Sexual orientation-related disparities in unintended pregnancies by state-level policy and structural contexts

PROJECT SUMMARY/ABSTRACT Sexual minority women (SMW; e.g., those with same-sex partners or attractions, or identify as lesbian, gay, or bisexual) are subjected to stigma and discrimination. They also disproportionately experience poverty, sexual violence, and limited access to high-quality reproductive healthcare (including family planning services). As a

result, SMW may have higher rates of unintended pregnancies than their heterosexual peers. Particular sub- groups of SMW may suffer from greater disparities. First, SMW who are racial/ethnic minorities may experi- ence greater disparities than white SMW due to their multiple marginalization. Second, SMW who live in states

with restrictive policies—including those related to reproductive health (e.g., abortion/contraception) or discrimi- nation (reflective of sexism/heterosexism)—may experience greater disparities due to having less access to reproductive healthcare and greater exposure to discrimination. Furthermore, as access to abortion is re-

stricted, especially post-Dobbs, more unintended pregnancies will be carried to term, and thus, increasing risk for adverse perinatal outcomes. However, we do not know the extent to which state-level reproductive health and discriminatory policies impact SMW, particularly those who are racial/ethnic minorities. This project will use

longitudinal data from the Growing Up Today Study (N=15,044) and Nurses’ Health Study 3 (N>51,094, open cohort) to investigate the sexual orientation-related disparities in unintended pregnancies and resulting adverse perinatal outcomes (Aim 1) and quantify the intersectional disparities in these outcomes among those doubly

minoritized by sexual orientation and race/ethnicity (Aim 2). I will also determine the extent to which state-level reproductive health (abortion/contraception) and discriminatory (sexist/heterosexist) policies modify these dis- parities, and the extent to which individual-level experiences of violence and discrimination ameliorate or exac-

erbate policy impacts (Aim 3). This work is timely as reproductive health policies have become more polarized since the Dobbs decision, and discriminatory policies impacting SMW have dramatically increased. This work is also innovative because the geographic spread of participants and ~30-years of ongoing follow-up will allow

me to examine impacts of policy changes over a long time period, how changes in sexual orientation identity impacts changes in disparities, and how moving to more or less restrictive states impacts unintended pregnan- cies among SMW. This award aligns with NICHD’s scientific priority to understand the impacts of reproductive

health policy changes in an NIH health disparities population, SMW. I will obtain advanced training in intersec- tionality and policy surveillance methods. This training and research will be critical for helping me build an inde- pendent career in quantifying how policies and structures affect reproductive health outcomes and reproductive

agency. The proposed research is an essential next step towards (1) identifying particular harmful policies for policy change, (2) elucidating the mechanisms by which state policies affect unintended pregnancies and their outcomes among SMW, and (3) laying the foundation for similar research in other stigmatized populations.