Sexual and Reproductive Justice and Health Equity for LGBTQ+ Women

Abstract

LGBTQ+ women have long been overlooked in sexual and reproductive health research. However, recent research has established that LGBTQ+ women have unique and specific needs that need to be addressed in order to improve effectiveness of sexual health education and practice with this historically and presently underserved population. Informed by a reproductive justice framework coupled with liberation psychology theory, this review discusses the current state of sexual and reproductive health and technologies among LGBTQ+ women. In particular, we focus on a range of HIV prevention and reproductive technologies and their use and promotion, including the internal condom, abortion, oral contraceptives, dapivirine ring, HIV pre-exposure prophylaxis, intrauterine device, and other less studied options, such as the contraceptive sponge. Grounded in an intersectional framing, this review acknowledges the intersecting systems of oppression that affect multiply marginalized women inequitably and disproportionately. A sociohistorical, critical lens is applied to acknowledge the well-documented racist origins of reproductive health technologies and ongoing coercive practices that have led to medical mistrust among marginalized and stigmatized communities, particularly racialized LGBTQ+ women, women with disabilities, and women who are poor or incarcerated. Moreover, we discuss the urgent need to center LGBTQ+ women in research and clinical care, community-engaged health promotion efforts, affirming non-heteronormative sexual health education, and health policies that prioritize autonomy and dismantle structural barriers for this population. We conclude with recommendations and future directions in this area to remedy entrenched disparities in health.

The National Institutes of Health Revitalization Act of 1993 sought to improve representation of cisgender¹ women in clinical research trials (U.S. Congress, 1993). Despite an increase in women-focused health research over the past 30 years, a relative dearth persists, particularly research focused on the impact of sex, gender, and other intersectional marginalized identities on health outcomes (White & Clayton, 2022). Lesbian, gay, bisexual, transgender,² queer, and other women who have sex with women (LGBTQ+ women)³ remain especially underrepresented in health research. Gaps are notable across multiple domains of health (e.g., substance use disorders [Kidd et al., 2018, 2022], mental health [Coulter et al., 2014], and breast cancer [Malone et al., 2019]). Research on sexual and reproductive health among LGBTQ+ women is particularly limited (Eliason, 2017; Mollon, 2012), despite unique and specific needs and persisting health disparities.

It is important to recognize that LGBTQ+ women are not monolithic. Prior studies found different social, economic, and health profiles and contraceptive use behaviors among sexual orientation subgroups of LGBTQ+ women (e.g., lesbian women, bisexual women, transgender women; Stoffel et al., 2017). Developing tailored sexual and reproductive health education is essential to increasing access to care, improving health outcomes, and reducing sexual and reproductive health disparities (Bodnar & Tornello, 2019; Doull et al., 2018). This critical review will provide an overview of sexual and reproductive health among LGBTQ+ women by integrating a reproductive justice framework with contributions from liberation psychology; describing the current state of sexual and reproductive health technologies for LGBTQ+ women; and concluding with recommendations and future directions for clinical practice, education and outreach, and research to remedy longstanding disparities.

Acknowledging Historical and Present-Day Harms: The Context of Oppressive and Dominant Societal Forces on LGBTQ+ Women’s Sexual and Reproductive Health

Historically, people who can become pregnant have experienced infringements on rights to bodily autonomy and reproductive justice. Recent reversals of laws protecting reproductive/contraceptive choice have markedly expanded these constraints to all women at state and even national levels. Restrictions on reproductive freedoms (e.g., abortion bans; historical and ongoing forced sterilization practices) have racist, classist, and colonial origins that predominantly impact marginalized and stigmatized communities of women (e.g., women who are racialized, LGBTQ+, immigrant, poor, and/or incarcerated; and who have disabilities and/or mental illness; Morison, 2021). Such historical and current unethical, abusive, and coercive practices, often initiated under the guise of “controlling poverty” and “population growth,” have historically contributed to medical mistrust, particularly among Black and Indigenous women (Suarez‐Balcazar et al., 2023; Thorpe et al., 2023). External, coercive control of other peoples’ reproduction is described as a tool of domination and oppression akin to genocide, termed “reprocide” (Ross, 2017, p. 293). Reprocide is aligned with white supremacy and eugenics (Ross, 2017), oppressive ideologies that limit reproductive options for marginalized populations.

The Reproductive Justice Movement as a Call to Action

Reproductive justice is a framework and movement that addresses bodily autonomy, or the human right to control one’s own sexuality, gender, work, and reproduction (Ross, 2020; Ross & Solinger, 2017). Black, lesbian, and decolonial feminists developed this critical framework and global movement. The framework was borne out of grassroots organizing to holistically and intersectionally address issues of bodily autonomy in reproductive decision-making with a foundation in social justice and human rights (Agénor, 2019; Grzanka & Frantell, 2017). The development of the reproductive justice framework was viewed as necessary to offer theory and practice capable of disrupting the harmful dominant narratives of Black women’s “reproduction, sexuality, and victimhood” that were pejorative, deficit-based, and oppressive (Ross, 2017, p. 288). In the U.S., the progenitors of the movement created SisterSong: Women of Color Reproductive Justice Collective in 1997, a national, multi-ethnic organization that supports the reproductive justice movement through organizing, facilitation, analysis, and training (SisterSong, 2023).

From an intersectional lens (Collins, 2000; Crenshaw, 1990, 2017; Davis, 1983), reproductive justice aims to account for the interplay between interlocking systems of oppression—including racism, sexism, classism, cissexism, ableism, and heterosexism, among others—on individuals’ rights and reproductive decisions. The core of reproductive justice is the belief that all people have the right to have children, the right to not have children, and the right to nurture children in a safe and healthy environment free from coercion, economic hardship, stigma, and discrimination (Agénor, 2019). Reproductive justice as a movement aimed to shift rhetoric and actions of feminist organizations from reproductive “choice” to a broader understanding of the political, social, and economic inequities that constrain the health and lives of those most marginalized (Mamo & Alston-Stepnitz, 2015). As such, reproductive justice emphasizes sexual health, sexuality, and reproductive decisions as human rights akin to other human rights (e.g., privacy, non-discrimination, health, safety; Miller et al., 2015).

The focus of reproductive justice on the historic and current day political, social, and economic factors that constrain health and well-being extends to other national public health policies. Reproductive justice advocates for policies that promote equitable access to care, improve care outcomes, and safeguard reproductive rights, including paid family leave, universal health insurance coverage, food security, universal basic income, and reparations (Fernald & Gosliner, 2019; Swanson et al., 2021). A major emphasis of reproductive justice is to move beyond a singular focus on abortion access, a focus that inadequately addressed intersectional oppressions of white supremacy, racial capitalism, misogyny, and neoliberalism on health and justice. Instead, reproductive justice advocates for inclusive, holistic healthcare that covers abortions, contraceptives, preventive care, pre- and post-natal care, fibroids, menstrual health, infertility, cervical cancer, breast/chest cancer, morbidity and mortality among infants and pregnant/postpartum people, intimate partner violence, and HIV/AIDS and other STIs (Ross, 2017). Figure 1 highlights a range of factors that influence reproductive autonomy central to reproductive justice.

Figure 1.

Oppressive societal and structural forces that impact sexual and reproductive health outcomes for LGBTQ+ women.

Integrating the Contributions of Liberation Psychology with Reproductive Justice

Liberation psychology (Comas-Díaz, 2021; Freire, 1970; Martín-Baró, 1994; Singh, 2020) is a theoretical approach and praxis that developed alongside the reproductive justice movement, yet has not been thoroughly integrated with reproductive justice. Although there are few existing explicit connections between reproductive justice and liberation psychology (Abbott et al., 2023; Hage et al., 2020), the many parallels and synergies benefit from their integration. Concepts from liberation psychology that can serve to strengthen reproductive justice include its (a) focus on increasing critical consciousness and empowerment as pathways to uplifting marginalized communities; (b) emphasis on social action to respond to societal problems; (c) attention to intersections of identities and communities that experience multiple forms of marginalization; and (d) explicit attention to mental health in relation to sexual and reproductive health.

Grounded in Freire’s (1970) pedagogy of the oppressed, liberation psychology seeks to raise the critical consciousness—or understanding of their oppressive circumstances—of oppressed individuals, groups, and communities (Comas-Diaz & Rivera, 2020). To promote the development of critical consciousness, liberation psychology encourages marginalized individuals and groups to recognize their history and connect with ancestral and Indigenous sources of empowerment. The goal of recovering historical memory is to decolonize Western revisionist histories and more accurately understand systems of oppression in their historical context. To address health inequities, we must familiarize ourselves with and interrogate cultural narratives that contribute to and maintain health inequity (Cook et al., 2023). This includes challenging the traditional framing of problems as residing within the individual (i.e., deficit-based perspectives), rather than being structural or systemic problems.

Core to liberation psychology is the tenet that social action must respond to social problems and inform theory (Martín-Baró, 1994). This dynamic, reflective process, mutually flowing from theory to practice, ensures actions (or practice) produce knowledge leading to new, enriched actions oriented toward social transformation and increasing critical consciousness (Montero, 2007). In applying liberation psychology principles to illustrate actionable ways to promote health equity, Cook and colleagues (2023) discussed the importance of acknowledging the ways that current healthcare systems are oppressive structures that directly drive health inequities in underserved and marginalized populations. Cook et al. (2023) emphasized the importance of attending to history, genuinely partnering with communities to re-imagine health structures, center lived experience, take a strengths-based lens, and identify and address the role of systemic oppression. Given how liberation psychology and reproductive justice both offer a foundational understanding of intersectionality that centers the voices and experiences of marginalized communities, their integration may galvanize collaboration and action, particularly in psychology, which has traditionally overlooked sexual and reproductive health and justice (Grzanka & Frantell, 2017).

However, as others have observed, the reproductive justice framework falls short in addressing experiences of non-heterosexual and non-cis people (Lane, 2019; Singh et al., 2020)—and specifically LGBTQ+ women, whose rights are contextualized in larger systems of oppression that contribute to and maintain inequities in health. From an intersectional lens, it is impossible to separate cisheteronormativity (i.e., the belief that heterosexuality and cis identity are the norm) and cisheterosexism (i.e., the system of oppression that values and centers cisgender and heterosexual people by upholding heterosexuality and the gender binary as normal and neutral, while marginalizing, oppressing, and making invisible LGBTQIA2S+ people) from racism, classism, sexism, and other forms of oppression. Although there are documented challenges in measuring intersectional stigma (Bauer et al., 2021), Black sexual minority women report more discrimination than white sexual minority women (Calabrese et al., 2015). Moreover, racism and economic oppression may influence contraception use among sexual minority women (Agénor, 2019). In one study, a Black lesbian woman expressed the difficulty of navigating intersections of oppression by sharing her experiences with cervical cancer screenings:

I’m not thinking: “Oh, they’re [providers] going to discriminate against me or they’re not going to give me good care because I sleep with women.” Maybe I should think about that … I actually think more about just being a person of color. Are they going to discriminate against me because I’m a person of color? Or I hate when they ask me what I do…. (Agénor et al., 2015, p. 725).

Patriarchal, racialized, and gender-based power dynamics may also prominently influence LGBTQ+ women’s contraceptive use, ranging from experiences of trauma and gender-based violence (King et al., 2021; McCauley et al., 2014) to societal stereotypes about Black women and pregnancy (e.g., more likely to need public assistance and be a single mother; Rosenthal & Lobel, 2016), and more basic assumptions inherent to gender socialization (e.g., women should not initiate conversations about contraception; Higgins et al., 2019). Applying liberation psychology theory to reproductive justice may further promote health outcomes and advance reproductive justice aims for multiply marginalized populations.

The integration of liberation psychology with reproductive justice also allows for explicit recognition of the inextricable links between mental health, substance use, and sexual and reproductive health (Flanders et al., 2017; Montejo, 2019). Many mental health and substance use conditions influence sexual symptoms and concerns related to sexual desire, arousal, or satisfaction (Montejo, 2019). Mental health and substance use are implicated in decisions to engage in HIV, STI, and unwanted pregnancy risk and preventive behaviors (Alexander et al., 2016). Reproductive justice scholars have highlighted links between mental health and perceptions of personal control, including the fundamental right for people to control their own sexual and reproductive health and decision-making (Chrisler, 2014). Mental health and substance use are also implicated in care for STIs and HIV, with people experiencing mental health and substance use problems at higher risk for suboptimal adherence to HIV treatment regimens and poor sexual, mental, and physical health outcomes (Mellins et al., 2003; Remien et al., 2019). As an example of the value of integrating liberation psychology and reproductive justice is the context for understanding risk factors through a systemic rather than deficit-based lens—to capture that low socioeconomic status and food insecurity are associated with increased HIV risk among Indigenous LGBTQ+ sex workers (Barreto et al., 2016)—rather than simply being Indigenous or a sex worker.

Reproductive Justice and Liberation for LGBTQ+ Women: Combating Oppressive and Dominant Social Forces

Based on a reproductive justice framework and liberation psychology perspective on the unique needs of LGBTQ+ women, we outline specific factors that must be attended to in order to address persistent sexual and reproductive health inequities. Advocating for reproductive justice requires attention to oppressive systems like heteronormativity, cisheterosexism, transphobia, and healthcare stereotype threat, as well as how these systems interact and are mutually influenced by other intersecting forms of oppression. Cisheteronormativity provides important context for understanding health inequities (Marques et al., 2015). Cisheterosexism manifests externally through healthcare system barriers, non-affirmative care environments, and discrimination enacted by healthcare providers, which are linked to delayed initiation of care, worse health outcomes, and lower satisfaction with providers (Higgins et al., 2019; Mosack et al., 2013; Scott et al., 2023).

Cisheteronormative assumptions and cisheterosexism take different forms in provider interactions (e.g., providers assuming patients are heterosexual; making assumptions about women’s contraceptive or STI testing needs based on their sex assigned at birth, gender identity, or reported partner sex or gender; Higgins et al., 2019). Non-affirming sexual and reproductive healthcare environments—e.g., intake forms that overlook or limit reporting of sexual orientation and gender identity or make heteronormative assumptions about family structures—may discourage receiving critical care (Agénor et al., 2015). Provider misinformation, stigma, and bias, as well as gaps in sexual and reproductive health literacy among sexual minority women, particularly those who are racial and ethnic minorities, are obstacles to accessing vital care (Apodaca et al., 2022; Paschen-Wolff, Greene, et al., 2020; Paschen-Wolff, Reddy, et al., 2020). Medical providers consistently downplay the necessity of Pap and STI testing for women who report no or infrequent cis male or sperm-producing sexual partners (Doull et al., 2018; Everett et al., 2019) and underestimate the risk of STI transmission among female partners (Gorgos & Marrazzo, 2011; Waterman & Voss, 2015). In turn, sexual minority women receive inadequate guidance on sexual and reproductive health screenings from providers, who are a primary source of their health information (Paschen-Wolff, Greene, et al., 2020; Waterman & Voss, 2015). Prior studies documented perceptions that providers placed greater value on heterosexual family formations, which increased perceptions of discrimination and lack of safety self-disclosing sexual identity (Agénor et al., 2015; Lane, 2019).

LGBTQ+ women may also experience internalized cisheterosexism, which includes the internalization of negative attitudes about queer, cis women (Szymanski et al., 2008). Internalized cisheterosexism can lead to the anticipation of prejudice and stigma in healthcare settings—termed healthcare stereotype threat—or the fear of confirming negative stereotypes and biases about social identities. Healthcare stereotype threat decreases willingness to self-disclose sexual identity to providers (Austin, 2013) and is associated with psychological distress and an increased number of poor physical health days among LGBTQ+ individuals (Fingerhut et al., 2022; Ojeda-Leitner & Lewis, 2021). Identity concealment and masculine gender presentation are linked to increased stereotype threat, lower access to care, and poorer quality care among LGBTQ+ women (Hiestand et al., 2008; Thorpe et al., 2023).

Cisheterosexism also influences family planning. The challenges LGBTQ+ women face in navigating fertility enhancing interventions (i.e., embryo freezing [or oocyte cryopreservation], in vitro fertilization [IVF], and surrogacy) reflect the broader challenges of heteronormative oppression (Lane, 2019). Women who have children outside of a heterosexual relationship challenge normative understandings of family configurations and how families are formed, which can lead to inequitable treatment and care through multiple systems of oppression (Lane, 2019). For example, cisheterosexism intersects with classism in accessing fertility enhancing interventions, which is highly inaccessible to low-income patients (Bell, 2009). Due to class-based gaps in accessibility, there is now an assumption of wealth and privilege that has influenced marketing for fertility services and may impact decisions to start a family (Smietana et al., 2018). Moreover, fertility preservation for transgender and nonbinary patients undergoing gender affirming care is often not foregrounded in patient-provider interactions or may be financially inaccessible (Becker, 2023); this may lead to elective sterilization like hysterectomy without options to preserve fertility. Taken together, the downstream effects of these oppressive and dominant societal forces, including heteronormativity, cisheterosexism, and transphobia, among others, manifest in adverse sexual health outcomes and heightened disparities that affect LGTBQ+ women.

Downstream Effects for LGBTQ+ Women: Sexual and Reproductive Health Disparities

Integrating reproductive justice framework with liberation psychology also allows for a critical examination of sexual and reproductive health disparities among LGBTQ+ women. For example, lesbian and bisexual female adolescents, as well as those who are unsure of their sexual identity, are at higher risk for unwanted pregnancies and terminations than heterosexual female adolescents (Everett et al., 2019; Paschen-Wolff et al., 2018); research suggests this disparity persists into adulthood (Everett et al., 2017). Further, the stressors of having a minoritized sexual identity are linked with earlier ages of menarche among lesbian/gay and bisexual female adolescents (Gibb et al., 2023). Additional risk factors for unwanted adolescent pregnancies include lower likelihood of condom use or other contraceptive methods (e.g., oral contraceptives) and greater likelihood of substance use in conjunction with sex compared to heterosexual female adolescents (Everett et al., 2019). Bisexual women who have sex with cis men and women also report higher rates of behaviors that may confer HIV- and STI-related risk (e.g., transactional sex, sex with multiple partners, condomless sex) compared to other sexual minority (e.g., lesbian) and heterosexual women (Paschen-Wolff et al., 2019). Transgender women experience disproportionate rates of HIV infection, with risk estimates as high as 34 times the general U.S. population (Baral et al., 2013) due to the syndemic of factors positioning them at risk (e.g., social marginalization, stigma, economic precarity, violence, psychological distress, substance use; Brennan et al., 2012).

Additionally, sexual minority women are less likely to obtain cervical cancer screening and testing for STIs (Agénor et al., 2017), despite documented transmission via female-to-female sexual contact (Gorgos & Marrazzo, 2011). Moreover, cis women who have sex with women have comparable and sometimes elevated rates of HPV (Waterman & Voss, 2015) and other STIs (Kerr et al., 2013) relative to heterosexual cis women. Sexual minority and transgender women living with HIV have reported feeling invisible and erased due to lack of recognition for HIV risk and prevention among LGBTQ+ women (Logie et al., 2012). Given intersecting oppressive systems that constitute and reproduce sexual and reproductive health inequities facing LGBTQ+ women, we outline the current state of sexual and reproductive health technologies, with implications for research, practice, education, and advocacy to promote health equity.

Current State of Sexual and Reproductive Health Technologies for LGBTQ+ Women

We focus on a range of sexual and reproductive technologies and their use and promotion, including notable barriers to and facilitators of access and uptake of contraception, STI prevention, HIV prevention, and reproductive interventions relevant for LGBTQ+ women.

Contraceptive Care

There are several forms of contraception—i.e., drugs, devices, or interventions to prevent pregnancy—that LGBTQ+ women may consider and adopt, including intrauterine devices (IUDs; Everett et al., 2018), internal condoms (Mantell et al., 2011), external condoms, diaphragms, spermicide and gel (Jones & Lopez, 2014), implant (i.e., Nexplanon; Krovi et al., 2021), and other birth control forms (i.e., ring, patch, injection, pill, sponge; Creatsas et al., 2001). Beyond preventing pregnancy, hormonal contraceptives are commonly used to suppress menstruation to alleviate dysphoria from unwanted uterine bleeding (Mehringer & Dowshen, 2019). Although contraception use is common among lesbian and bisexual women (Marrazzo & Stine, 2004), lesbian and bisexual women have had significantly lower odds of receiving contraception and obtaining contraceptive counseling compared to heterosexual women. Women of color tend to report the lowest odds of receiving contraception (Agénor et al., 2021). LGBTQ+ women are often excluded from contraceptive counseling (Higgins et al., 2019), as heteronormative provider attitudes fail to recognize LGBTQ+ women as contraceptive users. Some LGBTQ+ women internalize this idea, not perceiving a need for contraception despite reporting engaging in behaviors that could result in pregnancy. Some may engage sporadically in sexual behaviors that could lead to pregnancy (Higgins et al., 2019). For these individuals, longer-acting methods have been described as burdensome and unnecessary. The shame and stigma some LGBTQ+ women experience from engaging in sexual behaviors with cis men may lead them to avoid using contraception even if beneficial (Higgins et al., 2019).

STI Prevention Methods

In addition to internal and external condoms, dental dams are another barrier STI prevention method; however, dental dam usage is rarely studied. The few available studies have documented low rates of use, characterizing dental dams as one of the least popular safer sex methods (Jahn et al., 2019; Richters et al., 2010). The limited extant research documented common misperceptions about dental dams, including lack of knowledge about how to use or where to access them (Muzny et al., 2013).

Low risk perception is a barrier to the use of effective STI prevention methods (Paschen-Wolff, Reddy, et al., 2020). Studies suggest some LGBTQ+ women may hold a “false sense of invulnerability” related to STI transmission (Gil-Llario et al., 2023, p. 161). In one study with transgender women, a primary means of learning about STI risk and prevention was through being diagnosed and treated themselves (Balán et al., 2019). Particularly among lesbian women, scholars suggested that narratives of nonexistent STI risk may be rooted in biphobia and internalized homophobia (Whitlock, 2022). Research has found that bisexual women may feel pressure to engage in “riskier” sexual behaviors to “prove” their bisexuality (Flanders et al., 2017, p. 79), which may lead them to be viewed by others and themselves as at higher risk for STI infection and transmission.

HIV Prevention Methods

HIV pre-exposure prophylaxis (PrEP) is a medication taken to prevent HIV infection in case of potential exposure. PrEP is currently available as a once-daily oral tablet, a long-acting injectable, and a vaginal ring, although the ring has not been approved for use in the U.S. (Gollub & Vaughn, 2022). Despite the availability and high efficacy of oral PrEP, comparatively minimal research has explored PrEP among women, including LGBTQ+ women, and little is known about their PrEP needs, preferences, and other decision-making factors (Auerbach et al., 2015). Most research on PrEP among women has focused on cis women who use drugs or are otherwise at relatively higher risk for HIV (Tross et al., 2023). Concerningly, studies found that women who may benefit from PrEP receive consistently low rates of PrEP prescriptions (Hoffman et al., 2023; Theodore et al., 2020). Although monitoring data on PrEP uptake at national and state levels among transgender people is limited, studies suggest relatively higher rates of uptake among transgender populations (Downing et al., 2022). Racial and ethnic disparities in uptake of and retention on PrEP are stark; public health professionals have stated that ending the epidemic will require eliminating the race, class, and gender inequities and the discrimination and structural violence that exacerbate and maintain HIV disparities (Adimora et al., 2021). Especially because PrEP can be taken without a partner’s knowledge, PrEP has the potential to be a useful prevention method in the context of coercive or abusive relationships (Logie et al., 2021).

The vaginal dapivirine ring form of HIV PrEP was specifically created for cis women and people assigned female at birth (AFAB) and included in the World Health Organization HIV Prevention Guidelines (WHO, 2021). Public health experts noted how its lack of approval in the U.S. presents a structural barrier that limits access to the fullest range of HIV prevention methods that can be adopted and integrated into LGBTQ+ women’s lives with practicality and effectiveness (Gollub & Vaughan, 2022).

Reproductive Interventions

Abortion is “wildly ordinary” given that nearly one-quarter of U.S. women obtain an abortion in their lifetime (Thomsen & Morrison, 2020, p. 721). Abortion is also a form of gender transgression, in which refusing parenthood subverts gendered, heteronormative expectations of cis women (Thomsen & Morrison, 2020). Although most studies focused on cis, heterosexual women, many lesbian or bisexual women have had a prior pregnancy with a cis man and have high lifetime reports of abortion (Marrazzo & Stine, 2004; Schwartz & Baral, 2015). Cisgender male-partnered LGBTQ+ women are a particularly understudied population with unique needs (Januwalla et al., 2019). One qualitative study with LGBTQ+ women found abortion access to be just as crucial for LGBTQ+ women as heterosexual women (Carpenter et al., 2020). Although no population-level data exist on the proportion of transgender and nonbinary people capable of pregnancy, a recent study indicated that abortion is a persistent need; among 210 transgender and nonbinary people with capacity for pregnancy, 12% had ever been pregnant, and 21% of pregnancies ended in abortion (Moseson et al. 2021).

Hysterectomy, or surgery to remove the uterus, is extremely common in the U.S., as the second most common surgical procedure among all cis women (Doll et al., 2016). Hysterectomy is used to manage several chronic gynecological conditions (e.g., fibroids, endometriosis, adenomyosis) and is deemed an essential part of gender-affirming care for transgender men and nonbinary AFAB people (Wingo et al., 2018). There is a dearth of research on and clinical alternatives for managing gynecological conditions, leading to hysterectomy being a “constrained choice” for those with chronic illness (Becker, 2023, p. 21). Moreover, recent work documented various inequities in hysterectomy access (Becker, 2023), including particular difficulties for nonbinary patients; transgender men and Black women being suggested a hysterectomy without fertility preservation counseling; and lesbian women being denied a hysterectomy out of concerns they or a future cis male partner would regret this procedure.

Tubal ligation is surgery to close the fallopian tubes, which connect the ovaries to the uterus. Considered elective sterilization or a permanent medical decision to remain childless (Moultrie, 2021), there is scant research on experiences of tubal ligation among LGBTQ+ women from a reproductive justice perspective; however, tubal ligation is one of the more common forms of contraception in the U.S. and worldwide (Chan & Westhoff, 2010), with nearly one-third of cis women undergoing tubal ligation in their lifetime, often after completing childbearing. Tubal ligation may be desired as a gender-affirming procedure for transgender and nonbinary people with reproductive potential who wish to avoid capacity for pregnancy (Francis et al., 2018). Despite its high safety and efficacy, access can be difficult; in a study of 429 women who requested a postpartum tubal ligation, 31% did not receive the procedure, and one year later, 47% of those denied the procedure experienced another pregnancy (Thurman & Janecek, 2020). Additionally, women seeking tubal ligations at religious hospitals can face institutional policies barring access (Stulberg et al., 2014).

Scholars have suggested that reproductive justice falls short of addressing the right to access fertility enhancing interventions (Mamo & Alston-Stepnitz, 2015), and despite the usefulness of solutions to address fertility, major gaps remain (Tam, 2021). More explicit inclusion of these interventions within reproductive justice frameworks provides an opportunity for LGBTQ+ women to meet family planning goals and participate in new kinship forms (Mamo & Alston-Stepnitz, 2015). For instance, IVF is a complex series of procedures to assist fertility and conception; however, IVF is expensive and often not covered by insurance (Harvey & Ingraham, 2021), making cost a major structural barrier. To avoid these barriers, creative options like at-home insemination with known-donor sperm have become popular (Côté & Lavoie, 2019). IVF provides autonomy to the individual on the role they want in reproduction. For example, a transgender man may desire to have a child without carrying a pregnancy. The carrying partner can carry the transgender man’s egg through embryo transfer, or oocyte donation, which can provide a biological connection to a child without giving birth (Matorras et al., 2023). Transgender women may opt for banking sperm ahead of a later decision to pursue IVF with a partner (Broughton & Omurtag, 2017). Because fertility may be impacted by hormone therapy or surgical transitions, fertility preservation is a critical component of gender-affirming care (De Roo et al., 2016). Given most transgender people report a desire to be a parent (Alpern et al., 2022) and transgender people with children demonstrate better mental and physical health than those without (De Roo et al., 2016; Wierckx et al., 2012), fertility and childbearing desires merit attention.

Surrogacy entails an arrangement (often via legal agreement) in which someone agrees to carry a pregnancy on behalf of another person or couple. Similar to IVF, surrogacy is cost-prohibitive, and scholars have noted how marketing of surrogacy that predominantly excludes LGBTQ+ populations reflects normative ideas about gender, sexuality, and social class reproduced in the fertility industry (Jacobson, 2018). Accounts of LGBTQ+ women who pursue surrogacy are almost nonexistent, with the few qualitative studies focused on cis gay men (Fantus & Newman, 2019). The limited research with transgender people specifically has documented perceptions of surrogacy as unattainable due to cost (Tornello & Bos, 2017). It is important to note that surrogacy, depending on the context and circumstances, may also present an ethically fraught dynamic that takes advantage of or exploits individuals with economic vulnerability, particularly in the context of crossing international borders to engage in “reproductive tourism” (Deonandan, 2015, p. 111).

Recommendations and Future Directions

Clinical Practice

Given the deteriorating landscape for sexual and reproductive health freedoms in the U.S. (Johnson, 2024) and the disparate impacts these political realities hold, there is a distinct, urgent need for increased access to sexual and reproductive healthcare. The integration of liberation psychology and reproductive justice (Abbott et al., 2023; Comas-Díaz, 2021; Grzanka & Frantell, 2017) invites public health professionals to engage in practices that increase critical consciousness, promote empowerment, emphasize social action to respond to societal problems of reduced access and structural oppressions, and explicitly attend to how mental health is connected to sexual and reproductive health and well-being.

Providers need to recognize the considerable heterogeneity among communities of LGBTQ+ women and avoid assumptions about individuals or their behaviors based on their identities (Andrade et al., 2023). Providers need to ask affirming questions rather than making assumptions that all women need (or do not need) contraception based on their social identities. During clinical encounters, LGBTQ+ women should receive relevant, inclusive, and affirming contraceptive information and be offered a full range of non-hormonal and hormonal contraceptive methods as well as counseling for fertility and non-fertility (Higgins et al., 2019). Because contraception provides more than pregnancy prevention (e.g., menstruation management, gender affirmation), a comprehensive overview of benefits and risks is essential. Public health experts have offered best practices in gender-affirming care for patients of all genders (Moseson et al., 2020). Providers should deliver contraception in the context of fertility desires and intentions, support pregnancy and parenting decisions (particularly because the cisheteronormative pregnancy planning paradigm lacks salience for LGBTQ+ women; Carpenter et al., 2020), and address systematic factors (e.g., interpersonal and structural discrimination, history of reproductive coercion/abuse) that shape LGBTQ+ women’s reproductive health and healthcare experiences (Higgins et al., 2019).

Interventions designed for LGBTQ+ women should be tailored to include comprehensive sexual health education, or non-heteronormative health information related to STI risk and prevention (Baker et al., 2021). Clinicians should be comfortable and knowledgeable discussing safe same-sex intercourse methods, such as condom use with shared sex toys, cleaning sex toys before use and between partners, and dental dam use with oral sex (McCune & Imborek, 2018). These strategies may help alleviate the common experience of erasure and identity dismissal in safe sex conversations with providers (Gessner et al., 2019). Efforts by providers to reduce stigma and cisheteronormativity may have other indirect benefits for patients by not reinforcing internalized stigma. Less internalized homonegativity is associated with greater sexual satisfaction among LGBTQ+ women (Baldwin et al., 2019).

Given the interplay between mental health, substance use, and sexual and reproductive health, there is an important role for mental health professionals to attend to sexuality and intimate relationships over the lifespan with LGBTQ+ women. Counseling provides a critical space to explore sexual identity, needs, desires, and problems. The coming out process and associated identity development is a critical time period that may impact mental health, which could benefit from affirmative therapeutic support. Practitioners should collaborate with clients to use reproductive justice and liberation psychology principles to question and address institutional systems of oppression (e.g., racism) that are inextricably bound up with social and structural determinants of health. Such interventions are described as a means of creating space to acknowledge and name oppressive experiences rather than silently living with them (Afuape & Oldham, 2022).

Education and Outreach

Recent emphasis on structural competency was proposed to address health disparities among LGBTQ+ populations that have persisted despite decades of efforts to better serve these communities (Lampe et al., 2023). Structurally competent provider education includes training in affirmative, patient-centered sexual and reproductive healthcare (Gessner et al., 2019); addressing the role of heteronormativity in care and treatment; awareness of how the history of health-related discrimination, mistreatment, and experimentation created medical mistrust among communities of color (Thorpe et al., 2023); and practices to build trusting patient-provider relationships (Andrade et al., 2023). Strong patient-provider relationships, inclusive and affirmative care practices, accurate risk perception, and correcting misconceptions about STIs/HIV are crucial for better health outcomes, exemplified by associations between strong patient-provider relationships and future routine cervical cancer screening intentions among LGBTQ+ women (Tabaac et al., 2019).

Access to information alone is insufficient for promoting health behaviors (Paschen-Wolff, Greene, et al., 2020). Community-engaged health promotion efforts can emphasize contraception as LGBTQ-positive and sex-positive and focus on pleasure and resistance against oppression (Higgins et al., 2019). For example, LGBTQ+ women who make decisions about their own preventive behaviors, including whether and what kinds of contraception to use, may be proud of feeling control over their sexual experiences. Coming out is a transformative life event that can facilitate self-efficacy to use contraception and assert desires and needs in sexual encounters in ways previously uncomfortable (Higgins et al., 2019). Moreover, LGBTQ+ women who are out to their providers report being more comfortable discussing sexual health interventions compared to those whose providers lack knowledge of their identity (Mosack et al., 2013). Empowerment, capacity-building, and advocacy-based interventions are recommended to address medical mistrust in collaboration with communities (Suarez-Balcazar et al., 2023). Innovative online and peer-based interventions constitute accessible means to effectively reach LGBTQ+ women, who use the internet to seek evidence-based health information and may particularly seek personal accounts of peers’ experiences (Flanders et al., 2021). Peer-driven health interventions, led by uniquely credible role models with lived experience, may enhance sustained use of services by providing outreach, support, active referrals, navigation to clinics, advocacy, and follow-up.

Future Research

There is a distinct need for a robust study of LGBTQ+ women’s reproductive and sexual health and tailored health prevention and promotion efforts. The literature on reproductive health technologies among LGBTQ+ women is sparse, particularly on dental dams, HIV PrEP, abortion, hysterectomy, tubal ligation, IVF, surrogacy, sexual satisfaction, menstruation, and menopause, all of which require comprehensive study of perceptions, barriers, and facilitators to better understand and meet the unique needs of LGBTQ+ women. Research should focus on the design, evaluation, and effective implementation of tailored, affirmative interventions created in partnership with communities.

Research is a powerful tool to advocate for policy change. Most research on LGBTQ+ sexual and reproductive health has focused on health disparities. It is important to move beyond deficit-based narratives of disparities to conduct research that centers community participation, individual experiences, and the intersectional needs of LGBTQ+ women to advance our understanding of their sexual and reproductive health needs. We echo calls regarding the promise of reproductive justice to inform a contextualized, participatory approach to change policies (Morison & Herbert, 2018). Political movements that champion equitable health policies, expand access to reproductive technologies, and ensure bodily autonomy and self-determination are essential to remediate widening disparities.

Conclusion

Despite facing health inequities, LGBTQ+ women are underserved and understudied in sexual and reproductive health. This review integrates reproductive justice and liberation psychology frameworks to address LGBTQ+ women’s unique needs and promote health equity. Particularly for LGBTQ+ women with multiply marginalized identities who are disproportionately impacted and denied reproductive justice and bodily autonomy, there is an urgent need for increased access to care, affirmative and non-heteronormative sexual health education, community-engaged health promotion efforts, and equitable health policies that protect autonomy and dismantle structural barriers.

Biographies

Dr. Melissa Ertl is a counseling psychologist and an Assistant Professor of Psychology at University of Minnesota whose work is focused on addressing social, cultural, and structural determinants of health. Dr. Ertl has particular interest in understanding prevention and health promotion at the intersections of mental health, substance use, and sexual health with a priority for health equity in women, Latinx immigrants, young adult college students, LGBTQ+ communities, and individuals with disabilities and their informal familial caregivers. Dr. Ertl earned her Ph.D. in Counseling Psychology with a certificate in Health Disparities in Public Health. She teaches courses for psychologists-in-training in the Counseling Psychology Ph.D. program at University of Minnesota. She is also a licensed psychologist in Minnesota and New York and maintains a small private practice. In her work, she aims to contribute to our understanding of how to eliminate health disparities and promote health equity among underserved and marginalized populations.

Dr. Meredith R. Maroney (she/her) is an Assistant Professor in the Department of Counseling and School Psychology at the University of Massachusetts Boston and a licensed psychologist. She received her Ph.D. in Counseling Psychology from the University of Massachusetts Boston and completed her doctoral internship at the University at Albany. Dr. Maroney conducts LGBTQ+ affirmative and social justice-oriented focused on sexual and gender minority individuals, with a particular emphasis on the intersection of Autistic and LGBTQ+ identities. Specifically, she is interested in understanding and coping with minority stress and intersectional stigma, intervention development and evaluation, and collaborating with partners through community-engaged and participatory approaches.

Andréa Becker, PhD is an Assistant Professor of Sociology at Hunter College, CUNY. Dr. Becker is a medical sociologist whose research examines how inequality manifests at every stage of human reproduction—from contraception and sterilization, abortion and birth, to sexual experiences. Her forthcoming book Unchoosable: Hysterectomy, Gender, and Stratified Reproduction (NYU Press 2025) examines hysterectomy from a trans-inclusive reproductive justice framework. Before joining Hunter College, Dr. Becker was a postdoctoral fellow at the University of California, San Francisco in the interdisciplinary reproductive health research group ANSIRH. Her research has been published in several journals, including Social Science & Medicine, Gender & Society, Contraception, and Sexual and Reproductive Health Matters. Dr. Becker has also written extensively for mainstream media outlets, including The New York Times, The Washington Post, The Nation, and Slate.

Dr. Margaret Paschen-Wolff is an Assistant Professor of Clinical Psychiatric Social Work in the Department of Psychiatry at the Columbia University Irving Medical Center, and a Research Scientist at the New York State Psychiatric Institute. Dr. Paschen-Wolff’s academic background includes a Master of Science in Social Work and a Doctorate in Public Health. For nearly twenty years, Dr. Paschen-Wolff has managed and directed various federally funded projects in diverse environments, from academic research settings to real-world public health clinics. Dr. Paschen-Wolff is a Project Director/Co-Investigator for two National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) studies focused on improving services for HIV and substance use in health care settings across the U.S. She is part of the Opioid Response Network (ORN), a SAMHSA-funded initiative to expand capacity to provide technical assistance in evidence-based practices to meet locally identified needs for prevention, treatment, recovery, and harm reduction related to opioid and stimulant use disorders. Broadly, Dr. Paschen-Wolff’s research has focused on supporting optimal health outcomes among people living with HIV and substance use disorders, improving health outcomes among LGBTQ+ people, and facilitating the implementation of effective substance use disorder treatment and other services in health care settings.

Amelia Blankenau (she/her) is a doctoral student in Counseling Psychology at the University of Minnesota Twin Cities and a National Science Foundation Graduate Research Fellow. Amelia received her B.A. in Psychology from Occidental College with a minor in Gender, Women, and Sexuality Studies. Her research interests include transracial adoption, health equity, social determinants of health, colorblind racism, racial socialization, discrimination, and environmental and reproductive justice. She is particularly interested in the experiences and well-being of transracial, transnational adoptees raised in white families and individuals with multiple marginalized identities.

Susie Hoffman, DrPH, is Professor of Clinical Epidemiology in the Division of Gender, Sexuality, and Health, Department of Psychiatry at Columbia University, Research Scientist at the New York State Psychiatric Institute, and faculty in the Department of Epidemiology, Columbia Mailman School of Public Health. Her body of work spans descriptive and intervention studies around HIV prevention, care, and treatment, especially in sub-Saharan African settings and among groups experiencing HIV/AIDS disparities. As a social epidemiologist, she grounds her work in a perspective that considers how gender norms and inequalities, stigma, poverty, racism, and other social-structural factors influence these outcomes. Much of her intervention work has sought to enhance the acceptability, uptake, use, and roll-out of alternative biomedical prevention methods (female condoms, microbicides, and oral PrEP) for women and other marginalized groups, especially with interventions focusing broadly on sexual and reproductive health and rights.

Dr. Susan Tross is a clinical psychologist and Professor of Clinical Medical Psychology in Psychiatry at the Columbia University Irving Medical Center. Since 1985, Dr. Tross’ work has been dedicated to developing, delivering, and evaluating intervention programs in substance abuse, HIV risk behavior, and psychological adaptation to HIV. Her research has focused on work with disenfranchised people, including women, sexual minority men, (injection and non-injection) substance users, and sexual partners of substance users, at highest risk for or living with HIV and co-morbid diseases and/or substance abuse, in close partnerships with community agencies. It has been guided by a Community Based Participatory Research perspective – in which community stakeholders have been active collaborators at every phase. Her work also employs mixed method approaches – to obtain both broader quantitative outcomes and qualitative findings that capture first-person experiences, preferences, and impressions of stakeholders.