Why abortion isn’t a “women’s issue”, and how to use more inclusive language
Transgender people could be, and sometimes are, powerful pro-choice activists — but too often, the movement’s rhetoric further marginalizes us.
Over the past few months, over a dozen states have considered, debated, or passed highly restrictive abortion laws. Civil rights and reproductive health organizations are challenging these laws, while the news media widely reports on new developments. In the past two weeks, I’ve grown increasingly uncomfortable with the rhetoric used in both activism and reporting on abortion rights — and I’m not the only person expressing this sentiment. While others discuss the ethics of phrases like “pro-life” and “pro-choice,” people like me fight to merely have our existence acknowledged.
Though we are probably less than 1% of the population, transgender people deserve to be included in discussions that affect us — and that absolutely includes issues related to abortion and pregnancy. Just two weeks ago, the New England Journal of Medicine published a case of a transgender man who had a stillbirth in an emergency room. Despite a positive home pregnancy test, a nurse noted that he was obese but “stable” with “non-urgent” issues. He did not receive an ultrasound for hours — when he did, fetal heartbeat activity was unclear. A surgeon could not find a heartbeat while prepping for a C-section, and the man delivered a stillborn infant minutes later. Gillian Branstetter, a spokesperson for the National Center for Transgender Equality, said the case was “not terribly surprising.”
Why framing abortion as a “women’s issue” is exclusionary
To put it simply: anyone who can get pregnant may need abortion care. You don’t need to identify as a woman to get pregnant. If you have ovaries, they don’t magically stop working if you’re not a woman. Transgender men and non-binary people who were assigned female can and do get pregnant. According to a 2016 article in Obstetric Medicine, “transgender men have successfully conceived and carried a pregnancy after using testosterone. Transgender men also have unintended pregnancies while taking or still amenorrheic from testosterone, which was mistakenly thought to preclude pregnancy.” In the case described above, the man was on testosterone until his health insurance stopped covering it — and his blood pressure medication.
Even the ACLU refers to Roe v. Wade as “the landmark case that secured a woman’s right to abortion.” At least one magazine accused recent abortion bans of “criminalizing women’s bodies.” Make no mistake — these abortion bans are horrific attacks on reproductive healthcare rights. But a body with a uterus isn’t inherently a “woman’s body” — it can also be a man’s body, or a non-binary person’s body. Likewise, a body without a uterus, or an infertile body with a uterus, can be a woman’s body. Some cisgender women (those who were assigned female at birth) were born without a uterus, while others have had hysterectomies. In most cases, transgender women do not have uteruses. Bodies and gender are nuanced, and discussion about them need to reflect their complexity.
The discussion around reproductive rights needs to include everyone who can get pregnant.
I understand that public discussion about abortion has used this rhetoric for decades if not centuries, but feminist movements can and have changed over time. For example, the phrase “intimate partner violence” is slowly replacing “domestic violence” because it recognizes that partner-on-partner violence occurs outside domestic environments, too. Critically, it includes homeless victims of such violence — one of the most vulnerable populations. Likewise, the discussion around reproductive rights needs to include everyone who can get pregnant, including those already marginalized in the healthcare system.
Navigating a medical system built for cisgender patients
Last weekend, Laverne Cox spoke on the issue of inclusive language and abortion rights in a commencement address. She recounted being confronted by a Twitter follower for retweeting a post implying abortion was a women’s issue. Initially, she just wanted to be able to keep things simple — but then she thought about it more. “When we use language that excludes groups of people on pertinent issues, it can jeopardize their health and well-being,” Cox said. In this issue and beyond, transgender patients face heightened barriers to appropriate healthcare.
A 2015 survey of transgender persons in the United States asked about experiences with healthcare providers in the past year. 87% had sought healthcare in the past year, though only 85% had a transition-related or routine healthcare provider. Of those who saw a provider in the past year, 62% reported at least one positive experience and 33% “reported having at least one negative experience with a doctor or other health care provider related to being transgender.” Almost one quarter of survey respondents had to educate a healthcare provider to receive appropriate care.
Of the subgroups identified in the survey, Native American, Middle Eastern, and multiracial respondents had the highest chance of a negative experience. One-half of Native American, 40% of Middle Eastern, and 38% of multiracial respondents reported at least one negative encounter. Beyond this, 42% of transgender men, and the same percentage of disabled transgender persons, reported at least one negative experience. Among transgender women, 36% reported a negative experience, compared to 24% of non-binary respondents.
Since so many trans people have poor experiences in the healthcare system, it’s not surprising that just under a quarter of respondents avoided seeking care in the past year for fear of mistreatment. Among Native American and Middle Eastern populations, this statistic was over one-third. 31% of transgender men avoided care, compared to 22% of transgender women and 20% of non-binary respondents. This roughly reflects the differences in negative experiences between these groups.
Gynecology: A uniquely gendered specialty
The US Trans Survey prints comments from transgender people in sections labeled “In Our Voices” throughout its report. One of these experiences is from a transgender man who struggled to have his gender identity reflected in his college records and still get the health coverage he needed: “When I was in college, I had my health insurance list me as male, and then they denied coverage for my routine pap smear and a gynecological prescription due to my gender.”
This problem reflects a structural challenge in providing healthcare to transgender men and non-binary people who were assigned female. Many healthcare providers use phrases like “women’s health services” instead of obstetrics and gynecology (OB/GYN). Penn Medicine runs a Women’s Health Blog which uses the phrase “women’s health specialists” instead of OB/GYNs. Phrases like “well-woman visits” replace more straightforward descriptions of what actually happens in such visits throughout medical literature.
As a specialty, gynecology is necessary, but simply having a vagina shouldn’t make preventive healthcare harder to access.
Even the term “gynecology” is anomalous as far as medical specialties go. There is no “andrology” specialty — men receive reproductive healthcare from urologists and primary care physicians, who also treat women. Every other specialty, even obstetrics, is named for a bodily system or function. In effect, this means that any man or non-binary person with a cervix has to accept being misgendered, either explicitly (“women’s health services”) or implicitly (gynecology), to access comprehensive healthcare. This psychological discomfort exists on top of the physical discomfort involved in the procedures themselves, and the gender dysphoria many trans people feel when others focus on their genitals.
The effects are clear in a question on the US Trans Survey regarding pap smears: 27% of respondents who were assigned female at birth (AFAB) had a pap smear in the past year, compared to 43% of all AFAB adults. The documentary “Southern Comfort” tells the story of a transgender man who died in 1999 because gynecologists refused to treat his ovarian cancer. Later in the 2015 Trans Survey report, a respondent describes medical abuse by an OB/GYN: “[An] OB/GYN forced me onto birth control pills to ‘fix’ me into thinking I was a woman again. I ended up in the psychiatric ward of my local hospital on suicide watch after three days on birth control.” Another describes being denied preventive care based on their assigned sex at birth: “The nurse refused to give me HIV testing because she said those funds were reserved for men who have sex with men and I’m ‘not a real man.’ She told me I was born female and just needed to accept reality.”
More broadly, the medical establishment must re-evaluate the way it handles reproductive healthcare, especially for patients with vaginas. Gender-based recommendations for STI testing should be minimized. There needs to be a discussion about the phrase “well-woman exam” to identify more accurate and inclusive alternative phrases. Researchers should determine if prostate exams and Pap smears are equally accessible through primary care providers, and how medical schools and healthcare providers should address any disparity they find. As a specialty, gynecology is necessary, but simply having a vagina shouldn’t make preventive healthcare harder to access. Some patients may prefer to see both their gynecologist and primary care physician yearly — there may be benefits to doing so. But there are also benefits to having one doctor provide all preventive care services, and no one should have to see two different providers every year if that isn’t their preference.
How reproductive health activists can be more inclusive
While top-down change from medical institutions would benefit populations as a whole, we can also adjust our individual language use to make life easier for transgender people — and demystify uterus-based reproductive health overall. Sometimes, phrases like “women’s rights” become euphemistic, used to avoid words like pregnancy, abortion, or reproduction. Yet you can’t watch two minutes of ads on most TV channels without hearing the phrase “erectile dysfunction” at least once. Even feminist discussions often aren’t as frank about pregnancy and abortion as broadcast commercials are about erections.
Accuracy is vital — and in this discourse, being accurate and being inclusive are inseparable.
Some news organizations, like Vox, seem to be on the right track — much of their coverage avoids gendering those who may need or seek abortions (although even they aren’t perfect). So, here’s some examples of exclusionary phrases found in other online news coverage, and a few more inclusive and accurate alternatives:
Instead of “the woman’s health,” consider using:
- “The pregnant person’s health”
- “The person’s health”
- “The parent’s health”
Instead of “women who choose abortion or miscarry,” consider using:
- “People who choose abortion or miscarry”
- “People who miscarry or have an abortion”
Instead of “before many women know they are pregnant,” consider using:
- “Before many people know they are pregnant”
- “Before almost anyone would know they are pregnant”
Instead of “women’s reproductive rights advocates,” consider using:
- “Reproductive rights advocates”
- “Abortion rights advocates”
Instead of “women seeking abortions,” consider using:
- “People seeking abortions”
- “Anyone seeking an abortion”
Instead of “pregnant women,” consider using:
- “Pregnant people”
- “People who are pregnant”
Instead of “mothers dying during labor and childbirth,” consider using:
- “People dying during labor and childbirth”
- “People in labor and childbirth dying”
Instead of “a woman whose water has broken,” consider using:
- “A person whose water has broken”
- “A person who has gone into labor”
- “Someone who is in labor”
Instead of “economic cost for women,” consider using:
- “Economic cost for people who aren’t ready for parenthood”
- “Economic cost for people who can get pregnant”
- “Economic cost for people who may need an abortion”
Instead of “a woman can decide to end a pregnancy,” consider using:
- “Someone can decide to end their pregnancy”
- “A person can decide to end their pregnancy”
- “Anyone can decide to end their pregnancy”
Instead of “women’s reproductive decisions,” consider using:
- “Decisions about ending a pregnancy”
- “Decisions about terminating a pregnancy”
- “Decisions about abortion”
- “Decisions about pregnancy”
- “Reproductive decisions”
- “Decisions about reproduction”
Instead of “women and babies,” consider using:
- “Parents and babies”
- “Infants and new parents”
Instead of “women with unwanted pregnancies,” consider using:
- “People with unwanted pregnancies”
- “People who don’t want to be pregnant”
Instead of “women in Georgia,” consider:
- “People in Georgia”
- “Pregnant people in Georgia”
As a nonbinary transgender person, I have to weigh my own need to live authentically and respect myself with my deep desire to protest against these draconian laws. I have a deep interest in public health and I have some idea of how disastrous this will be for both physical and mental health if the Supreme Court upholds Alabama’s full ban, or even any of the six-week bans. The problem is, every time I consider going to a protest for reproductive rights, I have to consider the sort of rhetoric that will surround me. I have to ask myself if, as someone with a uterus and the capacity to get pregnant, I’m prepared to be implicitly misgendered by the protest signs, and often the speeches and chants. Whenever someone characterizes abortion as a “women’s issue,” I feel a little more ignored, a little less recognized for who I am. Sometimes, I have to stop listening to podcasts discussing abortion rights because I can feel my anxiety worsen with every reference to “women’s health” or “women’s choice”.
Consider the case described at the start of this article. If nurses did not think of pregnancy as exclusively a “women’s issue” — if more of them knew that transgender men can and do get pregnant — he may have had a live birth. Instead, the nurse disregarded his positive pregnancy test and wrote him off as obese. In topics like healthcare, language can have traumatizing or fatal consequences. Accuracy is vital — and in this discourse, being accurate and being inclusive are inseparable. Pregnant transgender men and nonbinary people exist; talking about pregnancy and abortion as women’s issues erases us, both in public and in healthcare settings. We cannot be complicit in the harm this causes.
Transgender patients are uniquely vulnerable when it comes to reproductive healthcare, and the way reproductive rights advocacy pushes us out is counterproductive. We know all too well the challenges of accessing appropriate healthcare. We know what it’s like for insurance to deny a necessary procedure. With many states requiring proof of transition-related care to change your gender on legal documents, we know how it feels for the government to insert itself into deeply personal matters. Every one of us could be a powerful advocate for reproductive healthcare access — we just need to be recognized, included, and given space to exist as we are.
If anyone working in the news media or public relations would like advice on ensuring your publication or organization is using inclusive language, I am willing to read a passage or draft and offer suggestions if anything can be improved. My email address is firstname.lastname@example.org.