Years ago, when I was a training to be a doctor, a male patient during a routine yearly physical asked me, very directly, if we could talk about his fertility. I was taken aback, as I wasn’t expecting this—I usually got this question from women. I had only been trained to counsel mostly cis-women patients about female infertility and had very little training in the reproductive health needs of other gender identities. And that’s precisely how the cultural narrative around sexual and reproductive health is—targeted toward cis-women having heterosexual sex.
This inherent inequality, while not always intentional, can worsen the burden and oppression felt by all genders. As a family medicine physician who cares for people of all gender identities, I believe it’s time that we change our language and approach. We need to stop using the words “reproductive health” and “women’s health” as if they mean the same thing. They don’t.
“Women’s health” is understood to mean all of the needs of the uterus of cis-women. It refers to contraception, pregnancy planning, infertility, and abortion, to name a few. But when “women’s health” is used in place of “reproductive health,” it ignores all the other people—with or without a uterus—who have reproductive health needs as well.
Men, too, carry the responsibility for preventing and managing unplanned pregnancy. Many men, regardless of sexual orientation, want to have children and become parents. Men face the hardships of infertility, just as women do. Some men even have abortions. People of many gender identities may want to avoid pregnancy, or may want to become pregnant. Reproductive health includes everyone and therefore the onus needs to be on everyone.
My argument is not intended to rob cis-women, or anyone, of their rights. It’s an attempt to reframe reproductive health so that we can start to make it more accessible and inclusive. The core of the frustration that fuels Women’s Marches and protests lies in the oppression of patriarchal policies that focus on religious ideology—ones that award more rights to an unborn fetus than to the person carrying the pregnancy. With the advent of the birth control pill and abortion, women were given more options to control their fertility when condom or withdrawal negotiation was not always possible. This meant access to achieving educational and career goals and a sense of freedom from the home. But somewhere along the way, a woman’s right to use birth control turned into solely woman’s responsibility to use birth control, which is not fair and not inclusive.
By siloing reproductive health as a “women’s” health issue, we play along with the myth that it’s just cis-women making decisions about sex and reproduction, independent of any outside factors. In real life, there is often consensual input from partners, plus cultural mores and religion to consider, not to mention career aspirations. Sometimes, unfortunately, these decisions are not made by women at all (as in the context of sexual assault or other power dynamics). When a person comes into my office, I recognize that their experience with sexual and reproductive health is layered by so much that I have to consider these factors.
The other day, I had a patient who was Pakistani and Muslim, who told me that she was pregnant and didn’t want to be. She and her fiancé chose to have an abortion because, while they wanted to become parents, doing so before marriage would mean they'd both be disowned by their respective families. While she was the one carrying the pregnancy, her family, her culture, and her (male) fiancé were all part of that decision.
Other genders have intersectional experiences with their reproductive health decisions as well—we’re just not talking about it enough inside or outside of the doctor's office. I saw a trans-masculine patient for care the other day and he said I was the first doctor to ask him about his thoughts on family building. Unfortunately, I wasn’t surprised. Prior to transitioning, he identified as a lesbian woman. And according to my patient, his previous medical provider assumed (incorrectly) that because he couldn’t get pregnant from sex with women, he did not want children.
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This example reinforced my point about both the cultural dialogue and the medical community continuing to frame sexual and reproductive health as a women’s health issue. You can see it in something as simple as marketing. Many family planning clinics are doused in baby pink and the walls are adorned with photos of cis-women holding their children. People of any gender should be able to walk into a family planning clinic, feel welcomed by the environment, and receive counseling and services regarding their sexual and reproductive health. A recent evaluation of contraceptive counseling methods in a California family planning clinic, however, found that male body-based methods like condoms, withdrawal, and vasectomy were either infrequently mentioned or framed as less preferable by the clinician. These other methods should be discussed as equally viable options, as equally viable options, with their pros and cons laid out just like any other method.
Back to the LGBTQIA community: They’ve historically been marginalized from healthcare spaces and often don’t receive appropriate sexual and reproductive services due to lack of provider training and/or stigma. It’s unfortunate, but general practitioners don’t often provide much sexual and reproductive healthcare outside of basic STI testing and contraception, if that. For instance, if someone wants a vasectomy, they would have to see a urologist, who is a surgeon and only available on a referral basis. The American Academy of Family Practice recommends that women receive counseling on family planning at their yearly zero co-pay visit (referred to as a well-woman visit), but there’s no mention of family planning outside of STI screening at the annual male wellness visit.
We have yet to move towards the concept of a well-person visit, but we should. And it should include a discussion around family planning, regardless of the person’s body parts. As a physician, I understand the importance of specialization, but I do feel that doctors should all, at the very least, be well-versed in the needs of all genders.
Culturally, the first step to moving to a more inclusive place lies in the way we frame it all, out loud and on paper. And this language and education should start early—in federally mandated comprehensive sex education programs in schools that are inclusive of all gender identities and sexual orientations and behaviors. In medical schools and residency programs. Placing the burden of reproductive health on cis-women is an outdated concept that should be left in the past, along with high school home economics classes which imply that it’s only girls who should now how to cook and sew.
As health professionals, my peers and I should be focusing on expanding our training to reach all patients about their comprehensive sexual and reproductive health experiences. We should be supporting more research around contraceptive options for those with a penis (studies for a topical gel are on their way). We need to advocate for reproductive health service insurance coverage for all genders, not just cis women. Sexual and reproductive health doesn't happen in a vacuum, it happens in a context that is influenced by intersections which can’t be ignored.
Meera Shah, MD, MPH, MS is the associate medical director of Planned Parenthood Hudson Peconic and a Fellow with Physicians for Reproductive Health.
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