Post written by Rachel Kitto, Stanback Fellow and Stephanie Chung, Research Associate, FHI 360
In the past decade, the healthcare community has achieved a richer understanding of the diverse needs of trans and gender-diverse individuals assigned female at birth (TGD AFAB). Despite these efforts, sexual and reproductive health research for this community has been chronically understudied. Though there have been many advancements in contraceptive R&D, research has concentrated on cis-women, and the potential benefits of contraceptives for the TGD AFAB community have yet to be sufficiently explored. We lack understanding in a number of different aspects of TGD AFAB needs related to contraceptives, including TGD AFAB individuals’ unique fertility desires, the effects of concurrent use of contraceptives and gender-affirming hormone therapy, and how different contraceptive methods might impact experiences of gender dysphoria.
This lack of knowledge facilitates the spread of cisgender and heteronormative assumptions, exposing TGD AFAB individuals to misinformation and feelings of isolation by the healthcare community. Current exclusionary practices create a seemingly cyclical effect where R&D lacks consideration of TGD AFAB experiences while TGD AFAB individuals simultaneously elect not to participate in research because of historical discrimination and mistreatment. Ultimately, this limits the advancement of reproductive medicine, including contraceptive R&D. But much can be done to make contraceptive R&D more inclusive and inviting for TGD AFAB populations. One important first step is the use of inclusive language.
Though this may seem like a small step, exclusive language reduces opportunities for TGD AFAB individuals to engage in the contraceptive R&D process. Generally, the practice of using inclusive language generates a baseline level of support and validation for TGD AFAB individuals in research and development. Further, changing the language for target users broadens the lens through which contraceptive technology is developed, allowing researchers to consider the varying needs of a more diverse client base. Using inclusive language when designing research studies is also paramount to creating openings for TGD AFAB populations to engage in product development and research as participants.
Inclusive Language Practices
Contraceptive researchers should switch to more inclusive phrasing whenever possible. When referring to people who may use contraceptive technology, researchers should use terminology like “people,” “clients,” “menstruators,” “people with uteruses,” or “people who can become pregnant” instead of “women.” These terms are more reflective of the populations who use contraceptive products. More examples of adjustments to current phrasing are listed below.
Instead of women’s health clinic, use sexual and reproductive health clinic
Instead of family planning visits, use sexual health visits
Instead of period, use cycle
Instead of both genders/either gender, use all genders OR be specify (cisgender man, trans man, cisgender woman, trans woman, non-binary person, etc.)
Instead of sexually active, use “engaging in sexual activity that could lead to pregnancy”
Instead of biologically female, use assigned female at birth (AFAB)
Besides making these terminology changes, contraceptive researchers can do the following to make their research more inclusive through the language they use:
Researchers should use clear and intentional language when identifying participant sex and gender. Surveys and records should always include different questions for gender identity and assigned sex, defining these terms wherever possible to avoid conflation. Additionally, rather than listing only two gender options on surveys/studies, researchers should offer at least man, woman, nonbinary, genderqueer, gender nonconforming, another gender not specified, or opt not to identify with a gender. When possible, studies should allow participants to self-identify (which may look like a blank space where participants can write in their gender). This practice aims to minimize feelings of gender dysphoria and exclusion. Further, it reduces the potential for misclassification bias, and it prevents vague or under-specific terms from causing inaccuracies in data and skewing results.
Study teams should avoid making assumptions about participants’ gender identity or sexual preferences. The most notable way to avoid making assumptions about gender identity is to ask study participants or patients their preferred pronouns. This is where many researchers stop; however, more steps can be taken to foster an inclusive environment. When relevant, researchers should ask about participants’ specific anatomy using an “anatomical inventory” (or “organ inventory”) which lists individuals’ potential anatomical features. This tool prevents researchers from assuming that participants’ or clients’ primary and secondary sex characteristics correspond to the stated gender or sex. Similarly, teams should avoid assuming the gender identity or anatomical characteristics of participants’ sexual partners.
Studies should allow participants to clarify language they are comfortable using when discussing their anatomy. Some participants may prefer “coded language” when describing their bodies to minimize feelings of discomfort or gender dysphoria. Though this may be a difficult practice to implement, study teams should consider the limitations and potential distress that standard clinical language may cause participants.
Researchers should clearly explain enrollment and exclusion criteria for their studies and be careful not to make assumptions about sexuality and gender. For example, in studies where the primary outcome is to assess contraceptive efficacy in preventing pregnancy, it is reasonable to limit enrollment to individuals currently at risk of pregnancy (i.e., engaging in sexual activity that could lead to pregnancy). However, this does not mean that the study needs to be restricted only to heterosexual cis-gendered couples. By using accurate, inclusive language, researchers can encourage TGD AFAB individuals to engage in contraceptive R&D.
Researchers should carefully consider their assumptions about contraceptive users' goals and preferences – not everyone uses contraception to prevent pregnancy. When designing studies to assess the personal and sociocultural acceptability of contraceptive products, researchers should be cognizant that different populations may have different needs and desires when using a contraceptive method. For example, one study of TGD AFAB individuals found that a primary reason to start a contraceptive method was to avoid monthly menstruation. Acceptability of contraceptive methods, especially for youth or unmarried women in more conservative areas, may be higher if linked to their association with their non-contraceptive benefits, such as cessation of heavy or painful periods, rather than pregnancy prevention. When conducting acceptability studies, a diverse range of contraceptive goals and attributes should be considered.
While we still have a long way to go in making inclusive language the standard for contraceptive R&D, there have been some developments. Most notably, the World Health Organization began including provisions for transgender and non-binary people in their normative guidelines for SRH providers in 2022. The inclusion of reproductive health research and guidelines in the international community demonstrates the evolving global commitment to equitable health interventions, encouraging healthcare providers and researchers alike to consider these historically marginalized groups.
Language not only shapes our perceptions and actions but also impacts who can meaningfully engage with research and development. Contraceptive product developers should familiarize themselves with best practices for inclusive language outlined here and begin to work with their teams to implement some of these strategies into their current research studies. Through the use of inclusive language practices, contraceptive researchers can work towards developing a contraceptive method mix that is responsive to the unique needs of a community that has been overlooked by the research and development field.
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