Reproductive Health Care for Trans People

Health care decisions are among the most important and personal decisions a person can make. But it’s hard to make informed decisions if you’re transgender and your medical provider isn’t well versed in gender identities. Many learn through trial by fire; or the burden falls on the patient to teach the medical provider how to best care for them. This lack of access to providers who are sufficiently knowledgeable on the topic is one of the biggest barriers to safe hormonal therapy and general medical care reported by transgender individuals.

Read: 5 Tips for Going to the Gynecologist as a Non-Binary Person

Finding a Health Care Provider

“Transgender treatment is not taught in conventional medical curricula and too few physicians have the requisite knowledge and comfort level,” writes Dr. Joshua D. Safer in his article, Barriers to Health Care for Transgender Individuals. Safer notes that the lack of providers with expertise in transgender medicine represents the single largest component inhibiting access.

“When you visit your healthcare provider, you deserve to be addressed with the correct name and gender and treated with respect and dignity."

Coming out to your gynecologist/general practitioner/family medicine doctor is an important first step. “When you visit your healthcare provider, you deserve to be addressed with the correct name and gender and treated with respect and dignity — both by your physician and by the other staff,” says Dr. Lynae Brayboy, Chief Medical Officer at the period tracking app Clue. “Being open about your sexual orientation, sexual behavior, and gender identity means that your provider will be able to offer care that is personalized and relevant to you.”

If your healthcare provider is not understanding, or you don’t feel comfortable with them, Brayboy says find a new one — there are several ways to find a provider with whom you connect. “To start, ask people you trust for recommendations. Friends, local support organizations, and online forums are all good sources for this information. You might want to ask another healthcare provider with whom you had a good experience.”

Alternatively, the World Professional Association for Transgender Health offers a list of recommended healthcare providers worldwide, and there are many more organizations working at a local level, too.

In the US and Canada, MyTransHealth, RAD Remedy or The Gay and Lesbian Medical Association are excellent resources for transgender and nonbinary people looking for healthcare.If you’re a health care provider and unaware of how to treat transgender patients, the Association of American Medical Colleges (AAMC) released guidelines in 2014 on training physicians to treat LGBT patients.

If you’re nervous about your first appointment, many online articles share insight into what you can expect during your first OB/GYN appointment.

In addition to limited medical training (not to mention the potential bias a transgender person may face during an initial patient visit), there are significant blind spots when it comes to transgender reproductive health. “Currently, there is very little research data to inform trans people of their reproductive care and contraceptive choices, and very few health care professionals with clinical expertise in transgender reproductive care, which also includes pregnancy, fertility, and sexual function,” says Brayboy.

"Currently, there is very little research data to inform trans people of their reproductive care and contraceptive choices."

Now, Brayboy thinks 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 in 2020) concludes that further studies are needed,” says Brayboy. “It would be fantastic to see these studies being carried out, especially as they are vital to the advancement of proper reproductive health for trans people all over the world.”

Read: Sexual Health: Why It May Not Mean What You Think It Does (and That's a Good Thing!)

Testosterone Therapy and Birth Control

For trans men, gender-affirming testosterone therapy is meant to produce desired, masculine characteristics such as a deeper voice or facial hair. Brayboy notes that one side effect of testosterone therapy, which is also sometimes considered a desirable outcome for trans men, is amenorrhea, or the absence of spontaneous periods.

However, Brayboy stresses an important detail—testosterone is not a contraceptive and people can become pregnant despite not having a period. “This means that reliable contraception is still very important for transgender men, even when taking testosterone—although it is sometimes a health issue which can be overlooked,” she says.

There is no clinical consensus on what the most appropriate contraceptive option is when it comes to the transition process. “It has been reported that no contraceptives are contraindicated, or unadvisable to use, for trans men,” says Brayboy. A very commonly prescribed method is the oral contraceptive pill. “Both components of the oral contraceptive pill (a synthetic estrogen called ethinyl estradiol and a synthetic progesterone called progestin) work independently to impede the production and effect of androgens (hormones associated with male characteristics, like testosterone and androstenedione) that are made naturally by the ovaries and adrenal glands. Therefore, there is a possibility combined oral birth control pills could negate the desired gender-affirming therapy for people assigned a female at birth who are now transitioning to male.”

Brayboy says there isn’t enough data to really know with certainty whether this is the case. “This is why we need further clinical research, and better enrollment of trans men in contraceptive studies in general: so we have more data.”For example, one method of contraception that transgender men could consider could be progestin only methods, say Brayboy, as these have a singular impact on testosterone production (rather than the dual one that the combined pill has). She says they could also consider a hormonal intrauterine device (IUD): the progestin-only IUD (which uses the synthetic hormone levonorgestrel) has the benefit of at least 20% of users having amenorrhea.

Read: We Asked An Expert: Which Birth Control is Best?“With the hormonal IUD, the hormone does circulate in the blood, but it has been reported to have a localized effect only in the uterus,” says Brayboy. “Finally, the etonogestrel progestin implant is the most effective form of birth control and many individuals experience infrequent bleeding or amenorrhea, but of course this implant, like the IUD, needs to be placed by a trained healthcare professional. Keep in mind that everyone is different so your bleeding profile could vary.”

According to The Endocrine Society clinical practice guidelines, gender affirming hormone therapy has the same risk as sex hormone replacement in the non-transgender populations. “This means that taking hormones as a trans person is the same as a cis-gender person taking hormone replacement,” says Brayboy.

However, Brayboy notes there are some possible issues that can arise when testosterone is overdosed. “These include an overproduction of red blood cells, sleep apnea, high blood pressure, excessive weight gain, salt retention, changes in blood cholesterol, liver disease and excessive or cystic acne. The medical adverse risks as a result of these changes include heart disease, a diagnosis of high blood pressure and breast/uterine cancer,” she says. “Therefore, those who are transitioning are advised by medical professionals – from both major European and American medical societies, as well as the World Professional Association for Transgender Health – to seek out the following kinds of screenings and care when it comes to reproductive care:”

Important Trans Health Care Screenings

1. Prior to transitioning all individuals should be counseled and offered fertility preservation in case the individual would like to become pregnant in the future, according to the American Society for Reproductive Medicine. Clue offers a non-binary Pregnancy Tracker with Clue Plus.

2. It's recommended that in the first year, trans males be evaluated every 3 months for for possible adverse reaction of desired effects (such as deepening of voice, male pattern hair growth and clitoral enlargement); for measurement of testosterone levels; a blood count; weight; blood pressure and lipids will also need to be monitored.

3. If a trans male has a cervix, regular pap smears will need to be done, according to the American College of Obstetricians and Gynecologists.

If top surgery/mastectomy is done then annual chest/areolar examinations, If not, then mammograms, as recommended by the American Cancer Society.

Discuss your reproductive life plan and contraceptive options with your healthcare provider.

Track your bleeding and make sure to discuss any changes with your healthcare provider.

All people - no matter their gender, sex or identity - should be regularly screened for STIs and practice safe sex. More information on STI prevention can be found on the Clue website.

Read: Chemical Romance: How Hormones Affect Sex, Love and Relationships

The Bottom Line

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

We need to demand that the US healthcare system provide affirming, inclusive, and adequate care for transgender individuals. Brayboy urges people to petition governmental representatives and local health officials to fund and approve studies, such as the PRIDE study, and new ones that specifically study both fertility, pregnancy, and contraceptive options for transgender and/or nonbinary individuals. She says we can also direct our attention towards volunteering for trans reproductive justice initiatives, shaping medical education for medical trainees and health care professionals, and our own awareness of the increased violence against Black trans lives. “Transgender health issues are public health issues, and we need everyone’s help to address the reproductive health disparities that exist,” she says.

For more information on hormones, listen to Clue’s podcast, Hormonal, where each week, doctors, experts, and scientists, break it all down.