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A Wider Lens on Reproductive Health

Emerging research on infertility, reproductive coercion, and barriers to care for transgender and nonbinary people aims for a more inclusive scope of care.

By Jessica M. Scully

Addressing Infertility in LMICs

The Ugandan women wanted to become pregnant but couldn’t. Their inability to conceive left them stigmatized, devalued, and depressed.

In the past, researchers from the Global North would have offered no help. They focused on preventing pregnancy—a bias that blinded them to the pain of infertility. Now, however, “there is growing interest in examining and better supporting people to achieve their full reproductive goals” in LMICs, says Suzanne Bell, PhD ’18, MPH, an assistant professor in Population, Family and Reproductive Health.

In September, Bell began a five-year project with researchers at Makerere University in Kampala to study infertility. To gather data on the prevalence and impact of infertility, the researchers will add questions on infertility to an existing survey in an ongoing family planning study among reproductive-age Ugandan women. They will also interview a sample of women and their partners on their infertility awareness, fears, strategies to prevent or treat it, and perceptions of stigma. Finally, the project will develop a survey to measure infertility stigma and fear to inform development of strategies to reduce them.

Bell also wants to better understand the toll infertility takes on women in a country where motherhood is central to women’s identities and social value. Infertility’s causes are evenly distributed between men and women—untreated STIs are a common culprit—but women are more commonly blamed and stigmatized, she says.

Women viewed as infertile, particularly those who are childless, may be emotionally or physically abused by their partners and in-laws or abandoned by their husbands. Some women have become severely depressed or taken their own lives as a result, she says.

“If we are truly committed to reproductive self-determination and helping women and families achieve their reproductive goals,” Bell says, “we need to address infertility in seeking to better meet the full spectrum of reproductive health needs.”

Recognizing and Preventing Reproductive Coercion

Someone who wants to get pregnant may be forced to use birth control. Or, someone who doesn’t want to become pregnant may be prevented from going to a clinic for contraception. Her partner might poke holes in condoms or hide her contraceptives.

While definitions may vary by culture, all of these are forms of reproductive coercion. And they are not uncommon.

In a 2017 study by Charvonne Holliday Nworu, PhD, MPH, an assistant professor in Population, Family and Reproductive Health, 1 in 4 women at five California family planning clinics reported experiencing reproductive coercion. The number was higher for Black (37.1%) and multiracial (29%) women.

Shannon Wood, PhD ’20, MSc, an assistant scientist in PFRH, has studied reproductive coercion in several countries in Africa and in Rajasthan, India. Pregnancy coercion is the most common form reported, Wood says.

Wood’s latest research shows rates vary from about 3% in Niger and Rajasthan, India, to over 20% in parts of the Democratic Republic of the Congo and Uganda. Like intimate partner violence, with which it’s often linked, reproductive coercion is usually about control, Wood says. The partner wants the woman to get pregnant to make her stay in the relationship and to bind her to him. “In that way, it’s about power and control over both her reproductive trajectory and really her life trajectory,” Wood says.

The American College of Obstetricians and Gynecologists recommends that providers screen for reproductive coercion. But such screening is performed inconsistently in low- and middle-income countries, Wood says, and many providers in health systems aren’t aware of the problem.

“That’s the biggest piece right now: gaining some attention to it, especially among ministries of health, recognizing this as a form of abuse,” she says.

Next steps are integrating screening guidelines for providers into health systems and developing and supporting safety strategies, such as covert use of contraceptive methods like injectables or IUDs, that give women agency and control in limiting or spacing pregnancies.

Overcoming Barriers to Care for Transgender and Nonbinary People

For transgender and nonbinary people, accessing quality sexual and reproductive health care is complicated at every step in the process. They may experience stigma, discrimination, and misgendering from providers and health care support staff, says Jennifer L. Glick, an assistant scientist in Health, Behavior and Society. And that’s if they can get health care: Pervasive societal stigma and discrimination can make it challenging to find employment, which in turn makes it hard to afford care.

Insurance companies can present additional obstacles. For example, companies may reject a trans man’s claim for services “associated with the body parts that they were born with, but not thought to be associated with their gender,” such as a Pap smear or egg retrieval, says Glick, PhD, MPH. And many doctors haven’t been trained in providing care for trans people, she notes.

In the 2015 U.S. Transgender Survey, 25% of respondents said they’d experienced an insurance problem in the past year related to being transgender, including being denied coverage for gender transition care, and 13% said they were denied coverage for services considered gender-specific. Nearly a quarter (23%) did not see a doctor when they needed to because they feared being mistreated, and 33% did not see a doctor because of cost.

The full scope of medical care trans and nonbinary people need requires further study, says Glick, who studies lesbian, gay, bisexual, transgender, and queer health and HIV prevention. For example, there’s little research on the long-term effect of the hormones some trans people take. And trans men can be an afterthought in HIV prevention and care conversations although they are at risk for contracting the virus, particularly if they have sex with cisgender men, she says.

To solve these problems, trans and nonbinary people and their concerns need to be included in setting research agendas, she says. “This way, appropriate research questions will be asked, prioritized, and properly resourced.”