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Contraception and Pregnancy Prevention for Transgender And

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Contraception and pregnancy prevention for transgender and gender nonbinary individuals across the gender spectrum

Chance Krempasky, FNP, WHNP (he/him) Callen-Lorde Community Health Center
New York, NY USA

Intros/Who's in the room?

A Little About Callen-Lorde...
Introduction

• Transmasculine persons (TMGNB=transgender men and gender nonbinary persons who are assigned female at birth), may utilize testosterone as part of gender affirmingtherapy

• They may have a uterus + ovaries and be capable of achieving pregnancy
• They also may engage in sexual activity which can achieve pregnancy

TMGNB people can still get pregnant, even if they are on testosterone and

haven’t had a recent period.

Pregnancy in TMGNB persons

• 31% trans masculine persons, 67% trans femininepersons believed or were unsure if gender affirminghormone therapy (GAHT) prevents pregnancy

• 6% trans feminine, 9% trans masculine reported that a provider stated that GAHT prevents pregnancy

• 3% TMGNB/trans masculine had

unplanned pregnancies

Contraception Knowledge in TMGNB

Persons

• Many believed testosteronefunctioned as a contraceptive

• Respondents reported receiving unclear or confusing informationfrom clinicians on need for

contraception while on GAHT

• Concerned contraception would interfere with

masculinizing effectsof GAHT

Pregnancy in TMGNB Persons

• 16.4% of TMGNB persons believed that GAHT is a contraceptive • 5.5% reported a provider stated that GAHT prevents pregnancy • 17% had been or were currently pregnant (11/60 pregnancies with current or past GAHT use)

• 60 pregnancies reported, 10 (17%) pregnancies occurred after stopping testosterone, 1 (1.6%) while taking testosterone irregularly

Clinical Barriers to TransmasculineContraception

• Unger, AJOG 2015:
• Less than one third of OBGYN clinicians surveyed recently stated that they were comfortable providing care forTM individuals

• NCTE U.S. Transgender Survey, 2015:
• One third of transgender respondents who had engaged in healthcare reporting at least one negative experience related to their gender identity, including verbal harassment and being

refused care

• Krempasky, AJOG 2019
• TM patients may want to avoid estrogen and/or progesterone due to perceived feminizing effectsof these hormones and association with an incongruent gender

Will Betke-Brunswick,

"A Trans Man’s Experience With Birth

Control"

and estrogen!

• Pregnancy can occur even while amenorrheic from testosterone

Effects of GAHT on Fertility

• GAHT's long term effects on fertility are unclear

• True decrease in fecundityafter discontinuance

of testosterone has yet to be ascertained
• All patients considering starting GAHT should be counseled about options for fertilitypreservation1

• Use of GAHT does not guarantee infertility
• The time to return of fertilityis unknown, route

dependent (topical vs short/long-acting

injectable testosterone), though some may experience permanent loss of fertility,or require assisted reproductive technologies

1. WPATH SOC7

Effects of Gender Affirming Hormone Therapy on Fertility

• It is unknown how long of a testosterone washout period is appropriate prior to pregnancy

• Testosterone is a teratogen and is contraindicated during pregnancy

• GAHT is not a substitute for contraception in patients wishing to prevent pregnancy

Why Isn't Testosteronea Contraception?

Changes in both LH and FSH occur in hyperandrogenic systems (both in amplitudeand pulsatility),
Androgen Receptors

however they are not suppressed to prepubertal levels1-3

1. Haraldsen et al, Horm Behav. 2007

2. Spinder et al J Clin Endocrinol Metab. 1989

3. Van Caenegem et al Curr Opin Endocrinol Diabetes Obes. 2015

Language and Gender

Language about fertilityis very gendered

“women’s health,” “well woman visits,” “GYN,” etc

**Use gender-neutral terms whenever possible

Naming Anatomy

Patients may use different words to describe their body

parts from “anatomical” terms

Mirror language that people use for their own body parts

Alternatives to Current Gendered Terminology

Krempasky, et al. 2019

Suggested Sexual History Script

Krempasky, et al. 2019

Anatomic Inventory

Organs Present Surgical Hx

❑ Breasts ❑ Cervix

❑ Ovaries ❑ Penis ❑ Prostate

❑ Testes ❑ Uterus ❑ Vagina
❑ Bilateral breast augmentation ❑ Bilateral orchiectomy

❑ Vaginoplasty (penile inversion, colon graft) ❑ Bilateral total reduction mammoplasty ❑ Vaginectomy

❑ Metoidioplasty ❑ Phalloplasty ❑ Scrotoplasty ❑ Urethroplasty

Who Needs Contraception?

Krempasky, et al. 2019

Case Study #1

Danny, a 27yo G0P0 trans man comes in to ask questions about his pregnancy risk. He has been on testosterone for 1 year. He is monogamous with a trans female partner who is on estradiol injections and spironolactone, and who has had no bottom surgeries. He has condomless receptive frontal and anal sex with her. He wants

to know if it’s possible for him to get pregnant.

PMH: Anxiety, PSH: None, Meds: escitalopram 10mg po daily, testosterone cypionate 80mg subcutaneously weekly

Case Study #1

How would you counsel this patient?

Will Betke-Brunswick,

"A Trans Man’s

Experience With Birth Control"
Will Betke-Brunswick,

"A Trans Man’s Experience With Birth Control"

Contraception for Transgender Men

1. No methods are contraindicated specifically due to TMGNB identity or hormone use

2. Comparative efficacyis the same as in use by cisgender women (LARCs > others)

3. Various aspects (insertion, side effects) of

contraceptive methods may uniquely affect

TMGNB patients

Contraception for Transgender Men

Krempasky, et al. 2019

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