“It’s ironic to me, in a really sad way, because so much of transphobia and transmisogyny is focused on the genitalia of a person, and in this instance our reproductive organs suddenly don't matter."

Awareness in the medical field of a need for trans inclusion has grown in recent years, yet much of the discussion surrounding reproductive health care—from routine checkups to abortion access—still centers on cis women, leaving many trans men and other trans people assigned female at birth (AFAB) feeling invisible.

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Despite working in the medical field for 15 years—six as an emergency medical technician and nine as a paramedic—Don Altemus rarely gets routine reproductive health-care examinations because they are often awkward for him as a trans man.

“I happen to have a very masculine presentation,” he told Rewire.News, “And long before my transition, people ‘read’ me as male.”

Altemus recalled one incident in which he went for a mammogram and was told not to answer certain questions about pregnancy and menstruation on his paperwork. The questions were “very valid for my body,” he told Rewire.News, “but I was told to skip them based upon my appearance.” When it was finally his turn, the technician didn’t know whose name to call. “The tech was confused because the name on her form was generally associated with a woman,” he told Rewire.News. “Although I was uncomfortable, I had to ask her if she was looking for me.”

As Rewire.News has previously reported, trans people face many obstacles while seeking reproductive health care, including medical providers who don’t understand trans issues and harassment from staff. Awareness in the medical field of a need for trans inclusion has grown in recent years, yet much of the discussion surrounding reproductive health care—from routine checkups to abortion access—still centers on cis women, leaving many trans men and other trans people assigned female at birth (AFAB) feeling invisible. Recent attacks on reproductive health access, like the wave of statewide abortion bans, the federal Title X domestic “gag rule,” and the U.S. Department of Health and Human Services’ “moral conscience” rule that will allow doctors to refuse to treat trans people based on religious beliefs, make the situation worse: They will make it even harder for an already vulnerable population to obtain care.

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“It’s hard to erase something that wasn’t even included in the conversation in the first place,” Washington, D.C.-based storyteller Morgan Givens told Rewire.News. Givens has faced many obstacles navigating the medical system to find proper health care, including having his medical concerns taken seriously. “It’s ironic to me, in a really sad way, because so much of transphobia and transmisogyny is focused on the genitalia of a person, and in this instance our reproductive organs suddenly don’t matter.”

Luc Athayde-Rizzaro, policy counsel for the National Center for Transgender Equality (NCTE), told Rewire.News that while the health-care system has made tremendous progress regarding trans inclusivity, there are many areas in which it needs to improve. One in four respondents to the NCTE’s 2015 U.S. Transgender Survey said they avoided seeking medical care, for example, out of fear of discrimination, and a third of respondents said they had experienced discrimination of some kind from health-care providers. The survey also found that trans people are less likely to get Pap smears than cis women are.

“There are barriers every step of the way: In understanding they’re welcomed somewhere, being able to go there [and] overcoming … fear of discrimination, and then being seen in an environment that is welcoming to trans folks,” Athayde-Rizzaro said. “And then if everything goes well, sometimes you can have that last challenge of being able to get insurance coverage.”

Both Givens and Athayde-Rizzaro agree that the recent attacks on reproductive health care as a whole will affect AFAB trans people of color more than AFAB trans people who are white. First, according to the Guttmacher Institute, people of color are more likely to get abortions than white people. Second, Athayde-Rizzaro told Rewire.News, “People of color tend to be lower income, so transgender people of color do not have the means … to be able to travel out of state to be able to access abortion.”

In addition, because it offers so many services to trans people, Planned Parenthood is often the only place many trans people can go to receive medical care. Advocates fear the Title X “gag rule,” which targets clinics like Planned Parenthood affiliates that provide abortions or refer people to abortions, will make access to reproductive health care more difficult for trans people, especially those of color.

“You can’t discount all of these things that specifically target trans people,” Givens told Rewire.News, “and then on top of that you’re going to add in institutionalized racism? You’re going to have that white supremacy, where our needs are discounted as if they’re not as important as the needs of some white folks.”

He perceives the discussion about reproductive health care and abortion rights as being centered particularly on white, cis, straight women.

“The fact that I am a trans man and I’m a Black trans man,” Givens told Rewire.News, “doesn’t take away from the fact that I still have a uterus. I still have ovaries. I still have all these parts of my body that need to be maintained and cared for. If you are already ignored and now people are giving permission to deny you access to reproductive health care, how does it get better from there?”

There is a growing effort among some advocates and allies to make the discussion surrounding reproductive justice more trans inclusive. During a recent commencement speech at Pitzer College in Claremont, California, Laverne Cox reminded the audience, “When we use language that excludes groups of people on pertinent issues, it can jeopardize their health and well-being. Language that is appropriate and fully inclusive is a matter of life and death for so many people out there.”

Democratic presidential candidate Julián Castro made such an attempt at inclusion during last week’s debate. He did mistakenly say “trans female” instead of “trans men,” but apologized for his error on Twitter the next day.

There are also ways to make reproductive health care more accessible to AFAB trans people, and the main one is education. “At this point in time,” Givens told Rewire.News, “why are you hiring doctors who say, ‘I don’t know how to treat a trans person?’ I got a human body. I am a person, I am a full person. This needs to be part of and integrated into medicine as a whole.” He also believes insurance companies should be more open about how they cover trans-related health, and it should be illegal nationwide for doctors to refuse to treat trans patients—a refusal that, by contrast, is in the process of being explicitly protected by the Trump administration.

“If you want to allow malpractice [lawsuits] or whatever the case may be [for] cis heteronormative people,” Givens told Rewire.News, “how can you then in good conscience turn around and allow this to happen to me?”

“Often the bodies of trans people are somehow portrayed as complex and difficult to deal with,” Athayde-Rizzaro told Rewire.News, “but really we’re all just humans and the same kind of basic medical school or nursing school or PA school education that people receive should be sufficient for somebody to know how to take care of a transgender person.”

On Monday, the American College of Physicians issued its first guidelines about the best practices around trans care. Unfortunately, Athayde-Rizzo told Rewire.News, trans bodies are still a mystery to many medical providers. “Signaling to patients that they are welcome there,” Athayde-Rizzaro said, “and then doing the work to make sure that you’re treating them with respect are really the two main things that providers can do to ensure access to care.”