Analysis Law and Policy

Even in States With Progressive Policies, Shame Can Contribute to Reproductive Health-Care Obstacles

Dr. Melissa Bird

When it came to accessing contraception, women I spoke with as part of my research often framed it as a way to prevent abortions rather than preventing pregnancy: a subtle, but important, difference.

“If I was pregnant because I wasn’t taking care of myself, I’d have to just suck it up and say, ‘This is your mistake, you have to live with it.'”

This was just one of the stories I heard while interviewing women in rural California in 2016, when I was a social work PhD student whose research focused on reproductive justice. Contrary to frequent misconception, despite the state’s robust family planning program and overall progressive policy stances on reproductive health, I found that it is not enough to have laws in place that protect a person’s right to make decisions about her body. Many women, especially women of color and poor women, are locked out of health-care systems because they don’t have transportation, money, or the support of their partner to access those services. Furthermore, internalized shame can contribute its own obstacles toward access.

Over the course of the summer, I conducted 68 in-depth semistructured interviews with adult women age 44 and younger who were accessing clinical reproductive health-care services in two rural California counties. Ninety percent of the women who participated self-identified as Hispanic. A majority of women reported that they were married or in a serious relationship, and nearly half had never had a child.

Many of the women’s attitudes toward reproductive health can best be described as conflicts between familial and community-based stigma and the need for personal agency over health-care choices. Some described this stigma as gender inequality and a glorification of sex for men, coupled with judgment and stigmatization against women. And when it came to accessing contraception, women often framed it as a way to prevent abortions rather than preventing pregnancy: a subtle, but important, difference.

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Some women in the study reflected that if they were not using contraception and became pregnant, they would live with their pregnancy rather than obtaining an abortion. These women felt that having a child, even from an unplanned pregnancy, would be “their responsibility.” If they wanted to be sexually active, they believed they should “own up” to the result.

At the same time, however, they faced both internal and external hurdles to contraception access. For one thing, the women reported that many providers in private practice or community health centers do not offer a wide range of birth control. Some said they had trouble finding a provider who honored their decisions to use contraception at all.

Furthermore, many of the women I spoke with felt the need to hide their desire or use of contraception from their families. One woman reported, “Someone in my family found out I was using contraception and their response was, ‘So you’re sleeping around or something?'” Another told me, “I don’t feel like I can tell my mom or my sister [about contraception use] because I’m just going to be judged.”

Many women talked about how their families and neighbors expected them to remain virgins until they were married. They say their communities generally tend to describe those seeking reproductive health care as “promiscuous.” This did not keep women from seeking reproductive health services, but it did prevent them from feeling like they could openly discuss their choices.

A few women were embarrassed to discuss issue with me because they are not like “those girls.”

“I don’t know how to say that in a nice way. I’ve heard people call them a lot of terrible things, saying that they’re easier because they’re this and that,” one said. Another told me that openly seeking contraception meant “you’re looked down upon. You’re bad names or a bad person.” Many women said in their communities, young men receive positive reinforcement for being sexually promiscuous, while young women are labeled as “sluts.”

“Most of the time when you hear about young couples having sex, you hear them talking about the girl. It’s like she’s easy and she’s just giving it up … but when it comes to the guy, no one ever really says anything. … They’re giving him props for it,” a respondent said.

For some women, the fear of familial stigma led to choices like crossing the border into Mexico to avoid having their parents find out that they are using contraception: “I’d rather pay this $10 … to get birth control than to come here to a family doctor and have them tell. I feel that’s the fear, too. Like I’m going to go to my family doctor and they’re going to tell my parents”—a clear breach of patient confidentiality.

Women also described religion as a barrier to seeking services. “Since religion says you should be married before being sexually active, it stops you from looking for help,” said one. In response, many created close relationships with friends who were going through something similar to normalize their experiences and give them opportunities to discuss reproductive health free of judgment from their family members.

Even as many participants spoke about the shame exerted on them for seeking birth control, they still expressed judgment about women who did not “take care of themselves”—in other words, by using contraception—and then chose to have an abortion after becoming pregnant.

“If you were irresponsible and you just didn’t take care of yourself and you came out pregnant and then you just want to end it, that makes me feel mad,” said one woman.

Many of the respondents talked about the effects stigma had on their decisions. “I couldn’t get here to do it,” one said. “The reason I delayed it was just going back and forth in my head, like. … how am I going to look at [my mom] in the face after this.”

Another woman talked about how nervous and scared she was—not about the procedure itself, but about potential reactions from her loved ones. “I chose not to talk to anyone in my family about it because they’re very judgmental and they’re probably going to be angry at me and they won’t understand me. I’ve heard them make comments about other girls who have abortions.” But after the care, she said, “I came out [of the clinic] and I felt good. Like I just felt a little sick and I went home and I rested and I felt good.”

A different participant described the experience as “horrible,” continuing, “Well, that’s why I’m [at the clinic]. I don’t want to have kids right now. That’s why I’m on birth control. It’s a really big deal.”

For these women, there is one exception to the abortion rule. Many women articulated that rape is the primary exception in which abortion should not only be considered but also encouraged.

These interviews illuminate the complexity of many women’s experiences with contraception and abortion. Religious beliefs, especially their mother’s, affected how they discuss sex and contraception. If their mother was passionately opposed to contraception or focused on abstinence until marriage, women would seek advice from female relatives who they knew would support their decision to “take care of themselves.” When it came to abortion, meanwhile, most would stick to speaking to friends or romantic partners.

The “pro-choice” community should not ignore the nuances surrounding feelings about abortion and contraceptive care among many individuals—a reality recognized by the reproductive justice framework, which Black women created in the early 1990s to recognize that bodily autonomy went beyond pro-family planning policies. Oversimplifying the reproductive health-care debate into a conflict between the rights of the government and the right of a woman to control her body ignores the philosophical underpinnings that rural women grapple with on a daily basis. And maintaining a narrow view of the purpose of contraception solely as avoiding pregnancy overlooks the deep cultural and religious experiences of some women in rural areas.

Policymakers, service providers, and health-care researchers must take into account the consequences of ignoring the background that shapes women’s belief systems. Many women stated that community leaders and service providers publicly talking about sex and sexuality, especially among young people, would make getting reproductive health-care services more acceptable in their communities.

“It’s the combination of ignorance, lack of knowledge of the resources you have and what an abortion really is, the culture, religion,” one concluded. “I think that stigma prevents women from obtaining services when they want them.”

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