In the United States, policies and practices enacted in response to the COVID‐19 pandemic—such as social distancing, sheltering in place, shifting to telemedicine and limiting care to “essential” procedures—are widening gaps in sexual and reproductive health (SRH) outcomes and access to services. As obstetrician‐gynecologists, pediatricians and adolescent medicine specialists who are frontline providers of SRH services, we are seeing firsthand the documented decreases in access to SRH education, abortion and contraceptives (particularly long‐acting reversible contraceptives, or LARCs), as well as increases in reports of gender‐based violence.^1-4 These trends have disproportionately affected minoritized and marginalized groups, including adolescents, people of color, those living in poverty, immigrants and undocumented individuals, and residents of rural areas.^{5, 6} In this viewpoint, we provide a clinician's perspective on the gaps in services and outcomes between these and more privileged groups, and make recommendations to narrow these gaps, both now and in the future.

In some cases, the gaps in access to SRH services have been an unintended effect of COVID‐19–related policies. For example, access to SRH services at federally qualified health centers and community‐based clinics has been limited because of budgetary constraints, shortages of personal protective equipment and staff, and the facilities’ need to care for sicker populations. This loss of access disproportionately affects youth and marginalized populations, who rely on these centers for health care. While the rapid expansion of telehealth has provided access to SRH providers for many individuals with established sources of care or insurance, the increased reliance on this technology has seriously reduced the initiation of LARC methods, which requires an in‐person visit with a health care provider. For adolescents, in particular, reduced opportunities for in‐person visits threaten to undo the gains made over the past 10 years in offering clients a wider range of contraceptive options, primarily through expanded access to LARCs.^7-9 Moreover, telehealth requires access to adequate and reliable Internet service, which is not available in some rural areas,¹⁰ and many individuals who do not have Internet service at home (because of cost or geography) and had relied on public access points such as libraries or coffee shops no longer have these options available because of pandemic closures and social distancing.¹¹

Although newer approaches for improving access to contraceptives, such as provision of hormonal methods through pharmacies, apps or telehealth,¹² have the potential to maintain access to contraceptives, these approaches are frequently not available to all, and may worsen disparities in SRH access among specific groups. For example, laws that regulate telehealth, authorize pharmacists to prescribe contraceptives, or permit minors to provide consent and obtain confidential services vary from state to state. In many states, these laws do not specifically allow adolescents to access contraceptives through telehealth, apps or pharmacies.^{12, 13} For women in rural areas, pharmacy access can be limited even in states with supportive laws.¹⁴ Further gaps in access to SRH services have resulted from the postponement or cancellation of well‐woman and well‐child visits; in the absence of such visits, many women are not being screened for asymptomatic STIs, abuse, gender‐based violence and contraceptive needs. At the same time, shelter‐in‐place requirements and quarantine restrictions have led to increases in gender‐based violence, as individuals in violent or abusive relationships may be unable to leave unsafe homes.¹

The impact of these pandemic‐related barriers and outcomes has been exacerbated by the enactment of targeted policies designed to limit women's ability to obtain SRH services. Abortion, in particular, has been targeted with additional restrictions, creating, for all women, a gap between the services they need and their ability to obtain them. The designation of abortion as an “elective” procedure allowed states that actively restrict abortion to immediately cut off access to this time‐sensitive procedure.¹⁵

Our challenge as health care providers is to identify gaps in access that affect—intentionally or not—the SRH care that our patients need, and to advocate for changing policies that exacerbate gaps in access and outcomes. Cataloging (identifying and tracking) gaps will allow us to address barriers in access and worsening disparities in outcomes, as restrictions loosen.

During the current pandemic, policymakers, providers and health care system administrators have had to make difficult decisions and confront challenging ethical questions. What is essential care? When are restrictions too restrictive? Which restrictions can be relaxed safely, and when? In making decisions about individual patients, clinicians frequently employ a broad, principle‐based medical ethics approach to balance autonomy, beneficence and justice. However, in a public health crisis, these principles often conflict with each other, and clear resolution may not exist. As SRH providers, we advocate for a public health ethics approach that combines an underlying respect for human rights with the application of the harm principle (adopting the least‐restrictive approach) in cases when access to SRH services might be restricted.

在美国，为应对 COVID-19 大流行而制定的政策和做法——例如保持社交距离、就地避难、转向远程医疗以及将护理限制在“基本”程序——正在扩大性健康和生殖健康 (SRH) 方面的差距结果和获得服务的机会。作为 SRH 服务的一线提供者的妇产科医生、儿科医生和青少年医学专家，我们亲眼目睹了 SRH 教育、堕胎和避孕药具（特别是长效可逆避孕药，或 LARCs）的可及性减少，以及增加在基于性别的暴力的报道中。^1-4这些趋势不成比例地影响了少数族裔和边缘化群体，包括青少年、有色人种、生活在贫困中的人、移民和无证人士以及农村地区的居民。^{5, 6}在这个观点中，我们提供临床医生对这些和更多特权群体之间的服务和结果差距的看法，并提出缩小这些差距的建议，无论是现在还是将来。

在某些情况下，获得 SRH 服务的差距是 COVID-19 相关政策的意外影响。例如，由于预算限制、个人防护设备和工作人员短缺以及设施需要照顾病情较重的人群，在联邦合格的卫生中心和社区诊所获得 SRH 服务的机会受到限制。这种无法访问的情况不成比例地影响了依赖这些中心获得医疗保健的青年和边缘化人群。虽然远程医疗的快速扩张为许多拥有既定护理或保险来源的人提供了使用 SRH 提供者的机会，但对该技术的日益依赖严重减少了 LARC 方法的启动，这需要亲自拜访医疗保健提供者. 尤其是对于青少年来说，^7-9此外，远程医疗需要获得充足且可靠的互联网服务，而这在一些农村地区¹⁰以及许多在家中没有互联网服务（由于成本或地理位置）并依赖公共接入点的人由于大流行关闭和社会疏远，图书馆或咖啡店等场所不再提供这些选择。¹¹

尽管改善避孕药具获取的新方法，例如通过药房、应用程序或远程医疗提供激素方法¹²有可能维持避孕药具的获取，但这些方法通常并非对所有人都可用，并且可能会加剧特定人群在性与生殖健康获取方面的差距团体。例如，监管远程医疗、授权药剂师开具避孕药具或允许未成年人提供同意和获得保密服务的法律因州而异。在许多州，这些法律并未明确允许青少年通过远程医疗、应用程序或药房获得避孕药具。^{12, 13}对于农村地区的妇女，即使在有支持性法律的州，药房的使用也可能受到限制。¹⁴健康妇女和健康儿童探访的推迟或取消导致了在获得性与生殖健康服务方面的进一步差距；由于没有此类访问，许多妇女没有接受无症状性传播感染、虐待、基于性别的暴力和避孕需求的筛查。与此同时，就地避难所的要求和隔离限制导致基于性别的暴力行为增加，因为处于暴力或虐待关系中的个人可能无法离开不安全的家。¹

这些与流行病相关的障碍和结果的影响因制定旨在限制妇女获得 SRH 服务能力的有针对性的政策而加剧。尤其是堕胎，受到了额外的限制，对所有妇女来说，她们需要的服务与她们获得服务的能力之间存在差距。将堕胎指定为“选择性”程序允许积极限制堕胎的国家立即切断对该时间敏感程序的访问。¹⁵

作为医疗保健提供者，我们面临的挑战是确定是否有意或无意地影响患者所需的 SRH 护理的可及性差距，并倡导改变政策以加剧可及性和结果方面的差距。随着限制的放松，对差距进行编目（识别和跟踪）将使我们能够解决获取障碍和结果差异加剧的问题。

在当前的大流行期间，政策制定者、提供者和医疗保健系统管理者不得不做出艰难的决定，并面临具有挑战性的伦理问题。什么是基本护理？什么时候限制过于严格？哪些限制可以安全放宽，什么时候放宽？在对个体患者做出决定时，临床医生经常采用广泛的、基于原则的医学伦理方法来平衡自主、仁慈和正义。然而，在公共卫生危机中，这些原则往往相互冲突，可能不存在明确的解决方案。作为 SRH 提供者，我们提倡一种公共卫生伦理方法，在可能限制获得 SRH 服务的情况下，将尊重人权与应用伤害原则（采用限制最少的方法）结合起来。