Transgender and gender diverse communities face many levels of barriers when seeking birth control services. They often face discrimination, showing up as explicit or implicit bias. Political hostility and wide-ranging laws that deny their human rights reinforce discrimination and restrict access to gender affirming care.
A new paper led by Yasaman Zia, PhD, used interviews with healthcare providers across the US to understand bias in contraceptive providers’ attitudes toward and interactions with transgender and gender diverse patients.
The interviews revealed several ways explicit bias manifests in contraceptive care for trans and gender diverse patients.
Reinforcing the gender binary in health care. Providers noted that clinics and healthcare systems were biased against patients. Electronic records systems and patient intake forms reinforced the idea that there are only two genders. These protocols and forms caused providers to use the wrong names and pronouns, creating a hostile environment for trans patients.
Limited understanding and experience. Many providers demonstrated bias that reflected discrimination and stigma, and little experience in caring for trans and gender diverse patients.
Tolerance falling short of acceptance. Several providers fell short of full acceptance and advocacy for patients’ needs, reflecting gaps in medical knowledge when providing care to transgender and gender diverse patients. They also noted a lack of training for the entire healthcare team, from front desk to medical assistants, creating an environment where transgender and gender diverse patients were not fully supported and welcomed.
Exoticizing and sexualizing transgender and gender diverse patients. One provider did this explicitly, including saying, "We’re in awe of like I mean he’s a good-looking man. I was like what, like this is crazy. So he probably received actually a lot of positive attention." This experience is common in the experiences of trans and gender diverse patients.
Implicit bias also showed up as a lack of awareness of the unique individual needs of transgender and gender diverse patients; some providers recognized these shortfalls.
Lack of understanding and experience. Providers frequently misused language to refer to transgender and gender diverse patients and/or lacked the correct terminology to refer to gender-affirming surgeries. They often conflated gender identity with sexuality.
Non-equitable approaches. Some responses reflected a one-size-fits-all approach to provider contraceptive care for patients. Providers may see themselves as approaching patients neutrally, amounting to a failure to treat a transgender or gender diverse patient as an individual with unique circumstances, needs, preferences, and goals.
Gaps in preparation to provide gender affirming care. While several providers expressed supportive attitudes and showed allyship for trans and gender diverse patients, their statements simultaneously showed large gaps in medical knowledge and cultural humility. Many of these gaps signified a lack of training, skills, and approaches for providing contraceptive care.
Providers shared ways to build rapport with trans and gender diverse patients through gender affirming sexual history-taking and gender affirming care. They demonstrated an understanding of people’s medical needs without conflating gender with body parts or making assumptions about the anatomy of patients and their partners, a patient’s identity, practices, or desires around contraception and sexual health. They shared that using gender affirming language in delivering inclusive care is achievable.
Some exemplified a culture of inclusivity that treats transgender and gender diverse patients with acceptance, respect, and humility. Providers reported actively seeking ways to build trust with patients and offer full acceptance of a patient’s gender.
Some providers shared ways that institutional advocacy supported their individual efforts to provide gender affirming care. For example, some mentioned removing gendered wording of clinics’ names, exam rooms, and procedures. Some described how removing burdens in navigating gendered paperwork creates a more inviting space for patients and communicates welcoming and belonging.
It's essential to recognize that providers operate within institutions and that institutional-level factors play a significant role in hindering or facilitating the delivery of equitable care to trans and gender diverse patients. Creating a trans-inclusive clinical atmosphere requires investments in waiting rooms and restroom access in addition to staff training.
Without institutional support, individual providers to be inclusive of transgender and gender diverse patients may fall flat. Training must be for all staff and be ongoing and mandatory. But training alone will not improve inequitable care and stigmatizing experiences. This research highlights many areas to focus advocacy to increase awareness of bias, dispel confusion about how to provide high-quality contraceptive care with updated research and evidence, and to integrate systemic changes within clinics to reduce the burdensome impacts of bias on transgender and gender diverse patients.