Opportunities for improving abortion care: a key stakeholder analysis of best practices for addressing the needs of transgender, nonbinary, and gender expansive people seeking abortions

Abstract

Objectives

Transgender, nonbinary, and gender expansive (TGE) persons experience pregnancies and have abortions, yet abortion care remains rooted in a gender binary, often centering the needs, experiences, and challenges of cisgender women. Despite guidance supporting gender-affirming sexual and reproductive healthcare (SRH), barriers for TGE people seeking abortions persist. We conducted an exploratory case study with key informants to understand their perception of TGE abortion seekers' needs with specific considerations for those in restrictive abortion settings.

Methods

Qualitative interviews focused on gender-affirming care and abortion provision were conducted with U.S.-based key informant clinicians (n = 4) who could provide powerful insights into gaps and experiences faced by TGE individuals. Participants were eligible if they currently or previously provided abortions and had experience practicing gender-affirming care. Interviews focused on informants’ perceptions of TGE patients’ needs when seeking abortions.

Results

Findings highlight the unique barriers TGE patients face when seeking abortions, including lack of provider knowledge, in-clinic stigmatization, and gender marginalization. It is notable that key informants who practiced in abortion-protective political environments have greater access to resources to implement gender-affirming care than those in restrictive contexts. Results are summarized in a clinical recommendations document which provides an accessible starting point for clinicians to begin building gender-inclusive abortion spaces.

Conclusions

It is necessary to further understand barriers facing TGE abortion seekers and integrate recommendations and emerging evidence into abortion practice. This study contributes to a growing knowledge base which emphasizes the need for inclusive abortion spaces and highlights key considerations for improving access and quality for TGE abortions seekers.

Introduction

Transgender, nonbinary, and gender expansive (TGE) persons experience pregnancies and have abortions, yet abortion care remains rooted in a gender binary, often centering the needs, experiences, and challenges of cisgender women [1,2,3,4,5]. Worldwide reproductive justice and gender equity struggles are intertwined, as gender inclusion is often at the forefront of conversations surrounding abortion rights, inviting the opportunity to look at abortion rights within the lens of queer inclusion [6].

Gender-affirming care is a widely recognized medical intervention that can range from hormone treatments to affirming language which can increase social, emotional, and physical health outcomes among TGE individuals [4, 7]. The American College of Obstetrics and Gynecology recommends the use of gender-affirming care in abortion care [2, 4]. The World Professional Association for Transgender Health (WPATH) has emphasized the global importance of accessible abortion care and gender-affirming care for gender diverse individuals [5].

Despite clinical guidance supporting gender-affirming sexual and reproductive healthcare (SRH), barriers for TGE abortion seekers persist [2, 3, 5, 7,8,9]. According to the 2022 U.S. Transgender Survey, 24% of respondents reported not seeing a doctor when medically necessary and 48% reported a negative provider experience related to gender identity [10]. TGE patients similarly report high rates of mistreatment in SRH facilities, often heightened through intersections with other experiences of marginalization, particularly related to race, socio-economic, and insurance status [1, 2, 7, 9,10,11].

Some literature has reported the challenges of TGE abortion-seekers, yet little is documented on abortion providers’ awareness of access barriers or specific needs of this population [1,2,3]. To contribute, we conducted an exploratory case study with key informants to understand their perception of the needs of TGE abortion seekers with specific considerations for those in restrictive abortion settings in the United States.

Methods

From November 2022 to March 2023, we conducted an exploratory qualitative study with U.S.-based clinicians in gender-affirming care and abortion provision (n = 4), recruited through informal networks, who could provide powerful insights into gaps and experiences faced by TGE individuals. Participants were eligible if they currently or previously provided abortions and had experience practicing gender-affirming care. Key informants worked in SRH settings in different U.S. states: two in abortion-protective landscapes, and two in Southern and restrictive contexts. Three of the four key informants self-identified as queer, and one key informant self-identified as trans and nonbinary. Interviews (lasting 40–80 min) were conducted via Zoom^™; informants provided verbal consent at the start of the interview and did not receive compensation.

Interviews were informed by literature and focused on informants’ perceptions of TGE patients’ needs when seeking abortion and further understanding the influence of abortion restrictions on abortion provision. The first author transcribed interviews, then used MAXQDA 2022 to conduct coding and analysis. A codebook of deductive and inductive codes was developed, which informed a thematic content analysis specifically focused on TGE barriers and clinical best practices.

Results

All four key informants discussed barriers specific to TGE patients seeking abortions and provided recommendations on ways providers can create more gender inclusive abortion spaces. Three themes emerged from the data, exemplified by key informant quotes (Table 1) and summarized in a clinical recommendations document (Fig. 1).

• 1. All reproductive healthcare providers see gender expansive patients (whether they know it or not).

Table 1 Summary of key validation parameters of the three immunoassays and LC-HRMS method

Fig. 1

Clinical recommendations document synthesizing major themes from key-informant interviews, to provide steps for clinicians to begin creating more gender inclusive abortion care spaces [16,17,18]

Informants noted that providers may mistakenly believe they do not serve TGE patients. They emphasized that TGE patients are present in abortion spaces and need access to the full scope of SRH care provided to cisgender patients yet are sometimes not asked about gender identity. This inattention can result in lack of feelings of safety for patients to disclose gender identity, setting the stage for providers’ incomplete understanding of patients’ lived experiences and health profiles resulting in less than comprehensive care.

• 2. For TGE patients, abortion settings can be rigidly gendered and thus exclusionary spaces.

All informants acknowledged that general-access barriers for people seeking an abortion (e.g., transportation, cost, stigma) are present for TGE patients, who also face compounding barriers such as gendered clinic spaces, which create exclusionary environments. Clinics are setup to serve and prioritize cisgender women, evidenced by the utilization of the word “women” in many SRH facility names. Additionally, clinics may not have resources tailored to TGE abortion seekers such as materials in waiting rooms and post-abortion care documents. Internal systems may also lack diverse gender reporting options in their clinic forms, electronic medical systems, and protocols.

• 3. Context, resources, and lack of knowledge or training on gender-affirming care present additional barriers for patients.

Key informants stated that clinic staff may not have the training, skills, nor resources to compassionately provide care to TGE patients. Key informants noted that gender-affirming care is not standard in medical education, and therefore regular, consistent training was critically necessary for providers. Furthermore, key informants from Southern U.S. contexts discussed how restrictive abortion policies impacted their ability to prioritize care for TGE abortion seekers, juxtaposing the responses from providers in non-restrictive states who explained how more resources and energy can be dedicated to inclusive, patient-centered care for TGE individuals in their practices.

Discussion

Findings from this exploratory case study highlight the unique barriers TGE patients face when seeking abortions, including lack of provider knowledge and resources, in-clinic stigmatization, and gender marginalization. These findings illuminate the necessity to further understand barriers facing TGE patients seeking abortions and to integrate recommendations and emerging evidence for TGE patients into abortion practice. It is crucial that voices of the most marginalized, particularly from abortion restrictive settings, be centered in broadening the current knowledge base.

It is notable that key informants who practiced in abortion-protective political environments have greater access to resources and support than those in restrictive contexts [7, 12]. The two Southern U.S. key informants reported navigating complex laws that increase stigma and limit their ability to provide lifesaving SRH care. Abortion restrictions are compounded by the proliferation of anti-trans legislation sweeping the U.S. South, further constraining implementation of gender-affirming SRH care, thus, highlighting the need to prioritize context-specific solutions for TGE abortion care [13]. Themes that have emerged from providers in restrictive abortion contexts in the U.S. are relevant in global settings where abortion and SRH is limited, especially in settings where legacies of or current anti-trans and LGBTQ+ legislation impact TGE health [6, 14, 15]. The importance of addressing barriers to safe abortion care for TGE people is of global importance and must be addressed to increase health equity for those who are the most marginalized with the least access to care.

We assert that TGE inclusion in abortion care is essential. This study contributes to a growing knowledge base which emphasizes the need for inclusive abortion spaces and provides an accessible starting point for clinicians (Fig. 1) [1, 2, 6, 7]. It is essential to integrate current literature on this subject into practice and implement context-specific training for TGE care into abortion education for all SRH providers. This study was designed to be solely exploratory, focused on a small group of key informants and thus was not intended to be generalizable. While one of the four key informants self-identified as TGE, including additional perspectives of TGE stakeholders themselves is necessary to build on the results from this study. Furthermore, there is a need to understand perspectives outside the U.S. in both restrictive and non-restrictive abortion settings, especially given the difficulty of integrating these best practices in settings where TGE and LGBTQ+ identities are criminalized. Still, these results have highlighted key considerations for improving access and quality for TGE abortion seekers and should be expanded upon for future studies and in informing clinical, context specific recommendations.