How birth control can be part of gender-affirming care for transmasc and gender-nonbinary folks

TW: Language about birth control and pregnancy is often gendered in ways that do not welcome or include transgender and gender-nonbinary (TGNB) people. Some TGNB people may prefer specific language to talk about their bodies and bodily functions, while other TGNB people may find those words triggering. This article will use the term “bleeding” to refer to periods/periods.

Note: This article focuses on the use of birth control for TGNB people with a uterus. For TGNB people whose bodies produce sperm, preventing pregnancy in partners can also be an important part of reducing gender dysphoria. Currently, barrier methods, vasectomy, pulling out, and orchiectomy are the only birth control methods available to people who produce sperm.

People of all gender identities use birth control for many different reasons, including preventing pregnancy and stopping or managing bleeding. For some TGNB people, experiencing pregnancy or bleeding can exacerbate feelings of gender dysphoria. Birth control can help reduce that dysphoria. At the same time, some TGNB people have questions about whether the use of birth control, especially hormonal methods, can interfere with the effects of testosterone or cause changes in femininity. Here are the facts.

Preventing pregnancy can be sex

Not everyone knows that TGNBs can get pregnant while taking testosterone. If being pregnant makes gender dysphoria worse for you, you may want to consider using birth control to prevent pregnancy. Regardless of gender identity or sexual orientation, if you have a body that can get pregnant and you have receptive frontal/vaginal sex with people whose body produces sperm, you can get pregnant. And while testosterone use can stop bleeding, it’s no substitute for birth control.

Can birth control stop or reduce bleeding?

Yes. Birth control can be used by people of all gender identities to stop or reduce bleeding. Because frontal/vaginal bleeding can exacerbate gender dysphoria for some TGNB folks, birth control can be an important part of gender-affirming care. Although there are a variety of different medications and methods that TGNB people can use to stop bleeding, hormonal birth control is often easier to obtain and use than other options. You can also use birth control to stop or reduce bleeding if you don’t want to take testosterone, can’t get testosterone, or are still bleeding while taking testosterone. (If you still bleed while taking testosterone, especially if you’ve been using testosterone for more than six months, contact your health care provider.)

But will it affect my transfer?

TLDR: probably not. Some people in TGNB worry that birth control can cause changes in femininity that don’t fit with their gender identity. There are many different forms of birth control out there, but there are three general types—methods without hormones, methods with only progestin hormones, and methods with a combination of estrogen and progestin hormones. None of these methods are likely to cause feminizing changes or interfere with testosterone.

Non-hormonal method

Copper IUDs, spermicides, diaphragms, internal and external condoms, and sterilization are methods that do not contain any hormones, which means they cannot cause female changes or interact with testosterone. However, the copper IUD can cause heavier bleeding and cramping for some people. We’re not sure if people who don’t bleed while they’re using testosterone are also at risk for increased bleeding or cramping with a copper IUD. These non-hormonal methods cannot be used to stop or reduce bleeding, but they can help you avoid pregnancy.

Progestin-only method

Progestin-only pills, shots, implants, and hormonal IUDs (and over-the-counter emergency contraception pills) contain only the hormone progestin, which does not interact with testosterone. In addition, these methods can be used to stop or reduce bleeding. However, progestin-only methods increase the chances that bleeding will be unpredictable in people not taking testosterone. We don’t know for sure if people who use these methods while taking testosterone have the same chance of irregular bleeding as people who don’t take testosterone. Another thing to keep in mind is that progestin-only methods can cause breast or breast pain which can worsen gender dysphoria for some people.

Estrogen-progestin combination methods

The patch, ring, and combination pill contain a combination of estrogen and progestin. These methods are the most effective at stopping bleeding completely for people who are not taking testosterone. They are less likely to cause the unpredictable bleeding that occurs with progestin-only methods. We don’t yet know if these methods are equally effective in people who also take testosterone. Keep in mind that these methods can also cause chest or breast pain, especially when you start them, but this usually gets better within the first month or two.

The amount of estrogen in combination estrogen-progestin birth control methods is not enough to cause feminizing changes or prevent the masculinizing effects of testosterone for most people. Although some people who have trouble accessing health care may use birth control pills as feminizing hormone therapy, health care providers do not recommend it. That’s because the type of estrogen and progestin used in feminizing hormone therapy are different from the types of hormones used in birth control pills.

A study looking at TGNB people taking combination pills and testosterone did not find increased levels of estrogen in the blood. However, there are several ways that combination methods can interact with testosterone. Combination methods can lower the amount of testosterone produced by the ovaries. For most TGNB people who take testosterone, the amount of testosterone that comes from the ovaries is very small compared to the amount of testosterone taken as sex-affirming hormone therapy. So for most people, it won’t have a noticeable effect on their transition.

Combination methods can also increase a protein in the body called sex hormone binding globulin (SHBG). SHBG binds to some of the testosterone in the bloodstream, so less of it is used by the body’s tissues. It is not known whether the increase in SHBG is sufficient to reduce the effects of testosterone taken as sex-affirming hormone therapy. If you notice a decrease in how well your testosterone works after starting a combination method, talk to your health care provider, and they can adjust your testosterone dose to maintain the same effects.

Bottom line: Birth control can be gender affirming for many TGNB people by preventing pregnancy and stopping bleeding. Neither hormonal nor non-hormonal birth control methods will significantly affect the effects of testosterone or create feminine changes for most people.

It is always up to you to decide what is most important when choosing a birth control method. Check out the Method Explorer or talk to a healthcare provider to find a method that’s right for you.