Looking Beyond the Binary: Addressing Reproductive Health Inequities for Birthing LGBTQ+ Individuals

In the United States, members of the queer community face exacerbated health care inequities in their pregnancy and postpartum care experiences and outcomes, as compared to their heterosexual and cisgender counterparts. From discriminatory treatment to exclusionary health care access, LGBTQ+ individuals and couples should be treated with the care, respect, and dignity they deserve. 

While Pride Month uniquely highlights the queer community’s ongoing fight for equality, it is crucial to also spotlight the reproductive health care crisis affecting LGBTQ+ individuals—especially those who are people of color, transmasculine, or gender-nonconforming. 

As systemic discrimination, stigma, and bias run unchecked, the LGBTQ+ community will continue to face worsening physical and mental health implications. Not only can uneducated providers impact the experience of birthing queer individuals, but an inability to access care or insurance coverage for reproductive services puts health and parenthood at risk. 

A system at fault: Discrimination, bias, and stigma

LGBTQ+ adults make up around 9.3% of the U.S. population and 3.8% of the Missouri population, according to data by Gallup and the UCLA Williams Institute. 

While these population percentages are small, they are not insignificant. These queer individuals are disproportionately experiencing disrespect and worse care.

A study by the Association of American Medical Colleges (AAMC) Center for Health Justice found that more than half (51%) of queer individuals felt their birthing care was impacted by bias or discrimination, as compared to 35% of straight, cisgender people. This deep-rooted inequity is perpetuated systemically by the overlooking of differing family structures and relationships, as well as insufficient training and education for health care providers. 

Missouri sees these reproductive inequities especially, as the state is ranked 43rd out of 51 for reproductive health outcomes according to Commonwealth Fund 2024 State Scorecard on Women’s Health and Reproductive Care. These include gestational mortality, infant mortality, as well as physical and mental health status. 

What’s more, a qualitative study on Black queer birthing individuals demonstrates the issue of OB-GYNs receiving lackluster training on queer reproductive health. Both providers and patients feel, and acknowledge, the lack of education, and “over 90% of sampled OB-GYNs report they desire more training in this area” (Adams and Ellithorpe, 1040). 

Health care providers are a vital part in determining one’s experience through pregnancy-–even more so for trans and nonbinary people. It is suggested that queer individuals can experience increased fear, misgendering, and gender dysphoria as a result of pregnancy. Pregnant transgender men may experience heightened mental and physical distress due to the changes in their bodies. Providers not trained to assess and treat this properly could potentially create a reluctance for queer individuals to seek proper care again. Environments can also create heightened stress, such as health care offices only having gendered bathrooms, or medical records lacking the ability to communicate preferred pronouns and gender.

Even though Missouri has the lowest percentage nationally of transgender individuals, they still face some of the highest levels of hate, bias, disrespect, and mistreatment by society in legislation and health care services. 

 

Barriers to Accessing Reproductive Health Care

To have children, queer individuals face many legal, medical, and systemic barriers across the United States and in the state of Missouri especially. Access to reproductive care is often limited due to a lack of insurance coverage, an inability to access fertility/reproductive services, and discriminatory legislation—especially for transgender and gender-nonconforming individuals. 

In Missouri, the current legislation surrounding insurance coverage reflects broader national trends—a systemic marginalization of queer individuals seeking health care. According to the Movement Advancement Project’s state equality profile, Missouri lacks several health care laws and policies relating to the LGBTQ+ community. 

For sexual orientation or gender identity, there are no private health insurance nondiscrimination laws, and no fertility treatment or fertility preservation coverage in Medicaid or private insurance. Additionally, there is no coverage or protection for individuals seeking transgender health care, and a negative law banning best practice medical care for transgender youth. 

These gaps in legal protection and coverage in Missouri create innumerable barriers for queer people. Individuals may not be able to afford to have a child through fertility services. Same-sex couples, transgender and queer individuals looking to become pregnant are disproportionately excluded from necessary financial and medical care.

Fertility and insurance expenses for queer couples in the U.S. are significantly higher than heterosexual couples due to insurance companies’ definition of infertility. Insurance companies do not consider fertility treatments as necessities, even though queer couples often do not have biological means for reproduction. These couples face additional financial burdens and barriers because they do not have equal access to fertility services such as intrauterine insemination and in vitro fertilization, or IVF.

Even if queer individuals have insurance and access to health care treatments, Missouri ranks 39th of 51 states in coverage, access, and affordability, as reported by the Commonwealth Fund. This category includes insurance coverage, provider accessibility, and health care affordability for Missourians. It reflects the poor state of reproductive services in Missouri, not including the unique challenges that marginalized individuals face at higher rates. 

Moreover, Black queer birthing people accessing reproductive care will face exacerbated barriers simultaneously, such as racism, homophobia, and transphobia. Research highlights how Black LGBTQ+ individuals struggle to find culturally competent care that acknowledges their queerness and supports the intersection of their identities. 

Black queer people face significantly worse birthing outcomes and medical experiences in the health care system. Several interview responses discussed mistreatment or a lack of education from OB-GYN and fertility providers, as well as worsening physical and mental health. However, the experiences weren’t completely negative, and some felt empowering support from providers. One participant in the study described their doula as “like my therapist if I’m being honest.” 

The insurance system is another complex aspect of pregnancy Black queer individuals must deal with. One person recounted their poor experiences, saying, “if you’re not careful, these people will ruin your life with bills, while you’re going through the medical system……but yeah, that was my worst experience, I think, is just dealing with the financial part of the insurance.”

Ultimately, a combination of financial, racial, political, structural, and medical discrimination makes achieving parenthood for queer Missourians not only difficult—but nearly impossible for many.

Mental and Physical Impacts

Queer individuals face nearly twice the rate of physical and mental health complications when accessing reproductive health care.They have more adverse health outcomes, “including miscarriage, stillbirth, preterm births, and infants with low birth weight.” These individuals also experience heightened complications returning to work and lactating as compared to straight people. Overall, 17% of LGBTQ+ individuals reported facing no complications as compared to 37% of straight individuals. 

Additionally, LGBTQ+ individuals were consistently more impacted by negative factors during their pregnancy, birthing, and/or postpartum experiences. These included individual health and well-being, economic stability, neighborhood and physical environment, and intimate partner violence. 

Another statistic by the Commonwealth Fund ranks Missouri 35th of 51 on health care quality and prevention and 43rd out of 51 for reproductive health outcomes. These categories include pre- and postpartum care, mental health care screening, physical/mental health status, infant mortality, and gestational mortality. 

An individual’s mental health may be at risk when experiencing significant life changes such as pregnancy. Queer people may be additionally affected as they often have worse socio-economic factors that additionally impact their pregnancy, birth, and postpartum experiences. 

A systematic review on the experiences of queer childbearing individuals and families found that their mental health was uniquely impacted during pregnancy, due to uneducated providers, hetero- and cisnormativity, exclusionary health care, and negative experiences surrounding the way pregnancy is tied to traditional ideas of gender. 

Queer individuals face unique challenges during their pregnancy, birthing, and postpartum period, which may make them more at risk for depression, anxiety, and emotional stress. The review has numerical information to support this topic, as “up to one in five people experience mental illness during pregnancy or the postnatal period.”

The review’s findings confirm that queer individuals have higher rates of low moods, depression, anxiety, trauma, PTSD, and stress. These disparities occurred due to challenging experiences conceiving through insemination and IVF, as well as fears about miscarriage. Experiences for transgender individuals were particularly distressing due to pregnancy-related medical procedures, providers’ lack of use of gender-inclusive language, and physical changes due to pregnancy. These individuals also reported higher rates of isolation and loneliness. 

LGBTQ+ individuals face compounded systemic and societal barriers to seeking mental health care. They often have providers who fail to recognize their experiences and provide affirming care. A general lack of social support then forces queer people to navigate these difficult experiences alone.

For queer individuals, they not only face medical disparities, but the physical and emotional toll of being pregnant in a system that consistently fails to meet their needs for inclusivity. 

The Importance of Language and Future Improvement

While many studies focus on general mistreatment in reproductive care for queer individuals, a study published this year shows that tools to assess discrimination toward queer birthing people need to be refined. The study examined three main topics, having LGBTQ+ individuals report their experiences in pregnancy with discrimination, autonomy and decision making, and respect. They found that these surveys worked well to document the specific inequities queer individuals faced. Implementing surveys similar to the ones created in the survey, rather than the current assessment tools, could prove essential in efforts to better the pregnancy experiences of queer individuals and families. 

Language matters, too. Maternal health is the catch-all term typically used to describe reproductive services or reproductive care for cisgender women. However, the health care industry’s common use of the term ‘maternal’ is explicitly exclusionary to those who don’t fall within this binary. While words and phrases such as ‘maternal’ may seem harmless, they have power, and can be weaponized against queer birthing individuals. 

This systemic heternormative and cisnormative bias, or emphasis on the labels of straight and cisgender as normal and preferred within the health care system, creates structural barriers for queer individuals and couples. 

Stigma surrounding sexual orientation or gender identity may make some hesitant to fully open up about their identity, potentially leading to unsatisfactory treatment and pregnancy outcomes. 

To make health care more inclusive, gendered phrases such as maternal care should be avoided. Reproductive care is an alternative phrase to broadly encompass the many aspects of having a child, including fertility treatments, family planning, perinatal, and postpartum care.

Curriculum by the American Academy of Pediatrics suggests more inclusive communication for childbirth, lactation, and infant feeding. Nongendered alternatives are inclusive of families with different dynamics and include: Family Care Unit, Peripartum or Postpartum Care, and Center for New Parents. Using gender-neutral terms like chestfeeding, nursing, or human milk can decrease gender dysphoria in transmasculine, nonbinary, and genderqueer birthing individuals. The most important thing to do is to use the preferred terms of the individual in communication.

Instead of referring to the gestational parent as ‘mom,’ health care providers should use phrases such as pregnant individual, birthing individual, or childbearing individual. Including gender-inclusive terms in one’s vocabulary—especially when interacting with those who don’t identify as a woman—can decrease the discrimination and anxiety associated with seeking reproductive health care.

It’s clear that improvements are needed. Increased access to mental health support, formal training for providers, and a better understanding of trustworthy organizations available to queer individuals is a start. Clinics and hospitals can also help the LGBTQ+ community by offering or guiding individuals to queer-specific resources that give insurance guidance and help to navigate fertility services. 

Additionally, strategies to improve care include “provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training, and tailored care.”

Implementing these improvements offers a path forward to better reproductive care and pregnancy outcomes for the LGBTQ+ community.