Analysis

People, Population, and Climate Change: Opportunities for Advancing Climate Resilience and Reproductive Rights

Sarah Fisher

In this article we explore the many critical links between population, sexual reproductive health and rights and climate change, the significance of which is all too important to ignore.

This fall, the world population will reach 7 billion people at a time of accelerated environmental disruption. This article part of a series commissioned by Rewire to examine the causes and consequences of population and environmental change from various perspectives and the policies and actions needed to both avoid and mitigate the inevitable impacts of these changes.

All of the articles in this series can be found here.

Introduction

The relationship between population and climate change raises a number of complexities and sensitivities, which mean that linking the issues is associated with much controversy, and is often shied away from. In this article we explore the many critical links between population, sexual reproductive health and rights and climate change, the significance of which is all too important to ignore. Not least, this is because a focus on the connections between population dynamics and climate change offers considerable opportunities to increase the capacity of the countries most vulnerable to climate change to adapt to its impacts, at the same time as advancing sexual and reproductive health and rights.

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Global population growth and unmet need for family planning

According to the latest UN population projections, the world population which was set to reach 7 billion this year, is now expected to exceed 9 billion by 2050 and to surpass 10 billion by the end of the century. The vast majority of this growth will take place in developing countries, particularly in many of the poorest nations of the world, including Sub-Saharan African countries. The rate of population growth in these countries is so high that the population of the 58 nations classified as ‘high fertility’ countries by the UN is set to more than triple between now and 2100, along with the entire population of Africa. With these countries already struggling to lift millions out of poverty, such rapid population growth will place even greater constraints on development, at the same time as these countries face the challenges of adapting to climate change.

Worldwide there is a vast unmet need for contraception, which as for population growth is concentrated in the poorest countries of the world, a point which is of course not unrelated. An estimated 215 million women in developing countries have an unmet need for contraception, meaning that they are at risk of pregnancy and say they do not want to have a child during the next two years, but are not using contraception. The reality of this situation is that women in developing countries are not able to choose to plan and space their children. While the scale and rate of population growth projected by the UN for this century is alone a cause for concern, even more worryingly the projections are based on the assumption that future fertility in the high-fertility countries will drop significantly: from the current 4.9 children per woman to 2.1 by the end of the century. To achieve such reductions, it is essential that access to family planning expands, yet since the mid-to-late 1990s, donor investment in family planning has decreased dramatically in absolute terms. As a result many countries where women have a high unmet need for contraception have experienced considerable declines in family planning assistance, at the same time that demand is increasing.

Climate change: it’s happening now

While some scepticism about climate change persists, the message from the Intergovernmental Panel on Climate Change (IPCC) is clear: climate change is already happening, and as a result of human activity. Increased energy consumption during the 20th century has caused the build-up of greenhouse gases (GHG) in the atmosphere which result in warming of the earth’s surface. Warming over the 100 year period prior to 2006 was 0.74°C, with most of the warming having occurred in the past 50 years. Global GHG emissions are expected to continue to grow over the next few decades, causing further warming and changes to the global climate system, and on a greater scale than previously. Based on climate change models considering six different emission scenarios, the IPCC reports that global temperatures are likely to rise between 1.1°C and 6.4°C by 2100, with best estimates between 1.8°C and 4°C. To put this into perspective: a rise of over 2°C above pre industrial average temperature is considered the level at which dangerous climate challenge poses a risk to all, not just the most vulnerable. Furthermore, global GHG emissions are rising faster than the most dire of the emission scenarios. What does this really mean?

We have already experienced a sea level rise of over 4cm, and sustained global temperature rises of 5–6°C could raise sea levels by up to 13 m by the middle of the next century. With a third of the world’s population living within 60 miles of a shoreline and 13 of the world’s 20 largest cities located on a coast, hundreds of millions could face environmental mass migration. The impact of sea-level rises will be greatest in densely populated low-lying river deltas. In Bangladesh for example, a 1 m rise will mean 20 percent land loss and displacement of 15 million people. Worldwide, increased frequency and intensity of floods, droughts and other extreme weather events is likely to expose hundreds of millions of people to increased water stress and food insecurity. The health and well being of billions of people will be at risk from impacts upon food and water security and changing patterns of disease. What’s worse is that it is the least developed countries that have contributed the least to climate change which are the most vulnerable to its impacts, and have the fewest resources available to them for climate change adaptation.

Population and climate change: a complex relationship

Population issues can be linked to climate change in two important and distinct ways. Climate change mitigation refers to lessening the impacts of climate change by reducing GHG emissions. Adaptation refers to responding in ways to reduce vulnerability to its impacts. Research over the last decade shows that population growth has significant implications for both climate change mitigation and adaptation, pointing to the positive role that increased investment in voluntary family planning could play in response to climate change. Yet discussion of the relationship between population dynamics and climate change has been largely absent from the international climate change agenda to date. This is in part because of the complex and sensitive nature of the links, relating to the uneven global distribution of the GHG emissions, as well as different patterns of demographic change.

The key driver of climate change is the high levels of GHG emissions by the developed world, where population growth is not for the most part, a major issue. In contrast, the vast majority of population growth is taking place in developing countries where average consumption and GHG emission rates are far lower. But due to both geographical factors and resource constraints it is these countries that are at greatest risk from climate change. Furthermore, population growth in these countries increases climate change vulnerability and makes adaptation difficult, with population and climate change placing a double burden on natural resources. Intensifying the relationship, other demographic variables, including population density, migration, household composition and urbanisation, have additional implications for climate change mitigation and adaptation. Confounding matters further, the legitimate development aspirations of countries in the global South will inexorably result in increased emissions. For although we talk about ‘low carbon growth’, we don’t know what that looks like in practice; development patterns to date have been characterised by significant increases in per capita emissions.

Population and climate change: a controversial link

Although population growth is identified by developing countries as a factor undermining national climate adaptation efforts, it is not easy to position increased investment in family planning as an important strategy in the face of climate change. As long as the industrialised global North fails to take the action necessary to cut dramatically its GHG emissions, advocating reduced population growth in the South risks appearing to blame climate change on that growth, instead of recognising that responsibility for this lies largely with Northern countries while it is those in the South that will suffer the most . Furthermore family planning is of course itself a contentious issue, and one which remains blighted by the history of coercive programmes of the ‘60s and ‘70s which were not managed in ways that respected and protected the needs and interests of women. This was a mistake that absolutely cannot and must not be repeated. It is essential therefore that any efforts to link population and climate change fully acknowledge and respond to the many associated complexities and sensitivities, and advocate clearly that coercive family planning programmes have no place in international development programmes.

Population and climate change: a critical connection

While developed countries deliberate over the ethics of linking population to climate change, developing countries are themselves identifying the negative ways in which the interaction of population dynamics and climate change is exacerbating their vulnerability and undermining adaptation. As part of the UN Framework Convention on Climate Change the 40 least developed countries in the world have produced National Adaptation Programmes of Action (NAPAs), in which they outline their top priorities for adaptation and specific local climatic vulnerabilities. In these reports, 37 least developed countries (93 percent) identify rapid population growth as making coping with climate change more difficult. Population growth is identified as increasing demand for key natural resources such as land and water, acting in tandem with climate change to deplete these resources, and heighten vulnerability by forcing people to migrate to more environmentally fragile areas. Frequently mentioned climate change adaptation issues exacerbated by population growth include: soil degradation and erosion, fresh water scarcity, migration, deforestation and shortages of farmland. Additional vulnerabilities linked to population growth include loss of biodiversity, diminishing fish stocks and constraints on health services. These issues have considerable implications for agriculture, food security and health, as well as for conflict fuelled by competition for natural resources.

Turning to the issue of mitigation, the potential for a focus on population to benefit climate change mitigation is less straight forward, and indeed more controversial, but still warrants attention. With the vast majority of population growth taking place in countries where per capita consumption levels are relatively extremely low, there is concern amongst many environmentalists that focusing on population distracts from the urgent action industrialised nations must take to tackle their inequitable and unethical patterns of consumption. Unmistakably, dialogue on population and climate change must encompass wider policy issues, including the causes of climate change and associated responsibilities of the global North. Yet given the scale of the threat posed by climate change, we need to move beyond simplistic either/or approaches. Instead we must embrace the full range of strategies available to support the countries most vulnerable to climate change to adapt, as well as to lessen the impacts in the future.

The global population pathway, alongside technological change, social and economic development and changing patterns of energy and land use, has been shown by the IPCC to be a critical factor determining the course of future GHG emissions. This is reflected in recent research estimating that a lower population path could provide 16-29 percent of the emission reductions necessary to avoid global warming of more than 2°C by 2050. While per capita emissions are far lower in developing countries, between now and the end of the century the population of less developed regions of the world is projected to increase by over 3 billion. This will inevitably result in increased GHG emissions, alongside those linked to the economic growth that will be promoted in these countries in order to achieve the necessary development and poverty alleviation. The right of these countries to develop must be recognised by international climate change policy, and responding to the resultant increased per capita emissions, the emissions of the developed world must significantly contract in return.

On the issue of unequal consumption rates in the global North, inequitable consumption rates are such that preventing one unplanned pregnancy in an industrialised country will have a far greater impact than preventing an unplanned pregnancy in the global South. Comparing carbon dioxide emissions in the US and India for example, the average person in America is responsible for over sixteen times that of the average person in Indian. The links between population growth, climate change and achieving universal access to family planning must therefore not be seen as relevant only in the global South. Furthermore, in both the North and the South consideration should also be paid to the significance of other demographic variables. Urbanisation and ageing for example have implications for emissions due to effects of economies of scale for energy use and differing energy consumption patterns. While these factors will influence emissions, the full extent to which they will shape emissions outcomes is not yet known.

An integrated and rights-based approach is needed

A focus on population dynamics offers such potential to further international response to climate change that it is time population commanded the consideration necessary, and crucially, in ways that advance sexual and reproductive health and rights. Women with an unmet need for effective contraception are estimated to account for 82 percent of all unintended pregnancies in developing countries, contributing significantly to population growth. This means there are real opportunities to reduce population growth in these countries, simply by preventing unplanned pregnancies, and bringing closer the day when every child is a wanted child. What is required is the political will to enable all women and men to have the access to family planning that is often taken for granted in the developed world. While the importance of family planning for women and children’s health and women’s rights alone should be more than sufficient to generate the necessary investment to achieve universal access to sexual and reproductive health services, sadly this has not been the case. Climate change however, offers yet another reason why ensuring all women have access to family planning makes sense, and one that might just yield more of the attention it deserves.

The critical nature of the links between population dynamics and climate change mean that it’s not a case of whether this will become more widely recognised, but when. For precisely this reason, those of us who care about women’s rights and sexual and reproductive health and rights need to be fully involved in the debate: so that programmes relating to population issues respect and protect these rights. A rights-based approach is essential to addressing the inter-related problems in the global South of high fertility rates, sustained poverty and vulnerability to climate change. With a central focus on choice, this approach would offer access to family planning services as part of comprehensive sexual and reproductive health services. It would address the large unmet demand for reproductive health services and choices, but encompass far more. A rights-based approach includes addressing issues such as sexual violence and coercion, and other interventions that seek to promote behaviour change through changing the social norms underlying gendered power inequalities. There is also a focus on education strategies that encompass rights-based ethos within programmes to increase people’s understanding of rights and instill a sense of entitlement. Lastly, a rights-based framework establishes means for ensuring accountability and for redress of rights violations.

Advancing a rights-based vision

To succeed in promoting an integrated population and climate change agenda as a legitimate part of a global response to climate change, a language must be found that reflects and addresses the need to emphasise resource consumption in the North, at the same time as advocating increased access to sexual and reproductive health care services in the South. We must be absolutely clear that our primary motivation is the welfare of citizens in the countries most affected by climate change, and that it is the developed world that must shoulder the responsibility for reducing GHG emissions. For climate change mitigation, tackling over-consumption of resources by the developed world is the most critical strategy, though population dynamics are relevant and must be one of the many approaches we need to drawn upon given the enormity and complexity of the challenges we face. For climate change adaptation, we must listen to the very real concerns and experiences being voiced by developing countries about the ways that population growth is heightening their vulnerability to climate change and undermining adaptation.

Universal access to reproductive health, irrespective of the opportunities it offers to reduce climate change vulnerability, is a basic human right which cannot be achieved without increased investment in the necessary services. Funding must be made available for the integration of rights-based reproductive health programmes into adaptation strategies, including through climate change funding streams. Women’s choices, needs and rights must be at the centre of these programmes. Rather than ignoring the ‘population issue,’ governments and donors must be called upon to embrace rights-based approaches to reproductive health as part of wider development goals, including climate change policy. We must emphasise the ‘win-win’ nature of this approach: securing reproductive health and rights while increasing climate change resilience in the countries which are at greatest risk, despite having contributed to climate change the least. Achieving this vision is both a matter of reproductive justice and climate justice.

Analysis LGBTQ

Reimagining Safety for Queer and Trans Communities in Wake of Orlando

Tina Vasquez

“We need to have a national conversation about racism, homophobia, and transphobia,” said Alan Pelaez Lopez, a member of the organization Familia: Trans Queer Liberation Movement. “If these things do not happen, the nation, by definition, will have done nothing to support our communities.”

The same day of the Orlando Pulse nightclub shooting that would take the lives of 49 mostly Latino and LGBTQ-identified people, thousands of miles away in Santa Monica, California, a man was found with weapons, ammunition, and explosive-making materials in his car with plans to attend the annual Pride festival taking place in West Hollywood later that day.

Conversations around security and safety were raised by law enforcement almost immediately. In the days since, reports have emerged that from San Francisco to New York, there will be more police and “ramped-up security measures” at Pride events nationwide.

But queer and trans people of color (QTPOC) say these responses are missing the mark, because what their communities really need are deeper conversations and more resources that address their specific experiences, including fewer police at Pride events.

House Democrats held a sit-in on gun control this week as a direct response to the Orlando shooting. Though Alan Pelaez Lopez—an Afro-Latinx, gender-nonconforming immigrant, poet, and member of the organization Familia: Trans Queer Liberation Movement—agrees that gun control is important and should be considered by Congress, they said it can also feel like the community affected by the shooting almost always gets erased from those discussions.

“We need to have a national conversation about racism, homophobia, and transphobia,” the poet said. “If these things do not happen, the nation, by definition, will have done nothing to support our communities.”

Rethinking ‘Pride’ for People of Color

In mid-May, Rewire reported on the National Queer Asian Pacific Islander Alliance (NQAPIA)’s week of action to #RedefineSecurity, which encouraged participants to reimagine what safety looked like in Asian and Pacific Islander communities, and called for them to push back against police presences at Pride events.

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Pride events and festivals take place each June to commemorate the Stonewall riots in New York City, a clash between police officers and members of the LGBTQ community—led by trans women of color—that would kickstart the modern LGBTQ movement.

Even after the Orlando shooting at a gay nightclub, NQAPIA organizing director Sasha W. told Rewire their stance on police at Pride events hasn’t changed, but only grown more resolute.

As an organizer working with queer and trans Muslim, South Asian, and Middle Eastern communities, Sasha W. said the populations they work with say that framing the Orlando shooting as a “terrorist attack” makes them feel “increasingly unsafe.”

“I think part of what we need to remember is to examine what ‘terror’ looked like in queer and trans communities over the course of our history in this country,” Sasha W. said. They cited the Stonewall riots and the inaction by the government during the HIV and AIDS epidemic as examples of some of the many ways the state has inflicted violence on queer and trans communities.

Sasha W. added that pointing blame at Daesh is too easy, and that the oppression queer and trans people face in the United States has always been state-sanctioned. “We have not historically faced ‘terror’ at the hands of Muslim people or brown people. That is not where our fear has come from,” they said.

What’s missing, they said, is a conversation about why police officers make certain people feel safe, and “interrogating where that privilege comes from.” In other words, there are communities who do not have to fear the police, who are not criminalized by them, and who are confident that cops will help them in need. These are not privileges experienced by many in queer and trans communities of color.

Asking the mainstream LGBTQ community to rethink their stance on police and institutions that have historically targeted and criminalized communities of color has been challenging for queer and trans people of color.

What’s become clear, according to Familia: Trans Queer Liberation Movement founder Jorge Gutierrez, is that after a tragedy like Orlando, white LGBTQ members want to feel united, but many don’t want to discuss how things like race and citizenship status affect feelings of safety. Instead, some will push for a greater police presence at events. 

There have already been instances of white members of the LGBTQ community publicly shutting down conversations around racial justice. Advocates say the public needs to understand the broader context of this moment.

“The white LGBTQ community doesn’t face the criminalization and policing that our community faces every day. Not just at Pride, but every day, everywhere we go. That’s our life,” Gutierrez said. “If you don’t listen to us when it comes to these issues of safety, you’re not just erasing us from a tragedy that impacted us, but you’re really hurting us.”

As Gutierrez explained, in the hours after the shooting, some media coverage failed to mention Pulse was a gay club, failed to mention it was people of color who were killed on Latino night, and failed to mention that trans women were performing just before the shooting broke out. Gutierrez told Rewire he felt like his community and their pain was being erased, so his organization put together a video featuring queer and trans immigrants of color, including Lopez, to discuss their immediate feelings after the Pulse shootingand many shared sentiments similar to Sasha W.’s and Lopez’s. One trans Latina said the shooting was “years in the making.”

“The video was important for us to release because the shooting was being framed as an isolated event that randomly happened, but we know that’s not true. We know that the United States has a history of hurting queer and trans people of color and we needed to produce our own media, with our own messaging, from our own people to tell people what really happened, the history that lead to it happening, and who it really impacted. We didn’t want our voices and our realities as immigrants, as undocumented people, as queer and trans people of color, erased,” Gutierrez said.

Without even factoring in an increase in law enforcement, Lopez told Rewire Pride already felt unsafe for people like them.

“I have experienced a lot of racism [at Pride events], the pulling of my hair from people walking behind me, and I have also been sexually harassed by white people who claim to want to experiment with being with a Black person,” Lopez said.

Though Lopez didn’t attend any Pride events in Los Angeles this year, they told Rewire that in previous years, there was already a large police presence at Pride events and as a “traumatized person” who has had many negative interactions with police officers, including being racially profiled and stopped and frisked, encountering law enforcement was scary.

“Seeing [cops] at Pride makes me remember that I am always a target because at no time has the police made me feel protected,” the poet said. “Signs of heavy police presence are really triggering to people who have developed post-traumatic stress disorder from violent interactions with the police, for undocumented communities, for transgender communities, for young people of color, and for formerly incarcerated individuals. When I think of security, I do not think of police.”

Lopez isn’t alone. Whether it’s law enforcement violence against women and trans people of color, law enforcement working with Immigration and Customs Enforcement (ICE) for the detainment and deportation of undocumented people, or the way law enforcement has reportedly discriminated against and harassed gender-nonconforming people, QTPOC have very real reasons for feeling vulnerable around police officers, advocates say.

Another reason Lopez chose not to attend Pride this year: It was being sponsored by Wells Fargo. The banking corporation sponsors over 50 yearly Pride events and has been called a “longtime advocate of LGBT equality” by organizations like the Human Rights Campaign, which also lists Wells Fargo as a top-rated company on its Corporate Equality Index. But Wells Fargo has a history of investing in private prisons, including detention centers. Calls to drop Wells Fargo from Pride events have been unsuccessful. For queer immigrants like Lopez, attending Pride would mean “financially contributing” to the same corporation and system that they said killed their friends, the same corporation that they said has incarcerated their family, and that they said has tried—but failed—to incarcerate them.

Sasha W. told Rewire that for QTPOC, it’s easy to forget that the event is supposed to be about celebration.

“For many of us, we can’t really bring our whole selves into these places that are meant to make us feel free or we have to turn off parts of who we are in order to enjoy ourselves” the organizer said. “And as far as the policing of these events go, I think it’s worth noting that policing has always been about protecting property. It’s always been about property over people since the days of the slave trade. When we see police at Pride events the assumption [by our communities] is that those police will protect money and business over our queer brown and Black bodies.”

“Really Troubling Policies”

As organizations and corporations work to meet the short-term needs of victims of the Orlando shooting, advocates are thinking ahead to the policies that will adversely affect their communities, and strategizing to redefine safety and security for QTPOC.

Gutierrez told Rewire that what has made him feel safe in the days since the Orlando shooting is being around his QTPOC community, listening to them, mourning with them, sharing space with them, and honoring the lives of the brothers and sisters that were lost. His community, the organizer said, is now more committed than ever to exist boldly and to make the world a safer place for people like themand that means pushing back against what he believes to be a troubling narrative about what safety should look like.

However, Gutierrez said that politicians are using his community’s pain in the wake of the Orlando shooting to push an anti-Muslim agenda and pit the LGBTQ community against Muslims, conveniently forgetting that there are people who live at the intersection of being queer and Muslim. Perhaps more troubling are the policies that may arise as a result of the shooting, policies that will add to the surveilling and profiling Muslims already experience and that will further stigmatize and criminalize vulnerable communities.

“The government, the police, politicians, they’re trying to equate safety with having more police on the street, at gay clubs—that are like home to many of us, and at Pride. We know that doesn’t make us safe; we know police are part of the problem,” he said.

“Of course we need to make it more difficult for people to get guns, but we also need more resources for our communities so our communities can truly be safe on the streets, in the workplace, at school, at the clubs, and at Pride,” he said. “That means having healthy communities that have resources so people can thrive and live authentically. The answer to our problems is not more police.”

Sasha W. echoed Gutierrez, saying that their community is already fearful of what’s to come because moments of national crisis often create the space for “really troubling policies.”

“That’s how we got the Patriot Act,” the organizer said. “There is a fear that we are in another one of those moments where there are calls for protection and it’s being tied to the false idea of a foreign threat that requires an increase of surveillance of Muslims. Think of how calls for protection have also hurt queer communities, communities of color, trans communities, like the idea that bathrooms aren’t safe because of trans people. Who is really unsafe in this country, and why do policies hurt us instead of protect us?”

Lopez added: “The Orlando shooting was powered by the fact that the United States has a history of violence against LGBTQIA communities, a history of violence against immigrants, a history of violence against women, and a history of colonization of the island of Puerto Rico … The U.S. needs to address institutional problems of race, ethnicity, class, gender, sex, and sexuality if it wants to put an end to future massacres.”

The question remains: How can vulnerable communities be made to feel safer not just at Pride events, but in a political moment when transphobia is state-sanctioned, Islamophobia is applauded, and communities of color still have to fight for their humanity?

Sasha W. urges QTPOC to “expand their political imagination” and re-envision what security looks like. In the long term, the organizer said, they hope more people recognize who their communities’ “actual enemies” are, instead of turning on each other.

“Let’s recognize that the state has always been something we’ve had to fight to survive and that institutions that hurt us are growing increasingly strong in this moment of crisis, as they often do, so we have to work to disarm and dismantle the institutions that terrorize our communities” they said.

“On another note, we have always been our own best defense, especially in communities of color,” they said. “Supporting each other to protect ourselves better doesn’t happen overnight, I know, but so much of this starts with building community with each other so that we know each other, love each other, and throw down for one another.”

Commentary LGBTQ

Trans? Good Luck Accessing Reproductive Health Care

s.e. smith

Trans patients now stand to access health care more easily, but enacting policies against discrimination isn't quite the same as actually eliminating it.

Dominick, a disabled transgender man, started making the arrangements for a hysterectomy at age 30. The experience turned out to be a living nightmare—and not just because being disabled had previously presented obstacles to medical care, like being unable to access his gynecologist’s office.

“The doctor,” he says, “sent me home while internally bleeding after the surgery because he needed more beds. He ignored my concerns and dismissed my symptoms as overblown.” He says he almost died when he started hemorrhaging at home.

The horrors of that experience led Dominick to shy away from follow-up care and had profound psychological consequences. “I was afraid to leave my house, for fear I’d start bleeding out. I remember being on a bus to school, completely alone, and having a complete meltdown. I called my girlfriend and was crying and shaking and begging her to come get me.”

While he survived the experience, the trauma lingers to this day—and he’s not alone. For many trans men, dismissive treatment in the gynecologist’s office is part of a larger framework of harmful health-care practices that include verbal and physical abuse and denial of care. Thanks to the finalization of an Affordable Care Act (ACA) rule banning discrimination on the basis of gender, trans patients now stand to access care more easily, but enacting policies against discrimination isn’t quite the same as actually eliminating it. Trans people often face obstacles to care in health-care fields, unless they’re lucky enough to live in a region with a well-organized and structured clinic. Doctors who are ignorant about trans needs, like the imperative of surgical transition for some transgender people, can become dangerous roadblocks. And self-advocacy—including standing up for one’s immediate needs or asking for additional support in cases like Dominick’s—can be exhausting or impossible when continuously faced with such experiences.

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Reproductive health care in particular cuts to the heart of bodily autonomy, something trans people are often already denied in other settings. Yet trans men are frequently left out of the discussion when it comes to accessing services, even as the Women’s Health Network and other organizations, like the American Congress of Obstetricians and Gynecologists (ACOG), argue that the health needs of people who are assigned female at birth, no matter their gender, are indeed matters for reproductive rights conversations.

When it comes to seeking medical care in general, trans people say they often face ignorance or outright prejudice from medical professionals. A 2011 study conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 20 percent of survey respondents were denied health care due to their transgender or gender-nonconforming identity—and people of color experienced even more profound disparities. Twenty-eight percent of all respondents said they had been harassed in physicians’ offices, and 2 percent experienced physical violence.

Chillingly, when care providers discovered that their patients were transgender, the incidence of discriminatory attitudes increased. Many didn’t understand the needs of the transgender community, forcing half of the respondents to provide basic education about managing transgender patients. While proactive self-advocacy—being educated about your own health, self-assured at the doctor’s office, and ready to speak up for yourself—can help everyone achieve better health-care outcomes, this goes far beyond advocacy. In a medical culture where people may have difficulty obtaining providers, trans patients can be forced to repeatedly discuss sensitive medical information that can trigger dysphoria and frustration. And gender dysphoria is fatal if untreated: A staggering 41 percent of the trans community has attempted suicide.

While all aspects of medical care are important, reproductive health care sits at the axis of many important oppressions: It determines whether people are able to have families, whether they receive treatment after rape and sexual assault, if potentially serious sexually transmitted infections (STIs) are treated in a timely fashion, or if they can obtain compassionate and appropriate abortion care. And here, too, trans people have reported difficulty when it comes to requesting and receiving breast and cervical cancer screenings, STI testing and treatment, fertility care, contraception, abortion and pregnancy care, and other reproductive health needs. When such care is provided, it may come with detrimental comments and practices like misgendering patients or making assumptions about their personal lives.

These are especially important issues for trans people: While transgender women are far and away the most likely to have HIV, with skyrocketing incidence rates thanks to poverty and other social factors, transgender men are also more at risk than the general population. They also have difficulty accessing pregnancy care. Approximately 50 percent of transgender people experience sexual violence, and insensitive care providers managing rape survivors can cause further trauma at a time when patients are particularly vulnerable. Denial of services ties into much larger human rights issues for the transgender community: We are in a climate, after all, where trans women risk bladder infections because they cannot use public restrooms.

But whether people are transgender men, along the nonbinary spectrum, agender, or along other axes of gender and experience, if they aren’t cisgender women, they say their reproductive health needs are often dangerously ignored.

“My first gyno, who was an older woman with all kinds of vocalized homophobic, transphobic, racist, and HIV-ignorant ideas,” says K., “left me so uncomfortable I wouldn’t let anyone touch me between my legs with their hands for a good ten years!” K., who is nonbinary, had a traumatic experience when seeking abortion care, and, like Dominick, wasn’t provided with counseling on the subject of egg storage before starting hormone therapy. “I personally never want to be pregnant again,” K. says, but the very option of freezing eggs and using a surrogate in the future was denied.

And this has real consequences: Trauma in reproductive health services, like that Dominick experienced, can drive transgender people into fearing the health-care system as a whole. Between discrimination and the fear that keeps people out of doctors’ offices, trans people are less likely to get preventive care—like HIV counseling and screening—and more likely to develop complications from delayed care. That includes vitally needed reproductive health services.

Discriminatory practices in gynecological care take place within the framework of another problem for trans people: Even with the ACA’s theoretical increased access to health care, substantial barriers to health-care access remain. Transgender people—particularly women and people of color, but also men to a lesser extent—are four times more likely to live in poverty, thus driving a disproportionate use of Medicaid coverage. As Rewire has reported, 16 states explicitly deny transition-related services under Medicaid coverage. Although the ACA explicitly bans discrimination on the basis of sex and gender, with additional protections for gender-nonconforming individuals now that the Department of Health and Human Services (HHS) has finalized its ruling on Section 1557, that doesn’t always work out in practice. Coverage of transition-related treatment, including hormones and surgery, may be denied as “elective” or “aesthetic” under insurance exclusions. For example, a hysterectomy may be deemed “not medically necessary.” Trans people can be instead forced to sue for their care, as in 2014, when Illinois woman Naya Taylor demanded access to hormones. This is especially true in cases where people have successfully changed the gender markers on their identifications, thereby creating a situation where Medicaid may deny coverage for activities like Pap tests for men or prostate cancer screening for women.

“I’ve got many stories about things that have gone wrong in my interactions with medical professionals,” remarks Everett Maroon, a transgender man who lives in the Pacific Northwest with his wife and family. “I’ve gotten inappropriate medical advice, incorrect therapies, seen medical and cultural incompetence, dealt with shitty care, not been provided options I should have gotten.” His issues are the health-care system’s issues, and they are a subject that should be of critical concern to everyone fighting for reproductive rights.

Fortunately, that’s growing to be the case more and more. As OB-GYN Cheryl Chastine wrote for Rewire last year, “How can providers or activists dare to presume that every patient we can’t ‘read’ as trans is cis?,” she said, adding “When those in the reproductive justice movement prioritize trans inclusivity, more trans individuals feel comfortable publicly identifying as such.”

Her commentary was just one example of the growing chorus of support from the reproductive rights and justice community as people come to understand that reproductive health needs are complex, and some populations have historically been left out of the equation.

Combating that oversight includes taking on challenges like providing competency training to health-care providers in medical school and beyond—including the recommendations ACOG is putting forward. Trans-competent health training should allow clinicians to put their patients at ease. At minimum, it should include discussions about gender identity and presentation, how to handle medical issues that may trigger dysphoria, how hormones might affect other prescriptions and the patient’s general health, and why trans patients may feel distrustful and uncertain around health-care providers.

It also includes passing comprehensive legislation to affirm that transition care and related medical treatments are covered by private insurance, Medicaid, and Medicare. And it includes robust third-party investigation—regulated by the HHS, whose Office of Civil Rights is responsible for enforcing the ACA’s nondiscrimination protections—of grievance complaints filed by trans patients, such as those made directly at clinics and hospitals in addition to those filed with state licensing boards.

It’s time to take trans health care seriously. Doing so will create a world of radical inclusion where people can feel safe seeking health care wherever they go.