of the fact that I do take testosterone and I believe, see I don't even know myself, I believe from what I have heard that puts me at higher risk for cervical cancer. I don't even know that for sure. It is something I have heard from other FTMs, but not all of them have said the same things. We don't know that much about our own healthcare needs, which is another component of being invisible" (participant shared a photo of text from the internet stating "Gynecology is healthcare for women: Staying healthy is important. Whether you're young or old, married or single, sexually active or not, or whether you're lesbian, straight, or bisexual- good gynecological care is key."42^(p.147)

"I think a lot of the [information] is quite often pretty gendered... When I went to have a hysterectomy, they had these brochures and stuff for like after surgery care and whatever... They looked like they were printed, like someone had typed them, and printed them. So to me, it felt like they could edit these quite easily by just retyping them with different words. All of the things that I had said 'woman' and... that kind of thing. And they knew, like they know that they have trans patients now, for sure. Especially now since [some gender-confirming surgeries are] getting covered [by insurance]. It seems to me like that could have been an easy edit to make people feel a little more included in that kind of thing."54^(p.140)

Category 2.3: Alienating spaces

Transgender men find that the spaces in which gynecological and reproductive care takes place are often gender specific. Many of these healthcare spaces cater exclusively to heterosexual, cis-gender women. Examination rooms, waiting areas, patient gowns, and even facility names and logos are designed in ways that convey traditional femininity. This is often described as alienating to transgender men and causes them discomfort in accessing care.

"Many OB/GYN spaces feel like they only cater to women giving birth... and that made me feel alienated"27^(p.13)

"Joe described the logo of one clinic as a drawing of a 'horrendous stick figure, lady, thing, with a really obviously pregnant belly and really prominent breasts.' Pink gowns and flowery decor were also a sign to Joe that he did not belong in a particular clinic. 'I recognized that I was going into an office that 99.99% of the time is used solely for cis women. I thought of it as enemy territory... It helps to give yourself a little narrative, so I was going into enemy territory."'48^(p.39)

Synthesis finding 3: Healthcare access adaptive behaviors

The third synthesized finding is healthcare access adaptive behaviors: Transgender men can experience gynecological care as an emotionally charged encounter. This can lead them to develop individualized adaptive behaviors that can be helpful or detrimental.

Gynecological care can be an uncomfortable experience both mentally and physically. This can be especially true for transgender men. The findings of the review show that gynecological and reproductive care can be an especially emotionally charged encounter for transgender men. Transgender men describe feelings of anxiety, stress, awkwardness, and fear. These feelings result in adaptive behaviors that include relaxation techniques, dissociation, concealment, and care avoidance. Many of these adaptive behaviors can lead to poor health outcomes and inadequate care.

This synthesized finding comprises three categories and 19 findings.

Category 3.1: Multifaceted coping strategies

As transgender men access gynecological care, they develop varied and multifaceted coping strategies to ease the discomfort of gynecological examinations. While some of these strategies may be beneficial to the patient, some may impair healthy patient-provider relationships and negatively impact gynecological health.

"I just relax my mind, relax my body, relax my muscles, and not tense up because then it's going to hurt."36^(p.31)

"I'm just glad they let [my spouse] be there and let me kind of retreat into my own mind. I remember specifically saying 'I'm checking out. See you guys later.' Letting the Ativan take over and just kind of not being present for it. [The doctor] did a great job explaining to me what she was going to do but she didn't expect me to talk or interact. She seemed to know that I was walled off in my own little protective fort in my mind and just try to disassociate as much as possible. That might not sound like so much that she allowed me to do that, but that was huge."48^(p.55)

Category 3.2: Me and my feelings

Emotional reactions to gynecological care play a large role in the decision to seek care for many transgender men. Anxiety, fear, vulnerability, and stress can greatly impact their care experiences. These feelings can prevent some transgender men from seeking care.

"Aiden, a 27-year-old male-identified participant, described feeling anxious prior to encounters with healthcare providers and concerned about the competence of the providers to treat transmasculine individuals in a sensitive manner. This trepidation resulted in his underutilization of routine cervical cancer screening: "But I think all anxiety around... that same anxiety of, like how are people going to treat me? Are they going to understand? Is it going to be a big deal? Some of the guys I know are... cautious, I guess, around that sort of thing and might err on the side of 'well, they won't understand so I just won't'."36^(p.36)

"The type of waiting room that caused the most anxiety was the gynaecologist's waiting room. One participant stated that his waiting room anxiety and vulnerability were so intense that it kept him from seeking gynecological healthcare. He depicted his feelings through a series of photographs taken in a hospital waiting room. 'The thing that came to mind was that I need to take a picture of myself in the waiting room, because that is where I would feel the most anxiety... This is actually where it would be the hardest, sitting there knowing that these women probably think that I am here waiting for my wife or girlfriend who's in there having an exam, and that she is going to come out and we are going to leave. What's going to happen when the receptionist calls my name and I stand up and go into the room?"'42^(p.144)

"I think it's just that the abruptness like, this fear of it all just happening so fast and like, I know I'm consenting to this, but it just feels like I'm not."56^(p.2145)

Category 3.3: Avoiding care

One of the adaptive behaviors that is the most concerning is that of avoiding gynecological care. Care avoidance emerged as a finding in several of the studies included within this review. Transgender men cite varied reasons for the avoidance of care. Previous abuse and sexual assault led to greater discomfort with gynecological examinations. Gendered care and its connection to femininity can lead to feelings of exclusion. Gender dissonance also can play a primary role in the avoidance of gynecological care. Transgender men are often either uninsured or under-insured, and the cost of gynecological care can be seen as a lesser priority.

"There is a history of abuse there, so you know, I don't like people sort of poking around or the idea of... you know, I mean my girlfriend is the only person I've actually physically been with, and so I would need somebody to like, hold my hand and keep me from freaking out beforehand at least."36^(p.44)

"Joe's reasons for avoiding gynecological care derived from the connection between gynecology and femininity. 'The exterior genitalia is [sic] very much associated with a gender I am not. I don't want anyone to judge my gender based on my genitalia. While I feel pretty secure in my gender, I think there is always that nagging voice from my head from when I was a kid, from when I was judged incorrectly on my gender based on my external features... there's a large part of me that's very much afraid that I would still be judged female by someone looking at my genitalia."'48^(p.45)

"I've avoided getting a Pap for the last three years because I don't want to go into a women's clinic. And there is no great place to go."34^(p.510)

"There's a disproportionate amount of unemployment and homelessness and things like that in our community that it's almost tangential, and it's not the biggest issue. I mean it's, you know, so many odds that you'll get this, and you know, not everybody's gonna get it, but like, there're more people who are like, starving and hungry and don't have jobs too. I mean, even if you contract [cervical cancer], you'll probably die of hunger before you actually die of cancer, so that's kinda forefront on trans issues I think, and it's just a shame that we can't really think about all of them at once."36^(p.52)

Synthesized finding 4: Verbal and nonverbal discrimination

The fourth synthesized finding is verbal and nonverbal discrimination: Transgender men experience episodes of both verbal and nonverbal discrimination and micro-aggressions while seeking gynecological care. This leads to a sense of being rejected, devalued, and mistreated.

This review revealed several findings that indicate transgender men experience discrimination and micro-aggressions in their gynecological and reproductive healthcare encounters. This discrimination comes in the form of both verbal and nonverbal behaviors that leave transgender men feeling rejected and devalued. Whether intended or unintended, discrimination and micro-aggressions impact their care experiences. Actions such as mis-gendering, use of their given rather than chosen name, and either intentional or unintentional use of pronouns with which the patient does not identify can all be considered micro-aggressions. Refusal of care and the attitude with which care encounters are carried out can further lead to feelings of rejection and mistreatment. These feelings can damage the patient-provider relationship and lead to worsening health for transgender men.

This synthesized finding comprises two categories and 14 findings.

Category 4.1: Rejection by healthcare providers

Several findings within this review indicate that transgender men face rejection by healthcare providers. This can be as overt as refusing to treat a patient or can be as subversive as not offering all of the available information when their transgender status is revealed. In whichever form, rejection by healthcare providers becomes a barrier to accessing care for transgender men.

"We were rejected from multiple clinics due to 'reasons unknown'. We had a range of appointments and each time the discussion centered almost entirely on my gender identity... everyone just seemed so uncomfortable seeing us."37^(p.70)

"I went to this doctor... to sign a form to get donor sperm... and he made me see the clinic psychologist to gauge whether or not I'd be fit as a parent. And so she saw me and [my spouse]. And then after that it went to their ethics board, and the ethics board said that they weren't going to treat us. So [the doctor] turned us away."27^(p.13)

"Hunter was repeatedly denied access to information and services related to the possibility of cryopreserving his gametes for future use. After several experiences of being dismissed by fertility clinic staff when he disclosed that he was a trans man over the telephone, Hunter began experimenting with purposefully not disclosing his gender identity when contacting clinics with the same questions about cryopreservation of gametes. He found that clinic staff were much more willing to assist him when he did not disclose that he was trans."50^(p.1370)

Category 4.2: Lack of caring attitude

Several illustrations and findings point to the lack of a caring attitude experienced by transgender men as they access gynecological care. The healthcare provider's demeanor when caring for transgender men significantly impacts how they view their care experience. Transgender men identified transphobia as the basis from which a lack of caring attitude was generated. This led to a reluctance to access future gynecological care.

"You know [my provider was] saying things like, 'Well, I'm going to treat you like a woman because that's what I am dealing with here."'36^(p.28)

"This midwife... forced me to reach inside and touch my babies head, even though I clearly didn't want to."27^(p.12)

"I went to the Clinic, and the practitioner that I had was actually really awful. While she was doing the pelvic exam she was grilling me about the trans stuff, and about the effect of hormones and what happens with your pH levels, but was kind of like yelling at me. And it's all this stuff that I don't know, you know, about the long-term effects of testosterone. I tried to explain that actually, nobody really knows that. She's like batting down the sheet between my knees to like make eye contact and yell at me, essentially for not having information. And then implied that I had multiple STIs that, it turned out, I didn't, everything came back negative and so I really think all of that was coming from a transphobic place. So, I think it was around transphobia, it was around how to handle me, it was around queerness, there was like, a lot happening. It was really awful."53^(p.73)

"I had a hysterectomy in October. [Earlier that year] in February, I was feeling pain sort of in my lower abdomen, pelvic area I had gone to see my doctor and after four times of him telling me that I was just having gas and making it up. He said there was nothing wrong, there was no pain and that I needed to stop coming in for that reason... Then in early June, I was in the ER because the pain was so severe. I was supposed to follow up with my doctor, but he was out of town for three weeks, so I ended up seeing a nurse practitioner. She said, this is a real problem. I'm gonna get you in to see a specialist because I don't know how to handle this... so I saw the specialist in August, late August, and she did a full pelvic exam and said the good news is, you're not making it up. The bad news is, I can feel something, and then asked me if I was later in life thinking about getting a hysterectomy at any point."48^(p.50)

Synthesized finding 5: Provider knowledge and trustworthiness

The fifth synthesized finding is provider knowledge and trustworthiness: When transgender men encounter healthcare providers and office staff who are trusted and knowledgeable about their unique needs, they feel supported to make empowered decisions about their gynecological and reproductive healthcare. Conversely, when providers lack the specialized knowledge required to care for transgender men's gynecological needs, it negatively impacts their care encounters.

Transgender men have specialized gynecological and obstetric needs both emotionally and physically. A provider who is informed about those unique needs and is viewed as trustworthy builds a trusting relationship, which leads to positive experiences. Providers who acknowledge the individual needs of each patient aid transgender men in feeling more at ease with care. Transgender men consistently access gynecological care when the healthcare provider builds a relationship of openness and trust, and exhibits a genuine caring attitude.

This synthesized finding comprises four categories with 26 findings.

Category 5.1: Provider relationships

The relationship that transgender men have with their healthcare providers has a profound impact on their experiences with gynecological care. Transgender men feel more comfortable with known providers who acknowledge their unique needs. Professional relationships with trusted providers are fostered by an understanding of transgender men's encounters with gynecological care and the individual relationship that each transgender man has with his body and health care.

"Henry a 34-year-old male-identified participant described how having a supportive relationship with one's healthcare provider can make it easier to motivate oneself to get a Pap exam. He also emphasized how having a professional healthcare provider who is knowledgeable about gender identity issues can facilitate the exam process: 'You're supported to make the appointment, and you're supported through the whole procedure in terms of that you know you're in a supportive environment. You're with someone that you can have a conversation with, and you don't feel that your identity is being questioned or that there's not a person there who understands. That will make it a whole lot easier."'36^(p.35)

"The closer relationship I have with my providers... I think that'll help me as well as other people to just be like, 'alright, you know, it sucks, but, you know, so does, you know, so do many other procedures.' Its uncomfortable to have your teeth drilled. But, if you feel comfortable with your dentist it's a little bit less uncomfortable... it's still gonna be an uncomfortable procedure, but if I feel more comfortable with my doctor and the fact that he's knowledgeable and very, you know immersed in the GLBT, um, policies and, you know um, [pause] just supporting me as a person. I think that helps incredibly so."56^(p.2142)

"I had a gynecologist once try to refer to my clit as my penis, which while I know a lot of guys like that, it just feels strange to me. I told her it was that she didn't need to do that, but I felt massively more comfortable around her after she tried."49^(p.45)

Category 5.2: Healthcare provider knowledge

Transgender men require a provider with specialized knowledge when considering gynecological and reproductive care. This provider knowledge (or lack of knowledge) regarding the unique physical and emotional needs of transgender men can significantly impact the care they receive. Lack of knowledge leads transgender men to consider avoiding gynecological care. Furthermore, lack of specialized care can lead to detrimental patient outcomes.

"Knowing that a healthcare provider was trustworthy and knowledgeable about transgender issues opened the door to communication about cervical cancer screening. 'Like, if I were to go somewhere new, having to, like, you know, come out to a whole set of new medical professionals would be a barrier. Like, I might say to myself, 'you know what? I'm just going to not do it because I don't want to have to, like, explain my story, and like, I don't want to have to come out."'36^(p.40)

"Healthcare professionals need to know that postpartum depression needs to be talked about more, and it really needs to be talked about with trans men who plan on having babies and plan on breastfeeding, meaning that they won't be getting back on testosterone to level out the hormones. Because that roller coaster was an insanity I cannot describe."27^(p.15)

"Someone should be educating the entire building's worth of people: 'Hey, you might see dudes in here looking for gyn. Just sent them up!"'54^(p.171)

Category 5.3: Positive experiences

Many of the findings of this review indicated that transgender men have positive experiences with gynecological and reproductive care. These experiences are often the result of providers and staff being knowledgeable and sensitive to patient needs. Acknowledgement of transgender men's unique needs without pathologizing or "othering" them leads to increased comfort and confidence in accessing care.

"I walked in and the doctor who I saw, like, the very first one, she was, like, 'look, you're not the first pregnant guy we've had. So don't worry about that'... I just really prefer if healthcare providers can act as though it's not exceptional or weird to be trans."27^(p.14)

"I was always called 'he,' I was always called 'dad,' and my body parts were called by the words I use."38^(p.1124)

"She realizes I have big issues relating to female health issues. Pap smear, breast check- Eeeeeew!- she does everything she can to put me at ease. Whilst having yucky pap thing still calls me sir! Love it."35^(p.489)

"At one point I was trying to get her to latch on and she had just latched when the nurse came in and she was like 'Oh, oh, I'll leave you guys,' and then she came back a bit later and was like 'I'll talk you through breastfeeding and help you,' and she used 'dad' the whole time and 'chest.' And I never asked her to do that. She was just like, 'Yeah, you wanna have her on dads chest,' and that was the language she used so I thought that was pretty cool."44^(p.11)

Category 5.4: Empowered to seek care

Accessing gynecological and reproductive care often requires transgender men to be empowered to overcome structural, institutional, social, and emotional barriers. When any of these barriers are lessened or removed, access to care is improved and the emotional burden is diminished for transgender men in accessing care. Transgender men feel empowered to seek gynecological care when the provider is viewed as knowledgeable and trustworthy.

"I think a lot of queer and trans people have had such negative experiences with medical practitioners- and I mean that really broadly- that they come in feeling really hesitant, come in feeling like they are already going to be treated badly. And I think there is a real difference [in the outcome] if you come in and act entitled, if you help a medical professional understand what their job is and how to do their job well and what you need... So the question [for medical practitioners] is 'what do you think is the most appropriate referral for a couple of trans guys' not 'do you think it is okay?' The question is 'What is the most appropriate referral."'50^(p.1370)

"Other participants cast undergoing a Pap test as an activity requiring toughness and personal responsibility, and a way to defend their right to a health life-that is the Pap is reconceptualized as a way to perform masculinity. 'It's so tough to get through this [transitioning], that if we've already got this far and valued ourselves, don't deny yourself taking care of the health you have. Don't!... So, man up, man up, and get it done... man up and get your Pap done!"'56^(p.2141)

Discussion

The results of this review reveal that transgender men face challenges when accessing gynecological and reproductive health care. The five resulting synthesized findings (negotiating the binary system, navigating the cis-normative world, healthcare access adaptive behaviors, verbal and nonverbal discrimination, and provider knowledge and trustworthiness) point to areas where the experiences of transgender men in reproductive and gynecological health care can be improved.

Synthesized finding 1: Negotiating the binary system

When accessing the current healthcare system, transgender men are obligated to fit within a binary structure. All aspects of access to health care are designed in a way that patients must be either fully male or fully female. The system does not allow for any variation in this area.57 Snelgrove et al.58 identified that the concept of "two gender medicine" presented barriers to care access for transgender individuals. Their participants point to sex-specific eligibility criteria for certain procedures, tests, and therapies as a roadblock to adequate care for transgender persons. Sex-specific eligibility criteria present a significant problem for transgender men and force them to make difficult decisions regarding their gynecological and reproductive health.

This finding also aligned with Torres et al.59 who found that navigation of the complex healthcare system was a primary barrier to health care. Key to this barrier was the incongruence between male identity and presentation while maintaining female documentation. Similarly, Samules et al.60 identified that patient names and documentation were often scrutinized and questioned during emergency department encounters presenting significant obstacles for participants who had not legally changed their name or gender designation. Likewise, Hagen and Galupo61 found that 100% of their participants had had difficulties with the discrepancy between sex designation for their insurance coverage and gender identity as it pertains to access to care. These findings align with the results of this review that transgender men experience barriers to care as a result of incongruence between masculine identity and their continued need for gynecological care. Not only does the binary system pose a threat to healthcare access, it can also present a barrier to job security. Transgender men fear being outed to their employer or losing access to healthcare coverage. This finding is consistent with the literature.45,53,55 Being outed without their consent causes many transgender men to avoid necessary gynecological care to the detriment of their health.

Additionally, insurers often refuse payment for any transition-related treatment such as hysterectomies. This requires a transgender man to work with their provider to show that a hysterectomy would be medically necessary, necessitating additional steps if the patient is identified as transgender to the insurer as compared to a cis-gender female.

The double standard of the binary system poses additional hurdles for transgender men. The binary system seeks to regulate "only those who deviate from normative gender trajectories."55^(p.160) A prime example of this double standard within the system is that both cis-gender males and cis-gender females have access to prescriptions for testosterone to treat sub-normal testosterone levels and diminished sex drive, respectively, yet transgender men must negotiate within the system or seek testosterone outside of the system to gain access to the same treatment. The double standard forces patients and providers alike to manipulate the system to get the care the patient requires. Roller et al.46 echo this by indicating their transgender participants cannot "take a direct route healthcare but rather needed to engage in a process of intentionally charting a course to overcome barriers."^(p.419) Our findings further illuminate that transgender men must often negotiate within the system to seek the care they desire, such as testosterone treatments and hysterectomies.

Fully transitioning documents such as personal identification and insurance documents to reflect masculine identity presents a barrier to gender-based care, such as gynecological cancer screening and reproductive care. In order to access this gender-based care, transgender men must develop workarounds to negotiate within the system. Some transgender men maintain female designation on personal identification and insurance documents. This requires them to be out as transgender to employers, leaving them open to discrimination in the workplace including job loss and loss of healthcare coverage. Other transgender men choose to seek care under assumed names, paying for care out of pocket. This leaves them vulnerable to the financial burdens of possible catastrophic illness. Perhaps most concerning were the transgender men who used the binary system to get the transition-related care they desired by waiting for cancer to develop before seeking care to get hysterectomies covered by insurance.

This finding reveals several system-based barriers to care. Removing these barriers would require work at the federal, state, local, and facility/office levels. This could include legislation over insurance coverage as well as changes to clinical documentation programs that currently maintain a strictly male or female format.

Synthesized finding 2: Navigating the cis-normative world

The findings of this review revealed that transgender men face barriers to accessing patient-centered care as a result of a cis-gender and hetero-normative environment. The women's health movement of the early 1970s focused on empowering women to take control of their own gendered health care.48 The movement encouraged women to be knowledgeable about their reproductive organs and to remain connected to their bodies during gynecological care. The women's health movement also led to the widespread establishment of health centers that cater only to women (women's health centers). Few can argue the merit of these centers for the empowerment of women to seek autonomy over their reproductive and gynecological health care, but they remain problematic for transgender men. The movement categorically excludes those individuals who identify as men yet require gynecological care. In no other specialty is gender normativity more of a focus. Women's health centers assume to 100% certainty that their clientele is feminine.48 The physical spaces of most obstetric and gynecological care centers are designed in a feminine manner, often decorated in muted pink or pastel tones. Patient gowns are usually pink and occasionally have floral or feminine designs. These settings foster complete erasure of the transgender men who require gynecological care.

Beyond the physical spaces and apparel, transgender men are confronted with intake forms, health history questionnaires, and educational resources that are also strictly geared toward cis-gender, heterosexual women. In a qualitative study of 85 transgender community members, Bauer et al.47 found two forms of erasure play key roles in health care for transgender individuals. Informational erasure in the form of surveys, intake forms, questionnaires, and research effectively erases the existence of the transgender population. They cite that health research often assumes cis-sexuality and cis-genderism. While this does not speak directly to care access, it does point to the paucity of evidence available prior to the early 2000s. Carrotte et al.62 conducted a qualitative study focused on the inclusivity of research to identify the unique needs of gender and sexually diverse persons. Their thematic analysis found that hetero-normativity is present in several settings including healthcare. Their participants also described hetero-normativity as a barrier to sexual health care and that it facilitates text-based miscommunication in the way of surveys and forms. Bauer et al.47 also found that institutional erasure plays a key role in the transgender person's access to care. They identify institutional erasure as the lack of acknowledgement that transgender persons are even a possibility in care. This includes their absence from policies and forms such as intake forms, prescriptions, and referral forms.

Another avenue in which transgender men must navigate a cis-normative world is that of the information and resources available to them. Agenor et al.40 found that their participants' perceptions of cervical cancer risk were driven by limited availability of sexual and reproductive health information specifically for transgender men. Many of their participants stated that they received no information from their physicians that was specific to cervical cancer in transgender men. Vermeir found that a few of their "participants remarked how medical information is in their opinion 'gendered' and 'heteronormative' aimed at 'cisgender' and 'straight people."'54^(p.139) This is mirrored by the work of Bauer et al.47 who found that the lack of research on transgender lives and issues has led to a "dearth of information on health related topics."^(p.352)

The presented evidence helps to validate the authors' finding that cis-normativity presents a significant obstacle for transgender men as they access care. These obstacles can be greatly accentuated when the care being sought is gender related, leaving transgender men alienated and erased. These barriers to accessing care could be alleviated by educating providers to establish a more inclusive environment. Spaces could be made less alienating by creating a more gender-neutral environment. This could be accomplished by renaming health centers with a gynecological or reproductive focus as "gynecological care centers" rather than "women's health centers." Apparel could be gender neutral. Forms and health history questionnaires could be made more inclusive of transgender and gender non-binary persons. Sexual history forms could be made less hetero-assumptive. Additionally, research could be undertaken to acknowledge the specialized needs of transgender men. This unique information could be added to medical and nursing curricula as well as patient information resources. These changes would create a care environment that would be more welcoming to transgender men and may affect willingness to access care.

Synthesized finding 3: Healthcare access adaptive behaviors

This review identified that encountering gynecological and reproductive care can be an emotionally charged experience for transgender men. Anxiety, stress, fear, and awkwardness are all feelings cited within the included studies.20,23,34,36,41,42,48,53-56 These feelings are closely linked with provider knowledge, trustworthiness, and discrimination as well as negotiation within the binary system and navigation of the cis-normative world.36,48,53,55

For transgender men, all aspects of gynecological and reproductive care (not only the gynecological examinations themselves) were associated with these emotions. This is an experience that is unique to transgender men. While it is true that cis-gender women can often also experience discomfort and challenging emotions around gynecological and reproductive care, the incongruence between gender identity and physical anatomy create an additional layer of discomfort for transgender men.

Both beneficial and potentially detrimental behaviors are adopted to manage the distress experienced in gynecological and reproductive care. Included studies indicate that transgender men use relaxation and calming techniques to prepare for and undertake gynecological care.36,53 Relaxation breathing, calming practices, carrying items that bring comfort, and conscious relaxation of abdominal and pelvic muscles were all cited as effective techniques to manage the emotional and physical discomfort of examinations.36,53,54

Forms of group coping were also noted. Transgender men spoke of having a support system with which to share information. This led to transgender men being well-informed consumers as well as gaining support of understanding individuals with shared experiences. Group support systems were both formal (transgender support groups and online transgender communities) or informal (circle of friends).36,38,41,43,46,49,53,55,56

Transgender men also adopted an alternative perspective to enable gynecological care. Included studies indicate that transgender men made a conscious choice to not "hate" their bodies.36,41,48 This led to a diminishing of gender dissonance and dysphoria.52,54,55 Studies further show that reframing of gynecological care can also have a positive impact on experience. Some transgender men reframe gynecological care to diminish or eliminate the "femaleness" of the experience by adopting the more masculine approach of "manning up," "checking under the hood," or "routine maintenance."36,48,49,53,54

Further revealed in this review was that many transgender individuals use self-advocacy and communication to manage healthcare encounters. By taking on the responsibility of ensuring that their bodies are treated with respect and accepting nothing less, transgender men begin to regain their power in the patient-provider dynamic. This is accomplished through communication with providers before, during, and following examinations.36,40,46,48,49,53-56

Many of the above strategies can lead to improved patient/provider relationships and potentially move transgender men closer to self-actualization. There are, however, adaptive strategies that are less beneficial. The included studies indicate that transgender men use dissociation as a strategy to aid tolerance of gynecological examinations.20,36,42,48,56 Some use imagery dissociation while others use anti-anxiety medication and the social support of having a trusted friend or family member in the examination room. While the findings and illustrations indicate that this is an effective mechanism, this can diminish the patients' power and control over their own body. As discussed earlier, the women's health movement of the early to mid-1970s sought to empower women in gaining control over their physical bodies and gynecological healthcare experiences. Its aim was to minimize dissociation of women in gynecological care.48 As transgender men choose dissociation as an adaptive mechanism, they relinquish this power.

The most-oft-cited adaptive technique was that of avoidance. All included studies revealed that transgender men select to avoid gynecological care as a result of discrimination, the cis-gender normative nature of care, and the binary healthcare system. There is extensive evidence around transgender individuals and avoidance of care as well as avoidance of gender identity disclosure.

There is a paucity of evidence concerning the ways in which transgender men adapt to gain healthcare access. This finding can be used as a launching pad for further research.

Synthesized finding 4: Verbal and nonverbal discrimination

It is virtually impossible to find qualitative research around the care experiences of transgender individuals that does not discuss discrimination and micro-aggressions. The 2008-2009 National Transgender Discrimination Survey revealed that 28% of participants postponed medical care due to discrimination and that 28% had experienced harassment or violence in a medical setting.4 The 2015 US Transgender Survey revealed that 33% of respondents stated they had experienced a negative encounter in health care in the past year (including harassment, being refused care, and needing to educate providers about how best to care for them) and 23% avoided health care out of fear of mistreatment.63

Nadal et al.64 identified 12 micro-aggressions specific to transgender persons. These include the use of transphobic and/or incorrect gendered terminology (incorrect pronouns, names, publicly questioning gender), assumption of universal transgender experience (assuming all transgender people undergo gender-affirming surgery), exoticization, discomfort/disapproval of transgender experience (becoming judgmental after learning of transgender status), endorsement of gender normative and binary culture of behaviors, denial of the existence of transphobia, assumption of sexual pathology or abnormality, physical threat or harassment, denial of individual transphobia, denial of personal body privacy (asking intrusive questions about genitals), familial micro-aggressions, and systemic and environmental micro-aggressions. One or more of these micro-aggressions were identified in the findings of almost all included studies.

Exposed within this review were several findings relevant to discrimination and micro-aggressions experienced by transgender men. The findings and illustrations were categorized as either rejection by healthcare providers or a perceived lack of caring. All included studies discuss findings of transgender men being mis-gendered (using incorrect pronouns) and/or being "dead named" (using their birth name rather than their chosen or preferred name). These experiences were either perceived as intentional or as a result of lack of knowledge. In all instances, however, the participant recounted them as negative experiences leaving them feeling "embarrassed," "angry," or "disrespected."53^(p.94) Several authors/researchers also identified that transgender men perceived provider discomfort or disapproval in treating them. This was perceived as more evident in gendered care environments such as gynecological care or reproductive care environments.23,27,36,48,50,51-55 Also illuminated within this review were experiences around seemingly inappropriate or unnecessary physical examinations.27,35,53 Aligning with this review, previous research indicates this type of experience leads transgender individuals to feel as though they are "a freak show" or "on display."59,60,65-67 Micro-aggressions lead transgender individuals to have emotional reactions such as anger, betrayal, distress, hopelessness, and feeling invalidated or misunderstood.64

While micro-aggressions are concerning, experiences of outright discrimination can be even more alarming. In the 2008-2009 Transgender Discrimination Survey, 28% of participants reported having been harassed and 2% had experienced violence in medical settings, while 19% of the sample had been refused care.4 In the 2015 survey of 27,715 participants, 6% reported having been verbally harassed, 5% reported a healthcare provider using harsh or abusive language, 3% were refused care not related to transition, and 2% reported experiencing a provider that was physically rough or abusive when treating them.63 These findings were reflected throughout the findings of this review.

Transgender men reported harsh or abrupt examinations as well as harsh language.23,27,36,38,53-55 Gruff examination techniques combined with harsh language led transgender men to feel distressed, disrespected, and unwelcome in gynecological and reproductive care settings.23,27,54 Additionally, almost all included studies identified that transgender men had been refused care or had experienced rejection by a healthcare provider.23,27,36,37,50,51,53,55 The literature reveals that these experiences can lead transgender individuals to feel unwelcome, powerless, devalued, and mistreated.6,59,60,64,65,67,68

A connection between discrimination and the delay or avoidance of care is well documented within the literature.4,10,12,27,35,48,65,67,69 When individuals avoid or delay needed care, it leads to further marginalization of the patient, and can be detrimental to their health and well-being. It is difficult to know without further data whether these episodes of discrimination stem from lack of knowledge or are more deeply rooted within the perpetrators' ethos and character. Regardless of the basis, discrimination toward transgender men (and transgender persons in general) should be considered the same as discrimination toward other marginalized groups and cease to be tolerated within the medical community. This may be accomplished with entry-level provider education, sensitivity education for current providers and staff, and education for the transgender community around self-advocacy and assertiveness in healthcare settings.

Synthesized finding 5: Provider knowledge and trustworthiness

This review revealed that the largest number of relevant study findings could be synthesized into the finding of "provider knowledge and trustworthiness." This finding emerged from four distinct but tightly inter-related categories. As evident throughout this review, knowledge and trustworthiness of providers play a key role in the patient experience.

Grant et al.4 found that 50% of respondents reported having to educate their providers on how best to care for them. This was echoed in additional literature with percentages of 24%64 to 56%10 of participants reporting that they needed to educate their providers about transgender individuals. The research of Jaffee et al.10 further revealed that persons who needed to educate their providers were four times more likely to delay care as a result of discrimination.

This aligns with the current review in that many of the included studies revealed that lack of provider knowledge led to negative experiences for transgender men.27,35,38,41,47,48,53-55 Provider knowledge was perceived to be the root of both discriminatory and micro-aggressive behavior in the form of refusal of care, inappropriate use of body-related language, improper pronoun usage, dead naming, and several other examples. As discussed in the previous section, these types of encounters are linked to negative experiences and delay or avoidance of care. Throughout the included studies, provider knowledge is directly related to trust and the comfort of transgender men with providers and their care experience. A perceived lack of provider knowledge often goes hand-in-hand with negative experiences in care. This finding is also supported by additional research around transgender care experiences.10,59,60,66,67

The findings of most of the included studies also point to positive experiences with providers and staff. Positive experiences were linked not only to provider and staff knowledge but also to sensitivity to the unique care needs of transgender men. Proper use of pronouns, chosen names, and preferred language as it pertains to transgender bodies were often cited as aiding in positive experiences. Positive experiences were discussed in light of providers and staff who had taken the responsibility to learn about transgender health issues and had done their own research into what transgender patients need.10,12,15,16,18-20,27,36,38,40,42,48,49,53-56

As discussed in the introduction, both nursing and medical curricula lack content around care of transgender individuals.10,13,14,58,70,71 This creates a knowledge base in which transgender lives and experiences are effectively erased from the healthcare narrative, which has led to a dearth of research on the topic.70 As more research is completed and becomes available, further knowledge and, therefore, knowledge transfer can be undertaken. Education alone, however, may not be an adequate answer for lack of provider knowledge and competence. In a multi-variable study, Stroumsa et al.72 found that limited provider knowledge of transgender and gender diverse individuals was negatively associated with transphobia. However, they found that increased hours of education (either formal or informal) was not associated with improvements in provider knowledge. Their work would indicate that in order for providers to gain competence in caring for transgender individuals, education focused on transgender care must also place emphasis on combating bias and transphobia.

Knowledge and trustworthiness are multi-faceted and complex concepts that require further research as they pertain to the transgender individual. Trustworthiness of providers requires not only knowledge of the clinical needs of transgender individuals but also knowledge and practice of cultural competency and sensitivity. This was affirmed by almost all included studies. This review revealed that positive experiences stem from relationships with providers who are knowledgeable not only about their physical needs but also their needs as individuals. When transgender men encounter providers who are knowledgeable, they can feel empowered to be full partners in their care experiences.

Limitations of included studies

While the included studies were appraised to be of adequate quality, there are notable limitations. Few of the studies dealt with the phenomenon of interest exclusively. While this is a minor limitation, it warrants discussion. The studies that focused exclusively on transgender men and their experiences with gynecological or reproductive care yielded more extensive data that were more specific to the topic of interest. This does not necessarily limit the quality of the overall review but further research specific to the topic of interest may warrant an additional systematic review in the future.

Strengths and limitations of this review

This review examined the experiences of transgender men as they seek and access gynecological and reproductive health care. It gives deeper insight into the specialized needs of this population as they navigate and negotiate through systems and environments. Because of the non-experimental nature of qualitative research, exact conclusions of the relationships between experiences and outcomes cannot be drawn. While this review offers extensive insight into the issues and experiences of transgender men and gynecological care, further research should be conducted to explore the synthesized findings in-depth.

Qualitative meta-synthesis is an inherently interpretive process. It is influenced by the researcher's subjective analysis and meaning. Measures were instilled during the review process to enhance the congruency between researchers and between the original findings and the resultant synthesized themes. Despite best efforts, the authors recognize this as a limitation of this review.

As discussed earlier, the majority of the included studies did not speak to the influence of the researcher on the research and visa-versa. The quality of qualitative research is contingent on the skill of the researcher to prevent personal biases. This is often not mentioned in the included studies. Based on this, the authors recognize that some personal bias may exist within the review. The literature search was conducted with minimal set limitations in the attempt to generate as many studies as possible that might fit the review criteria. With the generation of repeated titles, it is possible that some relevant studies were overlooked. Moreover, only studies published in English were included in this review. As a result, the experiences of other populations of transgender men may not be adequately represented.

Conclusions

This systematic review set out to locate and evaluate qualitative research that explored the experiences of transgender men seeking gynecological and reproductive health care in all settings. The meta-synthesis has provided clearer understanding on how transgender men perceive gynecological care experiences. In particular, transgender men shared their feelings of exclusion, erasure, invisibility, and alienation in healthcare settings. These feelings stem from healthcare systems that require them to conform to a binary structure. This binary structure leads to either denial of coverage for gynecological care, or the risk of unnecessary exposure of transgender status to employers. Exposure of transgender status holds the potential of job loss and, subsequently, loss of healthcare insurance altogether in countries such as the US where transgender status is not protected under US federal anti-discrimination legislation. Also integral to the development of these feelings are the environments in which transgender men must access care. These environments are set up for and cater almost exclusively to cis-gender, heterosexual women. When care environments lack inclusivity for transgender men, they are left feeling alienated and invisible. Episodes of rejection, discrimination, micro-aggressions, and an overall sense of lack of caring led transgender men to either avoid care or to develop other adaptive behaviors to cope with uncomfortable care encounters.

Transgender men shared positive experiences in gynecological and obstetric care as well. In these experiences, a positive patient-provider relationship is of paramount importance. This can be established when providers are knowledgeable about the specialized needs of transgender men and when they are sensitive to those needs. These relationships foster a patient's self-advocacy and empowerment.

The findings of this review identified several areas for improvement in practice environments, academic curricula, and future research. There are also opportunities for policy change at the federal, state, local, and organization levels. These recommendations are discussed below.

Recommendations for practice

This review has yielded insight for healthcare providers, healthcare academic institutions, researchers, and policy makers. Identified within this review are areas for practice change, policy change, future research, and educational curriculum. Based on the synthesized findings of this review, the following recommendations are made. The recommendations for practice are graded according to the JBI Grades of Recommendations.73

Based on ConQual scores, synthesized finding 1 (negotiating the binary system) and synthesized finding 5 (provider knowledge and trustworthiness) were rated as moderate while the remaining three synthesized findings (navigating the cis-normative world, healthcare access adaptive behaviors, and verbal and nonverbal micro-aggressions and discrimination) were all rated as low (see Summary of Findings). The following recommendations, having stemmed from the above findings, have thus been given a JBI grade of B as a result of the cost involved and dearth of evidence to specifically support the recommendations. As these recommendations are carried out in the future, research around their effectiveness can be completed.

i. All staff that encounter (or may encounter) transgender men seeking gynecological care or reproductive health care should receive cultural competency education to diminish episodes of discrimination, micro-aggression, and rejection. Grade B

ii. All staff who encounter (or may encounter) transgender men seeking gynecological or reproductive health care should be knowledgeable about the specialized physical and emotional needs of transgender men. Grade B

iii. Environments in which transgender men may seek gynecological and reproductive health care should be welcoming and inclusive for transgender men. Grade B

iv. Intake forms, health history forms, and other formats with which patients share information with providers should be inclusive for transgender men. Grade B

v. Systems should be developed in a manner that allows for gender variability (availability of pelvic examination, vaginal/uterine ultrasound, and cervical cancer screening for male gendered patients). Grade B

vi. Electronic medical records should be developed in a way that allows for gender identity variability. Grade B

Recommendations for policy change

All insurers should be required to cover gynecological care for natal females regardless of gender identity.

Recommendations for research

Given the comprehensive search strategy, it can be supposed that this review included the best available evidence. While it is possible that some studies may have been missed, this review is as comprehensive as possible. Further research should include in-depth investigation of the synthesized findings of this review. Each finding could be explored specifically to further illuminate the concepts.

Literature on the experiences of transgender men as they experience fertility treatments, pregnancy, and delivery are quite limited. This is an area of care for the transgender man that is currently expanding. Further research to investigate these encounters would illuminate these experiences.

There is an absence of research around transgender men's primary encounters with gynecological care. As the transgender community becomes more visible, people are acknowledging their gender identity at younger ages. There is a need to understand how first encounters with gynecological care impact future care usage.

Care of the transgender patient is a timely topic and it is likely that a great deal of research is currently planned or ongoing. As further data become available, additional reviews on this topic may be needed.

Recommendations for entry-level education

Training on the specialized needs of all transgender persons should begin in the primary stages of healthcare education. Both nursing and medical curricula should include education around culturally and medically competent care of the transgender community. This should be woven throughout all aspects of the curricula and not just a short session of a single course. Each course throughout the curricula should include a component around how the subject impacts the transgender patient. Providing a basis on which to build knowledge of transgender men and their gynecological needs would foster patient-centered care for generations to come. This education needs to focus on eliminating the system-based barriers as well as barriers at the point of care.

Acknowledgments

Marcia Kieth, nursing library scientist, The Indiana Center for Evidence Based Nursing Practice, A JBI Affiliated Group, for her assistance in developing and executing a search strategy.

Appendix I: Search strategy

Appendix II: Studies ineligible following full-text review

Baker LA. Transgender life outside the city: trans masculine identity and the non-metropolitan experience. Ann Arbor (MI): ProQuest; 2016. p. 1-134.Reason for exclusion: No voice re transgender (trans) men experiences with gynecological (GYN) or reproductive healthcare

Bith-Melander P, Sheoran B, Sheth L, Bermudez C, Drone J, Wood W et al. Understanding sociocultural and psychological factors affecting transgender people of color in San Francisco. J Assoc Nurses AIDS Care. 2010;21(3):207-20.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Carrotte ER, Vella AM, Bowring AL, Douglass C, Hellard ME, Lim MSC. "I am yet to encounter any survey that actually reflects my life": a qualitative study of inclusivity in sexual health screening research. BMC Med Res Methodol. 2016;16(86):1-10.Reason for exclusion: Not a qualitative study investigating trans men experience with gynecological and/or reproductive care

Chaplin B. "Why are you crying? You got what you wanted!" Psychosocial experiences of sex reassignment surgery [dissertation]. Brisbane (Queensland): Queensland University of Technology; 2016.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Chen JA, Granato H, Shipher JC, Simpson T, Lehavot K. A qualitative analysis of transgender veterans' lived experiences. Psychol Sex Orient Gend Divers. 2017;4(1):63-74.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Chisolm-Straker M, Jardine L, Bennouna C, Morency-Brassard N, Coy L, Egemba MO et al. Transgender and gender nonconforming in emergency departments: a qualitative report of patient experiences. Transgend Health. 2017;2(1):8-16.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Chrisler JC, Gorman JA,, Manion J, Murgo M, Barney A, Adams-Clark A et al. Queer periods: attitudes toward and experience with menstruation in the masculine of centre and transgender community. Cult Health Sex. 2016;18(11):1238-50.Reason for exclusion: Does not meet the criteria of a qualitative study. Asks open-ended questions and contains trans man voice but not analyzed thematically

Cicero EC. "I was a spectacle... a freak show at the circus": a transgender person's ED experience and implications for nursing practice. J Emerg Nurs. 2016;42(1):25-30.Reason for exclusion: Does not meet inclusion criteria of qualitative research. It is recount of a single trans man's experience in the emergency department with recommendations for providers

Crockett A. Trans masculine healthcare: utilization after sexual violence. Ann Arbor (MI): ProQuest. 2017:1-200.Reason for exclusion: No discussion of GYN or reproductive care for trans men

Dutten L, Koenig K, Fennie K. Gynecological care of the female-to-male transgender man. J Midwifery Womens Health. 2008;53(4):331-7.Reason for exclusion: Findings and illustrations do not make it clear that they are about GYN care for trans men.

Gordon D, Pratama MP. Mapping discrimination experienced by Indonesian trans*FtM persons. J Homosex. 2017;64(9):1283-303.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Greatheart MS. The Fred Study: stories of life satisfaction and wellness from post transition transgender men [thesis]. Vancouver (BC): University of British Columbia; 2010:1-144.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Shoveller J, Johnson J, Rosenberg M, Greaves L, Patrick DM, Oliffe JL et al. Youth's experiences with STI testing in four communities in British Columbia, Canada. Sex Transm Infect. 2009;85(5):397-401.Reason for exclusion: No trans man voice

Hagen DB, Galupo MP. Trans* individuals' experiences of gendered language with healthcare providers: recommendations for practitioners. Int J Transgend. 2014;15(1):16-34.Reason for exclusion: Duplicate publication of study already included in the review

Hunt J, Bristowe K, Chidyamatare S, Harding R. "They will be afraid to touch you": LGBTI people and sex workers' experiences of accessing healthcare in Zimbabwe: an in-depth qualitative study. BMJ Global Health. 2017:2(2);e000168.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Jones T, del Pozo de Bolger A, Dune T, Lykins A, Hawkes G. Female-to-male (FtM) transgender people's experiences in Australia: a national study. Germany: Springer; 2015.Reason for exclusion: Very limited trans man voice re GYN access and unclear methodology

Kano M, Silva-Banuelos AR, Sturm R, Willging CE. Stakeholders' recommendations to improve patient centered "LGBTQ" primary care in rural and multicultural practices. J Am Board Fam Med. 2016;29(1):156-60.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Kosenko K, Rintamaki L, Raney S, Maness K. Transgender patient perceptions of stigma in healthcare contexts. Med Care. 2013;51(9):819-22.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Lambrou NH. Trans masculine identities: making meaning in gender and tradition [dissertation]. Thesis and Dissertations. 2018.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Light A, Wang LF, Zeymo A, Gomex-Lobo V. Family planning and contraceptive use in transgender men. Contraception. 2018;98(4);266-9.Reason for exclusion: Does not meet inclusion criteria of qualitative research. Survey-based study without voice of respondent

Linander I, Alm E, Hammerstrom A, Harryson L. Negotiating the (bio)medical gaze - experiences of trans-specific healthcare in Sweden. Soc Sci Med. 2017;174:9-16.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Lindroth M, Zeluf G, Mannheimer LN, Deogan C. Sexual health among transgender people in Sweden. Int J Transgend. 2017;18(3):318-27.Reason for exclusion: Republication of a study that has already been included (see Lindroth, 2016)

Logie CH, Lys CL, Schott N, Dias L, Zouboules MR, Mackay K. 'In the north you can't be openly gay': contextualizing sexual practices among sexually and gender diverse persons in northern Canada. Glob Public Health. 2018;13(12):1865-77.Reason for exclusion: No indication of gender diversity in findings

Marshal SA, Allison MK, Stewart MK, Thompson ND, Archie DS. Highest priority health and healthcare concerns of transgender and non-binary individuals in a southern state. Transgend Health. 2018;3(1):190-200.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Mavhandu-Mudzusi AH. Citizenship rights, discrimination, and stigmatisation of LGBTI students by healthcare services at a South African rural-based university. Agenda. 2016;30(1):104-11.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Nygren KG, Ohmann S, Olofsson A. Everyday places, heterosexist spaces and risk in contemporary Sweden. Cult Health Sex. 2016;18(1):45-57.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Petit MP, Julien D, Chamberland L. Interlinkages between parental and trans trajectories: a life course perspective. Psychol Sex Orientat Gend Divers. 2018;5(3):371-86.Reason for exclusion: Does meet inclusion criteria: No discussion of healthcare impact

Pollock LC. Growing up outside the lines: experiences of gender among FTM transgender youth [thesis]. Berkeley (California): UC Berkeley; 2008.Reason for exclusion: Does not meet inclusion criteria: no discussion of healthcare impact

Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma transgender healthcare. Soc Sci Med. 2013;84:22-9.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Riggs DW, Bartholomaeus, C. Fertility preservation amongst Australian transgender and non-binary adults. Reprod Health. 2018;15(181):1-10.Reason for exclusion: Does not meet inclusion criteria: no specific trans masculine voice

Rocon PC, Rodrigues A, Zamboni J, Pedrini MD. Difficulties experienced by trans people in accessing the Unified Health System. Cien Saude Colet. 2016:21(8);2517-36.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Romanelli M, Hudson KD. Individual and systemic barriers to healthcare: perspectives of lesbian, gay, bisexual, and transgender adults. Am J Orthopsychiatry. 2017;87(6):714-28.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Rosentel K, Hill BJ, Lu C, Barnett JT. Transgender veterans and the Veterans Health Administration: exploring the experiences of transgender veterans in the Veterans Affairs Healthcare System. Transgend Health. 2016;1(1):108-16.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Ross LE, Tarasoff LA, Anderson S, Epstein R, Marvel S, Steele LS et al. Sexual and gender minority peoples' recommendations for assisted human reproduction services. J Obstet Gynaecol Can. 2014;36(2):146-53.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Rossman K, Salamanca P, Macapagal K. "The doctor said I didn't look gay" Young adults' experiences of disclosure and non-disclosure of LGBTQ identity to healthcare providers. J Homosex. 2017;64(10):1390-410.Reason for exclusion: No discussion of GYN or Reproductive care for trans men

Rowniak S, Chesla C. Coming out for a third time: transmen, sexual orientation, and identity. Arch Sex Behav 2013:42(3):449-61.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Russell AM, Galvin KM, Harper MM, Clayman ML. A comparison of heterosexual and LGBTQ cancer survivors' outlooks on relationships, family building, possible infertility, and patient-doctor fertility risk communication. J Cancer Surviv. 2016;10:935-42.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Sallans RK. Lessons from a transgender patient for healthcare professionals. AMA J Ethics. 2016;18(11):1139-46.Reason for exclusion: Does not meet inclusion criteria: not qualitative research

Samuels EA, Tape C, Garber N, Bowman S, Choo EK. "Sometimes you feel like a freak show" a qualitative assessment of emergency care experiences among transgender and gender non-conforming patients. Ann Emerg Med. 2018;71(2):170-182.e1.Reason for exclusion: No discussion of GYN or reproductive care for trans men

Schudson ZC, Dibble ER, van Anders SM. Gender/sex and sexual diversity via sexual configurations theory: insights from a qualitative study with gender and sexual minorities. Psychol Sex Orientat Gender Divers. 2017;4(4):422-37.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Scorgie F, Nakato D, Harper E, Richter M, Maseko S, Nare P et al. "We are despised in the hospitals": sex workers' experiences of accessing healthcare in four African countries. Cult Health Sex. 2013;15(4):450-65.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Smith SK, Turell SC. Perceptions of healthcare experiences: relational and communicative competencies to improve care for LGBT people. J Soc Issues. 2017;73(3):637-57.Reason for exclusion: No trans men in sample

Snyder BK, Burack GD, Petrova A. LGBTQ youth's perceptions of primary care. Clin Pediatr (Phila). 2017;56(5):443-50.Reason for exclusion: Does not meet inclusion criteria: no trans man voice

Stotzer RL, Ka'opua LSI, Diaz TP. Healthcare caring in Hawai'i? Preliminary results from a health assessment of lesbian, gay, bisexual, transgender, questioning and intersex people in four counties. Hawai'i J Med Public Health. 2014;73(6):175-80.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Tornello SL, Bos H. Parenting intentions among transgender individuals. LGBT Health. 2017;4(2):115-20.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Wagner PE, Kunkel A, Asbury MB, Soto F. Health (trans)gressions: identity and stigma management in trans* healthcare support seeking. Women and Language. 2016;39(1):49-74Reason for exclusion: No discussion of GYN or reproductive care for trans men

Willging C, Gunderspm L, Shattuck D, Sturm R, Lawyer A, Crandall C. Structural competency in emergency medicine services for transgender and gender non-conforming patients. Soc Sci Med. 2019;222:67-75.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Zeeman L, Aranda K, Sherrif N, Cocking C. Promoting resilience and emotional well-being of transgender young people: research at the intersections of gender and sexuality. J Youth Stud. 2017;20(3):382-97.Reason for exclusion: No voice re trans men experiences with GYN or reproductive healthcare

Appendix III: Characteristics of included studies

Appendix IV: Study findings and illustrations

References