Trans and nonbinary people who are taking gender-affirming hormone therapy may think that they no longer need birth control. But hormone therapy alone will not protect trans and nonbinary people from pregnancy.
Periods stop for most trans men and nonbinary people who were AFAB (assigned female at birth) after taking testosterone for a few months (1), but ovulation (release of an egg from the ovary) may still occur—even if they never have a period (2,3).
For trans women and nonbinary people who were AMAB (assigned male at birth) and are taking estrogen, the development of sperm in the testicles can still occur (1). Gender-affirming hormone therapy does generally decrease fertility, but it can not be relied upon as a form of contraception.
Regardless of gender identity, if two people are having unprotected penis-in-vagina sex, pregnancy can occur. Unplanned pregnancies do happen.
What about trans and nonbinary people who are not taking hormones?
The same holds true for trans and nonbinary people who are not undergoing gender-affirming hormone therapy. All that matters (in terms of pregnancy potential) are the body parts of a person and their partner, not gender identity. If someone is having sex where the potential for egg and sperm to meet exists, and they don’t want pregnancy to happen, then some form of contraception is recommended.
The best birth control methods for people on hormone therapy
No single method is best. Whatever someone is comfortable using is most important. According to expert opinion from the American College of Obstetricians and Gynecologists (ACOG), trans and nonbinary people who were AFAB can choose any method of contraception available to cisgender women—even if they are taking testosterone (4). They should discuss their options with a healthcare provider because there may be some methods that are not safe for them due to underlying health conditions, but not because of their gender identity.
Does hormone therapy affect fertility in the long term?
Gender affirming hormone therapy may affect long-term fertility. More research is needed, but some trans men and nonbinary AFAB people on testosterone who stop ovulating, and trans women and nonbinary AMAB people on estrogen who stop producing sperm, may not resume these functions after going off hormones (2). Others may be fertile again 3–6 months after stopping hormone therapy.
Discussing potential methods of fertility preservation is recommended before starting hormone therapy if biological children are desired in the future (1,5). Fertility preservation may include freezing eggs, embryos (from fertilized eggs), or ovarian tissue in AFAB people and freezing sperm or testicular tissue in AMAB people (6). Unfortunately in many countries these preservation techniques are expensive and/or not covered by health insurance, making them inaccessible for many people. Plans for future fertility should also be discussed before having certain gender affirming surgeries, such as removal of the uterus and/or ovaries in AFAB people or removal of the testicles in AMAB people, since these surgeries are permanent.
Can trans women use the birth control pill as a form of hormone therapy?
Trans women should know that birth control such as the pill should not be used as gender-affirming hormone therapy. The estrogen found in birth control is a different form and dose than what is prescribed to trans women (1,5). Trans women typically also use an anti-androgen, which blocks the effects of testosterone on the body (1,5). Trans women will have the safest and best results when they are prescribed the correct type and dose of estrogen and anti-androgen by a healthcare provider.
How to find a trans-friendly healthcare provider
It’s not always easy to find respectful, quality health care. About 30% of transgender people have delayed or avoided seeking needed health care due to perceived discrimination (7), and about 15% of transgender people report that they have been refused care because of their gender identity (8). Asking for a referral from a healthcare provider who has been helpful and supportive in the past, trusted friends or loved ones, or from local support or advocacy groups might be helpful. The World Professional Association for Transgender Health (WPATH) also keeps a directory of providers on their website.
What else should trans and nonbinary people know about birth control?
Trans men and nonbinary AFAB people (whether they are taking testosterone or not) may use some forms of birth control to stop or manage their periods (4,9).
Being protected from pregnancy may make sex more fun or satisfying by removing the stress and anxiety of an unplanned pregnancy. It’s important to remember that hormonal birth control and copper IUDs don’t protect against STIs (sexually transmitted infections). To prevent STI transmission use a barrier method like condoms or dental dams.