Advertisement

Culturally humble fertility care: education and advocacy

      Kirubarajan et al. (
      • Kirubarajan A.
      • Patel P.
      • Leung S.
      • Park B.
      • Sierra S.
      Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: a systematic review of patient and provider perspectives.
      ) conducted a systematic review of patient and provider perspectives on “cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people.” The review sheds light on disparities in access and satisfaction with fertility care among this population sometimes referred to as “sexual and gender minorities” (SGMs). One key highlight from the review is the need for tailored counsel and education for SGMs regarding fertility care, as majority of promotional and educational materials are targeted toward a heterosexual, cisgender population with heteronormative assumptions.
      Guidelines from the American Society for Reproductive Medicine state, “Programs should treat all requests for assisted reproduction without regard to gender identity status. Programs without sufficient resources to offer care have an ethical duty to assist in referral to providers equipped to manage such patients” (
      Ethics Committee of the American Society for Reproductive Medicine
      Access to fertility services by transgender persons: an Ethics Committee opinion.
      ). These are important stipulations on the provision of care and 1 important resource to consider is the cultural sensitivity /humility of the fertility care provider as well as the staff.
      A major barrier to providing culturally humble care is the provider’s lack of familiarity with SGM patients (
      • Tishelman A.C.
      • Sutter M.E.
      • Chen D.
      • Sampson A.
      • Nahata L.
      • Kolbuck V.D.
      • et al.
      Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey.
      ). While such knowledge gaps are not unique to fertility care (as the investigators point out, they unfortunately are too common in all realms of medicine), their negative side effects may be especially pronounced since fertility clinics traditionally are highly gendered, heteronormative spaces. The investigators make useful and practical recommendations for reducing heteronormativity and cisnormativity in fertility care. Although many of these recommendations are relatively easy to implement, for example gender-neutral bathrooms, given that reproductive medicine has centered traditionally on a binary, heterosexual couple (and often assuming traditional gender roles), making deeper, long-lasting change within this field may be more difficult than in other fields. To ensure what “parts” are available for reproduction (i.e., eggs, sperm, and uterus), clinicians need to know patients’ relationship status and sex assigned at birth. This information may be considered more private for some patients, and it is not necessary for all types of medical care (e.g., seeing an ear, nose, and throat specialist for allergies, getting a cast for a broken arm). Discussing sexual orientation and gender identity may be distressing for patients, especially if clinicians are not familiar with the needs of SGMs. For instance, clinicians may not know that the use of language (e.g., sperm in a transgender woman or referring to the pregnant patient as “mom”) and procedures (e.g., a pelvic exam for a transgender man) may be triggering for some patients (
      • Ingraham N.
      • Wingo E.
      • Roberts S.C.
      Inclusion of LGBTQ persons in research related to pregnancy risk: a cognitive interview study.
      ). In short, it would be helpful to know more about how to combat heteronormativity and cisnormativity in clinical spaces that revolve around sexual and reproductive organs. Coupled with this is the fact that most SGMs reporting negative experiences in a healthcare setting attribute those discriminatory experiences to interactions with staff, such as schedulers and laboratory technicians, and may enter the examination room pessimistic about the encounter (
      • Paine E.A.
      "Fat broken arm syndrome": negotiating risk, stigma, and weight bias in LGBTQ healthcare.
      ).
      It is important to contextualize fertility care for SGMs within the historical and current marginalization of SGMs as well as the politicalization of LGBTQ rights and reproductive rights. No aspect of medicine exists outside of the social realm, and this is the case especially for marginalized patient populations seeking care that often is contentious or seen as not “real” medicine, as often is the case with reproductive care. Within this cultural milieu, the practical recommendations the investigators make no doubt will help, but they may only scratch the surface. For SGMs to experience truly inclusive and equal access to fertility care, we also need a change on the social and legal levels, including policies, such as health insurance coverage for fertility preservation for transgender individuals, standardized fees for same-sex and opposite-sex couples, and decriminalization and improved access to gestational surrogates.
      Additionally, inclusive care means discarding the prevailing opinion that “good doctors treat all patients the same” and instead recognizing not just the unique needs of “nontraditional” populations, but also the uniqueness of each individual patient. In other words, we must treat the whole person, which means understanding who they are and what their health care goals are beyond just their sexual orientation and gender identity. For example, cisgender men who identify as gay may only have that in common. Each man or couple may have very different goals for parenthood, and they may have different needs and preferences for achieving those goals. Second, we must be careful not to treat SGMs as a homogeneous group. Each subgroup (lesbian, gay, bisexual, transgender, and so forth) faces unique barriers. To treat the whole SGM population as a homogeneous group does a disservice to the distinctiveness of the community. Third, the investigators encourage more intersectional studies in the future, as few studies addressed people of color and transgender individuals, and no studies addressed people with disabilities. We echo this call and assert that future studies should examine various aspects of people’s identities, such as race, ethnicity, dis/ability, socioeconomic status, and religion, to gain a more robust understanding of the diverse experiences of SGM seeking fertility care.
      To provide inclusive environments, educational materials, and services to SGMs, the fertility workforce must become more familiar with the needs of SGMs. This review is a helpful starting place, but more work is needed. In addition to more intersectional studies, it is essential that reproductive health professionals also advocate LGBTQ rights and reproductive rights to mitigate social, economic, and legal barriers SGMs may face in accessing fertility care. We must advocate the idea that access to fertility care is a right of all humans and not just those with private insurance or the ability to pay in cash.
      Finally, we must work toward creating societal acceptance of the idea that pregnancy, parenthood, and families can exist in many forms. While societal norms are slowly changing, we still see pregnant men on the cover of magazines touted as an anomaly.

      References

        • Kirubarajan A.
        • Patel P.
        • Leung S.
        • Park B.
        • Sierra S.
        Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: a systematic review of patient and provider perspectives.
        Fertil Steril. 2021; 115: 1294-1301
        • Ethics Committee of the American Society for Reproductive Medicine
        Access to fertility services by transgender persons: an Ethics Committee opinion.
        Fertil Steril. 2015; 104: 1111-1115
        • Tishelman A.C.
        • Sutter M.E.
        • Chen D.
        • Sampson A.
        • Nahata L.
        • Kolbuck V.D.
        • et al.
        Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey.
        J Assist Reprod Genet. 2019; 36: 579-588
        • Ingraham N.
        • Wingo E.
        • Roberts S.C.
        Inclusion of LGBTQ persons in research related to pregnancy risk: a cognitive interview study.
        BMJ Sex Reprod Health. 2018; 44: 292-298
        • Paine E.A.
        "Fat broken arm syndrome": negotiating risk, stigma, and weight bias in LGBTQ healthcare.
        Soc Sci Med. 2021; 270113609

      Linked Article