Imagine you are 18 years old, legally an adult, ready to take the steps you need to take care of your health and get on birth control before you have sex with your long-time boyfriend. You remember everything your mother and aunties told you: “Take care of yourself.”
Yet, when you try to go to the clinic, they ask if you are married.
And when you say no: “The nurses immediately gave me this face, like they were just in shock, like it was something completely new to them or something. When I went to try to talk to a doctor about it, the first thing he asked was, well, why was I having unprotected sex so young? And I had to defend myself by telling him I wasn’t. I was using protection.”
This woman wasn’t alone: For many women like her living in rural California, going to the doctor can be an emotionally exhausting experience that leaves them wracked with shame for asking questions about their health care. In areas where medical care is scarce and everyone knows your name, OB-GYNs in private practice may delay desired long-acting contraceptive methods such as IUDs and implants, give biased information about contraception, and openly judge women for their decisions to seek it.
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Although dozens of states have “provider conscience provisions” in place—which allow medical professionals to deny reproductive health services under the auspices of religious freedom—California is not among them where contraception is concerned. But in rural parts of the state, women say their doctors are still propagating stigma and robbing them of their right to access health care, regardless of whether such actions are explicitly protected under the law.
As a reproductive health researcher, I have spent years talking to women and policy makers in California about experiences that shape patients’ decisions to use contraception. The issues highlighted by women living in these areas illustrate that deciding to use contraception and pursue other reproductive services is not simply a matter of legal access.
Rural areas in California, like rural areas in other states, face shortages of medical providers. Often there are only one or two doctors who provide obstetric and gynecological services in rural counties, and many times those doctors are also treating patients’ aunties or mothers for pregnancies and other gynecological issues. Women usually have to wait months to be seen, even for a simple pelvic exam or contraceptive appointment. And for the 68 women in my study, judgment by providers whom they had been taught they could trust often became an additional barrier to seeking contraceptive care. Many women described how conservative medical providers misled them into believing false narratives about their reproductive health choices, sometimes forcing them to delay obtaining contraception or go elsewhere.
Take for instance, an 18-year-old woman who first tried to go to a private doctor whose services were covered by her insurance. She reported that the doctor told her she would have to go through unspecified testing to make sure she would be safe using contraception because of her age.
She ended up at the area’s only Planned Parenthood clinic because she wanted accurate information about the contraceptives she was seeking. “It’s a lot more discreet and they focus on contraception,” she said. “There’s no judgment really. You don’t have to worry about what the nurses are saying or if they’re going to judge you on why you’re there.”
Women reported that when they ask for postpartum contraception, they are sometimes denied outright. According to one woman, “You go to your OB doctor they’re like, ‘Oh, no, you can’t get that yet.’ And they don’t even offer birth control. They’re like, ‘OK, we’ll see you next month’ and don’t offer any kind of method … like they won’t provide that service, even though they do provide it there, but they won’t do it. And again, I would believe that because there are conservative doctors out here, and I say that because of personal experience.” (Medical research supports the use of contraceptives for women who are more than 42 days postpartum.)
One would assume that being married might create a buffer against such shaming and bias; several women, however, reported the opposite experience. Married women said that conservative providers talk about the “blessing of babies” and it being “God’s will” if they get pregnant within the bonds of matrimony. One woman’s experience was particularly shocking. When she asked for a birth control prescription, she says, her provider told her that pills would cause her and her husband problems and they should just use condoms, even though they are less effective than the birth control pill at preventing an unintended pregnancy: “We use condoms because the doctor told us to. Since we got married and started having intercourse, we didn’t want to get pregnant right away. He told us it was easier to use condoms, not pills.”
Unfortunately, this kind of approach to contraception can mean women have difficulty making informed decisions about their health. Many women and girls say they are taught by doctors—along with parents, church leaders, and teachers—that you shouldn’t have sex at all and then once you are married, the only reason you’re having sex is to have kids. The shaming of women in these communities makes it harder for them in both the short and long term to talk about contraception.
Furthermore, women say the subject of abortion—a practice that is legally protected in California—is nearly always left off the table at doctors’ offices. One woman that I talked to said, “Here they just see women as you’re supposed to have kids. That’s kind of what you were brought on earth to do.”
In these counties—where many women have no other options—any policies that restrict access to reproductive services can have dire consequences. And it may get worse: In January of this year, the Trump administration proposed new regulations related to “conscience and religious freedom” that could make it harder for women to access unbiased care throughout the country, including in California. Given that the U.S. Department of Health and Human Services now has an entire office tasked with discriminating against people because they are choosing to pursue contraception and abortion, we cannot afford to let these dangerous “conscience” policies rule the day.
A lack of compassion or willingness to provide comprehensive health care will lead to devastating long-term impacts on generations of women, especially when they’re prevented from obtaining information about the contraception that might best fit their needs. Providers are ethically mandated to ensure that women can receive access to services they request. We must do all we can to fight the fissure in the provision of medical services that allows health-care providers to openly judge women for their reproductive decisions, even in supposedly “progressive” parts of the country.