Challenging assumptions about sexual identity in family planning

Sexual identity does not always match sexual behavior and practice. In one study, one in three women attending family planning centers for contraception identified as a sexual minority (not strictly heterosexual) (Everett 2018). Compared with their heterosexual peers, women who are not strictly heterosexual have an elevated risk for unintended pregnancy (Higgins 2019). Providers should avoid assumptions about care based upon sexual identity, learn to take a thorough sexual history, and offer contraceptive and pregnancy options counseling to all patients regardless of sexual orientation. 

Gender identity and pregnancy

Everyone has a gender identity—an internal understanding of our gender—and thus, patients across the gender spectrum may require sexual, reproductive, and pregnancy-related care. The term “cisgender” is used to describe someone whose gender identity aligns with the sex assigned to them at birth. “Transgender” or “trans” is an umbrella term for people whose gender identity does not correspond to the sex assigned to them at birth or with the gender expectations associated with that sex (Transgender Law Center 2011). Trans and gender diverse (TGD) people are clinically underserved, and face barriers to both routine health care and transition-related care such as a lack of insurance coverage and mistreatment by health care providers (James 2016). 

TGD patients with ovaries and a uterus may want or need contraception, and can experience desired and undesired pregnancy and abortion if they engage in sex with a partner who produces sperm, even after social and/or hormonal transition and regardless of whether they are menstruating. Testosterone does not act as a contraceptive (Light 2018, 2014).

In order to support gender-affirming patient-centered care, providers should create a space that is welcoming, use inclusive language, and perform physical exams that consider the potential physical and emotional discomforts specific to these patients (Bonnington 2020). Implementing a gender-affirming approach to pregnancy options and abortion care is critical to creating a such an environment for TGD clients (Richards 2014). Note that patients’ names and gender identity may not be accurately reflected on their identification, medical record, or insurance documents. Avoid making assumptions around clients’ anatomy and identity, and consider patients’ potentially negative prior experiences with gynecological care.

In addition to the resources below, we also encourage you to reach out to your local resources. 

Counseling for People with Disabilities

Approximately 15% of people worldwide and 25% in the U.S. who have one or more disabilities, of whom <5% experience significant difficulties in functioning (WHO 2020, CDC 2020; note differences likely represent reporting).  A disability can be defined as any long-term physical, mental, intellectual, or sensory condition which substantially impairs a person’s full participation in society on an equal basis with others (United Nations 2014).

People with disabilities have the same sexual and reproductive health needs as the general population however are less likely to receive contraception counseling, STI testing, pap tests, mammograms and prenatal care (Taouk 2018). People with disabilities are at higher risk of sexual assault and of contracting HIV.  They face significant barriers to accessing comprehensive reproductive health care.  Barriers can include a lack of provider training, provider bias, incorrect stereotypes (i.e. they are not sexually active or at risk of pregnancy), or inaccessible health care facilities and equipment (Taouk 2018).

Disabled people are often mistakenly viewed as passive health care participants who are incapable of independent decision making. A range of counseling approaches can be used depending on the individual’s needs, ranging from shared decision making to supportive decision making.  Supportive decision making is an alternative to guardianship as it allows people to choose someone, whenever possible, they trust to assist them with making decisions regarding specific topics (NDRN 2019).

Contraceptive discussions should be guided by a reproductive justice framework, which honors the right of people to decide if and when to parent, and subsequently when to contracept (See Ernst 2020 and Contraceptive Counseling in Chapter 7). Extreme caution should be taken to avoid coercive contraceptive care that propagates stratified reproduction, referring to policies and practices that have historically devalued the fertility of marginalized communities. The following helpful video reviews contraceptive counseling for patients with disabilities (University of Michigan 2017).

Many guardians will request contraception or even permanent sterilization for patients with cognitive impairment, either for hygiene purposes or to avoid pregnancy. Providers should always assume intellectual capacity and decision making regarding these requests.  In cases of mild to moderate cognitive impairment providers should request patients be seen without their guardian to best assess the patient’s personal wishes. Permanent sterilization of patients with severe cognitive impairment is always an ethical dilemma and providers should seek guidance from an experienced ethics committee when faced with such requests (ACOG 2016).

Special Considerations

  • Assume intellectual competence- do not mistake speech impairment for intellectual incapacity; patients may have motor impediments that can hinder articulation.
  • In adolescents/young adults with mild to moderate cognitive impairment, sexual health screening questions should be done without the parent/guardian present.
  • Advocate for inclusive facilities/ equipment – ensure there is at least one space available in waiting areas for patients who use a wheelchair. If space is limited, plan ahead and move chairs to accommodate any patients scheduled who use a wheelchair.
  • Consider having at least one mechanically adjustable exam table with leg rests as opposed to heel rests. Some have extra padding or velcro that can be helpful.
  • Ask the patient how to best assist in transferring from a wheelchair to the exam table, and consider alternative positions for gynecologic exams.
  • Allocate extra time for visits so that the patient’s needs are appropriately addressed.

Early pregnancy loss

If a pregnancy loss is diagnosed, be sure that the patient understands the diagnosis, implications, and various management options. Reassure the patient that most pregnancy loss is caused because the pregnancy was not developing correctly, not because of something they might have done, thought, or wished for. Do not assume how a patient will feel. Some patients feel relief, others sadness or guilt, and others may have concerns about their health or fertility. Clients may also feel a number of emotions simultaneously. See Chapter 8, Counseling Tips for Early Pregnancy Loss.

Multiple pregnancies

Multiple pregnancies currently makeup approximately 2-3% of all pregnancies but occur at higher rates with assisted reproductive technologies and increasing maternal age. Miscarriage and complication rates are higher among multiple pregnancies. It is common to discover previously unrecognized multiple gestation during the ultrasound evaluation. Some patients may want to know if they have a multiple pregnancy, others may not. Anecdotally, this information may occasionally change a patient’s decision in either direction. Unless local law requires viewing or describing ultrasound findings, routinely ask each patient if they would want to know about multiple gestations prior to the ultrasound, so you can honor their wishes. Selective reduction is also an option in some settings.

Contraception counseling in the setting of abortion care

It can be helpful to offer contraceptive counseling while remaining aware that some patients prefer not to discuss contraception at the time of abortion (Matulich 2014, Kavenaugh 2011). Patients from historically marginalized communities may feel coerced to use contraception in abortion settings (Brandi 2018), making it particularly important to give patients enough time to think about choices. Advanced notice of method availability has been shown to be acceptable, and provides abortion patients more time and knowledge for decision-making (Roe 2018). Those who do desire contraceptive counseling report wanting to hear about methods that are easier to use and more effective than previous methods and want to leave the clinic with a method (Matulich 2014). See Chapter 7: Evidence-Based Contraceptive Guidance.

Reproductive coercion

Reproductive coercion (RC) is common. Internationally, nearly 20% of respondents in family planning clinics reported previous pregnancy coercion and 15% reported birth control sabotage by a partner (Grace 2016, Silverman 2014). RC may include explicit attempts to pressure a partner to have sex without a contraceptive method, either explicit or covert interference with contraceptive methods, or attempts to control outcomes of a pregnancy. RC can come from intimate partners, family members, clinicians, or community members. These actions limit patients’ reproductive autonomy and compromise their ability to make decisions around contraception, pregnancy, and abortion. While many clinical settings have integrated intimate partner violence screening tools, it may be challenging to identify subtler acts of power and control in relationships.

In addition to asking generally about your patient’s support people, you might ask them if anyone has tampered with or prevented their contraceptive use or is pressuring them to make a decision about this pregnancy. Offer support and resources if they are being coerced.

Sexual trauma

It is common to encounter patients who have experienced sexual trauma such as sexual abuse, rape, incest, or human trafficking. These individuals may have had little control over the abusive situation and are likely to feel especially vulnerable and powerless.

Some groups are particularly at risk of sexual trauma. Transgender individuals as well as those with disabilities are two-three times more likely to be raped (Office of Justice Programs 2014, Basile 2016). In addition, victims of human trafficking are often forced or tricked into working in dangerous conditions or having sexual contact with others against their will. Trafficking occurs in every country. It is estimated that 80% of trafficking victims are female, over 50% are children, and 40% are within the person’s country of origin (NCADV 2014). Many victims of sex trafficking do not recognize that they are the victims of trafficking and may simply believe they are in a bad situation, relationship, or job, and are often at high risk of unplanned pregnancy (Lederer 2014). It is important to screen for sex trafficking and have a planned response to assist. See Adult Human Trafficking Screening Tool and Guide

If a patient discloses they have been raped, consider supporting them by suggesting:

  • “This isn’t your fault. No one ever deserves for this to happen to them.”
  • “I’m so sorry that happened to you.”
  • “Thank you for telling me; you’re brave to do that.”
  • “I want you to know that you are safe here. We will take good care of you.”

If any patient is interested in reporting a sexual assault, access the sexual assault service providers most familiar with your local reporting laws and counseling. Consider developing and instituting forensic policies and procedures.

Self-managed abortion

Self-managed abortion is when a person chooses to end their pregnancy entirely outside of a medical setting. It is known to occur in every country worldwide irrespective of the legal climate surrounding abortion (Moseson 2019). Reported reasons include perceived greater bodily autonomy, distrust of medical providers and/or institutions, social stigma, cost, distance, and legal restrictions. For some it is preferred while for others, it is their only option. Methods have included safer methods such as misoprostol alone or with mifepristone, as well as herbs and objects or substances inserted into the vagina or cervix, and deep abdomen massage. While self-managed abortion is not new, medication abortion has changed how we think about it, by offering methods proven to be simple, safe, and effective (Jones 2019).

Additional resources:

Responding to challenging patient questions

It can be challenging to respond to complex patient questions. Here we will review some of the most common questions that arise. General guidelines are that you: 

  • Remain sensitive to both verbal and non-verbal expressions of emotion
  • Validate the patient’s feelings
  • Mirror the patient’s language (for example, if the client uses the term “procedure” for abortion, use the term “procedure.”)
  • Avoid assumptions and ask clarifying questions to assess patient’s specific question
  • Provide accurate information

“What do you do with the baby after the abortion?”
Providers might say, “A lot of patients ask about that. Can you tell me a little more about what is concerning you?” Consider responding, “I examine the pregnancy tissue to make sure that you are no longer pregnant.” If there are follow up questions you can say the pregnancy tissue is handled like tissue from any medical procedure. Sites have different policies for handling tissue based on local and hospital policies. You could say, “We send the tissue to the pathology lab if there is any concern, and otherwise it is handled similar to cremation.”

“Can I see it?”
In first-trimester abortion, many providers explain the process of fetal development and show the patient the pregnancy tissue if asked. Consider describing what the pregnancy tissue looks like at that stage, so they can make an informed choice about seeing it.

“Will this hurt the baby?”
Evidence regarding the capacity for fetal pain indicates that fetal perception of pain is unlikely before the third trimester (Lee 2005). For patients having a first-trimester abortion procedure, explaining the facts may alleviate this concern. For example, “At this point in the pregnancy, the fetal nervous system is still not developed enough to feel pain.”

Post-procedure support

After the procedure, you can reassure the patient that everything went well and that they are no longer pregnant. Let them know that the cramps they are feeling are a sign that the uterus is healthy and returning to its non-pregnant size. Reassure them that emotions arising with abortion are normal.

Reassure them that your staff will be available to them. They can be offered a follow-up visit if desired or you think it would be helpful, especially if there is relationship continuity. However, it is not usually indicated (Grossman 2004). Additional ideas:


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