"Holding the Door Open for Change"

The study and practice of reproductive care—a contested term that itself must be questioned for its assumptions and framing—has excluded, subjugated, and harmed the 2SLGBTQIA+ community. Rooted in colonial, cis-heteropatriarchal, and ableist knowledge systems, reproductive health services—including sex education, fertility and pregnancy care, childbirth, and abortion—lack the resources and training to provide a safe space for transgender and non-binary people. According to a 2020 Trans PULSE Project, 45% of transgender people in Canada reported having one or more unmet health care needs in the past year, in part due to the stigma and discrimination they continue to experience from health care providers.11The Trans PULSE Canada Team. Health and health care access for trans and non-binary people in Canada (March 10, 2020): 8, https://transpulsecanada.ca/results/report-1/.

In a year where anti-trans legislative proposals have swept across the United States, and prospects for gender-affirming care and education throughout North America and Europe continue to narrow, the Blackwood asked practitioners, organizers, and scholars working in gender-diverse health education and care-related sectors to answer two questions, inviting reflection on the health inequities and barriers faced by transgender and gender non-conforming individuals seeking reproductive care. Sharing changes needed for a transgender-inclusive health care system—from dismantling binary language and notions surrounding reproduction and the body, to centralizing marginalized voices and the needs of transgender people of colour—below, we hear from trans scholar, instructor, and inclusion consultant, A.J. Lowik; resident and fellow at the University of Toronto, TransHealthTO member, and doctor at SafeSpace, Tehmina Ahmad; facilitator, community organizer, and educator, Kori Doty; doula, perinatal mental health support worker, and sex educator, Gabrielle Griffith; poet, activist-scholar, and co-editor of Radical Transfeminism Zine, Nat Raha. Each contributor shares lessons that have informed their practice, offering ways, as Doty puts it, to “hold the door open” for change, in solidarity with reproductive health, rights, and justice movements. 

A.J. Lowik: Safe, inclusive reproductive health care starts with how we train providers—be they future doctors, nurses, midwives, allied health professionals, etc. Oftentimes, medical education focused on the health and care needs of 2S/LGBTQIA+ people is cursory, elective, and limited to only a few hours of learning, despite many heath care programs taking years to complete. This content, when it does exist, tends to focus on introducing learners to vocabulary, raising awareness, and improving attitudes, rather than developing pertinent clinical skills to provide competent and affirming care.

Health care providers in clinics and hospitals may think immediately about necessary shifts in their language, asking patients for their pronouns, and ensuring that lines of inquiry into patients’ histories don’t assume they’re heterosexual. These are certainly important. However, we need to look further if we are interested in making sure that every element of care is experienced positively by 2S/LGBTQIA+ patients.

I always advocate that people think through a patient encounter from start to finish. Consider a midwifery office with the word women in the clinic name, only gendered bathrooms, women’s health and lifestyle magazines in the waiting room, feminine art on the walls, and where all the pamphlets about birth planning refer to women and feature photographs of people whose gender expressions are traditionally feminine. All these communicate something about who has been anticipated and ultimately who is welcome. It could be that trans men, non-binary people, butch lesbians, gay men who are using a surrogate, and others will not see themselves reflected. Training clinical staff on how to provide affirming care is vital but will only go so far if the front desk person hasn’t also been trained, if the intake forms haven’t been updated, if you haven’t assessed the appropriateness of referral pathways, and if the workplace itself isn’t a safe place for employees who may themselves be queer, trans, Two-Spirit.

Importantly, we need to remember that the Canadian health care system was built with white, cisgender, able, heterosexual men in mind, first and foremost. It is a site of institutionalized violence, colonial oppression, injustice, and inequity for many. The changes needed to create safety and inclusivity in reproductive health are systemic changes we need to see in broader society: the eradication of poverty; dismantling cis-heteropatriarchy, white supremacy, ableism, and ageism; and recognizing Indigenous sovereignty.

AL: I am forever grateful for Dr. Cary Costello, a sociologist at the University of Wisconsin-Milwaukee. Dr. Costello brought to my attention the limits of cisnormativity, a concept that I was using to understand everything from gaps in medical education to the barriers that trans and non-binary people experience in accessing reproductive health care. As an intersex trans man, who is also an intersex and trans scholar, Dr. Costello introduced me to endosexnormativity, which has absolutely changed how I think and work.

Briefly, cisnormativity refers to an understanding that gender (as a binary) and sex (as a binary) will, or at least ought to, align in predictable ways, such that cisgender people are valued and normalized. Endosexnormativity allows us to expose the limits of the cis/trans binary and the mistreatment of intersex people on that basis. Intersex folks of all genders and sexes may have unique experiences of, and relationships to, their bodies and identities that cis/trans language simply doesn’t capture. Further, Dr. Costello and Pidgeon Pagonis (an intersex activist, academic, and writer) both remind me that the forced, invasive, and unnecessary surgeries performed on intersex infants and youth represent a reproductive justice issue. When intersex people have body parts surgically removed, and/or exogenous hormones administered, without their knowledge or consent, they are denied the possibility of using their gametes and reproductive systems, and may also be denied sexual pleasure.If we want to create safe and inclusive reproductive health care spaces for all, we need to take intersex people’s lives, health, and wellbeing very seriously.

I am grateful to Harlan Pruden, Dr. Jae Ford, and Jessy Dame. Each of these Two-Spirit people have impressed upon me the importance of centring Indigenous ways of knowing, being, and of doing, and of understanding the impacts of colonization on how we think about gender, sex, and sexuality. Rather than Two-Spirit being just like Western identity terms like gay, lesbian, trans, and queer, Two-Spirit represents a cultural and spiritual role and can serve as a community-organizing tool. I intentionally put a slash between 2S and the LGBTQIA+ acronym for this reason, and when designing research, I ask about Two-Spirit identity alongside questions about Indigeneity, rather than questions about gender and sexuality. I am always learning and unlearning from these incredible people. They remind me of all the reproductive injustices committed against Indigenous people as part of the historical and ongoing colonial projects here on Turtle Island, and of our responsibility to recognize the unique needs of Indigenous people when delivering reproductive health care or designing reproductive health-focused research.

Tehmina Ahmad: Fertility, pregnancy, and childbearing are not solely experienced by cis women, and it is time these narratives change to include transgender and gender diverse (TGD) people. This fundamental change must start by expanding beyond the binary language often emphasized in medical education and the spaces where TGD individuals seek care.

Gendered language is just one obstacle TGD people face; barriers exist at systemic, organizational, and individual levels when seeking access to reproductive health services such as contraception, fertility preservation, reproductive assistance, pregnancy, and abortion services.22Madina Agénor et al, “Mapping the Scientific Literature on Reproductive Health Among Transgender and Gender Diverse People: A Scoping Review,” Sexual and Reproductive Health Matters 29, no. 1 (2021): 57–74.

From a systemic perspective, our institutions must inwardly reflect through an intersectional lens. Intersectionality emphasizes that oppressive power structures do not exist in isolation but rather simultaneously, producing unique challenges for people who are harmed by multiple systems.33Kimberlé Crenshaw, “Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics,” The University of Chicago Legal Forum 140 (1989): 139–167; Kimberlé Crenshaw, “Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color,” Stanford Law Review 43, no. 6 (1991): 1241–1299.Our systems must be guided by the needs, preferences, and experiences not only of TGD people, but also folks with multiple intersecting identities inclusive of Black, Indigenous, and Latinx individuals, who remain under-represented in our clinics and research.44Alexis Hoffkling et al., “From Erasure to Opportunity: A Qualitative Study of the Experiences of Transgender Men around Pregnancy and Recommendations for Providers,” BMC Pregnancy and Childbirth 17 (2017); Shanna K. Kattari et al., “Correlations between Healthcare Provider Interactions and Mental Health among Transgender and Nonbinary Adults,” SSM-Population Health 10 (2020); Agénor et al., 2021.

We need to use our privilege to advocate on behalf of our patients. After all, trans rights are human rights, and trans care is human care. Care is the bare minimum and as a medical collective, we owe it to TGD patients to push beyond the nominal baseline.

TA: While working at SafeSpace—a drop-in support centre for sex workers, women, and gender non-conforming folks in crisis—I learned life-long lessons in humility, compassion, and the importance of narratives that grounded my perspective of this vibrant community.

One such pivotal event that shaped my outlook involved harm-reduction supplies. I had been restocking the supplies when I repeatedly noticed that the small, alcohol-laden Listerine bottles were always taken off the table by community members, despite being laid out with long-term use items like toothbrushes and toothpaste. I had a moment of cognitive dissonance, thinking to myself with judgment, “It must be the alcohol….” I became close with one of the women who frequented the space, and got the courage to ask, “Why not take the toothbrushes, because they’ll last longer?” She turned to me, not the least bit bothered by my curiosity, and said, “Hunny, if I am out on a job, I don’t know what Johns I’m seeing. If I use a toothbrush, it’ll cut lil’ tears in my gums, but if I use Listerine, then I’m not putting myself at risk.” This was her form of harm reduction.

I felt guilt and shame that I had these pre-conceived notions regarding the alcohol, recognizing that to outsiders, this community appeared morally poor—but the truth couldn’t be further from this. What I found was a rich community finding ways of knowing and caring for their health. Listerine was the best solution available because health care isn’t seen as safe or accessible to the folks utilizing this space. This experience changed my practice and opened my eyes to the realities of our most vulnerable. 

We owe it to our patients to do right by them, believe them, and prioritize their stories.

Kori Doty: Reproductive care—as a means of categorizing the health care people need in order to reproduce—is shallow and lacks inclusion in its very design. Reducing bodies to sites of production means only tending to the medical needs of the body in order to produce more potential labouring bodies for the capitalist system, as if parts of the body are solely for this purpose. Human “reproductive” systems are also pleasure systems. Seeing the health of the systems only as far as their ability to reproduce, without considering their capacity for pleasure, immediately excludes those who cannot or choose not to use their bodies for procreation. The tendering of genital health care needs to be shifted to include all bodies, including those who may have experienced congenital, incidental, intentional, or traumatic divergences to reproductive capacity. All bodies, including those who cannot or chose not to reproduce biologically, with or without medical assistance or intervention, need to be able to access affirming and safe genital health care.

When reproductive health starts meeting the needs of all bodies, then those who are often excluded on binary, ciscentric, nuclear family assumptions can be offered care that may attend to reproductive desires. But this may also include types of care under the broader umbrella of reproductive health such as STI screening, vaccinations for sexual health like Gardasil, prophylactic measures, gender-affirming hormone treatment, genital surgery, surrogacy, gamete preservation, vasectomy, pelvic floor physio, treatment of genital-based dermatological conditions like lichen sclerosus, postpartum recovery, puberty, menopause, recovery support for sexual trauma, sexuality-focused occupational therapy, sexual surrogacy, genital-inclusive body work, and so on. 

The assumption that two human adults with an opposing set of genitals are the only family structures that wish to reproduce leaves many people out, not just queer and trans folks for the obvious reasons, but also families with more than two parents, adults who cannot conceive without medical intervention due to medical conditions or injuries, gestating adults who do not wish to become parents, prospective adoptive parents, and more.

As with the rest of the medical system, fatphobia is a rampant and deeply problematic issue that cannot be overlooked in its devastating impacts. Reproductive health is no exception to this and larger-bodied individuals are routinely excluded from care.

KD: When I was pregnant, I was working with an unregistered midwife who had trained in holistic birth support and pre- and perinatal psychological support. She asked her teachers, along with another peer who was working with trans and non-binary doula clients, “What resources can we share with our clients? They have a need for this content, and we are having trouble finding tools to share that straddle the worlds of holistic birth support and gender inclusion. What are we missing?”

The teachers told them that they may have reached a point in their work where they had identified a gap they were most equipped to fill. “You are the resource you have been waiting for,” while not an answer that anyone struggling wants to hear, can be a call to step into our power and create the resources we so desperately need. Unfortunately, this labour is often left to marginalized folks who are not being served by the current systems. I have had to become the resource I was waiting for a number of times throughout my personal and professional work, and while it can be empowering to take personal agency, it is also exhausting. This reminds me to look at who may not be being reached, and to take measures where I can (using the privileges I have access to) towards intersectionally liberatory ways of being. I have come to trust my ability to be a strong and capable advocate for myself, and I try to use that to hold the door open—or reconfigure the space, to remove the need for a closing door altogether—for others whenever possible.

Another big lesson I would attribute to my studies with the Institute for Somatic Sex Education is moving at the speed of trust. This approach, most simply, gives permission to both the client and practitioner to maintain personal autonomy and agency, moving through procedures and interactions without externally mandated timelines of how things will unfold. This approach counters mainstream Western late-stage capitalist society and medical systems, and more closely resembles decolonial and traditional approaches to the body, but is also informed by modern understandings of brain function. When we are able to maintain a sense of being safe enough to keep our nervous systems regulated (not in a trauma response state), we remain more wholly in the window of tolerance (a term attributed to Dan Siegel and Pat Ogden) or alternately, the window of transformation (attributed to kai cheng thom). From this place we are able to engage with the work at hand in ways that are meaningful and connected.

Gabrielle Griffith: It is hard to put into words, because the medical community operates within the medical-industrial complex (MIC), a system designed to uplift certain people and oppress others. I would like to see more people within the medical community acknowledging this and advocating against it. There are so many layers to making a “space safe for all,” and if I’m honest, I don’t think it’s possible when the entire community functions within the MIC. The changes need to start at the root, where people start their journey to become medical practitioners. People need to be taught how to leave their bias at the door and remember they are there to provide a service, period.

While learning to become a medical care practitioner, people should also be required to go through anti-racist and anti-oppressive trainings to be able to genuinely hold space for all folks once in the field. Waiting until people are in the field, with their habits and biases, to take a one-time training isn’t enough. People need time to unpack and let go of these judgments that many are raised in due to the cis-heteropatriarchal society we live in. I would love to see people go beyond putting a rainbow sticker or poster in the office, because everyone in my community knows that just because they say they are accepting of all doesn’t mean they actually practice that in the space. It’s so important as a service provider to not make assumptions about gender, about relationship dynamics, about anything. Learn to ask questions, not for your education but for a deeper understanding of how to serve this client and treat them with respect regardless of race, gender, sex, or sexuality.

It’s also important to be honest with where you are on your own journey. Be honest about when you are not the right person for this client, not because of your bigotry but because you are still learning and want to connect them with someone who can better serve them. I want to see more inclusive networking within the medical community: Who do you know within your network who is of the 2SLGBTQIA+ community? Who within your work space? If there are none, how can you change this? How can you advocate within the space for better trainings and more inclusive hiring? This is the work. Use your voice, use your privilege to make the space safe internally and it will have a domino effect to the patients/clients.

GG: The pivotal lesson that informs my practice came from burnout. I dove into this world with my heart and arms wide open; I was ready to serve and learned the hard way that care work is never finished. In order to be a solid and reliable care worker you need to have a solid and reliable care network for yourself. You need to learn to have strong boundaries about what, when, where, and how you will serve. When I started to get serious about providing care to myself first and only giving from a place of overflow, this transformed my practice. It means that I take on less clients but I can provide higher quality care and support, and for me, that’s what is most important. I shifted my thinking to being the best community member I can be rather than the best helper or giver.

Nat Raha: Writing from the UK, it’s clear that a lack of research around trans and gender non-conforming people’s access to reproductive technologies and the interplay between reproduction and gender-affirming treatments (including hormones and surgeries) reproduces a dynamic where medical practitioners hold power over us. However, reproductive technologies are not just wielded by medical establishments. 2SLGBTQIA+ people have been engaged in DIY or DIT (do-it-together) reproductive practices against a medical establishment that works to service and reproduce primarily white, able, cis- and heteronormative bodies and lives.

It goes without question that the norms servicing this hegemonic idea of embodiment need to be actively dismantled. This entails challenging the idea of an individualized body rooted in Western Enlightenment thought—where the body is separated from the mind, and from the practices that shape bodyminds and the interdependencies in which our bodies are socially reproduced, survive, and are nourished. How are we actively dismantling these norms in our practices?

Marginalized people have profound understandings of how our bodies are situated and what is possible with them. Instead of “outreach,” perhaps dialogue and reverse tutelage or reverse pedagogy are needed: for the medical community to engage with us on local, regional, and international levels, building meaningful relations with marginalized groups, while paying us for our knowledge and time. We are always in need of resources—I’d love to see institutional medical practitioners offer their resources to marginalized groups and communities, decentralizing their power and putting provisions and skills into community hands. Can you itemize your resources and make them available for our communities, without questions or judgment, your pathologizing gazes abandoned on the floor of the car park? Plus, under conditions of precarity, the long term is the temporality that may feel most intangible or get pushed out of view. Practitioners can help facilitate the use, expression, and manifestations of what we can do (together) with our bodyminds in the long term.

Although, this will take a lot of trust, and some groups may not want to just inherit power that pathologizes and objectifies our bodies. Trans and queer people, especially Two-Spirit and Indigenous, Black and brown people, have already had too much power wielded by medical hands upon our bodies—including in service of eugenicist policies of colonial nation states. Many of us live with the scars, the memories, and the losses of this in the long term, even intergenerationally.

NR: As an activist-scholar working across different communities and relations, there’s no singular lesson to be held above the rest. I’m learning all the time, through conversations that emerge within organizing and supporting others, and also in the relations that make up everyday life. From other organizers, from friends, who’ve either worked on or tried similar strategies before, or who are going through different embodied experiences. We do the work of support and mutual aid, attest to differences, or bridge commonalities.

I think of Justice as a practice. It entails particular practices of solidarity, to address and redress harms, to recall and remember strategies and methods of being together and supporting life that may be glossed over, not understood or misunderstood, or actively historically erased. I am grateful for the writing and thought of scholars, organizers, and poets, especially Leanne Betasamosake Simpson, Leah Lakshmi Piepzna-Samarasinha, and Eli Clare, who each address deep truths of how we survive, what we have, and how different minoritized communities—Indigenous, disabled people, and queer and trans people—hold space to reconcile and rage for what we’ve lost.

We’ve learned to say that one never has to face pursuing medical care or support alone—when you’re alone, that’s when you get dismissed, face pushback, are refused the care that you need and deserve. This is where the political—the conditions of the infrastructure—becomes personal, in its forms of disqualification and harm. A society that is grounded on dispossession and inequalities, in which separation and isolation are strategies to further these dynamics, is not going to produce health care infrastructures that are exempt from these dynamics. We have power when we work together to get the health care we need—to reflect with each other on our experiences, encouraging a situated understanding of them.