What do I need to know about HRT and birth control?

Birds do it, bees do it, lots of trans and non-binary folks definitely do it. So, let’s do it, let’s …

… have safe, consensual, mutually pleasurable sex, ideally without getting anyone pregnant (unless pregnant is a thing you want to be). 

Contraception is a critical sexual health issue, one that can be particularly fraught for trans and non-binary folks, especially those on gender-affirming hormones, sometimes called hormone replacement therapy (HRT). While not all gender nonconforming people opt for for hormones, those who do have some factors particular to their lifestyle and experiences to consider when it comes to birth control and their reproductive health. 

Given the incredible importance of sexual and reproductive health—and the numerous ways our right to control what happens to our own bodies is being stripped away from us—here are a few things trans and non-binary people should know about about birth control, their fertility and HRT. 

First thing’s first: check your sources

Trans and non-binary folk often lack reliable information about their sexual and reproductive health, a problem that stems from an absence of research and cis-heteronomrative biases in medicine, says A.J. Lowik, Gender Equity Advisor with the Centre for Gender and Sexual Health Equity at the University of British Columbia. Lowik is also a trans scholar who studies trans and non-binary people’s reproductive health and experiences, with a focus on abortion.

Unless you’ve intentionally sought out a doctor who has experience in trans healthcare, says Lowik, “you should expect that you as a patient would probably know more than your doctor (about your own reproductive health), having collected that information from peers and community-produced resources.”

Reality check: who can—and can’t—get pregnant?

Regardless of all the hand-wringing and poorly written op-eds about inclusive language and the “erasure of women,” the group of people who can get pregnant includes cis women, trans men and AFAB non-binary folks, including those taking testosterone. This is true even if HRT has caused you to stop getting your period. 

What about trans women and AMAB non-binary people who are taking gender-affirming hormones and haven’t had bottom surgery? Can they get a partner pregnant?

The answer, says Lowik, is “technically, yes,” in the same way that “technically” you could get pregnant while using an IUD—it’s theoretically possible, but the likelihood is low for people who have been taking hormones long-term. This is because feminizing hormone therapy negatively impacts sperm health, production and mobility, severely impairing fertility.

Lowik notes that there has been very little research into the effects of gender-affirming hormones on transfeminine people’s fertility. For this reason, it’s still unclear how long a person needs to be on hormones before their fertility is affected, or how various treatments (estrogen alone versus estrogen and spiro taken together, for example) begin to impact sperm viability. 

Science is sexy: what’s up with birth control and HRT?

Trans men and AFAB non-binary folks, repeat after me: testosterone is not birth control. If you have penetrative sex with people who can produce viable sperm, you still need to use contraception. 

“I think there’s a prevalent misunderstanding about testosterone that when you’ve reached menstrual suppression, you’ve additionally achieved ovulation suppression, and so people either assume—or have been counselled by other trans folks or by their healthcare providers— that testosterone is an effective contraceptive … but that is not the case,” Lowik says. “There are many people who report getting pregnant while on testosterone.”

Lowik says no form of birth control is “contraindicated” with testosterone use—it’s safe to use any kind of proven contraceptive you would choose if you weren’t on hormones. 

“Some folks prefer something like an IUD, even though the insertion process might be triggering or upsetting or uncomfortable—once it’s inserted, then you can kind of forget about it,” says Lowik. “Whereas other folks might prefer something that they’re in more control of, like an oral contraceptives that they take daily.”

Although hormonal birth controls contain estrogen, taking them in combination with testosterone “is not bad for you,” Lowik says, nor does it increase the risk of side effects. Testosterone and hormonal IUDs in particular are known to be “quite compatible with one another.” 

But do the two hormones interact with each other, potentially reducing the effectiveness of either?

“To my knowledge, there’s no such effect,” Lowik says. “They simply exist simultaneously. Again, we’re lacking long-term large sample studies, but the anecdotal evidence and a little bit of peer-reviewed evidence that we have seems to suggest they don’t negatively interact with one another.” 

While no one form of birth control is medically preferable, patients may choose their preferred methods based on other factors including ease of use, cost or the amount of discomfort or gender dysphoria a given method might cause. 

Transmasc people might not want to use hormonal birth control, Lowik notes, because it can cause “a sense of incongruence or distress with taking something that’s quintessentially tied to cisgender women’s experiences,” like estrogen-based oral birth control. For these folks, good old-fashioned condoms or a copper IUD might be better options.

What happens if I accidentally get pregnant? 

Getting pregnant as a trans man or non-binary person on testosterone is, as we’ve mentioned, totally possible—but there can be some caveats to consider if you do find yourself pregnant while taking HRT. 

Testosterone is a known teratogen, meaning it can cause abnormalities in the fetus during gestation; in this case, it can effectively “masculinize” a developing fetus, a process called “virilization.” The longer the fetus is exposed to heightened levels of testosterone, the more likely it is to be affected. This is particularly important, since if you’re on hormones, you might not be getting your period to begin with, and so “knowing you’re pregnant might not be so simple,” says Lowik. This may mean trans folks realize they’re pregnant later than their cis peers, potentially complicating abortion and/or pregnancy care.  

Due to these risks, if you decide you want to carry the pregnancy to term, Lowik says it’s medically recommended that you stop taking testosterone immediately. If you don’t or can’t stop taking testosterone, or the pregnancy has gone unnoticed for a significant length of time while you’ve been on hormone therapy, it’s recommended that the pregnancy be terminated. 

Something to think about: what if I want a baby?

Trans and non-binary folk haven’t traditionally been given a lot of information about how HRT might impact their present and future fertility, says Lowik, which can lead to a lot of confusion (and possibly disappointment). 

As noted, it’s possible for transmasc people to get pregnant even while on HRT, but if you’re trying to conceive, it’s recommended you stop taking your hormones. Although there isn’t a lot of research on pregnancy and fertility for trans people in general, HRT doesn’t seem to impact long-term fertility in AFAB folk who choose to go off it. 

This is not always so for trans women, as HRT can irrevocably damage fertility for transfemme people, even if they stop taking hormones. As such, should they be able to afford it, transfeminine people might want to consider preserving sperm samples prior to starting HRT if they want to be sure of their option to becoming biological parents later on. That said, there are still a lot of unknowns; a recent study indicates it might be possible for some trans women to regain their fertility after stopping HRT.  

As so little is known about fertility after stopping hormone therapy, trans women who choose to go off hormones should be aware it’s not entirely impossible to get someone else pregnant (see: the key plot point in Torrey Peter’s novel, Detransition, Baby).

What if i want an abortion?

This is a really big question, especially at a moment when abortion rights are under attack. In the U.S., the situation is currently volatile, particularly for trans people, who are concurrently dealing with anti-trans care bills and high levels of medical discrimination. 

Given the noted potential impact of testosterone on the health and development of a fetus, and the fact that trans people usually notice pregnancies later than their cis counterparts, the overturning of Roe v. Wade creates some truly difficult—and almost certainly perilous—situations for trans people who find themselves pregnant in America.

Lowik says they don’t yet know what the exact consequences of Roe’s repeal will be on trans abortion seekers, except to say that it “adds to the already quite complex landscape of all of the factors that go into either deciding or having to terminate a pregnancy.”

In Canada, however, the process of going about getting an abortion for a trans person is similar to that of a cis person. You can search online for providers, or speak to your doctor—preferably finding a clinic close to where you live that has a history of providing inclusive care, as there are some trans-specific needs to consider. 

“We’ll try to find a place that has hints of inclusive language markers on their website, as a kind of cue that maybe the folks working there have had some trans cultural competence or gender-affirming care training,” says Lowik. 

“And then it’s a matter of being asked the date of one’s last menstrual period … if you are a person who is on testosterone, your last menstrual period becomes a really imprecise marker of how far along you might be in that pregnancy.”

In this case, you may need to use alternative methods of telling how far along you are in the pregnancy, such as an ultrasound or blood test. 

How late you can have an abortion in Canada varies from province to province, and can be anywhere from 12 weeks, as is the case in Prince Edward Island, up to a maximum of 23 weeks and six days  in certain places, at specialized facilities.

If you are within the gestational window of your particular provider, you’ll be offered either a medication abortion, (such as a combination of mifepristone and misoprostol, commonly referred to as Mifegymiso), or a surgical abortion, which is a relatively quick procedure, depending on how far into a pregnancy you are. 

Both of these options will effectively end the pregnancy, Lowik explains.

“And then if you want it, there’s the opportunity of kind of after-care counselling where folks have the opportunity to get support if they need it,” they add.