Trauma-Informed Reproductive Care for Transgender and Nonbinary People

Abstract

Stigma and minority stress affect the health of transgender and nonbinary (TGNB) people, leading to disparities across a range of outcomes. Barriers to accessing care, including reproductive care, further complicate these health disparities. Interpersonal stigma within the healthcare system, and high rates of physical and sexual violence survivorship, make TGNB people particularly vulnerable to healthcare trauma and poor care. This is particularly true among TGNB people with multiple intersecting marginalized identities. Trauma-Informed Care (TIC) provides a framework for medical practitioners to provide safe, holistic, and sensitive care. Scant academic literature discusses trauma-informed reproductive care for TGNB individuals. We present a narrative review of the evidence for trauma-informed reproductive care for TGNB people, and suggest potential application and implementation.

In Brief:

There are some unique aspects to providing trauma-informed reproductive care to transgender and nonbinary people, who are affected by minority stress, stigma, and particular forms of trauma; we review the evidence and suggest strategies for provision of trauma-informed reproductive care to gender minorities.

I. An Introduction to Trauma-Informed Reproductive Care

Establishing an environment in which transgender and nonbinary (TGNB) patients feel affirmed, safe, and secure is critical to building trust in the health system. All clinicians providing reproductive healthcare should have the training and tools to provide TIC. At the heart of TIC is the recognition of the impact of trauma on people’s lives, and the commitment to avoidance of further trauma. The concept of TIC was introduced in the 1990s in the psychiatric literature as a framework to provide more compassionate and sensitive care to those with post-traumatic stress disorder (PTSD), as mental health research demonstrated associations between trauma exposure and psychiatric conditions (Levenson, et al. 2023, Sperlich, et al. 2017). Various approaches to the provision of TIC have been described. For example, Goodman et al. describe five general dimensions of TIC (Goodman, et al. 2016):

1. “Fostering agency and mutual respect;

2. Providing psychoeducation;

3. Increasing opportunities to connect with other survivors;

4. Building on clients’ strengths; and

5. Practicing cultural sensitivity.”

The National Center for Trauma-Informed Care (NCTIC) developed six principles of TIC (Nagle-Yang, et al. 2022): safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and cultural and gender identity.

These principles and approaches may have specific resonance for TGNB people, who often face multiple forms of disempowerment such as trauma and transphobia, as well as additional marginalization of other identities. Specifically, there are unique opportunities to implement these principles with TGNB people. For example, ensuring safety as it relates to gender identity can include non-gendered bathrooms, use of chosen names and pronouns, and using last names to avoid outing people in waiting rooms. Peer connections among TGNB people improve mental health and enhance well-being (Austin, et al. 2018, Barr, et al. 2016, Testa, et al. 2014), and peers can be integrated into clinical services. Affirming patients’ gender identities—through correct use of pronouns and by acknowledging and supporting their sexual, reproductive, and embodiment choices—is empowering. These practices are supportive of community building, connection, and resilience, and together create an environment that enhances trans joy and affirmation and decreases traumatic experiences. Acknowledging the decades-long and ongoing medical trauma faced collectively by TGNB people (Shuster 2021), a reframing of the reproductive health encounter driven by trans people is needed.

Incorporating TIC into clinical practice improves patient outcomes, particularly in the realm of mental health. In one study where primary care providers were randomized to receive TIC training, those who received the training described an increase in patient-centeredness based on a quantitative scoring system (Green, et al. 2015). While much of the literature on TIC for TGNB people is specific to HIV care, there is some data on the broader Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) community. In a large study of over 200 LGBTQ+ intimate partner violence (IPV) survivors, those who perceived greater levels of TIC had greater emotional regulation and lower degrees of social withdrawal (Scheer and Poteat 2021). Another study of nearly 300 LGBTQ+ IPV survivors who received TIC mental health counseling showed that when there was a greater emphasis on agency and mutual respect, patients reported lower depression symptoms (Antebi-Gruszka and Scheer 2021).

TIC studies have historically focused on mental health services, with little evidence on reproductive healthcare (Levenson, et al. 2023). Mental health services are critically important given the higher rates of IPV and associated detrimental mental health outcomes among TGNB people (Peitzmeier, et al. 2020). Nevertheless, reproductive healthcare providers hold a unique opportunity to provide competent and sensitive TIC for their patients. Reproductive healthcare is often of a highly sensitive nature, and the encounters often place patients in an emotionally and physically vulnerable state, above and beyond that inherent to the care relationship. Emotional and physical trauma can have long-lasting impacts on reproductive health outcomes, including worse prenatal, intrapartum, and postpartum outcomes such as low birth weight, preterm delivery, increased fetal death, poor maternal-infant bonding, and early cessation of breastfeeding (Jasthi, et al. 2022, Meltzer-Brody, et al. 2013, Pastor-Moreno, et al. 2020), as well as gynecological outcomes such as chronic pelvic pain and sexual dysfunction (Basson and Gilks 2018, Krantz, et al. 2019). Furthermore, trauma and PTSD were found to be linked to unsatisfactory Pap smears among TGNB people with a cervix (Wang, et al. 2023).

Few studies directly evaluated the efficacy of TIC in the context of reproductive health; the inherent ethical issues with prospective direct observation comparing TIC with standard care make such an evaluation near impossible. Quasi-experimental designs have been used in childcare contexts (such as youth in foster care). In the reproductive health context, TIC has been recommended as a method to decrease parental PTSD and re-enactment of childhood (or other) trauma (Sachdeva, et al. 2022), and to create a positive childbirth experience (Taheri, et al. 2018).

II. Transgender People in the U.S.

TGNB people comprise 0.6 % of the adult U.S. population, with approximately 1.9 million U.S. adults identifying as transgender or nonbinary (Herman, et al. 2022, Jones and Gallup 2023). This proportion is over twice that reported in 2011 (Gates and The Williams Institute 2011). Furthermore, the proportion of people identifying as transgender is highest among youth and young adults (5% of adults ages 18–29 identify as TGNB (Brown and Pew Research Center 2022)—likely the result of increased visibility and acceptance over the last several years. Approximately 40% of the TGNB population is younger than 25 years, with 1.4% of youth ages 13–17 identifying as transgender (Herman, et al. 2022).

III. Trauma Among TGNB People

Trauma is the emotional response to a disturbing or threatening incident or series of events. This response can be long-lasting, with adverse effects on the individual’s functioning and well-being. Despite recent advances in social acceptance (Greenberg, et al. 2019), TGNB people continue to face high rates of structural and interpersonal violence, which can lead to trauma. TGNB people in the U.S. experience high rates of social disadvantages secondary to transphobia such as living below the poverty level, unemployment, homelessness, sexual and physical assaults, and bullying (James, et al. 2016). All of these experiences are linked to increased vulnerability and higher likelihood of being trauma survivors. TGNB individuals experience a dramatically higher prevalence of childhood trauma and adverse childhood events (ACEs) (Tran, et al. 2023), intimate partner violence (IPV) (Peitzmeier, et al. 2020), and reproductive coercion. These forms of violence have a particular impact on reproductive health encounters due to the highly sensitive nature and content of the encounter and the possibility of reproducing the trauma. This must be acknowledged in order to create a safe, healing, and affirming care encounter. Medical trauma is a trauma that occurs from direct contact with the medical setting and develops through a complex interaction between the patient, medical staff, medical environment, and diagnostic and/or procedural experience that can have powerful psychological impacts due to the patient’s unique interpretation of the event (Hall and Hall 2016). TGNB people endure discrimination and systematic oppression by healthcare professionals and within healthcare settings, including inappropriate care, care refusal, and mistreatment by health providers (Cicero, et al. 2019). Nineteen percent of TGNB people report being refused medical care due to their gender identity, and 28% report experiencing harassment within a medical setting (James, et al. 2016). Fifty percent of TGNB people had to teach their providers about care for TGNB people. These experiences not only reveal and lead to inappropriate care, but may also directly cause, lead to, and exacerbate healthcare trauma. One likely consequence of providers’ lack of knowledge is its correlation with delay of needed care (Jaffee, et al. 2016). Furthermore, delayed care likely contributes to the myriad health disparities affecting TGNB people, further exacerbating the cycle of alienation from care, medical trauma, and poor outcomes (Cicero, et al. 2019, Kcomt, et al. 2020, Scheim, et al. 2022). These data are striking and highlight the imperative for systemic change.

The medical encounter may also be a site for re-traumatization, or reactivation of past trauma during exposure to a new, similar event. The similarity of the medical encounter may be due to repetition of prior medical traumatic treatment; the physical and emotional vulnerability and exposure during the encounter; explicit or implicit transphobia in the medical encounter that is reminiscent of past transphobic trauma; or exposure to structural trauma at the encounter (Grossman, et al. 2021).

IV. Reproductive Health of TGNB People:

Like cisgender people, TGNB people’s reproductive health needs encompass preventive care, peri-conception care, fertility care, peri-partum care, and treatment of reproductive tract conditions and illnesses. While they face some specific medical needs and concerns (such as impact of gender-affirming medical interventions—designed to support and affirm an individual’s gender identity—on reproductive health), many of their needs are not dissimilar to those of cisgender patients. The major elements of TNGB-specific reproductive care, however, are tied to cis-hetero-normativity and transphobia. Cisnormativity is the assumption and reinforcement of cultural norms that gender is innate, binary, static, and immutable, and that all people are cisgender. Cisnormativity (Berger and Ansara 2021) can be both structural and interpersonal; for example, electronic medical records that only have a single field for “sex” will not accurately capture the sex of many TGNB people, for whom there is a distinction between sex assigned at birth and gender identity.

A rapidly increasing body of literature describes the specific reproductive health needs of TGNB people across the lifespan (Moravek and deHaan 2023).

V. Policy and legislation:

Over the past several years, there has been a rapid increase in extreme and coordinated anti-trans campaigns in the United States (US) (as well as in several other countries, including restrictive policies in the English National Health Service). At the forefront of these efforts are bans in multiple US states blocking TGNB youth from accessing gender-affirming care. These bills not only directly intrude on the ability to access essential, life-saving, best-practice care, but they have devastating direct and indirect effects on the mental health of TGNB youth and adults across the US (Borah, et al. 2023, Hughes, et al. 2021, Hughto, et al. 2022). This wave of legislation should be acknowledged as an ongoing and unfolding traumatic event, and its impact on reproductive health, reproductive health decision-making, mental health, and overall well-being must be addressed as part of a trauma-informed reproductive care interaction with TGNB people.

VI. Recommendations for Trauma-Informed Reproductive Care for TGNB People

Given the extremely high prevalence of traumatic experiences, and the impact these may have on patients’ lives and health, TIC should be practiced universally (American College of Obstetricians and Gynecologists 2021, Owens, et al. 2022). It is an integral part of high-quality clinical care that leans on principles of patient autonomy, respect, cultural sensitivity, and patient empowerment (Levenson, et al. 2023). It is of particular importance for TGNB patients, who experience traumatic events more frequently, and who often experience transphobic trauma and re-traumatization (or reactivation of past trauma when faced with a new, similar event) at the hands of medical professionals.

However, many reproductive health settings and providers are not prepared to provide routine TIC. Obstetrics and gynecology trainees often feel unprepared to screen and address trauma (LaPlante, et al. 2016, Nagle-Yang, et al. 2022). Furthermore, many reproductive health providers are ill prepared—or unwilling—to provide care to TGNB patients. In one survey of obstetrician gynecologists, only 29% of respondents reported that they felt comfortable caring for TGNB patients, and 11% were unwilling to perform screening Pap tests (Bernstein, et al. 2016, Unger 2015). In another study, willingness to provide care to TGNB patients was correlated with liberal political views, personal contact with TGNB people, and low transphobia (Shires, et al. 2019).

In implementing TIC in reproductive settings for TGNB patients, the principles listed above should be addressed. For each of them, there are TGNB-specific and reproductive care-specific elements. We will provide a few examples from within the clinical encounter, which should then be implemented based on clinic- and setting-specific needs (Table 1).

Table 1.

Examples of trauma-informed reproductive care

Realm	Example/Action	Rationale	Principle/Dimension
Built environment	Ensure clear access to gender neutral and single-use spaces.	Provide both physical and emotional safety, prevent unintended outing and misgendering of TGNB individuals, and affirm that people of all genders belong in the clinic space.	Safety
Clinic intake	Ask for consent prior to weighing a patient.	Many people have been pathologized and traumatized by medical providers around weight and BMI and have lost trust in providers around this issue, which is exacerbated by the intersection of transphobia, fatphobia, and racism.	Collaboration and mutuality; Fostering agency and mutual respect
Language	Mirror the language that a patient uses for their significant others, their identity, and their anatomy.	Many TGNB people have Queer kinship structures that are crucial to their emotional and material support; use of chosen language avoids triggering gender dysphoria.	Practicing cultural sensitivity
Physical exam	Offer alternatives to pelvic exams and Pap smears such as transabdominal ultrasounds and self-swabbing, HPV screening alone, or harm reduction with HPV vaccination.	The intersection of gender dysphoria, medical trauma, and other emotional or sexual trauma can be intensely experienced around pelvic exams; being open to all alternatives can both decrease retraumatization and improve patient-provider trust.	Empowerment and choice

TGNB=transgender and nonbinary

1. Safety: Given the highly sensitive nature of reproductive care, and the particular marginalization of TGNB people, special attention must be paid to ensuring physical, emotional, financial, and legal safety. “Outing,” or revealing a patient’s gender identity or transness to others, can result in grave bodily and emotional harm. One way to prevent this is by avoiding gendered honorifics, such as “Ms.” or “Mr.”—especially in public (Bernstein, et al. 2016, Stroumsa and Wu 2018). These can be replaced with a non-gendered protocol for calling patients in for an appointment—for example, by simply using last names only (“Patient with the last name of Jamal”) until clarifying with a patient which name they would like to be used for them, both in private and in public settings. Use of chaperones of the patient’s choosing should similarly be routine and stringently offered to TGNB, as well as cisgender, patients. The specific financial burdens faced by TGNB people, including difficulty in accessing adequate health insurance and coverage, should be acknowledged and discussed prior to any billed appointment or procedure. Lastly, as legislation limiting access to reproductive and gender-affirming care spreads across the U.S., every effort should be made to enable patients access to information and care in accordance with their needs.

2. Trustworthiness and transparency: Specific attention should be given to an honest and transparent communication of practices, alternatives for care, and the rationale for decisions. Documentation should be open and shared with patients (unless specific serious harm may ensue). Use of codes such as Gender Dysphoria should be with consent from the patient.

3. Peer support: In accordance with the principle of peer support in TIC, incorporating TGNB peers into the care continuum and care relationship is an important part of the process of reversing the power dynamics and empowering patients. Specifically for TGNB people, peers can be a source of gender affirmation; peer support has demonstrated effectiveness in improving mental health in other populations (Pfeiffer, et al. 2011) and has been used successfully in HIV interventions with TGNB individuals (Sevelius, et al. 2020).

4. Collaboration and mutuality: Due to decades of scientific neglect, and with grassroots and community-derived activism and learning that grew in a vacuum, many gender-affirming medical transition practices that are commonly used are not evidence-based. Thus, for example, progesterone is often used by TGNB women and transfeminine people to improve breast growth, sleep, and mood, and to achieve an emotional state more compatible with their affirmed gender. Variations on this practice include rectal route administration and cyclic use. Furthermore, in light of medical trauma, stigma, and access barriers, many TGNB people use hormones procured without a prescription from a licensed provider (Stroumsa, et al. 2020). Providers responding to patients sharing any of these practices should be open, non-judgmental, and supportive; the aim should be to share information, ensure informed patient decision-making, and maximize both safety and patient satisfaction, avoiding a hierarchical attempt to control patients and the decisions they make or to dismiss their perspective. A core component of TIC is to establish the patient as the expert in their own life and experience (Levenson, et al. 2023).

5. Empowerment and choice: It is particularly important to use shared decision-making when considering gender-affirming and reproductive care, where often there is not a single, evidence-based possibility. The range of options should be openly shared with patients, along with the evidence for each—and the lack thereof.

6. Cultural and gender identity: Before patients even reach a clinic, providers should advocate for a change in the work culture, hire trauma-competent staff, and offer training sessions for all staff (Bernstein, et al. 2016, Levenson, et al. 2023, Sperlich, et al. 2017). The trainings should include both TIC and gender-affirming care content. Infrastructure including visible signs of representation in the waiting room and gender-neutral restrooms are ways to show that patients of all backgrounds, relationships, and genders are welcome and safe (Levenson, et al. 2023, Stroumsa and Wu 2018). Being sensitive to, and respectful of, people’s identities and the language they use to describe them are essential to establishing trust. To promote inclusivity and avoid errors of language, all patients should be asked about their name and pronouns, and providers should offer their own pronouns during introductions (or have them displayed on their badges). Attention should be paid to the language used in all signage, documentation, and in-person interactions. Staff knowledge of appropriate terminology surrounding gender and sexual orientation should be assessed in a non-judgmental way, with education provided as needed. Intake forms should include a range of genders, sexual orientations, and other ways for patients to safely share their unique identity with their care team (Carabez, et al. 2015, Levenson, et al. 2023)—ideally with an open-ended (free-form) response format.

Especially within a reproductive healthcare setting, providers and systems should work to make waiting spaces and clinics gender inclusive in name (e.g. “Center for Reproductive Medicine” as opposed to “Women’s Reproductive Care”); appearance (avoid using all-pink decor and all-feminine imagery); and bathroom availability (ensure access to at least one gender inclusive bathroom) (Stroumsa and Wu 2018). Where this is not possible, or where the clinic is inherently serving mostly people of a single binary gender, providers and schedulers should consider offering clinic visit slots as the first or last visit of the day to patients known to be TGNB, to mitigate the wait times in a potentially uncomfortable waiting room (Bernstein, et al. 2016). Patients should receive TNGB-specific and gender-appropriate education materials that avoid gendered terms and assumptions about patient experiences (Wilkerson, et al. 2011). Clinics should ensure the use of appropriate (chosen) names and pronouns during patient encounters and in documentation and use gender-neutral or inclusive language in general. Specifically when discussing reproductive health, genitals, and reproductive organs, providers should mirror patients’ used terminology or ask directly about terminology preference. As a default, gender-neutral language should be used, with explanation as appropriate—for example, “gonads, or the hormone-producing organs of the reproductive system, commonly referred to as ovaries or testicles” as opposed to “ovaries.” Notably, all of the above practices are not TGNB-specific and are recommended in interactions with patients of all genders.

It is critical to remember that much of the work to create a trauma-informed reproductive care environment for TGNB people starts well before the clinical encounter and continues well after it. This includes structural change to improve clinics, but also advocacy vis-a-vis insurance carriers; thoughtfulness regarding coding practices; training of healthcare professionals along the entire learning spectrum in both trauma-informed and gender-affirming care; and importantly, advocacy for protective (and against suppressive) legislation.

Conclusion:

While TIC should be a universal practice, there are specific considerations for trauma-informed reproductive care for TGNB people. Adopting a trauma-informed approach is not accomplished through any single particular technique or checklist. Creating a TIC environment for TGNB people requires constant attention, continuous improvement, and cultural change. The principles delineated above can be applied throughout the clinic space and healthcare encounter, along with continuous organizational assessment and engagement with community members. Healthcare providers, researchers, and administrators should pay particular attention to the specific needs of TGNB people with intersecting minoritized identities; since they face multiple forms of discrimination, their trauma may be multifold and complex. In particular, racism and ableism in healthcare and medical trauma need to be acknowledged and addressed using all six principles of TIC (Figure 1) in order to create a safe environment for TGNB people of color and people with disabilities.

Figure 1. Components of Trauma-Informed Care.

TIC=trauma-informed care

These actions will enable creating an affirming, trauma-informed visit (including pre- and post-appointment interactions with the system), which can avoid re-traumatization, assist in restoring TGNB patients’ trust in the medical community, improve mental health outcomes, and increase engagement in care.