Transmasculine & Gender Non-Binary Persons with Pelvic Floor Disorders: Mixed-Methods Analysis

Objectives: Transmasculine(TM) and gender non-binary(GNB) people who were assigned female at birth also have pelvic floor disorders(PFD). This group of patients may experience different barriers to healthcare compared to cisgender women.

The aim of this study is to examine the concerns of TM and GNB persons when accessing healthcare for PFDs. We secondarily sought to evaluate the prevalence of PFDs through responses to validated questionnaires.

Methods: This was an IRB approved study. TM and GNB were recruited to participate from Emory OBGYN clinics. The Pelvic Floor Distress Index(PFDI-20) and the Pelvic Pain and Urgency/Frequency Symptom Scale(PUF) were administered. A sub-group of persons participated in a semi-structured, one-on-one interview using a standardized interview guide that was developed by urogynecological and transgender-care physicians. The presentation, perception, and experiences of PFDs, and interaction with the healthcare system were explored in 60–90-minute interviews. Interviews were audio-recorded and transcribed, analyzed and coded with MAXQDA. Codes were developed and the transcripts were analyzed by the research team. Variables are presented as means ±standard deviations or numbers(percentages). Comparisons were made using the student t-test or X² where appropriate.

Results: A total of 21 participants were enrolled and completed surveys. Fourteen of these participants were interviewed. Fourteen(67%) persons self-identified as TM and the remainder as GNB. Eight(38%) had a hysterectomy and 17(81%) were currently taking testosterone for gender affirming care. Emergent themes from the interviews were organized into the following categories: negative interactions, positive interactions, care in a gendered-space, reliance on community for information, and barriers to care. Negative interactions revealed that participants were often misgendered by physicians and staff, denied gender affirmation services, and felt lack of control over their own healthcare. Offices also had female-gender décor that increased discomfort. Participants relied heavily on their LGBTQIA community to seek out trans-friendly care. Due to the lack of easily accessible physicians, participants had long wait times and commuted long distances. Trans-friendly interactions included having questions answered in a non-judgmental way. The staff and physicians used appropriate pronouns and names. Physicians understood that gender identity has no bearing on sexual orientation. They counseled participants appropriately for their concerns and needs, while avoiding cisgender standards. These offices were gender-neutral including restrooms, décor, and signage. Ranges of scores on the PFDI-20 and PUF questionnaires were 69.5+53.1 (range 0-300) and 12.1+5.1 (range 0-35), respectively. There were no differences in scores between groups with or without a hysterectomy or between groups with or without testosterone treatment(all p > 0.05).

Conclusions: Understanding barriers that TM and GNB persons experience is important to provide quality medical care for these patients. Using these interviews, we can elucidate how to better care for this population. Currently available validated questionnaires may not adequately capture PFD symptoms experienced by this population.