Healthcare Providers’ Perspectives on Pregnancy Experiences among Sexual and Gender Minority Youth

Abstract

Objective:

To interview healthcare providers who serve adolescent populations to learn their perspectives on the factors that influence the continuum of sexual and gender minority (SGM) youth’s pregnancy expaeriences, including decision-making about sex, relationships, and pregnancy.

Methods:

As part of the SexuaL Orientation, Gender Identity, and Pregnancy Experiences (SLOPE) Study, semi-structured interviews were conducted with 10 U.S.-based healthcare providers who had experience providing care for both SGM youth and pregnant youth. Interview questions examined providers’ experiences caring for this population, including their perceptions of the risk and protective factors influencing SGM youth’s pregnancy prevention, avoidance, and decision-making processes. Audio-recorded interview data were analyzed using immersion/crystallization and thematic analysis methods.

Results:

Three themes were identified from the healthcare providers’ transcripts: 1) Cultural norms about adolescent pregnancy and sexuality, 2) Interpersonal relationships and family support, 3) Sex education, sexual and reproductive healthcare access, and sexual health equity.

Conclusion:

In conjunction with sexual health education and healthcare access, healthcare providers described many social contexts—like peers, family, and communities—that interact with each other and with adolescent development to shape pre-conception practices and pregnancy decision-making processes. Future research, practice, and sexual health messaging about adolescent pregnancy would benefit from acknowledging the complex interplay among social identities and positions, structural prejudice, and the nuanced diversity in community and interpersonal factors—including those in sexual healthcare settings, like provider-patient communication and sex education delivery—that shape SGM youth’s dating and sexuality experiences.

Introduction

Compared to heterosexual youth, sexual and gender minority (SGM) youth are more likely to experience or be involved in an adolescent pregnancy (occurring before age 20 years)(1,2). The adolescent pregnancy experiences of SGM youth have largely been framed from a risk perspective—i.e., pregnancy is assumed to be perceived by adolescents as a negative outcome, and it is connected to certain sexual behaviors that are elevated among SGM youth (e.g., greater number of sexual partners, inconsistent or absence of contraception use, younger age of sexual debut)(2–4). As a result of this framework, adolescent pregnancies among SGM youth are considered largely in isolation as adverse sexual health outcomes, with less attention paid to the context of SGM youth’s motivations behind pre-conception preventive behaviors and post-conception pregnancy decision-making processes. Additionally, further nuance is required in examining the pregnancy intentions and motivations of SGM youth since an unintended pregnancy could be considered either unwanted or merely mistimed (5).

Sex education messaging for youth compounds these issues with heteronormative content that excludes SGM youth from narratives and information about pregnancy (6–8)—ranging from preventive activities and decision-making to parenting. Assumptions about adolescent pregnancy are limited by more than heteronormative bias: assuming that unintended and adolescent pregnancies among SGM are always unwanted reflects an additional bias – that of White narratives of family and parenting that exclude the pregnancy, family, and parenting experiences of sexual minority women of color (9–11). In addition to this, SGM youth describe feeling fear and uncertainty about pregnancy and anticipating negative reactions of others toward themselves as a pregnant person, yet feeling positive about eventually becoming parents (12).

Healthcare providers are an important source of sex education, sexual and reproductive healthcare, and obstetrical care for SGM youth. Positive provider-patient communication has been associated with greater pregnancy prevention self-efficacy among U.S. adolescents. SGM youth have a more complex history of communication with healthcare providers than their cisgender heterosexual peers due to factors related to cultural competency (and lack thereof) in clinical practice (13–15). From SGM youth’s perspectives, engagement with sexual and reproductive healthcare services and providers tend to be negative, isolating, and dis-affirming, and discussions of sexuality, sexual orientation, and sexual health are often infrequent, and when present, uncomfortable (13). Dominant cultural narratives and heteronormative assumptions about pregnancy involvement and contraception use tend to exclude SGM (16), which in turn can negatively impact sexual orientation disclosure and opportunities for tailored sexual and reproductive healthcare counseling of SGM youth, and at worst leads to further sexual and pregnancy-related healthcare avoidance by SGM youth due to fears of discrimination or further exclusion (14).

In spite of the quality of these interactions, healthcare providers are still heavily involved in sexual and reproductive healthcare access (e.g., STI testing, abortion care) and experiences of SGM youth (17). As such, understanding healthcare providers’ clinical experiences with and views of adolescent pregnancy can provide an additional and complementary perspective to SGM people’s own experiences with and views of adolescent pregnancy (18,19) and their related interactions with the healthcare system. Healthcare providers, particularly those who identify as heterosexual, tend to feel underequipped for sexual and reproductive healthcare counselling of SGM youth and acknowledge that they operate within a larger status quo wherein SGM care represents a deviation from standard procedures (17). Less is understood about the perspectives of healthcare providers who have more exposure to, experience with, or insights about sexual and reproductive healthcare counselling with SGM youth. Particular focus is needed on its precise intersection with pregnancy-related prevention and decision-making care, which largely ignores SGM. To this end, we sought to interview sexual and reproductive healthcare providers who serve adolescent populations to understand their perspectives on the factors that may influence SGM youth’s pregnancy experiences, including both pre-pregnancy decision-making about sex and sexuality as well as decision-making processes surrounding pregnancy.

Materials and Methods

Participants

Study participants were 10 healthcare providers with experience caring for SGM and/or pregnant youth. Participants were a subsample from the SexuaL Orientation, Gender Identity, and Pregnancy Experiences (SLOPE) Study. The research team identified and contacted providers whose clinical expertise included caring for SGM youth and who were likely to interact with pregnant youth of any sexual orientation or gender identity. The participants represented a range of clinical professions including: physicians (n=5), nurse practitioners (n=4), and a licensed social worker (n=1). They also had differing areas of clinical practice with specialties in pediatrics (n=3), adolescent medicine (n=1), obstetrics and gynecology (n=2), and family medicine (n=1). Participants practiced in metropolitan areas in New England (n=7), the Mid-Atlantic (n=2), and the Midwest (n=1). Clinical sites included pediatric hospitals, safety-net hospitals, community centers, and independent clinics. Although sexual orientation and gender identity were not collected systematically from participants, four providers identified themselves as SGM (unprompted) during the interviews. Participants were recruited directly by team members via network and snowball sampling.

Researchers

The research team conducting this study held a range of personal identities and professional backgrounds that may have informed data analysis and interpretation of findings. Sexual orientation identities included queer, gay, and bisexual; gender identities included cisgender woman, transgender man, nonbinary, and genderfluid. Racial/ethnic identities included White and Black. Team members had expertise in adolescent health, developmental psychology, medical psychology, education, gender studies, and social epidemiology. All members of the research team had prior experience conducting research and/or clinical work with SGM youth and many of them had lived experiences as an SGM youth. To account for potential research team bias, a biases and assumptions meeting was held prior to starting data analysis. During this meeting, relevant identities, experiences, and perspectives related to pregnancy in SGM youth were discussed and documented as a reflexivity exercise, as well as to prime members of the later coding analysis teams for biases during secondary coding and/or analysis. Note-taking procedures during coding were also used to discuss discrepancies or concerns about biases between coders, and unresolved conflicts were discussed during team meetings throughout coding and analysis.

Measures

The semi-structured interview protocol was developed by Dr. KatzWise (study PI) and was reviewed and revised by the research team. Interview guide development was informed by minority stress theory (20); which suggests that experiences with sexual orientation-based stigma and discrimination shapes mental and physical health experiences and outcomes for sexual minority individuals. Interview questions asked about health problems that SGM adolescents face, their experiences caring for this population, and their perspectives on risk and protective factors for adolescent pregnancy in SGM youth. Example questions from the interview protocol are provided in Table 1.

Table 1.

Sample interview questions.

Section	Sample questions
Teen Pregnancy	• Can you tell me about the last patient you treated who had a pregnancy while they were a teen? • Do you think these factors are the same for sexual and gender minorities? If not, what are some factors that may be specific to sexual and gender minorities?
Sexual and Gender Minorities	• What kinds of experiences have you had in treating sexual and gender minority patients? • What unique needs have your sexual and gender minority patients had?
Teen Pregnancy Among Sexual and Gender Minorities	•Have you ever cared for a sexual or gender minority patient who had a teen pregnancy or was involved in a getting their teen partner pregnant?  • The latest research shows that sexual and gender minorities are about twice as likely as their heterosexual peers to either have a teen pregnancy or have gotten another teen pregnant. What do you think are some unique risk factors for SGM youth that lead to this teen pregnancy disparity?  • Beyond earlier sexual initiation, what are some other risk factors that you think about for teen pregnancy among sexual and gender minorities?

Procedure

Data were collected from April 2017 through May 2019 for the entire SLOPE study; healthcare provider data were collected from July 2017 through January 2018. Trained interviewers on the research team conducted one-on-one, semi-structured interviews with participants via phone. All participants gave informed consent prior to participation and received $75 remuneration for their time. Study interviews lasted between 45–90 minutes. Interviews were audio-recorded, professionally transcribed, and masked by trained members of the study team. This study was approved by the Institutional Review Board at Boston Children’s Hospital.

Analytic Method

Interviews were analyzed by three members of the research team using immersion/crystallization (21) and template organizing style (22) approaches Brown, Godwin, and Jonestrask developed and refined the codebook, coded all interviews using the refined codebook, and identified themes based on the codes. Katz-Wise oversaw codebook development, coding, and theme creation. The coding team began by reading through two full interview transcripts to immerse themselves in the data. They then used observations from those transcripts to develop a draft codebook. Through group conferencing and with Katz-Wise’s supervision, the codebook was tested on the same two transcripts, and revised by adding newly identified codes and clarifying code definitions. Once all four researchers agreed on a finalized codebook, Brown, Godwin, and Jonestrask coded the two original transcripts a final time to ensure that all three coders were applying the codes in the same manner.

Each transcript was coded by a primary coder using the finalized codebook in the online mixed methods platform Dedoose, then reviewed by a second coder; any coding differences were resolved via discussion between the two coders. Any disagreements that could not be resolved were brought to the full coding team for discussion. Once all the transcripts were coded, a thematic analysis approach (23) was used to develop themes. Each team member independently generated preliminary themes from the codes, pulling together codes that fit into themes based on the excerpts. Draft themes were presented in team meetings with Katz-Wise and Charlton for review and refinement. At this stage, a third analyst,Tabaac, reviewed draft themes and assisted with finalizing these themes into their final form presented in this paper. All iterations of the codebook and manuscript, including past analysis, were preserved as part of the study record.

Results

Study interviews queried the experiences and motivations behind pregnancy and pregnancy prevention among SGM youth from a healthcare provider’s perspective. The process of coding interview transcripts and subsequent analyses showed that providers framed this population’s pregnancy experiences along the lines of several themes encapsulating the multi-level nature of the continuum of pregnancy intentions, prevention behaviors, reactions, and decision-making. Three themes were identified: 1) Cultural norms about adolescent pregnancy and sexuality, 2) Interpersonal relationships and family support, 3) Sex education, sexual and reproductive healthcare access, and sexual health equity. Within each of these three themes, providers described the pregnancy experiences of SGM youth as occurring within two primary contexts: motivation for relationships and sexuality-related experiences prior to pregnancy, and the factors that shaped post-conception pregnancy-related decisions. Below, we explore the individual and interconnected factors that, from a provider’s perspective, may impact the pregnancy intentions, incidence, and outcomes among SGM youth, and how these factors may contribute to pregnancy as an outcome of risk or resilience among SGM youth.

Theme 1: Cultural Norms about Adolescent Pregnancy and Sexuality

Cultural norms, such as those surrounding age and pregnancy or stereotypes about SGM people, were factors that providers perceived as influencing pregnancy intentions, avoidance, and/or post-conception decision-making. Healthcare providers ranged in such descriptions: for some SGM adolescents, this meant avoiding the stigma of adolescent pregnancy, while for other youth, providers perceived a pregnancy was an attempt to fulfill community norms or was seen as one of few pathways open to them. An OB/GYN from the South recounted, “These kids are raised in what the expected norm is. You know, if everyone that you know is parenting as a teen, you don’t wanna be the odd one out necessarily. And particularly, in our community, in like [MAJOR CITY]… if you’ve got nothing to look forward to, like your only life goal is to be a parent, that definitely can influence it too.”

Providers also noted that, for other SGM youth seen at their practices, pregnancy was viewed as a way to fulfill familial expectations of providing grandchildren, enabling them to subsequently seek out same-gender partners. For instance, one nurse practitioner in the Northeast described pregnancy as a strategy some SGM youth employed both to maintain ties to families of origin and gain autonomy to build chosen families: “A couple of the youth, it was to sort of fit back into the family, like, ‘yes, I can have a child, and now I fulfilled my obligation in creating a grandchild for my family, and I can now have a same-sex partner.’” For other adolescents, pressure to pass as heterosexual could create pressure during their pregnancy intentions and subsequent decision-making process, as noted by the OB/GYN in the South: “I can imagine, there’s youth who feel like, “Oh, if I like get someone pregnant or if I’m pregnant, then they won’t suspect and kind of blend in more.” Other providers proposed that negative attitudes toward SGM people can cause minority stress, which likely plays a role in the pregnancy experiences of SGM youth. For example, one pediatrician in the Northeast stated that “we have a culture that does not appreciate differences and struggles with differences…Any minority is potentially subject to minority stress theory, and the minority stress health outcomes, which are typically more adverse than their non-minority peers.”

Theme 2: Interpersonal Relationships and Family Support

In addition to cultural and subcultural norms, interpersonal relationships were noted as potential drivers of pregnancy-related decision-making, both conscious and subconscious. One family nurse practitioner in the Northeast described “disenfranchisement from a family unit” wherein SGM youth “may be like, neglected, you may be abandoned, you may be emotionally not valued in your home.” Lacking supportive relationships in the home, the provider posited, “where are you gonna find attention and love? With another partner would be another risk factor.” In extreme cases, providers noted trends in childhood sexual abuse and trauma as prevalent aspects of their SGM patients’ case histories, which could be a challenge when addressing pregnancy risks from a contraception counseling approach, as described by this nurse practitioner from the Northeast: “…but, like, how do you…what do you say, you know? Like, what do you say to that person of, like, ‘Well, then, you should have contraception in case you get assaulted again’? No.” In other cases, providers noted that not all adolescent pregnancies are unintentional; for some, pregnancy may be a desired outcome, with particular social relationships leveraged as a strategy for conception. Another nurse practitioner noted: “I can think of a couple of the girls who’ve sort of picked the [male] partner that they wanted to have the baby with, with that partner, knowing that they had a female partner, and so was a willing participant in that, was sort of helping them out for that.”

Family support (whether from family of origin or chosen family) was also commonly described by providers as an influence on SGM adolescents’ pregnancy reactions and post-conception decision-making processes. Supportive relationships were described as a positive resource for pregnant SGM adolescents. For instance, several providers discussed the sources and forms of support available to adolescents seeking abortions. A family physician in the Northeast noted how maternal support was important in establishing a patient’s autonomy and decision-making process: “She and her mom, even though they both for religious reasons were opposed to abortion, they were still, like, very close, very close with each other. And her mom, even though she opposed abortion…she really supported her [daughter’s] autonomy around that decision.” In another case, the OB/GYN in the South noted that having a stable and supportive romantic relationship could mitigate negative consequences of unintended adolescent pregnancy: “But she has a relationship with her girlfriend. I actually ran into her on the street about a year later, and they were in the process of getting married. And she had, like a stable job and was doing GED classes. So she was kind of a success story of someone with two kids.”

Conversely, a number of providers described lack of family support as adversely impacting SGM adolescents with respect to post-conception pregnancy-related decision-making. For example, a mental health provider in the Northeast described circumstances in which pregnancy was a strategy for one of their SGM adolescent patients in a toxic home environment to take more control over her living situation and family relationships:

She pretty deliberately set out to meet a guy who she was most sure that her mother would hate, and to have unprotected sex with him as many times as she could until she became pregnant. And then - this was not a healthy or functional family situation at all - and then sort of subsequently, that pregnancy sort of became, in a lot of sort of family arguments, sort of a bargaining chip in a number of particularly super uncomfortable family therapy sessions where this young person said [to] her mom, like… “Well, I’ve been asking you for a car, and you won’t get me a car. Get me a car or I’m gonna have an abortion.”

Theme 3: Sex Education, Sexual and Reproductive Healthcare Access, and Sexual Health Equity

Pregnancy intentions, experiences, and decision-making processes were also largely described by providers in terms of sex education exposure and healthcare access. For SGM adolescents, providers proposed that family rejection could pose a risk factor for homelessness and inadequate healthcare access, as discussed by the family physician from the Northeast: “But I do think that when queer and trans young people, when they are not accepted by their family, it’s harder for them to talk about their health care needs. It’s harder for them to access health care when they are…and they also experience more, you know, other risks like homelessness, alcohol use, survival sex.”

Healthcare providers also emphasized the need to recognize the specific pregnancy information needs among SGM adolescents, and therefore to tailor care to this population. For instance, this pediatrician from the Northeast noted that family planning counseling is an important facet of pregnancy-related care for SGM people that needs to be done using a broader reproductive justice-based lens:

If you’re talking about reproductive justice, you’re not just talking about contraception, you’re not just talking about abortion. You’re talking about overall family planning, which means what/when/how do you support folks who want to get pregnant, as well as what/when/how do you support folks who don’t want to be pregnant? And so, I think including that aspect of reproductive justice in the conversation is important in terms of looking at gender and sexual minority persons having the same options for reproductive integrity, reproductive success as their cisgender/heterosexual peers.

SGM-specific barriers to sexual health information and care access are further complicated by barriers that can be encountered by all youth, resulting in a distinct intersection of marginalization based on age and SGM status. Formal sex education from schools was commonly indicated by providers as such an area of information disparities: “But [in] middle schools I would love to see abstinence-only education go away. I would like to make sure that, right, that everyone’s actually receiving accurate information on pregnancy risk. Because there is still a ton of patients who don’t think that they can get pregnant because X, Y, or Z.” Providers also described how SGM adolescents with unsupportive family relationships, barriers to contraceptive access were pervasive, as described by this OB/GYN in the Midwest:

There was a handful of young, pregnant patients that I knew of that were either bisexual or lesbian or otherwise not hetero-cisgender. And for them the pregnancy was strongly linked to their ability, or inability, to talk to the people around them in their lives about their sexuality, and their genders, that the lack of family support for who they are is inextricable from the way in which they’d interact sexually with the people in their lives. And hence probably also too is that they either weren’t previously counselled on pregnancy and pregnancy risk and intervention or that they couldn’t go to their provider and talk about these things…for whatever reason, that those, elements are just absent in their lives.

Several healthcare providers also noted that differential access to sexual and reproductive health education and care could magnify pregnancy outcome disparities among SGM individuals. One mental health provider described this phenomenon as “being siloed”:

It is the assumption of heterosexuality, unless you go to a clinic that is more in tune to that, but really for most practices that is the assumption. Then, if you disclose that you’re only having female partners, then it’s sort of, well, we don’t have to talk about birth control or anything else, because we’ve put you in that silo, and there you’re gonna stay for the rest of your life, and that’s not so.

Discussion

In this study, healthcare providers described the pregnancy-related experiences of SGM youth along three themes: 1) Cultural norms about adolescent pregnancy and sexuality, 2) Interpersonal relationships and family support, and 3) Sex education, sexual and reproductive healthcare access, and sexual health equity. These themes encompassed both pre- and post-conception pregnancy-related processes (e.g., intentions), behaviors, and decision-making. A variety of risk and resilience factors were identified in each theme.

In Theme 1, providers described how cultural norms, both positive and negative, about adolescent pregnancy and sexuality can also shape SGM youth’s pregnancy-related sexual health behaviors. A primary takeaway is that community norms about adolescent pregnancy are not homogenous in the United States, and caution should be made in assuming that adolescent pregnancy is universally viewed as an invariably adverse health outcome. For instance, Black sexual minority women in the United States have described adolescent pregnancy as an opportunity for family-building (10,11). It is important to note that norms within communities also differ (e.g., another study found African American adolescent girls saw pregnancy as a negative outcome (24), which may indicate differences between heterosexual and SGM youths’ pregnancy norms and desires). Competing messages can also exist within the same community (e.g., pregnancy may prevent academic success but early pregnancy is desirable among certain religious communities)(25). A primary implication of this theme is that both family and community dynamics can interact to differentially shape SGM youths’ perceived norms and decision-making surrounding pregnancy and support youth in making decisions that maximize their autonomy and well-being along multiple axes.

In Theme 2, providers shared their perspectives on how interpersonal relationships, family support, and relationship quality can influence pregnancy-related sexual health behaviors and processes. Family support has previously been associated with a host of positive physical and mental health outcomes for SGM youth (26). Our findings contextualize these analyses, as supportive maternal relationships were described as important for SGM youth’s decisions about pregnancy, adoption, and abortion. Meanwhile, negative or toxic family relationships acted as additional stressors, and in some cases motivated SGM youth to continue their pregnancies as a means of exerting more autonomy and gaining respect in their families. In some family situations, becoming a parent (rather than the pregnancy itself) may be a means for SGM youth to feel they can integrate more fully with their families in the face of underlying stigma (12), or as a means of creating family in the form of a child that loves them unconditionally (10,11). In such cases, adolescent pregnancy may also represent a conscious or subconscious strategy geared toward family- and/or community-building for SGM youth, which may in turn act as a resilience factor in a landscape in which access to other forms of support is unavailable. In this context, adolescent pregnancy may act as a resilience strategy for certain SGM youth, especially if they have long-term pregnancy intentions that may be difficult to realize in early adulthood due to the high cost of traditional family planning services (e.g., assisted reproductive technology)(11,27).

In addition to family relationships, romantic and sexual relationships can act as an important source of social support for SGM youth (28), though such relationships may also act as risk factors if abuse and/or violence is present (29). As noted by a provider in our study, having a stable partner relationship could help SGM youth with children navigate life successfully despite the multiple social (e.g., stigma) and economic (e.g., childcare costs) challenges associated with adolescent pregnancy. In other cases toxic or abusive relationships could place young and isolated SGM people at considerable risk for unintended and undesired pregnancies with little social and economic resource access outside these relationships.

In Theme 3, providers described their perspectives on SGM youth’s access and exposure to sex education and sexual and reproductive healthcare. Traditional sex education from schools is largely described in health communication literature as poorly representative of SGM people and often containing stigmatizing or irrelevant information (7,8,30), which can lead to unintended pregnancy among SGM youth. Further, providers have also speculated that the hyper-focus on sexual minority men in HIV prevention messaging has had the unintended consequence of contraception losing its association with pregnancy prevention uses for this group (30).

In particular, healthcare providers are often youth’s first contact with sexual and reproductive health information, and the quality of these provider-patient encounters have many implications for SGM youth’s sexual health behaviors. Lack of sexual orientation disclosure, often driven by fear of discrimination (13,14,16) or as a strategy for successfully accessing sexual and reproductive healthcare (31), can lead to missed opportunities for sexual and reproductive healthcare counseling. SGM youth cite unaccommodating environments, poor representations of sexual and gender diversity in sexual health, a lack of comfort with or fear of the consequences of sexual orientation disclosure, and perceived discomfort of healthcare providers with sexual health topics as barriers to care (13). For SGM with past adolescent pregnancies, exclusion and erasure of transgender individuals (19) and sexual minority women (18) from sex education narratives and sexual healthcare services related to pregnancy explicitly shaped their pre-conception contraception behaviors and experiences with pregnancy. Overall, this theme underscores the necessity of improving sexual and reproductive health education and access in culturally humble ways that address the variety of stressors related to heteronormativity and discrimination faced by SGM youth. Attention should be paid not only to the nuances of how SGM youth navigate their sexuality and relationships based on their sexual and gender identities, but also on how structural factors, including those that manifest in provider-patient encounters, shape their access to obstetrical services (including abortion) and mediating factors of healthcare quality, like sexual orientation disclosure.

Minority stress may be a particular structural and interpersonal mechanism behind certain pregnancy prevention behaviors (e.g., navigating contraception use) or decision-making processes. Minority stress has been characterized in pregnancy literature as an outcome of heteronormativity in sexual health and relationship education and messaging that not only serves as a barrier to adequate health information access, but may also influence SGM youth’s dating decision-making processes (30). Dating presumably “opposite sex” partners can be a strategy for young SGM to “pass” as heterosexual (10,30), though it is important to note that this rationale does not appear to extend to pregnancy decision-making [i.e., SGM youth do not name “passing” as a reason for carrying out a pregnancy (10,12,30)]. Instead, a combination of socioeconomic factors (including healthcare access), and subculture norms around adolescent pregnancy—whether it is considered, acceptable, common, supported, or desired in one’s community—may influence subsequent decision-making about unintended pregnancies. This enacted stigma is likely to be amplified further for SGM youth with multiply marginalized identities; as one provider noted, many pregnant SGM at their clinic were also young women of color.

Themes from this study present several implications for clinical practice with SGM youth. Foremost, clear practices grounded in cultural humility are needed in both sex education for youth and medical education. Cultural humility necessitates moving from affirmation to active resistance against discrimination and stigma. That is, sex education content and provider practices should not only be inclusive of young SGM identities (e.g., including SGM-relevant content in contraception and pregnancy prevention messaging) but should also come from a place of understanding the structural and interpersonal barriers young SGM face (32). For example, stigma can create a strong desire to “pass” as heterosexual due to potential consequences of bullying, ostracizing, and even assault by peers and families; this may motivate young SGM to conceal their sexual orientation or gender in sex education or clinical care environments. Being cognizant of this social reality and providing ways for SGM youth to self-disclose without risk of being outed to family members or peers is an example of a culturally humble way of addressing sexual orientation disclosure barriers in adolescent sexual health settings. Further, there are important differences among sexual minority subgroups and between cisgender and gender minority youth. Thus, care must be taken not to enact health communication strategies that are intended to be culturally competent (e.g., providing a greater focus on gay or lesbian relationships without attention paid to bisexual or transgender people) but end up excluding many SGM youth in a manner similar to traditional sex education curricula that focus on heterosexual relationships.

There are several limitations to the present study. Demographic characteristics were not systematically collected from providers, thus we cannot accurately characterize the demographic make-up of the sample. Since providers needed to have experience caring for SGM youth and pregnant youth to be eligible, they do not represent the views of healthcare providers outside with less contact with SGM youth. Further, providers were recruited through snowball sampling methods, thus the sample is biased toward SGM-affirming providers from the researchers’ personal networks. However, since the aim of this paper was to investigate providers’ recommendations and observations of pregnancy-related care from SGM youth, this was an intentional sampling strategy. Given themes are derived from the perspectives of providers’ whose patients disclosed their sexual orientation, the scope of the analyses and subsequent themes derived from our provider interviews may not be comprehensive of patients with a history of dis-affirming healthcare encounters, limited healthcare access, or who do not disclose sexuality information and reproductive healthcare contexts. However, a growing extant literature on SGM pregnancy, including of various qualitative and quantitative methodologies, can approach these gaps by designing studies around SGM with varying levels of reproductive healthcare access and disclosure experiences. Many providers from our sample were SGM, which can result in a different level of familiarity and more personal insight about the sexual and reproductive health needs of SGM youth. However, sexual orientation was not collected in our demographic survey, thus we cannot uniformly report sexual orientation for all providers in our sample. Future work examining diversity in provider identities and experiences or capacity for affirming care with SGM people should be careful to recruit a broader sample of providers, and should take into account how provider gender and sexual orientation may further drive perspectives, assumptions, and practices related to SGM care. Participants in this sample were all from metropolitan areas in New England, the Mid-Atlantic, and the Midwest, and thus perspectives from providers practicing in rural areas or the U.S. South are not represented by this study. Due to this limitation, cultural attitudes described by providers will not be generalizable to all U.S. Census regions. The sample size of providers was also small; although this research is exploratory, it provides some direction for future research in this area. Another limitation is that healthcare provider accounts of SGM patients who experienced adolescent pregnancy were primarily about cisgender young women, and findings from these themes may not be applicable to cisgender male or transgender youth.

Conclusion

In conclusion, themes from this study indicate that, in conjunction with sexual health education and access settings, many social contexts—like peers, family, and communities—interact with each other and with adolescent development to shape pre-conception practices and pregnancy decision-making processes. Factors like social inclusion/exclusion of SGM, perceived norms about adolescent pregnancy acceptability, and direct emotional or financial support from parents or sexual/romantic partners were all described by providers in this study as factors that may influence young SGM people in their pregnancy-related experiences. As such, making assumptions about relationship quality or community norms—or viewing these factors from solely a risk perspective—may end up alienating SGM youth as much as heteronormative messaging that ignores or stigmatizes their SGM identities, leaving them to disregard pregnancy prevention messaging. Future research, practice, and sexual health messaging about adolescent pregnancy experiences, decision-making, and associated quality of life would benefit from acknowledging the complex interplay among social identities and positions, structural prejudice, and the nuanced diversity in community and interpersonal factors that shape SGM youth’s dating and sexuality experiences.

Highlights.

• Providers described social contexts that shaped pregnancy decision-making processes for sexual and gender minority youth

• Providers view sex education and healthcare access as barriers to youth’s sexual health

• Providers observed that prejudice and stigma can affect sexual and gender minority youth’s adolescent pregnancy risks