Can “Tele-health” Cut Maternal Mortality in Zambia?

Brenda Zulu

Zambia is struggling with high maternal mortality rates, but new information technology will allow providers better access to patients' medical records and may make childbirth safer.

Zambia is
unlikely to meet the Millennium Development Goal (MDG) on maternal health as more than 700 women die each year from
pregnancy related complications. This is cording to former Health Minister
Angela Cifire, who bemoans that Zambia’s
maternal health is one of the highest in the sub-Saharan Africa region — with 720
of 1,000 live births resulting in death.

In the 2007 MDG report, Cifire observes that unlike the latest
Hollywood trend, in which celebrities give birth in an exclusive labor ward
especially furnished for the babies’ arrival with video cameras ready to put
everything on record and more doctors than necessary at one’s disposal, labor
is usually tormenting for most Zambian women — especially those in rural areas.

Recently there has been an
increase in cases of women even in urban areas delivering in non-conducive
situations, thereby endangering their lives. Most of these women die due to lack
of skilled labor, excessive bleeding, as well as lack of donated blood. The country must grapple with the challenges of meeting the millennium
development goal on reducing maternal mortality by the year 2015. Cifire called for collective action to save
hundreds of mothers who die from pregnancy related complications.

Women for Change Executive Director
Emily Sikazwe says she was saddened by the 
high maternal mortality rate in the country. World Health
Organization Country Representative Stella Anyangwe said it was sad that the
just-launched Vision 2030 does not address maternal health and primary health
care like it does on HIV/AIDS.

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In 2001-2002, 77.2 per cent of the women who had a non-institutional
delivery did not
receive
postnatal check-up. W
omen in rural areas (81 percent) were discharged before receiving the
postnatal check-up, compared with those in urban (53 percent) who did not
receive the postnatal care. Other reasons for increasing Maternal Mortality Ratio
(MMR) include limited access to facilities due to few health facilities; long
distance to facilities; lack of or costly transportation facilities;
shortage of trained staff; attitude of some health staff; and poor quality of
care (untrained staff and lack of surgical and medical supplies). Low postnatal
care, prenatal complications, complicated deliveries, postpartum deaths from hemorrhage
and infections and post abortion complications also contribute to increased maternal mortality rates. 

Maternal
mortality increased from 649 deaths per 100,000 in 1996 to 729 deaths per
100,000 births during the period 2001 to 2002.
According
to the UNDP 2003 MDG report, the target for maternal mortality ratio in 2015
is 162. The critical indicators in maternal health include access to antenatal,
delivery and postnatal care. A total of 95.7 per cent of the women in
2001-2002 received antenatal care; 93.4 per cent from a health
professional and 2.3 per cent from a Traditional Birth Attendants (TBAs). 

The
percentage of women receiving antenatal care from a health professional
slightly decreased from 96 per cent in 1996 to the 93.4 per cent in 2001-2002
period. One contributing factor to high maternal ratio could be the increase in
the number of women delivering at home. During the 2001-2002 ZDHS, 56 per cent
of the women delivered at home and fewer of them, 44 percent, at a health
facility. 

Medical
persons are also attending slightly fewer deliveries, while the proportion of
births attended by traditional birth attendants (TBAs) increased to the highest
record in 2001-2002 since 1992. The proportion of women delivered by a medical
person declined, from 51 per cent of births in 1992 to 47 per cent in 1996 and
44 per cent in 2001-2002. The proportion of women delivered by a relative or
friend consequently, increased from 33 percent in 1992 to 41 per cent in 1996,
though slightly declined to 38 per cent in 2001-2002. Postnatal care is
important in detecting complications related to delivery.

Meanwhile, the use of information communication technologies (ICTs) in delivering
care to pregnant women and newborns in Lusaka is on the verge of becoming
easier and more efficient, thanks to the advent of Tele-health, which is
simply the use of information technology to deliver health services and
information from one location to another.

Collins Chinyama, former information technologist at the Central Board of
Health, describes the concept of tele-medicine as a multimedia system using
voice, video and data to deliver medical services remotely. "People may phone
their doctors and prescriptions are done either by telephone or fax," he says.

But the new technology overcomes the limitations of the telephone and fax to
ensure that patients are diagnosed from remote locations. Tele-medicine has its
advantage and negative sides: though it meets government needs for bringing
health care as close to the family as possible, the need for medical workers
will also diminish. But it has the potential to bridge the gaps created by Africa’s
brain drain as health professionals seek greener pastures in developed nations.
"There is need for tele-health in Africa because it has
very few doctors and there are increasing health needs and staff constraints in
most hospitals," says Chinyama.

Tele-health works by installing information technology such as digital cameras,
camcorders, digital senders and other medical equipment in all health centers. Lusaka
women and their babies are the first beneficiaries of new technology in health,
with the establishment of an electronic prenatal record system.

It is fitting that this new technological adventure should start at the source
of life: many of the basic needs in the care of pregnant women and newborns
have largely been unmet in Zambia.
This is despite the fact that inadequate resources can literally be a matter of
life and death in the maternity situation. Zambia’s
maternal and infant mortality indicators are unacceptably high. United Nations
statistics show a one in 14 lifetime risk of death in pregnancy for women. The just
released demographic and health survey show that these statistics have not
improved over the past five years, making this a high priority concern.

Customized software designed by doctors from Lusaka district, the University of
Zambia Teaching Hospital (UTH) and the Central Board of Health (CBOH) will
eventually replace the paper records currently in use. Computers in all Lusaka
clinics that provide antenatal care will be linked with several wards at the teaching
hospital through a high speed wireless network. Patient data will, therefore,
be entered just once and not a dozen times. Whether or not a woman goes to the
same clinic, the nurse attending her will be able to see all the relevant
information about her without having to ask for it and re-entering it again.

Healthcare for pregnant women in Lusaka
is a large and complex system. Nearly 50,000 deliveries take place in Lusaka
district clinics and the teaching hospital. Most mothers make multiple antenatal
and postnatal visits, and many of them go to several sites for health care.
Benefiting groups will receive better care because clinicians will have more
information and more time to focus on giving care.

Maureen Chitalu, a mother of three, says she hopes the use of information
technology will also manage complicated cases. She explains: "I live in
Mutendere, where I also go for my antenatal care. During my previous
pregnancies, nurses kept on referring me to the UTH, where there are
specialists, because I delivered by cesarean section last time I was pregnant.
It was not easy. I had to spend a lot of money on transport and, in the
process, wasted a lot of time. With the new system in place this should now be
a thing of the past."

At one time, clinic staff at the teaching hospital could not find her records
as they were never kept in an organized manner. But the tele-health project now
means clinicians will be able to monitor and track patients, see their entire
history at a glance and analyze the outcomes. Health care officials will be
able to generate better information about the population.

Tele-health will also ensure security and confidentiality of patient
information because it will be more difficult to gain access to patient data.
Nurses and doctors will have to enter a password to see individual records.
Although officials of the Central Board of Health and the district health
management board will be able to see statistical information but only
authorized clinicians will have access to personal patient information.

For now, an automated referral system is being written for Lusaka
and it will be the first program that will be used in the computers. It is
hoped to be introduced soon.

Chinyama explains that each clinician will receive an individual e-mail
address. Telephones will be connected to the computers, allowing phone calls
throughout the network and training manuals will be available on the computers.
Free computer training is expected to take place through the end of 2003. It
will include general computer knowledge, e-mail, filling out web-based forms,
refereeing patients using the automated referral system and using Acrobat
reader to access training manuals.

The benefits to clinical care will be that training materials will be easily
available and there will be better communication between sites and automated
checks on care quality. Voice Over Internet Protocol (VOIP) telephone will
allow district health management board midwives to speak to teaching hospital
midwives or doctors at any time. The health management board midwives will also
be able to track their referred patients as the system will allow more accurate
monitoring.

It is of great relevancy that Zambia
applies emerging technologies to empower rural communities towards the
attainment of the MDGs goals as this is the theme of the Africa
Telecommunications Day which is observed on December 7 every year.

Roundups Politics

Campaign Week in Review: Clinton Criticizes Trump’s Child-Care Proposal in Economic Speech

Ally Boguhn

Hillary Clinton may be wooing Republicans alienated by Trump, but she's also laying out economic policies that could shore up her progressive base. Meanwhile, Trump's comments about "Second Amendment people" stopping Hillary Clinton judicial appointments were roundly condemned.

Hillary Clinton may be courting Republicans, but that didn’t stop her from embracing progressive economic policies and criticizing her opponent’s child-care plan this week, and Donald Trump suggested there could be a way for “Second Amendment people” to deal with his rival’s judicial appointments should she be elected.

Clinton Blasts Trump’s Child-Care Proposal, Embraces Progressive Policies in Economic Speech

Democratic nominee Hillary Clinton took aim at Republican nominee Donald Trump’s recently announced proposal to make the average cost of child care fully deductible during her own economic address Thursday in Michigan.

“We know that women are now the sole or primary breadwinner in a growing number of families. We know more Americans are cobbling together part-time work, or striking out on their own. So we have to make it easier to be good workers, good parents, and good caregivers, all at the same time,” Clinton said before pivoting to address her opponent’s plan. “That’s why I’ve set out a bold vision to make quality, affordable child care available to all Americans and limit costs to 10 percent of family income.”

“Previously, [Trump] dismissed concerns about child care,” Clinton told the crowd. “He said it was, quote, ‘not an expensive thing’ because you just need some blocks and some swings.”

“He would give wealthy families 30 or 40 cents on the dollar for their nannies, and little or nothing for millions of hard-working families trying to afford child care so they can get to work and keep the job,” she continued.

Trump’s child-care proposal has been criticized by economic and family policy experts who say his proposed deductions for the “average” cost of child care would do little to help low- and middle-wage earners and would instead advantage the wealthy. Though the details of his plan are slim, the Republican nominee’s campaign has claimed it would also allow “parents to exclude child care expenses from half of their payroll taxes.” Experts, however, told CNN doing so would be difficult to administer.

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Clinton provided a different way to cut family child-care costs: “I think instead we should expand the Child Tax Credit to provide real relief to tens of millions of working families struggling with the cost of raising children,” Clinton said in Michigan on Thursday. “The same families [Donald Trump’s] plan ignores.”

Clinton also voiced her support for several progressive policy positions in her speech, despite a recent push to feature notable Republicans who now support her in her campaign.

“In her first major economic address since her campaign began actively courting the Republicans turned off by Donald Trump, Clinton made no major pivot to the ideological center,” noted NBC News in a Thursday report on the speech. “Instead, Clinton reiterated several of the policy positions she adopted during her primary fight against Bernie Sanders, even while making a direct appeal to Independent voters and Republicans.”

Those positions included raising the minimum wage, opposing the Trans-Pacific Partnership trade deal, advocating for equal pay and paid family leave, and supporting a public health insurance option.

“Today’s speech shows that getting some Republicans to say Donald Trump is unfit to be president is not mutually exclusive with Clinton running on bold progressives ideas like debt-free college, expanding Social Security benefits and Wall Street reform,” said Adam Green, the co-founder of the Progressive Change Campaign Committee, in a statement to NBC.

Donald Trump: Could “Second Amendment People” Stop Clinton Supreme Court Picks?

Donald Trump suggested that those who support gun ownership rights may be able to stop Democratic nominee Hillary Clinton from appointing judges to the Supreme Court should she be elected.

“Hillary wants to abolish, essentially abolish the Second Amendment,” Trump told a crowd of supporters during a Tuesday rally in Wilmington, North Carolina. “By the way … if she gets to pick her judges, nothing you can do, folks. Although, the Second Amendment people—maybe there is. I don’t know.” 

Trump campaign spokesperson Jason Miller later criticized the “dishonest media” for reporting on Trump’s comments and glossed over any criticism of the candidate in a statement posted to the campaign’s website Tuesday. “It’s called the power of unification―Second Amendment people have amazing spirit and are tremendously unified, which gives them great political power,” said Miller. “And this year, they will be voting in record numbers, and it won’t be for Hillary Clinton, it will be for Donald Trump.”

“This is simple—what Trump is saying is dangerous,” said Robby Mook, Clinton’s campaign manager, in a statement responding to the Republican nominee’s suggestion. “A person seeking to be the President of the United States should not suggest violence in any way.”

Gun safety advocates and liberal groups swiftly denounced Trump’s comments as violent and inappropriate for a presidential candidate.

“This is just the latest example of Trump inciting violence at his rallies—and one that belies his fundamental misunderstanding of the Second Amendment, which should be an affront to the vast majority of responsible gun owners in America,” Erika Soto Lamb, chief communications officer of Everytown for Gun Safety, said in a Tuesday statement. “He’s unfit to be president.”

Michael Keegan, president of People for the American Way, also said in a Tuesday press release, “There has been no shortage of inexcusable rhetoric from Trump, but suggesting gun violence is truly abhorrent. There is no place in our public discourse for this kind of statement, especially from someone seeking the nation’s highest office.”

Trump’s comments engaged in something called “stochastic terrorism,” according to David Cohen, an associate professor at the Drexel University Thomas R. Kline School of Law, in a Tuesday article for Rolling Stone.

“Stochastic terrorism, as described by a blogger who summarized the concept several years back, means using language and other forms of communication ‘to incite random actors to carry out violent or terrorist acts that are statistically predictable but individually unpredictable,’” said Cohen. “Stated differently: Trump puts out the dog whistle knowing that some dog will hear it, even though he doesn’t know which dog.”

“Those of us who work against anti-abortion violence unfortunately know all about this,” Cohen continued, pointing to an article from Valerie Tarico in which she describes a similar pattern of violent rhetoric leading up to the murders that took place at a Colorado Springs Planned Parenthood.

What Else We’re Reading

Though Trump has previously claimed he offered on-site child-care services for his employees, there is no record of such a program, the Associated Press reports.

History News Network attempted to track down how many historians support Trump. They only found five (besides Newt Gingrich).

In an article questioning whether Trump will energize the Latino voting bloc, Sergio Bustos and Nicholas Riccardi reported for the Associated Press: “Many Hispanic families have an immense personal stake in what happens on Election Day, but despite population numbers that should mean political power, Hispanics often can’t vote, aren’t registered to vote, or simply choose to sit out.”

A pair of physicians made the case for why Gov. Mike Pence “is radically anti-public health,” citing the Republican vice presidential candidate’s “policies on tobacco, women’s health and LGBTQ rights” in a blog for the Huffington Post.

Ivanka Trump has tried to act as a champion for woman-friendly workplace policies, but “the company that designs her clothing line, including the $157 sheath she wore during her [Republican National Convention] speech, does not offer workers a single day of paid maternity leave,” reported the Washington Post.

The chair of the American Nazi Party claimed a Trump presidency would be “a real opportunity” for white nationalists.

NPR analyzed how Clinton and Trump might take on the issue of campus sexual assault.

Rewire’s own editor in chief, Jodi Jacobson, explained in a Thursday commentary how Trump’s comments are just the latest example of Republicans’ use of violent rhetoric and intimidation in order to gain power.

Culture & Conversation Law and Policy

The Modern Struggle Over Anti-Trans Bathroom Laws Has Its Roots in Decades of Title VII Fights

Jessica Mason Pieklo

Because of Sex: One Law, Ten Cases, and Fifty Years That Changed American Women’s Lives at Work, written by Gillian Thomas, senior staff attorney with the American Civil Liberties Union Women’s Rights Project, goes beyond cases that helped shape workplace anti-discrimination policies. Rather, it focuses on ten key women whose own lives changed the law.

In 1966, Ida Phillips, a single mother working as a waitress, sat down at her kitchen table and wrote a letter to then-President Lyndon B. Johnson. She told him her story: Despite her qualifications, Phillips had been told by a Martin Marietta employee not to apply for an assembly-line position at one of the construction-material company’s manufacturing plant. The job would have paid more than double what she was making as a waitress. It included a pension plan and insurance, benefits unavailable in most female-dominated industries at the time (and which since have only marginally improved.) The reason Phillips was turned away? She was a woman with a preschool child.

That letter, Phillips’ subsequent lawsuit, and her Supreme Court win would help spark a civil rights revolution in the workplace—one with consequences that reverberate today.

So opens Because of Sex: One Law, Ten Cases, and Fifty Years That Changed American Women’s Lives at Workwritten by Gillian Thomas, senior staff attorney with the American Civil Liberties Union (ACLU) Women’s Rights Project. Despite its full title, though, Because of Sex goes beyond cases that helped shape workplace anti-discrimination policies, focusing on ten key women whose own lives changed the law.

Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on race, color, religion, sex, and national origin. And it was Phillips’ case, and the nine others profiled in the book, that would ultimately shape that law into one that, decades later, is an important tool in advancing gender and sex equality. As Thomas explained to Rewire in an interview, Title VII it is not just a foundational piece of civil rights legislation important for its historical effect on workplace equality. In the face of anti-transgender bathroom bills and statewide “religious liberties” legislation sweeping the country, it is a crucial tool for pushing equality forward.

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Thomas’ book is organized along three key themes in employment discrimination law: pregnancy-related workplace policies, gender stereotypes in the workplace, and sexual harassment. Those themes act as an inroad toward thinking more broadly about how, in Thomas’ words, we achieve “substantive equality” in the workplace. They illustrate how early fights over promotions and workplace policies that kept women out of certain jobs due to concerns of harming their potential fertility foreshadowed the legal showdowns over contraception coverage in employee health-care plans in cases like Burwell v. Hobby Lobby and Zubik v. Burwell.

“The subject matter areas that I saw [as a researcher and employment discrimination litigator] were, number one, women’s capacity for pregnancy, and then their subsequent roles as mothers, which, historically, has played a huge role in their second-class status legally,” Thomas told Rewire. “Women of color have always been seen as workers, irrespective of whether they had children, so that’s not an entirely universal stereotype. But I think it’s pretty safe to say that generally pregnancy and motherhood have proven to be enormous conflicts in terms of what equality looks like when you have these distinct differences” in how race and gender are perceived.

Take, for instance, the case of Peggy Young and the question whether an employer can refuse to make on-the-job accommodations for pregnant employees when it does so for nonpregnant employees. Young, another one of the women featured in Thomas’ book, was a United Parcel Service (UPS) “air driver” who became pregnant. When Young told her employer she was pregnant, UPS told her they couldn’t accommodate the light-lifting recommendation made by Young’s medical providers. Instead, UPS told Young, she would have to take unpaid medical leave for the remainder of her pregnancy.

In March 2015, the U.S. Supreme Court ruled against UPS, vacating the Fourth Circuit Court of Appeals ruling that had supported UPS’ policy. The decision produced a new test for assessing pregnancy discrimination claims and sent Young’s case back to the lower courts for another look. Not long after the Roberts Court’s decision, UPS and Young settled the lawsuit, bringing an end to Young’s case.

The decision was a qualified win for advocates. The Roberts Court had accepted Young’s argument that UPS had no legitimate business reason for failing to accommodate her particular request, but the decision went short of ruling businesses must accommodate any pregnancy request.

But Because of Sex doesn’t stop at unpacking overt discrimination like the kind detailed in Young’s 2015 case or Phillips’ one in 1966. The book also takes a look at what the law has described as more “benevolent” kinds of discrimination. These include employment policies designed to “protect” women from endangering possible future pregnancies, such as prohibiting women employees from working jobs where they may be exposed to hazardous chemicals.

“It really all boils down to two issues that we are talking about in all these things,” Thomas explained, when discussing workplace policies that, employers have argued, were put in place to protect their female employees from potentially endangering a pregnancy. “One is [employers] ignoring hazards that apply to men and making women into baby-making machines. And number two is [employers] treating health effects or health hazards on the job as reasons for diminishing women’s opportunities, instead of arming women with information and assuming that they will make the right choice for themselves.”

This disconnect is most apparent in the case of United Automobile Workers vJohnson Controls, Inc., another case Thomas highlights in her book. In 1982, the car battery manufacturer Johnson Controls sent a memorandum to all its employees that said “[w]omen who are pregnant or who are capable of bearing children will not be placed into jobs involving lead exposure or which would expose them to lead through the exercise of job bidding, bumping, transfer or promotion rights.”

The policy amounted to a demotion for many female employees and a closed door for others.

Title VII actually permits employers, in a limited context, to have employment policies that discriminate on their face, such as policies that permit churches to only hire members of the same faith. Johnson Controls argued its policy of keeping women out of certain positions due to employer concerns of health risks to future pregnancies fit within Title VII’s narrow window for permitting explicit discrimination.

The Supreme Court would eventually rule in 1991 that Johnson Controls’ policy violated Title VII because it forced female employees to have to choose “between having a child and having a job,” thereby rejecting the argument made by Johnson Control’s that a woman’s fertility—or infertility—can in most situations be considered a bona fide occupational qualification.

As Thomas noted in her book, “It was no coincidence that fetal protection politics were most prevalent in well-paid, unionized industries from which women historically had been excluded. Indeed they had been excluded precisely because they had been deemed physically unsuited for the dirty, sometimes strenuous work.”

But “in female-dominated fields, though, fetal protection policies made no business sense; they effectively would gut the workforce. That reality apparently trumped any hypothetical harm to employees’ future pregnancies,” Thomas wrote.

In other words, these policies didn’t exist in female-dominated fields.

Johnson Controls may have helped grant women the agency to determine how and when they earned a paycheck with regard to policies targeting their potential fertility, but it hardly ended the debate around when and how employers attempt to diminish women’s opportunities related to their roles as potential mothers. This has played out in the hundreds of lawsuits over the contraception benefit, for example.

In other words, if Johnson Controls had settled the question of whether a woman’s fertility was an appropriate grounds for discrimination, we would not have Hobby Lobby.

Because of Sex draws another connection between the historical fight over Title VII and the contemporary one: How do employers adjust workplace policies around shifting gender norms, and when is it discriminatory if they don’t?

The law asks, “What are women supposed to want to do?” said Thomas in her interview with Rewire. “What work are they able to do? What work do they want to do? [Given] assumptions and stereotypes that are about their abilities, their preferences, their interests and how [they are] conforming to [those] in terms of stereotypes about what femininity is—what [are] women … supposed to look and act like?”

Gender nonconforming behavior, and the manner in which employees experience discrimination as a result of that behavior, is a key component over the debate around transgender rights. But it would take a “shrill” woman and the birth of the notion of “workplace harassment” to get us and the law there first.

By every measure, Ann Hopkins should have been made a partner in the global accounting firm Price Waterhouse. She was smart. Ambitious. Worked hard and constantly outperformed her peers. But it was those very attributes that her male partners deemed “too aggressive” or as evidence that she needed “charm school,” and ultimately used to deny her a partnership that by every objective measure she had earned.

The Supreme Court would ultimately disagree. In 1989, it ruled Hopkins should have been made a partner and that the comments relating to her demeanor amounted to improper gender stereotyping, a violation of Title VII’s sex discrimination provisions.

If Hopkins was initially shut out of workplace advancement due to her defiance of feminine stereotypes, so too are women subjected to on-the-job harassment, as Thomas draws out in Because of Sex. “Sexual harassment didn’t even have a name in 1974, but was such a prevalent force driving women out of the work force, driving them into different jobs [and] subjugating them just generally in terms of the identity as sexual objects on the job,” Thomas further explained in her interview.

1974 was the year Mechelle Vinson first hired a lawyer to represent her in a case against her boss, who was chronically sexually abusing her on the job. But at the time, courts largely wrote off those kinds of complaints as a kind of chasing-around-the-office, and not sexual harassment, or in Vinson’s case, on-the-job rape. As described by Thomas in her book, “throughout the 1970s, many courts responded to complaints about abusive bosses with a collective shrug that conveyed, ‘You can’t blame a guy for trying.'”

“Sexual harassment was such a prevalent force driving women out of the workforce, driving them into different jobs, and subjugating them just generally in terms of the identity as sexual objects on the job,” Thomas told Rewire.

That “you can’t blame a guy for trying” attitude hasn’t completely gone away as far as the federal courts are concerned. After all, in 2013 the Roberts Court in Vance v. Ball State made it even harder for employees to bring workplace harassment suits, and employees still face losing jobs for “being too cute” or having their sexuality be a perceived threat to their employer’s ability to remain professional in the workplace.

Which is why, in the fight over transgender bathroom access in 2016, Title VII should be a powerful force in defeating these latest attempts to stymie social progress. The idea that “you can’t blame a guy for trying” has morphed into “how the hell can we police gender roles if we don’t know where you pee.” That’s thanks almost entirely to the manner in which the law has wrestled with gender stereotypes under Title VII, Thomas explained.

In 2012, the Equal Employment Opportunity Commission (EEOC), the federal agency charged with enforcing workplace anti-discrimination laws, issued the landmark decision Macy v. Holder, which held that employment discrimination based on transgender status was a form of unlawful sex discrimination under Title VII. Then in 2015, it issued a ruling stating that denying employees access to restrooms consistent with their gender identity is also a violation of Title VII. Meanwhile several federal courts of appeals have ruled that Title VII protects against gender identity discrimination.

But the Roberts Court has yet to weigh in.

“I think sexual orientation in a way is the sort of a final frontier” in Title VII litigation, said Thomas. “The court seems really fixated on this idea of analogizing very precisely from Hopkins. In other words, if you look or act in a way that doesn’t conform to gender stereotypes then, OK, [the courts] can understand that’s sex discrimination,” said Thomas. “But if your identity is not conforming to stereotypes in that you, you know, are romantically attracted to someone of your sex, that is harder for [the courts] to get, even though it’s obviously the most obvious manifestation of stereotype.”

This is, in many ways, a fight that started in the workplace—one that eventually got the backing of the Obama administration before becoming a flashpoint of conservative election-cycle politics. Thomas’ book doesn’t close on a prediction of what the next big Title VII fight will be per se, but it is impossible to finish it and not see the narrative threads of the historical fight for workplace equality woven throughout the the contemporary one. Sex. Gender. How the law understands and navigates the two. All this is what makes Thomas’ Because of Sex the closest thing to an assigned reading I can make.

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