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When we talk about reproductive rights or reproductive justice, we have to acknowledge that guaranteeing rights does not guarantee access to services. Economic security has a huge impact on individuals’ ability to access reproductive healthcare, and the effect is even more pronounced for members of the LGBT community.

If we want to have a truly inclusive conversation about reproductive justice that takes into account the full spectrum of an individual’s experience — income, employment, race, ethnicity, disability, education, marital status, history of abuse, mental health, and many other factors that directly impact a person’s reproductive choices — then we must include sexuality, gender identity, and gender expression as factors that not only impact a person’s practical right to choose but also may limit a person’s reproductive options.

LGBT individuals face extra hurdles when accessing healthcare, period. Insurance companies may refuse to recognize someone’s gender or sexuality or discriminate against them and deny coverage based on that identity. The same thing goes for reproductive health specialists. Reproductive healthcare specialists are supposed to consider a person’s medical history, sexual history, and lifestyle habits when evaluating certain risk factors and proscribing treatment methods. But what if that doesn’t happen?

What if the patient is a transgender man whose family has a long history of breast cancer, and he wants to know whether he should get screened? Does the fact that he presents as male and has had gender confirmation surgery impact his chances of getting cancer, or does his family history still put him at risk? Will the doctor even be willing to recognize his male identity?  What if a lesbian woman wants to discuss birth control options, but the nurse handling intake keeps assuming that she is straight and that her sexual history reflects that? What if a transgender man seeks an abortion? What if an HIV-positive person has to choose whether to reveal their status on a medical form in a state where they can still be fired for having HIV/AIDS? Cisgender heterosexual people do not have to face the added challenge of whether to present their authentic selves when seeking medical care. We need to talk about the people who do, and what that means for their ability to access reproductive healthcare.

We also need to talk about the lack of job security that many LGBT Americans face. Over 20 states still do not have employment non-discrimination laws. According to a 2013 Pew Research Center survey, more than 20 percent of LGBT adults have experienced workplace discrimination.

In another study conducted by the Williams Institute, 38.2 percent of openly LGBT people said they had been harassed at work. An overwhelming majority of transgender and gender non-conforming people report harassment and mistreatment in the workplace — almost half report being fired, denied a job, or denied a promotion because of their gender identity or expression. These grim statistics highlight the profound lack of economic security that many LGBT individuals face, and without stable job security, many lack stable access to healthcare benefits.

Access to healthcare services is also impacted by housing security. According to the National Coalition for the Homeless, as many as 40 percent of youth serviced by agencies identify as LGBT, and 30 percent of street outreach clients identified as LGBT.

LGBT individuals are at high risk of homelessness — the stigma they face amongst families and in social settings may literally land them on the street. Despite being homeless, anyone can enroll in government-sponsored health insurance, including under the Affordable Care Act, and you do not need to have an income or address to fill out the application. But access to such resources requires access to internet, assistance with paperwork, and a valid form of ID, which can present a serious challenge. Once a person gets access to insurance, they also need to be able to get to the doctor’s office. If the clinic is too far away, people cannot afford to access their doctors even if their insurance covers the visit.

These are some of the challenges LGBT Americans may face in trying to access reproductive healthcare. We look forward to advancing a national conversation on reproductive rights that includes LGBT experiences and perspectives and invites LGBT voices to help shape advocacy and legislation for years to come.