The sexual and reproductive health and rights of transgender and gender expansive people are integral to reproductive freedom. With dual attacks on transgender rights and reproductive rights in many state legislatures it is important to understand these intersections to be truly inclusive in proactive policy responses (see ‘5 Policy Opportunities Identified in the Research’ below).
We partnered with a team of researchers at Ibis Reproductive Health studying the contraceptive and abortion care needs of transgender and gender expansive (TGE) people to bring you this in-depth research spotlight.
Sexual and Reproductive Health Needs of Transgender and Gender Expansive People
Presented by Laura Fix, MSW, Heidi Moseson, PhD, and Sachiko Ragosta at Ibis Reproductive Health
Transgender describes a person whose gender (e.g., agender, man, nonbinary, woman) differs from the gender commonly associated with the sex that they were assigned at birth (i.e., female, intersex, male).
Nonbinary and gender-expansive are overlapping terms that describe gender identities that are not limited to man or woman – though this could include a combination of both or neither. Some individuals who identify as nonbinary and/or gender-expansive may also identify as transgender; some may not.
Intersex describes people assigned intersex at birth or who identify as intersex and have “natural variations in sex characteristics that do not seem to fit typical binary notions of male or female bodies”. These variations do not necessarily impact capacity for pregnancy.
Cisgender describes a person whose gender identity aligns with the gender commonly associated with the sex that they were assigned at birth.
U.S. states are seeing an onslaught of discriminatory anti-transgender legislation that impose further barriers on necessary and affirming healthcare for transgender individuals who already face a variety of health inequities. These laws intend to criminalize clinicians who provide gender-affirming care that respects the autonomy, health, and safety of their patients. Such policies impose harmful directives for clinical care based on spurious claims about the fixed nature of sex and gender, and assumptions about the care that transgender people do or do not need. These claims are not grounded in scientific evidence and are far outside the scope and expertise of legislators.
Although proponents of anti-trans bills and bans on gender-affirming medical care for transgender people misleadingly characterize such legislation as mechanisms to protect against harm, the evidence shows that stigma, discrimination, and erasure of one’s lived experience in a healthcare setting can delay TGE and intersex people from seeking necessary preventive care and screening, and thereby contribute to poor health outcomes.
In addition to higher rates of discrimination and care denial in the medical system, TGE and intersex people also face barriers identifying knowledgeable and affirming clinicians, and obtaining and maintaining insurance coverage. When seeking sexual and reproductive healthcare such as contraception, STI screening, obstetrical care, or abortion, navigating gendered spaces such as “women’s health” centers can present additional barriers to care.
Since 2016, Ibis Reproductive Health has collaborated with an interdisciplinary team of researchers and Community Advisory Boards comprised of members of transgender, non-binary, gender expansive, and intersex communities to document the sexual and reproductive health (SRH) needs and experiences of sexual and gender minority (SGM) adults in the United States. These findings from a 2019 nationwide survey of SGM people in the US provide important evidence that can be used to improve access to and the quality of SRH care for people of all sexes and genders.
Sexual and Reproductive Health Terminology
Key findings: We analyzed the words that TGE individuals and cisgender sexual minority women use to describe sexual and reproductive health-related body parts, such as vagina and uterus, and physiological processes, such as menstruation and pregnancy. Thirty-six percent of TGE participants and 7% of cisgender sexual minority women (CSMW), replaced at least one of nine SRH terms with their own word. Nearly one-quarter of those responses were unique, including responses that explicitly expressed discomfort with the SRH term.
Takeaway: Common medical terms relating to SRH care can cause discomfort and gender-dysphoria for some SGM people. Intentional use of language provided by individuals that is specific to their experiences and identities can support affirming experiences within medical and research environments and improve the quality of those experiences for SGM individuals.
Ragosta S, Obedin-Maliver J, Fix L, Stoeffler A, Hastings J, Capriotti MR, Flentje A, Lubensky ME, Lunn MR, Moseson H. From ‘shark-week’ to ‘mangina’: an analysis of words used by people of marginalized sexual orientations and/or gender identities to replace common sexual and reproductive health terms. Under review.
Pregnancy experiences and intentions
Key findings: Of the 1,694 TGE study participants who provided pregnancy-related information, 12% had been pregnant at least once, with some reporting multiple past pregnancies. Across all participants, 433 pregnancies were reported, of which 54% were characterized as unintended. Of all pregnancies, 39% resulted in a live birth, 33% ended in a miscarriage, 21% ended in abortion, 0.5% ended in stillbirth, 0.5% were ectopic pregnancies, 2% were still pregnant at the time of the study. Eleven percent of participants wanted a future pregnancy, and 16% unsure about a future pregnancy.
Takeaway: TGE and intersex people experience intended and unintended pregnancy, actively plan for family building, and experience the full range of pregnancy outcomes including birth, miscarriage, and abortion. Thus, TGE and intersex people need access to high-quality and gender-affirming clinical care that accounts for the full range of pregnancy circumstances, intentions, and outcomes.
Moseson H, Fix L, Hastings J, Stoeffler A, Lunn MR, Flentje A, Lubensky ME, Capriotti MR, Ragosta S, Forsberg H, Obedin-Maliver J. Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey. International Journal of Transgender Health. 2020 Nov 12:1-2.
Key findings: Of the 1,694 people who provided information about their contraception use, 71% had ever used birth control. The most frequently reported reasons for using contraception were to prevent pregnancy (49%), prevent symptoms of a period (39%), stop one’s period (32%), and prevent STIs (26%). These reasons were similar between those who had never taken testosterone, those who had taken testosterone in the past, and those who were currently taking testosterone at the time of the survey.
Takeaway: TGE people assigned female or intersex at birth have sex that can result in pregnancy, and use birth control for a range of reasons, including to prevent unintended pregnancy, STIs, and to manage or prevent symptoms of a period.
Key Findings: Of the 433 pregnancies reported by TGE people assigned female or intersex at birth in our study, 21% ended in abortion. Sixty-one percent of abortion procedures were surgical and 34% were medical. However, participants indicated a preference for medical over surgical abortion 3:1 if they were in need of an abortion today, indicating a possible misalignment between method preference and access. In addition, although most abortions took place before 10 weeks of pregnancy, 21% took place at 10 weeks or later in a pregnancy, ruling medical abortion out for most people. The most common recommendations to improve abortion care for TGE people included using gender-neutral or -affirming language in intake forms and staff/patient interactions, and using intake forms that are inclusive and affirming of all sexual orientations.
Takeaway: TGE and intersex people seek out and obtain abortion care despite barriers to access that are compounded by the gendered cis- and hetero-normative environments of many “women’s health clinics.” Barriers to gender-affirming care may be contributing to a discrepancy between the abortion method preferred by TGE and intersex people and what they are able to access.
Moseson H, Fix L, Ragosta S, Forsberg H, Hastings J, Stoeffler A, Lunn MR, Flentje A, Capriotti MR, Lubensky ME, Obedin-Maliver J. Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States. American Journal of Obstetrics and Gynecology. 2021 Apr 1;224(4):376-e1.
Key findings: Thirty-six percent of TGE study participants who’d ever been pregnant reported considering ending a pregnancy on their own and of those, 19% had attempted to do so. Reasons for managing one’s own abortion without clinical supervision included efficiency, desires for privacy, and structural barriers to care including lack of health insurance coverage, legal restrictions on abortion, and mistreatment or denials of care.
Takeaway: TGE and intersex individuals attempt to end their own pregnancies without clinical supervision for increased privacy and in response to structural barriers to abortion care and discrimination.
Moseson H, Fix L, Gerdts C, Ragosta S, Hastings J, Stoeffler A, Goldberg E, Lunn M, Flentje A, Capriotti M, Lubensky M, Obedin-Maliver J. Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States. BMJ Sexual & Reproductive Health. Published Online First: 04 March 2021. doi: 10.1136/bmjsrh-2020-200966
5 Policy Opportunities Identified in the Research
- Use gender-inclusive language when drafting legislation to specifically include sexual and gender minorities where applicable and to avoid unintentional exclusion of populations for whom policy protections may be particularly important.
- Advance proactive legislation to protect against physician refusals of care based on gender or sexual orientation.
- Support measures to require comprehensive insurance coverage that does not exclude coverage based on gender markers and prevents against unnecessary denials of care, thereby supporting access to the full spectrum of sexual and reproductive healthcare for TGE and intersex people.
- Repeal abortion bans and advance proactive legislation, such as bills to expand telemedicine for medical abortion provision and to increase medical abortion availability, in order to uphold the right to abortion care and ensure access to safe abortion care for all people.
- Support measures to make contraception and medication abortion available over-the-counter in the United States, thereby expanding access for all people and removing barriers to contraception and abortion for people who may encounter discrimination and stigma in healthcare settings.
Bookmark these resources:
- Research briefs and one-pagers on Inclusive Sexual and Reproductive Health from Ibis Reproductive Health
- Research Project Site: Understanding the Contraceptive and Abortion Needs and Experiences of Transgender and Gender Expansive People in the United States
- Trans-Centered Reproductive Justice resource page (Positive Women’s Network)
- A Call to Action: LGBTQ+ Youth Need Inclusive Sex Education (SIECUS: Sex Ed for Social Change, URGE: Unite for Reproductive & Gender Equity Advocates for Youth, Answer, Black & Pink, the Equality Federation, GLSEN, the Human Rights Campaign, the National LGBTQ Task Force, and Planned Parenthood Federation of America)
For more information or connections to research experts on the sexual and reproductive health needs of transgender and gender expansive people please contact [email protected]