All people, including those who identify as lesbian, gay, bisexual, transgender and queer (LGBTQ), need sexual and reproductive health care. LGBTQ health issues and sexual and reproductive health care are inextricably linked, because they both involve individuals’ autonomy in their most intimate decisions. Unfortunately, the health care system in the United States has historically failed and largely continues to fail the LGBTQ community, as LGBTQ people experience major disparities in sexual and reproductive health care and worse health outcomes than the population overall. These differences are due to a series of barriers in the health care system, including fragmentation of health services, discrimination from providers and insurance issues, all of which can be exacerbated by racism and intersecting oppressions. Fortunately, sexual and reproductive health care providers can and do help to address these barriers, taking steps to make tailored, appropriate and lifesaving reproductive health care a reality for millions of LGBTQ people across the country.
Sexual and Reproductive Health Needs
LGBTQ people need and deserve excellent sexual and reproductive health care. Those who identify as LGBTQ are not a monolithic population, and people within that community have different needs, experiences with barriers and levels of access to care.
Sexual and reproductive health care services are crucial components of a holistic picture of health care for LGBTQ people. In particular, all people who are capable of becoming pregnant—which may include queer women, transmasculine people and nonbinary people—may have a need for full-spectrum pregnancy, family planning and abortion care.
A Guttmacher study estimated that several hundred transgender and nonbinary individuals obtained abortions nationally in 2017, primarily at facilities that did not provide transgender-specific health care. LGBTQ people may also need care related to infertility and assisted reproductive technologies, and transgender women and men may have a need for fertility preservation services. Further, LGBTQ people may need STI and HIV testing and treatment; mammograms, Pap smears and other services related to reproductive cancers; screening and support for intimate partner and sexual violence; and gender-affirming services.
Several leading sexual and reproductive health associations have recognized these needs and have begun to integrate reproductive and sexual health for LGBTQ patients into their policies and guidelines. For example, the “Providing Quality Family Planning Services” guidelines set by the Centers for Disease Control and Prevention and U.S. Department of Health and Human Services Office of Population Affairs call for a person-centered approach that integrates the needs of LGBTQ patients. The American College of Obstetricians and Gynecologists has adopted a number of position statements on transgender health, which call for providers to create a welcoming environment for transgender patients and introduce the concept of gender-affirming care. However, these guidance documents for providers have room for expansion in emphasizing contraceptive services and other reproductive health care for LGBTQ patients. Recently, the Society of Family Planning published clinical recommendations on contraceptive counseling for transgender and gender-diverse people, recognizing the need for a tailored approach to contraceptive services for these patients.
Sexual and Reproductive Health Disparities
LGBTQ patients experience disparities in sexual and reproductive health care and outcomes. A recent study suggests that queer people who can get pregnant (except lesbians) are more likely than their straight counterparts to have an unintended pregnancy, a pregnancy when younger than 20 or an abortion, a finding that may suggest structural barriers to contraceptive care and a need for LGBTQ-inclusive comprehensive sex education. Research has shown that lesbian and bisexual women are less likely than straight women to perceive themselves as being at risk of acquiring STIs, a perception associated with minimized use of preventive reproductive health services.
Other research has found queer women do not access routine preventive screenings for breast cancer and cervical cancer at the same rate as their straight peers. These differences in perception and action regarding sexual and reproductive health services can lead LGBTQ individuals to have fewer diagnoses and treatments than their straight counterparts.
The COVID-19 pandemic may exacerbate the disparities LGBTQ people already experience. A recent Guttmacher study found that 46% of queer women reported pandemic-related delays or cancellations of contraceptive or other sexual and reproductive health care compared with 31% of straight women. The study also found that queer women were more likely than straight women to report wanting to delay childbearing or have fewer children.
Barriers to Care
The health care system in the United States has historically failed and largely continues to fail LGBTQ people, with LGBTQ patients experiencing health disparities across the lifespan because they face multiple, and often compounding, barriers to accessing appropriate care. Barriers for LGBTQ people specifically related to sexual and reproductive health care include systemic infringements on their dignity and right to access health care, and those often play out in the legal and policymaking realm.
At the individual level, there are flaws in how the health care system is structured and how health care providers and institutions operate in the forms of a fragmented system, discrimination and lack of provider training, and insurance barriers that impede access for LGBTQ patients, particularly those who face multiple layers of oppression.
Lack of integration in health care. There is fragmentation across the U.S. health care system, and services for LGBTQ people are often separated from sexual and reproductive health care due to structural and funding divisions as well as harmful heteronormative assumptions. (A heteronormative worldview centers straight people and relationships, such as by assuming that queer women do not need birth control.) As a result, LGBTQ people often do not receive comprehensive sexual health counseling, screenings or care, because providers assume they do not need certain services or information.
When it comes to LGBTQ patients, health care systems and providers have historically prioritized HIV/AIDS prevention and treatment, which largely centers men who have sex with men, and more recently have focused on gender-affirming care for transgender people. These types of care are crucial, but do not represent the whole picture of sexual and reproductive health care that LGBTQ individuals need.
Although many leading organizations have made progress in identifying the importance of sexual and reproductive health care for LGBTQ patient populations, significant guiding documents exist that do not meaningfully address this topic. Among these is the World Professional Association for Transgender Health’s globally authoritative 120-page “Standards of Care” document, which dedicates a scant page and a half to reproductive health guidance.
Discrimination and lack of cultural competency. The health care system is unfortunately rife with anti-LGBTQ discrimination: Majorities of queer and transgender patients report having experienced discriminatory treatment by health care professionals, and nearly a quarter of transgender patients have delayed seeking health care because of the fear of being mistreated. The health care sector broadly struggles with, but in many ways is working to address, issues of cultural competency—“the ability of systems to provide care to patients with diverse values, beliefs and behaviors,” according to the American Hospital Association.
Many sexual and reproductive health care providers have good intentions yet lack cultural competency and training to adequately address LGBTQ patients’ needs and make them feel comfortable in a medical setting. Stories abound of LGBTQ patients having bad experiences while seeking sexual and reproductive health care. For instance, providers often give contraceptive counseling based on their assumptions about a patient’s sexual behavior, and noncontraceptive benefits of birth control may not be taken into account.
These biases undermine LGBTQ patients’ contraceptive care by assuming they are not at risk for pregnancy or STI transmission. Untrained providers also may fail to address a particular concern for transmasculine and nonbinary patients about how hormonal birth control containing estrogen or progesterone may interact with gender-affirming testosterone, and whether testosterone alone is a contraceptive (it is not).
Lack of cultural competency goes beyond the exam room. The vast majority of queer and transgender youth do not see themselves reflected in sex education—only 7% of LGBTQ students report receiving sex education that includes positive representations of both sexual orientation and gender identity topics.
Insurance barriers. In general, LGBTQ patients are more likely than straight patients to be uninsured. Even patients who have health insurance and visit medical providers who provide competent care may still face insurance denials because of gender markers in their patient profile. For example, an insurer could deny coverage for a transmasculine person seeking birth control because contraceptive care does not align with what the insurance plan categorizes as “male” or “men’s” health services.
Intersecting oppressions. People who experience intersecting oppressions have worse health outcomes overall than those who do not. Barriers to obtaining sexual and reproductive health care can be high for LGBTQ people who are Black, Indigenous or other people of color, those with disabilities, immigrants and those who are low income, as they face layers of systemic marginalization. In the Guttmacher study on early impacts of the COVID-19 pandemic on reproductive health, unpublished data from the small number of queer women in the sample showed that more women of color than White women reported wanting to delay or reduce childbearing and having to delay or cancel sexual and reproductive health care, including contraceptive care.
There is much more work to be done to ensure that LGBTQ people have the resources, information and care they want and need from a culturally competent, affordable, affirming, inclusive and accessible sexual and reproductive health care system. But there are signs of progress. Increasingly, health care providers and administrators are integrating sexual and reproductive health care for LGBTQ patients into their practices in order to break down silos and ensure access to excellent care. One such promising step is family planning providers increasingly offering gender-affirming care, such as hormone therapy, to their patients. In recent years, state policymakers and advocates have also championed policies and curricula to implement LGBTQ-inclusive sex education.
The sexual and reproductive health field still has work to do. Provider associations should revisit and more meaningfully integrate sexual and reproductive health care for LGBTQ patients into their positions, guidelines and policies. Providers should continue service delivery innovations—such as telehealth or app-based care—that have expanded and accelerated access to gender-affirming services. Sexual and reproductive health care organizations should continue to adopt gender-inclusive language to demonstrate they are welcoming and experienced in serving LGBTQ patients. Individual health care practitioners should adopt an inclusive approach by offering culturally competent, unbiased care, rooted in the understanding of barriers that exacerbate health disparities for LGBTQ people.
Health care for LGBTQ people and sexual and reproductive health care are both constantly scrutinized, criticized, withheld and stigmatized—largely for ideological reasons—and while each faces unique challenges, they are closely linked by a shared value of bodily autonomy. Sexual and reproductive health advocates must stand in support of LGBTQ patients and ensure they receive health care that is tailored for their individual and unique needs.