Pregnancy prevention and unintended pregnancy across gender identity: a cross-sectional study of college students

Keywords: female-to-male, health disparity, non-binary, pregnancy prevention, reproductive health, transgender, transmaculine, unintended pregnancy.

Transgender and non-binary (TNB) people face unique barriers to reproductive health care, including often-lacking health insurance or being denied coverage for reproductive health services (e.g. Pap tests).^1,2 TNB people may also avoid care, or disclosing their assigned sex at birth to their provider, due to discrimination.^3–5 Additionally, some providers may not understand that some of their TNB patients are at risk of unintended pregnancy and may need or want pregnancy prevention counseling.² This may partially be due to the misconception that gender-affirming testosterone use functions as contraception.^3,6–9

Few studies have addressed unintended pregnancy risk by gender identity.^6,10–12 Research from the Pride Study found that 1% of TNB participants who were assigned female at birth or intersex had a past-year pregnancy, and half of reported lifetime pregnancies were unintended.¹⁰ The Canadian Trans Youth Health Survey found that 2% of participants aged 14–25 years had ever been pregnant or caused a pregnancy.¹¹ Another survey of TNB people assigned female at birth found 6% had ever had an unplanned pregnancy.⁶ However, these studies used convenience samples and lacked cisgender participants, thus preventing comparison across gender identity. We expand on previous research by documenting young people’s receipt of, desire for, and unmet need for pregnancy prevention information from their school, as well as risk of unintended pregnancy by gender identity, using data from 18- to 25-year-old assigned-female students in the Fall 2015 through Spring 2018 National College Health Assessment.¹³ Multivariable log-binomial regression was used to estimate adjusted risk ratios (ARRs) and 95% confidence intervals (95% CIs) for pregnancy prevention information and unintended pregnancy across gender identity (Table 1).

Table 1.  Pregnancy prevention information and unintended pregnancy by gender identity among US college cisgender, non-binary, and transmasculine students who were assigned female at birth (n = 185 658).

Nearly half of students reported wanting (47.7%) or receiving (47.2%) pregnancy prevention information from their school, whereas more than one-fifth had an unmet need for such information (21.6%). After adjusting for covariates (e.g. age, race/ethnicity, geographic region), non-binary students (e.g. those who identified as genderqueer, agender, genderfluid, etc.) were more likely than their cisgender counterparts to report wanting (ARR: 1.12; 95% CI: 1.08–1.16), receiving (ARR: 1.09; 95% CI: 1.04–1.13), and having an unmet need (ARR: 1.10; 95% CI: 1.02–1.19) for pregnancy prevention information (Table 1). Transmasculine students (e.g. those who identified as men, male, masculine, etc.) were as likely as cisgender students to want, receive, and have an unmet need for pregnancy prevention information.

Past-year unintended pregnancy was rare (0.8%). We did not find any significant differences in unintended pregnancy risk by gender identity; however, the point estimates for the risk ratios suggest unintended pregnancy was less common among transmasculine students than cisgender students. Results were consistent for unintended pregnancy among those at risk of unintended pregnancy and for any (unintended and intended) pregnancy. These findings are consistent with results from the Canadian Trans Youth Health Survey, which found the proportion of sampled TNB students who had ever been pregnant was similar to external estimates for the occurrence of pregnancy among youth in British Columbia.¹¹ The high proportion of students who wanted pregnancy prevention information from their school may indicate inadequate prior sex education, which is concerning, because most students in our sample were sexually active. In light of this critical knowledge gap, college health centres should take a proactive role in ensuring that all students, regardless of gender identity, have access to comprehensive sex education, reproductive health counselling, and care. Recent papers have outlined guidance on the provision of reproductive health care and pregnancy-prevention counselling for TNB patients.^4,9,14–17

We hope these findings help dispel the notion that TNB people are not at risk of unintended pregnancy. TNB students are as likely as their cisgender peers to experience an unintended pregnancy. These young adults need to receive comprehensive counselling and care to ensure they meet their reproductive goals.

Data may be obtained from the American College Health Association and are not publicly available.

The opinions, findings, and conclusions presented/reported in this article/presentation are those of the authors, and are in no way meant to represent the corporate opinions, views, or policies of the American College Health Association (ACHA). ACHA does not warrant nor assume any liability or responsibility for the accuracy, completeness, or usefulness of any information presented in this article/presentation.

The authors declare no conflicts of interest.

Dr. Charlton was supported by the American Cancer Society (MRSG CPHPS 130006).