Sexual and Gender Minorities Inclusion and Uptake of Sexual and Reproductive Health Services: A Scoping Review of Literature

Abstract

Despite the efforts to ensure that sexual and reproductive health services are integrated into global, regional, and national initiatives, a significant number of countries are overwhelmed by frames of exclusion and violations of fundamental human rights, particularly for sexual and gender minority groups such as lesbians, gays, bisexuals, and transgender people. This study sought to review the literature on access and barriers faced by sexual and gender minorities. A scoping literature review was conducted on literature that focused on sexual and gender minorities and sexual and reproductive health services and published in the English language. Studies were independently screened and coded, categorizing themes such as policies, uptake of services, barriers to sexual and reproductive health access, and strategies to aid the uptake of services. The search yielded 1,148 literature sources, of which 39 met the inclusion criteria and were reviewed. The average sexual and reproductive health service uptake was generally low overall and was influenced by factors such as clinical settings, punitive laws, and availability of services specific to sexual and gender minorities. Noted strategies to aid sexual and reproductive health uptake include education, friendly health care facilities, availability of specific services, and legislative reform. The sexual and reproductive health program is an important component of short-term and long-term sexual and reproductive health needs. Health intervention initiatives targeted at improving or increasing sexual and reproductive health uptake must be supported by suitable legal and regulatory framework contexts and based on context-specific evidence.

Keywords

sexual and gender minorities sexual and reproductive health uptake barriers to sexual and reproductive health uptake sexual and reproductive health policies

Background

One of the primary goals of the United Nations Sustainable Development Goals (SDG) is to ensure universal access to sexual and reproductive health (SRH) services (SDG 3.7 and 5.6) (Callahan et al., n.d.). Furthermore, the World Health Organization’s 13th General Program of Work includes a strategic focus on Universal Health Care with a specific reference to sexual and reproductive health and rights (SRHR) (Müller, 2017). This is an important opportunity to ensure that SRH services are integrated into global, regional, and national initiatives to achieve universal health care. All people, including those identifying as lesbian, gay, bisexual, transgender, or queer (LGBTQ), require sexual and reproductive health care (Sert et al., 2019). LGBTQ health issues and sexual and reproductive health care are inextricably linked because they both involve individuals’ autonomy in their most intimate decisions (Alencar Albuquerque et al., 2016).

A significant number of countries are swamped by conceptions of exclusion and breaches of fundamental human rights, particularly for minority social groups such as LGBTQ individuals. The health care system has historically failed and continues to fail the LGBTQ community, with LGBTQ individuals experiencing significant gaps in sexual and reproductive health care and poorer health outcomes than the general population (Lionço, 2008). These discrepancies are the result of a number of challenges in the health care system, including fragmentation of health services, provider prejudice, and a lack of policies that promote access to SRH services for sexual and gender minorities (SGM) (Mello, 2011).

SGM face several overlapping structural barriers to their basic SRH rights, including access to sexual and reproductive health care. SRH care includes various services such as HIV/sexually transmitted infection (STI) treatment, Human Papillomavirus (HPV)-related cancer prevention, and other reproductive-tract morbidities (Hubach et al., 2022). One of the most formidable barriers to SRH care is the criminalization of same-sex relationships, which restricts access to and use of health services (Wirtz et al., 2014). In numerous settings, the harmful effects of SGM criminalization are exacerbated by other rights-violating laws and policies, such as laws against same-sex relationships and gender nonconformity, including laws against “cross-dressing” or “impersonating the opposite sex,” which exacerbate SRH inequities among SGM. Criminalization can also stifle HIV testing and access to social services and support and increase the prevalence of HIV/STIs and physical/sexual violence (Hoffman et al., 2009). As such, the number of SGM utilizing sexual and reproductive health services remains poor despite these services’ availability.

While a significant body of research explores SGM access to SRH services and sexual and reproductive health needs, little is known about the effects of SRH policies on service uptake by SGM. This is a concern because the number of SGM utilizing sexual and reproductive health services remains poor, leading to poor sexual and reproductive health outcomes. As such, this scoping review explores the effects of SGM’s inclusion and uptake of sexual and reproductive health services. The following specific objectives have guided this enquiry:

To analyze major policies that influence access to sexual and reproductive health services by SGM.

To determine the uptake of sexual and reproductive health services by SGM.

To explore barriers faced by SGM when accessing sexual and reproductive health services.

To determine the strategies that can be implemented to aid the uptake of sexual and reproductive health services by SGM.

Methodology

Literature Sources

Keywords were applied in search engines such as PUBMED, Cochrane Library, ProQuest, Dimensions, Scopus, AJOL, and other reputable search sites such as EBSCO Host, WHO, CDC, and UNAIDS. Literature from the reference lists of the retrieved articles was also used and included in the study. The snow bowling technique was used to search relevant articles and websites. Other data sources involved academic thesis. The review searched and focused on studies investigating the uptake of SRH services among SGM. Those studies included cross-sectional studies, cohort studies, randomized controlled trials, and other quantification studies or qualification studies. The search, however, was only limited to articles published in English. The review included studies on SGM. Studies were included if they reported SRH uptake among SGM for reasons related to access to SRH and awareness, barriers, and facilitators on SRH uptake.

Literature Search

Using the Population, Intervention, Comparison and Outcome (PICO’s) concept, a scoping literature review was conducted by looking for relevant studies. This scoping review had only studies that followed the PICO’s framework, where the problem is inclusion, and interest is SRH uptake in the context of SGM. The researcher excluded those studies with full articles unavailable. The researcher excluded studies that did not include the sections in the preferred reporting items in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. Literature sources from other languages besides English were excluded. Studies were also excluded if they focused only on SRH uptake among other population groups which are not SGM, such as sex workers and women. The following search string “Sexual and gender minorities” NEAR “barriers to sexual and reproductive health uptake” OR “sexual and reproductive health policies” AND“sexual and reproductive health services uptake” would be used to search for the literature sources in the listed databases. The study excluded unpublished research papers, conference abstracts, and presentations (Table 1).

Table 1.

Exclusion and Inclusion Criteria

Criteria	Inclusion	Exclusion
Article type	Peer-reviewed studies, book chapters, books, reports, and dissertations. Original articles with full text available online	Full text not accessible Studies that do not include the sections in the preferred reporting items in the PRISMA
Location	Global	None
Date	Any time	None
Language	English only	Any other language
Population of interest	Sexual and gender minorities	Heterosexual, cisgender
Key themes	• Sexual and gender minorities • Sexual and reproductive health, as defined by WHO • Uptake of sexual and reproductive services	• Non-SRH services

Note. SRH = sexual and reproductive health; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis; WHO = World Health Organization.

Data Extraction and Synthesis

DistillerSR, a web-based software program, was used for screening, management, and data extraction in the review process. A descriptive literature analysis was performed to extract data that answer review objectives. The synthesis of quantitative results involved extracting results and recommendations from similar studies and comparing them according to the context in which they were performed. Data from qualitative studies were classified and coded, and a coding framework was developed for this study. The resulting codes and their units of meaning were analyzed by topic to obtain salient themes. The analysis was performed using tables and themes that emerged from different literature. All relevant findings were then summarized in tabular form by topics that emerged.

Quality Assessment

For this review, the quality was assessed using a purposive rating tool adapted from the PRISMA 2020 checklist. The primary purpose of this rating tool was to evaluate the scientific quality and rigor of the scoping. See Table 2 for the completed PRISMA 2020 checklist.

Table 2.

PRISMA Checklist

Section and topic	Item#	Checklist item	Location where item is reported
Title
Title	1	Identify the report as a systematic review.	Page 1
Abstract
Abstract	2	See the PRISMA 2020 for Abstracts checklist.	Page 2
Introduction
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	Pages 3 and 4
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	Page 4
Methods
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	Page 5
Information sources	6	Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	Page 5
Search strategy	7	Present the full search strategies for all databases, registers, and websites, including any filters and limits used.	Page 5
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	Pages 5 and 21
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	Page 5
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	N/A
Data items	10b	List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	Page 5
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	N/A
Effect measures	12	Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results.	N/A
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g., tabulating the study intervention characteristics and comparing against the planned groups for each synthesis [item #5]).	Page 6
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.	Page 6
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	Page 6
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	N/A
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, meta-regression).	N/A
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.	N/A
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	N/A
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	N/A
Results
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	Page 20
Study selection	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	Page 20
Study characteristics	17	Cite each included study and present its characteristics.	N/A
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	N/A
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g., confidence/credible interval), ideally using structured tables or plots.	N/A
Results of syntheses	20a	For each synthesis, briefly summarize the characteristics and risk of bias among contributing studies.	N/A
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g., confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	Pages 25–35
	20c	Present results of all investigations of possible causes of heterogeneity among study results.	Pages 7–10 and 25–35
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.	N/A
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.	N/A
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	N/A
Discussion
Provide a general interpretation of the results in the context of other evidence.			Pages 11 and 12
Discuss any limitations of the evidence included in the review.			Page 13
Discuss any limitations of the review processes used.			Page 13
Discuss implications of the results for practice, policy, and future research.			N/A
Other information
Provide registration information for the review, including register name and registration number, or state that the review was not registered.			N/A
Indicate where the review protocol can be accessed, or state that a protocol was not prepared.			N/A
Describe and explain any amendments to information provided at registration or in the protocol.			N/A
Describe sources of financial or nonfinancial support for the review and the role of the funders or sponsors in the review.			Page 15
Declare any competing interests of review authors.			Page 15
Report which of the following are publicly available and where they can be found: template data collection forms, data extracted from included studies, data used for all analyses, analytic code, any other materials used in the review.			N/A

Note. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Findings

A total of 1,148 literature sources from electronic databases were obtained. After excluding 49 duplicates, sources were left where screening of titles and abstracts led to the further exclusion of 24 records. About 75 articles were retained for full-text reading, and 17 sources were further removed after the abstract screening. A total of 58 articles were left for full-text reading, and a total of 19 articles were removed for the following reasons; not answering objectives (11), not SGM (5), and not English (3). About 39 sources were eligible and included in the review process, as presented in Figure 1. This section will categorize themes that emerged from the literature sources used in the scoping literature review. The most notable themes that emerged include the policies that influence SRH uptake in different countries, uptake of SRH by SGM, barriers to SRH access, and strategies to aid the uptake of SRH.

Figure 1.

Document Review Process

Policies that Influence SRH Access by SGM

The constitution is the supreme law of a country, and any law, practice, custom, or conduct that is inconsistent with it is void to the degree of the inconsistency. The responsibilities set by this constitution are binding on all natural or legal persons, including the state and all executive, legislative, and judicial institutions and agencies of government at all levels. They must be fulfilled by them (Constitution of Zimbabwe, 2013). The law is used in all legal systems to deter, prosecute, and punish harmful behavior and protect individuals from harm. However, 67 countries have national laws criminalizing same-sex relationships between consenting adults (Table 3). At least nine countries have national laws criminalizing transgender and gender-nonconforming people’s gender expression. These countries use criminal law to prohibit access to and provision of certain sexual and reproductive health information and services and to punish HIV transmission and a wide range of consensual sexual conduct between competent persons, such as same-sex sexual behavior and consensual sex work.

Table 3.

Countries that Criminalize Same-Sex Marriages

Country	Type of law	Name of law	Legal provision(s)	Sentence
Algeria	Outlaws same-sex relations	1966 Penal Code, article 338.	Homosexual acts	Two months to 2 years in prison and a fine of between 500 and 2,000 Algerian dinars (US$5–$20).
Bangladesh	Outlaws same-sex relations	Penal Code 1860, section 377	Carnal intercourse against the order of nature	Ten years to life in prison.
Chad	Outlaws same-sex relations	Chad Penal Code 2017	Sexual relations with someone of the same sex	Three months to 2 years in prison
Iran	Outlaws same-sex relations	Islamic Penal Code of Iran, 2013, articles 233–41.	Sodomy	Sentences range from 31 lashes (for homosexual acts other than anal sex or thigh sex) to 100 lashes to death.
Malawi	Outlaws same-sex relations, criminalizes forms of gender expression	Penal Code of 1930 (amended 2010), sections 153, 137A.	Carnal knowledge against the order of nature; indecent practices between males; indecent practices between females	Sexual acts between men: up to 14 years in prison; sexual acts between women: 5 years in prison.
Malawi	Gender expression	Penal Code of 1930 (amended 2010), section 180
Myanmar (Burma)	Criminalizes same-sex conduct	Penal Code 1861, section 377	Carnal intercourse against the order of nature	Up to 20 years in prison, fine
United Arab Emirates	Outlaw’s same-sex relations; criminalizes forms of gender expression	Penal Code Article 409	Sodomy between adult men	No less than 6 months of imprisonment
Zambia	Outlaws same-sex relations	Penal Code Act (as amended by Act No. 15 of 2005), sections 155, 156.	Carnal knowledge against the order of nature, gross indecency	Seven years to life in prison.
Zimbabwe	Outlaws same-sex relations	Criminal Law (Codification and Reform) Act, (Effective 2006), section 73.	Sodomy	Up to 1 year in prison and/or fine

The criminalization of these behaviors and actions has negative consequences for health, including sexual health. Persons whose consensual sexual behavior is deemed a criminal offense may try to hide it from health workers and others for fear of being stigmatized, arrested, and prosecuted. This may deter people from using health services, resulting in serious health problems such as untreated STIs and unsafe abortions, for fear of negative reactions to their behavior or health status. In a number of circumstances, those who do access health services report discrimination and ill-treatment by health care providers (A. Daley, 2006).

An attempt was made to analyze the key sections on the different countries’ constitutions and try to fish out how these related to SRH uptake by SGM. The detailed findings from this policy review are presented in Table 4.

Table 4.

Policy Analysis

Policy	Content	Context	Actors	Strategies	Relationship with SRH
Constitution of Zimbabwe (2013)	The Supreme law of the country takes precedence over all the laws in the country.Stipulates the fundamental human rights and freedoms (right to life, human dignity, personal security, health care, marriage, profession, trade, or occupation)Recognizes the nation’s diverse cultural, religious, and traditional values	Implemented in a culture that only promotes heterosexual marriages or interactions and other types of marriages not recognized	The custodian of the Constitution is the judiciary and all arms of the governmentApplicable to all citizens of all age groups and organizations in Zimbabwe	Ensuring the protection of citizens by offering them quotas to ensure gender balance and offer equal representation in institutions and agencies	Prescriptive and suppresses some freedoms; for example, same-sex marriage is prohibited
Spain SRH policy	To guarantee fundamental sexual and reproductive health rights, regulate conditions for voluntary termination of pregnancy, and set out related obligations for the competent authorities.	Implemented in the context where government assures quality, comprehensive sexual health care services, and standards of care based on the best scientific knowledge available. Universal access to effective family planning practices through addition to the roster of National Health System services of state-of-the-art contraceptives whose effectiveness is supported by scientific evidence.	Government, women, council of ministers	To enact a sexual and reproductive health strategy	The policy ensures provision of quality pregnancy, childbirth, and postpartum services to women and couples. It is silent on persons who identify as LGBT
Ghana, Ghanaian anti-LGBT bill	To provide for proper human sexual rights and Ghanaian family values.	Implemented in the context where homosexuality in Ghana is criminalized under the Offenses Against the Person Act 1861.	Parliament, NGOs, and Christian council, applicable to all citizens of all age groups	Seeks to protect and support children, persons who are victims or accused of Lesbian, Gay, Bisexual, Transgender, Transsexual, Queer, Questioning, Intersex, Asexual, Allies and/or Pansexual and other (LGBTTQQIAAP+) and related activities and other persons, and related matters.	The bill bans LGBTQ+ and related activities; propaganda of, advocacy for, or promotion of LGBTTQQIAAP+ and related activities. As such, the bill hinders the LGBTQ from accessing SRH services.
China, Constitution of People’s Republic of China	The law of the country takes precedence over all the laws in the country.Stipulates the fundamental human rights	All people are equal before the law. And the State has the responsibility to protect its citizens from stigma and discrimination.	Government, NGOs, all citizens of all age groups, and organizations in China	Establish anti-discrimination laws and regulations to ensure that LGBT individuals and other populations, such as people with disabilities and people living with HIV, enjoy equal rights.	The Constitution does not ensure LGBT people enjoy equal rights, including SRH rights, as other citizens.The implemented policy framework does not fully guarantee all LGBTs’ health rights.
Iran, Islamic Penal Code of Iran, 2013, articles 233–41.	The Islamic Penal Code consists of crimes and punishments; the security and correctional measures, requirements and barriers of criminal responsibility; and the rules that apply to all citizensMaking health services physically and financially accessible to the entire population and removing social and cultural barriers of women’s access to health services are main considerations of the health laws and policies of Iran.	Implemented were discrimination based on gender in enjoyment of the right to health is prohibited.	Government, church (Islam), all citizens of the country	The country should remove the disparities and use all the necessary means including legislative, administrative, budgetary, promotional, and judicial measures monitoring system, and certain benchmarks for tracing the progress of the plans should be established.	The code outlaws same-sex relations as such LGBT people cannot enjoy SRH rights as other citizens.

Note. SRH = sexual and reproductive health; NGO = non-governmental organization; LGBTQ = lesbians, gays, bisexuals, transgender, and queer.

Uptake of SRH Services Among SGM

Fifteen research articles assessed uptake levels of SRH among SGM. Eight (53%) research articles reported that SGM had low uptake of SRH in different geographic locations. SRH uptake factors that promote uptake of SRH services among SGM were categorized into major themes related to clinical or health care settings; confidence to report the STIs suffered from; availability of SGM-specific services, drugs, and other medical supplies; and past experiences as presented in Table 5. Clinical or health care setting was one of the major factors that influence SRH uptake among SGM. The leading sub-themes that emerged include the availability of LGBT-friendly services, friendliness of health workers, inclusiveness of health facilities, and a perceived need for health care (refer to Table 5). Confidence to report the STIs they suffered from also affected access to diagnosis and quality health care services by the SGM (1 in 15; 6.7%). One of the factors identified that influence SRH uptake among SGM is the availability of SGM-specific services, drugs, and other medical supplies. From this major theme, different sub-themes emerged from the literature reviewed: no access to appropriate SRH services, hence the absolute rate of SRH services utilization remains low, and utilization of a wide range of services is hindered by stockout of drugs (refer to Table 5). Past experiences of SGM when accessing SRH services were also identified as a major factor that leads to low uptake of SRH services among SGM; refer to Table 5.

Table 5.

Uptake of SRH Services

Uptake of sexual and reproductive health services
Major theme	Sub-theme	Literature sources
Clinical setting (promotes uptake of SRH services among the SGM)	The availability of LGBT-friendly services	Alencar Albuquerque et al., 2016; Coşar, 2020; Delany-Moretlwe et al., 2015; Liang et al., 2022; Mancebo, 2020; Mkhize & Maharaj, 2020; Radix & Maingi, 2018; Ssekamatte et al., 2020; Tabaac, n.d.
	Friendliness of health workers
	Inclusiveness of health facilities
	A perceived need for health care
Confidence to report the STIs they suffered from.	A lack of confidence in the SGM affects access to diagnosis and quality health care services.	Tabaac, n.d.
Availability of SGM-specific SRH services.	No access to appropriate SRH services; hence, the absolute rate of SRH services utilization remains low.	Hubach et al., 2022; Müller, 2017; Müller et al., 2018
	The stock hinders the utilization of a wide range of services out of drugs	Mancebo, 2020; Ssekamatte et al., 2020
Past experiences	Some have never sought SRH services for different reasons (past experience).	Coşar, 2020
	Negative experiences with health care providers contribute to the erosion of a sense of safety in the healthcare system, and as a consequence, LGBT people avoid seeking care.	Mello, 2011; Müller, 2017
Utilization of SRH services	Utilization is high when there is access to free contraceptives at health centers	Alencar Albuquerque et al., 2016
Utilization of SRH services	Exclusion and marginalization lead to a reduction in attendance by SGM	Directorate & Board of Canada, 2009; Mello, 2011

Note. SRH = sexual and reproductive health; SGM = sexual and gender minorities; LGBT = lesbians, gays, bisexuals, and transgender; STI = sexually transmitted infection.

Barriers to SRH Uptake Among SGM

Thirteen studies discussed the barriers to SRH uptake among SGM in different locations. Barriers to SRH uptake were categorized into major themes: individual-level barriers, health care system–level barriers, and structural-level barriers, as presented in Table 6.

Table 6.

Barriers to SRH Services Uptake Among SGM

Barriers to SRH services uptake among SGM
Major theme	Sub-theme	Literature sources
Individual-level barriers to care	Low levels of education and knowledge of SRH	Hubach et al., 2022
Health-system-level barriers	Stigma, discrimination, or victimization at the hands of health care providers.	Coşar, 2020; Hubach et al., 2022; Müller et al., 2018
	Unavailability of specific sexual and reproductive health resources for LGBT people.	Logie et al., 2019; Narasimhan et al., 2020; Tabaac, n.d.
	Stockout of hormones, drugs, lubricants, and other medical supplies	Ssekamatte et al., 2020
	Inadequate availability of well-equipped treatment centers	Barbosa & Facchini, 2009; Coşar, 2020; Müller, 2017
	High cost of drugs	Alencar Albuquerque et al., 2016; A. E. Daley & MacDonnell, 2011
	Fear of health care providers	Liang et al., 2022; Müller et al., 2018; Ssekamatte et al., 2020
Structure-level barriers	Criminalization of same-sex marriages	Coşar, 2020; A. Daley, 2006; Ssekamatte et al., 2020; Mkhize & Maharaj, 2020; Müller, 2017; Müller et al., 2018

Note. SRH = sexual and reproductive health; SGM = sexual and gender minorities; LGBT = lesbians, gays, bisexuals, and transgender.

Individual-Level Barriers

This was one of the major barriers to SRH uptake among SGM. The sub-theme that emerged includes low levels of education and knowledge on SRH (2 in 13; 15.4%; refer to Table 6).

Health-System-Level Barriers

One of the barriers identified to influence SRH uptake among SGM is health care system–related factors. Stigma and discrimination were the leading sub-themes that emerged from obstacles that affected the uptake of SRH among SGM. Not only does stigma influence the low uptake of SRH among SGM, but it is also associated with the low willingness to use SRH services. The cost of drugs was noted to be the second leading barrier to influencing uptake among SGM under this theme (6 in 13; 46%). Other notable sub-themes identified were inaccessibility and inadequate specific sexual and reproductive health resources for SGM; stockout of hormones, drugs, lubricants, and other medical supplies; fear of health care workers; and negative attitudes by health care workers toward SGM. Lack of confidentiality by health care workers was also one of the barriers identified from the literature; refer to Table 6.

Structure-Level Barriers

This was among the identified major themes on the barriers to SRH uptake. One of the most common sub-themes that emerged from a number of research articles was criminalizing same-sex marriages (refer to Table 6).

Strategies to Aid the Uptake of SRH Services Among SGM

Sixteen research studies discussed the strategies to aid the uptake of SRH among SGM. These strategies were classified into major themes: individual-level strategies, health care system–level strategies, and structure-level strategies, as presented in Table 7.

Table 7.

Strategies to Aide Uptake of SRH Services

Strategies to aide uptake of SRH services by the SGM
Major theme	Sub-theme	Literature sources
Individual-level strategies	Education and outreach for SGM around SRH issues	A. Daley, 2006; A. E. Daley & MacDonnell, 2011; Liang et al., 2022; Radix & Maingi, 2018
Individual-level strategies	Self-care interventions
Health-system-level strategies	LGBTI affirmative training for health care providers	Glasier et al., 2006; Mkhize & Maharaj, 2020; Radix & Maingi, 2018
	Sensitization of the community on who the SGM persons are	Delany-Moretlwe et al., 2015; Mancebo, 2020
	Increased funding of SRH programs.	Narasimhan et al., 2020; Wingo et al., 2018
	Awareness and transparency of LGBTQI-focused services.	Delany-Moretlwe et al., 2015; Müller et al., 2018; A. E. Daley & MacDonnell, 2011; Dobinson et al., 2008; Radix & Maingi, 2018
	Specialization or integration of SRHS	Logie et al., 2019; Narasimhan et al., 2020
	Need for integrated stigma and discrimination mitigation strategies alongside self-care SRHR implementation.	Dobinson et al., 2008; Glasier & Gülmezoglu, 2006; Logie et al., 2019; Narasimhan et al., 2020
Structure-level strategies	Enactment of non-discrimination policy	Coşar, 2020; Delany-Moretlwe et al., 2015; Tabaac, n.d.
Structure-level strategies	Need for legislative reform	Coşar, 2020

Note. SRH = sexual and reproductive health; SGM = sexual and gender minorities; LGBTQI = lesbians, gays, bisexuals, transgender, queer, and intersex.

Individual-Level-Related Strategies

Different sub-themes emerged as the potential strategies to SRH uptake among SGM from the individual-level-related strategies. Education, dissemination of information and outreach for SGM around SRH issues (3 in 16; 19%), and the use of self-care interventions were among some identified strategies from the literature (refer to Table 7).

Health Care System–Level Strategies

From the factors related to the health care system level, the different sub-themes emerged as the potential strategies for SRH uptake among SGM. LGBTI-affirmative training for health care providers emerged as the most favored strategy to improve SRH uptake among this population. Availability and accessibility of specialized SRH services for SGM, increased funding of SRH programs, awareness and transparency of LGBTQI-focused services, and the existence of SGM-friendly facilities were among some of the identified facilitators from the literature. Other strategies include integrating stigma and discrimination-mitigation strategies alongside self-care SRHR implementation; refer to Table 7.

Structure-Level Strategies

From the structure level, related strategies leading sub-themes that emerged as the potential strategies to SRH uptake among SGM included enactment of non-discrimination policies (3 in 16; 19%) and the need for legislative reform; refer to Table 7.

Discussion

When certain groups of people, such as gay, bisexual, and transgender people, people who sell sex or use drugs, detainees, and prisoners, are excluded or ignored by policies, their communities suffer (Müller, 2017). Although most legislated policies are broad in scope and arguably cover “everyone” or “all persons” in their language, it is critical to have specific policies that address the needs of those groups who are more likely to be victims of societal prejudice, stigma, and discrimination (Alencar Albuquerque et al., 2016). As a result, policies should specifically mention these groups as part of a human rights–based approach to promoting and protecting their SRHR.

One of the study’s objectives was to investigate SGM’s global uptake of SHR services. According to the findings of this study, the average SRH service utilization was low overall (Zhao et al., 2022). This suggests that most SGM in the study lacked the WHO-recommended SRH service content. All these factors have also been noted to differ from one nation to another due to economic status, punitive laws toward homosexuals, culture, ethnicity, and other variables.

Literature has presented that most SGM does not opt for SRH services due to constitutions that criminalize same-sex relationship (Coşar, 2020). Punitive laws against same-sex marriages were mostly cited in a number of African countries as a barrier to influence uptake, such as Uganda (Kalichman et al., 2020) and Zimbabwe (Directorate & Board of Canada, 2009). The cost of services in Africa was not cited more often as a barrier because SRH services are usually donor-funded by different organizations such as The Global Fund, UNAIDS, and others; hence, SGM can access services for free (Narasimhan et al., 2020).

This review found an overall low uptake of SRH services in different countries, especially in low- and middle-income countries such as China (Liang et al., 2022), Uganda (Ssekamatte et al., 2020), Turkey (Coşar, 2020), and South Africa (Müller et al., 2018). It also revealed that SGM people were frequently victims of stigma, prejudice, and marginalization, for example, in South Africa, despite the Constitution’s strong emphasis on equality (Müller et al., 2018). In health facilities, certain SRH information and resources to raise awareness and meet the needs of SGM people were still lacking (Alencar Albuquerque et al., 2016). It also revealed that most health systems were planned and implemented in a way that was accommodating to heterosexual people, as most information and resources did not address the practical SRH health issues confronted by SGM populations (Delany-Moretlwe et al., 2015).

To improve the uptake of SRH, it is imperative to ensure the availability of SGM-specific services among this population. This is essential in ensuring services are available anytime and in SGM-friendly health care facilities. However, the availability of SGM-specific SRH on its own does not serve any purpose for SGM. In Zimbabwe, Population Service International provides most SGM-particular services for free to SGM. Yet, the uptake remains low due to poor health systems, which infringe on SGM’s rights to access sexual and reproductive health services (Directorate & Board of Canada, 2009). In addition, health care professionals require standard training in professional skills and ethical practices.

The study also identified some strategies that improve the uptake of SRH services among SGM. In general, SGM preferred clinical settings that were SGM-friendly and inclusive (Mkhize & Maharaj, 2020). However, it can be noted that even if clinical settings can be SGM-friendly and inclusive, it does not increase uptake of sexual and reproductive health services as there are other barriers noted among SGM, such as lack of knowledge on SRH services and confidence in seeking the services (A. E. Daley & MacDonnell, 2011).

Overall, literature on the effects of restrictive laws and policies and socioeconomic status on access to services was limited. Data on access to services and knowledge about the availability of SRH services by socioeconomic status, sexual orientation, gender identity, ethnicity, and geographical area were also scarce.

Limitation

The review’s limitation is that the analysis is not an in-depth one but provides a baseline of issues under consideration. In the assessment of SRH service uptake by SGM, identified numbers may not accurately depict this population’s current levels of SRH uptake.

Conclusion

The right to SRH includes the freedom to reproductive decision-making “free of discrimination, coercion, and violence,” access SRHR information and services, engage in consensual sex, and “make free, informed, and voluntary decisions” based on one’s “sexuality, sexual orientation, and gender identity.” As a result, the right to good SRH is inextricably linked to universal human rights principles. The SRH program is an important component of both short-term and long-term SRH needs. This scoping review uncovered numerous aspects of SGM inclusion and SRH service uptake in the most recently published literature (2006–2022), such as availability and utilization, impediments, and recommendations for enhancing SRH uptake. The number of studies on SGM and SRH uptake has increased over the years, indicating that SRH policies are beginning to be implemented in a significant number of countries to reach U.N. targets of universal health coverage for all by 2030. Despite these efforts, some (71) nations still have punitive laws that criminalize same-sex relationships, which has resulted in low SRH uptake among SGM and societal stigma and exclusion of SGM from sexual and reproductive health services in these countries. Health intervention initiatives targeted at improving or increasing SRH uptake must be supported by suitable legal and regulatory framework contexts and based on context-specific evidence. This review contributes to the body of knowledge by demonstrating various factors that influence SRH uptake among SGM and techniques that can aid health care uptake among SGM.

Footnotes

Author Contribution

MYK conceptualized the research idea and drafted the manuscript. WNN co-ordinated the manuscript writing process, guided the manuscript writing process, and revised the draft manuscript. Both authors read and approved the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate

A scoping review protocol was submitted for ethical approval to the Institutional Review Board at the National University of Science and Technology in Bulawayo, Zimbabwe. This ethics committee granted ethics clearance (Ethics number: NUST/IRB/2023/76). All the protocols that relate with handling of data were observed, and the PRISMA extension for systematic reviews was followed.

Consent for Publication

Not applicable.

ORCID iDs

Methembe Yotamu Khozah

Wilfred Njabulo Nunu

Availability of Data and Materials

Not applicable.

References

Alencar Albuquerque

De Lima Garcia

Da Silva Quirino

Alves

M. J. H.

Belém

J. M.

Dos Santos Figueiredo

F. W.

Da Silva Paiva

Do Nascimento

V. B.

Da Silva Maciel

É.

Valenti

V. E.

De Abreu

L. C.

Adami

. (2016). Access to health services by lesbian, gay, bisexual, and transgender persons: Systematic literature review. BMC International Health and Human Rights, 16(1), 1–10. https://doi.org/10.1186/S12914-015-0072-9/FIGURES/2

Barbosa

R. M.

Facchini

(2009). Access to sexual health care for women who have sex. Cad Saude Publica, 25(Supp 2), 291–300. https://doi.org/10.1590/s0102-311x2009001400011

Callahan

Chertack

Cleary-Sills

Daly

Hurley

Landry

(n.d.).Sexual and gender minorities and the sustainable development goals. United Nations Development Programme.

Constitution of Zimbabwe . (2013). Testimony of Government of Zimbabwe. https://www.constituteproject.org/constitution/Zimbabwe_2013.pdf

Coşar

(2020). Barriers encountered by young lesbian and bisexual women in accessing health care services: The case of Turkey. https://open.metu.edu.tr/handle/11511/45247

Daley

(2006). Lesbian and gay health issues: Outside of the health policy arena. Critical Social Policy, 26(4), 794–816. https://doi.org/10.1177/0261018306068474

Daley

A. E.

MacDonnell

J. A.

(2011). Gender, sexuality and the discursive representation of access and equity in health services literature: Implications for LGBT communities. International Journal for Equity in Health, 10(1), 1–10. https://doi.org/10.1186/1475-9276-10-40/FIGURES/1

Delany-Moretlwe

Cowan

F. M.

Busza

Bolton-Moore

Kelley

Fairlie

(2015). Providing comprehensive health services for young key populations: Needs, barriers and gaps. Journal of the International AIDS Society, 18(2 Suppl 1), 29–40. https://doi.org/10.7448/IAS.18.2.19833

Directorate & Board of Canada. (2009). Zimbabwe: Treatment of sexual minorities, including legislation, state protection, and support services (2009–March 2012).

10.

Dobinson

Macdonnell

Hampson

Clipsham

Chow

(2008). Improving the access and quality of public health services for bisexuals. Journal of Bisexuality, 5(1), 39–77. https://doi.org/10.1300/J159V05N01_05

11.

Glasier

Gülmezoglu

A. M.

(2006). Putting sexual and reproductive health on the agenda. The Lancet, 368(9547), 1550–1551. https://doi.org/10.1016/s0140-6736(06)69485-3

12.

Glasier

Gülmezoglu

A. M.

Schmid

G. P.

Moreno

C. G.

Van Look

P. F.

(2006). Sexual and reproductive health: A matter of life and death. The Lancet, 368(9547), 1595–1607. https://doi.org/10.1016/s0140-6736(06)69478-6

13.

Hoffman

N. D.

Freeman

Swann

(2009). Healthcare preferences of lesbian, gay, bisexual, transgender and questioning youth. Journal of the Adolescent Health, 45(3), 222–229. https://doi.org/10.1016/j.jadohealth.2009.01.009

14.

Hubach

R. D.

Zipfel

Muñoz

F. A.

Brongiel

Narvarte

Servin

A. E.

(2022). Barriers to sexual and reproductive care among cisgender, heterosexual and LGBTQIA+ adolescents in the border region: Provider and adolescent perspectives. Reproductive Health, 19(1), 1–11. https://doi.org/10.1186/S12978-022-01394-X/TABLES/2

15.

Kalichman

S. C.

Shkembi

Wanyenze

R. K.

Naigino

Bateganya

M. H.

Menzies

N. A.

Lin

C. D.

Lule

Kiene

S. M.

(2020). Perceived HIV stigma and HIV testing among men and women in rural Uganda: A population-based study. The Lancet HIV, 7(12), e817–e824. https://doi.org/10.1016/S2352-3018(20)30198-3

16.

Liang

Hee

Peng

Cao

Tang

(2022). Comparing access to sexual and reproductive health services among sexual minority youths and their peers: Findings from a national survey in China. BMC Public Health, 22(1), 1–9. https://doi.org/10.1186/S12889-022-14508-8/TABLES/3

17.

Lionço

(2008). What do health rights mean for the GLBT population? Considering human, sexual and reproductive rights in the search for equity and integrality in the health system. Saude e Sociedade, 17(2), 11–21. https://doi.org/10.1590/S0104-12902008000200003

18.

Logie

C. H.

Khoshnood

Okumu

Rashid

S. F.

Senova

Meghari

Kipenda

C. U.

(2019). Self care interventions for sexual and reproductive health: Self care interventions could advance sexual and reproductive health in humanitarian settings. BMJ, 365, Article L1083. https://doi.org/10.1136/BMJ.L1083

19.

Mancebo

M. E.

(2020). Sexual orientation and gender identity differences in initiation and utilisation of sexual and reproductive health services. https://shareok.org/handle/11244/330820

20.

Mello

Peril o

de Braz

C. A.

Pedrosa

(2011). Health policies for lesbians, gays, bisexuals, transsexuals and transvestites in Brazil: The pursuit of universality, integrality and equity. Sexualidad Salud y Sociedade, 9, 7–28.

21.

Mkhize

S. P.

Maharaj

(2020). Structural violence on the margins of society: LGBT student access to health services. Agenda, 34(2), 104–114. https://doi.org/10.1080/10130950.2019.1707000

22.

Müller

(2017). Scrambling for access: Availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa. BMC International Health and Human Rights, 17(1), 1–10. https://doi.org/10.1186/S12914-017-0124-4/PEER-REVIEW

23.

Müller

Spencer

Meer

Daskilewicz

(2018). The no-go zone: A qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa. Reproductive Health, 15(1), 1–15. https://doi.org/10.1186/S12978-018-0462-2/TABLES/2

24.

Narasimhan

Logie

C. H.

Gauntley

Gomez Ponce

Leon

Gholbzouri

Siegfried

Abela

Ouedraogo

(2020). Self-care interventions for sexual and reproductive health and rights for advancing universal health coverage. Sexual and Reproductive Health Matters, 28(2), Article 1778610. https://doi.org/10.1080/26410397.2020.1778610

25.

Radix

Maingi

(2018). LGBT cultural competence and interventions to help oncology nurses and other health care providers. Seminars in Oncology Nursing, 34(1), 80–89. https://doi.org/10.1016/J.SONCN.2017.12.005

26.

Sert

Narman

İ.

Erkan

Emre

Ö.

Özden

Tursun

Başar

(2019). General comment no. 22 (2016) on the right to sexual and reproductive health (Article 12 of the international covenant on economic, social and cultural rights). Turkish Journal of Bioethics, 6(2), 65–81. https://doi.org/10.5505/TJOB.2019.99389

27.

Ssekamatte

Isunju

J. B.

Naume

Buregyeya

Mugambe

R. K.

Wanyenze

R. K.

Bukenya

J. N.

(2020). Barriers to access and utilisation of HIV/STIs prevention and care services among trans-women sex workers in the greater Kampala metropolitan area, Uganda. BMC Infectious Diseases, 20(1), 1–15. https://doi.org/10.1186/S12879-020-05649-5/TABLES/2

28.

Tabaac

A. R.

(n.d.). Queer health equity and cervical cancer: Identifying social determinants of Papanicolaou test uptake in a sample of sexual minority women and gender nonbinary individuals [PhD Thesis, Virginia Commonwealth University]. https://scholarscompass.vcu.edu/etd/5324

29.

Wingo

Ingraham

Roberts

S. C. M.

(2018). Reproductive health care priorities and barriers to effective care for LGBTQ people assigned female at birth: A qualitative study. Women’s Health Issues, 28(4), 350–357. https://doi.org/10.1016/J.WHI.2018.03.002

30.

Wirtz

A. L.

Kamba

Jumbe

Trapence

Gubin

Umar

Strömdahl

S. K.

Beyrer

Baral

S. D.

(2014). A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi. BMC International Health and Human Rights, 14(1), Article 20. https://doi.org/10.1186/1472-698x-14-20

31.

Zhao

Luo

(2022). Risky sexual behaviour and HIV testing uptake among male college students: A cross-sectional study in China. BMJ Open, 12(6), Article e054387. https://doi.org/10.1136/BMJOPEN-2021-054387