Contraception

Pregnancy can occur when the right conditions are met between individuals of opposite biologic sex. For example, a biologic male must be able to produce viable sperm and ejaculate during intercourse to deliver the sperm load into the vagina. At the same time, a biologic female must be able to produce viable eggs, ovulate, and have the egg fertilized by the sperm to become an embryo. The embryo implants in the endometrium (uterine lining), leading to pregnancy.

Contraception guidelines for transgender individuals are not explicitly mentioned in the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention documents. Therefore, the recommended contraception practice for transgender individuals is based on recommendations for cisgender individuals and the few available studies on the transgender population.

Contraception in male-to-female transgender individuals

Male-to-female transgender individuals who have not undergone genital gender-affirming surgery can produce sperm from the testes regardless of the feminizing hormone treatment they have received. If that male-to-female transgender individual has unprotected penile- vaginal sexual intercourse with a biologic female who has an intact reproductive system and can ovulate, the female can risk unwanted pregnancy. Although male-to-female transgender individuals taking estrogen have lower sperm counts (because the hormone inhibits the testosterone production in the testes, a key factor of sperm production), estrogen is not an approved male contraceptive method. Consequently, male-to-female transgender individuals should either consider using the same contraceptive methods as biologic males – such as condoms or vasectomy – or have their biologic female partner apply the usual contraceptive measures for natal females.

Medical professionals should counsel male-to-female transgender individuals who have intercourse with biological females on proper contraceptive methods and STI prevention by using condoms with every intercourse.

Contraception in female-to-male transgender individuals

Female-to-male transgender individuals with intact reproductive organs (uterus, oviducts and ovaries) engaging in unprotected penile-vaginal sex with biological males can be at risk for an unwanted pregnancy. It should be noted that the use of testosterone in female-to-male transgender individuals does not completely suppress ovulation. Therefore, it is not considered an appropriate contraceptive method. Female-to-male transgender individuals may be able to ovulate even when the effects of testosterone therapy have caused the cessation of menstruation. However, female-to-male transgender individuals who did not take testosterone are three times more likely to conceive than those using testosterone. Female-to-male transgender individuals who stopped testosterone therapy will be able to ovulate and become pregnant even before the resumption of menses. Pregnancy in female-to-male transgender individuals on testosterone therapy will result in hormonal effects on the fetus, which may cause harm.

Testosterone is not a contraindication to any type of contraception. Female-to-male transgender individuals with an intact natal reproductive system may use non-hormonal female contraceptive methods, such as copper IUDs, sterilization, cervical caps, or female condoms. Using condoms has an advantage of STI prevention. If hormonal contraception is desired, female-to-male transgender individuals can consider non-estrogen methods to avoid effects on female secondary sex characteristics. These methods, including progestin-only contraceptives, progestin-only IUD, three-month injectable contraceptives, or contraceptive implants, will complement the testosterone effect of stopping menstruation (examples of estrogen-based contraception include the combination pills, monthly injectable contraceptives, contraceptive patches, and birth control rings). Furthermore, female-to-male transgender individuals can choose to use emergency contraceptive pills or a copper IUD in emergencies. The same precautions and contraindications for emergency contraception should be considered as that for natal females.

Female-to-male transgender individuals with an intact reproductive system engaging in penile-vaginal sex with biological males may have their partner use male contraceptive methods instead, such as male sterilization or condoms. They must also consider the limitations and contraindications of male contraception.

Healthcare professionals should advise female-to-male transgender individuals with an intact reproductive system along with their natal male partners on suitable contraceptive methods. Condoms with every intercourse should be advocated to prevent STIs.

Refer: Reproductive Services for Transgender People, The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University