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ADDRESSING DIVERSE NEEDS

Providing reproductive health care requires an inclusive, affirming, and responsive approach to people’s diverse identities and experiences. Individuals seeking abortion care and pregnancy counseling come from varied backgrounds, encompassing different sexual orientations, gender identities, and life circumstances. Often people may have multiple intersecting identities that can negatively impact their reproductive health care experiences. Many face additional access barriers, including discrimination, systemic inequities, and historical mistreatment in health care settings. People who are LGBTQIA+, use substances, or have experienced trauma may have unique concerns, making it critical for providers to offer person-centered care that prioritizes dignity, autonomy, and trust. By approaching care with curiosity and humility rather than assumptions, using inclusive language, and acknowledging systemic barriers, providers can foster an environment where people feel seen, respected, and empowered in their needs and decisions (Guttmacher 2020).

 Image from UCSF Beyond the Pill Program

Sexual Orientation

People of all sexual orientations experience pregnancy, and sexual orientation does not always align with sexual behavior or reproductive health needs. Over 15% of people seeking abortion surveyed recently did not identify as heterosexual (Jones 2023), underscoring the importance of avoiding assumptions and ensuring that sexual and reproductive health services are tailored to individual needs. This includes offering accurate information on contraception, fertility, and pregnancy options relevant to the person’s experiences and sexual practices. Creating an environment that normalizes inclusive conversations about sexual practices across sexual orientations helps reduce stigma and fosters trust in healthcare interactions.

Gender Identity and Pregnancy

Everyone has a gender identity—an internal understanding of their gender. People across the gender spectrum may require sexual, reproductive, and pregnancy-related care. “Cisgender” describes someone whose gender identity aligns with their sex assigned at birth. “Transgender” or “trans” is an umbrella term for people whose gender identity does not correspond to the sex assigned at birth or with the expectations associated with that sex (Transgender Law Center 2011). Trans and gender diverse (TGD) people are clinically underserved and face barriers to routine health care and transition-related care such as a lack of insurance coverage and mistreatment by healthcare providers (James 2024).

TGD people with ovaries and a uterus can experience pregnancy if they engage in sex with someone who produces sperm, even after social and/or hormonal transition. Menstruation is an unreliable marker for fertility. Testosterone may be used in TGD individuals and may lead to amenorrhea but should not be considered contraception as there can be breakthrough ovulation resulting in pregnancy (Light 2014, 2018). All contraceptive options may be safely used by TGD people and do not interact with testosterone (Krempasky 2020).

TGD people are also more likely to self-manage their abortion via unsafe methods such as substance use and abdominal trauma, so messaging about SMMA should be inclusive and distributed within gender diverse communities (Moseson 2022a).

To provide gender-affirming, person-centered care, create a welcoming space and use inclusive language (SFP2020). Note that a person’s name and gender identity may not be accurately reflected on their ID, health record, or insurance documents. Ask questions to avoid making assumptions about anatomy and identity. Practice trauma-responsive care, considering high rates of negative and traumatizing experiences with accessing gynecological and general health care within this community (USTS 2022). Also, consider that many health centers are still gendered spaces that may not be comfortable or acceptable to TGD people, so encouraging changes to decor, name, and paperwork can help create more inclusive spaces.

Additional resources:

Counseling for People Who Use Substances

People who use criminalized drugs face profound stigma, barriers to care, and criminalization in the context of health care. Understanding the stigmatization that people using substances face can help us understand how people choose to engage with or avoid the healthcare system. Substance Use Disorder (SUD) – defined as a disorder leading to a person’s inability to control their use of substances – is a treatable, chronic illness. People with SUD have higher rates of undesired pregnancy, STIs, infertility, pregnancy-related mortality, and lower rates of contraceptive use (Zwick 2020).

Clinicians can help reduce these health disparities by supporting people using substances with comprehensive preventative, harm reduction, and primary care services. Urine toxicology screening is not indicated before providing contraceptive, abortion, or pregnancy care, does not diagnose acute intoxication or a use disorder, and is an expensive test with false-positive and negative results with serious consequences (Kale 2019). We recommend against documenting substance use information unless it is directly related to the person’s immediate care.

SUD, in itself, does not impair one’s ability to make health care decisions. Any person who can understand the risks and benefits of a procedure at the time of consent can consent. A person recently using their primary substance often has more consent capacity than one in active withdrawal, which can cause significant cognitive impairment, including impaired judgment, memory problems, and difficulty concentrating (Morán-Sánchez 2016).

Counseling should also include that chronic substance use can cause oligo- or amenorrhea, and pregnancy may occur even when periods are infrequent (Flannagan 2020). For people with SUD who want to conceive or continue a pregnancy to term, trauma-responsive care and medication for addiction treatment should be initiated to support a person in having a safe and healthy pregnancy.

Additional resources:

Counseling in the Context of Sexual Trauma

It is not uncommon to encounter people who have experienced sexual trauma such as sexual abuse, rape, incest, or human trafficking (Sharkansky 2025).

Some communities are particularly at risk of sexual trauma. Transgender individuals, as well as those with disabilities, are 2-3 times more likely to experiencesexual violence (Basile 2016, Mailhot Amborski 2022). In addition, victims of human trafficking are often forced or tricked into working in dangerous conditions or having sex against their will and are at high risk of unintended pregnancy. Trafficking occurs in every country. Many being trafficked do not recognize it or may simply believe they are in a bad situation, relationship, or job (Lederer 2014). It is important to routinely screen for sex trafficking and have a planned response and resources to assist.

If a person discloses they have been raped or trafficked, consider initial support by suggesting the following:

  • “This isn’t your fault. No one ever deserves for this to happen to them.”
  • “I’m so sorry that happened to you.”
  • “Thank you for telling me; you’re brave to do that.”
  • “I want you to know that you are safe here.”

If any personis interested in reporting a sexual assault, access the sexual assault service providers most familiar with your local reporting laws and counseling. Consider developing and instituting forensic policies and procedures. To report suspected trafficking, contact the National Human Trafficking Hotline.

Access, Accommodations, and Counseling for People with Disabilities

Approximately 15% of people worldwide and 25% in the U.S. are living with some kind of disability (WHO 2020, CDC 2020). In the U.S., disability rights law defines a person with a disability as someone who has a physical or mental impairment that substantially limits one or more major life activities (U.S. Department of Justice). However, this legal definition does not capture the breadth of societal understandings of disability.

Clinician understanding of the different models of disability will help ensure framing avoids shortcomings of the medical model.  The medical model of disability views disability as an impairment of the body or mind that deviates from “normal” and posits that clinicians should work to “fix” or “cure” the disability. In contrast, the social model of disability views it as something that is caused by an inaccessible environment failing to meet the needs of disabled people. As such, a disabled person need not be “fixed” by the medical establishment—instead society must be transformed to be more accessible for disabled people. Beyond the social model, the relational model, in which disability is context specific, and the experience of disability is created and influenced by ideological systems that disenfranchise people with disabilities. For example, autistic people may need fewer specific accommodations or supports in a neurodivergence-affirming setting. A Deaf person may experience their Deafness differently In a family where the hearing members sign compared to a family where they do not.

Disabled people have similar sexual and reproductive health needs and are as likely to become pregnant as non-disabled people (Horner-Johnson 2016). However, people with disabilities are less likely to receive comprehensive sex education, contraception counseling, STI testing, and prenatal care (Andiwijaya 2022, Mhatre 2021, Taouk 2018, Mosher 2017). Disabled people are also at higher risk for severe pregnancy complications and are 11 times more likely to die during childbirth than non-disabled people (Gleason 2021). Disabled people are at higher risk of sexual coercion, assault, and contracting HIV (Mailhot Amborski 2022). People with disabilities face significant barriers to care due to a lack of provider training, provider bias, harmful stereotypes (e.g., that they are not sexually active or are not “fit” to be a parent), and inaccessible health care facilities (Biggs 2023, Taouk 2018).

Disabled people are often perceived as perennial children, leading society to distrust disabled people’s capacity to make self-determined decisions. Providers should examine their own biases towards people with disabilities in order to ensure the counseling they provide is empowering and supportive of the autonomy of disabled people.

These facts, as well as the history of eugenics and context of pervasive ableism in healthcare provision, illustrate the importance of protecting the bodily, reproductive, and decisional autonomy of people with disabilities.

Relevant Laws and Regulations 

Multiple federal laws (i.e., ADA 1990, ACA 2020, Rehabilitation Act 1973) establish nondiscrimination requirements for providers and require them to take affirmative steps to make services and programs accessible to and usable by people with disabilities. These laws are the floor and not the ceiling for accessibility, setting a minimum standard for accessibility. States, municipalities, and individual facilities or practices can set higher standards. Accessibility for disabled people can be achieved by:

  • Adapting practices to be readily accessible
  • Granting reasonable accommodations
  • Ensuring effective communication
  • Being flexible and responsive to people’s stated needs
  • Having accessible facilities and equipment

More information on making physical spaces and administrative and clinical practices more accessible for people with disabilities is included in Chapter 10: Disability.

Effective Communication and Reasonable Accommodations for Accessible Counseling

To ensure that people are provided with adequate support, health centers should ask about any access or communication needs at the first point of contact, note requested accommodations in their charts., and implement their requests prior to their appointment if possible.

Clinicians must take affirmative steps, at no cost to the person receiving care, to ensure communication with disabled people is as effective as communication with nondisabled people. Effective communication is an essential element of counseling and ensuring people provide informed consent to medical procedures. If a person cannot understand the communication, they cannot provide informed consent. Ensuring effective communication for people with disabilities during counseling may require “auxiliary aids and services,” including:

  • Qualified interpreters in-person or through video remote interpreting (VRI). (Note that VRI may not provide effective communication for some individuals and circumstances).
    • Some people, particularly those who use non-standard ASL, may need a team of interpreters, including one hearing interpreter and one Deaf interpreter.
    • Interpreters must be integrated into the video platform for video appointments.
    • Always speak directly to the person receiving care, not the interpreter or their supporter.
  •  Real-time captioning for in-person and video appointments
    • Captioning must be integrated into the video platform for video appointments.
  •  Assistive listening devices (e.g., hearing loop, pocket talker)
  • Written materials in alternative formats (e.g., braille, large text, plain language)

People may also need additional reasonable accommodations for counseling to be accessible. Reasonable accommodations, ideally arranged ahead of time, are changes to the usual way of doing things to include disabled people and provide equal opportunity for them to benefit from services. Common counseling accommodations may include:

  • Using plain language and/or visual aids to facilitate understanding
  • Allowing a support person to be present and facilitating supported decision-making to support understanding (see below)
  • Arranging for an interpreter to be present during an appointment
  • Reserving additional time for an appointment (for engaging with interpreters, checking understanding, taking breaks, etc.)
  • Turning down the brightness of exam room lights for people with sensory sensitivities

Counseling Using Supported Decision-Making  

Supported decision-making (SDM) may be a helpful reasonable accommodation for some people with disabilities who need help with any aspect of the decision making process. SDM is an individualized arrangement in which a disabled adult chooses one or more trusted supporters (friends, family, experts) to help them understand, communicate, and make or act on their own choices (ACLU 2016). A SDM agreement may be informal (not written) or formal (written). Almost every state requires that guardianship only be used as a last resort when less restrictive alternatives (like SDM) are insufficient (Martinis 2021, NCLER 2025).

When using SDM, a supporter may help a disabled person:

  • Fill out paperwork
  • Schedule appointments and arrange transportation
  • Communicate—for example, the supporter may re-speak their words if difficult to understand
  • Understand concepts and treatments
  • Review risks and benefits of different treatments or procedures

Unlike guardianship, the support person does not make decisions for the disabled person. Because of elevated rates of reproductive coercion of disabled people by caretakers, clinicians should center on the preferences of the disabled person and assess if a different support person may be helpful if coercion is suspected.

Guardianship/Conservatorship

Guardianship (also known as conservatorship in some states) is a formal legal arrangement where a court appoints a person to make certain decisions on behalf of a disabled adult. Guardianships can vary in scope and may, but do not always, include health care decision-making authority. If a support person identifies themselves as the patient’s guardian during an appointment, the provider:

  • Should not assume that a person who identifies as a guardian automatically has medical decision-making authority on behalf of the person with a disability.
  • Should request a copy of the court guardianship and consult local counsel to confirm the guardianship’s validity and scope. If no relatives to consult, an application should be made for a court order.
  • Should involve the disabled person in decision-making, assessing their preferences without the guardian present, before obtaining informed consent.
  • Should address abortion and sterilization extremely carefully, never over the objection of the person with a disability, and with the understanding that fundamental rights are at stake. When faced with such requests, guidance from an ethics committee or legal counsel may be instrumental (ACOG 2016).

Additional Resources 

 

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TEACH Abortion Training Curriculum 8th Edition Copyright © by The TEACH Program. All Rights Reserved.

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