“I Don’t Know How to Treat You”: Testosterone and Gynecological Care for Transmasculine and Gender Diverse Adults

Participants were eligible if they (1) identified as a transgender man, transmasculine, nonbinary, genderqueer, and/or genderfluid person; (2) were assigned female sex at birth; (3) had used testosterone as gender-affirming hormone therapy for at least one year; (4) aged 18 or older; (5) lived in the US or its territories; (6) were comfortable reading and speaking in English. We excluded participants who had had a phalloplasty or vaginectomy. This study received ethical approval from Stanford University and WCG Institutional Review Boards before data collection. Study recruitment was conducted through PRIDEnet, a national community engagement network of >20 LGBTQIA2S+ individuals and organizations. The study was advertised over social media and through PRIDEnet community partner consortium (see Supplemental Materials ). Interested participants completed an online screening survey that asked questions related to eligibility criteria and key demographics variables used for purposive sampling. We included a short biography of each researcher who conducted interviews so that participants could indicate by whom they preferred to be interviewed. We used a reCAPTCHA and removed duplicate IP address to screen out fraudulent responses and bots. We received 2,009 responses to the screening survey, among whom 381 (19%) met study inclusion criteria. Among eligible participants, 89 (23%) indicated a preference to be interviewed one of the two trans and nonbinary researchers. We used purposive sampling to ensure participants were diverse with respect to age, ethnoracial identity, gender identity, sexual orientation, and geographic location, with an a priori goal of recruiting at least 50% non-White participants. Sampling decisions were made iteratively based on the evolving sample composition. We oversampled participants who were aged 40 or older and those who had used testosterone for over 10 years to capture experiences of aging and long-term testosterone use as they related to gynecological health experiences. This choice was driven by the screening pool being skewed toward younger participants age 18–29 with a short duration of testosterone use, and by the existing body of literature that has disproportionately focused on short-term effects, leaving long-term gynecological trajectories understudied. We contacted 38 participants, among whom 30 (79%) scheduled and 28 (74%) completed an interview between May and July 2024. A qualitative interview guide was developed to probe gynecological health history, experiences seeking gynecological health care, and the impact of gynecological health on overall wellbeing. Mock interviews were used to standardize interview methods and further refine the guide. The interview guide was revisited after each interview and iteratively revised, and minor changes were implemented over the first six interviews. At the start of the interview, participants were asked to identify which gynecological health topics had impacted them the most. If participants needed further prompting, they were provided with a list of potential topics (see Supplemental Materials ). Interviews were conducted and recorded via Zoom and lasted 30–90 minutes. Audio recordings of the interviews were transcribed using a professional transcription service. At the end of the interview, participants completed a brief survey to collect sociodemographic data. Participants who completed an interview received a $50 gift card. Data were analyzed using a thematic analysis approach, and included the steps outlined by Braun and Clarke. 25 First, the data analysis team members familiarized themselves with the data by listening to and re-reading all interview transcripts. During this time, we iteratively generated a broad list of initial codes. Thematic codes included both deductive codes that derived from our theoretical frameworks ( e.g., cumulative exposure) and inductive codes that emerged from close reading of the transcripts ( e.g . identity erasure). Thematic saturation was reached after 24 interviews; the remaining four interviews were coded and analyzed but did not generate new codes. After the codebook was finalized, each transcript was coded in duplicate using Dedoose (version 10.0.25). The team met regularly to discuss discrepancies, to group related codes, and to iteratively refine candidate themes. Subthemes were retained where codes represented meaningfully distinct aspects of a parent theme. Finally, we defined and named the final themes and subthemes. We prioritized analytic richness over parsimony, generating themes at a lower level of abstraction to preserve within-group variation and remain closely aligned with participants’ accounts, consistent with recommendations for exploratory qualitative research with understudied populations. 26 – 28 Our core study team was comprised of four researchers: three individuals who developed the interview guide and conducted interviews, as well as a fourth researcher who was a member of the PRIDEnet participant advisory committee and actively participated in data analysis. Our expertise included clinical care, epidemiology, and transgender health. Researchers identified as trans men, a nonbinary individual, and a queer cis woman; all researchers were White. All interviewers had prior experience conducting qualitative interviews with trans communities. Our experiences as queer and trans clinicians and researchers – some with personal experience with testosterone use as well as the gynecological topics that arose during interviews – informed our understanding and interpretation of the data. Our team met weekly over 12 months to discuss emerging interpretations, surface disagreements, and interrogate potential sources of bias.

We interviewed 28 participants aged 21–62 years (median 32) who identified as men, transgender men, transmasculine, nonbinary, genderqueer and/or two-spirit. In terms of ethnoracial identity, 15 (54%) reported at least one non-White ethnoracial identity: 6 identified as Black, 5 Hispanic or Latinx, 3 Asian, and 3 Native American. Additional sociodemographic characteristics are reported in Table 1 . Participants’ duration of testosterone use ranged from 1.2–30 years (median 5.5); age at testosterone initiation ranged from 17–44 years (median 26). Most participants reported one or more gender-affirming surgeries (n=24, 86%): most commonly mastectomy (n=23, 82%) and hysterectomy (n=10, 36%). Most participants (n=22, 79%) reported seeing a healthcare provider for gynecological health within the past year. The most common participant-identified gynecological health topics were pelvic pain (n=24, 86%), genital infections (n=20, 71%), genital atrophy (n=18, 64%), and hysterectomy (n=18, 64%). Pelvic pain discussions encompassed chronic noncyclic pain, painful penetration and sex, pain with orgasm, pain during menstruation or spotting, and pain with movement or exercise. Genital infections included recurrent urinary tract infections (UTIs), yeast infections, and bacterial vaginosis. A full list of participant-identified topics is reported in Table 2 . Some participants described gynecological conditions that preceded testosterone initiation, while others discussed the onset of new concerns that emerged after starting testosterone. Onset of new symptoms ranged from less than 3 months to over a decade after starting testosterone, but were not always clearly etiologically related. Six parent themes were identified: (1) Erasure, (2) Authority of Knowledge, (3) Navigating Uncertainty Regarding Testosterone’s Gynecological Effects, (4) Prolonged and Fragmented Care Pathways, (5) Cumulative Exposure, and (6) Resistance and Agency. Themes and subthemes are summarized in Figure 2 . Participants described three interrelated forms of erasure that shaped their gynecological healthcare experiences. Consistent with Bauer’s conceptualization, institutional erasure encompassed the structural failure of healthcare systems to accommodate trans bodies and informational erasure included the absence of research, clinical guidance, and provider knowledge about transmasculine gynecological health. A third form of erasure emerged from the data that we describe as identity erasure , reflecting how institutional and informational erasure are enacted at the interpersonal level of patient–provider interactions through identity invalidation, incorrect assumptions about genital anatomy, and repeated disclosure of trans identity. Institutional erasure was evident in the organization and delivery of care and included gendered “women’s health” spaces, scarcity of trans-inclusive providers, explicit refusal to treat trans patients, and insurance denials due to diagnosis, procedure, or pharmacy codes being assumed to only apply to certain genders. One participant shared that his “insurance company actually called me to find out why I was getting female pelvic floor treatment. And I had to explain to her like, ‘I have a vagina,’ and it just felt so intrusive” (White, man/trans man, age 45, 6 years on testosterone). Informational erasure encompassed the lack of research, clinical guidance, and provider training on the gynecological health of transmasculine people, particularly regarding the impact of testosterone. Participants described that “it’s hard to find people that are knowledgeable enough to [ask], ‘Is this normal? Is it bad? Is it something we can do something about? Is it something I just kind of have to deal with?’” (Hispanic, trans man, age 29, 4 years on testosterone). The absence of information and knowledgeable providers was experienced as frustrating, frightening, and demoralizing. As one participant explained: At times, it’s almost been scary, just not having access to information. There have been times where I feel like I’m doing something that I don’t fully know what the outcome…because there’s so little research. Informational erasure significantly shaped clinical decision-making. Providers were hesitant to initiate gynecological care due to their limited knowledge about testosterone. In contrast, some participants felt their care was experimental, which undermined trust. One participant with recurrent UTIs described concerns about being prescribed topical genital estrogen in the absence of evidence specific to trans men: You want me to take something because you know it’s going to be helpful, but you also really don’t know… So we’re being used as guinea pigs. If you’re telling me that it was never tested on our bodies, then how am I supposed to trust you when you’re making a recommendation? Lastly, identity erasure characterized clinical encounters, often through invisibility or misrecognition. Some participants described being addressed “as if I was a cis[gender] woman,” while others described providers assuming they were cisgender men and making incorrect assumptions about their anatomy. These interactions generated confusion, distress, and diminished confidence in care. One participant recalled a provider refusing to prescribe topical genital estrogen for his severe atrophy symptoms: When she explicitly said, “Because your body already makes it,” it sounded to her like it was absurd for me to want my body – it’s just like she forgot who I was. I just felt such identity erasure in that moment. I felt she’s like, “You are a woman,” or she could have just been saying to me, “You are a biological female.” Other participants described situations in which providers assumed the presence of anatomy they did not have. For example, one participant recounted a provider interpreting a urine culture based on the assumption that he had a penis: She was like, “Well, you must have touched the tip of your penis to the inside of the sterile collection cup because I’m seeing this type of bacteria. It’s not the bacteria that we normally see in a UTI.” And I was like, “Oh, no. I don’t have a penis. I was not born with one.” And she was really shocked. Another participant described being told his prostate appeared normal on imaging, limiting his confidence in provider competence: I feel I need to be hyper-vigilant … I want people who understand and know what is in my body, [that] they aren’t making an assumption based on my gender marker on my ID. Participants described the cumulative psychological impact and safety concerns associated with repeatedly disclosing their trans status. A participant with recurrent UTIs described two incidents of disclosing his trans identity, first when seeing a urologist for kidney stones and later needing emergency pelvic surgery: I was like, “Look, I need to come out to you and let you know I’m trans. I have a vagina.” And it just ended up being very awkward. I’m constantly having to prepare myself to come out to whatever new specialist I’m referred to… It’s a lot because you’re not feeling well. You just want to go in, get tested or treated, get your medication, and leave. This same participant described later needing emergency pelvic surgery, and that after he came out as trans to his provider, “the whole attitude of the surgeon shifted, and I wasn’t provided quality care… coming out either right before a procedure or in your pre-op, it can affect our lives. And it puts us in dangerous situations.” Nearly all participants described experiences in which their embodied and community knowledge was subordinated to medical epistemologies, producing four related dynamics: power and conflict over knowledge , in which participants navigated tension between their lived expertise and providers’ formal authority; dismissal and minimization of symptoms , in which embodied experiences were devalued relative to clinical findings; tension between embodiment and diagnostic findings , in which negative or inconclusive test results were used to invalidate ongoing pain or discomfort; and gaps in informed consent , particularly regarding testosterone’s gynecological effects, which participants frequently discovered through community networks rather than clinicians. Participants frequently articulated a sense of expertise grounded in lived experience–“I’m the expert on how I’ve been taking hormones and what my body needs and how I do things”–while simultaneously recognizing their limited formal authority within clinical settings. Participants described having to navigate uncertainty about which medical recommendations were evidence-based versus shaped by bias: “I want to trust these people, right? But I have to figure out what is true and factual versus what is opinionated and biased” (White, nonbinary/transmasculine, age 27, 4 years on testosterone). Despite these tensions, participants often deferred to their providers medical authority. As one participant shared, “I didn’t really feel that was the best solution, but I knew I wasn’t really an expert, so I was like, ‘Okay’” (Black, transmasculine/trans man, age 21, 1 year on testosterone). Another recalled their surgeon refusing to let them keep one of their ovaries during their hysterectomy: “He acted like that was weird. He wouldn’t do it. And so I was like, ‘Okay. Well, I guess we’re doing it your way then.’ And so he just took everything” (White, man/trans man, age 45, 6 years on testosterone). These encounters highlight how authority was structurally concentrated with providers. Participants described a tension in which with they were expected to educate providers about their bodies and care need while simultaneously not being believed: It’s just stressful to have to navigate a system where I don’t feel seen, right? I think to constantly have to feel like I’m the educator in a space where I’m trying to seek care is super annoying… and also feeling like people aren’t believing me. Conflicts over authority of knowledge frequently manifested as the dismissal and minimization of symptoms. For example, one participant described reporting severe pain during orgasm to a gender-affirming care provider, only to feel completely disregarded: She really didn’t listen to me and devalued everything that I said. When I mentioned that I’ve been having this pain, she’s like, “Oh, that’s weird.” And never brought it up again. Just completely did not listen or consider it a medical issue. I felt completely ignored. Dismissal of symptoms often occurred in the context of diagnostic testing, in which embodied experiences were devalued relative to clinical findings. Participants described a wide range of scenarios that included pelvic exams to assess the presence of genital atrophy, laboratory panels to diagnose genital infections, and ultrasounds and exploratory laparoscopic surgery to investigate the cause of pelvic pain. When medical providers found negative or inconclusive results, they often told participants that they were “fine” or that “nothing was wrong”, despite ongoing pain or discomfort. One participant explained that “the doctor look[ed] at body parts instead of the person. And if she couldn’t find anything wrong with the body parts, then she wasn’t going to take any action” (White, trans man, age 51, 19 years on testosterone). Another shared that “it felt less like they believed me despite obvious symptoms and that they were really only willing to look at what the test results say” (White, genderqueer, age 38, 11 years on testosterone). These experiences left participants feeling disrespected, frustrated, angry, and in some cases, they stopped or delayed seeking care or turned to non-allopathic medical alternative treatments. As a participant explained, “that’s why, when I’ve had issues with my vagina, I haven’t been able to go see a gynecologist… because I am dismissed” (Native American and Hispanic, transmasculine/Two-Spirit, age 40, 9 years on testosterone). In some cases, validation came only after invasive procedures revealed underlying pathology. One participant described a provider apologizing after hysterectomy revealed extensive uterine polyps, following years of unaddressed pain: She said, “I’m sorry, we didn’t know how bad it was. I didn’t realize what that pain could have been causing you to have all that stuff inside of you.” I was like, “I’ve been talking with you for three years already about how much pain I was in.” It took for her to actually see it to be able to apologize. Finally, authority of knowledge was closely tied to issues of informed consent, particularly related to testosterone initiation and its gynecological effects. Participants described not being informed about potential outcomes such as genital atrophy, increased risk of UTIs or BV, or ongoing pregnancy risk, often discovering this information through community networks. As one participant stated, “it was never something that was disclosed to me that could be a possibility with testosterone. And it’s really frustrating that there’s next to no medical literature about it. I had to find out about it myself through online forums” (Native American, transmasculine/Two-Spirit, age 25, 8 years on testosterone). This theme captures the clinical and psychological consequences of encountering providers who were ill-equipped to manage gynecological concerns in the context of testosterone. This required participants to navigate uncertainty regarding symptom etiology, appropriate treatment options, and long-term health implications. Five interrelated subthemes emerged: treatment gaps , in which limited provider knowledge left participants without viable care options; uncertainty about testosterone’s impact on symptom etiology; concerns about long-term health and aging on testosterone; diagnostic overshadowing in which providers attribute all symptoms to testosterone; and shame and internalized blame , in which participants came to question whether their health concerns were caused by their own decision to use testosterone. One participant experiencing severe pain and bleeding due to genital atrophy described being repeatedly told by providers that they did not know how to treat him because he used testosterone and had undergone hysterectomy: My primary care doctor [said] “I don’t know how to treat you.” And when she was able to get me a referral to a gynecologist, the gynecologist is like, “I don’t know how to treat you. You don’t have the reproductive organs needed. You’re on testosterone.” And I’m like, “I’m in pain. How would you treat any other cisgender woman that has vaginal atrophy after having a hysterectomy?” Such encounters left participants feeling abandoned by healthcare systems and responsible for managing their own care. As one participant summarized, “You do go to the doctor and they’re just like, I don’t know. Your illness didn’t read textbook… so you’re on your own to figure it out” (White, man/trans man, age 45, 6 years on testosterone). Many participants described ongoing uncertainty about whether testosterone contributed to their symptoms, particularly when care was delayed or ineffective. One participant reflected on a prolonged UTI that progressed to a kidney infection: “I don’t know if it was because of being on testosterone or if I just wasn’t being treated properly for it” (Native American, transmasculine/Two-Spirit, age 25, 8 years on testosterone). Others emphasized uncertainty about the long-term effects of testosterone on gynecological health and aging, noting a lack of research and clinical guidance: “I also think that there’s a real lack of knowledge, especially [in] gynecology. There’s just like a real lack of being able to see gender existing sort of outside of the cis-hetero norm. And there’s also a real lack of research around what the impacts of long-term testosterone use does to these organs that we’re carrying.” On the other hand, some providers over-attributed health concerns to testosterone, resulting in diagnostic overshadowing and diminished quality of care. One participant who experienced severe post-hysterectomy complications described, “A lot of the doctors had this unspoken attitude where they acted like, ‘Well, you’re really a woman. If you think you’re going to insist you’re a man, this is the price you’re going to pay’” (White, man/trans man, age 45, 6 years on testosterone). These dynamics contributed to feelings of shame and self-blame with participants questioning whether their health concerns were caused by testosterone despite lacking evidence. One participant described the cumulative psychological impact of repeatedly having his symptoms attributed to hormone use: It is almost like shame. I’m ashamed that I am trans and that I’m doing this to myself, which I know is not true, but it’s something that I have to grapple with. Then there’s this feeling of hopelessness like, what do you expect me to fucking do then? Stop taking hormones? I can’t do that. This shame reflected a broader problematizing of trans bodies that occurs within medical systems; unresolved symptoms were often attributed to trans identity rather than considered legitimate health concerns. As one participant shared: “Something’s not right, again, with this trans body of mine, and no one can seem to tell me what it is other than… it’s just because you’ve decided to take testosterone” (White, genderqueer/trans man, age 44, 4 years on testosterone). Participants described prolonged and fragmented healthcare journeys, characterized by five subthemes: difficulty in the search for competent or trans-inclusive providers ; being shuffled through repeated referrals ; excessive testing and evaluations that prioritized diagnostic certainty over symptom relief; reaching a point of exhausting available diagnosis and treatment options ; and ultimately receiving no diagnosis or explanation for their gynecological complaints. Nearly all participants described difficulty identifying trans-inclusive or competent providers who were able to address their gynecological concerns. Seeking care was often accompanied by anxiety and discomfort, particularly when seeing new or unfamiliar clinicians. Participants from rural or politically conservative areas described the dual challenge of finding trans-inclusive specialists: Where I live, there’s a significant lack of healthcare providers in general. It’s even worse when you’re a trans person… I’ve had doctors turn me away because they don’t do the trans thing. So trying to access, especially, gynecological healthcare and pelvic healthcare is really, really difficult. Participants described being “shuffled” between providers, subjected to repeated referrals, and undergoing excessive testing and evaluations, resulting in fragmented and poor-quality care. One participant with chronic pelvic pain described undergoing prolonged testing prior to getting approval for a hysterectomy. This participant’s account illustrates how identity erasure, informational erasure, and prioritization of diagnostic evidence intersected to delay care: The doctor kept trying to talk to me as if I was a cis[gender] woman and talking about how I could maybe regret not being able to have kids later… I kept asking them, “Can you please do more testing? Can you please do more research? What’s happening? Why am I in so much pain?” They didn’t have enough experience. All these doctors are trying to figure out what’s happening with me. And I’m like, “Can we just do a hysterectomy?” [My doctor] sent me to do more testing. She just kept adding tests and tests before she approved. Despite prolonged entanglements with healthcare systems, many participants never received a diagnosis or an adequate explanation for their symptoms. Instead, care focused on short-term symptom management rather than underlying causes. One participant described the treatment that he received for recurrent UTIs as “band-aids” noting, “I don’t expect to get a firm [explanation of] why this is happening, because providers just don’t know” (Native American and Hispanic, transmasculine/Two-Spirit, age 40, 9 years on testosterone). Over time, repeated delays and inconclusive care led some participants to feel they had exhausted available options and to disengage from medical care altogether. This was particularly common among participants with persistent pelvic pain: Nobody’s ever been able to give me a definitive answer. They’re just like, “Well, this is your problem. Good luck figuring it out.” And it’s just been everything I’ve had to do feels like DIY or experimentation. Similarly, a participant with a treatment resistant genital infection described the impact of being told by their provider that “I can no longer help you:” I was like, [you] haven’t solved my problem, and now you’re saying, “I’m done.’“ But I’m not done because I still have this incredibly uncomfortable problem and now I feel like I have no options… If this medically trained doctor can’t solve my problems, why would a different medically trained doctor be able to solve my problems? Taken together, these experiences show that prolonged and fragmented care shift the burden of persistence, experimentation, and decision-making onto patients. Consistent with ecosocial theory, participants described how repeated and fragmented care accumulated over time as embodied harm across four domains: overwhelm in managing health and navigating access to care; the compounding context of chronic health conditions that intersected with and complicated gynecological care; cumulative burden of treatment ; and healthcare violence . The accumulation of healthcare encounters marked by erasure, dismissal, and long trajectories of fragmented care resulted in profound overwhelm related to managing health and navigating access to care. One participant described the cumulative toll of these experiences: I’m exhausted, to be honest with you. It’s like I work, and when I’m not working, I’m fighting for my access to care. And I’m just tired at the end of it. It’s just come to a point where it’s like doing the things I love doesn’t bring me joy anymore because I feel uncomfortable. I’ve noticed I’m isolating a little bit more than I used to because I’m just mentally and emotionally tired. The same participant described this was exacerbated by their other chronic health conditions: Being type 2 diabetic and being trans, there’s not a lot of research even on that realm either. With some of the medications with my diabetes, it causes me to urinate out my sugars, which increases UTI infections. But then with being on testosterone and then my other care needed with my reproductive system, my doctor doesn’t know how to navigate or manage things. I’m constantly educating her and explaining, “This is what I need. This is what I need you to prescribe. This is why this is happening.” And it’s just been a lot. Cumulative exposure also manifested as ongoing management of other chronic health conditions, as well as concerns regarding the cumulative burden of treatment, most commonly repeated courses of antibiotics for recurrent genital infections and use of pain medications. for chronic pelvic pain. Lastly, cumulative exposure frequently included healthcare violence, a term that broadly refers to healthcare experiences that inflict or exacerbate trauma through invasive, coercive, or dismissive practices that undermine patient autonomy and dignity. Participants described a wide range of instances of healthcare violence, including pelvic exams that were not trauma informed, transvaginal ultrasounds performed without adequate consent or preparation, withholding of pain medication, and dismissal of embodied pain in favor of continued or excessive testing. Rather than isolated incidents, participants described these encounters as recurrent and cumulative, contributing to medical trauma, heightened distress, and avoidance or disengagement from care over time. One participant described the cumulative consequences of surgical trauma, post-operative complications, and being denied access to topical estradiol despite repeated requests: After the hysterectomy, not only did I have the initial trauma from literally being tortured by the nurse [who withheld pain medications], I also developed complications like wound dehiscence. And I developed a life-threatening infection. I had almost a liter of blood in an abscess in my pelvis. I was re-hospitalized. It took me like 18 weeks to recover. And I had to fight with the surgeon to get topical estradiol cream. That, I think, created the wound dehiscence. The wound wouldn’t heal. And if I had been given estradiol cream, I think I would have had a lot fewer complications. Another participant with endometriosis described avoiding gynecologic care altogether after initiating testosterone and coming out as transgender, citing the compounding effects of prior medical trauma, symptom dismissal, and identity erasure. They articulated how repeated invalidation and fear of mistreatment shaped their disengagement from care: I probably have some medical trauma just from being not believed or having what I know to be true about my own body questioned so many times that it makes it hard for me to want to go back. And now there’s this extra layer of, “I don’t want to be misgendered. I don’t want to be disrespected or treated like a woman necessarily when I go to the gynecologist.” Despite significant structural barriers, four subthemes described how participants engaged in resistance and agency: self-advocacy in medical settings ; community connectedness and knowledge , in which peer networks provided information, validation, and support that was often more trusted; a search for alternative or non-medical treatments , driven by diagnostic uncertainty and lack of provider guidance; and trans joy and positive embodiment , in which moments of gender affirmation, symptom resolution, and access to competent care functioned as an important counterbalance to cumulative harm. Participants frequently described having to actively advocate for themselves to receive appropriate care, including requesting specific tests, treatments, referrals, and correcting provider assumptions. Self-advocacy often required extensive preparation, including bringing summaries of extant medical literature, particularly in the context of providers’ limited knowledge about testosterone and gynecological health. While advocacy sometimes led to improved care, this advocacy was described as exhausting and unevenly effective, shaped by power dynamics, race and ethnicity, insurance constraints, and provider receptivity. One participant with urinary incontinence characterized their relationship with their gynecologist as requiring a significant degree of self-advocacy and negotiation over authority of knowledge, with care contingent on the participant’s ability to educate and challenge their provider: A lot of my experiences is [asking], “I know this [treatment] can be provided. Will you provide it?” And then him saying, “Well, I don’t know about that.” And I’m like, “That’s not what I’m asking you. I’m asking you, will you provide this because I know . Why don’t you know?” Another participant described tensions with their provider around adjusting their testosterone to stop menstruation. However, his provider was initially reluctant because their serum testosterone levels: [My doctor] was like, “Well, but you’re close to the top of the range.” At that point, Kaiser had recently changed the range from just checking you on the male range to a “trans male” range, which was lower. And I was like, “What’s the difference?” I was like, “What does this mean?” And everyone was like, “It’s the trans range.” Ultimately, after slightly increasing his testosterone dose, this participant was able to achieve the embodiment he was seeking: My period stopped, finally. And I’ve actually gotten a bunch more masculinizing things. My voice dropped quite a bit again. I’m finally starting to grow some facial hair. And I’m like, “Look, I know you don’t like that my labs come back with a little yellow dot or whatever, but my body just-- I feel better. Everything seems to be working like I want it to. Participants relied heavily on transmasculine community networks for information, validation, and support. Knowledge about symptoms such as genital atrophy and pelvic pain as well as treatment options, was frequently shared through friends, partners, support groups, online forums, and social media. Peer knowledge was often described as more trustworthy and practically useful than provider guidance, and community connectedness played a key role in reducing isolation, normalizing symptoms, and informing care-seeking decisions. Participants described extensive trial-and-error approaches to managing symptoms, often experimenting with a wide range of medical, non-medical, and alternative treatments over time. Experimentation was frequently driven by diagnostic uncertainty and a lack of provider guidance, leading participants to assume primary responsibility for managing their own care. Participants described a wide range of self-directed approaches developed in the absence of provider guidance, including heat therapy, dietary elimination, cranberry juice, topical application of coconut oil, yoga, massage, acupuncture, cupping, boric acid suppositories, and cannabis. One participant with endometriosis and an ovarian cyst reflected “alternative medicines or non-hormonal, non-invasive things have been much more successful for me than any type of medication.” Another participant described independently managing recurrent BV with boric acid suppositories after concluding that repeated antibiotic prescriptions were not a sustainable solution: “I don’t want my body to just rely on antibiotics, but it’s going to be chronic anyways because I do the antibiotics, but it’ll come back again.” Finally, despite significant challenges, participants described moments of relief, validation, and improved well-being related to gender affirmation, symptom resolution, and access to trans-competent care. For some, joy was rooted in bodily relief following symptom resolution. On participant with unexplained uterine bleeding described the freedom that followed hysterectomy: “it’s just been great. I just don’t have to think about that part of my body anymore” For others, trans joy was tied to encounters with affirming, knowledgeable care. A participant described seeing a trans provider for the first time as “pretty life-changing,” while another described a provider who immediately recognized and addressed his severe atrophy symptoms: “straight away, she identified what I was talking about… And literally, within two days, I was feeling so much better.” Joy and positive embodiment were grounded in concrete moments of symptom resolution, gender affirmation, and the rare but meaningful experience of care that was competent and affirming; it functioned as an important counterbalance to cumulative harm while supporting participants’ continued engagement with care.

Using qualitative interviews, this study explored how transmasculine and gender diverse adults navigate gynecological health concerns in the context of testosterone use. Informational, institutional, and identity erasure often limited provider competence and constrained participants’ clinical decision-making, while conflicts over authority of knowledge privileged diagnostic certainty over embodied experience. Contemporary medical epistemologies prioritize knowledge derived from empirical data and positions hierarchies of evidence as foundational to clinical decision-making. Yet for transmasculine patients, this epistemological infrastructure falters as the evidence to guide clinical judgment is sparse to nonexistent. Uncertainty and lack of knowledge regarding the physiological impact of testosterone—stemming both from limited evidence and provider knowledge—were central to shaping barriers to gynecological care and treatment trajectories for transmasculine people. Navigating clinical uncertainty regarding testosterone had significant psychological impacts and often resulted in prolonged and fragmented care pathways that required sustained patient effort and rarely resulted in clear diagnoses or resolution. Consistent with ecosocial theory, repeated exposure to dismissive, delayed, and non-affirming care accumulated over time and became embodied as medical trauma, overwhelm, and medical care disengagement. At the same time, resistance and agency capture the ways individuals and communities adapt to and challenged these structural inequities. This study highlighted gynecological health topics of greatest salience to transmasculine people using testosterone—pelvic pain, genital atrophy, and recurrent urogenital infections, particularly recurrent UTIs. Notably, some of our findings mirror cisgender women’s experiences with these conditions. Qualitative studies of cisgender women with vulvodynia, endometriosis, interstitial cystitis, and other forms of chronic pelvic pain consistently report that patients feel their pain or concerns are not believed or taken seriously. 29 – 31 Lack of provider knowledge regarding gynecological health conditions leads to misdiagnosis and delayed care, necessitating individuals to do their own research. 32 – 35 The absence of research and funding to gynecological conditions leads to gaps in medical knowledge that leave providers unprepared and patients underserved. 36 However, these dynamics are significantly exacerbated for transmasculine people, compounded by cisnormative erasure and testosterone-related information gaps. Our findings are consistent with prior research documenting trans people’s general barriers to healthcare access, including the need to educate providers, navigate provider discomfort or lack of competence, navigate insurance exclusions, and manage anticipated or enacted stigma in clinical settings. Our study extends this literature by examining how these barriers operate specifically within gynecological care in the context of testosterone use where informational erasure and clinical uncertainty are particularly pronounced. Our findings also extend both theoretical frameworks in important ways. First, we describe identity erasure as a third form that operates at the level of individual clinical encounters, translating institutional and informational erasure into embodied harm through misrecognition, invisibility, and the repeated burden of disclosure. Second, our findings reveal a productive tension within ecosocial theory: testosterone use functions simultaneously as an act of resistance and agency and as a pathway of embodiment whose physiological effects became a site of harm when participants encountered healthcare systems that were structurally and epistemically unprepared to manage their care. Finally, these findings must be interpreted within a US sociopolitical context of escalating restrictions on gender-affirming care, defunding of transgender health research, and erosion of discrimination protections. 37 , 38 These shifts will undoubtably deepen the informational erasure, clinical uncertainty, and identity erasure our participants described. This study should be considered in the context of several methodological strengths and limitations. Our topic-neutral approach, in which participants identified gynecological topics most significant to them, allowed us to identify experiences that are underrepresented in research. High interest in participation suggests that the community perceives gynecological health in the context of testosterone use as salient and meaningful. With respect to qualitative rigor, credibility was supported by prolonged engagement with the data, researcher positionality reflective of the study population, and recruitment through PRIDEnet facilitated trust and broad reach. Participants were diverse with respect to ethnoracial identity, age, and duration of testosterone use. They reported relatively high levels of educational attainment and healthcare utilization, which may bias findings toward the experiences of individuals with greater access to information, resources, and medical care and may underrepresent the experiences of those facing more substantial structural barriers. Gynecological healthcare experiences for transmasculine and gender diverse adults using testosterone are shaped not only by biomedical uncertainty but by systems that produce erasure, concentrate authority, and shift the burden of care onto patients. Addressing these inequities will require expanding research on the gynecological health of transmasculine people using testosterone, improving provider education, and re-centering embodied patient knowledge within trauma-informed, trans-competent models of care.

Many transmasculine and gender diverse people assigned female at birth use testosterone as gender-affirming hormone therapy, which is associated with significant changes to sexual and reproductive health. 1 , 2 Testosterone typically suppresses ovarian function and menstruation, often a desired effect. 3 , 4 Suppressed ovarian function, combined with testosterone’s binding at androgen receptors in urogenital tissues, creates a hypoestrogenized vaginal environment similar to what is observed after menopause that frequently results in urogenital atrophy 2 , 5 – 7 as well as adverse changes to the genital microbiota. 8 , 9 Although relatively few studies have examined the downstream health implications, available evidence suggests that these hormonal changes are associated with bacterial vaginosis 10 and a high prevalence of dyspareunia. 11 Testosterone is also associated with changes in chronic pelvic pain, with some individuals experiencing resolution of cyclic and endometriosis-related pain, while others experience new-onset or worsening pelvic pain following testosterone initiation. 12 , 13 In addition to these physiological changes, transmasculine and gender diverse people experience significant barriers to accessing any or appropriate gynecological care. 14 , 15 In response, existing research has emphasized the importance of affirming language, 16 , 17 moving beyond “women’s health” frameworks, 18 – 20 and implementing clinic-level interventions to improve access to gendered healthcare for transgender patients. 18 , 20 Despite the growing body of research on creating trans-inclusive reproductive healthcare environments, the specific impact of testosterone on gynecological health and how it reshapes clinical decision-making remains poorly understood. Therefore, this study examined the perceived role of testosterone from the patient perspective in individuals’ gynecological health and how testosterone use shaped access to gynecological care for transmasculine and gender diverse people. This study was informed by two theoretical frameworks ( Figure 1 ). First, the concept of cisnormative erasure as described by Viviane Namaste and Greta Bauer 21 , 22 underpins much of the existing literature regarding transgender people’s access to medical care and systems. Namaste and Bauer describe erasure as the primary consequence of cisnormativity—the structural system that assumes all people are cisgender and organizes social institutions, policies, and practices around that assumption. 21 , 22 Namaste described erasure as the “defining condition of how transsexuality is managed in culture and institutions, a condition that ultimately inscribes transsexuality as impossible.” Bauer expanded upon this work, defining a reinforcing cycle of informational erasure and institutional erasure that negatively impacts the health of trans communities. Second, Nancy Krieger’s ecosocial theory of embodiment framed our analysis of how structural inequities accumulate and become biologically incorporated to impact population-level distribution of health. 23 , 24 Ecosocial theory explains how the political economy and ecological conditions literally become embodied via pathways such as through economic deprivation, social trauma, and degrading health care. 23 , 24 Core concepts include cumulative exposure over the life course, resistance to the social causes of health inequities, and the insistence that health inequities cannot be understood—or addressed—without attention to the social relations of power that influence exposure, vulnerability, and access to resources. Together, these frameworks allowed us to examine how cisnormative structures shape embodied gynecological health experiences and how testosterone itself functions as a pathway of intentional embodiment whose physiological effects are refracted through those same systems.