I once received a patient message asking me to help settle a bet with a friend: could transgender men on testosterone get pregnant? He was confident that the answer was no but wanted me to confirm. I replied (promptly!) to let him know that, yes, transgender men can get pregnant, even on testosterone, and even if they haven’t had a period in years. He messaged me back to let me know he’d taken about six at-home pregnancy tests that day.
His numerous pregnancy tests were negative, but it took him raising the issue and undergoing a great deal of stress before he received contraception counseling. Despite having seen this patient for several visits, I had never taken an adequate sexual health history to assess his pregnancy risk. Taking transgender-inclusive sexual health histories, from the beginning, can help patients get the care they need. You don’t have to be an expert in transgender health to take a transgender-inclusive sexual health history. As with most new skills, it will probably feel clumsy at first, but it will get easier with practice. Here’s what you need to know:
Who needs a transgender-inclusive sexual health history?
Taking a transgender-inclusive sexual health history is important for all of your patients, not just the ones who have disclosed to you that they are transgender and/or gender nonbinary (TGNB). TGNB communities have a long and painful history of mistreatment and abuse by health care providers, and TGNB patients may not feel safe telling you about their gender identities until you have demonstrated some competence in talking about gender. Taking a transgender-inclusive sexual health history is one way to convey this competence. Additionally, any of your cisgender patients may have transgender partners. Your ability to assess whether their partner(s) could get them pregnant (or vice versa) depends on you taking a transgender-inclusive sexual health history.
Beyond “Men, Women, or Both?”
If you received your health care training in the past 10 years, you probably learned to ask about sexual health by inquiring “Do you have sex with men, women, or both?” — that is, if taking a sexual health history was even discussed. However, this question fails both patients and providers. It doesn’t elicit any information about whether the men or women in question are cisgender (people who identify with the sex that they were assigned at birth) or transgender (people who identify as a gender or sex other than that which they were assigned at birth). It tells us nothing about whether those partners are capable of getting pregnant or getting someone else pregnant, nor whether the sex taking place involves penis-in-vagina activities. It also assumes that all possible partners are either men or women, erasing non-binary folks and reinforcing the gender binary. If you’re trying to assess a patient’s need for contraception, the “men-women-or-both” paradigm definitely doesn’t give you enough information to make an accurate assessment.
Evaluating pregnancy risk and desires
The ability of all people to get pregnant or get someone else pregnant depends, in part, on what sexual organs are present. This is typically covered during a medical visit as a part of surgical history. If you wanted to clarify this with a TGNB patient, you could ask “Have you had any gender-affirming surgeries?” A person assigned female at birth (AFAB) who has had a hysterectomy, for example, is not at risk for pregnancy regardless of their sexual activity. A person assigned male at birth (AMAB) who has had an orchiectomy (surgical removal of the testicles) is not at risk for getting a partner pregnant. However, it is essential to keep in mind that gender-affirming hormones are not a substitute for contraception. AFAB people taking testosterone, even if they aren’t having periods, can still get pregnant. AMAB people taking testosterone-blockers and/or estrogen and/or progesterone may still produce viable sperm.
Many TGNB patients have been misinformed (sometimes by a health care provider) about their fertility while using gender-affirming hormones and think that they can’t get pregnant or get someone else pregnant because they are on hormones. This is why I avoid asking “Are you having any kind of sex that could get you (or get your partner) pregnant?” because it requires the patient to assess their own fertility. Patients may feel surprised or skeptical about this information; this Bedsider article is a great educational resource for patients about birth control needs for TGNB people.
In addition, some TGNB patients, including those currently using gender-affirming hormones, may desire a pregnancy. If your patient has the capacity to become pregnant, asking “Would you like to become pregnant in the next year?” helps you and your patient determine their need for birth control, preconception health care, or other services.
Language for taking a transgender-inclusive sexual health history
As with many other best practices in health care, the most effective way to ask your patients about sex is to start with open-ended questions. Keep in mind that TGNB patients are often asked intrusive and unnecessary questions about their bodies and sex lives; while relevant in this setting, telling patients why you’re asking helps to give context. I often say something along the lines of “I talk to all of my patients about sex to help them get the health care they need. Tell me about the genders and bodies of your partners.” Patients may answer in ways that don't provide enough information to assess pregnancy risk; in that case, some follow-up questions are in order. Someone might answer, “I just have sex with women.” To follow up, I might ask “Are any of your partners transgender women?” and then ask for more information about those partners' bodies and kinds of sexual activities as needed. If a patient answers “I have sex with people of all genders,” I might ask “Do any of your partners have bodies that make sperm?” and if, yes, ask whether they’re having penis-in-vagina sex with those partners.
When talking with patients about the genders and bodies of their partners, using gender-affirming language conveys your knowledge about care for TGNB patients. Avoid describing someone as a ‘biological’ or ‘natal’ man, woman, male, or female. Depending on the context, you might use the terms cisgender or transgender (if regarding their identity), or AFAB or AMAB (if discussing the sex they were assigned at birth). When discussing pregnancy or parenting, use gender-neutral language like “parent” or “gestational parent” instead of “mother” or “father.”
When discussing bodies or sexual activity, TGNB patients may prefer words to describe their bodies that differ from the anatomic or medical terms. For example, some people prefer “front opening” or “front hole” instead of vagina or vaginal opening, or “clitoris” instead of “penis.” The only way to know what words your patient would like you to use is to ask. You might ask “Are there any words you would like me to use or to avoid when talking about your body parts with you?”
Taking a transgender-inclusive sexual health history gives you the information you need to accurately assess the sexual and reproductive health needs of all your patients, regardless of their gender identities. It also makes your practice a safer space for TGNB patients. Don’t wait for a patient to experience an unintended pregnancy (or lose a bet with their friend) before incorporating this into your routine practice.