Welcome to ASRM Today, a podcast that takes a deeper dive into the current topics in reproductive medicine. I am Jeffrey Hayes, and today on the show, we continue our season long discussion of LGBTQ plus issues in reproductive medicine by diving into the question, how do we make fertility care inclusive? Joining me this season as always for this discussion is my cohost, Dr. Lowell Koo. Our guests today are Dr. Samuel Pang.
Dr. Pang is a board certified reproductive endocrinologist who has been in practice since 1990. He's been a pioneer in providing assisted reproductive care to LGBTQ plus patients for over three decades. In 1998, he was among the earliest physicians applying ART to gay men who sought parenthood via donor eggs and gestational surrogacy.
In 2007, he began providing IVF services to lesbian couples without infertility, coining the term reciprocal IVF for one person providing oocytes and the other gestating. In 2012, he began treating transgender men for fertility preservation and reciprocal IVF, as well as transgender men who choose to gestate themselves. In 2022, Dr. Pang was the ASRM recipient of the Arnold P. Gold Foundation Humanism in Medicine Award for practicing physicians.
In 2024, he received the Hope Award for Achievement by Resolve, the National Infertility Association recognized for his commitment to inclusive care for LGBTQ plus families. Also joining us is Dr. Daphna Stroumsa. Dr. Stroumsa is an assistant professor in the Department of Obstetrics and Gynecology in the Division of Reproductive Endocrinology and Infertility at the University of Michigan.
In their clinical work and research, Dr. Stroumsa focuses on provision of gender-affirming care and on sexual and reproductive health services for gender and sexual minorities. Their goal is to improve sexual and reproductive care for LGBTQ plus people through the development and evaluation of evidence-based, community-engaged interventions. They have published extensively in top-tier journals on transgender people's access to and quality of care and reproductive health.
Dr. Stroumsa is a health services researcher and a graduate of the National Clinician Scholars Program Fellowship at the University of Michigan. Dr. Stroumsa is a recipient of an NIH K23 Career Development Award. They have developed a peer support intervention for transgender people, menopausal women and women with PMOS.
In 2026, they were awarded the ASRM Rescuing Research Grant for a multi-site study on the roles of minority stress and testosterone in the development of hypertensive disorders of pregnancy. I'll open by making this an open question for whoever wants to jump in here for an answer. How can clinics create an affirming environment for LGBTQ plus patients throughout the fertility process? And are there specific practices that help reduce the stigma or the bias in patient interactions? So there are several things that we have done to convey to our patients that we are welcoming and affirming.
We have strategically displayed rainbow flag logos on our website and stickers prominently throughout the clinic, on the front door, the reception desk and procedure and exam rooms, etc. Our staff are offered the opportunity to use a rainbow lanyard for their staff ID if they choose to do so. We have ensured that all of our consent forms use gender neutral language so that the wording applies to everyone, regardless of their sexual orientation or gender identity.
Our intake forms and patient history questionnaires are separate for patients who are assigned female at birth or assigned male at birth, and they are not combined because we make no assumptions that the patient is coupled, nor do we assume the sex or gender of the patient's partner, if any. It's essential to educate the staff on LGBTQ cultural competency. In my experience, with rare exceptions, the majority of clinic staff do not intentionally behave unkindly towards LGBTQ patients.
If their behaviour reflects bias, it is frequently unintentional as a result of the heteronormative culture that we are all programmed to live in. Another point I'd like to make is that the culture of being welcoming and affirming to LGBTQ patients trickles down from the top. So it is crucial that this behaviour is modelled by the medical director and all the physicians and management staff.
That is spot on. I can only echo Dr. Pan's words. I will say that those are all actions that reflect a deeper underlying respect and understanding for members of the community, which also means a deeper openness to family building of all varieties and to people who come from all walks of life and who lead different lives with different priorities.
And so for LGBTQ plus people, that means also letting go about assumptions, for example, about partnership, not assuming people are partnered, and that is true for everyone who comes through our doors, but also not differentiating a partner between heterosexual couple and same-sex couple. If somebody is a spouse, then somebody is a spouse, echoing the language of our patients. I think importantly for transgender people specifically, the element of how we, the gendered element of our clinic is very important.
And I think one important thing is to shift from a gender-based paradigm to a biology-based paradigm. I caution, I by no means intend here to erase gender as a valuable, important construct through which we and our patients see ourselves, but rather an approach for those of us who come from the women's health field and pregnancy has been gendered as women's or feminine to de-gender that, and that really harms all patients, right? So lots of cisgender women, whether heterosexual or lesbian couples or lesbian women are not comfortable in that pink, overly pink space. That is not the right mindset that says, yeah, whatever, wherever you're coming from, this is the right space for you.
So gender-neutral bathrooms, gender-neutral forms that are all like, like you said, Dr. Pang, about like, hmm, what kind of reproductive organs do you have and how can we work with that? Yeah, very good point. I totally agree. I know that the other thing is I know in our office, not only are we constantly trying to strive to make sure that we are current, make sure that we are very affirming, but also we have to continually have sessions and seminars with our staff because we have turnover in our staff who may not be indoctrinated in our culture like that.
So we always have to kind of be mindful and refresh the counseling to our staff so that they can be affirming to our patients. So thank you very much, both of you guys. That's awesome.
And when it comes to the transgender people, I know that studies show that they delay health care due to prior negative experiences. But what sort of negative experiences have you seen occur, let's say in the fertility settings and how, what sort of consequences does this play on the role of fertility treatments? So first and foremost, I think it's important to acknowledge that people walk through our doors the first time they walk through our doors, they already carry experiences with them. They carry trauma of a variety of sorts.
And many people carry health care trauma, places where they were mistreated, disrespected. Many transgender people actually share that they were assaulted in clinical spaces. And of course, they're not going to come back to those spaces.
They're not going to get the care they need, whether it's preventive care, making sure that they get into a family building process in good health or whether it's the reproductive health process. And so we have to, as when we are seeing someone for the first time or for the nth time, acknowledging whatever they bring in with them, the trauma that they bring with them, the positive experiences that they bring with them and understanding and acknowledging that is extremely important. And understanding and acknowledging that one of the things people bring in with them is their baseline health that we know for many minoritized people, the pressures of minority stress on the physiologic stress response can have long term physiologic repercussions, specifically in pregnancy.
We know that that has been linked to preterm labor, preeclampsia and hypertensive disorders in other minoritized populations, in people who have suffered from racism. And there is broad consensus in the field that that is probably the same for LGBTQ people who suffer lifelong stigmatization and stress. And so we have to acknowledge that and bring that into our perspective.
Of course, for trans people, there's also delay in receiving gender affirming care, which we know is causally related to decrease in overall well-being and mental health. So opening those doors up and sometimes the fertility process is an opportunity to improve on all of these on preventive care, whether it's the pap smear or the mammogram that people are due for, or whether it's the gender affirming care that someone has been waiting for an opportunity and for a provider who is willing and knowledgeable to be able to get that. I definitely couldn't have said it better myself.
I will just add that the transgender patients whom I have treated because of that background have specifically sought me out for their reproductive care, specifically because they are aware of my reputation in the LGBTQ community, frequently by word of mouth. And I've had many transgender patients travel from different states to receive their reproductive care with me in Massachusetts because they were very anxious about whether they would be welcome in IVF clinics closer to where they live. I want to go back to this idea that Dr. Koo was also talking about, about ensuring that the staff knows what to do.
In your experiences, how do you ensure that all staff from front desk to clinicians are trained to provide culturally competent, gender affirming care? And is there a way that that training, is there a way to evaluate whether that training is effective or not? Are there measures in place right now? Well, in our clinic, we brought in a consultant from the LGBTQ community to provide our staff with LGBTQ cultural competency training in a lunch and learn type setting. And we schedule this on multiple days to allow all the staff members the opportunity to attend, given that it's impossible to have all staff members attend a single scheduled session. But you're correct.
After many years, we had to repeat this educational exercise because there was staff turnover. And after we did that, we decided to engage a consultant to create an educational webinar that all newly hired staff are required to watch as part of their onboarding by the Human Resources Department, because we have these webinars unrelated to LGBTQ competency that the HR department has our newly onboarded staff watch. And it's for the effectiveness of the training that we usually gather from the feedback that we receive from the routine surveys, feedback surveys that we solicit from our patients.
And if we see either positive or negative comments, that's how we know that our training is effective. Yeah, I will add there are lots of trainings available online, for example, from the Fenway Institute that are intended precisely for this purpose, right? When there are many clinics who are in need of this training, and this is not, as you said, Dr. Koo, a one and done, and we all are in a continuous learning mode. I think Dr. Pang has brought up earlier a really important point, which is about modelling.
And modelling is also continuous through the staff, through faculty in a division or in a clinic, and through occasional correction if needed. So modelling language, modelling gendering, correct gendering. And we know from transgender patients, for example, that misgendering by front desk staff is often one of the most painful points of contact.
In terms of effectiveness, there is a lot of literature on the effectiveness of training and cultural competency in LGBT health. And most of the literature is amongst clinicians, medical students, nurses, residents, faculty, attending physicians. And there are multiple interventions that have been shown to improve short-term pre-post assessments.
But we know that the strength, the validity of those pre-post assessments is low. One cross-sectional study that I was actually part of, that I led a few years ago, actually showed us that in terms of when you assess cross-sectionally in terms of knowledge and cultural competence for clinicians in primary care specialties, there was no correlation between how many hours of education someone received and how competent, capable, knowledgeable they were. And this is either self-directed learning or formalised learning.
And that the thing that really mattered the most is, and this is around transgender health, the thing that mattered most is transphobia. So that was the only factor that had a negative correlation with knowledge levels. And my main take-home point from that is that we can train people all we want, but unless we have real sit-down conversations with people, and that can be a casual lunch or coffee break conversation with our staff in the clinic saying, hey, I had this patient, they didn't feel welcome.
Or somebody says, this makes a comment about how a person looks or how they present or their gender. We have to address it. We have to face the conflict, the internal and externalised conflict and really address it and say, hey, did you meet our co-worker's transgender daughter? And really personalise and humanise it.
Do you think then we're, you know, in talking about modelling and in your responses, it doesn't sound like, you know, that's going to be enough. You know, we're going to have to be deeper. We're going to have to take conversations into other places.
Do either of you feel that there are certain areas as far as if we were to provide professional development or if there was, say, another track added to their training, is there something that you feel would be optimal with that? To me, I feel like the most important, if you're going to add one thing, it's always going to be the humanising element. Learning is rich. There is a lot to learn.
We work with professionals who are in a lifelong learning process. There's always going to be, but you have to start from a point of humanising, of understanding, understanding that the importance or the potential importance of family building for a gay couple and why they will be as good or actually potentially, says the literature, better parents than a heterosexual couple. Humanising the experience of a transgender youth whose life will be changed by gender-affirming care, including, for example, fertility preservation.
That's excellent. In our office, we started very basically like, okay, we've got to look at our consent forms. We're going to make sure they are affirming.
You had mentioned, let's have gender-neutral or non-binary restrooms, but what other things are we missing in our offices in terms of the consents, the paperwork? What did you find in your offices that you really needed to drill down to change to make sure that everything was culturally competent and affirming for all individuals? At our clinic, we actually had a project where we systematically examined all of our intake forms and consent forms to ensure that the wording was gender-appropriate or gender-neutral. However, we found that it was impossible to have patient history questionnaires that are not sex-specific. So, the patient history questionnaires need to be separately labelled as either assigned female at birth or assigned male at birth because of the biology, and I think that the transgender and non-binary patients understand and accept that their sex assigned at birth is relevant and important for their medical history, regardless of their gender identity.
So, this needs to be done, but it could potentially be challenging if the clinic doesn't have control over the electronic medical records software programming, especially if your intake questionnaire forms are part of the EMR. You would need to work with the EMR company to work with them to revise the EMR intake questionnaires accordingly. Good points with the EMR.
That is something that we battle with all the time. So, very good points. That was a challenge for us as well.
We were wondering also about what are some unique medical and emotional considerations when supporting transgender individuals in fertility preservation and assist reproduction, especially in the care if it's, you know, it's been delayed, and what should we be considering in these types of cases? So, in my experience, one of the major challenges that I experience is with the adolescent patients, the majority of whom at their age are not really thinking about future reproduction. Their focus is on gender transition, and most of them are, in my opinion, psychologically and emotionally too young to think seriously about future reproductive capacity. I have counseled many adolescent teenagers, all of whom are brought in by their parents, and their parents are thinking ahead about having grandchildren, but their adolescent child really couldn't care less.
They're just sitting there, and they're laser-focused on their desire to transition. So, the majority of the transgender patients that I treated have actually been in their early to mid-20s when they're actually mature enough to make an adult decision about their desire for reproduction. And from my perspective, as a treating RE, as long as they have not had any irreversible procedures, hormone therapy may be discontinued to facilitate their fertility preservation or assist their reproduction.
Yeah, and specifically with testosterone, I think here is a very, very different story with gender-affirming testosterone-based therapy and estrogen-based therapy. But with testosterone, we've seen a handful of good reports from the United States and from elsewhere showing good results or management of getting good results with fertility preservation without discontinuation of testosterone for fertility preservation. With estrogen-based therapy, it's obviously different, and that does require discontinuation, sometimes prolonged discontinuation.
Having said that, I think in those conversations, it's important to acknowledge the potential emotional weight of fertility, both of fertility preservation and of the process that may be emotionally difficult for someone where they need to take what essentially is for them that pause in gender-affirming hormones is like someone who's cisgender going on cross-sex hormones for a period of time. That can be extremely distressing. For folks undergoing fertility preservation who are assigned female at birth, the process involves ultrasounds, usually transvaginal, potentially exams.
That part can be distressing. If the clinic is very women's health-oriented, that's like a whole environment can be dysphoria-inducing. For many people who are assigned male at birth, the process of semen cryopreservation can be distressing.
And so just acknowledging, accepting, addressing that, putting that on the table sometimes or with an open-minded question can be very important. Thank you so much for that answer. We're almost out of time.
It just has flown by today, and I want to respect everybody's time also. I want to ask our guests, and I'll start with you, Dr. Peng. What is something that you would like, if you could, I hate to always say distill it down to one thing, but what would you like our listeners to walk away from this conversation today having learned or maybe thinking about? I would say that they need to be open-minded.
When it comes to treating LGBTQ patients and be empathic with the patients that they're seeing, try and put themselves in the patient's shoes and try and understand where they're coming from when they're seeking reproductive care. I would say two things. The first is we're often taught to make no assumptions, but it's very hard to act on that when you don't know what assumptions you're making.
I don't know precisely because they're assumptions. Before I see any patient or while I'm seeing patients, I often stop myself and ask myself as I'm going through, what assumptions am I making? We do it with all kinds of prejudices that comes up with elements of racism and fat phobia. Am I making assumptions about a fat person about their overall health? I'm assuming they're not healthy.
I'm assuming they're not ovulating just because they're fat. We make assumptions all the time and to question ourselves. Similarly, stop and ask yourself, am I making assumptions about these people because their sexual orientation or because their gender identity? How can I let go of those? How can I treat them better? I will say one more thing.
We are living in a time and place where there is a lot of anti-scientific sentiment in general that impacts all of our care. The anti-scientific sentiment also is coming along with a lot of overt anti-trans sentiment. That is the thing that is the most directly hurtful to our trans patients these days.
I would argue that reproductive endocrinologists are some of the best trained physicians to actually understand the hormonal process and gender affirming care. As we fight for maintenance of IVF and access to increasing access to IVF and our ability to freeze embryos and et cetera, I think we should make gender affirming care part of, it is part of our scope of practice and something that we are part of the to ensure, part of the struggle to ensure that gender affirming care is led by science and by the best interest of our patients. Absolutely.
Again, I want to thank both of you for taking time out to be here today. It's been an absolute honor to be able to speak with you both. Thank you for being here.
If our audience has questions or questions for us, questions for you, they can email us asrm at asrm.org and we will share those. Until next time, I'm Jeffrey Hayes. I'm Lowell Coo.
This is ASRM Today. This concludes this episode of ASRM Today. For show notes, author information, and discussions, go to asrmtoday.org. This material is copyrighted by the American Society for Reproductive Medicine and may not be reproduced or used without express consent from ASRM.
ASRM Today series podcasts are supported in part by the ASRM Corporate Member Council. The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.
