Reproductive Health

Key points:

  • Check your assumptions–think outside the boxes of heternormative, cisgender, and monogamous paradigms 

  • Use inclusive language to refer to body parts, not sex/gender.  For example, “people with a uterus” rather than “women.”  Depending on the health literacy of the patient you may have to define some of these terms for them. A patient’s needs and risks depend mainly on the body parts they and their partner(s) have and the types of sex they engage in. 

  • Let patients guide you as to the language they prefer and ask clarifying questions so they know they are safe with you

  • Use language that is inclusive of all family structures (a good practice with cis/heterosexual people as well). 

  • Changing language and attitudes in your practice may be slow and awkward at first, but it is necessary to persevere with educating yourself and your staff until they become a natural part of your thought process and vocabulary.

  • Most of the options for LGBTQIA+ to have children are expensive, time-consuming and may cause additional stress on individuals/families

Introduction

The needs of LGBTQIA+ patients in regard to reproductive health and family planning are not dissimilar to those of cisgender and heterosexual patients. In general, these needs break down into two categories: having children (including fertility and conception) and preventing pregnancy (including contraception).  However, these patients may be stigmatised and need extra support navigating fertility services and community support networks, which are often biased toward cis/heterosexual couples and use language that excludes the diverse identities and family structures of the rainbow community.

Reproductive Health History

  • General guidelines for taking an appropriate history which is inclusive of LGBTQIA+ patients can be found here.  As with any consultation, it’s best to introduce your questions in a way that makes it clear that the questions are medically necessary and not just based on the doctor’s desire for education or to satisfy their curiosity. 

  •  Remember that LGBTQIA+ people have had many experiences in which they are put in the awkward position of educating their doctors whilst navigating a system fraught with bias and the exhausting process of constantly having to assess their own safety. Be mindful of this when asking questions and remember to check your own biases and assumptions.

  • The history will guide you as to whether the patient needs advice on contraception or whether they want to explore adding children to their family.  

Contraception

Assessing needs

  • Sometimes the need for contraception is not immediately obvious to the patient.  Any patient with a uterus and at least one ovary (regardless of gender identity) who has not gone through menopause could potentially become pregnant. 

  • It is important to get a clear picture of what kind(s) of sex people are having. Don’t make assumptions–and use clear language about what body parts are going where but be careful to ask questions respectfully and make sure to clearly communicate why you are asking

  • Transgender patients who are taking hormones may assume that they either cannot conceive or cannot impregnate someone.  It is important to note that while gender affirming hormones reduce fertility (sometimes permanently), they do not result in a person being completely sterile and if a patient or their partner(s) is potentially at risk for an unwanted pregnancy, contraceptive options need to be discussed as for any other patient.

  • While it is important to accurately assess the need for contraception, many people who don’t require contraception (eg cisgender lesbians who only have sex with other cisgender women, or asexual people) find that repeatedly having to explain this to their doctor to be an irritating and exhausting task.  Checking in regularly to make sure circumstances haven’t changed is important but must be done in such a way as to reassure the patient that they feel that you are listening to and understanding what they have told you in the past.

For AFAB people, whether trans or cis, who may want to suppress menstruation hormonal options can be considered such as continuous use of combined oral contraceptive, depo Provera, the Mirena IUD or the Jadelle implant.All of the above are safe and viable options in transmasculine people requiring either contraception or suppression of menstruation (or both), although many transmen may object to the use of oestrogen, making the COCP a less attractive option.

Pregnancy

Many LGBTQIA+ individuals desire to add children to their family through pregnancy and may come to you for advice and help to achieve this.  This may include single AFAB or AMAB (assigned male at birth) people, lesbian couples (2 cisgender women), and couples in which one of both people are AFAB and trans or non-binary. 

It is important to be able to discuss options and preferences with patients desiring pregnancy and to have an awareness of clinics and specialists who are LGBTQIA+ friendly and inclusive.  Furthermore, once pregnancy is achieved, referrals to midwives who are also LGBTQIA+ inclusive are essential wherever possible.

There are several things to stay on top of in this process:

1. Make sure the language in all information and educational handouts is gender-inclusive (Such as Empwr: who are midwives running a queer-friendly pregnancy service in Auckland)

2. Don’t forget to discuss and arrange for fertility preservation (eg sperm banking) if needed prior to starting a trans person on hormones. Access to publicly funded fertility care through Fertility Associates is available for both sperm and egg preservation prior to starting GAHT

3. Transmasculine AFAB people MUST stop taking testosterone prior to trying to conceive as it is teratogenic

4. Aside from the need to stop testosterone, preconception counselling is much the same for LGBTQIA+ people as it is for cisgender straight people. 

Download this PDF on Supporting Transgender and Non Binary Parents.

Different types of families

It is important to respect all types of family configurations.  In addition to single people  (who may or may not identify as LGBTQIA+) choosing to have children on their own, there may be people in polyamorous relationships where there may be more than two people intending to coparent a child or children.  There may also be lesbian or AFAB couples where both partners want to carry a pregnancy.  All family constellations are valid and the job of the primary care provider is to present options and medical advice and support.

Fertility Issues

Apart from those engaged in sexual relationships in which there is a partner with sperm and a partner with uterus and ovaries, LGBTQIA+ people seeking to have a baby through pregnancy will often present with barriers to fertility.  

Pre-conception 

Screening for potential fertility and health issues should be done prior to trying to conceive.  The usual requirement for heterosexual couples to try for one year before being referred to fertility services doesn’t apply here because it doesn’t make sense to waste time and money on insemination if the partner receiving the sperm has undetected or untreated fertility issues.   

Referral to a fertility clinic with services that cater to LGBTQIA+ families will enable patients to discuss the options and necessary pre-conception assessments.  Private clinics such as Fertility Associates have comprehensive information about how the options and process for patients can be accessed through patient self-referral. However, it is important to be able to provide support for patients through this process and be sensitive to their particular needs.  Sometimes accessing secondary care can be nerve-wracking for LGBTQIA+ patients for all the reasons already discussed. 

Sperm donation

Sperm can be obtained through a known (‘personal’)  donor or a fertility clinic.  If one of the partners is a transfem person who has banked sperm prior to starting hormones, this is also  available. 

Sperm banks at fertility clinics will do all necessary screening of sperm donors (whether known or anonymous), which makes this the safest option.  It’s best to refer patients to a fertility clinic to discuss the options so they can make the best decision.

Private insemination through a known donor is possible (through the proverbial “turkey baster”) but patients should be given appropriate information about the medical and legal considerations of doing this. Please refer to this handout for further information.

Egg donation

In some cases an egg donor may be required or desired.  In some cases, an AFAB person might want to donate an egg to their partner who will be carrying the pregnancy.  If the person carrying the pregnancy is too old to produce viable eggs or has premature ovarian failure, egg or embryo donation may be required.  Again, referral to a fertility clinic will enable patients to discuss these options with a specialist.

Surrogacy and other options 

LGBTQIA+ individuals and families may need or desire to have a child through a surrogate (a person who, essentially, donates their womb for the purpose of gestating a baby for another person/family). 

In New Zealand, there are complex legal requirements for surrogacy.  Fertility Associates has recommended the following article for more information about the process.

For families for whom pregnancy or surrogacy is either not desired or not possible, other options include adoption or foster care. 

Final consideration

Most of the options for LGBTQIA+ to have children are expensive and time-consuming.  Infertility puts a strain on all couples/families and rainbow people will face even more obstacles and stresses for all of the reasons discussed above. GPs should be able to navigate the resources and provide inclusive and culturally sensitive support to rainbow families as they go through this process.