The scenario:
A young man comes to your emergency department in the early morning. He is seeking HIV post-exposure prophylaxis (PEP) following unprotected sex with a male partner the night before. During intake, he discloses that he is transgender and was assigned female at birth (AFAB). He is amenorrheic (doesn’t have a period) as a result of testosterone use for gender-affirming hormone therapy. At your facility, cisgender women seeking PEP are also offered emergency contraception (EC).
Is EC indicated for this transgender male patient?
All patients, including transgender or gender nonbinary (TGNB) patients, who have the capacity to become pregnant should be offered emergency contraception if they desire pregnancy prevention, present within 5 days (120 hours) of condomless receptive penile-vaginal intercourse, and are not using a reliable method of contraception. While testosterone may stop menstruation, it is not a substitute for contraception. A person taking testosterone may still ovulate and be able to get pregnant. Research is limited, but unintended pregnancies in amenorrheic patients using testosterone have been documented.
Finding out if a TGNB patient has sex that puts them at risk for pregnancy requires a thorough trans-inclusive sexual health history. Key questions to determine a patient’s pregnancy risk include:
- Does the patient’s sexual partner(s) make sperm? If this patient’s male partner is cisgender (a person who identifies with the sex that they were assigned at birth), EC should be offered. However, if this patient's male partner is transgender (a person who identifies as a gender or sex other than that which they were assigned at birth), this patient doesn’t need EC.
- What kind of sex does the patient have with this partner? A transgender man who has receptive penile-vaginal (PV) intercourse may need EC. If this patient only has receptive anal sex, EC might not be indicated but sex can be messy and anytime sperm get on the vulva, or in the vagina, pregnancy is possible. Talk to your patients about their risk and when in doubt, offer EC. (Please note that some TGNB patients prefer “front opening” or “front hole” instead of vaginal opening or vagina; be sure to use patients’ preferred terms for their body parts when discussing types of sexual activity.)
- Has the patient had any gender-affirming surgical procedures? A patient who has had a hysterectomy and/or bilateral oophorectomy is not at risk for pregnancy and doesn’t need EC.
During your sexual health history, the patient in this scenario shares that he had condomless receptive PV intercourse with a cisgender male partner (who makes sperm) last night and has not had any gender-affirming surgeries. He does not use any other contraceptive methods.
With this additional information, the patient in this scenario should be offered EC.
Counseling TGNB patients on EC method
TGNB patients can use all methods of EC available in the US: levonorgestrel (Plan B), Ulipristal acetate (ella), and the copper IUD (Paragard). As with all patients, regardless of gender identity, the patient’s body weight and time since PV intercourse can impact the effectiveness of EC pills. When counseling a TGNB patient regarding EC selection, also consider:
Drug-drug interactions with testosterone
Some TGNB patients may be concerned that testosterone will decrease the efficacy of EC, or that taking EC will decrease their testosterone levels. You can reassure patients that testosterone will not reduce the efficacy of either of the EC pills or the copper IUD. TGNB patients can also be reassured that ulipristal acetate (ella) and over the counter, levonorgestrel EC (Plan B One-Step and generics such as Take Action or AfterPill), despite being a progestin, will not have “feminizing” effects.
Gender dysphoria and IUD placement
A copper IUD is the most effective method of EC, but placement can be stress-inducing for any patient and this stress may be further heightened for a TGNB patient. For some TGNB patients, a pelvic procedure such as IUD insertion may exacerbate feelings of gender dysphoria. A TGNB patient electing to use a copper IUD as EC may be offered pre-procedure anxiolytic and/or local analgesia (i.e. cervical block).
Bleeding after EC use
TGNB patients, even those who are amenorrheic, may experience irregular bleeding and cramping following use of LNG or UPA EC, or after insertion of a copper IUD. This experience may trigger or worsen feelings of gender dysphoria. Provide anticipatory guidance that this may occur, and counsel to use NSAIDs to reduce bleeding and cramping.
Barriers to access the most effective EC
Even before the IUD insertion itself, TGNB patients may face additional barriers in finding a clinic or provider to perform the procedure. Some “women’s health” clinics are unwelcoming to TGNB patients and unfamiliar with their needs. Establishing connections with local trans-affirming providers who perform IUD insertions will improve your patients’ experiences in a time-sensitive situation.
Picking up a prescription
TGNB patients may encounter challenges in picking up their EC pills at their local pharmacy. Pharmacists or pharmacy techs may question a prescription for EC for a patient listed as “male” on their insurance or ID, or for someone who presents as male. Including “prescription appropriate for patient’s sex” in the pharmacy note when prescribing EC may avert this problem. While there are no requirements for sex (or age) to purchase levonorgestrel EC over the counter in the US, that isn’t the on the ground reality for many. So, make sure patients know how to promptly contact you if the pharmacist refuse to fill their prescription or provide over-the-counter EC.
To avoid the pharmacy altogether or get EC for future use, there are some trusted online sources for getting EC—the only downside is that most don’t offer overnight shipping so it’s not a great option if you need it right away.
How to confirm EC worked
TGNB people who don’t get periods won’t be able to rely on the occurrence of their next period to confirm that their EC was effective in preventing pregnancy. So, recommend patients take a pregnancy test 14 days after EC use. If patients have additional condomless PV intercourse during that time, they can take an additional dose of EC (including the same type that they took the first time) and repeat a pregnancy test 14 days after each does of EC.
Testosterone is a potent teratogen
A TGNB patient using testosterone who finds that their EC has failed should be counseled to stop testosterone while they consider pregnancy options. TGNB people often experience challenges in addition to those facing all people seeking abortion. Patients seeking abortion services can use Bedsider’s easy-to-use search tool connected to a comprehensive, nationwide database of abortion providers to find a provider near them at AbortionFinder.org.
Bottom line
Any patient who has the capacity to become pregnant, who has had receptive penile-vaginal intercourse within the past 120 hours, is not using another form of contraception, and is seeking pregnancy prevention is a candidate for emergency contraception. All methods of EC available in the US may be used by TGNB patients, and do not have reduced efficacy when used in conjunction with testosterone. When assisting a patient in selecting an EC method, in addition to factoring in body weight and time since PV intercourse, also consider a patient’s potential desire to avoid use of a progestin and/or the invasiveness of IUD insertion. Provide anticipatory guidance regarding possible bleeding and cramping following any type of EC use, and advise amenorrheic patients to take a pregnancy test 14 days following EC use. Finally, any TGNB patient seeking EC should be offered other birth control methods for ongoing pregnancy prevention.
This provider guide from the American Society of Emergency Contraception (ASEC) has everything you need to know about EC for TGNB patients—click below to check it out, bookmark it, and print it out for quick reference.
