Contraception 95 (2017) 186 – 189

Original research article

Contraceptive use and pregnancy intentions among transgender men

presenting to a clinic for sex workers and their families in San Francisco☆
Danielle Cipres a , Dominika Seidman b,⁎, Charles Cloniger III c, d, e
, Cyd Nova e ,
Anita O'Shea e , Juno Obedin-Maliver b, f
a
University of California, San Francisco, School of Medicine, 513 Parnassus Avenue, San Francisco, CA, USA, 94143-0410
b
Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, USA, 94158
c
University of California, San Francisco, Department of Social and Behavioral Sciences, 3333 California Street, San Francisco, CA, USA, 94118
d
San Francisco Department of Public Health, Population Health Division, 25 Van Ness Avenue, Suite 500, San Francisco, CA, USA, 94102
e
St. James Infirmary, 234 Eddy Street, San Francisco, CA, USA, 94102
f
Department of Medicine, Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, 4150 Clement Street, Building 18, Room
111A1, San Francisco, CA, USA, 94121
Received 16 March 2016; revised 25 August 2016; accepted 4 September 2016

Abstract

Purpose: Although many transgender men may be able to conceive, their reproductive health needs are understudied.
Methods: We retrospectively reviewed charts of transgender men presenting to a clinic for sex workers to describe the proportion at risk for
pregnancy, pregnancy intentions, and contraceptive use.
Results: Of 26 transgender men identified, half were at risk for pregnancy. Most desired to avoid pregnancy but used only condoms or no
contraception. Two individuals desired pregnancy, were taking testosterone (a teratogen), and not using contraception.
Conclusion: Further research is needed to explore how to best provide family planning services including preconception and contraception
care to transgender men.
© 2017 Elsevier Inc. All rights reserved.

Keywords: Transgender; Female-to-male; Contraception; Testosterone; Family planning; Reproductive health

1. Introduction testosterone who have not undergone hysterectomy are

The reproductive health needs of transgender men are
understudied, and research to date often focuses on sexually
transmitted infection prevalence and risk factors in this
population [1]. Transgender men are individuals who
identify as male but were assigned female sex at birth, and
may use hormonal therapy (testosterone) and surgery to
affirm their gender identity [2]. While data are limited on
testosterone's effects on fertility, pregnancies and birth
outcomes, reports demonstrate transgender men using
☆
Conflict of Interest: None.
⁎ Corresponding author.
E-mail addresses: Danielle.cipres@ucsf.edu (D. Cipres),
Dominika.seidman@ucsf.edu (D. Seidman), Chuck.sjimedical@yahoo.com
(C. Cloniger), Registration@stjamesinfirmary.org (C. Nova),
Juno.obedin-maliver@ucsf.edu (J. Obedin-Maliver).
http://dx.doi.org/10.1016/j.contraception.2016.09.005
0010-7824/© 2017 Elsevier Inc. All rights reserved.
able to conceive [3,4]. Though unlikely to be representative
of most transgender men due to the population sampled, one
survey reported even after sexual reassignment surgery, 54%
of transgender men desired parenthood, suggesting the
potential need for not only comprehensive contraceptive
services, but also preconception counseling if a transgender
man chooses to carry the pregnancy [5].
No literature describes contraception use in the setting of
pregnancy intentions among transgender men. The purpose
of this study is to report pregnancy desires as well as past and
current contraceptive use among a sample of transgender
men presenting to a clinic for sex workers and their families.
Results of this study are meant to highlight the reproductive
health needs of this population and may form the basis for
future study and interventions to deliver inclusive family
planning care to transgender people.
 D. Cipres et al. / Contraception 95 (2017) 186–189 187

2. Material and methods Table 1

Characteristics of transgender men presenting to St. James Infirmary (n=26).

We conducted a retrospective chart review of transgender N (%)⁎

men presenting to St. James Infirmary, a San Francisco-based Characteristic
clinic for current and former sex workers and their families. We Age, years (median, IQR) 27.5 (24–30.5)
Race/Ethnicity
reviewed records of transgender men younger than 50 years old
White, Non-Hispanic 16 (62)
presenting to the transgender clinic between 2012 and 2015. Black/African American 2 (8)
Clients indicated their gender by choosing female, male, Hispanic/Latino 4 (15)
male-to-female transgender, female-to-male transgender, or Asian 3 (12)
intersex options at presentation. We collected information on Other 1 (4)
Primary language
demographics, obstetric and gynecologic history, and testoster-
English 25 (96)
one and contraception use. Clients responded to the following Spanish 1 (4)
questions regarding pregnancy intentions on intake forms: “Are Household income
you planning to get pregnant in the next 2 years?” We b $21,660 24 (92)
categorized “yes” or “maybe” responses as desiring pregnancy. $21,661–$29,140 2 (8)
Housing†
Clients who responded, “No″ were asked, “How important is it
Stable 13 (50)
for you to avoid pregnancy now?” We categorized responses of Unstable/homeless 3 (12)
“very” or “somewhat important” as desiring to avoid pregnancy. Not reported 10 (38)
Descriptive statistics report the proportion of people “at-risk” Any history of violence ‡ 9 (35)
for pregnancy, those desiring pregnancy avoidance, and those Sexual history
Sex work
using contraception. We defined subjects as “at-risk” for
Past or current sex work 16 (62)
pregnancy if they had not had a hysterectomy and reported Denies past or current sex work 2 (8)
receptive vaginal intercourse with a cisgender man — an Not reported 8 (31)
individual who identifies as male and was assigned male sex at Any receptive vaginal sex in the past 12 months 17 (65)
birth — or transgender woman — an individual who identifies Partner is cisgender man or transgender woman § 16 (62)
History of sexually transmitted infection 13 (50)
as female but was assigned male sex at birth.
Reproductive health
Prior hysterectomy 2 (8)
History of pregnancy ¶ 2 (8)
3. Results Pap smear in past 5 years 18 (69)
Amenorrheic 10 (38)
Current testosterone use 13 (50)
Twenty-six transgender men presented to St. James
Past birth control methods
during the study period and 16/26 (61%) subjects reported None 6 (23)
current or past sex work. Thirteen of 26 (50%) were currently Condoms 15 (58)
using testosterone, of whom 69% (9/13) were amenorrheic. Same sex partner # 7 (27)
While 15 (58%) of 26 had used condoms in the past, 42% Emergency contraception 6 (23)
Oral contraceptive pills 5 (19)
(11/26) reported no current contraceptive method (Table 1).
Diaphragm 1 (4)
Half of the sample had a uterus and reported receptive Intrauterine device 1 (4)
vaginal sex with a cisgender man or transgender woman in the Partner vasectomy 1 (4)
prior year, making them “at risk” for pregnancy (Table 2). Two Current birth control methods
of these 13 individuals desired pregnancy (15%), both of whom None 11 (42)
Condoms 10 (38)
were taking testosterone and not using contraception.
Always use condoms⁎⁎ 7 (70)
Of the 13 transgender men “at-risk,” 11 (85%) wanted to Same sex partner 5 (19)
avoid pregnancy. Among these individuals, 36% (4/11) used Partner vasectomy 1 (4)
testosterone, of whom 75% (3/4) were amenorrheic. The 11 ⁎ Some proportions do not add up to 100% due to missing data or
transgender men “at risk” for pregnancy who wanted to avoid potential for multiple concurrent answers.
†
pregnancy reported condoms more than any other contraceptive Housing categories based on definition used by the Department of Health
method (63%). Of these seven condom users, 71% (5/7) and Human Services which defines homelessness as unstable housing, living on
affirmed consistent use. Of the 27% (3/11) subjects not using the streets (n=2), hotel/single room occupancy (n=1), or shelter (n=0). Stable
housing refers to owning/renting a house/apartment (n=13).
contraception despite desiring pregnancy avoidance, 67% (2/3) ‡
Any form of violence, threats, or forced sex by intimate partner,
were using testosterone, one of whom (50%) was amenorrheic. commercial partner, or other persons during their lifetime.
§
Response to question “In the last 12 months, have you had sex with
(check all that apply): Men, Women, TransMen, TransWomen, Intersex”.
¶
4. Discussion Refers to an individual having had one or more prior pregnancies.
#
Intake questions did not specify the gender identification or assigned
sex of same sex partners.
These data demonstrate half of transgender men presenting to ⁎⁎ Self-reported use pattern on 3-point scale in response to “How often
St. James Infirmary are “at-risk” for pregnancy and have varied do you use condoms?”
188 D. Cipres et al. / Contraception 95 (2017) 186–189

Table 2
Characteristics of transgender men “at-risk” for pregnancy (n=13).
Total (N=13) Desire pregnancy (n=2) Desire pregnancy prevention (n=11)
N (%)⁎ n (%)⁎ n (%)⁎
Demographic characteristic
Age, years (median, IQR) 29 (26–31) 38 (32–44) 28 (24–30)
Any history of violence ‡ 6 (46) 1 (50) 5 (45)
Sex work
Past or current sex work 10 (77) 1 (50) 9 (82)
Never reported sex work to medical provider 1 (10) 0 (0) 1 (11)
Denies history of sex work 1 (8) 0 (0) 1 (9)
Not reported 2 (15) 1 (50) 1 (9)
Reproductive health
History of pregnancy ¶ 2 (15) 0 (0) 2 (18)
Current testosterone use 6 (46) 2 (100) 4 (36)
Amenorrheic 5 (38) 2 (100) 3 (27)
Current birth control methods
No method 5 (38) 2 (100) 3 (27)
Condoms 8 (62) 0 (0) 8 (73)
Always use condoms⁎⁎ 5 (63) 0 (0) 5 (63)
Partner vasectomy 1 (8) 0 (0) 1 (9)
⁎ Some proportions do not add up to 100% due to missing respondent data.
‡
Any form of violence, threats, or forced sex by intimate partner, commercial partner, or other persons during their lifetime.
¶
Refers to an individual having had one or more prior pregnancies.
⁎⁎ Self-reported use pattern on 3-point scale in response to “How often do you use condoms?”

reproductive intentions. Despite the majority desiring to avoid
pregnancy, few used highly effective contraception, and many
used no method, suggesting an unmet contraceptive need.
Beyond the many healthcare barriers faced by transgender
men [6], possible reasons for not using contraception include
stigma around attending family planning clinics, discomfort
with taking “female” hormones that could undermine gender
identity, misinformation that testosterone prevents pregnan-
cy, and healthcare providers' hesitancy to discuss reproduc-
tive intentions with transgender men [7].
Testosterone use without contraception is concerning given
teratogenicity. In a cross-sectional survey of transgender men who
experienced pregnancy after gender transition, 12% reported
pregnancies occurred in the setting of testosterone-induced
amenorrhea and 24% of pregnancies among testosterone users
were unplanned [3]. Consistent with our results, this prior study also
found a similar reliance on condoms or no method of contraception
[3]. While many transgender men experience amenorrhea with
prolonged testosterone use, healthcare providers should counsel that
testosterone is not an effective contraceptive [8].
Limitations of this study include a small sample size from a
single clinic. The individuals studied — current and former sex
workers and their families — have unique family planning
needs, limiting generalizability. Second, all data are
self-reported. While social desirability and recall bias are
inherent in self-reported behaviors, we expect data collection in
a transgender clinic may support patient candor. Third, clinic
intake questions did not differentiate between contraception use
with commercial and non-commercial partners, and did not
elicit details of timing and route of testosterone use. Moreover,
intake questions may not capture variability and nuances of
pregnancy intentions and gender identity.
Strengths include a description of contraceptive use in
light of pregnancy desires in an under-studied population
with multiple barriers to healthcare access [6]. Rather than
making a prescriptive recommendation for contraception in
transgender men, we highlight the importance of addressing
contraceptive needs in the context of pregnancy desires. As
in prior studies, the narrow racial and socioeconomic
diversity of the study sample emphasizes the need to
elucidate how race, class, socioeconomic status, culture,
and political environment may impact pregnancy desires and
contraceptive use among transgender men.
Further study is needed to explore reasons for the mismatch
between pregnancy intentions and contraceptive use in
transgender men. As family planning services expand to
include cisgender men, we need to ensure clinics are also
welcoming to gender minorities. Provider training is needed to
equip clinicians to care for transgender individuals, sensitively
addressing gender, sex, contraceptive needs, and fertility
desires [9,10]. Furthermore, investigation of testosterone's
effect on conception, pregnancy, birth outcomes, and
interactions with contraception is needed to provide compre-
hensive and evidence-based family planning care. Finally,
qualitative research is imperative to understanding transgender
men's experiences with the health care system and preferences
around reproductive care, facilitating interventions to best
address their reproductive health care needs.
Acknowledgements
The authors want to express their gratitude to the St.
James Infirmary for their partnership in this study.
 D. Cipres et al. / Contraception 95 (2017) 186–189
DC received support from the UCSF PROF-PATH
program, National Institute on Minority Health and Health
Disparities (R25MD006832).
This study was CHR exempt and approved by the St.
James Infirmary advisory board.
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