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Sexual and Reproductive Health

The following section outlines the information that pertains to gender-affirming care in relation to sexual and reproductive heath. This section covers fertility, family planning, sexual health screening and pelvic exams, and HIV PrEP considerations for Two-Spirt, trans, Indigiqueer, and gender-diverse (2STIGD) patients. 

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Fertility and Birth Control

2STIGD people have the same range of reproductive desires as cisgender people do. Therefore, it is important that PCPs are aware of the options available to 2STIGD people. In this section, you will find information on fertility preservation, contraception, and family planning.

 

Every person will have a unique journey in their decision-making and planning around reproduction. Some may choose to pursue gender-affirming care before reproductive planning, and others may decide to postpone accessing GAHT or surgery until they have a reproductive plan in place. 

 

Estrogen-based and testosterone-based GAHT regimens have variable temporary and long-term impacts on fertility. Accordingly, there is a need to discuss both birth control and fertility preservation with patients prior to the initiation of GAHT. Choosing to move forward with starting hormones or having lower surgery does not change a patient's ability to become a parent, however it may limit some of the reproduction options available to them. 

 

Though there are numerous ways that people may create families without the use of their own gametes, many people have a wish for genetically-related children. Patients who are planning to conceive in the near future may even wish to delay medical transition in order to minimize the need for harvesting, storage and/or advanced reproductive technologies (ARTs), which can be costly and involve procedures that can intensify feelings of gender dysphoria.

 

Options for fertility preservation in 2STIGD people are similar to those undergoing gonado-toxic therapies for malignancy or elective preservation. If indicated, referral for fertility preservation should be initiated as soon as possible as this process may take several months. While the cryopreservation of sperm is much less costly than the harvesting and cryopreservation of ova, in both scenarios, budgeting in the short and the long term for up-front and ongoing storage costs may be required.

 

Unfortunately, N.B. does not cover the costs associated with fertility preservation. N.B. does offer a Special Assistance Fund for Infertility treatment as a one-time maximum grant to alleviate the financial burden of those dealing with infertility. Please note that Conceptia is the only fertility clinic in N.B. However, they have been noted to support cisnormative views on family planning and do not directly market for 2STIGD folks’ fertility preservation. After engaging in community consultation, 2SQTP-NB/P2SQT-NB does not recommend Conceptia for 2STIGD folks’ fertility preservation. Instead, it is suggested that PCPs refer to the next closest fertility clinic located in Halifax, Nova Scotia - Atlantic Assisted Reproductive Therapies (AART). AART is well-known to welcome people of all genders, sexual orientations and family structures. Their services are available for people hoping to start or expand their family, as well as those planning to undergo gender affirmation surgery who wish to preserve their options for future fertility. For resources from AART, please click here. 

 

It is important to note that many 2STIGD people have conceived successfully following the discontinuation of GAHT. Whether long-term GAHT causes unique risks to the reproductive capacity of those undergoing GAHT is unknown. Several healthy live births have been reported, but patients should be counselled regarding the lack of knowledge in this area. 

 

To help subsidize the lack of medical knowledge and expertise in this area, it can be beneficial to connect patients to community groups with experience in the areas of reproduction. Although medical communities are still in the early stages of understanding the needs of 2STIGD people who wish to conceive, 2STIGD communities have long engaged in knowledge sharing. While there is a time and a place for medical knowledge, it is important to note the value of community knowledge when it comes to 2STIGD people’s ability to navigate, access, and engage with health care.

 

Making decisions about fertility

While it is important to make sure a 2STIGD patient has all the necessary information to make decisions regarding their fertility, it is just as important to make sure that, no matter what decision they make, they are supported and affirmed – including if it results in potential or definite infertility.

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2STIGD people are able and allowed to make decisions that affect their current or future fertility for any reason, including comfort, affirmation, or immediate relief. This is also the case for young 2STIGD people, who are allowed to make decisions about gender affirmation even if this might affect their future fertility.

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It is also important  to ensure any information shared is clear. When talking about fertility preservation with patients before hormone initiation or bottom surgery referral it can be helpful to provide them with some information to take home with them. For some folks, whether or not they wish to undergo fertility preservation is a clear decision; whereas, for other folks they may need more time to sit with information on their options. Patients may need time to reflect on the information provided to them and a handout can offer them the time to do this and consider any questions that they may have.

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Finally, it is important to communicate to patients that people are not any less valuable or valid if they are infertile, and that fertility is not required to be a parent, carer, or family member. Families take many forms, and while some come from pregnancy, they can also grow from fostering, adopting, or finding chosen families.

In most cases, testosterone-based therapy leads to reversible amenorrhea without depletion of ovarian follicles. However, there may be an adverse effect on the growth of follicles, particularly in the more mature stages of follicular development. Unfortunately, research in this area remains limited. 

 

While many 2STIGD people have intentionally become pregnant after discontinuing testosterone to pursue pregnancy, patients may wish to consider postponing testosterone initiation if they would like to become pregnant in the future, since fertility may be permanently affected. Patients should also be counselled regarding options for fertility preservation prior to starting hormones. While ideally completed prior to starting hormones, fertility preservation can also be performed following (temporary or permanent) discontinuation of testosterone. 

 

For 2STIGD people with uteri who are concerned about fertility loss after testosterone use, or for those planning to have hysterectomies (removal of the uterus) and oophorectomies (removal of the ovaries), there are currently two options for fertility preservation:
 

Oocyte (Egg) banking involves hormone-induced ovulation and the retrieval of the eggs using a needle, guided by ultrasound, inserted through the vaginal wall into the ovary. Many cryogenically frozen eggs do not survive because they are sensitive to the freezing and thawing process. Additionally, cryopreservation can also be done concurrently with gender-affirming gonadectomy.

 

Embryo banking is egg retrieval (as above) followed by immediate fertilization and banking of the embryo. It has a better success rate, but the sperm donor (whether known or anonymous) must be chosen at the time of the egg retrieval.
                                                

Despite reduced fertility during testosterone administration, it should not be considered an adequate method of contraception. Given the teratogenic potential of testosterone, patients on testosterone should be counselled on the risk of pregnancy, and those who are sexually active with people with sperm should be offered contraceptive options, such as progesterone-only contraception or an intrauterine system/device (IUS/IUD). It may be easier to insert an IUS/IUD prior to initiating testosterone due to the subsequent atrophic changes of the vaginal and cervical tissues.

 

Once testosterone is initiated, the provider should check with the patient periodically regarding their sexual health needs and reiterate the necessary precautions if the patient becomes sexually active with people who produce sperm. If an accidental pregnancy does occur, counselling regarding all options, including abortion care, should be provided. If termination is chosen, it may be helpful for the provider to directly contact a local abortion clinic to ensure that the clinic is gender-affirming.

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The administration of estrogen-based GAHT results in a reduction of testicular volume and has a suppressive effect on sperm motility and density in a cumulative, dose-dependent manner. Sperm motility and density can also be further impacted by the practice of tucking. Nonetheless, it is important to counsel patients about their fertility preservation options and the potential need for birth control if they are sexually active with partners who may become pregnant. 

 

A 2STIGD person who has external gonads and plans to have them removed must bank sperm beforehand to retain the option of having genetically-related children. Whenever possible, patients should be counselled regarding options for sperm banking prior to starting hormones. For those already using hormones, a suspension of hormone treatment is recommended for a few months so that sperm production and quality can recover prior to banking. If interrupting hormone treatment is not an option, poor quality semen can still be frozen for later use, which may include assisted reproductive technologies. In cases where sufficient sperm cannot be produced through ejaculation, fertility clinics can provide surgical options for sperm extraction. 

 

For 2STIGD people with sperm who are concerned about fertility loss after estrogen use, or for those planning to have an orchidectomy (removal of enteral gonads/testes) there are currently two options for fertility preservation:

 

Sperm cryopreservation (freezing) is a technique utilized to store sperm at very low temperatures for future use.  Sperm cryopreservation following ejaculation is the simplest and most reliable form of preservation. STBBI screening (i.e., chlamydia, gonorrhea, HIV, syphilis and hepatitis serologies) is required prior to banking, and PCPs can expedite the process for patients by completing these tests prior to referral.

 

Testicular sperm extraction (TESE) involves percutaneous removal of sperm from the testes or epididymis under local anesthetic. This procedure may be considered when ejaculation is overly burdensome or difficult. Resulting sperm counts are often low and thus multiple samples and/or the use of in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) may be required. 

 

Patients with sperm may also attempt conception or undergo fertility preservation following the suspension of GAHT for three to six months, since testicular function may recover to a variable degree. In a variety of scenarios, semen analysis can be helpful in assessing current fertility and informing options. 

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It is recommended that children and adolescents, and their guardians (if applicable), also be informed and counselled regarding options for fertility preservation prior to the initiation of pubertal suppression and GAHT. In children who have initiated natal puberty, fertility preservation options include sperm, oocyte, and embryo cryopreservation. Currently, it is not possible for children who have not undergone natal puberty (and who may have used gender-affirming hormones) to preserve gametes.

 

Prolonged pubertal suppression using gonadotropin releasing hormone (GnRH) analogs is usually reversible and should not impair resumption of puberty upon cessation, though most children who undergo pubertal suppression go on to begin GAHT without undergoing natal puberty. For further discussion, please see GAHT for Youth. 

Approximate Costs of Fertility Preservation

Fertility preservation is not covered by N.B. Medicare, and the cost can be extremely high. It may be possible to claim some uncovered medical costs as a personal tax credit on your income tax, and/or apply for the Special Assistance Fund for Infertility Treatment. The approximate costs associated with fertility preservation (verified in August, 2022) are as follows:

  • Consultations with a clinic may cost $200 or more. This amount may be billable to Medicare if the patient has a referral letter from a physician, NP, primary care provider.

  • Semen analysis (for motility and viability) can run from $85-350, and initial freezing and storage of semen can cost $125-300 and with an additional $200 per year in annual storage fees. If sperm must be retrieved surgically, this may cost from $550- 1500.

  • Preserving eggs can cost $5000 for the initial procedure, and as much again in annual storage fees. If drugs are needed to initiate the release of eggs these drugs can cost an additional $4000.

  • Preserving frozen embryos costs approximately $480-650 with $150-300 in annual storage fees. Transferring a frozen embryo to a uterus for gestation can run between $540-1100.

Sexual Health and Sex

Many 2STIGD people become involved in sexual relationships; however, many also do not. This section provides information specific to the sexual health of 2STIGD people, while respecting those who identify as asexual, demisexual, grey-sexual, or otherwise on the asexual spectrum.

 

Unfortunately, it is not always easy for 2STIGD people to find accurate and inclusive information about sexual health and sex. As PCPs, it is important to have up-to-date and inclusive information to help support and affirm patients’ sexual health needs. 

 

There are many changes that may come along with a social transition, including shifts in one’s sexual orientation and comfort with a changing sense of self. With a medical transition, people may experience new sensations with hormonal changes and different opportunities because of access to surgeries. Ultimately, to understand the sexual health needs of 2STIGD people, it is important to ask each individual patient affirming questions that will allow you to provide the best possible advice and care. With this being said, it is also important to let patients know that you will not be asking things that are not necessary to their health care. Asking invasive questions or encouraging physical exams without explaining why they are essential to a patient's care can contribute to a patient feeling uncomfortable, and unlikely to return for care. While it can be  important to ask for intimate information, it is equally as important to ask only about what you need to know, and to give the reason why you are asking. Being clear and honest at the start of the conversation can assist in normalizing this process and these questions, and let your patient know that you’re there to support their health. 

The Parts and Practices Model

 

The parts and practices model focuses on the body parts a person has, and what they are doing with them, rather than making assumptions based on a patient’s gender, sexuality, or the language they use. This model can be helpful if you are struggling to find the correct language for a person’s identities and experience. Some examples may include, but are not limited to:

 

  1. Do you have sex with people with a penis, people with a vagina, or both?

  2. During sex, do any parts of your body enter a partner’s body, such as their genitals, anus, or mouth?

  3. During sex, do any parts of a partner’s body enter your body, such as their genitals, anus, or mouth?

  4. Do you or any of your partners use any barriers, such as condoms, gloves, dental dams, or PrEP?

  5. Is there a chance of pregnancy for any of sex that you are having?

 

It often can be helpful to provide an explanation for why you may be asking invasive questions, for example, “The reason I am asking about any receptive sex you are having is so we can figure out what STI tests you might need today.”

Using Affirming Language

 

The language used always matters, but when talking about body parts, sexual health, and sexual activity that can cause distress or disphoria for 2STIGD people, it is important that PCPs do so in an affirming manner. The table below offers guidance on some ways neutral language can be used to talk about bodies, sex, and health, while remaining clear and precise.

Try
Instead of
Erogenous or erectile tissue
Vulva
Internal genitals / Genitals
Vagina
Thinning of the internal genitalia tissue
Vaginal atrophy
External gonads
Testes / Testicles
Common
Regular/ Correct / Right
Pregnant person
Pregnant woman
Monthly bleeding
Period / Menses
Erogenous or erectile tissue / External genitals / Genitals
Penis
Sexual health screening / Internal exam / Cervical screening
Pelvic exam / Female reproductive exam
Internal gonads
Ovaries
Cisgender
Not trans / Normal / Real
Phenotypical development
Natural / Normal development
Parenthood
Motherhood / Fatherhood
Hair loss
Male pattern balding
External condom / Internal condom
Male condom / Female condom
Looks healthy
Looks normal
Opening of the genitals
Introitus / Opening of the vagina
Receptive IC / Insertive IC (IC = Intercourse)
Genital sex
Internal reproductive organs
Female reproductive organs
Physical arousal / Hardening or stiffening of erectile tissue
Erection
Erogenous or erectile tissue
Clitoris
Chestfeeding (for non-binary or transmasc people)
Breastfeeding (keep breast feeding for transfemme parents, unless another term is preferred)
Upper body
Breast / Chest
Assigned male at birth
Biological male
Assigned female at birth
Biological female

Of course, it is always best to ask patients about the language they prefer for their body and sexual activity. If possible, it is best to know this prior to their first appointment with you (i.e., by asking questions on your registration form). If you do not have this option, it is also perfectly acceptable to ask: “Before we get started, I am going to take a brief sexual history - do you have any language you prefer to use for you body, genitals, sexuality or sexual/reproductive activity, so that I can help you feel as comfortable as possible?” If you are ever unsure about what a term means, ask your patient to clarify. 2STIGD people may use a range of different words to describe their body and sexual practics.

Sexual function

 

For some 2STIGD people, hormonal and/or surgical affirmation may alter their sexual desires and function. If this is the case, it is important to ask how your patient may want to treat this, if at all (e.g., “Do you have any questions about your current sex life, or is there anything you are concerned about that I can help you with?”). For example, for some patients on estrogen-based GAHT, the impact of estrogen on sexual function is welcomed, whereas for others, these changes are not wanted at all. A conversation that asks what changes they have experienced, and what changes they feel comfortable or uncomfortable with can open up a space to talk about how you may be able to assist them.

 

This may look like:

  • Prescribing topical vaginal/front hole estrogen for insertive sex, and talking about the benefits of lubricant;

  • Supporting a patient exploring sex for the first time after an affirmative genital surgery;

  • Directing your patient to a qualified mental health professional (see Part 7: Mental Health) to discuss any difficult feelings they are having about changing sexuality;

  • Working with a patient to alter their hormones or to prescribe medication to better stimulate genital or reproductive function;

  • Reassuring all patients that changing sexual inclination and function over a person’s lifetime is common, but that you can support them if they want to explore changing what this looks like.

Sexual Health Testing

2STIGD people can be tested for all the same bacterial and viral infections as cisgender people, and should be assessed for risk and testing needs based on their sexual activity.  This may include screening throats, rectums, genitals and genital lesions as indicated. Serology should be included during routine STI screening for all patients, including TP EIA, Chlamydia, Gonorrhea, HIV, and Hepatitis A, B & C as indicated. Assess the need for immunizations (HPV, HAV, HBV) and HIV PrEP on an individual basis. Self-swabbing, blind swabs and urine CT/GC NATs are appropriate for symptomatic patients who do not desire a physical exam.

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Note: Symptomatic patients should have microbiological analysis (which includes yeast and BV prn) in addition to STI screening. 

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Below is a list of recommended sexual health screening based on anatomy that is inclusive of gender-affirming surgeries and GAHT.        

Penile urethra (with or without phalloplasty or metoidioplasty with urethral lengthening)

*If urethral symptoms occur after gender- affirming surgery, consult with an experienced clinician and/or with the surgeon who performed the surgery, as swabs may be contraindicated.

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Asymptomatic

  • CT/GC NAT urine

 

Symptomatic

  • STI Screen:

    • CT/GC NAT (urine)

    • Trich NAT

  • Microbiological analysis:

    • GC culture

    • Yeast

    • C&S superficial wound

    • Urine dipstick and/or urinalysis prn

  • Use liquid Amies culture yellow-top swab

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Notes

  • All swabs may be self or practitioner collected.

  • Requisition tips:

    • If applicable, specify site as “Urethra” prn

    • If ‘female’ or ‘X’ gender marker, indicate “Two-Spirit, trans, or gender-diverse patient” to reduce likelihood of sample rejection

Tips for Sexual Health Screening 

For 2STIGD people sexual health screening may induce significant body dysphoria, as well as physical and emotional discomfort. In order to make patients feel as comfortable as possible, clear communication, patience, and flexibility in screening methods is required. Below are some suggestions on how to minimize discomfort and distress.

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Keep in mind that patients may:

  • Have experienced transphobic violence and discrimination;

  • Have experienced sexual encourter that was non-consensual; 

  • Find it hard to remove affirming clothing, compression garments, or prosthetics that, in doing so, will reveal a part of their body that may not align with their gender and/or that may have changed from GAHT;

  • Have had traumatic experiences with the health care system; and

  • Have experienced unnecessary and inappropriate physical exams.

 

Safety and Trustworthiness:

  • Work to create a stronger therapeutic relationship before providing a sexual health exam;

  • Recommend assessments and exams only when they are clinically indicated;

  • Provide rationales:

    • Explain why a specific exam, screening, or procedure is recommended

    • Distinguish between cancer screening and STI screening

    • Discuss possible outcomes and related follow up

    • Communicate what is involved in each part of the assessment, exam, procedure, or treatment;

    • Take your time – consider booking two appointments (one for teaching and one for screening);

    • Ask about affirming or neutral terminology before, during, and after the exam;

    • Ask for consent prior to each portion of an assessment, exam, procedure, or treatment.

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Choice, Collaboration, and Connection:

  • Ask about their goals for sexual health and screening, understanding that patients may not be mentally prepared for some examinations during that visit;

  • Provide choices, including non-invasive options for STI screening (for example, the patient may feel more comfortable showing a photo they have taken rather showing the PCP directly);

  • Ask what they would like to happen if they feel stressed or need to cry during the exam. For example:

  • Pause and practice relaxation techniques

  • Stop the exam right away

  • Proceed with the exam after a quick check-in

  • Provide alternatives to the dorsal lithotomy position (e.g. frog-leg position or side-lying with a raised upper leg).

  • Get creative and collaborate with the patient to determine what will make them most comfortable. For example, it may be helpful for some patients to wear a pair of boxer shorts with a hole cut out in the bottom. 

 

Strengths-Based and Skills Building:

  • Remind patients that they are in control of the visit and can stop at any point, no matter what;

  • Ask how they would like to engage in the exam, such as by:

    • Taking a step-by-step walkthrough, perhaps following along with a mirror

    • Introducing the speculum themselves (providing adequate privacy and time)

    • Distracting themselves with their phone

    • Playing music and practicing deep breathing or other stress management techniques

  • Invite them to bring a support person for part or the entire visit;

 

For clients with significant anxiety, PTSD, or difficulties tolerating the speculum, consider:

  • Prescribing an oral benzodiazepine to be taken 20-60 minutes prior to the exam;

  • Reminding them to arrange transportation to and from the appointment

  • Prescribing topical estrogen to be used for two weeks prior to the exam to decrease symptoms of genital discomfort related to genital atrophy.

  • For additional resources on supports for 2STIGD survivors and victims of sexual and/or gender-based violence, click here.

HIV Considerations for 2STIGD Patients

Introduction

HIV stands for Human Immunodeficiency Virus, a virus that can weaken a person's immune system. HIV lowers your body’s self-defense mechanism against illness and disease. There are two main different strains of HIV, HIV-1 and HIV-2. The most common form of the virus is HIV-1, which accounts for around 95% of all world infections. HIV-2 is much less common and is genetically distinct from HIV-1. HIV-2 is known to be less infectious and to progress more slowly, resulting in fewer deaths. Among the existing HIV-1 and HIV-2 categories, there are different subtypes of the virus which represent a variety of transmission speeds and infection progressions.

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When untreated, HIV can lead to AIDS, Acquired Immuno-Deficiency Syndrome. AIDS progressively compromises your immune system, leaving your body more vulnerable to different infections and diseases. Given modern advances in HIV research, HIV-positive people who have access to treatment do not develop AIDS, and live healthy lives without being able to transmit the virus.

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There are only five bodily fluids that can transmit HIV. Transmission can occur when one of these fluids enters the bloodstream of somebody else:

  • Anal fluids

  • Blood

  • Breastmilk

  • Semen (including pre-cum)

  • Vaginal fluids

 

These fluids can transmit HIV through broken skin, the opening of external genitals, internal genital linings, rectum, or foreskin. The main ways HIV is passed are through sex and by sharing needles. It can also be passed from parent to child through birth or breast/chestfeeding.

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