In the wake of the Obergefell decision, the movement for LGBT rights has found itself in a period of reevaluation and transition. Advocates whose issues were sidelined by the attention focused on marriage rights can pursue their campaigns for equality, non-violence, and respect without marriage equality dominating the airwaves or the funders’ checkbooks. The movement as a whole has an opportunity to capitalize on the momentum of the same-sex marriage campaign and the public’s increased familiarity with sexual minorities as it continues to fight for those who are marginalized and vulnerable on account of their differences. However, the legalization of marriage does not necessarily represent a victory for all members of the LGBT community; in fact, as recent conflict over bathroom use suggests, anxiety about sexuality and gender-nonconformity may simply be shifting away from the institution of marriage into other social spaces.
The struggle to meet the healthcare needs of trans people is one area where the work continues, largely unaided by the marriage victory and possibly complicated by increased post-marriage attention to trans people as deviant and threatening. For years, advocates have worked to educate healthcare providers in culturally competent care for trans men and women, to increase access to appropriate and affordable care (especially for trans people lacking insurance due to unemployment), and to develop alternatives models for delivering healthcare services to those who need them. In the spirit of post-Obergefell reevaluation, I propose to analyze the advocacy strategies employed by trans healthcare advocates using the work of maternity care reform advocates as a point of comparison and source of inspiration. In recent years, childbirth advocates have targeted policymakers, hospitals, physicians, and community members to advance a model of maternity care that would increase the quality of care provided, lower costs, and improve health outcomes. According to advocates, the maternity care system is broken—with high maternal and infant mortality rates, high intervention rates leading to unnecessary complications, and staggering costs—and requires systemic reform.
Although their similarities may not be immediately apparent, trans healthcare advocacy and maternity care reform advocacy have much in common. Both take place against a historical backdrop of health care that was often neglectful, disempowering, and even barbaric. Both require dismantling sex and gender stereotypes about what it means to be a woman (or a man) in order to prevent those stereotypes from determining what health care is available and how it is administered. Both must grapple with a deeply pathological conception of what healthcare needs exist; for trans people, healthcare providers have understood their gender identity and expression as a manifestation of psychological defect (or worse), and for pregnant people, providers have come to view childbirth as a condition or disease that needs to be managed, rather than a natural, physiologic process. The centrality of pathology in provider-patient interactions shapes what services are made available and whether they are truly health affirming.
Comparing trans healthcare advocacy and maternity care reform advocacy suggests a variety of other commonalities: gaps in research and data about the health needs and health outcomes of both trans and pregnant populations; the powerful role of discrimination in health care and the difficulty of using traditional legal tools to address it; and the prioritization of patient-centered health care and grassroots efforts to re-educate providers about evidence-based and culturally competent clinical practices. There are important differences too. For some trans people, the demand is for more health care—routine medical attention as well as transition-related services, not simply psychological counseling—while claims by maternity care advocates tend to focus on the need for fewer medical interventions into childbirth. Relatedly, trans healthcare advocacy seeks access to medically necessary care—for example, prostrate screenings for trans women and ovarian cancer treatments for trans men—whereas maternity care advocates frame the struggle as one in pursuit of freedom from medically unnecessary care. In practical terms, childbirth represents a major expenditure within the health care system and touches millions of lives each year, while trans health care is an issue for a much smaller proportion of the population. This reality may impact issue prioritization and strategies employed by advocates.
The existence of similar themes in both the trans and maternity health care arenas suggest that a close analysis of advocacy strategies may yield important lessons for both movements—including in the development of effective framing, the mobilization of law, and engagement with physicians and other stakeholders in healthcare institutions. Such analysis will also develop opportunities for cross-fertilization between advocates working to improve health care for trans people and advocates working to promote a safer, more cost-effective, and empowering approach to childbirth. For example, in both arenas, advocates have developed alternative approaches to meeting community needs outside mainstream institutions; questions remain about the growth of such outsider models and the need to assimilate them into dominant institutions. Advocates in both arenas must also consider their contributions to a larger societal discourse around the healthcare needs of trans and pregnant people, developing strategies to name and shame bad actors, incorporate the human rights language of dignity into their messaging, and appeal to the broader public with compelling narratives.
This paper will provide a close analysis of the strategies and campaigns of advocates for trans health care and maternity care reform advocates, identifying similarities between the two movements and opportunities for cross-fertilization. Proposed as an academic presentation for the CLAGS conference, the paper will explore new territory for research and analysis to advance the health care needs of trans people as part of a renewed agenda for LGBT rights in a post-Obergefell world.