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 affirming therapy • 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 feminine persons believed or were unsure if gender affirming hormone 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 testosterone functioned as a contraceptive • Respondents reported receiving unclear or confusing information from clinicians on need for contraception while on GAHT • Concerned contraception would interfere with masculinizing effects of 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 Transmasculine Contraception • Unger, AJOG 2015: • Less than one third of OBGYN clinicians surveyed recently stated that they were comfortable providing care for TM 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 effects of 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 fecundity after discontinuance of testosterone has yet to be ascertained • All patients considering starting GAHT should be counseled about options for fertility preservation1 • Use of GAHT does not guarantee infertility • The time to return of fertility is 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 Testosterone a Contraception? Changes in both LH and FSH occur in Androgen hyperandrogenic Receptors systems (both in amplitude and pulsatility), 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 fertility is 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 ❑ Bilateral breast augmentation ❑ Cervix ❑ Bilateral orchiectomy ❑ Ovaries ❑ Vaginoplasty (penile inversion, colon graft) ❑ Penis ❑ Bilateral total reduction mammoplasty ❑ Prostate ❑ Vaginectomy ❑ Testes ❑ Metoidioplasty ❑ Uterus ❑ Phalloplasty ❑ Vagina ❑ 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 efficacy is 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 What aspects of contraceptive methods could uniquely affect TMGNB patients? What aspects of contraceptive methods could uniquely affect TMGNB patients? • Increased pelvic cramping • Risk for spotting/bleeding • Reduces/ceases bleeding • Invasiveness/pelvic procedure • Contains estrogen/progesterone • Chest/breast tenderness • Privacy/concealability • Clinician needed to discontinue? • Effect on moods/mental health • Others? Krempasky, et al. 2019 Case Study #2 Kelley, 17yo G0P0 AFAB nonbinary patient (pronouns: they/them) presents to discuss contraceptive methods. Pt recently started dating a cisgender male partner. They would like menstrual cessation and wear a binder daily to flatten their chest. They currently live with their parents with whom they have a strained relationship, and they are concerned about their dad snooping in their room and finding contraceptive supplies. They have never had a pelvic exam before. PMH: Cluster headaches, PSH: none, Meds: testosterone 50mg subcutaneously q2wks, topiramate IR 50mg PO BID Comparison of Relevant LARC Characteristics Progesterone IUD Duration of use Approved Inserter tube size Amenorrhea rates (Researched) LNG-IUS 20 5 years (7 years) [1] 4.4 mm [2] 20% after 1 year (Mirena®) Suspect rates similar to LNG20 after 2-5 years [3] LNG20 5 years (n/a) 4.8 mm 9% after 1 year (Liletta®) 27% after 2 years 37% after 4 years 42% after 5 years[ 4] LNG-IUS 12 5 years (n/a) 3.8 mm 12% after 1 year (Kyleena®) 23% after 5 years [5] LNG-IUS 8 3 years (n/a) 3.8 mm 6% after 1 year (Jaydess®/Skyla®) 12% after 3 years [6] Copper IUD 10 years (12-20 years) [1, 7, 4.01 mm [9] n/a - increased dysmenorrhea [10], menstrual blood Copper T-380A 8] loss increases by approximately 50% and persists for (ParaGard®) duration of use [11] Progestin Implant 3 years (5 years) [12] n/a 24% after 1 year Etonogestrel implant 17% after 2 years (Nexplanon®) [package insert] Long-acting Injection 15 weeks n/a 55% after 1 year DMPA 68% after 2 years 80% at 5 years [51,52] Krempasky et. al (2019) Contraception for Trans women/gender nonbinary transfeminine spectrum • GAHT doesn’t (necessarily) stop spermatogenesis • N/A if s/p orchiectomy and/or vaginoplasty • Talking to patients about genders and bodies of partners, types of sexual activity to determine risk Schneider et al. summary • Review of 11 studies showed wide variation of effect of feminizing HRT on spermatogenesis • 3 publications found marked reduction of the spermatogenic level in all patients examined, 8 publications reported inconsistent results (d/t insufficient duration, dosing) • Own study showed 24% of 108 pts had intact spermatogenesis when testicular tissue analyzed post-orchiectomy or vaginoplasty, despite treatment strategy (discontinuing hormones 6wks, 2wks, or no time prior to lower surgery) Spermatogenesis in transeminine spectrum patients Case Study #4 Alice is a 26 yo trans woman, who is sexually active with cisgender and transgender women. She would like to prevent pregnancy with her partners but struggles to find condoms that fit well. She is not interested in vaginoplasty or orchiectomy. PMH: none, PSH: breast augmentation, Meds: estradiol valerate 20 mg IM q14 days, spironolactone 50mg PO BID, emtricitabine/tenofovir disoproxil fumarate 200-300mg PO QD Contraception for Transgender Women Condoms small/“snug fit” condoms, internal condoms Vasectomy Orchiectomy / Vaginoplasty Summary • Accurate assessment of pregnancy risk requires open-ended questions and use of gender-affirming language • Selection of an appropriate contraceptive method should be based on the patient’s individual needs and priorities Add your own colors to the Rainbow! Coloring book by Sophie Labelle Chance Krempasky: [email protected] Co-authors: Lauren Abern Frances Grimstad Miles Harris Contraception across the transmasculine spectrum, AJOG (2019).