by Miles Harris, FNP-BC and Kelly Cleland, MPA, MPH

The scenario:

A young man comes to your emergency department in the early morning. He is seeking HIV post-exposure prophylaxis (PEP) following unprotected sex with a male partner the night before. During intake, he discloses that he is transgender and was assigned female at birth (AFAB). He is amenorrheic (doesn’t have a period) as a result of testosterone use for gender-affirming hormone therapy. At your facility, cisgender women seeking PEP are also offered emergency contraception (EC).

Is EC indicated for this transgender male patient?

All patients, including transgender or gender nonbinary (TGNB) patients, who have the capacity to become pregnant should be offered emergency contraception if they desire pregnancy prevention, present within 5 days (120 hours) of condomless receptive penile-vaginal intercourse, and are not using a reliable method of contraception. While testosterone may stop menstruation, it is not a substitute for contraception. A person taking testosterone may still ovulate and be able to get pregnant. Research is limited, but unintended pregnancies in amenorrheic patients using testosterone have been documented.

Finding out if a TGNB patient has sex that puts them at risk for pregnancy requires a thorough trans-inclusive sexual health history. Key questions to determine a patient’s pregnancy risk include:

Does the patient’s sexual partner(s) make sperm?
What kind of sex does the patient have with this partner?
Has the patient had any gender-affirming surgical procedures?