Ask An Ob-Gyn: Contraception for Transmasculine Patients

A District VII member contacted us asking which contraception or LARC method is recommended for an adolescent who is transitioning from female to male but still needs protection from pregnancy.  Clinical guidance is currently in development, so we reached out to Dr. Frances Grimstad – a gynecology fellow at Children's Mercy Hospital and founder of the transgender clinic at the Kansas City Care Clinic – for her expert advice.

  WORDS TO KNOW

  • Cisgender: Refers to an individual whose gender identity aligns with the one typically associated with the sex assigned to them at birth. May be abbreviated to cis.
  • Transgender: A person whose gender identity differs from the sex that was assigned at birth. May be abbreviated to trans. A transgender man is someone with a male gender identity and a female birth assigned sex.
  • Trans-masculine: Term to describe gender nonconforming or nonbinary persons, based on the directionality of their gender identity. A transmasculine person has a masculine spectrum gender identity, with the sex of female listed on their original birth certificate.

    For the purpose of brevity in this article, transmasculine person refers to transgender men and gender nonconforming or nonbinary persons on the masculine spectrum of identity.

Current recommendations for transmasculine persons who have the potential for pregnancy is that they should be offered contraception which includes all forms of contraception offered to their cis female counterparts. Testosterone is not a form of birth control and transmasculine persons have achieved pregnancy while on testosterone (a teratogen).

There are no contraindications to concomitant use of estrogen/progesterone with testosterone. Many patients opt for progesterone only methods due to concerns for adding estrogen to their system, however (anecdotally, from those of us who see patients and prescribe these methods) we have yet to see substantial changes in masculinization when transmasculine patients using combination estrogen/progesterone forms on top of testosterone.

From current unpublished studies which have been presented at meetings, many transmasculine persons opt for hormonal IUDs, Depo-Provera, or the contraceptive implant.

Often contraceptives can also be offered as a way to manage persistent bleeding on testosterone.  A large study has yet to be done to show if this is fruitful. Some patients appear to improve, while others do not.

Pelvic dysphoria and hypoestrogenized vaginal tissue can cause issues with IUD placement. Asking the patient what support systems they desire (headphones, light sedative) is a way of helping to mitigate dysphoria. In addition, asking the patient what terms they choose to use for their reproductive parts, and honoring those terms when discussing IUD placement during the procedure itself, is important to reducing dysphoria.  

I have seen a few copper IUDs in transmasculine persons, all of whom strongly desired avoidance of any “feminizing hormones” (estrogen and progesterone). One study published recently was a case of three transmasculine persons who were amenorrheic from testosterone and had no new bleeding following copper IUD placement, however I would caution against the utilization of this method in someone who is not already amenorrheic on testosterone due to the theoretical risk for persistent irregular bleeding with this method which is often dysphoric for this patient population.

If you will be caring for transgender and gender expansive patients, I recommend referring to the UCSF Transgender Center for Excellence website which has the latest protocols with terminology that is in line with the community’s most contemporary standards.


Further Reading

Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco
Cipres, D., Seidman, D., Clongier, C., Nova, C., O'Shea, A., & Obedin-Maliver, J.
https://www.ncbi.nlm.nih.gov/pubmed/27621044

Terminology and definitions

University of California, San Francisco
http://transhealth.ucsf.edu/trans?page=guidelines-terminology

Transgender men who experienced pregnancy after female-to-male gender transitioning

Light, A., Obedin-Maliver, J., Sevelius, J., & Kerns, J.
https://www.ncbi.nlm.nih.gov/pubmed/25415163

Use of Copper Intrauterine Device in Transgender Male Adolescents
Bentsianov, S., Gordon, L., Goldman, A., Jacobs, A., & Steever, J.
http://www.contraceptionjournal.org/article/S0010-7824(18)30072-6/fulltext


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