Non-heteronormative sexual health education and policies needed
By Melinda Young
Contraceptive Technology Update (CTU) asked Melissa Ertl, PhD, assistant professor of Psychology at the University of Minnesota-Twin Cities in Minneapolis, about her new research paper on health equity and research with people in the LGBTQ+ community. She provided these written answers, via email:
CTU: In your paper on “Sexual and Reproductive Justice and Health Equity for LGBTQ+ Women,” you write that LGBTQ+ women have been long overlooked in sexual and reproductive health research. Why is that?1
Etrl: Rooted in sexism and heterosexism, part of the reason that LGBTQ+ women have been neglected in biomedical and reproductive health research is that, until 1993, most health research was conducted only with white male and heterosexual populations. In 1993, the National Institutes of Health sought to improve representation of cisgender women in clinical research trials by passing the National Institutes of Health Revitalization Act, which required all NIH-funded research needed to include minoritized racial and ethnic communities and women, including those of childbearing age. More recently, it was not until 2020 that the NIH commissioned a report that highlighted the critical need for data collection on sex, gender identity, and sexual orientation. Prior to this point, most studies did not even collect information on sexual orientation, which led to an almost total lack of information on whether and how well interventions were working with LGBTQ+ populations. As a result, many communities have been understudied and left out of research entirely.
CTU: Would you please describe some of the methods of sexual risk reduction that work for this group and how the methods differ from what cisgender, heterosexual women might use?
Ertl: LGBTQ+ women and heterosexual women may have different sexual health needs based on their desires, preferences, partnerships, and life situations. Depending on who they are partnered with and what their reproductive goals are, various sexual and reproductive technologies may be ideal for sexual risk reduction and to prevent pregnancy, human immunodeficiency virus (HIV), and other sexually transmitted infections (STIs) at various points in time. In addition to sexual risk reduction using condoms, HIV pre-exposure prophylaxis, and different available forms of contraception, other reproductive technologies or procedures may be especially of interest and relevance to LGBTQ+ women compared to heterosexual women, including IVF [in vitro fertilization] or assisted fertility procedures, as well as surrogacy and hysterectomy.
In our paper, we discuss specific sexual and reproductive technologies and the current state of the science for LGBTQ+ women, and we highlight how LGBTQ+ women are positioned at greater vulnerability for adverse sexual health outcomes compared to heterosexual peers and systematically underserved by providers and healthcare systems.1
CTU: Your paper mentions the racist origins of reproductive health technologies and medical mistrust among marginalized and stigmatized communities, including LGBTQ+ women. How does this mistrust affect reproductive healthcare for these communities and what can clinicians do to rebuild trust?
Etrl: Certain reproductive health technologies were used in harmful and oppressive ways historically, including to reduce reproductive freedoms among populations that have been marginalized and stigmatized, such as people of color, LGBTQ+ populations, immigrant populations, poor or incarcerated populations, and more. These practices included forced sterilization, eugenics, or other coercive practices that shaped reproductive care. Because of this history and histories of other oppressive experiences in healthcare — including but not limited to medical racism, ableism, and sexism — some marginalized and minoritized groups have higher rates of mistrust in medicine as a whole and reproductive healthcare in particular. For these reasons and more, some communities are less likely to want to participate in research and are mistrustful of new technologies that may be more recent innovations for fear of being treated as test subjects. Rebuilding trust, although difficult, is very necessary, and it starts with practices that empower, build capacity, and increase advocacy at a community level that partner to inform the design of tailored interventions that are carried out in close collaboration with communities.
CTU: What do “non-heteronormative sexual health education and health policies” look like in practice?
Etrl: Some examples of non-
heteronormative sexual health education and policies include comprehensive, inclusive sexual health education and behaviors on behalf of providers who do not assume patients’ identities, preferences, or needs without asking them. Clinicians should be comfortable and knowledgeable discussing safe same-sex intercourse methods, such as condom use with shared sex toys, cleaning sex toys before use and between partners, and dental dam use with oral sex. These strategies may help alleviate the common experience of erasure and identity dismissal in safe sex conversations with providers. Efforts by providers to reduce stigma and cisheteronormativity may have other indirect benefits for patients by not reinforcing internalized stigma.
CTU: What are some of your recommendations to help reduce health disparities for LGBTQ+ women?
Etrl: Our article offers ideas for future directions in research, clinical practice, education and training, and outreach to reduce and eliminate health disparities for LGBTQ+ women. One of the best means of reducing and eliminating disparities is by reducing stigma and increasing access to care that is inclusive, affirming, and tailored to the needs of LGBTQ+ women. Another important goal is to diversify the scientific workforce and make room for LGBTQ+ women investigators who can develop deep partnerships with communities to conduct research on ways to optimize prevention and intervention efforts and promote health and well-being in underserved groups.
REFERENCE
- Ertl MM, Maroney MR, Becker A, et al. Sexual and reproductive justice and health equity for LGBTQ+ women. J Lesbian Stud 2024; June 30:1-29. [Online ahead of print].
