Terminology

Navigating through a discussion about gender and sexuality with the many terms used today can be confusing. Here is a brief introduction to terminology regarding the multifaceted gender spectrum.¹

• Cisgender: Gender identity matches assigned gender at birth²
• Transgender: Gender identity differs from assigned gender at birth²
• Gender nonbinary/queer/fluid: Individuals do not identify with a male-female binary and may have a fluid, multifaceted gender identity²

Now let’s review contraception for transgender patients…with a focus on transgender men (male gender identity and female assigned gender at birth)…

Considerations for contraception care

Gender affirmation therapy does not take the place of contraception.

Each patient may prefer different gender affirmation methods, which may affect their contraceptive needs.³ Methods include hormone therapy with testosterone, surgery, or no intervention. For patients undergoing testosterone therapy or no intervention who desire contraception, an additional contraceptive method becomes necessary. On the other hand, patients who undergo reaffirming surgery may or may not need additional contraception to reduce risk of pregnancy, depending on the extent of surgery performed.

 

There are knowledge gaps around fertility and contraceptive needs amongst transgender patients and their providers.

Some transgender men and providers have a lack of knowledge regarding their reproductive potential and risk of pregnancy if sexually active with a capable partner.³ Misperceptions include testosterone as effective contraception (may decrease fertility, but does not eliminate pregnancy risk) and midlife patients as infertile (presumed menopausal).^3,4,5

 A transgender man has reproductive potential if they have an intact uterus and ovaries and until menopause or surgical sterilization.³ In addition, testosterone use may not completely suppress ovarian function, causing irregular or suppressed periods, which should not be confused with perimenopause in midlife patients.^3,5 It is important to note there is still a risk of pregnancy despite a lack of menstruation. In a study of 41 transgender men who had been pregnant and given birth, one-third of pregnancies were unintended.⁶ Contraception use prior to pregnancy was lower in patients who used testosterone compared to those who did not.⁶ Use of a contraceptive is still necessary even with testosterone therapy.

 

Transgender patients have barriers to care that may prevent provision of adequate sexual and contraceptive care

Examples of barriers include stigmatization and feeling unsafe in health care settings.³ Health care teams should provide a supportive, open, and safe environment for transgender patients by accepting their gender identity and sexual orientation and using their preferred name and pronouns. Providers should ask if patients have an intact uterus and ovaries, are sexually active with a partner that may result in pregnancy, have a history of sexual violence, are at risk of sexually transmitted infections (STIs), and use gender affirmation methods.³

 

There is a lack of research on pregnancy risk and fertility in transgender patients, and consequently, contraceptive guidelines for this patient population.³

 

Contraception for transgender men

All transgender men with reproductive potential should be offered contraception.⁵ Patients should decide which contraceptive they prefer to use, if any. 

 

Reversible contraceptives

Reversible methods are most appropriate for patients who have not decided or do not want to make long-term or irreversible decisions regarding their reproductive potential.³

 

Progestin-only contraceptives

Progestin-only methods do not interfere with testosterone use. Regardless of testosterone use, patients who continue to have menstrual cycles may prefer this method due to high rates of amenorrhea and potential for masculinizing effects (e.g., increased hair growth).^5,7

Traditional progestin-only pills (POP) containing norethindrone have a risk of low patient adherence due to its strict 3-hour window, which by missing correct timing of doses, may compromise contraceptive efficacy.⁸ However, the new POP, Slynd, allows for a 24-hour missed pill window.⁹ Irregular bleeding may occur, which patients may want to avoid.⁸

For patients seeking longer acting methods, the progestin-only injectable and long-acting reversible contraceptive devices — implant and IUDs — may be more convenient and have higher rates of amenorrhea.

 

Combination hormonal contraceptives

There is a lack of evidence regarding combined hormonal contraceptives including pills, patches, and vaginal rings) for transgender men as the estrogen may or may not interfere with testosterone therapy. At this time, there are no contraindications to concurrent use.⁵ Though patients can choose combination hormonal contraceptives, some may not prefer this method due to concerns about having estrogen in their system and the potential for female traits to appear.^5,10 Other available and acceptable methods should be considered before considering combination hormonal contraceptives.⁵

 

Nonhormonal contraceptives

Although the copper IUD does not interfere with testosterone, there is a risk of increasing any existing menstrual bleeding.⁵ Patients with an intact uterus who want to avoid both progestins and estrogens and who are already amenorrheic may prefer this method.⁵

The contraceptive effectiveness of external and internal condoms is lower than hormonal methods and LARCs, however they are essential to prevent HIV and other STDs.³

Permanent surgical options are available for patients who do not want to get pregnant at all.^3,7

 

Contraceptives for transgender women

For patients with a female gender identity and male sex assigned at birth taking estrogen, condoms may be used as well as permanent options, including orchiectomy (removal of testicles) and vasectomy (blockage of vas deferens tubes, preventing sperm from reaching testicles).⁷

 

For more information regarding transgender care and terminology, please visit the UCSF Transgender Care Navigation Program website at transcare.ucsf.edu/guidelines.

 

References

1. Justice for Sisters. “Update: Gender Bear Now in BM, Chinese Language & English.” Accessed on September 5, 2019. Available at: https://justiceforsisters.wordpress.com/2016/07/13/updated-gender-bear-in-bm-chinese-language-english/.
2. UCSF Transgender Care Navigation Program. “Terminology and definitions.” UCSF Transgender Care Navigation Program. June 17, 2016. Accessed on September 11, 2019. Available at: https://transcare.ucsf.edu/guidelines/terminology.
3. Francis A, Jasani S, Bachmann G. Contraceptive challenges and the transgender individual. Womens Midlife Health. 2018;4:12.
4. Amato P. “Fertility options for transgender persons.” UCSF Transgender Care Navigation Program. June 17, 2016. Accessed on September 11, 2019. Available at: https://transcare.ucsf.edu/guidelines/fertility.
5. Boudreau D, Mukerjee R. Contraception care for transmasculine individuals on testosterone therapy. J Midwifery Womens Health. 2019;64(4):395-402.
6. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127.
7. Shah M. “Birth control across the gender spectrum.” Bedsider. 2017. Accessed on September 11, 2019. Available at: https://www.bedsider.org/features/1070-birth-control-across-the-gender-spectrum.
8. Jones K, Wood M, Stephens L. Contraception choices for transgender males. J Fam Plann Reprod Health Care. 2017;43(3):239-240.
9. Exeltis USA, Inc. “Exeltis USA, Inc. announces the approval of Slynd, the first and only progestin-only pill providing pregnancy prevention with a 24/4 dosing regimen and 24-hour missed pill window.” Exeltis USA, Inc. June 6, 2019. Accessed on November 19, 2019. Available at: https://www.prnewswire.com/news-releases/exeltis-usa-inc-announces-the-approval-of-slynd-the-first-and-only-progestin-only-pill-providing-pregnancy-prevention-with-a-244-dosing-regimen-and-24-hour-missed-pill-window-300863390.html.
10. Reproductive Health Access Project. “Birth control across the gender spectrum.” Reproductive Health Access Project. 2019. Accessed on September 11, 2019. Available at: https://www.reproductiveaccess.org/wp-content/uploads/2018/06/bc-across-gender-spectrum.pdf. 
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About the Author

Cydnee Ng, PharmD completed her pharmacy training at UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences in 2019. She is currently a community pharmacist at Walgreens in the San Francisco Bay Area.