Improving Service Delivery by Understanding Family Planning Clients’ Experiences With Unfair Treatment

---

Child Trends surveyed 1,016 individuals ages 18 to 34 who had been assigned female at birth, who had recently received family planning care, and who were income-eligible for publicly funded services.[1] Respondents were asked whether the provider or clinic staff at their most recent reproductive health visit had treated them unfairly or made them uncomfortable for reasons related to their age, race/ethnicity, gender or sexual identity, or sexual or reproductive history. Respondents could choose multiple reasons they felt described their unfair treatment; alternatively, they could select that they were not treated unfairly during their visit.[2]

We found that:

• One in six survey respondents reported that they had been treated unfairly by a family planning provider or clinic.
• Clients who were non-Hispanic Black, LGBTQ, younger, or had lower incomes were more likely to report unfair treatment.
• The most common reasons for unfair treatment cited were related to age, sexual or reproductive history, and race or ethnicity.
• Most clients (72%) who reported unfair treatment also reported responding in some way (e.g., deciding not to share certain information, trying to end an appointment early, giving providers feedback, forgoing treatment, planning a future visit with a different provider or clinic).

---

Findings

Reports of unfair treatment differed by client characteristics

One in six respondents to our survey (17%, n=168) reported unfair treatment for at least one reason (Figure 2). Furthermore, those with marginalized identities experienced unfair treatment at higher rates. More than one quarter of LGBTQ respondents (26%) reported unfair treatment—twice the percentage reported by those who are not LGBTQ (13%). Twenty-one percent of non-Hispanic Black respondents reported unfair treatment, compared to 14 percent of Hispanic and non-Hispanic White respondents. One fifth of those with incomes below 100 percent of the Federal Poverty Line (FPL) and of younger respondents (ages 18-24) reported unfair treatment.

---

Figure 2: Non-Hispanic Black clients, LGBTQ clients, clients with lower incomes, and younger clients were more likely to report unfair treatment from family planning providers

Percentage of family planning clients reporting unfair treatment for any reason

*p<.05 ^p<0.1

^a The difference between Black non-Hispanic respondents and all other respondents is statistically significant (p=.022).

---

Reasons for unfair treatment varied by client characteristics

Among all clients who reported any unfair treatment, the most common reasons were their age (34%); their sexual or reproductive history, including number of partners and past pregnancies, births, or abortions (32%); and their race or ethnicity (30%). Clients’ gender or sexual identity and their size or physical appearance were also frequently reported as reasons for unfair treatment. Additionally, respondents could report multiple reasons for unfair treatment and almost half (46%) did so. The most commonly reported reasons for unfair treatment by client characteristics are summarized below and in Figure 3.

• Unfair treatment due to age was the top reason for clients overall and in the top three reasons for all client subpopulations except non-Hispanic Black clients.
• Unfair treatment due to sexual or reproductive history was one of the top three reasons reported by all client populations except those with incomes under 100 percent FPL.
• Unfair treatment due to race or ethnicity was a top three reason for non-Hispanic Black clients, cisgender/heterosexual clients, those with incomes under 100 percent FPL, and clients ages 25 to 34.
• Unfair treatment due to gender or sexual identity was a top three reason for non-Hispanic Black respondents, LGBTQ respondents, those with incomes under 100 percent FPL, and clients ages 18 to 24.
• Unfair treatment due to size or physical appearance was a top three reason for non-Hispanic White and Hispanic clients, those with incomes above the federal poverty level, and clients ages 25 to 34.

---

Figure 3: Clients’ reported reasons for unfair treatment varied across several characteristics

Top three reasons for unfair treatment among those who reported any unfair treatment, as well as percentage selecting each reason

* Data suppressed due to small cell size (n<10). Notes: 1) This table only includes the reasons that were a top three reason for at least one group. The appendix table provides full data on the reasons for unfair treatment. 2) 14 individuals reporting unfair treatment did not identify as Hispanic, non-Hispanic Black, or non-Hispanic White. They are included in the total, but top reasons for this subgroup are not included in this table due to small sample sizes (n<10 for each reason).

---

Many clients actively responded to unfair treatment

Survey clients who reported unfair treatment were asked how, if at all, they had responded to their experience; participants could select more than one response (Figure 4) and could also select “Other” and write in a response. Nearly three in four respondents (72%) who had experienced unfair treatment reported that they had actively responded to their treatment. Nearly one third of clients (32%) did not ask some questions or share information they had otherwise wanted to ask/share, and nearly as many (30%) tried to end their appointment quickly. Other clients booked or planned to book their next visit with a different provider or clinic (20%), gave feedback to the provider or clinic (17%), or decided not to ask for or receive the medical help or treatment they had wanted or needed (17%). Notably, however, 28 percent of clients reporting unfair treatment took none of the actions offered as responses in the survey question.

---

Figure 4: Nearly three in four clients (72%) who experienced unfair treatment reported an active response to this treatment

Percentage of respondents reporting each type of response to unfair treatment

Note: Of the 168 respondents who reported unfair treatment, 5 did not respond to the question about responses to unfair treatment. They are not included in our analyses of responses to unfair treatment. There was one write-in response, which was recoded to an existing category.

---

Discussion

Overall, our findings highlight the potential negative health impacts of providers’ discriminatory treatment of family planning clients. We found that non-Hispanic Black respondents, LGBTQ respondents, respondents with lower incomes, and respondents ages 18 to 24 were more likely than their counterparts to report unfair treatment during their most recent family planning visit. In evaluating unfair treatment by subpopulation, it’s important to note that all individuals have multiple identities that combine and interact in complex ways to impact how they experience marginalization and discrimination (a framework known as intersectionality). While our analyses did not account for this, previous research has found that individuals with multiple marginalized identities may experience discrimination due to overlapping systems of oppression like racism, sexism, and heterosexism.

In our analysis, those who were treated unfairly were most likely to report their age, sexual/reproductive history, or race/ethnicity as reasons for unfair treatment, followed by their size or physical appearance or their gender or sexual identity. These findings align with previous research finding that people of color, adolescents and young adults, those with larger bodies, and LGBTQ people are more likely to report discriminatory treatment and other negative interactions with health care providers. Size or physical appearance as a commonly reported reason for unfair treatment aligns with research on the high prevalence of weight bias among health care providers, which has been found to lower the quality of patient-physician communication.

Previous experiences with discrimination and bias may discourage people from seeking health care, receiving preventive screenings, and sharing health information with providers, and may cause them to switch health care providers. Our findings align with this research, with approximately 72 percent of our respondents who experienced unfair treatment taking actions that included trying to end their appointment quickly, deciding not to share necessary medical information, deciding not to ask for or receive the care they needed, or planning to switch providers. However, approximately one in four respondents indicated taking no action. Some patients may not have the option to switch providers or clinics or may not have an opportunity to share feedback or feel comfortable doing so.

Although not measured in our study, discrimination and poor provider-patient communication have also been linked to negative attitudes toward contraception, reduced contraception use, and lower method satisfaction among those not seeking pregnancy, and to poor maternal and infant health outcomes.

---

This publication was supported by the Office of Population Affairs (OPA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,548,353 with 100 percent funded by OPA/OASH/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by OPA/OASH/HHS, or the U.S. Government. For more information, please visit https://opa.hhs.gov/.

---

Acknowledgments

The authors would like to thank Emma Pliskin, Kylee Novak, and Brent Franklin for their reviews of this brief and Catherine Nichols for her visual design work. We would also like to thank our project officer, Callie Koesters, for her thought partnership throughout the project and her review of this brief.

---

---

Footnotes

[1] For more information about the survey sample, see Child Trends’ methods brief.

[2] The response options included: a) not applicable – I was not treated unfairly; b) your race or ethnicity; c) your gender or sexual identity, d) your relationship status; e) a disability or health condition; f) your size or physical appearance; g) your age; h) your religion, language, citizenship status, or other aspects of your culture; i) your income or health insurance status; j) your sexual or reproductive history, including number of partners and past pregnancies, births, or abortions; and k) other (write-in).

---

Appendix Table: Number and percent of respondents reporting each reason for unfair treatment, among those reporting any unfair treatment (full survey data)

Notes: NH = non-Hispanic; LGBTQ = lesbian, gay, bisexual, transgender, queer/questioning, FPL = Federal Poverty Line. Data are suppressed for cells where n<10 Improving Service

---