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Sexual Behavior and Contraceptive Use Among Cisgender and Gender Minority College Students Who Were Assigned Female at Birth

  • Colleen A. Reynolds
    Correspondence
    Address correspondence to: Colleen Reynolds, Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Kresge Building 9th Floor - student mail, Boston, MA 02115. Phone: (425) 223-0589.
    Affiliations
    Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

    Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
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  • Brittany M. Charlton
    Affiliations
    Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

    Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts

    Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

    Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Published:April 07, 2021DOI:https://doi.org/10.1016/j.jpag.2021.03.009

      Abstract

      Study Objective

      Our objective was to describe sexual behavior and contraceptive use among assigned female cisgender and gender minority college students (ie, those whose gender identity does not match their sex assigned at birth).

      Design

      Cross-sectional surveys administered as part of the fall 2015 through spring 2018 administrations of the National College Health Assessment.

      Setting

      Colleges across the United States.

      Participants

      A total of 185,289 cisgender and gender minority assigned females aged 18-25 years.

      Main Outcome Measures

      Recent vaginal intercourse; number and gender of sexual partners; use of contraception; use of protective barriers during vaginal intercourse.

      Results

      Both gender minority and cisgender students often reported having male sexual partners, but gender minority students were more likely to report having partners of another gender identity (eg, women, trans women). Gender minorities were less likely than cisgender students to report having vaginal intercourse (adjusted odds ratio [AOR]: 0.86; 95% confidence interval [95% CI]: 0.80, 0.93). Gender minorities were less likely than cisgender students to report using any contraceptive methods (AOR: 0.86; 95% CI: 0.73, 1.03), and were less likely to consistently use barrier methods (AOR: 0.72; 95% CI: 0.64, 0.81) or emergency contraception (AOR: 0.56; 95% CI: 0.48, 0.65). However, gender minorities were more likely to use Tier 1 and Tier 3 contraceptive methods than cisgender women.

      Conclusions

      Providers must be trained to meet the contraceptive counseling needs of cisgender and gender minority patients. Providers should explicitly ask all patients about the sex/gender of the patients’ sexual partners and the sexual behaviors in which they engage, to assess sexual risk and healthcare needs.

      Key Words

      Introduction

      The majority of research on the sexual and reproductive health of gender minorities (ie, individuals whose gender identity does not match their sex assigned at birth) has focused heavily on outcomes such as sexually transmitted infections (STIs) and sexual violence, but little research has addressed health outcomes related to contraceptive use, pregnancy, or fertility.
      • Reisner S.L.
      • Poteat T.
      • Keatley J.
      • et al.
      Global health burden and needs of transgender populations: a review.
      Emerging research suggests that the use of ineffective contraceptive methods or no contraceptive methods may be common among gender minorities who were assigned female at birth.
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • et al.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      • Veale J.
      • Watson R.J.
      • Adjei J.
      • et al.
      Prevalence of pregnancy involvement among Canadian transgender youth and its relation to mental health, sexual health, and gender identity.
      • Light A.D.
      • Obedin-Maliver J.
      • Sevelius J.M.
      • et al.
      Transgender men who experienced pregnancy after female-to-male gender transitioning.
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      • Stark B.
      • Hughto J.M.W.
      • Charlton B.M.
      • et al.
      The contraceptive and reproductive history and planning goals of trans-masculine adults: a mixed-methods study.
      Gender minorities face unique barriers to contraceptive use. For example, gender minorities are more likely than the general population to be uninsured and many delay or avoid care due to cost.
      • James S.E.
      • Herman J.L.
      • Rankin S.
      • et al.
      The Report of the 2015 U.S. Transgender Survey.
      Insurance plans may also deny coverage for “gender-specific” care that does not align with an insured person's gender marker on record, such as contraceptive counseling for trans men.
      • James S.E.
      • Herman J.L.
      • Rankin S.
      • et al.
      The Report of the 2015 U.S. Transgender Survey.
      ,
      • Fix L.
      • Durden M.
      • Obedin-Maliver J.
      • et al.
      Stakeholder perceptions and experiences regarding access to contraception and abortion for transgender, non-binary, and gender-expansive individuals assigned female at birth in the U.S..
      Gender minorities may also avoid care due to experiences with transphobic discrimination in healthcare settings.
      • James S.E.
      • Herman J.L.
      • Rankin S.
      • et al.
      The Report of the 2015 U.S. Transgender Survey.
      • Fix L.
      • Durden M.
      • Obedin-Maliver J.
      • et al.
      Stakeholder perceptions and experiences regarding access to contraception and abortion for transgender, non-binary, and gender-expansive individuals assigned female at birth in the U.S..
      • Agénor M.
      • Cottrill A.A.
      • Kay E.
      • et al.
      Contraceptive beliefs, decision making and care experiences among transmasculine young adults: a qualitative analysis.
      When gender minorities seek care, many do not disclose their identity,
      • James S.E.
      • Herman J.L.
      • Rankin S.
      • et al.
      The Report of the 2015 U.S. Transgender Survey.
      ,
      • Veale J.
      • Saewyc E.
      • Frohard-Dourlent H.
      • et al.
      Being Safe, Being Me: results of the Canadian Trans Youth Health Survey.
      ,
      • Dutton L.
      • Koenig K.
      • Kristopher F.
      Gynecologic care of the female-to-male transgender man.
      so healthcare providers may not recognize their patients’ need for contraceptive counseling. By contrast, some providers may refuse to provide contraceptive counseling to gender minorities because they have inadequate formal training in reproductive healthcare for this population.
      • Fix L.
      • Durden M.
      • Obedin-Maliver J.
      • et al.
      Stakeholder perceptions and experiences regarding access to contraception and abortion for transgender, non-binary, and gender-expansive individuals assigned female at birth in the U.S..
      ,
      • Unger C.A.
      Care of the transgender patient: a survey of gynecologists’ current knowledge and practice.
      Gender minorities who overcome these hurdles still may not use contraception. Contraception can cause gender dysphoria by providing daily reminders of an individual's reproductive anatomy.
      • Fix L.
      • Durden M.
      • Obedin-Maliver J.
      • et al.
      Stakeholder perceptions and experiences regarding access to contraception and abortion for transgender, non-binary, and gender-expansive individuals assigned female at birth in the U.S..
      ,
      • Agénor M.
      • Cottrill A.A.
      • Kay E.
      • et al.
      Contraceptive beliefs, decision making and care experiences among transmasculine young adults: a qualitative analysis.
      Some gender minority individuals and their healthcare providers may underestimate the need for contraception because they erroneously believe that gender-affirming testosterone use also prevents pregnancy.
      • Light A.D.
      • Obedin-Maliver J.
      • Sevelius J.M.
      • et al.
      Transgender men who experienced pregnancy after female-to-male gender transitioning.
      ,
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      ,
      • Abern L.
      • Nippita S.
      • Maguire K.
      Contraceptive use and abortion views among transgender and gender-nonconforming individuals assigned female at birth.
      • Gomez A.
      • Walters P.
      • Dao L.
      Testosterone in a way is birth control”: contraceptive attitudes and experiences among transmasculine and genderqueer young adults.
      • Kanj R.V.
      • Conard L.A.E.
      • Trotman G.E.
      Menstrual suppression and contraceptive choices in a transgender adolescent and young adult population.
      Finally, gender minorities may avoid hormonal contraception due to concern that these methods will interfere with their testosterone therapy or have “feminizing” effects.
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      ,
      • Fix L.
      • Durden M.
      • Obedin-Maliver J.
      • et al.
      Stakeholder perceptions and experiences regarding access to contraception and abortion for transgender, non-binary, and gender-expansive individuals assigned female at birth in the U.S..
      ,
      • Agénor M.
      • Cottrill A.A.
      • Kay E.
      • et al.
      Contraceptive beliefs, decision making and care experiences among transmasculine young adults: a qualitative analysis.
      ,
      • Gomez A.
      • Walters P.
      • Dao L.
      Testosterone in a way is birth control”: contraceptive attitudes and experiences among transmasculine and genderqueer young adults.
      ,
      • 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.
      Much of this research has been qualitative or has had significant methodological limitations, including small sample sizes, convenience sampling, and a lack of cisgender comparison groups. This limits the ability of healthcare providers and policy makers to develop evidence-based approaches to improve the sexual and reproductive health of gender minorities. This study expands on previous research on the sexual and reproductive health of gender minority people. We used the National College Health Assessment (NCHA) II-C, a cross-sectional survey of college-attending adults in the United States, to describe sexual behavior and contraceptive use. The large sample provided adequate statistical power to detect differences between students who were assigned female at birth and are cisgender compared to those who are gender minorities.

      Materials and Methods

      Data

      The NCHA is administered in fall and spring academic terms by schools that purchased the survey from the American College Health Association.
      American College Health Association: American College Health Association−National College Health Assessment, Fall 2015−Spring 2018 [computer file].
      The national dataset contains data from schools that randomly sampled students or classrooms. Additional information about the study recruitment, response rates, and characteristics of participating schools is detailed elsewhere.

      American College Health Association: Publications and reports: ACHA-NCHA II. 2019. Available from: https://www.acha.org/NCHA/ACHA-NCHA_Data/Publications_and_Reports/NCHA/Data/Reports_ACHA-NCHAIIc.aspx. Accessed December 9, 2019.

      We accessed data from fall 2015 through spring 2018. We limited the present study to assigned female students, aged 18-25 years, who provided sufficient detail to categorize their gender identity and answered questions on at least 1 sexual and reproductive health outcome of interest (N = 185,289) (Fig. 1).
      Fig 1
      Fig 1Sample Inclusion and Exclusion Flow Chart.

      Measures

      Gender identity

      Gender identity was assessed through 3 questions. First, students report their sex assigned at birth as either “male” or “female.” Then, students responded to 2 questions about their gender identity: “Do you identify as transgender? (1) No, (2) Yes,” and “Which term do you use to describe your gender identity? (1) Woman, (2) Man, (3) Trans woman, (4) Trans man, (5) Genderqueer, (6) Another identity (please specify).” A simplified variation of these questions, using only assigned sex and gender identity, has been in use for over 2 decades and has performed well in validation studies.
      Gender Identity in U.S. Surveillance Group (GenIUSS): Gender-related measures overview
      The Williams Institute at the University of California Los Angeles School of Law.
      • Adams N.
      • Pearce R.
      • Veale J.
      • et al.
      Guidance and ethical considerations for undertaking transgender health research and institutional review boards adjudicating this research.
      • Reisner S.L.
      • Conron K.J.
      • Tardiff L.A.
      • et al.
      Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults.
      We categorized students as cisgender women or gender minorities. Students who identified as women and did not report that they were transgender were categorized as cisgender. We used the term “gender minority” to capture both trans men and genderqueer individuals, including those who reported their gender as “man,” those who identified as transgender and reported their gender as “trans man,” and those who identified as genderqueer regardless of whether they identified as transgender.
      A total of 1,101 students provided a write-in response to “Another identity (please specify).” We recoded identities that were reported at least twice into the existing gender identity categories. The most commonly written-in identities included agender, nonbinary, and genderfluid. We recoded 24 students as cisgender women and 720 as gender minorities. In a secondary analysis, we disaggregate transmasculine and genderqueer students and present outcomes for students whose gender was not ascertained or categorized. Respondents were considered transmasculine if their gender identity included terms such as man, masculine, male, or butch. Respondents with other gender minority identities, such as genderqueer, agender, or nonbinary, were classified as genderqueer because the majority of this group self-selected that label. Of the 185,289 respondents, 98.4% (n = 182,385) were cisgender and 1.6% (n = 2,904) were gender minorities.

      Sexual behavior

      The survey asked whether students had had vaginal intercourse in the past 30 days. Students were not provided a definition of “vaginal intercourse.” Responses were dichotomized into “ever” and “never” had vaginal intercourse.
      Students were also asked how many “oral sex, vaginal intercourse, or anal intercourse” partners they had had in the past 12 months. We modeled responses to this question continuously.
      Additionally, all students were asked whether their sexual partners in the past 12 months were women, men, trans women, trans men, genderqueer, and/or person(s) with another identity. We assessed whether a student had a partner of each of these categories independently.

      Contraceptive use

      All students were asked “Did you or your partner use a method of birth control to prevent pregnancy the last time you had vaginal intercourse? (1) Yes, (2) N/A, have not had vaginal intercourse, (3) No, have not had vaginal intercourse that could result in a pregnancy, (4) No, did not want to prevent pregnancy, (5) No, did not use any birth control method, (6) Don't know.” Students who indicated they did not want to prevent pregnancy or did not use any method were categorized as using no method. Students who indicated they were unsure, had not had vaginal intercourse, or had not had vaginal intercourse that could result in pregnancy were excluded from the analysis.
      Students who reported using contraception or who did not respond to the question on contraception were subsequently asked to specify all methods that they or their partner used to prevent pregnancy at last vaginal intercourse. The NCHA does not assess contraceptive use for noncontraceptive purposes. For comparability to broader family planning research, we grouped contraceptive methods using the World Health Organization's tiered comparative effectiveness chart. These categories include the following: Tier 1 (implants, intrauterine device [IUD], and sterilization); Tier 2 (birth control shots, pills, patch, and ring); Tier 3 (male condom, diaphragm or cervical cap, and fertility awareness); and Tier 4 (female condom, withdrawal, spermicide, and contraceptive sponge).
      World Health Organization Department of Reproductive Health and Research
      Johns Hopkins Bloomberg School of Public Health Center for Communication Programs. Family planning: a global handbook for providers : evidence-based guidance developed through worldwide collaboration.
      We created an additional set of contraceptive categories of particular interest to gender minorities: barrier methods, long-acting reversible contraceptives (LARCs; eg, IUD, implants), sterilization, and “other” methods. We assessed usage of barrier methods (male condom, female condom, and diaphragm, or cervical cap) because there is a paucity of research on STI risk among gender minority assigned females.
      • Reisner S.L.
      • Poteat T.
      • Keatley J.
      • et al.
      Global health burden and needs of transgender populations: a review.
      We assessed LARC use since these can cause amenorrhea, do not contain estrogen, and are a recommended contraceptive method for gender minorities.
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      ,
      • Francis A.
      • Jasani S.
      • Bachmann G.
      Contraceptive challenges and the transgender individual.
      ,
      • Dodson N.A.
      • Langer M.
      The reproductive health care of transgender young people: a guide for primary care providers.
      We suspected that some gender minority students would report sterilization as a result of surgical transition. Finally, some gender minority students may report their use of hormone therapy as “other” contraceptive methods.
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      ,
      • Abern L.
      • Nippita S.
      • Maguire K.
      Contraceptive use and abortion views among transgender and gender-nonconforming individuals assigned female at birth.
      ,
      • Gomez A.
      • Walters P.
      • Dao L.
      Testosterone in a way is birth control”: contraceptive attitudes and experiences among transmasculine and genderqueer young adults.
      All participants were asked, “Within the last 12 months, have you or your partner(s) used emergency contraception (‘morning after pill’)?” Emergency contraception use among those who had vaginal intercourse was dichotomized as “yes” or “no.”
      Finally, all participants were asked, “Within the last 30 days, how often did you or your partner(s) use a condom or other protective barrier (eg, male condom, female condom, dam, glove) during vaginal intercourse?” Barrier use was modeled as consistent (always or most of the time) and inconsistent (sometimes, rarely, and never).

      Covariates

      We included age (in continuous years), race/ethnicity (categorized as non-Hispanic White; Hispanic or Latino/Latina; non-Hispanic Asian or Pacific Islander; non-Hispanic Black; non-Hispanic American Indian, Alaska Native, Native Hawaiian; non-Hispanic Multiracial; non-Hispanic Other), as well as the geographic region of the college or university the student attended (Northeast, Midwest, South, and West) as covariates. We used a complete case approach, as less than 1% of participants were missing data on covariates.

      Statistical Analysis

      The distribution of demographic characteristics and covariates by gender identity were tabulated (Tables 1-3). Multivariable logistic and linear regression models were used to estimate adjusted odds ratios (AOR), differences in continuous outcomes, and 95% confidence intervals (CI) for the association between gender identity and sexual behavior (Table 4) and contraceptive use (Table 5). Models were adjusted for age, race/ethnicity, and geographic region. Analyses were conducted using R 3.5.1.
      Table 1Demographic Characteristics by Gender Identity Among US College Cisgender and Gender Minority Students Who Were Assigned Female at Birth (N = 185,289)
      % (n) Unless otherwise specifiedCisgender (98.4%, n = 182,385)Gender Minority (1.6%, n = 2904)P
      P values calculated using χ2 tests for categorical variables and ANOVA for continuous variables.
      Age, yr, mean (SD); range: 18-2520.34 (1.85)20.23 (1.83).001
      Race/ethnicity
       White, non-Hispanic112,043 (61.4)1806 (62.2)<.001
       Hispanic or Latino/Latina27,257 (14.9)386 (13.3)
       Asian or Pacific Islander, non-Hispanic20,551 (11.3)262 (9.0)
       Black, non-Hispanic7989 (4.4)79 (2.7)
       American Indian, Alaska Native, Native Hawaiian, non-Hispanic717 (0.4)17 (0.6)
       Multiracial, non-Hispanic1718 (6.4)309 (10.6)
       Other, non-Hispanic2110 (1.2)45 (1.5)
      Region
       Midwest36,808 (20.2)593 (20.4)<.001
       Northeast37,511 (20.6)744 (25.6)
       South40,452 (22.2)472 (16.3)
       West67,614 (37.1)1095 (37.7)
      Sexual orientation
       Asexual7573 (4.2)365 (12.6)<.001
       Bisexual13,201 (7.3)434 (15.0)
       Gay263 (0.1)115 (4.0)
       Lesbian2669 (1.5)180 (6.2)
       Pansexual3182 (1.7)623 (21.5)
       Queer1555 (0.9)642 (22.2)
       Questioning3731 (2.1)101 (3.5)
       Same-gender loving90 (0.0)12 (0.4)
       Straight/heterosexual148,365 (81.6)274 (9.5)
       Another identity1234 (0.7)150 (5.2)
      Ever had vaginal intercourse116,090 (64.0)1761 (60.9).001
      Number of oral/anal/vaginal sex partners, past 12 m, mean (SD)1.40 (2.48)1.55 (3.29).001
      Gender of sex partners, past 12 mo
       Men118,033 (65.2)1077 (38.4)<.001
       Women8,747 (4.9)920 (32.7)<.001
       Trans men444 (0.2)221 (8.1)<.001
       Trans women357 (0.2)134 (4.9)<.001
       Genderqueer1167 (0.7)519 (18.7)<.001
       Person(s) with another identity501 (0.3)233 (8.6)<.001
      a P values calculated using χ2 tests for categorical variables and ANOVA for continuous variables.

      Ethics Approval

      All participating universities received approval from their respective Institutional Review Boards to administer the NCHA survey. Informed consent was obtained from all participants. We received permission from the American College Health Association to conduct this study. This study was considered exempt from Institutional Review Board review.

      Results

      Demographic Characteristics

      We observed significant differences in the distribution of demographic factors by gender identity. Gender minority students were more likely to report that they were non-Hispanic Multiracial (10.6%) than were cisgender students (6.4%). Gender minority students were also less likely to attend a school in the South (16.3%) than were cisgender students (22.2%), and more likely to attend school in the Northeast (25.6%) than were cisgender students (20.6%).

      Sexual Behavior

      Cisgender students predominantly identified as straight/heterosexual (81.6%), whereas gender minority students most commonly identified as queer (22.2%), pansexual (21.5%), and bisexual (15.0%). Gender minorities were slightly less likely to report ever having vaginal intercourse (60.9%) compared to cisgender students (64.0%). In all, 65.2% of cisgender and 38.4% of gender minority students reported having sexual partners who were men, but gender minority students were more likely to report having partners of another gender identity.
      After covariate adjustment, gender minority students reported slightly more sexual partners in the past year (0.12 more sexual partners, ie, less than 1 partner, 95% CI: 0.03, 0.21), but had lower odds of ever having vaginal intercourse, compared to cisgender students (Table 4). Gender minority students had 68% lower odds (AOR: 0.32; 95% CI: 0.29, 0.34) of reporting past-year sexual partners who were men, compared to cisgender women, but were considerably more likely to report sexual partners who were women, trans men, trans women, genderqueer, or persons with another identity).

      Contraceptive Use

      Use of any contraceptive method at last vaginal intercourse was high among both gender minority students (86.8%) and cisgender students (88.1%; Tables 2 and 3). Compared to cisgender students, gender minorities were less likely to report using emergency contraception in the past year (18.8% and 11.4%, respectively), and less likely to report consistently using a barrier during vaginal intercourse in the past 30 days (48.8% and 41.0%, respectively). After covariate adjustment, gender minority students had slightly lower odds (AOR: 0.86; 95% CI: 0.73, 1.03) of using any contraceptive method at last vaginal intercourse than cisgender students, although this was not statistically significant (Table 5). Gender minority students had lower odds than cisgender students of reporting using Tier 2 and Tier 4 methods but had higher odds of using Tier 1 and Tier 3 methods. Although the use of “other” methods and sterilization were rare overall, they were considerably more common among gender minority students than cisgender students. Gender minority students also had higher odds than cisgender students of using long-acting reversible contraception (LARC) (AOR: 1.56; 95% CI: 1.35, 1.81) and barrier methods (AOR: 1.16; 95% CI: 1.03, 1.31) at last vaginal intercourse. However, past-year emergency contraception use (AOR: 0.56; 95% CI: 0.48, 0.65) and consistent barrier use during the past 30 days (AOR: 0.72; 95% CI: 0.64, 0.81) were less common among gender minorities than among cisgender students.
      Table 2Contraceptive Use Among Participants Who Have Had Vaginal Intercourse, by Gender Identity (n = 123,246)
      MethodCisgender (98.6%, n = 121,511)Gender Minority (1.4%, n = 1767)P
      P calculated using χ2 tests for categorical variables and analysis of variance for continuous variables.
      Method of birth control
      At last vaginal intercourse, to prevent pregnancy.
      No method used13,445 (11.9)155 (13.2).183
        None, did not use any method12,410 (11.0)147 (12.5)
        None, did not want to prevent pregnancy1035 (0.9)8 (0.7)
      Tier 1 methods16,108 (14.5)250 (21.7)<.001
        Birth control implants7035 (6.3)84 (7.3)
        Intrauterine device (IUD)9977 (9.0)166 (14.4)
        Sterilization (eg, hysterectomy, tubal ligation, vasectomy)279 (0.3)12 (1.0)
      Tier 2 methods64,600 (58.0)479 (41.5)<.001
        Birth control pills58,864 (52.9)410 (35.6)
        Birth control shots3460 (3.1)43 (3.7)
        Birth control patch734 (0.7)9 (0.8)
        Vaginal ring2512 (2.3)36 (3.1)
      Tier 3 methods63,449 (57.0)715 (62.0).001
        Male condom60,961 (54.8)677 (58.7)
        Diaphragm or cervical cap127 (0.1)4 (0.3)
        Fertility awareness-based methods (eg, calendar, cervical mucus, basal body temperature)8283 (7.4)127 (11.0)
      Tier 4 methods36,271 (32.6)302 (26.2)<.001
        Female condom551 (0.5)16 (1.4)
        Contraceptive sponge128 (0.1)3 (0.3)
        Spermicide (eg, foam, jelly, cream)2353 (2.1)33 (2.9)
        Withdrawal34,994 (31.4)277 (24.0)
      Other method1413 (1.3)48 (4.2)<.001
      Emergency contraception
      In past 12 Months.
      21,814 (18.8)185 (11.4)<.001
      Barrier method consistency during vaginal intercourse
      In past 30 days.
      <.001
       Never25,075 (27.9)460 (39.4)
       Rarely9839 (10.9)94 (8.0)
       Sometimes11,067 (12.3)135 (11.6)
       Most of the time15,508 (17.3)168 (14.4)
       Always28,377 (31.6)311 (26.6)
      Consistent barrier use
      In past 30 days.
      43,885 (48.8)479 (41.0)<.001
      a P calculated using χ2 tests for categorical variables and analysis of variance for continuous variables.
      b At last vaginal intercourse, to prevent pregnancy.
      c In past 12 Months.
      d In past 30 days.
      Table 3Contraceptive Use Among Participants Who Have Had Vaginal Intercourse, by Gender Identity (n = 124,210)
      MethodCisgender (98.6%, n = 121,848)Gender Minority (1.4%, n = 1775)P
      P calculated using χ2 tests for categorical variables and analysis of variance for continuous variables.
      Method of birth control
      At last vaginal intercourse, to prevent pregnancy.
       Any99,487 (88.1)1018 (86.8).183
       Tier 116,108 (14.5)250 (21.7)<.001
       Tier 264,600 (58.0)479 (41.5)<.001
       Tier 363,449 (57.0)715 (62.0).001
       Tier 436,271 (32.6)302 (26.2)<.001
       LARC15,924 (14.3)240 (20.8)<.001
       Barrier61,240 (55.0)681 (59.1).006
       Sterilization279 (0.3)12 (1.0)<.001
       Other method1413 (1.3)48 (4.2)<.001
      Emergency contraception
      In past 12 Months.
      21,814 (18.8)185 (11.4)<.001
      Consistent barrier use
      In past 30 days.
      43,885 (48.8)479 (41.0)<.001
      a P calculated using χ2 tests for categorical variables and analysis of variance for continuous variables.
      b At last vaginal intercourse, to prevent pregnancy.
      c In past 12 Months.
      d In past 30 days.
      Table 4Sexual Behavior Among Participants in the Past Year, by Gender Identity [AOR
      Adjusted for age, race/ethnicity, and geographic region.
      (95% CI)] (n = 185,220)
      Cisgender (98.4%, n = 182,317)Gender Minority (1.6%, n = 2903)
      Number of sexual partners
      Adjusted linear regression coefficient.
      ref.0.12 (0.03, 0.21)
      Ever had vaginal intercourse1.00 (ref.)0.86 (0.8, 0.93)
      Gender of sexual partners
       Men1.00 (ref.)0.32 (0.29, 0.34)
       Women1.00 (ref.)9.31 (8.57, 10.11)
       Trans men1.00 (ref.)34.02 (28.78, 40.22)
       Trans women1.00 (ref.)24.70 (20.15, 30.28)
       Genderqueer1.00 (ref.)33.32 (29.77, 37.29)
       Another identity1.00 (ref.)31.66 (26.93, 37.21)
      a Adjusted for age, race/ethnicity, and geographic region.
      b Adjusted linear regression coefficient.
      Table 5Contraceptive Use Among College Students Who Have Had Vaginal Intercourse, by Gender Identity [AOR
      Adjusted for age, race/ethnicity, and geographic region.
      (95% CI)] (n = 123,278)
      MethodCisgender (98.6%, n = 121,511)Gender Minority (1.4%, n = 1767)
      Contraceptive method
      At last vaginal intercourse, to prevent pregnancy.
       Any1.00 (ref.)0.86 (0.73, 1.03)
       Tier 11.00 (ref.)1.63 (1.41, 1.88)
       Tier 21.00 (ref.)0.50 (0.44, 0.56)
       Tier 31.00 (ref.)1.21 (1.07, 1.37)
       Tier 41.00 (ref.)0.73 (0.64, 0.84)
       LARC1.00 (ref.)1.56 (1.35, 1.81)
       Barrier1.00 (ref.)1.16 (1.03, 1.31)
       Sterilization1.00 (ref.)4.28 (2.39, 7.66)
       Other1.00 (ref.)3.37 (2.51, 4.52)
      Emergency contraception
      In past 12 months.
      1.00 (ref.)0.56 (0.48, 0.65)
      Consistent barrier use
      In past 30 days. Tier 1 = implants, intrauterine device (IUD), sterilization; Tier 2 = birth control shots, pills, patch, ring; Tier 3 = male condom, diaphragm or cervical cap, fertility awareness; Tier 4 = female condom, withdrawal, spermicide, contraceptive sponge. Long-acting reversible contraception (LARC) methods include implants, IUD; barrier methods include male condom, female condom, diaphragm or cervical cap; sterilization includes sterilization; other includes other; consistent barrier use denotes use of a barrier method always or most of the time during vaginal intercourse, in past 30 days.
      1.00 (ref.)0.72 (0.64, 0.81)
      a Adjusted for age, race/ethnicity, and geographic region.
      b At last vaginal intercourse, to prevent pregnancy.
      c In past 12 months.
      d In past 30 days.Tier 1 = implants, intrauterine device (IUD), sterilization; Tier 2 = birth control shots, pills, patch, ring; Tier 3 = male condom, diaphragm or cervical cap, fertility awareness; Tier 4 = female condom, withdrawal, spermicide, contraceptive sponge. Long-acting reversible contraception (LARC) methods include implants, IUD; barrier methods include male condom, female condom, diaphragm or cervical cap; sterilization includes sterilization; other includes other; consistent barrier use denotes use of a barrier method always or most of the time during vaginal intercourse, in past 30 days.

      Secondary Analyses

      In the supplementary material, we report sexual behavior (Supplementary Table 1) and contraceptive use (Supplementary Table 2) separately for genderqueer students and transmasculine students, as well as students’ whose gender we were unable to ascertain or to categorize. The outcomes were broadly similar for genderqueer and transmasculine students. Transmasculine students had higher odds of reporting sexual partners who were trans men or trans women, whereas genderqueer students were more likely to report genderqueer sexual partners. Transmasculine students also had higher odds of using sterilization or “other” contraceptive methods. Estimated odds ratios comparing outcomes for students with unknown gender to cisgender students are closer to the null than the odds ratios for genderqueer and transmasculine students. This is likely because students with unknown gender comprise a mix of cisgender and gender minority students.

      Discussion

      The present study used a large sample size, cisgender comparison group, and random sampling to describe differences in sexual behavior and contraception use by gender identity among those who were assigned female at birth and now identify as either cisgender or as a gender minority.
      We found that gender minorities were considerably more likely than cisgender students to report a sexual orientation other than straight/heterosexual and more likely to report having other gender minorities as sexual partners. Healthcare providers should not make assumptions about the sex (biology) or gender (social identity) of their patients, or that of their patients’ sexual partners. To provide appropriate sexual and reproductive care, providers must be trained to take a comprehensive sexual history that assesses both the sex and gender of sexual partners, as well as specific sexual behaviors. Moreover, providers should also perform an “anatomical inventory,” as patients’ reproductive health needs will vary based on whether they have had gender-affirming surgeries.
      • Krempasky C.
      • Harris M.
      • Abern L.
      • et al.
      Contraception across the transmasculine spectrum.
      However, more formal training is needed for providers to deliver high-quality sexual and reproductive healthcare for gender minority patients
      • Unger C.A.
      Care of the transgender patient: a survey of gynecologists’ current knowledge and practice.
      ,
      • Stroumsa D.
      • Shires D.A.
      • Richardson C.R.
      • et al.
      Transphobia rather than education predicts provider knowledge of transgender health care.
      ; only 2 in 7 obstetrician-gynecologists report being comfortable providing care for gender minorities who are assigned female (eg, female-to-male).
      • Unger C.A.
      Care of the transgender patient: a survey of gynecologists’ current knowledge and practice.
      Providers can refer to recent commentaries and guidelines for more detailed recommendations on providing contraceptive counseling and reproductive healthcare for gender minorities.
      • 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.
      ,
      • Dodson N.A.
      • Langer M.
      The reproductive health care of transgender young people: a guide for primary care providers.
      ,
      • Boudreau D.
      • Mukerjee R.
      Contraception care for transmasculine individuals on testosterone therapy.
      ,
      • Krempasky C.
      • Harris M.
      • Abern L.
      • et al.
      Contraception across the transmasculine spectrum.
      We observed a high prevalence of use of any contraceptive method at last vaginal intercourse, regardless of gender identity. However, gender minorities reported lower use of Tier 2 methods than cisgender students. Some gender minorities may avoid hormonal methods because they are concerned about the effect of “feminizing” hormones.
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      These contraceptive methods require regular contact with a healthcare provider and may be associated with use of preventive services such as Papanicolaou (Pap) testing.
      • Charlton B.M.
      • Corliss H.L.
      • Missmer S.A.
      • et al.
      Influence of hormonal contraceptive use and health beliefs on sexual orientation disparities in Papanicolaou test use.
      Future research should assess the use of preventive health services among gender minorities who are assigned female, as well as potential mediation by contraception use.
      By contrast, gender minorities were more likely to report using sterilization, LARC, and “other” contraceptive methods, as compared to cisgender students. The high prevalence of sterilization as contraception among gender minorities may reflect the voluntary use of gender affirmation surgery as well as coercive state policies that force gender minorities to undergo surgical transition to have their gender legally recognized.
      • Nixon L.
      The right to (trans) parent: a reproductive justice approach to reproductive rights, fertility, and family-building issues facing transgender people 2013 special issue: reproductive Justice.
      “Other” contraceptive method use may reflect that some gender minorities believe, or have been told by their healthcare providers, that testosterone acts as a contraceptive, even though some gender minorities have conceived while using testosterone.
      • Light A.D.
      • Obedin-Maliver J.
      • Sevelius J.M.
      • et al.
      Transgender men who experienced pregnancy after female-to-male gender transitioning.
      ,
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      ,
      • Abern L.
      • Nippita S.
      • Maguire K.
      Contraceptive use and abortion views among transgender and gender-nonconforming individuals assigned female at birth.
      • Gomez A.
      • Walters P.
      • Dao L.
      Testosterone in a way is birth control”: contraceptive attitudes and experiences among transmasculine and genderqueer young adults.
      • Kanj R.V.
      • Conard L.A.E.
      • Trotman G.E.
      Menstrual suppression and contraceptive choices in a transgender adolescent and young adult population.
      This highlights the need for clear guidelines on contraceptive use among gender minority patients, as well as the need for further education for providers and patients about the effects of testosterone on a patient's reproductive capabilities.
      The prevalence of contraceptive use among gender minorities in our sample was higher than observed in some previous studies on transmasculine adults (87% compared to 37-77%).
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • et al.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      • Veale J.
      • Watson R.J.
      • Adjei J.
      • et al.
      Prevalence of pregnancy involvement among Canadian transgender youth and its relation to mental health, sexual health, and gender identity.
      • Light A.D.
      • Obedin-Maliver J.
      • Sevelius J.M.
      • et al.
      Transgender men who experienced pregnancy after female-to-male gender transitioning.
      • Light A.
      • Wang L.-F.
      • Zeymo A.
      • et al.
      Family planning and contraception use in transgender men.
      • Stark B.
      • Hughto J.M.W.
      • Charlton B.M.
      • et al.
      The contraceptive and reproductive history and planning goals of trans-masculine adults: a mixed-methods study.
      This may be because the NCHA assesses contraceptive use only to prevent pregnancy and does not gather data on the contraceptive methods used by students who have not had vaginal intercourse or do not perceive themselves to be at risk for pregnancy. Although our analysis was necessarily restricted to students on whom we had contraceptive data, some of the previous studies assessed contraceptive use among all gender minority participants regardless of sexual behavior.
      A second implication of the wording of the survey instrument is that the NCHA cannot be used to assess the use of contraceptives for non-contraceptive purposes, such as menstrual suppression.
      These limitations may explain why we found that gender minorities were more likely than cisgender women to report using barrier methods at last vaginal intercourse but were less likely to report using barrier methods consistently over the past 30 days. Barrier use consistency was ascertained for all students, whereas only those who perceived themselves to be at risk for pregnancy were asked about barrier use at last vaginal intercourse.
      Our study has other potential limitations. Gender minorities who experience less gender-based discrimination and receive more social support at school are more likely to plan on attending college.
      • Kosciw J.G.
      • Greytak E.A.
      • Zongrone A.D.
      • et al.
      The 2017 National School Climate Survey: the experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation's schools.
      Many gender minorities leave college because of discrimination.
      • James S.E.
      • Herman J.L.
      • Rankin S.
      • et al.
      The Report of the 2015 U.S. Transgender Survey.
      Therefore, this sample may contain gender minorities who have experienced less discrimination, who have higher levels of social support, or who may have other protective factors that contribute to their educational resiliency than the broader population of gender minorities. Colleges and universities participating in NCHA data collection may not be representative of all postsecondary schools. Finally, the NCHA did not collect data on medical transition, which makes it difficult to assess STI and pregnancy risk among gender minorities.
      This study is one of the first to document disparities in contraception use by gender identity among assigned females, and has clear implications for future research and clinical practice: specifically, future research should assess the risk of unintended pregnancy and STIs among gender minorities who are assigned female, as well as their use of preventive health screenings (eg, Pap tests). Healthcare providers, beginning during their undergraduate medical education and on through continuing education, must be trained to provide comprehensive and affirming reproductive care to all patients, regardless of the patients’ gender identity.

      Acknowledgments

      Dr. Charlton was supported by Grant MRSG CPHPS 130006 from the American Cancer Society. The authors thank Olivia Gutenschwager for her assistance recoding the participant's write-in gender identity responses.

      Disclaimers

      The opinions, findings, and conclusions presented/reported in this article are those of the authors, and are in no way meant to represent the corporate opinions, views, or policies of the American College Health Association (ACHA). The ACHA does not warrant nor assume any liability or responsibility for the accuracy, completeness, or usefulness of any information presented in this article.

      Appendix. Supplementary materials

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