Victory Congressional Fellow White Paper

June 2019 Queering : How to Ensure LGBTQ Access to Sexual and Reproductive Health Care on the Federal Level By Aliya Bean, David Bohnett Victory Congressional Fellow LGBTQ Victory Institute

Abstract I. Introduction: defend the rights of women of Reproductive Justice color and other marginalized women and transgender This white paper will explore why and LGBTQ Sexual and reproductive justice is an LGBTQ people.4 Consequently, the issue and outline the federal policy Reproductive Health term reproductive justice and the steps lawmakers must take in accompanying movement was born. order to ensure access to inclusive, LGBTQ rights are Rooted in the comprehensive, and affordable inextricably linked with internationally-accepted reproductive health, rights, and human rights framework sexual and reproductive health 1 for LGBTQ people. This paper will justice. More often than not, the created by the United Nations, explain why a series of intersecting same forces working to restrict reproductive justice combines factors increase the vulnerability and sabotage everyone’s access reproductive rights and social of the LGBTQ community in to sexual and reproductive health justice. SisterSong, a national accessing such care, putting care are the same people who membership organization want to deny legal recognition dedicated to improving the particular emphasis on the barrage 2 of attacks on LGBTQ people, and rights to LGBTQ people. It is reproductive lives of marginalized reproductive justice, and health for this reason that reproductive communities, defines care more broadly by the Trump justice is such an important reproductive justice as “the administration. This paper will framework to discuss and analyze human right to maintain personal go one step further and pinpoint LGBTQ access to sexual and bodily autonomy, have children, four federal policy solutions to reproductive health care. not have children, and parent help ensure access to inclusive, Reproductive justice the children we have in safe comprehensive, and affordable was first established as a and sustainable communities.”5 sexual and reproductive health care framework in in June SisterSong goes on to say, that for LGBTQ people: repealing the 1994 by a group of prominent reproductive justice is “[a]bout Hyde Amendment, funding Title X Black women, including Loretta access, not choice” and that it is: and eliminating the domestic gag Ross, co-founder and the first national coordinator of the Not just about . rule, guaranteeing access to the 3 full range of contraceptive options, organization SisterSong. This Abortion access is critical, and safeguarding the Affordable group of women recognized and women of color and other Care Act’s LGBTQ protections and that the broader women’s rights marginalized women also gender-affirming care. movement, because it was led often have difficulty accessing: by and representing middle contraception, comprehensive class and wealthy white women, sex education, STI prevention could not sufficiently secure or and care, alternative birth options, adequate prenatal factors make it more challenging II. The State of Sexual and and pregnancy care, domestic for the LGBTQ community to Reproductive Health for violence assistance, adequate access sexual and reproductive wages to support our families, health care, calling particular LGBTQ People safe homes, and so much attention to the onslaught Unlike other marginalized more.6 of attacks on LGBTQ people, communities, evaluating the reproductive rights, and health health needs and barriers In other words, reproductive care more broadly by the Trump to care for LGBTQ people is justice not only encompasses administration. This paper will go particularly challenging. This reproductive health and rights, one step further and identify four is in part due to the lack of but also economic security, approaches federal policymakers formal data collection on sexual criminal justice, domestic should adopt to ensure access orientation and gender identity violence, and the full spectrum to inclusive, comprehensive, in major health surveys and of issues that affect women and and affordable sexual and studies. Where data is available, marginalized communities. reproductive health care for it mostly focuses on smaller When we approach LGBTQ people: repealing the sample sizes, same-sex couples, sexual and reproductive health Hyde Amendment, funding Title and lesbian, gay, and bisexual care access with a reproductive X and eliminating the domestic people rather than transgender justice lens, we acknowledge that gag rule, guaranteeing access to individuals.9 However, the certain groups—including women the full range of contraceptive National Center for Transgender of color, transgender people, options, and safeguarding the Equality does conduct an annual and queer communities—have ’s (ACA) U.S. Transgender Survey,10 a more difficult time accessing LGBTQ protections and gender- which is the largest—and only— care than others. Reproductive affirming care. survey devoted to the lives and justice centers women of color, Throughout this paper experiences of transgender LGBTQ people and other “LGBTQ” and “Queer” will be people. In order to fully assess historically oppressed groups used as umbrella terms for the health needs and limitations and their right to make their own the Lesbian, Gay, Bisexual, to care for LGBTQ people, we decisions about their bodies and Transgender, Non-Binary, need more routine and more their families. By centering and Intersex, Asexual, Pansexual, substantive data collection. uplifting the most marginalized, Queer community. This is in With the data we do we in turn are uplifting us all. In no way an exhaustive list. have available, it is clear that other words, by implementing Expressly, LGBTQ and Queer not only do LGBTQ people have policy solutions focused on aiding will refer to everyone who does unique sexual and reproductive the communities most at harm, not identify as cisgender (not health care needs, but that a we improve the lives of every transgender) heterosexual. While variety of issues work together community. This intersectional there is no single definition to increase the vulnerability of approach to LGBTQ rights and of the “LGBTQ community”— the LGBTQ community in this sexual and reproductive health is because it is such a diverse area of health. For example, a essential because marginalized and multidimensional group of high percentage of the LGBTQ communities face multiple, individuals with unique identities community is low-income and intersecting oppressions. We and experiences, with variations living below the poverty line.11 can only make effective policy by race, ethnicity, income, and LGBTQ young people, particularly decisions and best serve these other characteristics—LGBTQ queer and transgender youth, communities if we understand individuals do share the are disproportionately homeless and address how these common experience of being and housing insecure and oppressions impact one another. stigmatized due to their actual consequently are more likely to As Audre Lorde said, “There is or perceived sexual orientation, engage in survival sex work (sex no such thing as a single-issue gender identity, and/or gender work engaged in by a person in struggle because we do not live expression.8 This paper will order to survive or to supplement single-issue lives.”7 It is therefore also use the term “sexual and low incomes, due to systemic through a reproductive justice reproductive health” to refer to factors and extremely restricted framework that we can best and encompass reproductive options),12 which may result in tackle the issues of sexual and health, rights, and justice unintended pregnancy or sexual reproductive health care access more broadly. In other words, assault.13 LGBTQ people are for LGBTQ people. sexual and reproductive health also more likely to be uninsured Using reproductive justice will signify the full range of and rely on federal programs as a lens, this paper will explain intersectional issues that are a like Medicaid and Title X.14 This why a series of compounding part of the reproductive justice framework. 2 combination of factors makes level in this year alone.21 That the Congressional appropriations affording and gaining access means that more than half of all bill in 1977 for the Department to comprehensive health care a reproductive-aged cisgender of Health and Human Services significant challenge. women—and even more people (HHS). Since then, the Hyde In addition, LGBTQ if you include transgender and Amendment has been renewed people—and youth in particular— non-binary people that also need annually by Congress. The lack inclusive and comprehensive abortion care—live in states that Hyde Amendment’s reach not sex education and health care.15 are hostile or extremely hostile only includes Medicaid but also This lack of sex education to abortion rights.22 And with the includes the Indian Health Service, coupled with stigma is part newly conservative makeup of the Medicare, and the Children’s of what makes LGBTQ people Supreme Court, national access to Health Insurance Program. In at greater risk of unintended abortion is under unprecedented addition, language similar to that pregnancy, sexually transmitted threat.23 in the Hyde Amendment has been infections (STIs), sexual violence, Given the unique health incorporated into a range of other and high-risk activities in respect care needs of LGBTQ people, the federal programs that provide or to drug and alcohol use and intersecting factors that make the pay for health services to people sexual behavior.16 LGBTQ people LGBTQ community particularly including the military’s TRICARE face the prospect of having to vulnerable when it comes to program, federal prisons, the hide their sexual orientation sexual and reproductive health, Peace Corps, and the Federal and/or gender identity and and the onslaught of attacks by Employees Health Benefits risk being traumatized or the Trump administration, there Program.25 Only 15 states have discriminated against by lack are four palpable ways federal a policy that directs Medicaid of competent, inclusive care.17 policymakers can ensure access to pay for all or most medically This is disproportionately true to inclusive, comprehensive, necessary , so the Hyde for transgender and non-binary and affordable sexual and Amendment effectively functions people.18 Furthermore, we often reproductive health care for as a nationwide ban on Medicaid talk about abortion or birth LGBTQ people. These four federal coverage for critical reproductive control as just a “women’s issue” policy solutions are: repealing the health care.26 which erases transgender people Hyde Amendment, funding Title Millions of women and and anyone that falls outside X and eliminating the domestic LGBTQ people rely on Medicaid the gender binary and may need gag rule, guaranteeing access to for sexual and reproductive health access to such critical health care the full range of contraceptive care coverage, which makes the services.19 options, and safeguarding the Hyde Amendment a particularly To make LGBTQ health Affordable Care Act’s LGBTQ insurmountable obstacle. more complicated, a barrage protections and gender-affirming Approximately one in five of attacks by the Trump care. cisgender women of reproductive administration in recent years has age rely on Medicaid to access severely limited access to sexual III. Repealing the Hyde no-cost, essential reproductive and reproductive health care, as Amendment health care such as birth control, well as health care more broadly. life-saving cancer screenings, and 27 The Trump administration has not The first method maternity care. Medicaid is also only targeted LGBTQ people— federal policymakers can use the largest source of reproductive particularly transgender people— to ensure access to inclusive, health care coverage, paying but also mounted an all-out comprehensive, affordable sexual for 75 percent of all public assault on reproductive health, funds spent on family planning and reproductive health care for 28 rights, and justice and steadily LGBTQ people is to repeal the services. Medicaid enrollees are undermined the Affordable Care disproportionately low-income 20 Hyde Amendment. The Hyde Act. In many places in the Amendment blocks low-income and/or women of color and country, legal abortion care is far people from accessing the sexual Medicaid is an essential insurance from guaranteed, and for people provider for many LGBTQ and reproductive health care 29 who are low income, LGBTQ, they need by banning Medicaid people. The Williams Institute and of color, abortion access has coverage for abortion-related estimates that 1,171,000 LGBTQ been systematically diminishing. health care, except in the limited adults ages 18-64 years old have Nearly 430 abortion restrictions Medicaid as their primary source cases of rape, incest, and life 30 were enacted between 2010 and endangerment.24 of health insurance. 2018, and so far as of August The Hyde Amendment Given the enormous 2019, 59 abortion restrictions— is not permanent law but rather reliance on Medicaid for sexual including some near bans—have a temporary appropriations and reproductive health care been enacted on the state “rider.” It was first attached to and insurance coverage, the

3 benefits of repealing the Hyde IV. Funding Title X and in 10 cisgender women receiving Amendment are considerable. Eliminating the Domestic contraceptive care at a Title If Congress lifted the ban, it X-supported health care center could potentially provide federal Gag Rule report that provider as their sole support for abortion coverage source of medical care in the The second method to over 15 million reproductive- previous year.42 federal policymakers can age cisgender women enrolled Because LGBTQ people ensure access to inclusive, in Medicaid,31 in addition to the are more likely to live in poverty, comprehensive and affordable nearly one million cisgender rely on Medicaid or public sexual and reproductive women of reproductive age who insurance, or be uninsured, and health care for LGBTQ people are currently enrolled in Medicare, Title X primarily serves those is by funding Title X (ten) and many others who receive populations, it is clear that Title X and eliminating the recently their care through other affected is an essential source of care for implemented “domestic gag federal programs.32 It would LGBTQ people. LGBTQ patients rule.” Title X is the nation’s specifically broaden abortion particularly rely on Title X for its only federal funding program coverage for 8 million cisgender uniquely comprehensive, high- dedicated solely to providing women on Medicaid who live in quality, and confidential care. high-quality, culturally sensitive the 34 states and the District of Compared with other publicly family planning services and Columbia that currently abide funded health centers that offer other preventive health care to by Hyde restrictions.33 These family planning services, sites predominantly poor and low- numbers are even greater if you that receive Title X funding are income people.36 It was created include the many transgender more likely to stock a broad as part of the Public Health and non-binary individuals range of contraceptive supplies Service Act and signed into law who also rely on Medicaid and and have protocols that allow by Republican President Nixon federally-funded programs for quick starts of contraceptive in 1970 with broad bipartisan for reproductive health care methods.43 Unlike many other support.37 The Title X program coverage. health centers, Title X centers is administrated by the Office Limiting people’s access to also abide by unparalleled patient of Population Affairs (OPA) in abortion increases their chances confidentiality protocols.44 This is the Department of Health and of poverty, unemployment, and particularly important for LGBTQ Human Services and is funded dependence on public people who may not be out in in the annual discretionary assistance programs. The denial their day-to-day life or want to appropriations process. In of abortion care leads to further disclose medical treatment. Title addition to providing grants economic insecurity.34 As LGBTQ X further provides a wide range for family planning and related people—particularly transgender of services including pregnancy preventive health services, and gender nonconforming testing; contraceptive counseling the Title X program also funds people of color—are more likely and services; pelvic exams; training, research, and technical to be low-income, the Hyde screening for cervical and breast assistance projects. Amendment poses a particular cancer, high blood pressure, Over four million patients hurdle. Most LGBTQ people anemia, diabetes, and STIs and rely on Title X’s nearly 4,000 are already struggling to get HIV/AIDS; infertility services; centers across the country for affordable health care, and the health education; and referrals their sexual and reproductive Hyde Amendment creates an for health and social services.45 health care services. 38 Two-thirds impregnable barrier to abortion. LGBTQ people are at a higher of those patients live below the Being denied an abortion or risk of contracting STIs and HIV/ poverty line.39 Forty-two percent being forced to pay out of AIDS due in large part to a lack of of Title X patients are uninsured, pocket for such care only pushes sex education and stigma, as well 38 percent have Medicaid or LGBTQ people deeper into as socioeconomic and systemic other public health insurance, poverty, may compel them to factors.46 Therefore, Title X centers and 19 percent have private carry an unwanted pregnancy are a particularly important insurance. 40 Title X patients are to term, and puts their lives and resource for STI and HIV/AIDS disproportionately Black and/ livelihood at risk.35 By repealing testing for LGBTQ people. In or Hispanic or Latinx, with 22 the Hyde Amendment, LGBTQ 2017, for example, Title X centers percent of Title X patients self- people will be able to access the provided more than 5.3 million STI identifying as Black or African reproductive health care they tests (excluding HIV/AIDS tests), American and 33 percent need safely and affordably, and and 1.1 million HIV/AIDS tests.47 identifying as Hispanic or Latinx. in turn, will have the economic However, because the Title 41 Title X centers are often the security they need to live healthy X program is funded in the annual only place patients will go to and successful lives. discretionary appropriations receive medical care. In fact, six

4 process and is administered by administration that will effectively their bodies or sex lives. Because OPA within HHS, the presidential dismantle the Title X program and of stigma and marginalization, administration in power has deny comprehensive, high-quality, LGBTQ people are more likely to a large say in how much and affordable family planning and engage in risky sexual behavior in what manner the program sexual health care to those who and experience worse health is funded. This has posed a need it most. outcomes than their heterosexual significant obstacle under the By providing LGBTQ and cisgender peers.56 LGBTQ Trump administration. Not only people with comprehensive, high- adolescents are more likely to did the Trump administration quality, and affordable sexual and be sexually active, have sexual not even include the word reproductive health care services, intercourse before age 13 and contraception in its first Title Title X allows LGBTQ individuals have sexual intercourse with more X funding announcement, but to have more control over their partners, and are less likely to they also shortened the time- health, career, and economic use condoms, which puts them periods for Title X grants and security. Title X saves lives with at increased risk for STIs and consistently proposed deep cuts early detection of cancer through unintended pregnancy.57 Queer to the program, which threatens its affordable Pap tests and women are at a particularly high the financial and operational breast exams. Title X helps people risk of unintended pregnancy, stability of the health centers screen for STIs and HIV/AIDS and and young queer women and providers that rely on these avert a host of other health issues. and transgender women are grants. 48 Title X helps prevent millions of more likely to experience The most devastating unintended pregnancies.54 Title X sexual violence compared to attack on the Title X program also saves taxpayers money. For heterosexual and cisgender came recently. On February 22, every dollar invested in publicly women.58 2019, the Department of Health funded family planning programs When we talk about and Human services released the like Title X, the government saves contraception, we need to final version of its new regulations $7.09 in Medicaid-related costs.55 remember that cisgender straight for the Title X program.49 The rule, Lawmakers must adequately fund women are not the only ones which was initially announced in Title X and repeal the destructive with vested interest.59 LGBTQ May of 2018, was modeled after gag rule so that providers can people do engage in sex that requirements adopted under meet their health care demands can result in pregnancy. Some President Ronald Reagan but and LGBTQ people can get the LGBTQ people take birth control never enforced. The rule bans health care they need. for reasons other than pregnancy, federal family planning funds like regulating menstruation from going to health providers and alleviating migraines and who perform or refer patients V. Guaranteeing Affordable cramps, and managing certain for abortion services and creates Access to the Full Range of reproductive syndromes. onerous “physical separation” Contraceptives Counter to public perception, requirements specifically some transgender men use designed to block patients from contraception and can experience coming to The third federal policy unintended pregnancy, even health centers50—centers which approach to ensure access after transitioning socially and many LGBTQ people rely on for to inclusive, comprehensive, hormonally.60 Transgender men, inclusive care.51 According to affordable sexual and reproductive therefore, also need counseling the most recent data, Planned health care for LGBTQ people and care regarding reproductive Parenthood affiliates make is by guaranteeing access to health, including contraceptive up 13 percent of clinics funded contraception. LGBTQ individuals and conception counseling. through Title X and provide care experience the full range of In advocating for sexual and to 41 percent of Title X patients family planning outcomes and reproductive health—and seeking contraceptives.52 Groups need family planning services contraception in particular—we receiving money under the that include services to prevent need to include the entire LGBTQ Title X program were already and achieve pregnancy and community.61 prohibited from performing that promote overall sexual and One recent policy abortions with those funds.53 This reproductive health. that has most notably helped rule is essentially a “domestic LGBTQ people— LGBTQ access comprehensive gag rule”—censoring Title X particularly transgender and and culturally competent providers from ever mentioning non-binary people—experience contraceptive care is the abortion or abortion care. This barriers to culturally-competent Affordable Care Act. The ACA new rule is a dangerous and life- reproductive health care because has provided millions of people— threatening attack by the Trump most doctors do not understand including LGBTQ people—with

5 access to no-cost contraceptive additional transgender and non- sexual and reproductive health coverage.62 Prior to the ACA’s binary people who rely on the and gender-affirming care.70 birth control benefit, cost was ACA for insurance coverage of LGBTQ people need a huge barrier in accessing birth control without out-of- affirming and inclusive health contraceptive care due to high pocket costs.69 The birth control care, especially because they face out-of-pocket costs like copays benefit already permitted certain such high rates of discrimination and deductibles.63 Long-term religious exemptions, but the in health care settings that, in highly effective methods of Trump administration has been turn, deter them from getting contraception like intrauterine working vigorously to broaden any the care they need. According to devices (IUDs) and contraceptive opportunity for religious refusal of the most recent U.S. Transgender implants were especially contraception coverage. Survey, one-third (33 percent) of unaffordable because of their Lawmakers must fight respondents who saw a health high upfront costs. As of 2012, the back against these administrative care provider in the past year ACA requires most private health attacks on the ACA and the birth reported having at least one plans to cover a designated list control benefit to safeguard negative experience related of 18 methods of contraception access to comprehensive and to being transgender; one in without out-of-pocket costs, low-cost contraception. LGBTQ four (25 percent) respondents which includes all FDA-approved people have unique sexual and experienced a problem in the contraceptive methods and reproductive health needs that past year with their insurance contraceptive counseling for must be met. LGBTQ people face related to being transgender; women.64 Because of the ACA, delays in getting the reproductive more than half (55 percent) of LGBTQ people can access the care they need because of fear those who sought coverage for full range of contraceptive of discrimination, lack of health transition-related surgery and services they need without cost insurance, and/or a dearth of 25 percent of those who sought barriers. One study estimates knowledgeable and inclusive coverage for hormones in the that cisgender women saved providers. By ensuring that past year were denied.71 Similarly, $1.4 billion in out-of-pocket costs LGBTQ people have access according to data collected by in 2013 alone as a result of the to the full range of affordable the Center for American Progress, ACA’s contraceptive benefit.65 contraception options, we are among LGBQ respondents, Legislative attacks on ensuring that LGBTQ people have eight percent said that a doctor contraception, however, have stability in their lives, control over or other health care provider made it much harder for the their bodies, and can achieve refused to see them because of LGBTQ community to get the greater economic security. their actual or perceived sexual contraceptive care they need orientation, and six percent said and deserve. In addition to that a doctor or other health care cutting funding to Title X, the VI. Safeguarding the provider refused to give them Teen Pregnancy Prevention Affordable Care Act’s health care related to their actual Program, and other federal LGBTQ Protections and or perceived sexual orientation.72 family planning programs that Gender-Affirming Care In light of the provide contraception,66 as well disproportionate rates of as appointing a host of people discrimination LGBTQ people The final federal policy to HHS and the courts who face in health care settings, solution to ensure access to range from birth control skeptics factors commonly found to inclusive, comprehensive, to people actively working to encourage LGBTQ patients in and affordable sexual and block birth control access,67 establishing continued health reproductive health care for the Trump administration has care include a welcoming clinic LGBTQ people is by safeguarding also made every effort to roll environment with access to the Affordable Care Act’s LGBTQ back contraceptive coverage. In family planning information, protections and gender-affirming October 2017, HHS released rules availability of health insurance, care. Affirming and inclusive care allowing virtually any employer, and the absence of differential for LGBTQ people necessarily school, or other entity to opt care by providers.73 According includes: understanding of out of providing contraceptive to a recent study, once in care, LGBTQ identities and language; coverage for religious or moral LGBTQ patients described competency in serving LGBTQ reasons—essentially eliminating several factors associated with a people and LGBTQ health care the birth control coverage positive clinic experience, such needs; confidentiality; non- guarantee.68 These rules would as providers demonstrating discrimination protections; endanger the nearly 63 million knowledge about LGBTQ health, affordability; and the full range cisgender women and the displaying supportiveness, using of health care services including

6 gender inclusive language (e.g., based on sex stereotyping, rule that would dismantle and in clinic visits and on forms) gender identity, and pregnancy roll back Section 1557.87 This and creating welcoming clinic are all prohibited forms of sex proposed rule would open the environments (e.g., visuals discrimination. Section 1557 door for insurance companies, suggesting safety for all clients).74 applies to programs that receive hospitals, doctors, and nurses Patients in the study also federal funding (many insurance to deny patients care because emphasized the need for provider carriers and hospitals), programs of their sexual orientation or assurances of confidential care administered by a federal agency gender identity, or because and maximal facetime with their (including Medicaid, Medicare, they have had or are seeking provider during the clinic visit.75 TRICARE and VA programs, abortion care. It would ultimately As previously stated, CHIP, Indian Health Service), put individual’s lives and health the Affordable Care Act was a and programs governed by any in danger. This rule comes on landmark law for LGBTQ people’s entity established under Title I the heels of another final rule, access to health care. Not of the ACA (such as the federal released earlier in May, that only did the ACA significantly Health Insurance Marketplace would allow health care providers decrease the rates of uninsurance and state-run Marketplaces).84 to refuse to perform or assist and increase Medicaid and The Health Care Rights Law in medical care that violates contraceptive coverage for is particularly important for their religious or moral beliefs— hundreds of thousands LGBTQ transgender people, who face essentially giving health care people, it also provided harassment, denial of treatment, entities and providers a license to unprecedented nondiscrimination and other forms of discrimination discriminate.88 This rule therefore protections.76 Prior to the ACA, at disproportionate rates.85 It is part of a broader agenda to insurance companies could deny is also especially significant for allow health care entities and LGBTQ individuals insurance women experiencing pregnancy providers to discriminate against coverage, exclude certain services, complications who have been LGBTQ people under the guise or charge higher rates based denied the care they need, even of “religious freedom.”89 The on sexual orientation or gender in life-threatening situations. institutionalization of religious identity.77 Insurers were also able For example, under refusals under the Trump to deny insurance coverage or Section 1557, an insurer cannot administration is a direct attack charge higher rates to people automatically deny coverage on the health and wellbeing of with health conditions that for transition related care or LGBTQ people. disproportionally affect LGBTQ refuse to cover a particular In light of these attacks individuals78 such as HIV/AIDS, health service for a transgender on the Affordable Care Act, mental illness, and substance use person when similar services lawmakers must safeguard the disorders.79 Because of the ACA, are covered for cisgender Health Care Rights Law and in most health care programs people with other conditions. In protect LGBTQ people’s access to and activities, people cannot be essence, Section 1557 requires affirming care. Every person has discriminated against on the basis that insurers and health care a right to health care without fear of sex, which has been interpreted providers treat everyone in a way of discrimination. as including both sexual that is in accordance with their orientation and gender identity.80 gender identity, guaranteeing VII. Conclusion: Uplifting It also provided discrimination that transgender people have the Most Marginalized protections for people with HIV/ equal access to health programs AIDS and has made HIV/AIDS and facilities. Section 1557’s sex Uplifts Us All treatment more affordable for discrimination protections also those who need them.81 prohibit health care providers LGBTQ rights are Section 1557 of the from treating individuals poorly inextricably and inseparably ACA—also known as “The Health or denying care or coverage intertwined with reproductive Care Rights Law”– was the because they are in a same-sex health, rights, and justice. Because first broad prohibition of sex relationship or do not identify as reproductive justice addresses discrimination in health care in heterosexual.86 the full range of issues that affect federal law.82 It was passed as part Even though the ACA’s oppressed peoples throughout of the ACA in 2010 and prohibits protections have helped ensure their reproductive lives and discrimination on the basis of that LGBTQ individuals can get centers the most marginalized race, color, national origin, sex, the affirming care they need, through an intersectional age, or disability in most health these protections are under framework, it is the most apt care programs or activities.83 threat. The Trump administration approach to investigate LGBTQ Under Section 1557, discrimination in May 2019 released a proposed sexual and reproductive health care access.

7 When investigating this issue through a reproductive justice lens, the available data is clear: LGBTQ people have unique health care needs and a variety of intersecting factors make the LGBTQ community particularly vulnerable when it comes to sexual and reproductive health access. However, there are four palpable ways federal policymakers can ensure access to inclusive, comprehensive, and affordable sexual and reproductive health care for LGBTQ people: repealing the Hyde Amendment, funding Title X and eliminating the domestic gag rule, guaranteeing access to the full range of contraceptive options, and safeguarding the Affordable Care Act’s LGBTQ protections and gender-affirming care. By prioritizing LGBTQ people—particularly transgender people of color—in efforts to defend and expand reproductive health, rights and justice, we will improve sexual and reproductive health care for all communities. As we look towards the future, advocates, lawmakers, and every one of us must focus on those most vulnerable, join together across aisles, disciplines and movements, and tackle the intersecting and systemic oppressions that affect every facet of our lives.

8 experiences-lgbtq-youth-ymsm-and-ywsw- are-hostile-or-extremely-hostile Endnotes engaged-survival-sex/view/full_report; 23 Jill Filipovic, “It's Naive to Think a 1 Zsea Beaumonis and Candace Bond- “Addressing Anti-Transgender Violence: Conservative Supreme Court Wouldn't Target Theriault, “Queering Reproductive Justice: A Exploring Realities, Challenges and Solutions Roe v. Wade,” Time, July 12, 2018 http://time. Toolkit,” National LGBTQ Task Force (2017) for Policymakers and Community Advocates,” com/5336630/kavanaugh-roe-v-wade/ http://www.thetaskforce.org/wp-content/ and Trans People 24 See Deborah Kacanek, Amanda Dennis, uploads/2017/03/Queering-Reproductive- of Color Coalition, (November, 2015) http:// Kate Miller, and Kelly Blanchard, “Medicaid Justice-A-Toolkit-FINAL.pdf assets2.hrc.org/files/assets/resources/HRC- Funding for Abortion: Providers’ Experiences 2 Jon Wong, “Repro Justice Isn’t Just for Cis, AntiTransgenderViolence-0519.pdf with Cases Involving Rape, Incest and Life Straight Women. It’s for Queer Folks Like Me, 14 “Medicaid and Reproductive Health,” Endangerment,” Perspectives on Sexual and Too.” If/When/How, June 27, 2018 https:// Planned Parenthood Action Fund, 2019 Reproductive Health 42 (June, 2010): 79- www.ifwhenhow.org/pride-2018-queer-repro- https://www.plannedparenthoodaction.org/ 86 https://www.guttmacher.org/journals/ justice/ issues/health-care-equity/medicaid-and- psrh/2010/04/medicaid-funding-abortion- 3 Alex Berg, “Why Reproductive Justice Is reproductive-health providers-experiences-cases-involving-rape- an LGBTQ+ Rights Issue,” Out Magazine, 15 “A Call to Action: LGBTQ Youth Need incest; Sarah Erdreich, “The Fallacy of Rape, February 19, 2019 https://www.out.com/ Inclusive Sex Education,” Human Rights Incest, and Life Endangerment Clauses,” out-exclusives/2019/2/19/why-reproductive- Campaign, 2019 https://www.hrc.org/ Rewire.News, March 22, 2013 https://rewire. justice-lgbtq-rights-issue resources/a-call-to-action-lgbtq-youth-need- news/article/2013/05/22/the-fallacy-of-rape- 4 “Reproductive Justice,” SisterSong Women inclusive-sex-education incest-and-life-endangerment-clauses/ of Color Reproductive Justice Collective 16 Kates, Ranji, Beamesderfer, Salganicoff, and 25 S. 142, Sess. of 2013 https://www.congress. https://www.sistersong.net/reproductive- Dawson, “Health and Access to Care.” gov/113/bills/s142/BILLS-113s142is.pdf justice 17 Shabab Ahmed Mirza and Caitlin Rooney, 26 “State of Funding of Abortion Under 5 “Reproductive Justice,” SisterSong. “Discrimination Prevents LGBTQ People Medicaid,” Guttmacher Institute, April 1, 2019 6 Ibid. from Accessing Health Care,” Center for https://www.guttmacher.org/state-policy/ 7 Audre Lorde, “Learning from the 60s,” in American Progress, January 18, 2018 https:// explore/state-funding-abortion-under- Sister Outsider: Essays & Speeches by Audre www.americanprogress.org/issues/lgbt/ medicaid Lorde (Berkeley, CA: Crossing Press, 2007), news/2018/01/18/445130/discrimination- 27 “Medicaid and Reproductive Health,” 138. prevents-lgbtq-people-accessing-health-care/ Planned Parenthood. 8 For a more expansive definition list of 18 Sandy E. James, Jody L. Herman, Mara 28 Ibid. LGBTQ-related terminology see: Zsea Keisling, Susan Rankin, Lisa Mottet, and 29 Ibid. Beaumonis and Candace Bond-Theriault, Ma’ayan Anafi, “The Report of the 2015 U.S. 30 Kerith J. Conron and Shoshana K. “Queering Reproductive Justice: A Toolkit,” Transgender Survey,” National Center for Goldberg, “LGBT Adults with Medicaid National LGBTQ Task Force (2017) http:// Transgender Equality (December, 2016) Insurance,” The Williams Institute UCLA www.thetaskforce.org/wp-content/ https://www.transequality.org/sites/default/ School of Law (January, 2018) https:// uploads/2017/03/Queering-Reproductive- files/docs/USTS-Full-Report-FINAL.PDF williamsinstitute.law.ucla.edu/wp-content/ Justice-A-Toolkit-FINAL.pdf 19 Lauren Paulk, “Abortion Access Is an LGBT uploads/LGBT-Medicaid.pdf 9 Jen Kates, Usha Ranji, Adara Beamesderfer, Issue,” National Center for Lesbian Rights, 31 “Women’s Health Insurance Coverage,” Alina Salganicoff, and Lindsey Dawson, October 1, 2013 http://www.nclrights.org/ Keiser Family Foundation, December 2018 “Health and Access to Care and Coverage abortion-access-is-an--issue/ http://files.kff.org/attachment/fact-sheet- for Lesbian, Gay, Bisexual, and Transgender 20 Ty Cobb, “The Trump administration womens-health-insurance-coverage Individuals in the U.S.” Kaiser Family wants to help LGBTQ people abroad. 32 Alina Salganicoff, Caroline Rosenzweig, Foundation (May, 2018) http://files.kff.org/ Maybe it should start at home.” Washington and Laurie Sobel, “The Hyde Amendment attachment/Issue-Brief-Health-and-Access- Post, February 22, 2019 https://www. and Coverage for Abortion Services,” to-Care-and-Coverage-for-LGBT-Individuals- washingtonpost.com/opinions/2019/02/22/ Kaiser Family Foundation, October 16, 2017 in-the-US trump-administration-wants-help-lgbtq- https://www.kff.org/womens-health-policy/ 10 “2015 U.S. Transgender Survey,” National people-abroad-maybe-it-should-start- perspective/the-hyde-amendment-and- Center for Transgender Equality http://www. home/?utm_term=.65064d5b859d; coverage-for-abortion-services/ ustranssurvey.org/ Kinsey Hasstedt and Heather D. Boonstra, 33 Salganicoff, Rosenzweig, Sobel, “The Hyde 11 Nico Sifra Quintana, “Poverty in the LGBT “Taking Stock of Year One of the Trump Amendment and Coverage for Abortion Community,” Center for American Progress, Administration’s Harmful Agenda Against Services.” July 1, 2009 https://www.americanprogress. Reproductive Health and Rights,” Rewire. 34 Diana Greene Foster, “Turnaway Study,” org/issues/lgbt/reports/2009/07/01/6430/ News, January 18, 2018 https://www. Advancing New Standards in Reproductive poverty-in-the-lgbt-community/ guttmacher.org/article/2018/01/taking-stock- Health, December 2015 https://www.ansirh. 12 Jordan N. DeLoach, “Decriminalizing year-one-trump-administrations-harmful- org/research/turnaway-study Sex Work Is a Matter of Survival,” Truthout, agenda-against-reproductive; “Sabotage 35 “Hyde Amendment Fact Sheet,” All* Above March 2, 2019 https://truthout.org/articles/ Watch: Tracking Efforts to Undermine All, January 25, 2019 https://allaboveall.org/ decriminalizing-sex-work-is-a-matter-of- the ACA,” Center on Budget and Policy resource/hyde-amendment-fact-sheet/; survival/; “Language Matters: Talking About Priorities, March 29, 2019 https://www.cbpp. Diana Greene Foster, M. Antonia Biggs, Lauren Sex Work,” Stella and Allies to Educate org/sabotage-watch-tracking-efforts-to- Ralph, Caitlin Gerdts, Sarah Roberts, and M. and Mobilize Communities Around Legal undermine-the-aca Maria Glymour, “Socioeconomic Outcomes Advocacy and Decriminalization of Sex Work, 21 Elizabeth Nash, Rachel Benson Gold, of Women Who Receive and Women 2013 https://www.nswp.org/sites/nswp.org/ Zohra Ansari-Thomas, Olivia Cappello, Sophia Who Are Denied Wanted Abortions in the files/StellaInfoSheetLanguageMatters.pdf Naide, and Lizamarie Mohammed, “State United States,” American Journal of Public 13 Andrew Cray, Katie Miller, and Laura E. Policy Trends 2018: With Roe v. Wade in Health 108 (March, 2018): 407-413 https:// Durso, “Seeking Shelter: The Experiences Jeopardy, States Continued to Add New ajph.aphapublications.org/doi/10.2105/ and Unmet Needs of LGBT Homeless Youth,” Abortion Restrictions,” Guttmacher Institute, AJPH.2017.304247 Center for American Progress (September, December 11, 2018 https://www.guttmacher. 36 “Title X: An Introduction to the Nation’s 2013) https://www.americanprogress. org/article/2018/12/state-policy-trends-2018- Family Planning Program,” National org/wp-content/uploads/2013/09/ roe-v-wade-jeopardy-states-continued-add- Family Planning & Reproductive Health LGBTHomelessYouth.pdf; Meredith Dank, new-abortion; “State Policies on Abortion,” Association, September 2018 https:// Jennifer Yahner, Kuniko Madden, Isela Guttmacher Institute, 2019 https://www. www.nationalfamilyplanning.org/file/ Banuelos, Lilly Yu, Andrea Ritchie, Mitchyll guttmacher.org/united-states/abortion/state- Title-X-101-2018-.pdf; “Title X Family Planning,” Mora, and Brendan Conner, “Surviving policies-abortion U.S. Department of Health & Human Services the Streets of New York: Experiences of 22 “More than half of U.S. women of Office of Population Affairs, September 7, LGBTQ Youth, YMSM, and YWSW Engaged reproductive age live in states that are hostile 2018 https://www.hhs.gov/opa/title-x-family- in Survival Sex,” Urban Institute (February or extremely hostile to abortion rights,” planning/index.html 25, 2015) https://www.urban.org/research/ Guttmacher Institute, January 5, 2015 https:// 37 Family Planning and Services and publication/surviving-streets-new-york- www.guttmacher.org/infographic/2015/more- Population Research Act of 1970, Public Law half-us-women-reproductive-age-live-states- 91-572 (December 24, 1970) http://uscode.

9 house.gov/statutes/pl/91/572.pdf opa/sites/default/files/Title-X-2014-Program- Abortion in Post-Midterm Attack,” Rewire. 38 “Title X Family Planning Annual Report: Requirements.pdf News, November 8, 2018 https://rewire.news/ 2017 National Summary,” U.S. Department of 54 “Publicly Funded Family Planning Services article/2018/11/08/trump-administration- Health & Human Services Office of Population in the United States,” Guttmacher Institute, moves-to-restrict-birth-control-benefit-and- Affairs (August, 2018) https://www.hhs.gov/ September, 2016 https://www.guttmacher. abortion-in-post-midterm-attack/ opa/sites/default/files/title-x-fpar-2017- org/fact-sheet/publicly-funded-family- 69 “New Data Estimate Nearly 62.8 Million national-summary.pdf planning-services-united-states. Women Have Coverage of Birth Control 39 “Title X Family Planning Annual Report,” 55 Adam Sonfield, “Beyond Preventing without Out-of-Pocket Costs,” National U.S. Department of Health & Human Services. Unplanned Pregnancy: The Broader Benefits Women’s Law Center (November, 2018) 40 Ibid. of Publicly Funded Family Planning Services,” https://nwlc-ciw49tixgw5lbab.stackpathdns. 41 Ibid. Guttmacher Policy Review 17, no. 4 (2014). com/wp-content/uploads/2017/09/New- 42 Megan L. Kavanaugh, Mia R. Zolna, and 56 David A. Klein, Erin Nicole Berry-Bibee, Preventive-Services-Estimates-4.pdf Kristen Burke, “Use of Health Insurance Kristin Keglovitz Baker, Nikita M. Malcolm, 70 “Providing Inclusive Services and Care Among Clients Seeking Contraceptive Julia M. Rollison and Brittni N. Frederiksen. for LGBT People,” National LGBT Health Services at Title X–Funded Facilities in 2016,” “Providing quality family planning services Education Center: A Program of the Fenway Perspectives on Sexual and Reproductive to LGBTQIA individuals: a systematic Institute https://www.lgbthealtheducation. Health 50, no. 3 (September, 2018): 101- review.” Contraception 97, no. 5 (2018): 378- org/wp-content/uploads/Providing-Inclusive- 109 https://www.guttmacher.org/journals/ 391. Services-and-Care-for-LGBT-People.pdf; psrh/2018/06/use-health-insurance-among- 57 Klein, Berry-Bibee, Baker, Malcolm, Rollison “Affirmative Care for Transgender and Gender clients-seeking-contraceptive-services-title-x and Frederiksen. “Providing quality family Non-Conforming People: best Practices 43 Mia R. Zolna and Jennifer J. Frost, “Publicly planning services.” for Front-line Health Care Staff,” National Funded Family Planning Clinics in 2015: 58 Ibid; “Sexual Assault and the LGBTQ LGBT Health Education Center: A Program Patterns and Trends in Service Delivery Community,” Human Rights Campaign, 2019 of the Fenway Institute (Fall, 2016) https:// Practices and Protocols,” Guttmacher Institute https://www.hrc.org/resources/sexual-assault- www.lgbthealtheducation.org/wp-content/ (November, 2018) https://www.guttmacher. and-the-lgbt-community. uploads/2016/12/Affirmative-Care-for- org/report/publicly-funded-family-planning- 59 “Why We Need to Talk About Queer Transgender-and-Gender-Non-conforming- clinic-survey-2015 and Trans People and Birth Control,” The People-Best-Practices-for-Front-line-Health- 44 “Program Requirements for Title X Funded Establishment, December 2, 2017 https:// Care-Staff.pdf. Family Planning Projects,” U.S. Department of theestablishment.co/why-we-need-to-talk- 71 James, Herman, Keisling, Rankin, Mottet, Health & Human Services Office of Population about-queer-and-trans-people-and-birth- and Anafi, “The Report of the 2015 U.S. Affairs (April, 2012) https://www.hhs.gov/ control-972952542269/. Transgender Survey.” opa/sites/default/files/Title-X-2014-Program- 60 Alexis Light, Lin-Fan Wang, Alexander 72 Mirza and Rooney, “Discrimination Prevents Requirements.pdf Zeymo, Veronica Gomez-Lobo. “Family LGBTQ People from Accessing Health Care.” 45 “Title X Family Planning Annual Report,” planning and contraception use in 73 Klein, Berry-Bibee, Baker, Malcolm, Rollison U.S. Department of Health & Human Services. transgender men.” Contraception 98, no. 4 and Frederiksen. “Providing quality family 46 “Lesbian, Gay, Bisexual, and Transgender (2018): 266-269. planning services.” Health,” Centers for Disease Control, March 61 Caitlin Lowell and Erin Longbottom, “Trans 74 Ibid. 28, 2018 https://www.cdc.gov/lgbthealth/ & Non-Binary Folks on Why Birth Control Isn’t 75 Ibid. index.htm Just for Cis Women,” National Women’s Law 76 Kates, Ranji, Beamesderfer, Salganicoff, and 47 “Title X Family Planning Annual Report,” Center, November 16, 2016 https://nwlc.org/ Dawson, “Health and Access to Care”; Lindsey U.S. Department of Health & Human Services. blog/trans-non-binary-folks-on-why-birth- Dawson, Jennifer Kates, and Anthony Damico, 48 Jessica Ravitz, Trump administration control-isnt-just-for-cis-women/ “The Affordable Care Act and Insurance hit with lawsuits over low-income family- 62 National Partnership for Women & Coverage Changes by Sexual Orientation,” planning dollars, CNN, May 2, 2018 https:// Families, Aliya Bean, “Scarier than your worst Kaiser Family Foundation, January 18, 2018 www..com/2018/05/02/health/title- 90s outfit,” Medium (blog), January 26, 2017 https://www.kff.org/disparities-policy/issue- x-lawsuits-bn/index.html; Katelyn Burns, https://medium.com/@NationalPartnership/ brief/the-affordable-care-act-and-insurance- “Trump Administration Dramatically Shortens scarier-than-your-worst-90s-outfit- coverage-changes-by-sexual-orientation/ Funding Period for Title X Grants,” Rewire. 83f835293ef3 77 Dawson, Kates, and Damico, “The News, August 31, 2018 https://rewire.news/ 63 Bean, “Scarier than your worst 90s outfit.” Affordable Care Act and Insurance Coverage article/2018/08/31/trump-administration- 64 “Insurance Coverage of Contraceptives,” Changes.” dramatically-shortens-funding-period-for- Guttmacher Institute, April 1, 2019 https:// 78 Ibid. title-x-grants/ www.guttmacher.org/state-policy/explore/ 79 Kates, Ranji, Beamesderfer, Salganicoff, and 49 Ariana Eunjung Cha, “Trump administration insurance-coverage-contraceptives Dawson, “Health and Access to Care” bars clinics that provide abortions or abortion 65 Jamila Taylor and Nikita Mhatre, 80 “Nondiscrimination Protection in the referrals from federal funding,” Washington “Contraceptive Coverage Under the Affordable Care Act: Section 1557,” National Post, February 22, 2019 https://www. Affordable Care Act,” Center for the Women’s Law Center, September 2015 https:// washingtonpost.com/health/2019/02/22/ American Progress, October 6, 2017 https:// nwlc.org/wp-content/uploads/2015/09/ trump-administration-bars-family-planning- www.americanprogress.org/issues/women/ Reproductive-Rights-and-Health_1557_2.2.16. clinics-that-provide-abortion-referrals-million- news/2017/10/06/440492/contraceptive- pdf program/?utm_term=.55eb328fb9f3 coverage-affordable-care-act/ 81 Lindsey Dawson and Jennifer Kates, “What 50 “Title X Notice of Final Rule,” U.S. 66 “Timeline: Trump’s Attacks on Access is at Stake in ACA Repeal and Replace for Department of Health & Human Services to Birth Control,” Planned Parenthood People with HIV?” Kaiser Family Foundation, Office of Population Affairs, March 4, 2019 Action Fund, 2019 https://www. May 5, 2017 https://www.kff.org/hivaids/issue- https://www.hhs.gov/opa/sites/default/files/ plannedparenthoodaction.org/fight-for-birth- brief/what-is-at-stake-in-aca-repeal-and- title-x-notice-of-final-rule.pdf control/facts/timeline-trumps-attacks-access- replace-for-people-with-hiv/ 51 “This is Who Planned Parenthood birth-control 82 “Summary: Final Rule Implementing Is,” Planned Parenthood Federation of 67 “The Trump Appointees Who Want Section 1557 of the Affordable Care Act,” U.S. America, Inc. (September 2017) https:// to Take Your Birth Control,” Planned Department of Health and Human Services www.plannedparenthood.org/uploads/ Parenthood Action Fund,” 2019 https://www. Office of Civil Rights, June 6, 2016 https:// filer_public/59/9d/599dbbaf-10be-4f49- plannedparenthoodaction.org/fight-for-birth- www.hhs.gov/sites/default/files/2016-06-07- a6f3-97999027e3d9/who_we_are_lgbtq_ control/facts/meet-trump-appointees-who- section-1557-final-rule-summary-508.pdf community_september_2017.pdf want-sabotage-your-access-birth-contro 83 “Nondiscrimination in Health Programs and 52 Frost, Frohwirth, Blades, Zolna, Douglas- 68 Christine Grimaldi and Jessica Mason, Activities; Final Rule,” 81 Federal Register 96 Hall, and Bearak, “Publicly Funded “Trump Opens Door for End of Birth Control (May 18, 2016), pp. 31376-31473 https://www. Contraceptive Services.” Benefit,” Rewire.News, October 6, 2017 govinfo.gov/content/pkg/FR-2016-05-18/ 53 “Program Requirements for Title X Funded https://rewire.news/article/2017/10/06/ pdf/2016-11458.pdf Family Planning Projects,” U.S. Department of trump-opens-door-end-birth-control-benefit/; 84 “Final HHS Regulations on Health Care Health & Human Services Office of Population Katelyn Burns, “Trump Administration Discrimination: Frequently Asked Questions,” Affairs (April, 2012) https://www.hhs.gov/ Moves to Restrict Birth Control Benefit and National Center for Transgender Equality

10 http://www.transequality.org/sites/default/ files/HHS-1557-FAQ.pdf 85 James, Herman, Keisling, Rankin, Mottet, and Anafi, “The Report of the 2015 U.S. Transgender Survey.” 86 Kellan Baker, “LGBT Protections in Affordable Care Act Section 1557,” Health Affairs (blog), June 6, 2016 https:// www.healthaffairs.org/do/10.1377/ hblog20160606.055155/full/ 87 “Nondiscrimination in Health and Health Education Programs or Activities; Proposed Rule,” Federal Register (May 24, 2019) https:// www.hhs.gov/sites/default/files/1557-nprm- hhs.pdf 88 Ema O’Connor and Dominic Holden, “The Trump Administration Will Allow Health Workers To Refuse Abortion And Sex Reassignment Services,” BuzzFeed.News, May 2, 2019 https://www.buzzfeednews.com/ article/emaoconnor/trump-rule-religious- doctors-refuse-abortion-sex 89 “The Discrimination Administration: Trump’s record of action against transgender people,” National Center for Transgender Equality, (2019) https://transequality.org/the- discrimination-administration

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