FAQ: Birth control while gender transitioning

I think it is important for everyone to realise that testosterone is not a contraceptive. Even if someone stops having periods while taking testosterone, they still have ovaries that produce eggs, functional fallopian tubes (that guide the fertilised egg or embryo to the uterus) and a uterus that can carry an ensuing pregnancy.

In short, people taking testosterone to transition are still at risk for pregnancy. Although there have been some observational studies that claim testosterone may cause some anovulation (meaning not ovulating or releasing an egg), but even so it should not be relied upon as a contraceptive. There is very little data about trans men when it comes to contraception, so patients and health care providers alike need to be aware of the risk of unintended pregnancy if the person using testosterone therapy is having sexual intercourse with a sperm-producing individual.

Every person is different, and transitioning is not a single event, so the needs of individuals vary depending on the type of gender-affirming therapy a person is receiving.

While there is no contraindication (meaning a reason to withhold medical treatment) to any type of contraceptive for trans men, the physiology of the combined oral contraceptive pill will lower the levels of androgens, which are hormones associated with male characteristics like facial hair, made by the ovaries and adrenal glands. Therefore it is also possible that the oral contraceptive pill will counteract exogenous testosterone, otherwise known as gender-affirming testosterone therapy, but there is very limited research in this field.

Read more: Transgender and over 50 - Rhys's story

A non-hormonal intrauterine device or progestin intrauterine device, which many people will know as the IUD or the coil, might be the best option to avoid this issue. This is because the former has no hormonal interaction, while the latter has a very localised effect and may induce amenorrhea (this is a medical term for the absence of periods, which may be desirable as a side effect for people who are transitioning).

For trans women who have not had their testes removed, it is important to recognise that sperm production does occur even if the person in question is taking anti-androgens and estrogens for gender-affirming therapy. While some research suggests the sperm of someone going through gender-affirming therapy may not have the exact same physiology as the sperm of cis-gender men who are not taking anti-androgens and estrogens, the sperm of a transitioning or trans person could still fertilise an egg during penile-vaginal intercourse. Therefore, external or male condoms should be used with every episode of intercourse as a barrier method.

Read more: Transgender and over 50 - Kate's story

The information I’ve outlined is incredibly important, and we still have much to learn. There is a study called the PRIDE Study from the UCSF that will hopefully improve our understanding of many reproductive LGBTQ issues. On top of this, all trans individuals should be counseled about fertility preservation before undergoing a gonadectomy (a surgery to remove either the ovaries or testes), as the decision a trans individual makes about this procedure will impact their opportunity to have a biological child.

People who desire practitioners trained in trans health should go to WPATH.org and look under resources to “Find a Provider”.

Specifically, endocrinologists and reproductive endocrinologists are another resource for individuals who desire family planning.

In the US, it was only in 1993 that the National Institute of Health policy required women to be included in all of the research that the body supported. Now, I think that it is time for the mandate to be re-evaluated, to make sure all genders are included.

There are an estimated 1.5 million trans people in the United States, but unfortunately, there is really sparse data about transgender individuals across the field of reproduction and even emerging research (such as a study on ovulation during testosterone therapy by Taub et al which was published this year) concludes that further studies are needed.

Transgender health issues are public health issues and we need everyone’s help to address the reproductive health disparities that exist.  

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