Best practices in sexual and reproductive health care for transgender and nonbinary people

INTRODUCTION

The most precious and sacred form of personal information that we possess is our body. Thus, it is not surprising that visiting a health care provider and allowing for the intricate inspection and examination of our body is a source of trepidation and anxiety for most people. Perhaps the deepest level of vulnerability is an examination of the genital area. As such, sexual and reproductive health (SRH) represents one of the most vulnerable, personal, and sensitive areas of health care. For transgender and nonbinary (TNB) people this level of intimacy and sensitivity is amplified by interacting with a system that has enacted historical and current abuses at the individual and structural levels on TNB bodies. As a result, provider proficiency in the SRH needs of TNB people is an essential area of knowledge and study.

Significant structural and interpersonal barriers to SRH have been well documented among TNB people (American College of Obstetricians and Gynecologists, 2011; Hughto et al., 2018). The nature and extent of health disparities for TNB people is a rapidly expanding area of research as despite their small numbers, TNB people are a population with substantial adverse health indicators. These health inequities and disparities are likely multifactorial, with risks including structural social and economic marginalization, discrimination, and violence, including in health care settings (Reisner et al., 2016).

Allostatic load

Allostatic loads refers to how chronic life stressors, including traumatic stress, impact individuals’ health via physiological responses to such chronic stressors (McEwen,

1998). The concept of allostatic load has been applied in research across various disciplines, and findings have generally confirmed that cumulative effects of social and environmental stressors increase the risk of adverse mental and physical health, particularly among vulnerable populations (Rosemberg et al., 2017). Briefly, when exposed to persistent external stressors, the endocrine system and the sympathetic nervous system are chronically stimulated, altering cardiovascular, metabolic, and inflammatory systems. The concept of allostasis is also useful when looking at outcomes related to SRH. These include increased risk for adverse pregnancy and birth outcomes, such as preterm birth (Lu et al., 2010; Wallace & Harville, 2013) and mortality from breast cancer (Parente et al., 2013).

Given that TNB people experience stigma in numerous contexts throughout their lives, it is likely that these experiences take a similarly additive toll on most aspects of their health. Many TNB people experience the cumulative allostatic load that comes with coping not only with transphobia, but also with racism, ableism, and other stigmatized identities. Despite this connection, there is a dearth of research exploring long-term physical health effects of stigma-related stress in TNB people, particularly with their SRH needs.

Health care systems and providers

One avenue in which stigma impacts TNB people is access to insurance. In the U.S., insurance access is linked almost entirely to employment (Zimlichman et al., 2013). Many TNB people lack insurance, potentially due in part to higher prevalence of unemployment among TNB people relative to the general population (James et al., 2016), likely a direct result of employment discrimination (Miller & Grollman, 2015). Even for those with access, their insurance may make assumptions of what type of care they are eligible for based on legal sex, which may or may not match their assigned sex at birth. These complex markers can create barriers to accessing necessary SRH services, such as cervical cancer screening, breast cancer screening, prostate screening, and pregnancy care, as well as accurate testing and treatment for sexually transmitted infections. As a result, TNB people are often forced to go through lengthy processes to get these services covered or pay out of pocket (Sanchez et al., 2009).

TNB individuals experience discrimination in general health care settings at rates exceeding those experienced by cisgender individuals (Hughto et al., 2018), resulting in avoiding and delaying of seeking needed medical care (James et al., 2016). For more information on general health care discrimination, see Chapters 1 and 2. One issue is lack of provider training, and this is likely even greater in the area of SRH.

Lack of training may lead to providers performing extensive health histories and unnecessary exams out of curiosity, as opposed to providing necessary SRH care to TNB patients (James et al., 2016). Despite the value of Trans 101 trainings in providing perspective on caring for TNB people, culturally responsive clinical practice with TNB people - even unrelated to gender-affirming therapies - requires knowledge that exceeds this 101 level of education. Health care providers must understand the unique experiences related to minority stress and allostatic load that TNB people encounter and how these experiences relate to both SRH vulnerability and resilience.

 
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