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“It’s a walk of shame”: Experiences of unintended pregnancy and abortion among sexual- and gender-minoritized females in urban India

Background: Unintended pregnancy and safe abortion access in India remain critical public health concerns. The health of sexual- and gender-minoritized females (SGMF; those assigned female at birth and identify as other than heterosexual and/or as other than cisgender women) in India is understudied. Aim: We examined experiences of unintended pregnancy and abortion among SGMF individuals in urban India. Methods: We used focus group discussions (n = 8 individuals in two groups) and interviews (n = 20) with SGMF individuals. Data were collected in December 2017. Transcripts were analyzed using a priori thematic analysis and then open thematic analysis in Dedoose online software. Results: Nine participants experienced or suspected they had unintended pregnancies. Pregnancy circumstances were mostly due to sex without using a barrier method. Participants discussed using traditional methods to induce abortion or changing their approach to contraception. Social support was often lacking, though partners were supportive of abortion choices. Participants reported stigma and surveillance from family, friends, providers, and community members. Conclusion: These findings highlight the effects of stigma in relation to abortion and unintended pregnancy on health and relationships.


Introduction
Universally, unintended pregnancy and safe abortion access remain critical public health concerns. Unintended pregnancy often carries stigma, 1 associated with challenging decisions regarding parenting, adoption, or abortion. 2,3 On a global scale, abortion rates for upper middle-income countries have consistently declined over the past 20 years, and lower middle-income countries have continued to witness a steady increase. Many of these abortions can be attributed to the lack of primary reproductive health services linked with expanding populations in rural areas. 4,5 In 2015, researchers found that approximately half of all pregnancies in India were labeled as "unintended" with nearly one-third of all pregnancies ending in abortions, equating to about 15.6 million per year. 5 "It's a walk of shame": Experiences of unintended pregnancy and abortion among sexual-and gender-minoritized females in urban India In 1971, abortion was legalized in India through the Medical Termination of Pregnancy Act (MTP Act), which authorizes abortions up to 20 weeks of pregnancy with specific limitations (including physical injury, mental health, in cases of economic or social necessity, in cases of rape for married women, or likely physical or mental disabilities for the child). 6 Another study from India found that only 31% of reported reasons for abortion fell under the guidelines laid out by the MTP, while the vast majority cited that the pregnancy was unwanted. 7 Abortions among unmarried women in particular appear to be relatively common. A study out of northeast India found that nearly three-quarters of women opting for a first-time abortion were unmarried and seeking abortion due to socioeconomic reasons. 8 Unmarried women in India seek abortions for a variety of reasons, including the negative perception and social stigma associated with pregnancy outside of marriage, experiences of domestic violence, costs associated with childbearing, work-related pressures, and desires to continue education. [9][10][11] Abortions outside of marriage were often characterized by the need for secrecy and perceived stigma, particularly among young people, as minors are required to get guardian consent for the procedure under the MTP. 12,13 For unmarried women over the age of 18, lack of partner or family support may exacerbate access barriers if providers insist on obtaining consent from relatives or the other person involved in the pregnancy. 9,11,[13][14][15][16] Given the pervasive stigma around unintended pregnancy outside of marriage, younger women are also more likely to identify and disclose their pregnancies later in gestation, given amid fear of social repercussions. 9,11,13,16 Unmarried women are more likely to access abortion later in pregnancy, to utilize informal providers, and abortion self-management (with limited options for self-management later in pregnancy) due to their concerns regarding confidentiality. 9,17 Barriers such as lack of mobility and lack of financial resources may also influence the decision to seek abortion outside medical settings. 13 Characteristics such as being older and having more formal education are associated with obtaining abortion earlier in pregnancy among unmarried women. 11 Beyond policy barriers, clinics and providers may act as gatekeepers for abortion in India. Although spousal or familial consent is not legally required for adults seeking abortion in India, studies have documented medical providers create and enforce their own rules regarding external consent for abortion. 7,14 Other studies have documented stories from married women wherein providers were reluctant to perform later abortions due to concerns about sex selective motives, suggesting further potential barriers exacerbated by the medical community. 7 Despite the passage of the MTP Act, people in India may use alternative methods than medical abortions as they navigate existing barriers and stigma. Those who lack access to abortion through trained and licensed doctors and safe medical facilities may turn to pharmacists to procure medication kits (typically consisting of mifepristone and misoprostol) to self-manage their abortion at home. 26 Due to these drugs availability, many people depend on these medications to terminate their pregnancy without first consulting a physician. Life-threatening complications are not uncommon in people administering these drugs by themselves. 27 Banerjee et al. 18 focused on 381 women in India with post-abortion complications and found that 53% of these women first attempted a self-induced abortion. Of those women, 95% had related complications.
Alternately, people may seek unqualified vendors of medication or use traditional medicine to induce and selfmanage abortion. 5 Other reasons for self-induction included avoiding the logistical issues and inconvenience associated with traveling to a hospital for an abortion procedure, as well as the ability to discreetly terminate a pregnancy without having to explain absences from the home to relatives. 26 Despite a body of research examining unintended pregnancy and abortion experiences in Indian women, previous work has yet to examine experiences of unintended pregnancy and abortion among sexual-and gender-minoritized females (SGMF; i.e. those assigned female at birth whose sexual identity is other than heterosexual, such as lesbian, bisexual, and/or whose gender identity is other than cisgender woman, such as genderqueer or nonbinary). Evidence from industrialized Western countries indicates higher rates of unintended pregnancies among SGMF compared with heterosexual female individuals. [19][20][21] Homophobia, transphobia, cisnormativity, and heteronormativity have been cited as driving negative health outcomes among SGMF people for many common reproductive health issues (e.g. pap screenings, cancer rates). 22,23 Studies examining abortion experiences among transgender and gender expansive people in the United States indicate that identity-related denial or care and mistreatment by medical practitioners leads some people to consider or attempt self-managed abortion. 24 Self-management through the use of medication, or in some cases use of herbs, was also perceived to be less invasive and to offer more privacy than clinicbased abortion. 25 This may be particularly salient in settings that do not have competency in transgender or gender-inclusive health care. 28 Research with SGMF in India has documented how stigma related to sexual and/or gender identity affects some aspects of reproductive health and sexual autonomy, including family formation, intimate and family relationship support, and access to contraception. [29][30][31] However, studies have yet to examine this in relation to abortion. Although it is likely that some issues surrounding unintended pregnancy and abortion among SGMF people in India apply to females in general (e.g. reasons for abortion, abortion stigma), SGMF individuals in India may be subject to additional barriers to access, including identitybased discrimination and isolation. This study seeks to examine experiences of unintended pregnancy and abortion among SGMF in urban India.

Materials and methods
This is a multi-method qualitative study using focus group discussions and interviews. We partnered with two community organizations, Nirangal in Chennai and Kolkata Rista in Kolkata. Community partners collaborated on protocol development, participant recruitment, data collection, analysis, and dissemination. Recruitment messaging advertised a study about contraception and sexuality. We conducted two focus group discussions with SGMF in Bangalore (n = 4) and Chennai (n = 4) in December 2017. We conducted semi-structured in-person interviews with SGMF in Bangalore, Chennai, and Kolkata (n = 20). Eligibility criteria included being at least 18 years of age and identifying as something other than "heterosexual" and/or "cisgender." Because of our focus on pregnancy and abortion for the present analyses, this article focuses on participants who were assigned female at birth, though the full study included those who were assigned male at birth as well. Participants were recruited through community partners' social media and word of mouth in a convenience sample, and were compensated with 500INR (about US$8). No participants dropped out, though due to passive recruitment we do not know how many participants saw the recruitment but did not participate.
Before the study, participants did not know the US-based team members but knew at least one community partner. Participants were told that the researchers were from a US university, had conducted previous research with SGM individuals, and were interested in how SGM individuals in India were thinking about sexuality. All participants gave verbal consent to proceed to the interview or focus group, as the research team's previous experience with SGM research in India included fears of stigma related to identity disclosure with written names. The Institutional Review Board at Indiana University, Bloomington approved all research protocols (#1710732738).
Both the interviews and focus groups were conducted in participants' preferred language (Bangali, English, Hindi, and/or Tamil) in community venues such as SGM community centers or a rented conference room with only participants and researchers present. Focus group discussions and interviews were co-facilitated/conducted by US-based researchers with community partners (J.B., M.S., V.S., B.L.), lasting between 30 and 90 min. Team members based in the United States were all white, cisgender, and born in the United States. Team members based in India were all gender and/or sexual minority individuals from India. Nearly all team members had conducted research with SGM individuals in India previously. Participants selected their own pseudonyms which will be used in this article. (We use "they/them/theirs" when referencing individual participants because of unknown or inconsistent pronoun collection.) Both methods were audio-recorded and translated and transcribed; field notes were collected which informed probes for subsequent interviews. We used Dedoose online qualitative software 32 to analyze the data, with each transcript coded by two coders from the full team of four coders. A priori coding based on interview and focus group discussion guides was used first, followed by open coding of additional themes from the collected data. 33 Interrater reliability was confirmed through the "test" function of Dedoose. Codes with a Cohen's Kappa less than 0.80 were discussed and refined by the coding team. The team then conducted inductive thematic analyses by grouping common concepts to form themes. 33 See Table 1 for the coding tree of relevant themes. Coders used the memo function in Dedoose, or electronic notes attached to excerpts; these informed discussions of bias, influenced by social locations and personal experiences. 34

Results
Among the 28 participants, nine participants reported experiences with unintended pregnancies or unconfirmed/ suspected pregnancies (see Table 2 for included participant demographic information). The recency of unintended pregnancy experiences ranged from a few months to years prior to participation in the study. Participants reflected on the circumstances in which they became pregnant, emotional and behavioral reactions to the pregnancy or suspected pregnancy, pregnancy decisions and abortion care seeking, and barriers to care, which occurred across personal, interpersonal, organizational, and cultural levels. Participants described negative emotional reactions upon realizing they were pregnant, were often unaware of their options (e.g. methods of abortion), faced isolation and

Pregnancy circumstances and personal reactions
Participants discussed their contraception (or lack thereof) with partners at the time that they realized they were pregnant. Finding out about pregnancy caused negative emotional reactions as well as actions to prevent future unintended pregnancies. Lack of condom use was attributed to a variety of factors, including lack of access, getting caught up in the moment, sexual coercion, and preference for other methods of contraception. (For more information on participants' reasons for and against contraceptive use, see Simmons et al., 2020.) Reflecting on a budding relationship, Asma related the fear they and their partner experienced after they got caught up in the moment during sex and failed to use a condom ( Participants who had experienced a confirmed (such as through a pregnancy test) or unconfirmed unintended pregnancy expressed a number of negative emotional reactions to the situation. Fear, worry and concern, and self-blame were common. This was exacerbated for Aquafina who experienced a second unintended pregnancy ( Responding to the fear experienced surrounding an unintended pregnancy, Pompi expressed the desire to take action to avoid another such situation ( Similarly, after experiencing an unintended pregnancy in graduate school, Jia became insistent about male partners wearing a condom during sex (Table 3, 1.1f). Jia is describing the care in which they took to taking contraceptive pills but still having a pregnancy and resulting abortion. Karla described less fear due to knowing their menstrual cycle and having a partner helping to prevent pregnancy (Table 3, 1.1 g). Karla also presents a counter viewpoint from others, as abortion is viewed as part of a holistic plan to avoid childbearing.
Pregnancy options. Participants generally described not knowing what options were available when first finding out or suspecting they were pregnant, from how to confirm a pregnancy to ways to end the pregnancy. Aquafina was unsure what to do with the pregnancy test (Table 3, 1.2a). Shivvie describes the many processes and decisions that they began when they were pregnant (Table 3, 1.2b). When Karla suspected they might be pregnant, they turned to traditional means of inducing menstruation, rather than seeking medical care through a physician (

Social support (or lack thereof)
In general, many participants operated in isolation while making decisions in relation to an unintended pregnancy without partner or family support. Shivvie described the fear that isolation instilled (Table 3, 2a). Like Shivvie, Aquafina did not know who would be the best person to (f) "What ended up happening is he [my boyfriend] took me to a maternity clinic which is a little far from my house, 'cause we had to get as far away as possible from my place. We can't be anywhere there, so we went all the way over there and this is the time I was still living with my grandparents . . . After class one day we just went to the maternity clinic and the doctor checked and I was in my first trimester and she was like 'Two more weeks and I cannot abort this child' . . . She was like 'Okay, there are two options. We can either surgically remove it, or we can use the pill, but I will ask you to surgically remove it because it's a lot less pain and you are a smaller-bodied person and it will get over faster' and my boyfriend was kind enough to be like 'I'll obviously pay for most of it'."-Pooja's (Bangalore, 22 years, genderfluid, homosexual) lend support and described that support was conditional (Table 3, 2b). Beyond conditional support, Aquafina points to others' involvement in Aquafina's contraceptive decisions and resulting discomfort. Support was not only emotional but tangible, such as the need for money for abortions (Table 3, 2c).
In the initial stages of decision making, partners were not always supportive as Jia previously described their partner laughing upon finding out about the pregnancy. Shivvie described having "no idea" during their first sexual experience when their partner gave them "the pill that should be taken within 72 hours" (emergency contraception) and they later missed their period (Table 3, 2d). Pooja's gratitude when a partner asked them about their own desires in relation to an unintended pregnancy provides evidence for the general lack of support from partners (Table 3, 2e).

Anticipated judgment
Participants discussed concerns with stigma and surveillance at pharmacies, clinics, as well as from family members. Annette not only faced the barrier of judgment at the pharmacy, but also described a lack of trust in methods of testing for pregnancy (Table 3, 3a). Many participants had minimal to no support through the process and were faced with questions about their husbands and/or fathers when they accessed care for unintended pregnancies (Table 3, 3b).
Jia navigated providers' stigma about their unmarried status by going to three different providers (Table 3, 3c). Jia described surveillance generally by the community as well as by staff and providers. This surveillance was exacerbated by Jia's lack of queer community, with few "female bodied people" at local queer events and being older than many people, such that Jia didn't know "which group to be with." Aquafina was also worried about surveillance and acknowledged that cultural silence surrounding sexual health among young and unmarried people worsened the issue (Table 3, 3d). Annette's father's anger was one of the most pressing factors in relation to worrying about an unintended pregnancy (

Discussion
This study explores the understudied area of unintended pregnancy and abortion experiences among SGMF in urban India. Our findings indicate that these experiences are often met with fear and shame, which are compounded by isolation created by lack of support from partners and family, and bias among health care providers. There are similarities with other unmarried women in in India, but the additional stigma from social networks 30,35 and providers may exacerbate the effects of unintended pregnancy and abortion.
The circumstances surrounding pregnancies within our sample mainly centered around contraceptive issues, including method failure, misuse/non-use, and partner coercion or dishonesty (i.e. participants believed they were using contraception but found out later they were not). SGMF may not see themselves as contraceptive users and use contraception less frequently. 36 Research has shown that a number of barriers to contraceptive use occur among unmarried people and SGMF in India, including costs, lack of access or knowledge, stigma surrounding sex outside marriage, and medical provider bias. 37, 38 We did not ask about sex of sexual partners, though research has found that SGMF not planning to have penile-vaginal intercourse with males are less likely to use contraception. 39 Previous work in less urban parts of India reported that one in six unintended pregnancies resulted from nonconsensual intercourse. 11 Kalyanwala et al. 11 and Sowmini 16 describe nonconsensual experiences such as forced or coerced sex as being more prevalent among unmarried young people seeking abortion. Although contraceptive sabotage has been documented to increase the likelihood of abortion among married women in India, 40 research has yet to address the issue among unmarried young people or SGMF.
The lack of perceived options in the face of an unintended pregnancy was a source of stress for individuals. The Pregnancy Decision-Making Model includes evaluation of values, narratives, and capital, which are influenced by barriers to access and social influence. 41 Participants in this study discussed their barriers to access and social influences more than their personal evaluations, which may be an artifact of the retrospective nature of the study. Previous research has identified a general lack of awareness among women in India about how to access safe abortions. 42,43 The use of both allopathic medicine as well as ayurvedic medicine (such as eating specific foods) was reported by participants, though India primarily relies on allopathic medicine. 44 India's restrictions on providers' training and access to facilities for abortion care mean that many ayurvedic providers are not able to provide abortions. 44 Self-managed abortion was seen as an effective alternative to clinic-based care. In one study of Indian women presenting for a medical abortion, nearly one-third had tried to abort on their own in the last week. 44 In the current study, ayurvedic methods were the only evidence we found of participants attempting abortion outside of an allopathic system.
Karla's use of the phrase "almost pregnancy," when describing using ayurvedic methods to manage a suspected, yet unconfirmed pregnancy, illustrates the overlap between abortion and menstrual regulation. Studies out of Bangladesh and other countries document the use of surgical methods or medication to remove the uterine lining in patients with or without pregnancy confirmation to bring back one's period. 14,45,46 Describing suspected pregnancies as "almost pregnancies" may reflect participants' interest in preventing implantation of the fertilized egg. It may also serve to mitigate stigma associated with unintended pregnancy and abortion, just as the phrase "menstrual regulation" creates the opportunity to reframe abortion in a positive light by addressing how it allows a person to return to typical menstrual functioning. 47 Alternately, it may "communicate the impermanence of pregnancy without assigning agency to anyone." 47 For unmarried women, stigma related to marital status in unintended pregnancy has been documented as a barrier to seeking abortion care. 48,16 Sexual minority females in India often experience general surveillance related to their sexual identity and behaviors. 29,30 Additional pregnancyrelated surveillance and judgment from providers, family members, as well as others at clinics may be may compound negative assessments of stigma. Previous research with SGMF in the United States describes the challenges of navigating contraception in addition to queer identities, including judgment for having sex with men. 36 Providers' judgment or stigma related to marital status reported by participants in this study may be related to providers' lack of knowledge related to abortion laws and/or fears of liability. 6 In line with the buffering effects of community belonging, participants in our study mentioned using informal networks of friends and acquaintances to identify potentially supportive medical providers that would act with discretion, suggesting that social networks may play a role in health care seeking behaviors of SGMF.
Disclosure of unintended pregnancy was common among our participants, which has also been found in samples of unmarried Indian women. 11 As with other studies, participants noted selectively disclosing their pregnancies to those from whom they were most likely to receive support. 11,49 Still, support from partners involved in the pregnancy was mixed among our sample. Jejeebhoy et al. 9 and Kalyanwala et al. 11 found young unmarried women received greater amounts of emotional support (80%) than financial support (55%) from sexual partners. Unmarried people in India may prioritize their career advancement and share abortion decision making between partners. 50 The presence or lack of social support influenced their reactions and coping with unintended pregnancy and abortion. Participants who felt supported by partners, friends, and family described having help with the logistics surround abortion appointments, as well as help dealing with fear and guilt associated with the pregnancy. Communities of SGM individuals in India can help buffer stigma, 52,51 though intersectionality can temper feelings of belonging (as Jia points to being older and not feeling included). 53 Generally, social support mediates the relationship between stressors and health. 54 In the context of abortion, social support is associated with higher self-efficacy in coping, lower anxiety after abortion, and fewer delays in accessing abortion. 11,53-57 None of the participants discussed their gender or sexual identity specifically in relation to unintended pregnancy; potentially they were presenting more cisgender and/or in monogamous partnerships with cisgender men.

Strengths and limitations
This study expands upon the literature about unintended pregnancy and abortion among unmarried people in India and provides a glimpse into those experiences among SGMF. Although the research team was primarily from the United States, our partnership with community organizations facilitated recruitment and contextualization of findings. Individuals in this study were connected to sexual and gender minority-serving organizations, which may also indicate higher levels of access to resources in general. Data saturation related to unintended pregnancy was not reached in this sample, as the study was not primarily focused on unintended pregnancy and abortion experiences. It is possible that additional themes specific to identifying as a sexual-or gender-minoritized person were not captured here. Therefore, future research should explore this topic among SGMF more in-depth.

Conclusion
These findings highlight the effects of stigma in relation to abortion and unintended pregnancy on health and relationships. Many of participants' experiences are similar to studies on heterosexual and cisgender women, though we find evidence of stigma operating in unique ways for SGMF.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Bill and Melinda Gates Foundation Grant under Grant # 064138.