On Stigma and How to Make Safe Abortion Services Scarce in the U.S.

@SheRights

This week, Indiana saw several developments that could help or hurt women’s ability to access the medical care they need when they need it, especially if what they need is an abortion.

On Tuesday, a federal court fixed a time for its evaluation of the constitutionality of Indiana Senate Bill 371 (SB371). And on Wednesday, another bill—Indiana Senate Bill 292 (SB292) was debated in the Senate health committee.

SB371 seeks to limit access to abortion by stigmatizing comprehensive reproductive health clinics as “abortion clinics,” while SB292 seeks to limit access to abortion by stigmatizing medical providers as “abortion doctors.”

At heart of both SB 371 and SB 292 is the notion that clinics and medical providers who provide abortions somehow are different and therefore merit calling out.

Yet, as the very public schism between Susan B. Komen and Planned Parenthood in 2012 made clear, abortion is just one of the health services a comprehensive clinic provides. In the case of Planned Parenthood, only 3 percent of the services provided nationwide are abortions. So if one were to name Planned Parenthood clinics after the services most frequently provided, it might be the “HIV and Cancer Prevention Clinics” or, appropriately, the “Planned Pregnancy Clinics.”

Likewise, defining a doctor or midwife who is willing to perform abortions (surgical or not) as an "abortion doctor" or "abortionist" is equivalent to describing your most well-stocked local grocer as the “Gluten Free Bread Dealer.” Sure, it may be near impossible to obtain gluten-free bread in your neighborhood, and for most it won’t matter. But if you have celeriac disease, it is significant that someone is willing to take valuable shelf-space up with the one kind of bread you can eat without getting a stomach-ache.

But of course the point of Indiana’s bills is not to accurately describe what goes on in reproductive health clinics, or to dignify medical providers with descriptors that go to what they actually do. The point is to stigmatize abortions as bad, and the clinics and doctors who provide them as worse. The corollary of this thinking is that such “bad” clinics and people must be subject to more stringent government oversight. The ultimate objective is to make it very hard for anyone to provide or obtain a legal and safe abortion.

And it works. When Texas imposed more stringent rules on “abortion clinics” in 2013, at least a dozen clinics closed down. New restrictions allegedly proposed in Louisiana could take away any possibility for obtaining a legal and safe abortion in that state.  This week, Mikki Kendall recounted how Illinois laws allowing for the separation of service providers into those who do and those who don’t provide abortions almost cost her her life.

No one, however, should be under the misapprehension that making abortion less accessible will make it less prevalent. In countries where abortion is illegal, for example, women and girls who need to terminate their pregnancies still find ways to do so—usually unsafely. Researchers from the World Health Organization have called unsafe abortion “a preventable pandemic,” and estimates suggest that approximately 68,000 women per year die from complications caused by unsafe abortions. Yet abortion, when provided early in the pregnancy, is one of the safest medical procedures around, with less than 0.05 percent risk of complications needing hospital care.

In other words, it is not that abortion is an unsafe medical procedure. It is that laws limiting access to abortion—such as the laws debated in Indiana this week—make it unsafe. Instead of stigmatizing doctors who will provide abortions, we should stigmatize those who won’t.

Dress Codes and Other Sorry Excuses for Policing Identity

@HuffPostGay

Last month, the fifth grade parent group at my daughter's school had the first of many conversations about how to mark our children's transition to junior high. Unfortunately, the issue we discussed -- whether the kids would be wearing caps and gowns at the end-of-year celebration -- sidelined a much more important issue: what the kids would be wearing under these gowns. (My daughter's school had sent out a notice to parents that boys must wear one thing and girls another.)

For many children, a gendered dress code may be just another imposition by adults, and to some it may seem small compared with decisions related to bedtime, computer usage, and the precise meaning of the phrase "clean up your room." But to others it is a big deal. Indeed, clothing is such an essential expression of who we are that international law recognizes it as a human right to wear what we want, barring reasonable restrictions for the purposes of safety or to protect the rights of others.

And it is precisely because clothing can project our identity so concisely that the clothing associated with particularly stigmatized populations is vigorously policed around the world. For example, several European countries and some North American jurisdictions place restrictions on head coverings. These restrictions are closely linked to discomfort with Islam and are based on the negative and erroneous stereotype that Muslim women are "oppressed" and "submissive." In fact, even where headscarves are not explicitly prohibited by law, women can be fired for wearing them, and many are discriminated against even before landing a job.

Likewise, many jurisdictions enforce strictly gendered dress codes in public by eitherrequiring specific attire or criminalizing cross dressing. These restrictions are tied to stereotypes about sexuality and sex. Cross dressing is conflated with transgenderism, which again is conflated with an insatiable, predatory, or "perverted" sex drive. A good example of this is the comment reportedly made by a lawyer who was arguing against a 6-year-old trans girl's right to use the girl's bathroom at her school. "How do you know if someone is really thinking this way or not?" the lawyer is quoted as saying. "How do you know if someone just wants to go in the restroom and be a peeping Tom?"

The suspicion directed at trans people, cross dressers, or anyone whose gender expression is not traditional finds its most extreme expression in violent crimes committed against individuals who visibly do not conform to gender norms. But it is fueled by the little injustices in our daily lives. Being forced to wear clothing associated with an identity that we do not share or cannot align with is a powerful reminder that our true sense of self must be hidden to be safe.

Moreover, dress codes facilitate abuse, first by enforcing the notion that there is a "right" and a "wrong" way to dress, and that transgressers can and should be punished, and secondly by normalizing the punishment. Where we face sanctions and exclusion for being who we are (such as being thrown out of a public bathroom, being expelled from school, or being fired, for example), it is hard to avoid the basic feeling of being somehow "wrong." Over time, this feeling of "wrongness" can contribute to depression and the conviction that violence and discrimination is inevitable.

But it is not.

There is no legitimate reason for gendered dress codes, or for dress codes that enforce or prohibit a specific faith. The European Court of Human Rights has repeatedly noted that gender identity, including the right to dress according to who we feel we are, is one of the most basic essentials of self-determination. In the Americas, this sentiment finds legal expression in the adoption of several new laws that seek to protect everyone against discrimination, regardless of their gender identity.

We, the adults, need these laws because many of us have internalized gendered dress codes, which we have to unlearn. Not so for our children: They learn dress codes from us. So I, for one, will be telling my daughter that she can wear whatever keeps her warm, comfortable, and happy under her graduation gown (if she chooses to wear one).

When Do Depictions of Sex Constitute Assault?

@RHRealityCheck

In June, a story of “girl power”-style revenge made the rounds on social media. Reportedly, a woman sent unsolicited penis pictures she had received to the sender’s mother, despite his protestations. Meanwhile, an ongoing debate in Britain about what—if any—depictions of sex should be banned has resurrected the age-old question: Does pornography cause rape?

Both stories raise interesting questions about the limits of privacy and consent.

Most of us agree that when adults voluntarily share generic photos of themselves with friends who consent to viewing them, this is no matter for censorship or state intervention. There is, however, less agreement on how much autonomy we should have when those images involve nudity or are explicitly sexual. Some jurisdictions ban “hard-core” or “extreme” pornography, while others place limits on the “obscene.”

Part of the problem is that we do not have a homogenous view of what constitutes pornography or obscenity in the first place. The difficulty in stating clearly what we believe is immoral or wrong was memorably captured by U.S. Supreme Court Justice Potter Stewart in 1964, when he stated that constitutional protections of free speech clearly did not protect “hard-core pornography,” a concept he couldn’t define, though he was certain he would “know it when I see it.”

It was also recently highlighted by a successful grassroots campaign to push Facebook to implement better guidelines on what content the social networking site should take down. The campaigners argued Facebook wrongly identified breastfeeding mothers as “obscene,” while leaving up photos and speech they felt advocated violence against women. Facebook argued it routinely removed hate speech, while leaving up humorous, though offensive, content.

And the difficulty is at the core of the current debate in Britain about a 2008 act that prohibits the possession of “extreme pornography,” defined to include images produced for the purposes of sexual arousal of acts that, if real, would likely cause serious injury to a person’s anus, breasts, or genitals.

Last summer, this act was put to the test in a case against a London mayoral aide who was charged with possessing images of a sado-masochistic nature. The images depicted friends and acquaintances of the aide, who, the prosecution does not contest, had consented to the pictures being taken and shared. The aide was ultimately acquitted after a very public trial, but lost his job. Those who advocate for maintaining and expanding the prohibition of “extreme pornography” argue that such images, in themselves, are a form of assault, and that they cause more violence by trivializing abuse.

It is important to note that a causal link between pornography and violence has not been proven. A 1991 study of criminal data in four European countries concluded that incidences of rape had not increased more than nonsexual violent crimes as pornography had become more easily available. This was confirmed in a 2009 study, which concluded that evidence for a causal relationship between exposure to pornography and sexual aggression is slim and may have been exaggerated.

So the real question is whether pornography (or sexual imagery) in and of itself constitutes assault. And this depends on consent and affects privacy. Rape apologies aside, there is no longer confusion (at least in the law) that anyone forced to carry out a sexual act, on or off camera, is a victim of assault. In other words, pornography constitutes assault when it depicts individuals who have not consented to have sex, let alone to having it filmed.

Pornographic images also constitute a form of assault when they are thrust on people who have not consented to seeing them. This is the case with unsolicited penis pictures, and is the reason those forwarding such pictures to the sender’s family and friends (or the public in general) argue that thrusting them on others is par for the course.

To be sure, claiming privacy rights over penis pictures you have imposed on someone who did not want to see them is like suing for libel when publicized security camera footage shows you robbing a bank. Then again, there is something slightly off about forwarding photos you did not want to see on others who likewise have not consented to viewing them. In such cases, a more ethical (though much less immediately satisfying) course of action would be filing a complaint for aggravated harassment.

But not all pornographic images are wrong. Photos that have been taken and shared with the full consent of everyone involved, including the recipients, should not be banned, but rather benefit from privacy and free speech protections—because such images are not assault, but sex. And surely we would be hard-pressed to think of anything more private than that.

Why Is El Salvador Letting A Woman Die?

@RHRealityCheck

This past month, the world has been watching a 22-year-old pregnant woman in El Salvador die, little by little. I want to say it is like watching an accident happen in slow motion, but this situation is no accident. El Salvador’s government is deliberately denying lifesaving treatment to the woman, for no reason other than that she is pregnant.

At first I couldn’t understand why.

I am not trying to be naive. I know that abortion is criminalized in all circumstances in El Salvador, and that the government therefore can hide behind the law to justify denying Beatriz (a pseudonym) medical treatment. I also know that El Salvador is a predominantly Catholic country, and that church officials are very active in the country’s political life, in particular on this issue.

But this same constellation of facts has not prevented select women in similar situations from getting access to the services they need in other countries in the region. Over the years, I have interviewed a small handful of women in Latin America who needed abortions to protect their health and lives. In most cases, after an initial negotiation with the public health ministry or prosecutor, the intervention went through on the dual condition that it got registered as “appendicitis” in the woman’s medical record, and that the women didn’t tell anyone about it. It didn’t much matter if abortion was legal or illegal in the countries where each case happened—the main motivation for allowing the intervention for the prosecutors and other public officials involved was to avoid negative publicity.

Because it doesn’t look good for El Salvador’s government officials. Sure, they are following the law. But they are also watching a woman die. And for what? The fetus Beatriz is carrying does not have a forebrain, and is likely to survive only scant hours after birth, if that. Human rights officials from the United Nations have publicly called out the situation as counter to El Salvador’s international obligations, and international media are portraying the government as “not moving a finger.”

The only reasonable explanation for the public stand-off is that Beatriz and other resource-poor women are politically expendable, and that crossing the Catholic Church is seen as worse than being hung out in the press as inhumane.

It wouldn’t be the first time poor women pay with their health and lives for politics. In Nicaragua, a mere ten days before the 2006 presidential election, the parliament voted to eliminate the possibility for legal abortion when a woman’s life is threatened by her pregnancy. Members of the Sandinista party were reportedly told to vote for the change, with the promise that it would be “fixed” after their candidate had won the election. And during the Pope’s 2007 visit to Brazil, then-President Lula publicly announced his opposition to abortion.

Let us be clear: the Catholic Church, and any other religious group or civil society organization, has the right to try and influence policies and further its agenda within the limits of the law. But governments owe everyone the same rights, regardless of faith, sex, family status, or ability to pay for votes or medical treatment. In the recent ruling, the Inter-American Court on Human Rights stated that governments cannot implement laws in a manner that reflects only one particular religion, as this would infringe on the rights of those who do not share that faith.

Nowhere is this more obvious than when it comes to the laws that criminalize abortion, even where the pregnant woman’s health or life is compromised. Not all visions of Catholicism require a woman to die for the sake of her pregnancy. And even if they did, it is Beatriz’s faith, wishes, and life the law must uphold.

I don’t understand what El Salvador’s government has to gain from watching this young woman die a preventable death. And I don’t understand how we can continue to allow this to happen.

When Health Care Providers Refuse Care, Whose Rights Are At Stake?

@RHRealityCheck

Recently, an appeals court in Scotland ruled that a wide range of service providers have a right to object to helping with the provision of abortions, even if the care they provide is not directly related to the termination of a pregnancy. In the original ruling, last year, the duties carried out by the two Catholic midwives who brought the case had been considered so removed from the actual abortion that there could be no objection. The appeals court, however, disagreed. Everyone even tangentially involved, it said, has the right to object to providing a wide range of services. The only exception would be life-saving care.

This ruling highlights issues that have relevance beyond Scotland.

The tragic death of Savita Halapannavar in Ireland last year crystallized that no one really knows for sure when a woman is dying from pregnancy-related complications. Over the years, I have interviewed dozens of medical providers in countries with restrictive abortion laws. A key concern for the vast majority of them was how to make sure their actions were legal. Those working in countries where only life-saving abortions are permitted often expressed fear that they would either turn too many women away, with fatal consequences, or ultimately lose their license for providing care to someone who wasn’t “dying enough.”

Let’s apply this notion in a context where anyone involved, however tangentially, in the provision of abortion services, can refuse to treat a woman who is not dying.

This situation raises questions which, regardless of the answers given, compromise quality care. Who gets to determine how lethal each pregnancy is? Can a treating doctor compel assisting midwives or nurses to intervene if she or he believes the patient otherwise will die? And would midwives and others have the right to sue if they had been compelled to help provide an abortion to a woman who ultimately survived? There are no good answers to these questions, and any regulatory solution would almost inevitably lead to substantial delays in care.

Another key concern with a broadly defined right to conscientious objection in the context of health care is access to care in remote—or sometimes not so remote—areas. In the United States, much anti-choice activism is directed at making abortion impossible rather than illegal. Legislators, judges, and other officials in states including Mississippi, Virginia, and North Carolina have made it their goal to run every last abortion provider out of their state. Already, 35 percent of the U.S. population lives in counties without an abortion provider.

Moreover, broad conscientious objection clauses in combination with the stigmatization of abortion generally can stifle the provision of care anywhere. In small communities where everybody knows each other and where abortion is thought of as “evil,” doctors, nurses, and midwives often object to providing care out of fear rather than faith. After all, they still have to make their living where they are.

When I researched access to abortion for rape victims in Mexico, I came across various innovative “solutions” to this problem. In one area, abortion teams were circulated between public hospitals to ensure that no one had to provide care in his or her home town. In another, abortions were provided with the knowledge only of the senior-most officials at selected hospitals, with the result that many women in need of urgent care were turned away because “we don’t do that here” (even at hospitals where they, in fact, did).

Neither of these approaches solved the underlying problem: that abortions are seen as separate from other medical care (which they are not), and that abortion providers are considered different from other medical providers (again, not true). As a result, patients had to seek legal care in a clandestine manner, and in many cases the additional option of conscientious objection for anesthesiologists or nurses—who were not part of the core teams—made abortions virtually impossible to obtain.

Everyone has the right to freedom of thought, religion, and conscience. But international human rights standards do not protect our right to express those thoughts or that conscience in a manner that infringes on other people’s human rights. The more I learn about the concrete repercussions of conscientious objection in the context of health care, the more it is clear to me that there is no room for it. Ultimately, if you don’t want to provide the obstetric or gynecological services your patient needs—which may include an abortion—maybe you should choose another field of specialty.