Pride, Power and Family Planning

Catherine Lane, Director, Adolescents and Youth, FP2030

If the COVID-19 pandemic has taught us anything, it’s that everyone’s health is deeply interconnected. We recognized this in the Sustainable Development goals, in SDG3: good health and well being for all. But we will never achieve this goal by segmenting people and their health care. This applies to family planning as well. For too long, family planning has been siloed as a “women’s issue,” but if the most excluded and stigmatized people in our communities can’t use the family planning services available, we won’t succeed in meeting our family planning goals.

FP2030 is arguably the largest family planning convener in the world. Created at the 2012 London Summit on Family Planning, partners committed to ensuring all women, no matter where they live, should be able to use voluntary, rights-based, contraceptives. By 2020, 320 million people were using modern contraception in FP2020 focus countries. It was an incredible feat, but there are still so many more people who would like to use contraception but aren’t — or can’t. So as we are reorienting around a new partnership and a new set of goals for FP2030, we are reflecting on how to create a partnership that is more intentional and inclusive.

At the center of FP2030 are women and girls’ reproductive health and rights, but we recognize that “women and girls” doesn’t capture the full community of people who use family planning services. FP2030 is working to better recognize the experience of LGBTI communities, which for too long have been excluded from our thinking, our narratives, our funding, and our data. As Pride month draws to a close, we are taking time to discuss how this new family planning partnership will better serve the needs and preferences of LGBTI populations.

LGBTI people need the same reproductive health services heterosexual people have – and further, they need those services in an environment that is inclusive, free of stigma, and doesn’t put their safety at risk. While data is still limited, studies show that LGBTI communities have unique burdens and challenges when it comes to accessing reproductive healthcare. According to the World Health Organization (WHO), men who have sex with men are 24 times more likely to acquire HIV than the general public, and transgender individuals are 18 times more likely. Unintended pregnancies are more common among lesbian, gay, and bisexual people, for many reasons including stigma and gender-based violence. Transgender men are at high risk of unintended pregnancy and HIV. Integrating HIV testing and treatment with other STI care and family planning is critical to meeting this community’s needs, as they are uniquely at risk for HIV and unplanned pregnancy.

Lesbians, in particular, have high rates of unintended or mistimed pregnancy. Even if someone identifies as a lesbian, she might be forced or coerced into a relationship with a man, she might choose to be in one in order to hide her sexuality, she might be at higher risk of assault or rape, or she might engage in sex with men to hide her sexuality.

Assumptions about gender and sexuality have also created serious hurdles to people trying to access reproductive health care. Trans people can be denied health care, or risk violence and stigma, if the gender marker on their identification does not match their gender presentation or identity.

Why have LGBTI communities been overlooked for so long in global health? In many cases it comes down to funding, and the way international development funds are segmented by sectors.

For example, it seems natural that family planning and HIV programming would be related and interconnected, but in reality there are enormous global infrastructures built around family planning, women’s health, and HIV that keep them separate. From the perspective of a person seeking care at a community health center, there is no reason for these services to be disconnected, and separating them is only confusing.

The weakness here is structural, and comes from the unnatural separation of interrelated human issues: for family planning services, you go through the door on the right; for HIV care, the door on the left. The separation of “women’s health care” from “LGBTI health care” contains the same flaws, isolating people from their full range of health care needs, and exacerbating stigma by segmenting populations that have multiple, overlapping identities.

The enormous infrastructures built by global institutions and donors are designed to improve family planning, women’s health, and HIV outcomes, yet pay limited attention to the articulated preferences of the intended beneficiaries, instead relying on “global experts” to determine optimal approaches to achieve increases in modern contraceptive prevalence and condom use, and reductions in maternal and child morbidities and mortalities.  This “top down” approach is increasingly being rejected, as countries demand their voices and perspectives be acknowledged and validated

At FP2030, we are working to dismantle power structures that exclude certain groups, and better spread the power across our diverse partners. As we move forward, we will continue to center women and girls, but we will also be a convening platform to ensure family planning for all people, understanding that the question of whether, and when to have children or not concerns everyone, no matter how old you are, who you love or how you identify.