A Reproductive Justice Approach to Patient-Centered, Structurally Competent Contraceptive Care Among Diverse Sexual Minority US Women

In their article in this issue of AJPH, Higgins et al. (p. 1680) provide novel and nuanced information on an understudied yet critically important public health issue: contraceptive use among sexual minority women (SMW; e.g., lesbian and bisexual women, women with female sexual partners). Indeed, while SMW engage in sexual behaviors that could lead to pregnancy and have unique reproductive health needs and concerns, including higher rates of unintended pregnancy relative to non-SMW (e.g., heterosexual women, women with only male sexual partners), research on SMW’s reproductive health in general and contraceptive use in particular remains scarce.¹ Using focus groups and in-depth interviews, the authors identified several unique barriers to and facilitators of contraceptive use among young adult cisgender SMW at the individual, interpersonal, and structural level.

Although this new study makes an important contribution to the scientific literature, using a reproductive justice approach² would have enabled the authors to elucidate how not only sexism and heterosexism but also racism and economic oppression influence contraception among SMW. Indeed, reproductive justice is a framework and movement developed by Black women that addresses bodily autonomy, intersectionality (namely, the interplay between interlocking systems of oppression, including sexism, racism, classism, and heterosexism³), human rights, and social justice and pertains to the right to not have a child, the right to have a child, and the right to parent children in a healthy and safe environment.² By using a reproductive justice lens,² research on contraceptive use among SMW can help inform patient-centered, structurally competent interventions that address the unique contraceptive needs of socially and economically marginalized groups of SMW, including SMW of color and poor and low-income SMW.^4,5

STUDY STRENGTHS AND LIMITATIONS

The study has several notable strengths. First, by using qualitative research methods, the authors generated nuanced, rich, and detailed understandings of contraceptive use from the participants’ perspective. Second, the qualitative approach that Higgins et al. used allowed them to explore contraceptive use in the context of various aspects of women’s lives, including queer identification, sexual behavior, and gender-based violence. Third, the study team was composed of both social scientists and clinical researchers, which allowed the authors to elucidate how social (e.g., sexism, heterosexism) as well as health care (e.g., patient–provider interactions) factors influence contraceptive use among SMW. Fourth, the investigators’ interdisciplinary approach allowed them to identify determinants of contraceptive use among SMW not only in multiple domains but also at multiple levels—including the individual, interpersonal, and structural level. Thus, the present study may help inform the development of multilevel community-based and health care interventions that facilitate access to and utilization of voluntary contraception among SMW.

As the authors recognize, the study has some limitations. First, study results would have been strengthened if the researchers had included sufficient numbers of SMW from different sexual orientation identity subgroups. Specifically, although the majority (52%) of study participants identified as queer and a substantial minority (27%) identified as bisexual or pansexual, only 15% identified as lesbian or gay. Previous studies indicate that sexual orientation identity subgroups of SMW (e.g., lesbian women, bisexual women) have different social, economic, and health profiles and contraceptive use behaviors.¹ As a result, the themes presented in the article may or may not apply to all SMW in the same way or to the same extent and may also not be relevant to those who were underrepresented in the study. Moreover, the sample composition (especially the small number of lesbians) also precluded the authors from being able to systematically identify differences in contraceptive attitudes and experiences among SMW (e.g., lesbian vs bisexual/pansexual vs queer women). Thus, Higgins et al. missed an important opportunity to expand our understanding of contraceptive use not only among SMW overall but also among different sexual orientation identity subgroups of SMW.

Second, as the authors noted, most study participants identified as White. Only a relatively small proportion (21%) of the sample consisted of people of color (who represented about 40% of the US population in 2010), and no Black or Native American woman was included in the study. Thus, Higgins et al. were unable to identify the unique and specific contraceptive experiences of diverse groups of SMW of color or elucidate how racism, alone and in conjunction with sexism and heterosexism, shaped contraceptive use among SMW. However, ample research has shown that Black, Native American, and Latina women have suffered discrimination, abuse, and oppression in the context of contraception.^2,6 Thus, it is possible that SMW from marginalized racial/ethnic backgrounds face unique and disproportionate barriers to receiving high-quality contraceptive care, which should be explored in future research.

Third, participants were highly educated and resided in major US cities, which hindered the elucidation of the unique and potentially disproportionate barriers to contraceptive use among SMW from lower socioeconomic positions and those living in rural areas and precluded the exploration of the role of economic oppression and marginalization in shaping contraceptive use among SMW.

RESEARCH IMPLICATIONS

This new study by Higgins et al. has important implications for future research. Moving forward, investigators should utilize purposive sampling strategies such as maximum variation and quota sampling to increase sample diversity and facilitate subgroup analyses in relation to, for example, sexual orientation identity, race/ethnicity, and socioeconomic position. In addition, in line with a reproductive justice approach,² future studies should elucidate the role of not only sexism and heterosexism but also racism and economic oppression, at both the interpersonal and structural level, on contraceptive use among socially and economically diverse groups of SMW.

Furthermore, while the authors investigated SMW’s contraceptive use in the context of certain aspects of their lives and in relation to some health care factors, the reproductive justice framework² and a patient-centered, structurally competent approach to contraceptive care^4,5 suggest that future research should identify how other salient facets of SMW’s lives (e.g., fertility desires and intentions, relationship dynamics, sexuality education, social and economic resources) and health care experiences (e.g., discrimination in the health care system, patient–provider communication, sexual orientation disclosure, patient–provider demographic concordance) shape contraceptive use among diverse groups of SMW.

Lastly, reproductive justice underscores the need for studies that use a community-based participatory research approach and involve SMW in all aspects of the research process—including identifying research priorities and questions, collecting and analyzing salient and actionable information, interpreting and disseminating study findings, and developing and implementing solutions to observed problems—to advance research and action pertaining to high-quality contraceptive care in this underserved population.²

CLINICAL AND PUBLIC HEALTH PRACTICE IMPLICATIONS

The research findings of Higgins et al. make clear that, during clinical encounters, SMW should be offered the full range of nonhormonal and hormonal contraceptive methods as well as relevant, inclusive, and affirming contraceptive information and counseling for both fertility and nonfertility reasons. By adopting a patient-centered approach that equitably engages SMW in contraceptive care, health care providers will ensure that SMW can make informed decisions and choose the contraceptive method(s) that best suits their needs and preferences.⁴

In addition, from a reproductive justice perspective, health care providers should deliver contraception in the context of SMW’s fertility desires and intentions, support SMW in their pregnancy and parenting decisions and needs, and ensure that they address the role of sexism, heterosexism, racism, and economic oppression in shaping women’s reproductive health, health care experiences, and lives.² To achieve these goals, health care institutions need to train providers in the reproductive health and contraceptive needs of diverse SMW, patient-centered care and shared decision-making, influence of interpersonal and structural discrimination on health and health care, and history of reproductive abuses among women of color and poor women in the United States.^2,4,5

Moreover, to provide diverse groups of SMW with high-quality contraceptive care, health care institutions need to ensure that their policies and practices are inclusive of SMW from marginalized social and economic backgrounds and prevent and address health care provider bias, stigma, and discrimination toward diverse SMW and other marginalized patients.⁷ Moreover, Higgins et al. underscore the need for public health initiatives thatfacilitate SMW’s access to relevant, inclusive, and affirming contraceptive information and methods, ideally in partnership with trusted community-based organizations that serve diverse groups of SMW.

Lastly, these clinical and public health efforts should be accompanied by the implementation of social policies, norms, and practices that dismantle not only sexism and heterosexism, as the authors note, but also racism and economic oppression, and instead promote social justice and, in turn, health equity.²