Pharmaceutical Contraceptive Approaches for 2SLGBTQIA+ Patients

Written by: Alex Hosein (they/them), RPh.

Edited by: Miles Llewellyn (they/them).

Hormonal contraceptives, commonly known as birth control, can be used by many individuals with varying needs and desires. Unfortunately, it can be difficult to find 2SLGBTQIA+ competent prescribers to assess and inform patients appropriately about these types of medications.

Although gender affirming hormone therapy can decrease fertility, it does not eliminate risk of conception entirely, therefore contraception is an important topic to keep in mind with all patients who are engaging in sexual activities that could result in pregnancy (1,2,3,4). In Canada, there are currently no pharmaceutical contraceptives for people with external reproductive organs; therefore, this article focuses on individuals with internal reproductive organs who can get pregnant, and are currently not wanting to.

Those with a uterus and ovaries (internal reproductive organs) who are on testosterone can still become pregnant if they have receptive frontal sex with a sperm producing partner. Even if monthly bleeding has subsided, ovulation can still occur, thus pregnancy can still be possible (3,4,5). Testosterone, a known teratogen, needs to be discontinued if the pregnancy is to be carried to term (4).

Those with a penis and testicles (external reproductive organs) who are on estrogen and/or an androgen blocker, and are having frontal penetrative sex with someone with internal reproductive organs, can still get them pregnant (2,5).

Two-Spirit, trans, and gender diverse people with internal reproductive organs have all of the same contraceptive options as cisgender women (6). Reversible pharmaceutical options include the pill (both the combined oral contraceptive (COC) or the progesterone only mini-pill (POP)), the ring, the patch, the shot (DMPA), the implant, and an IUD or IUC (intrauterine device/intrauterine contraception) (3,7,9). Emergency contraception is also available, including the over the counter “morning after” or LNG-EC pill, and the prescription medications ulipristal acetate and the copper IUD (5,8,10,11).

The combined oral contraceptive (COC) pill, patch, and vaginal/internal ring contain both an estrogen and a progesterone component. There are many variations of COC containing different types and amounts of progestin and estrogen. DMPA, the progesterone only pill, and hormonal IUCs contain progesterone only. There are some IUD options without any type of hormone, which use copper as the contraceptive. Estrogen and testosterone can be taken concurrently, however, some individuals may prefer to avoid adding estrogen, and the progesterone-only options allow for this. With each option, we should discuss with our patients the mechanism of action, potential adverse drug reactions, immediate and future patient goals and desires, and contraceptive/noncontraceptive effects.

The pill, patch, and ring all have similar mechanisms of action and efficacy rates. During the first year of use, 3 out of 1000 people may become pregnant, but with typical or real-world use, this rises to 90 out of 1000 people (9). The shot, the implant, and the hormonal IUC all contain progesterone only, and all have higher efficacy rates and less chance of user error. The copper IUD is the only contraceptive mentioned that does not contain any hormones (10).

**The statistics referenced monographs or guidelines come from people who are not taking testosterone. The efficacy or failure rates refer to the number of pregnancies that occur over one year**

Tips in Practice

Following this reminder of the different types of pharmaceutical contraceptives, how do we as health care providers best interact with and care for 2SLGBTQIA+ and gender diverse patients? Here are some guidelines for interactions, care, and knowledge translation, with the disclaimer that the culture of language and best practice are (excitingly!) constantly evolving (4,6,12,13). What is written here may not be considered best practice in the future.

Know your patient. Know what they are trying to achieve or avoid. Ask them their concerns, fears, and goals around starting a contraceptive. Be aware of language that helps you provide a supportive, open, and safe environment to promote shared decision making.

Ask your patient what name and pronouns they use (with the realization that this may not align with their health card or insurance). Ask if they have intact internal reproductive organs. Ask if they are sexually active with partner(s) in a way that may result in pregnancy. Many forms of sexual activity do not have the possibility to result in pregnancy, and many do. Be clear in your questions and be prepared to clarify, and hear, what your patient is saying. When referring to body parts such as the penis and vagina, or chest/breasts, ask how they like to refer to these body parts.

Have knowledge surrounding permanent options for contraception – this may or may not overlap with a patients’ desire for gonadectomy and/or genital reconstruction. For people with internal reproductive organs this could include tubal ligation or hysterectomy/salpingectomy/oophorectomy. For people with external reproductive organs, this could include vasectomy or orchiectomy (13).

Talk about barrier methods such as condoms, gloves, and dental dams, as none of the above-mentioned contraceptive methods help prevent against sexually transmitted or blood borne infections (STBBI). Let patients know how different barriers work, which infections are transmitted via blood or bodily fluids, and which are transmitted via skin or mucous membrane contact. Provide information on vaccinations and medications which may help protect against different STBBIs.

Think about side effects of medications – be aware of the non-contraceptive effects that may be beneficial or unwanted. For example: reduced or eliminated bleeding or cramping, increased hair growth, reduced hormone-related acne or migraines, increased chance of unscheduled bleeding, required internal examination, reduced development of uterine fibroids and ovarian cysts or increased breast/chest tenderness (4, 6, 12, 13). Discuss with your patient their preferences around frequency of medication dosing, application or insertion, and visibility of medication, as that will help guide their options.

Know where to access information quickly, and how to be comfortable with saying that you don’t currently have the best available information and will follow-up with them or direct them to a knowledgeable resource. In my opinion, it is truly impossible for one human to have all the knowledge they would like to, so double-checking references is very common. Be aware that at times, patients may be more anxious about obtaining information from someone without the knowledge at their fingertips, especially without having a previous relationship. Reassure them that reviewing up to date evidence is a regular part of prescribing and patient care!

Be aware of community-based resources in your area and recognize the scope and breadth of care, both historically and presently, that these organizations and resources offer.

Lastly, be open to learning. 2SLGBTQIA+ healthcare has changed and evolved vastly and there is still much to be done. Look for educational seminars, workshops, papers, and conferences to help advance your knowledge and competencies. Talk to your peers and colleagues. Ask your licensing body to give more education on this topic and demand it in the curriculum of current learners. Do your best with the information you have, and when you know better, do better.

Sex[M]ed appreciates that many readers may feel that healthcare resources often leave their identities and needs out of the conversation, even when discussing gender diversity. We acknowledge a current gap in representation and resources surrounding the specific sexual health needs of 2 Spirit individuals. As an organization we are reflecting on why we have a lack of 2 Spirit representation in our resources and working to improve this gap through engaging in anti-oppression learnings and creating meaningful partnerships and consultations with 2 Spirit HCPs, researchers, and writers.

Here are a few resources that are helping to inform our learning about 2 Spirit Health created by Indigenous organizations and individuals:

References:

1. Deutsch MB. Overview of masculinizing hormone therapy. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2^nd edition. 2016 Jun 17;49–59. Available from: https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf

2. Deutsch M. Information on Estrogen Hormone Therapy [Internet]. UCSF Transgender Care. 2020 [cited 2022 Feb 13]. Available from: https://transcare.ucsf.edu/article/information-estrogen-hormone-therapy

3. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People [Internet]. The World Professional Association for Transgender Health; 2012. Available from: https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf?_t=1613669341

4. Amato P. Fertility options for transgender persons. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2^nd edition. 2016 Jun 17;100–2. Available from: https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf

5. Harris M, Cleland K. Clinical minute: Emergency Contraception for transgender or gender nonbinary patients [Internet]. Bedside Providers. 2020 [cited 2022 Feb 13]. Available from: https://providers.bedsider.org/articles/clinical-minute-emergency-contraception-for-transgender-or-gender-nonbinary-patients

6. Birth Control Across the Gender Spectrum [Internet]. Reproductive Health Access Project; 2022. Available from: https://www.reproductiveaccess.org/wp-content/uploads/2018/06/bc-across-gender-spectrum.pdf

7. Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, et al. Canadian Contraception Consensus (Part 1 of 4). Journal of Obstetrics and Gynaecology Canada. 2015 Oct 1;37(10):936–8.

8. Emergency Contraception [Internet]. Sex & U. [cited 2022 Feb 13]. Available from: https://www.sexandu.ca/contraception/emergency-contraception/

9. Hormonal Contraception [Internet]. Sex & U. [cited 2022 Feb 13]. Available from: https://www.sexandu.ca/contraception/hormonal-contraception/

10. Contraception Pearls for Practice [Internet]. Dalhousie CPD Academic Detailing Service; 2015. Available from: http://www.medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service.html

11. Boyce TM, Neiterman E. Women in larger bodies’ experiences with contraception: a scoping review. Reproductive Health. 2021 Apr 29;18(1):89.

12. Hastings J. Approach to genderqueer, gender nonconforming, and gender nonbinary people. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2016 Jun 17;69–71. Available from: https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf

13. Nicole J. Todd, MD, FRCSC. At risk of pregnancy? Contraception for transgender, nonbinary, gender-diverse, and Two Spirit patients | British Columbia Medical Journal [Internet]. 2022 [cited 2022 May 30]. Available from: https://bcmj.org/articles/risk-pregnancy-contraception-transgender-nonbinary-gender-diverse-and-two-spirit-patients