{"id":2397,"date":"2023-09-25T16:21:46","date_gmt":"2023-09-25T16:21:46","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjsrh\/?p=2397"},"modified":"2023-10-01T14:59:32","modified_gmt":"2023-10-01T14:59:32","slug":"contraceptive-care-for-trans-nonbinary-and-gender-diverse-people","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjsrh\/2023\/09\/25\/contraceptive-care-for-trans-nonbinary-and-gender-diverse-people\/","title":{"rendered":"How can we Offer Better Contraceptive Care for Trans, Nonbinary and Gender-Diverse People?"},"content":{"rendered":"

By Tyne Baynton Cairns (They\/Them) & Julia Bailey (She\/They)<\/em><\/p>\n

 <\/p>\n

Contraceptive care guidelines are usually designed for cisgender, heterosexual women.\u00a0 In the heavily gendered context of contraceptive care, gender dysphoria is common among trans, non-binary and gender-diverse people. <\/span>\u00a0<\/span>In healthcare settings, gender dysphoria can be brought on by the environment, the behaviours of providers, and the contraceptive methods themselves.\u00a0\u00a0<\/span><\/p>\n

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Gender dysphoria<\/a> is the distress experienced from a societal misperception of a person’s gender identity (often described as an incongruence between sex assigned at birth and gender identity).
\n<\/em><\/h6>\n
In contrast,\u00a0Gender Euphoria<\/a>\u00a0is the joy experienced when one\u2019s gender identity aligns with gender expression, and is affirmed by others. It has been suggested that gender euphoria could be a\u00a0valuable framing<\/a> of gender diversity in healthcare.
\n<\/em><\/h6>\n<\/blockquote>\n
\n

We interviewed seven gender-diverse people in British Columbia, Canada, who were assigned female at birth to explore their views and experiences of contraception and healthcare. Participants were encouraged to outline what they considered to be contraception. Participants intentionally included dental dams and gloves as contraceptive methods, knowing they do not prevent pregnancy. The inclusion of gloves and dental dams was due to their protection against sexually transmitted infections (STIs), and sentiments that they center queer pleasure.<\/span><\/p>\n<\/div>\n

<\/div>\n
\n
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1. Accessibility of different contraceptive methods<\/strong><\/div>\n
<\/div>\n
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Copper Coils<\/strong><\/a>\u00a0and\u00a0Intrauterine systems<\/strong><\/a>\u00a0(IUS<\/b>s<\/b>,\u00a0<\/b>also called intrauterine devices (IUDs) globally)\u00a0<\/b>were less accessible due to insertion procedures, which were described as invasive and painful.\u00a0\u00a0Internal Condoms<\/a><\/b>,\u00a0Gloves<\/strong><\/a><\/b>\u00a0and\u00a0Dental Dams<\/strong><\/a>\u00a0were considered the least accessible by participants, as they were not often available in stores or clinics in Canada.\u00a0\u00a0The\u00a0Contraceptive\u00a0Injection<\/a><\/b>\u00a0and\u00a0Contraceptive Pill<\/strong><\/a>\u00a0required prescription appointments with physicians but were otherwise considered accessible.\u00a0\u00a0External Condoms<\/strong><\/a><\/b>\u00a0were the most accessible contraceptive method, as they were available in stores and freely available in clinics and universities.<\/p>\n

 <\/p>\n<\/div>\n<\/div>\n

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2. Contraceptive use: Empowerment<\/strong><\/div>\n<\/div>\n
<\/div>\n
\n

Participants used contraception to increase their bodily autonomy through empowerment in achieving a contraception-related goal (i.e., pregnancy\/STI prevention, gender affirmation) without sacrificing psychological or social safety.<\/span><\/p>\n

\u201cI learned you can insert [internal condoms several] hours before you use them, and, like, they\u2019re perfectly effective and, like, that is amazing [\u2026] all this agency was put into the hands of somebody who has \u2013 like, who has a vagina, to do what they want to protect themselves [\u2026] I\u2019m really scared of stealthing*, like, I\u2019m super like \u2013 cause like, it-it freaks me out that someone can just like betray you like that so. I like the idea of having a lot more control over that.\u201d<\/em><\/p><\/blockquote>\n<\/div>\n<\/div>\n

\n
<\/div>\n
*Stealthing is the removal of an external condom without consent<\/em><\/div>\n
<\/div>\n<\/div>\n
<\/div>\n
\n

 <\/p>\n

Different contraceptive methods carried varying levels of empowerment (<\/span>see Figure 1<\/b>).\u00a0 IUSs, copper coils, internal condoms, gloves and dental dams were associated with increased bodily autonomy.\u00a0 The contraceptive injection and contraceptive pill empowered those wanting to prevent pregnancy, but caused gender dysphoria in others due to their frequency of administration and hormonal content.\u00a0 External condoms did not increase participant empowerment; external condom usage was considered outside of participants\u2019 control if they were not the person wearing the condom.\u00a0 Fears of <\/span>stealthing<\/span><\/a>, and coercion into condomless sex, and other forms of sexual assault were serious concerns.\u00a0 Participants described an increased likelihood of coercion into condomless sex if they used an additional contraceptive method<\/span>.<\/span><\/p>\n<\/div>\n

\"\"<\/a><\/p>\n

Figure 1. Empowerment and Accessibility of Contraceptive Methods<\/strong><\/p>\n

 <\/p>\n

3. Access to Healthcare: Geographic and Financial Barriers<\/i><\/strong><\/p>\n

Primary care is responsible for most contraceptive prescriptions in Canada, complicated by a <\/span>national shortage<\/span><\/a> of primary care providers.\u00a0 Participants either did not have a primary care provider or travelled long distances (up to 6 hours) to see their provider.\u00a0 Long wait times posed a barrier, especially for contraceptive methods that require multiple appointments.\u00a0 Lack of insurance coverage for non-Canadian citizens impeded access to healthcare; one participant would travel to their country of citizenship for affordable contraceptive care.<\/span><\/p>\n

 <\/p>\n

4. Discrimination in Healthcare settings<\/strong><\/p>\n

Disclosing gender diversity to healthcare providers was seen as inviting discrimination.\u00a0 Discrimination was heightened for those who were <\/span>not<\/b> assumed cisgender, white, or did not have Canadian citizenship.\u00a0\u00a0<\/span><\/p>\n

\u201cIt does feel like add a layer of stress [\u2026] just like, I act very white when I\u2019m around people who don\u2019t like acknowledge my Asianness [\u2026] I\u2019ve gotten really good at compartmentalizing myself and so, my gender nonconformity is like, just another part of that.\u201d\u00a0<\/span><\/i><\/p><\/blockquote>\n

The historical and <\/span>ongoing<\/span><\/a> systemic<\/span><\/a> medical violence<\/span><\/a> against Indigenous peoples, Black people, and other people of colour made contraceptive care environments feel unsafe, deterring racialized participants from contraceptive care.\u00a0\u00a0\u00a0<\/span><\/p>\n

\u201cI think it\u2019s just, like, racialized medical things [\u2026] thinking about [the] medical experiments on black people, especially black women.\u00a0 And then I think about Indigenous women being forcefully sterilized \u2013 sterilized!\u00a0 And they\u2019re just like \u2013 I just feel like there\u2019s so much uncomfiness when it comes to AFAB people\u2019s bodies in the medical system and [specifically] contraception, [\u2026] I feel like I carry that anxiety with me in every interaction I go [through] for my contraceptive health.\u201d<\/span><\/i><\/p><\/blockquote>\n

Past experiences and fears of discrimination prevented participants from seeking contraceptive care.\u00a0 Participants relied on their community networks to find trusted providers, and were less likely to see unfamiliar providers (e.g., in walk-in clinics).\u00a0 Participants were less likely to advocate for their healthcare needs in hostile environments (e.g., staff <\/span>microaggressions<\/span><\/a>, <\/span>rejection<\/span><\/a> of patients\u2019 gender identity, <\/span>misgendering<\/span><\/a> and <\/span>deadnaming<\/span><\/a>, denial of healthcare, and physical or verbal abuse).\u00a0\u00a0<\/span><\/p>\n

\u201cI\u2019m also straight up terrified to [disclose my gender] just because I\u2019ve \u2013 so many people react so poorly, that I don\u2019t \u2013 I\u2019m so scared to lose a doctor in BC right now that like if I lose her or she like thinks it\u2019s a psychiatric issue like [\u2026] I\u2019m concerned, sometimes, if I fill [out my gender on forms] that it\u2019ll affect the level of care I get.\u00a0 Or how I\u2019ll be treated [\u2026] I need a doctor in BC \u2013 you can\u2019t find a GP right now, are you kidding me?\u201d\u00a0<\/span><\/i><\/p><\/blockquote>\n

Participants described exhaustion from constant self-advocacy \u2013 persevering through microaggressions, dismissiveness, hostility, denial of healthcare, and verbal and physical abuse.\u00a0 No participant filed reports of discrimination for fear that their provider would not be held accountable and their report could become public, endangering future healthcare.<\/span><\/p>\n

\u201cYou can\u2019t anonymously-anonymously submit [a complaint] [\u2026] What if that, like I don\u2019t know, [if] that info is mishandled?\u00a0 [\u2026] [what] if that info like gets back to the doctor? [\u2026] I didn\u2019t need that added stress, so that\u2019s why I didn\u2019t pursue anything.\u201d\u00a0<\/span><\/i><\/p>\n

 <\/p><\/blockquote>\n

5. (Dis)Trust of Healthcare Providers<\/strong><\/p>\n

Participants gathered information from their community on how different contraceptive side effects would influence gender dysphoria\/euphoria.\u00a0 Participants did not trust healthcare providers to provide accurate or relevant information; often, participants had to educate their healthcare providers on their needs.\u00a0 Providers were not trusted to consider the impact of contraceptive methods on comorbidities (e.g., mental health and autoimmune disease).\u00a0\u00a0<\/span><\/p>\n

\u201c[\u2026] now I don\u2019t trust what my doctors just straight up tell me, because people have warned me that the [IUS] was like this.\u00a0 People warned me about the pill and all this stuff.\u00a0 So now I just want first-hand experiences [from my community].\u201d\u00a0<\/span><\/i><\/p><\/blockquote>\n

Lack of representation of 2SLGBTQIA+ and racialized communities among healthcare providers hugely impacted participant experiences of psychosocial safety; participants described this as leading to feeling \u201c<\/span>like an interesting thing at the zoo<\/span><\/i>.\u201d\u00a0 Many participants were uncomfortable with their power dynamic with providers that were white, cisgender men, especially if the provider was less educated on gender diversity or displayed less consideration for their bodily autonomy.\u00a0 Ultimately, participants did not trust healthcare providers to protect their autonomy.\u00a0\u00a0\u00a0<\/span><\/p>\n

6. Participants\u2019 Recommendations for Contraceptive Care<\/strong><\/p>\n

Participants offered detailed recommendations for contraceptive care appropriate for gender-diverse people (see <\/span>Figure 2<\/b>).<\/span><\/p>\n

\"\"<\/a><\/p>\n

Figure 2. Participant Recommendations for Contraceptive Care<\/b>: <\/span>more primary care providers, healthcare provider\u00a0education<\/a>,\u00a0continuity<\/a>\u00a0of care, access to contraceptives, clinical\u00a0chaperones<\/a>, inclusive language (for patient\u00a0disclosure<\/a>\u00a0and\u00a0health-seeking behaviour<\/a>), shared\u00a0decision-making<\/a>, and trauma informed\u00a0contraceptive care<\/a>\u00a0in the context of prevalent\u00a0sexual violence<\/a>.<\/p>\n

\"\"<\/a><\/p>\n

Figure 3. Contraceptive Choices:<\/b>\u00a0<\/span>FSRH Guidelines: <\/span>Contraceptive Choices and Sexual Health for Transgender and Non-Binary People<\/span>, <\/span>Krempasky et. al\u00a0<\/span><\/p>\n

 <\/p>\n

7. What Does This Mean for Contraceptive Care?<\/strong><\/p>\n

Gender-affirming care <\/span>saves lives<\/span><\/a>, in <\/span>all healthcare sectors<\/span><\/a>.\u00a0 Contraceptive care can be <\/span>tailored<\/span><\/a> to the needs of gender-diverse patients and contribute to positive experiences, including gender affirmation.\u00a0\u00a0<\/span><\/p>\n

It\u2019s the individual workers.\u00a0 I try and keep faith [\u2026] I don\u2019t go into it trying to manifest that I\u2019m going to have a bad experience [\u2026].\u201d\u00a0<\/span><\/i><\/p><\/blockquote>\n

Making <\/span>contraception free<\/span><\/a> and freely accessible is a first step toward accessibility, and more must be done to ensure that gender-diverse communities can trust that they will receive appropriate and affirming contraceptive care.<\/span><\/p>\n

 <\/p>\n

Acknowledgements & About the Author<\/strong><\/em><\/p>\n

Thank you to my supervisor and principal researcher, <\/span>Dr. Julia Bailey<\/span><\/a> (she\/they), and co-supervisor <\/span>Dr. Anne Lanceley<\/span><\/a>.\u00a0 The people who participated in this study honoured us by sharing their experiences.\u00a0 We are profoundly grateful for their vulnerability and trust.\u00a0 Thank you for giving us your time and energy; thank you for teaching us.<\/span><\/p>\n

We acknowledge and respect the Songhees, Esquimalt, and W\u0331S\u00c1NE\u0106 peoples and the H\u0259n\u0313\u0313q\u0259min\u0313\u0259m\u0313 and S\u1e35wx\u0331w\u00fa7mesh speaking peoples on whose traditional, ancestral, and unceded lands this study took place.\u00a0 To learn more about how to actively contribute to Truth and Reconciliation, visit the Reconciliation Education <\/span>website<\/span><\/a>.<\/span>\u00a0<\/span><\/i><\/p>\n

Thank you to the people at the University of Victoria\u2019s Office of Indigenous Academic & Community Engagement for taking the time to help us write a respectful land acknowledgement.\u00a0<\/span><\/p>\n

This project was approved by University College London\u2019s Research Ethics Committee (UCL Ethics ID: 22083\/001) and received a waiver from Research Ethics BC in Canada.\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

By Tyne Baynton Cairns (They\/Them) & Julia Bailey (She\/They)   Contraceptive care guidelines are usually designed for cisgender, heterosexual women.\u00a0 In the heavily gendered context of contraceptive care, gender dysphoria is common among trans, non-binary and gender-diverse people. \u00a0In healthcare settings, gender dysphoria can be brought on by the environment, the behaviours of providers, and […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":472,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2599,2601,15153,15154],"tags":[],"class_list":["post-2397","post","type-post","status-publish","format-standard","hentry","category-contraceptive-methods","category-latest-research","category-sexual-health","category-transgender-health"],"yoast_head":"\nHow can we Offer Better Contraceptive Care for Trans, Nonbinary and Gender-Diverse People? - BMJ Sexual & Reproductive Health blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmjsrh\/2023\/09\/25\/contraceptive-care-for-trans-nonbinary-and-gender-diverse-people\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"How can we Offer Better Contraceptive Care for Trans, Nonbinary and Gender-Diverse People? 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