EXECUTIVE SUMMARY

More research is needed about contraceptive needs and health effects on transgender and gender-diverse people, experts say.

  • Reproductive health clinicians especially need more data on how testosterone, often used by transgender men, might affect patients’ health when they also take an estrogen-based contraceptive.
  • Clinicians need to help transgender patients identify the best contraceptive to meet their needs. This should be a shared decision-making process.
  • All contraceptives are safe for transgender populations, but many unknowns remain.

One of the challenges facing family planning clinics and obstetricians/gynecologists when serving transgender and gender-diverse patients is the lack of research and evidence-based guidelines to inform their clinical decisions.

“One of the biggest issues is we just don’t have enough data about trans folks on testosterone,” says Chance Krempasky, WHNP-BC, FNP-BC, AAHIVS, associate director of medicine — education at Callen-Lorde Community Health Center in New York City.

Too few studies exist for providers to give patients evidence-based risk information. “Patients want to know, and there’s frustration because there’s not enough research across the board,” Krempasky says.

This deficit is notable at a time when the numbers of transgender and gender-diverse people are increasing.

“We know that at the very minimum, one in 200 adults are transgender,” says Juno Obedin-Maliver, MD, MPH, MAS, FACOG, assistant professor in the department of obstetrics and gynecology at Stanford University School of Medicine. She also is the co-director of the PRIDE Study.

There is some evidence that more young people identify as gender diverse. Estimates based on 2017 data about California teenagers suggest that up to 27% are either a gender minority or have nonconforming gender identity, Obedin-Maliver says. (More information is available at: https://newsroom.ucla.edu/releases/27-of-california-adolescents-are-gender-nonconforming-study-finds.)

Amount of Data ‘Slim to None’

Obedin-Maliver and coauthors recently published clinical recommendations on contraceptive counseling for transgender and gender-diverse populations.1

“This paper was worked on with collaboration with the Society of Family Planning, so these guidelines are a very first step,” she says. “My hope is people will pick up the call in these guidelines to do this research that we need on a biochemical, physiological level.”

The recommendations provide some answers to clinical questions, including the first question on which data are available to guide contraceptive counseling with transgender and gender-diverse individuals who were assigned female sex at birth. The short answer is there are limited data on the patterns, safety, and efficacy of various contraceptive methods for use in these populations.

“The amount of data is slim to none,” says Adam Bonnington, MD, associate position and volunteer clinical faculty in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. Bonnington is the lead author of the recommendations.

There are some data on transgender and nonbinary individuals, who were assigned female at birth, becoming pregnant. For instance, one study of 26 transgender men found 13 were at risk of an unintended pregnancy, and reported using condoms more than any other contraception. About one-third were amenorrheic.2

Results of existing studies about testosterone reveal some effects in transgender individuals who also use hormonal contraceptives, Bonnington explains. “There are qualitative pieces that show transgender, nonbinary people using contraception, but there is no data on safety, efficacy, and long-term outcomes of these products when used in the setting of testosterone,” he adds. “What we’re left with is we have to extrapolate what we know about testosterone on its own and what we know about hormonal contraceptives. Then, we make educated assumptions based on those findings.”

More research about the effect of testosterone on fertility is necessary, Obedin-Maliver says.

“There are some small studies in terms of in vitro fertilization outcomes, but we need much larger studies on fertility and prevention of pregnancy, in terms of thinking about what the impact of testosterone is,” she says. “We need to know what testosterone does, how it impacts fertility.”

Learn Patients’ Health Goals

While there are many unanswered questions about transgender and
gender-diverse people and contraception use, one common theme is that each person’s experience and reproductive health goals are different.

For example, some transgender men might desire to keep their uterus and/or ovaries. Some might take hormonal contraceptives to stop their menstruation. Other transgender patients might prefer estrogen-containing contraceptives because they want to stop monthly bleeding, at least until testosterone injections achieve the same goal. Others might prefer progestin-only pills to avoid estrogen.

Some transgender patients might prefer a quarterly contraceptive shot because they are accustomed to injections due to daily testosterone shots. Other patients might prefer something long-term so they do not have to visit a gynecological clinic often. A clinic or doctor’s office might make them feel uncomfortable in the way it is designed to accommodate cisgender women, says Frances W. Grimstad, MD, MS, faculty in the division of gynecology in the department of surgery at Boston Children’s Hospital, and instructor of surgery at Harvard Medical School. Grimstad specializes in transgender reproductive healthcare, focusing on adolescents and youth.

“I perform gender-affirming hysterectomies at Boston Children’s Hospital,” she says. “I help with menstrual suppression and complex management of gynecological issues, particularly for transmasculine youth, both those on testosterone and those not on testosterone.”

A clinician’s goal should be to help transgender patients identify the best contraceptive to meet their physical and emotional needs. Clinicians should reassure patients that they can change their mind.

“The way I approach it with my patients is I first remind them that I’m not holding them to anything they’re saying today,” Grimstad says. “They can come back in three to six months and have a completely different idea of what they want in their future, and I’ll never criticize them.”

For example, some transgender patients might want a hysterectomy, but they may wish to keep their ovaries because of a possible future desire to have a genetic child.

“They can have their ovaries in and still get a penis,” Grimstad says. “We need to affirm the patient’s gender and the way they desire, and also leave open doors they might want to have open in the future because people’s minds do change.”

Physicians should discuss risks, even if they are rare and not well-researched. For example, both testosterone and/or some contraceptive methods can cause elevations in cholesterol levels, lipids, triglycerides, and cause weight gain, Bonnington says.

“Those changes are not thought to be clinically significant for cisgender women, but the question becomes, ‘Do two nonsignificant scenarios create something of concern?’” he asks. “We need to closely watch these patients.”

All methods of contraception are safe for transgender and nonbinary patients, but there are a lot of unknowns. It is good to advocate for shared decision-making, Bonnington adds.

“Have frank conversations with patients, saying, ‘This is what we know; this is what we don’t know. What is important to you, and how can we find a method that will be acceptable to you?’” he explains.

A clinician can provide data based on cisgender women, and can help patients extrapolate for transgender patient populations, too, Bonnington adds.

Be Sensitive to Patients’ Dysphoria

One important part of treating a transgender patient involves sensitivity to their experiences of dysphoria. Transgender people experience dysphoria when their appearance or behavior — as perceived by others — are not concordant with the gender with which they identify, Krempasky says. This can happen when someone calls them the wrong pronoun, or when they have a discordant experience.

For example, a transgender man might feel dysphoria if someone sees his package of birth control pills fall out of a bag, as happened to someone Krempasky knew. “They felt exposed, unsafe, and it made them want to change their method of taking birth control,” he explains.

Reproductive health providers can help prevent dysphoria among transgender patients by being sensitive to their language and expectations.

“Every transmasculine patient has a different experience with dysphoria,” Krempasky says. “Meet with each patient and determine what their priorities are.”

Clinicians can talk with them about what makes them uncomfortable, such as their chest, undergoing pelvic procedures, or buying products like menstrual pads that are associated with femininity, he explains.

“Have these conversations with patients and ask them what are their sources of dysphoria and what gives them discomfort with their body,” Krempasky says.

REFERENCES

  1. Bonnington A, Dianat S, Kerns J, et al. Society of Family Planning clinical recommendations: Contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth. Contraception 2020;S0010-782430104-9. [Epub ahead of print].
  2. Cipres D, Seidman D, Cloniger C III, et al. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception 2017;95:186-189.