Contraception and Pregnancy Prevention for Transgender And

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

Contraception and Pregnancy Prevention for Transgender And

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