By Melinda Young
The United States has about 300,000 transgender youth, and the population of young people identifying as transgender is on the rise. These young people are sexually active, and some will become pregnant. Like cisgender adolescents, they may need contraception. Research suggests transgender adolescents’ pregnancy rate is equivalent to age-matched general populations.1
The challenge for reproductive healthcare providers is meeting this patient population’s needs in a way that reduces their gender-related distress. “Our key purpose here is that we see that trans and nonbinary young people are sexually active in the same way as cisgender adolescents, and some of them do get pregnant or cause pregnancies,” says Elizabeth Saewyc, PhD, RN, FSAHM, FAAN, professor and distinguished university scholar and executive director of the Stigma and Resilience Among Vulnerable Youth Centre at the University of British Columbia in Vancouver, BC, Canada.
Saewyc’s research is part of a larger study to develop sexual health and pregnancy prevention programs for sexual minorities and trans and gender-diverse young people. “A key part of this work is to understand why young people might be at risk of pregnancy,” Saewyc explains. Investigators want to know what trans and gender-diverse youth think about pregnancy, contraceptives, and reproductive health.
“We did national online focus groups throughout the United States — eight of them — among young people assigned female at birth who identified as trans or nonbinary,” she says. “The purpose was to understand and get a sense of what some of the issues are to pay attention to for an intervention and the potential implications for clinical practice.”
The research, which received partial funding from a National Institutes of Health (NIH) grant, had an ongoing study that was cancelled in March 2025 — two years into its four-year grant, Saewyc notes. NIH terminated about 800 research projects early in the administration of President Donald Trump. Scientists had to halt their work after receiving notices that their research did not meet the agency’s priorities. This led to dismissal of personnel and shutting down labs.2
Of the grants that were terminated, 24.3% were trans health related.2 “Our human rights code in Canada has a section for sexual identity and gender expression at every level, and we have required funding for diversity and identity,” Saewyc says.
The study found that trans youth understand dysphoria and how both pregnancy and contraception can affect it. The most recent term to describe the phenomenon of experiencing something that is incompatible with a person’s gender identity is gender incongruence.1
For example, a transgender man may have difficulty handling the body changes that occur with pregnancy or may experience dysphoria during childbirth. Some transgender men prefer cesarean deliveries over other types of birth for this reason.1
They also may experience gender incongruence with menstruation and/or contraception or certain types of contraceptives.1 “Gender dysphoria among trans and nonbinary young people may help explain some of their decisions around contraception and pregnancy,” Saewyc says. “Some changes could make gender dysphoria worse for people,” she adds. “For a lot of young people, pregnancy is associated with being a woman or being female.”
Researchers found that gender dysphoria around pregnancy is not experienced by everyone. “Not everyone in our focus group felt that way, including some who had been pregnant,” Saewyc says. “Not all trans men will get dysphoria from being pregnant.”
For other trans and nonbinary people, pregnancy could be a source of distress, but their desire to give birth or have children might outweigh anticipated distress. “They might cope with dysphoria because they want to give birth,” she says.
The adolescents also had a nuanced view of contraception for the purpose of preventing pregnancy. “For a lot of young people for whom getting pregnant would worsen gender dysphoria, you think they would want to prevent it,” Saewyc explains. “But birth control is marketed to girls and women; it’s feminine, so having to take a pill every day is so connected with being female that it reminds them of gender identity and ends up being distressing.”
Those nuanced experiences and views are a challenge to sexual and reproductive health and family planning providers, and each individual trans patient’s understanding and concerns and preferences need to be discussed during contraceptive counseling. “Some people felt like there are methods that are less dysphoria-inducing,” she says. “A number of young people talked about IUDs as preferable.”
The benefits of intrauterine devices (IUDs) are that they are long-term and can be forgotten as the person goes about their day. Also, some IUDs can cause menstruation to stop, which is another benefit, she adds. “As one person said, birth control has feminine connotation, so every time you take a pill, you’re reminded of your birth sex. Other methods are out of sight and out of mind,” Saewyc explains.
These are the kinds of things that providers should be aware of when they meet with gender-diverse patients. The reproductive healthcare environment and experience can be problematic for gender-diverse patients. For instance, the clinic space often is decorated in a way that emphasizes feminine qualities in the choice of colors, posters, and magazines.
When a gender-diverse patient enters a clinic for an IUD, it is not just the pain of IUD insertion that troubles them. It is the entire experience: “Some described it as a nightmare or torture,” Saewyc says. “It wasn’t just about getting the IUD itself; it was being in the room with a gynecologist was torture because they have to talk about something they hate.”
This is challenging from the provider’s perspective. But if this is the reason why trans patients avoid visits to the OB/GYN or contraceptive counseling, then there are steps providers can take to make the experience less unpleasant for them.
One strategy is for providers to talk about the effect of contraceptives on the person’s body parts, saying, “When using the IUD, menstruation may stop or be light,” instead of saying things like, “Some women like it when their period stops.”
Providers can talk about the pros and cons of different methods without assuming their gender-diverse patients are going to be distressed.
“Ask, ‘How do you think it might feel to be taking this pill every day,’” Saewyc suggests. “Or say, ‘Here are some options and this is how they might meet your goals.’”
Another important thing to discuss with gender-diverse patients involves the effect some contraceptives may have on the patient’s gender-confirming treatment. Some types of estrogen in certain contraceptives are contraindicated with patients’ testosterone and gender-confirming care. For example, people who use estrogen-based contraception over the long term could find that breast tissue develops.3
Clinicians need to educate trans-diverse patients about the limitations of testosterone therapy in preventing pregnancy. Some patients may believe — mistakenly — they cannot get pregnant while receiving their gender-confirming care. “A lot of trans young people do not know that testosterone, itself, is not an effective contraception,” Saewyc says. “You can still get pregnant, and a lot of them may not have gotten that information on the internet.”
Lower doses of testosterone, especially, will not prevent pregnancy, she adds. “Physicians need to provide good education about how hormones may be influenced by different types of contraception and explain which types will be better for their goals,” Saewyc says. Asking patients about their goals and discussing their various options is a good starting point.
Another strategy is to make OB/GYN spaces more welcoming for trans patients. “Think about the pictures on the walls and the magazines on the tables,” she says. “Do not assume that everyone who shows up is going to have an identity as a woman or she/her pronouns.” When addressing patients, use the titles they select, which could be Mr. instead of Ms. or Miss or Mrs. And maybe it is time to retire the color pink in clinics that cater primarily to women.
“It’s been fascinating to see some places that are relentlessly pink — the way they’re designed,” Saewyc notes. “I’m not sure cisgender women of any age feel the gendered clinic all that appealing. So don’t assume that everyone coming in the door expects to be treated as a girl or woman.”
It also is important to avoid misgendering patients and to use their requested names. Gender-diverse patients often have new names, which may or may not be reflected on their drivers’ licenses. Clinic staff can ask patients for their preferred name and make certain staff call them what they prefer.
“It’s about not making assumptions and trying to think about ways you can talk accurately and straightforwardly about options for pregnancy prevention or contraception,” she says. “And reflect on how hormone therapy might have an interaction with any contraceptive decision.”
Clinicians should ask patients about their gender-affirming care and explain how this treatment would work with various contraceptive options. Discussions about contraception will distress some trans patients, but not all of them, so it is important to not prejudge their potential reactions.
“It’s also important to know your context in some countries or in some states in the United States, where transgender health — as well as reproductive health — has specific limits,” Saewyc says. “For example, there are states where the provision of contraception requires parental consent for adolescents. And gender-affirming care is an issue that may be limited in the state in which you practice.”
Providers should know their state’s laws and also be aware of whether their patients are taking hormones or pursuing surgery. “Respect and honor people’s gender identity and provide them with the confidentiality that is the right of all patients and clients,” Saewyc says. “It goes a long way for young people to be respected and to be treated respectfully, related to their gender identities. That makes such a difference and is a really small point.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
1. Lowik AJ, Al-Anzi SMF, Chan A, et al. Transgender youth’s perspectives on the relationships between pregnancy, contraceptives, and dysphoria. J Adoles Health. 2025; Apr 3:S1054-139X(25)00063-1. doi: 10.1016/j.jadohealth.2025.01.024. [Online ahead of print].
2. Kozlov M, Ryan C. The science fields and state hit hardest by Trump NIH cuts, in 4 charts. >Scientific American. April 11, 2025. https://www.scientificamerican.com/article/hiv-trans-health-and-covid-research-targeted-by-trump-cuts-to-nih/
3. What happens if a cisgender or trans man takes hormonal birth control? Healthline.com. https://www.healthline.com/health/what-happens-if-a-guy-takes-birth-control
The challenge for reproductive healthcare providers is meeting the needs of transgender and nonbinary patients in a way that reduces their gender-related distress.
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