Actualizado
Reviewed Dic. 30, 2021

Special Populations

Perinatal HIV Prevention for Transgender and Gender Diverse People Assigned Female Sex at Birth

Recommendations
  • The Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission has determined that, in most cases, it is appropriate to extrapolate its recommendations based on data in presumed cisgender women to all people assigned female sex at birth, including transgender and gender diverse people, with modification when indicated (e.g., drug interactions with gender-affirming hormones) (AIII).
  • Patient-centered HIV and perinatal services should be provided using gender-affirming approaches and models of care that address the unique and varied needs of transgender and gender diverse people and reduce barriers to ongoing engagement in care that can affect adherence to antiretroviral therapy and the likelihood of viral suppression during prepregnancy, antepartum, and postpartum periods (AII).
    • Patients should be asked about the pronouns they use and language preferences, including how they want to be referred to as a parent (e.g., the baby’s mother, father, or by another name) and terms they prefer to use for sexual and reproductive anatomy and examinations (e.g., breast exams, pelvic exams) (AIII).
  • Health care providers should assess reproductive and parenting intentions and support access to appropriate contraception and perinatal HIV prevention services for transgender and gender diverse people (AIII).
  • Prepregnancy care for transgender and gender diverse people should incorporate shared decision-making that addresses needs related to gender identity, with consideration of the potential risks and benefits of gender-affirming pharmacologic treatment in relation to pregnancy (AIII).
  • Some transgender and gender diverse patients may experience the onset or worsening of gender dysphoria and associated symptoms—such as depression—during prepregnancy, antepartum, and postpartum periods; health care providers should regularly assess patients’ comfort with their care and provide referrals for mental health or other support services as needed (AIII).

For additional information, see Transgender People with HIV in the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV.

Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

It is important for health care providers to be aware that not all people who become pregnant identify as women or female. Because many transgender and gender diverse people retain their reproductive organs, pregnancy can occur, and some may desire pregnancy at some point in their lifetime.1-3 This section provides an overview of recommendations from the Panel on Treatment of HIV During Pregnancy  and Prevention of Perinatal Transmission (the Panel) regarding perinatal HIV prevention and treatment of HIV in pregnancy for transgender and gender diverse people assigned female sex at birth. The Panel uses the terms transgender and gender diverse people assigned female sex at birth to include people who do not identify as cisgender women while acknowledging individual preferences and ongoing changes in the terminology used to describe this population. The Panel aims to make the guidelines inclusive of transgender and gender diverse people by incorporating inclusive language, considering the appropriateness of existing Panel recommendations for the care of transgender and gender diverse individuals who were assigned female sex at birth, and adding relevant recommendations and content. Additional information is available in the Adult and Adolescent Guidelines (see Transgender People with HIV), guidance from the American College of Obstetricians and Gynecologists about health care for transgender and gender diverse individuals4, standards of care developed by the World Professional Association for Transgender Health 5 and guidelines for primary and gender-affirming care developed by the Center of Excellence for Transgender Health at the University of California – San Francisco.6

Perinatal HIV Prevention and Care of Transgender and Gender Diverse People During Prepregnancy, Antepartum, and Postpartum Periods

The evidence ratings of Panel recommendations about the use of antiretroviral drugs during pregnancy and other interventions for reducing perinatal HIV transmission are based on data from studies of reproductive-aged women and pregnant women whose gender identity was not reported. Research into the fertility, pregnancy-related, and perinatal HIV prevention needs of transgender and gender diverse people is in early stages, and descriptions of pregnancy-related care are limited. After consideration, the Panel has decided it is often appropriate to extrapolate existing recommendations to transgender and gender diverse people assigned female sex at birth and to provide additional content and recommendations, when data are available, to address the unique and varied needs of this population if indicated. This approach is consistent with other guidelines for primary care, family planning,7 and HIV care8 of transgender and gender diverse people.

Health care providers should periodically assess the reproductive and parenting desires and intentions of transgender and gender diverse patients and support access to contraception and perinatal HIV prevention services.9 Transgender and gender diverse people assigned female sex at birth who are receiving gender-affirming hormones—such as testosterone—should be counseled about the need for contraception to avoid unintended pregnancy and about potential risks before trying to become pregnant, since testosterone is not an approved or reliable contraceptive and is teratogenic.10-12 For people wanting to conceive, prepregnancy planning and care provides an opportunity to address HIV prevention—including HIV testing and pre-exposure prophylaxis—for those who are HIV negative. For people with HIV, it provides an opportunity to optimize antiretroviral therapy (ART) and viral suppression before pregnancy. It also enables providers to identify and address transgender and gender diverse people’s concerns about the relationships between pregnancy or parenthood and their gender identity and gender-affirming medical interventions, such as hormones or surgeries. For additional information, see Pre-Exposure Prophylaxis (PrEP) to Prevent HIV During Periconception, Antepartum, and Postpartum Periods; Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV; and Reproductive Options for Couples When One or Both Partners Have HIV.

Selection and management of ART for transgender and gender diverse people with HIV should follow General Principles Regarding Use of Antiretroviral Drugs During Pregnancy and Recommendations for Use of Antiretroviral Drugs During Pregnancy. The potential for drug interactions should be considered and discussed with patients who plan to start or resume hormonal therapy postpartum (see Table 17. Potential Interactions Between the Drugs Used in Gender-Affirming Hormone Therapy and Antiretroviral Drugs in Transgender People with HIV).

Gender-Affirming Care

Health care providers should work to develop patient-centered approaches that assess and address the gender affirmation needs of transgender and gender diverse individuals in all health care settings.9,11 Gender affirmation encompasses processes and interventions that recognize and support a person’s gender identity and expression.13 Gender-affirming care may include psychosocial support, hormone therapy, surgery, and other interventions.11 Gender affirmation—including medical interventions, such as hormonal therapy—has been shown to improve mental health outcomes and quality of life in transgender individuals.14-17 A prospective evaluation of the effects of medical gender affirmation on HIV-related outcomes—including viral suppression—is currently in process.18 A national needs assessment found that transgender and gender diverse people with HIV were more likely to be virally suppressed when they worked with HIV care providers who affirmed their gender (e.g., providers who use their chosen name and pronoun[s]).8,19 Language is important for inclusivity and for providing respectful, affirming health care.9,20 Patients should be asked about the pronouns they use and language preferences, including how they (and their partners) want to be referred to as parents (i.e., the baby’s mother, father, or by another name). Clinicians should also ask patients about terminology they use for sexual and reproductive anatomy (e.g., breasts, vagina) and examinations (e.g., breast exams, pelvic exams) because terms may vary.20

Health care providers should be aware that although transgender and gender diverse patients may adjust well to pregnancy, some patients may experience and require support for the onset or worsening of gender dysphoria and associated symptoms during prepregnancy, antepartum, and postpartum periods. Gender dysphoria and associated symptoms may be precipitated or exacerbated by the need to stop or delay the use of testosterone for pharmacologic gender affirmation when trying to conceive and during pregnancy.10,11 Gender dysphoria refers to the distress that results from incongruence between a person’s sex assigned at birth and their gender identity21 and is manifested by a range of symptoms, such as a sense of unease, depression, and anxiety.22 Gender dysphoria can be reduced when a person receives affirmation for their gender identity through various interventions that include interpersonal approaches—such as adaptations made in women-centered clinic environments and procedures—and medical interventions, such as hormones.11,22 During the postpartum period, some patients may need referrals to a hormonal therapy prescriber or a specialist in transgender medicine.

References

  1. Cipres D, Seidman D, Cloniger C 3rd, Nova C, O’Shea A, Obedin-Maliver J. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception. 2017;95(2):186-189. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27621044.
  2. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25415163.
  3. Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception. 2018;98(4):266-269. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29944875.
  4. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health Care for transgender and gender diverse individuals. ACOG Committee Opinion Number 823. 2021. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals.
  5. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. Available at: https://wpath.org/publications/soc.
  6. Deutsch M. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2016. Available at: https://transcare.ucsf.edu/guidelines.
  7. Bonnington A, Dianat S, Kerns J, et al. Society of Family Planning clinical recommendations: contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth. Contraception. 2020;102(2):70-82. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32304766.
  8. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. 2021. Available at: https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelines.
  9. Moseson H, Zazanis N, Goldberg E, et al. The imperative for transgender and gender nonbinary inclusion: beyond women’s health. Obstet Gynecol. 2020;135(5):1059-1068. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32282602.
  10. Brandt JS, Patel AJ, Marshall I, Bachmann GA. Transgender men, pregnancy, and the “new” advanced paternal age: a review of the literature. Maturitas. 2019;128:17-21. Available at https://www.ncbi.nlm.nih.gov/pubmed/31561817.
  11. Hahn M, Sheran N, Weber S, Cohan D, Obedin-Maliver J. Providing patient-centered perinatal care for transgender men and gender-diverse individuals: a collaborative multidisciplinary team approach. Obstet Gynecol. 2019;134(5):959-963. Available at https://www.ncbi.nlm.nih.gov/pubmed/31599839.
  12. Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020;222(2):134-143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31394072.
  13. Sevelius JM. Gender Affirmation: a framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013;68(11-12):675-689. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23729971.
  14. Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015;15:525. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26032733.
  15. White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health. 2016;1(1):21-31. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27595141.
  16. Keo-Meier CL, Herman LI, Reisner SL, Pardo ST, Sharp C, Babcock JC. Testosterone treatment and MMPI-2 improvement in transgender men: a prospective controlled study. J Consult Clin Psychol. 2015;83(1):143-156. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25111431.
  17. Mahfouda S, Moore JK, Siafarikas A, et al. Gender-affirming hormones and surgery in transgender children and adolescents. Lancet Diabetes Endocrinol. 2019;7(6):484-498. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30528161.
  18. Reisner SL, Deutsch MB, Mayer KH, et al. Longitudinal cohort study of gender affirmation and HIV-related health in transgender and gender diverse adults: the LEGACY Project Protocol. JMIR Res Protoc. 2021;10(3):e24198. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33646126.
  19. Chung C KA, McBride B, Roebuck C, Sprague L, Center TL. Some kind of strength: findings on health care and economic wellbeing from a national needs assessment of transgender and gender non-conforming people living with HIV. 2016. Available at: http://transgenderlawcenter.org/wp-content/uploads/2017/03/TLC_REPORT_SOME_KIND_OF_FINAL_REV3.pdf.
  20. Klein A, Golub SA. Enhancing gender-affirming provider communication to increase health care access and utilization among transgender men and trans-masculine non-binary individuals. LGBT Health. 2020;7(6):292-304. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32493100.
  21. American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70(9):832-864. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26653312.
  22. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf). 2010;72(2):214-231. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19473181

Special Populations

Perinatal HIV Prevention for Transgender and Gender Diverse People Assigned Female Sex at Birth

Recommendations
  • The Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission has determined that, in most cases, it is appropriate to extrapolate its recommendations based on data in presumed cisgender women to all people assigned female sex at birth, including transgender and gender diverse people, with modification when indicated (e.g., drug interactions with gender-affirming hormones) (AIII).
  • Patient-centered HIV and perinatal services should be provided using gender-affirming approaches and models of care that address the unique and varied needs of transgender and gender diverse people and reduce barriers to ongoing engagement in care that can affect adherence to antiretroviral therapy and the likelihood of viral suppression during prepregnancy, antepartum, and postpartum periods (AII).
    • Patients should be asked about the pronouns they use and language preferences, including how they want to be referred to as a parent (e.g., the baby’s mother, father, or by another name) and terms they prefer to use for sexual and reproductive anatomy and examinations (e.g., breast exams, pelvic exams) (AIII).
  • Health care providers should assess reproductive and parenting intentions and support access to appropriate contraception and perinatal HIV prevention services for transgender and gender diverse people (AIII).
  • Prepregnancy care for transgender and gender diverse people should incorporate shared decision-making that addresses needs related to gender identity, with consideration of the potential risks and benefits of gender-affirming pharmacologic treatment in relation to pregnancy (AIII).
  • Some transgender and gender diverse patients may experience the onset or worsening of gender dysphoria and associated symptoms—such as depression—during prepregnancy, antepartum, and postpartum periods; health care providers should regularly assess patients’ comfort with their care and provide referrals for mental health or other support services as needed (AIII).

For additional information, see Transgender People with HIV in the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV.

Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

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