Sexual and reproductive health considerations among transgender and gender-expansive youth

Sexual and reproductive health are an integral part of all youths’ health and wellbeing, including youth who are transgender and gender-expansive. This article will discuss general approaches to the sexual and reproductive health care of transgender and gender-expansive youth, and review the topics of contraception and menstrual suppression, fertility preservation and family building, and the prevention and treatment of sexually transmitted infections and HIV in this population. Although transgender youth on testosterone therapy often become amenorrheic, ovulation and pregnancy can still occur, and thus all youth on testosterone therapy should be counseled on the potential for pregnancy and have access to effective contraception. Many forms of hormonal contraceptives are both safe and efficacious when used by youth on testosterone therapy. Hormonal contraceptives may also be used to provide menstrual suppression for those experiencing dysphoria from unwanted uterine bleeding. All transgender youth should receive counseling on fertility preservation and reproductive options prior to starting pubertal blockers and/or gender-affirming hormones, therapies that have varying effects on long-term fertility potential. Several different methods of fertility preservation exist, however there are numerous barriers to transgender youth receiving fertility preservation services, and rates of utilization of these services is low. Transgender individuals suffer from a disproportionate burden of HIV compared to their peers—thought to result from stigma, marginalization, and lack of access to appropriate care. All providers caring for youth should be informed about HIV pre-exposure prophylaxis (PrEP) and HIV post-exposure prophylaxis (PEP), which may help to prevent HIV acquisition.