Contraception for Transgender and Nonbinary Individuals
Transgender individuals do not identify with their assigned gender at birth. Gender dysphoria is a term commonly used to describe the discomfort and suffering caused by this discordance. To obtain the characteristics of their desired gender, some gender nonconforming individuals undergo gender-affirming hormone therapy (GAHT) and/or undertake gender-affirming genital surgery (GAGS).
This article aims to highlight the importance of contraception amongst transgender and nonbinary individuals. You may also wish to learn more about the LGBTQ community, which transgender and nonbinary individuals are often considered part of.
Gender-affirming hormone therapy (GAHT) and gender-affirming genital surgery (GAGS)
To better understand the role of contraception for transgender and nonconforming individuals, it is important to also understand what are GAHT and GAGS.
GAHT involves the administration of medicine either containing reproductive hormones or hormonal blockers - these prevent the action of the hormones. GAHT induces mostly reversible reproductive and phenotypical changes, which are changes in observable traits such as the development of breasts in feminizing hormone therapy, a type of GAHT. On the other hand, GAGS such as hysterectomy, the removal of the uterus, and removal of ovaries as well as other reproductive glands leads to a permanent loss of reproductive function.
The risk of unintended pregnancy and the importance of contraception
According to recent data estimates, several hundred abortions are performed among the transgender and gender nonbinary population within a year in the USA. GAHT includes administering testosterone to transmen and estrogen to transwomen. However, the administered hormones only partially suppress the reproductive hormone function, which means there is still a chance of a pregnancy occurring.
Hence, before initiating transition, transgender men and women should be counselled appropriately regarding reversible, less reversible, and irreversible changes that may occur during these processes, including fertility issues and contraception. This is an essential part of gender transition in order to avoid misunderstandings regarding the reproductive and fertility effects of GAHT and GAGS. The counselling should also comply with clinical practice guidelines and World Professional Association for Transgender Health (WPATH) Standards of Care.
Little is known about the effect of testosterone on fertility. The lack of knowledge and awareness of the risk of pregnancy is common among transgender men. Some studies have reported cases of unplanned pregnancies among transgender men under testosterone therapy or with previous testosterone use, although these evidence is limited. A study in 2014 reported data from 41 transgender men who experienced pregnancies after gender transition. Among those 41 men, about 75% of them were on testosterone therapy and 24% of those pregnancies were unplanned. A 2018 survey also reported 60 pregnancies among transgender men, where 17% of them occurred after stopping testosterone use and 1 pregnancy was reported by a transman who took testosterone irregularly. 80% of pregnancies occurred in transgender men who never took any testosterone prior to conception.
As well as the need to be aware of the risk of pregnancy, sexually active transmen with intact female reproductive organs should also understand the potentially harmful effects of testosterone on the baby.
More research and data are needed to further evaluate the risk of an unintended pregnancy among transgender and non-binary individuals, particularly those on GAHT such as testosterone. Reported rates of contraceptive use among transmen are also extremely variable, with current data indicating that around 20–60% of transgender men use any form of contraception.
Currently, there is no evidence regarding the best contraceptive option for transmen (and no available studies comparing different contraceptive methods). Testosterone has not shown to interact with any form of contraception (hormonal or non-hormonal methods), therefore all options may be offered to transmen. However, there is limited evidence regarding the use of combined hormonal contraceptives, as it is not been fully evaluated whether estrogen interferes with testosterone therapy.
As it is with anyone intending to use hormonal contraception, transmen and nonbinary individuals would need to undergo the same process before starting contraception. This includes ensuring they are eligible for their choice of contraception through their personal, medical and drug history. It is also important to be given accurate advice about protection against sexually transmitted diseases, cervical screening and human papillomavirus (HPV) vaccination (if relevant).
As it is very important to understand how gender affirming treatments can affect reproductive organs and fertility, detailed counselling is thus essential to ensure the safety and wellbeing of the transgender and nonbinary individuals.
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