Inclusion is not erasure

On June 24, 2022, the US Supreme Court’s ruling in Dobbs v Jackson Women’s Health Organization ended federal protection for abortion access, allowing states to enact stringent limitations on abortion services for all individuals who can become pregnant. Although much of the public discussion about abortion access has appropriately focused on the erosion of women’s fundamental rights, the clinical reality is that pregnancy is neither experienced solely by women nor possible for all women.

Abortion is health care that cisgender women and transgender and gender-diverse individuals with a uterus may need. Despite this fact, public figures in medicine and the lay media contend that inclusive language is erasing women or forbidding the use of the word woman.¹ Such mischaracterizations miss a fundamental point: Rather than representing a threat to women’s rights, an inclusive approach is needed to advance the rights of all affected individuals in post-Dobbs America.

Inclusive language is terminology that includes all affected genders (ie, women and transgender individuals who can become pregnant) and encompasses all individuals who might need medical care. For clinicians, using inclusive language when discussing the loss of access to safe abortion has become an essential tool in delivering medical care accurately, effectively, and respectfully. Transgender and gender-diverse youth consistently identify fears about clinicians’ views on sexual and gender minority identities as a barrier to engaging with routine medical care, such as sexually transmitted infection testing and Papanicolaou tests.² Good care starts with using terms that reflect the patients who sit in front of us in the exam room.

As clinicians who are cisgender women, we believe that the inclusion of transgender and gender diverse individuals in abortion advocacy does not erase us, nor will it erase our cisgender female patients.

Use of inclusive language when discussing access to abortion also keeps us from losing sight of the substantial barriers to accessing reproductive care that transgender and gender-diverse individuals face. These individuals have an elevated risk of unintended pregnancy and high abortion utilization when pregnant and lower rates of accessing basic reproductive and sexual health services than their cisgender peers.^3,4 These disparities are compounded by the effects of systemic racism for transgender and gender-diverse individuals of color.5 Insisting that access to abortion is important only for women threatens to more deeply entrench existing inequities in reproductive health
care access.

Dobbs v Jackson Women’s Health Organization

Dobbs v Jackson Women’s Health Organization is hardly a standalone decision, but rather reflects an increasingly pervasive political and legal strategy of attempting to outlaw or criminalize medical standards of care. Since 2021, numerous states have proposed or passed legislation limiting or eliminating access to gender-affirming care for transgender youth and adults. Then, on June 27, less than 3 days after the decision on Dobbs was released, the Alabama attorney general cited it multiple times in a brief filed with the US Court of Appeals for the Eleventh Circuit to defend the state’s law classifying the provision of gender-affirming care to adolescents as a felony.

These recently enacted legal restrictions on abortion and gender-affirming care are grounded in the shared strategy of constraining the bodily autonomy of those who are not cisgender men, with the goal of reinforcing normative expectations of how bodies should look (cisgender) and function (reproduce). Framing the use of gender-inclusive language as detrimental to women’s rights ultimately undermines the legitimacy of the fundamental claims regarding the importance of basic reproductive health care access. For many cisgender women, and some transgender and gender diverse individuals, this includes the right to choose if, when, and how pregnancy will occur. For many transgender and gender -diverse individuals, this also includes the right to access evidence-based and lifesaving gender-affirming medical care.

Inclusive language isn’t solely of benefit to transgender and gender-diverse individuals. Decoupling the word woman from the assumption of fertility is also affirming and supportive of cisgender women who are unable to become pregnant. It is also medically sound, which is why using precise, accurate terminology is a skill emphasized again and again during medical training. Ignoring the variability in presentation of pregnancy—that a man who is transgender may become pregnant or seek pregnancy termination—risks compromising the ability to accurately assess and
treat patients, with potentially devastating consequences.

As providers of reproductive and gender-affirming health care to adolescents and young adults, we see firsthand the ways in which limitations on abortion and gender-affirming care emerge from a common foundational belief in the unfitness of certain groups of individuals to have bodily autonomy and make decisions about their health care. Historically, these rights have most often been denied to those seen as less than fully human, including women, sexual and gender minority individuals, people of color, and individuals with disabilities, groups who often forcibly sterilized because their reproduction was considered undesirable. By setting the rights of cisgender women and those of gender-minority individuals in opposition, discourse that frames inclusive language as antiwoman serves to erode the rights, and the humanity, of both.

Fighting the good fight

As clinicians who are cisgender women, we believe that the inclusion of transgender and gender-diverse individuals in abortion advocacy does not erase us, nor will it erase our cisgender female patients. We are committed to fighting for the rights of all cisgender and transgender patients to safely access vital and lifesaving medical care. We believe in using language that accurately reflects the concerns of our patients and affirms who they are. Furthermore, we know that the Supreme Court’s decision to repeal access to safe abortion will have devastating consequences for more than just women.

Conclusion

To address the particular needs of gender-diverse populations, there is a need for improvement in physician training and supporting systems,
such as electronic medical records. Providers should work to put into place the systems they need to support the individual and systemic medical and psychosocial stressors more commonly experienced by diverse populations.

Scientifically inaccurate, antitransgender rhetoric will not help against unprecedented attacks on health care access. Inclusive language does not erase women. It does not forbid us from discussing and centering women’s rights. Talking about transgender and gender-diverse individuals’ reproductive health care needs allows us to recognize the full scope of patients whose lives and bodies are at risk when abortion is outlawed and the importance of fighting for the well-being of all.

References

1. Paul P. The far right and far left agree on one thing: women don’t count. New York Times. July 3, 2022. Accessed July 9, 2022.
https://www.nytimes.com/2022/07/03/opinion/the-far-right-and-far-left-agree-on-one-thing-women-dont-count.html

2. Fisher CB, Fried AL, Desmond M, Macapagal K, Mustanski B. Perceived barriers to HIV prevention services for transgender youth. LGBT Health. 2018;5(6):350-358. doi:10.1089/lgbt.2017.0098

3. Charlton BM, Reynolds CA, Tabaac AR, et al. Unintended and teen pregnancy experiences of trans masculine people living in the United States. Int J Transgend Health. 2021;22(1-2):65-76. doi:10.1080/26895269.2020.1824692

4.Moseson H, Fix L, Ragosta S, et al. Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States. Am J Obstet Gynecol. 2021;224(4):376.e1-376.e11. doi:10.1016/j.ajog.2020.09.035

5. Agénor M, Geffen SR, Zubizarreta D, et al. Experiences of and resistance to multiple discrimination in health care settings among transmasculine people of color. BMC Health Serv Res. 2022;22(1):369. doi:10.1186/s12913-022-07729-5