Clinical scenario: Emergency contraception (EC) for transgender or gender nonbinary (TGNB) patients

Is EC indicated for transgender male patients?

All patients, including TGNB patients, who have the capacity to become pregnant should be offered EC if they desire pregnancy prevention, present within five days (120 hours) of condomless receptive penile-vaginal (PV) 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 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 the term “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 does not need EC.

In this scenario, while taking a sexual health history, the patient 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. Should this patient be offered EC?

Given this additional information, this patient should be offered EC.

What are key counseling points for TGNB patients regarding choosing a method of EC?

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:

Are there any drug-drug interactions with testosterone and EC?

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 type of EC pills or of 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.

How can gender dysphoria impact IUD placements?

A copper IUD is the most effective method of EC but placement can be stress-inducing for any patient; 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).

How should you counsel patients about potential 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.

What barriers do TGNB patients face in accessing 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.

What do TGNB patients need to know about picking up an EC prescription at the pharmacy?

TGNB patients may encounter challenges 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 reality on the ground for many. So, make sure patients know how to promptly contact you if the pharmacist refuses to fill their prescription or provide over-the-counter EC.

To avoid the pharmacy altogether or to get EC for future use, there are several trusted online sources—the only downside is that most don’t offer overnight shipping so it’s not a great option if a patient needs it right away.

How should you counsel patients who don’t get periods about how to confirm whether EC worked to prevent pregnancy?

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, you can 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 they took the first time) and repeat a pregnancy test 14 days after each does of EC.

If the EC doesn’t work to prevent pregnancy, do patients need to stop testosterone? 

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 beyond those facing all people seeking abortion. Patients seeking abortion services can use AbortionFinder.org, a comprehensive, nationwide database of abortion providers connected to Bedsider.org’s easy to use search tool, to find a provider near them.

Key points

• Emergency contraception (EC) is appropriate for any patient who:
  • Has the capacity to become pregnant
  • Has had receptive PV sex in the past 120 hours
  • Is not using another form of contraception
  • Is seeking pregnancy prevention
• All EC methods available in the US are safe and effective for TGNB patients, including those using testosterone. Testosterone does not decrease the efficacy of EC methods.
• When helping TGNB patients choose an EC method, consider:
  • Time since intercourse
  • Body weight
  • Preference to avoid progestin
  • Comfort with or desire to avoid IUD insertion
• Provide anticipatory guidance about possible side effects like bleeding and cramping.
• Advise amenorrheic patients to take a pregnancy test 14 days after using EC.
• Offer ongoing birth control options to all TGNB patients seeking EC.

This provider guide from the American Society of Emergency Contraception (ASEC) has everything you need to know about EC for TGNB patients—check it out, bookmark it, and print it out for quick reference.