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Review of Reproductive Rights as Human Rights: Women of Color and the Fight for Reproductive Justice

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Zakiya Luna, Review of Reproductive Rights as Human Rights: Women of Color and the Fight for Reproductive Justice, Social Forces , Volume 100, Issue 1, September 2021, Page e13, https://doi.org/10.1093/sf/soab033

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Reviewer: Rocío R. García, Arizona State University, USA

In the introduction to her book, Zakiya Luna raises the question: “What happens when we center women of color’s organizing?” (p. 9). Reproductive Rights as Human Rights: Women of Color and the Fight for Reproductive Justice demonstrates the ontological and epistemological importance of this question using an array of qualitative data, including interviews, participant observations, and archival documents. In an empirically rich text with implications across sociology, feminist studies, anthropology, public policy, and ethnic studies, Reproductive Rights as Human Rights joins a powerful body of scholarship that draws on the unique standpoints of feminists of color for making sense of reproductive politics and strategies for engaging intersecting grievances, motivations, and claims-making.

Luna focuses on the intersectional movement for reproductive justice, in particular the social movement organization SisterSong that “grew to be the largest and most visible organizational coalition in the reproductive justice movement” (p. 4). Luna notes that reproductive justice—defined as equally advocating for the right to have children, the right not to have children, and the right to parent—is often understood by activists and scholars alike as intimately linked to human rights. Luna draws on this observation as a launching point to interrogate why and how reproductive justice is recognized as a human rights issue, a significant undertaking given that the United States reflects a longstanding mixture of hostility and confusion regarding the human rights approach. As Reproductive Rights as Human Rights demonstrates, the fact that few social movements in the United States draw on the human rights approach as a claims-making strategy is neither inconsequential nor a mere coincidence.

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Reproducing Rights

6 UC Irvine L. Rev. 579 (2018)

Temple University Legal Studies Research Paper No. 2018-27

33 Pages Posted: 15 Jun 2018 Last revised: 6 Sep 2018

Rachel Rebouché

Temple University - James E. Beasley School of Law

Date Written: March 1, 2018

This Article argues that reproductive justice writings, by relying on human rights arguments, may perpetuate a limited vision for global justice—one that contradicts the movement’s core commitments and detracts from the change that the movement’s advocates seek. International human rights law and practice, as traditionally conceived, relies heavily on courts and law reform projects. And it reflects many of the commitments of the U.S. reproductive rights movement. In adopting a human rights framework, reproductive justice may miss possible alliances with other movements, such as those working to understand the social determinants of health and to advance health justice. In highlighting the potential tension between reproductive justice and human rights, this Article has in mind U.S. advocates, who are central to campaigns for international reproductive rights and seek to incorporate human rights approaches at home. Part I of this Article summarizes the influence of human rights reasoning in reproductive rights generally and abortion rights specifically, the embrace of human rights by U.S. reproductive rights advocates, and the influence of U.S. abortion politics in the international arena. Part II describes the origins of the reproductive justice movement in the United States as well as reproductive justice’s core priorities. It demonstrates how reproductive justice activism moves beyond a focus on abortion and at the same time calls for meaningful access to abortion care for women with and without resources. Part III reviews the references to human rights in reproductive justice literature and questions if human rights, as described by reproductive justice advocates, respond to the deep inequalities of income and socioeconomic status in the delivery of healthcare.

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Rachel Rebouche (Contact Author)

Temple university - james e. beasley school of law ( email ).

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Reproductive rights in America

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Reproductive Rights and Justice: A Multiple Feminist Theories Account

2018, SSRN Electronic Journal

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10 Essential Essays About Women’s Reproductive Rights

“Reproductive rights” let a person decide whether they want to have children, use contraception, or terminate a pregnancy. Reproductive rights also include access to sex education and reproductive health services. Throughout history, the reproductive rights of women in particular have been restricted. Girls and women today still face significant challenges. In places that have seen reproductive rights expand, protections are rolling back. Here are ten essential essays about reproductive rights:

“Our Bodies, Ourselves: Reproductive Rights”

bell hooks Published in Feminism Is For Everyone (2014)

This essay opens strong: when the modern feminism movement started, the most important issues were the ones linked to highly-educated and privileged white women. The sexual revolution led the way, with “free love” as shorthand for having as much sex as someone wanted with whoever they wanted. This naturally led to the issue of unwanted pregnancies. Birth control and abortions were needed.

Sexual freedom isn’t possible without access to safe, effective birth control and the right to safe, legal abortion. However, other reproductive rights like prenatal care and sex education were not as promoted due to class bias. Including these other rights more prominently might have, in hooks’ words, “galvanized the masses.” The right to abortion in particular drew the focus of mass media. Including other reproductive issues would mean a full reckoning about gender and women’s bodies. The media wasn’t (and arguably still isn’t) ready for that.

“Racism, Birth Control, and Reproductive Rights”

Angela Davis Published in Women, Race, & Class (1981)

Davis’ essay covers the birth control movement in detail, including its race-based history. Davis argues that birth control always included racism due to the belief that poor women (specifically poor Black and immigrant women) had a “moral obligation” to birth fewer children. Race was also part of the movement from the beginning because only wealthy white women could achieve the goals (like more economic and political freedom) driving access to birth control.

In light of this history, Davis emphasizes that the fight for reproductive freedom hasn’t led to equal victories. In fact, the movements driving the gains women achieved actively neglected racial inequality. One clear example is how reproductive rights groups ignored forced sterilization within communities of color. Davis ends her essay with a call to end sterilization abuse.

“Reproductive Justice, Not Just Rights”

Dorothy Roberts Published in Dissent Magazine (2015)

Dorothy Roberts, author of Killing the Black Body and Fatal Invention , describes attending the March for Women’s Lives. She was especially happy to be there because co-sponsor SisterSong (a collective founded by 16 organizations led by women of color) shifted the focus from “choice” to “social justice.” Why does this matter? Roberts argues that the rhetoric of “choice” favors women who have options that aren’t available to low-income women, especially women of color. Conservatives face criticism for their stance on reproductive rights, but liberals also cause harm when they frame birth control as the solution to global “overpopulation” or lean on fetal anomalies as an argument for abortion choice.

Instead of “the right to choose,” a reproductive justice framework is necessary. This requires a living wage, universal healthcare, and prison abolition. Reproductive justice goes beyond the current pro-choice/anti-choice rhetoric that still favors the privileged.

“The Color of Choice: White Supremacy and Reproductive Justice”

Loretta J. Ross, SisterSong Published in Color of Violence: The INCITE! Anthology (2016)

White supremacy in the United States has always created different outcomes for its ethnic populations. The method? Population control. Ross points out that even a glance at reproductive politics in the headlines makes it clear that some women are encouraged to have more children while others are discouraged. Ross defines “reproductive justice,” which goes beyond the concept of “rights.” Reproductive justice is when reproductive rights are “embedded in a human rights and social justice framework.”

In the essay, Ross explores topics like white supremacy and population control on both the right and left sides of politics. She acknowledges that while the right is often blunter in restricting women of color and their fertility, white supremacy is embedded in both political aisles. The essay closes with a section on mobilizing for reproductive justice, describing SisterSong (where Ross is a founding member) and the March for Women’s Lives in 2004.

“Abortion Care Is Not Just For Cis Women”

Sachiko Ragosta Published in Ms. Magazine (2021)

Cisgender women are the focus of abortion and reproductive health services even though nonbinary and trans people access these services all the time. In their essay, Ragosta describes the criticism Ibis Reproductive Health received when it used the term “pregnant people.” The term alienates women, the critics said, but acting as if only cis women need reproductive care is simply inaccurate. As Ragosta writes, no one is denying that cis women experience pregnancy. The reaction to more inclusive language around pregnancy and abortion reveals a clear bias against trans people.

Normalizing terms like “pregnant people” help spaces become more inclusive, whether it’s in research, medical offices, or in day-to-day life. Inclusiveness leads to better health outcomes, which is essential considering the barriers nonbinary and gender-expansive people face in general and sexual/reproductive care.

“We Cannot Leave Black Women, Trans People, and Gender Expansive People Behind: Why We Need Reproductive Justice”

Karla Mendez Published in Black Women Radicals

Mendez, a freelance writer and (and the time of the essay’s publication) a student studying Interdisciplinary Studies, Political Science, and Women’s and Gender Studies, responds to the Texas abortion ban. Terms like “reproductive rights” and “abortion rights” are part of the mainstream white feminist movement, but the benefits of birth control and abortions are not equal. Also, as the Texas ban shows, these benefits are not secure. In the face of this reality, it’s essential to center Black people of all genders.

In her essay, Mendez describes recent restrictive legislation and the failure of the reproductive rights movement to address anti-Blackness, transphobia, food insecurity, and more. Groups like SisterSong have led the way on reproductive justice. As reproductive rights are eroded in the United States, the reproductive rights movement needs to focus on justice.

“Gee’s Bend: A Reproductive Justice Quilt Story From the South”

Mary Lee Bendolph Published in Radical Reproductive Justice (2017)

One of Mary Lee Bendolph’s quilt designs appears as the cover of Radical Reproductive Justice. She was one of the most important strip quilters associated with Gee’s Bend, Alabama. During the Civil Rights era, the 700 residents of Gee’s Bend were isolated and found it hard to vote or gain educational and economic power outside the village. Bendolph’s work didn’t become well-known outside her town until the mid-1990s.

Through an interview by the Souls Grown Foundation, we learn that Bendolph didn’t receive any sex education as a girl. When she became pregnant in sixth grade, she had to stop attending school. “They say it was against the law for a lady to go to school and be pregnant,” she said, because it would influence the other kids. “Soon as you have a baby, you couldn’t never go to school again.”

“Underground Activists in Brazil Fight for Women’s Reproductive Rights”

Alejandra Marks Published in The North American Congress on Latin America (2021)

While short, this essay provides a good introduction to abortion activism in Brazil, where abortion is legal only in the case of rape, fetal anencephaly, or when a woman’s life is at risk. The reader meets “Taís,” a single mother faced with an unwanted pregnancy. With no legal options, she researched methods online, including teas and pills. She eventually connected with a lawyer and activist who walked her through using Cytotec, a medication she got online. The activist stayed on the phone while Taís completed her abortion at home.

For decades, Latin American activists have helped pregnant people get abortion medications while wealthy Brazilians enter private clinics or travel to other countries. Government intimidation makes activism risky, but the stakes are high. Hundreds of Brazilians die each year from dangerous abortion methods. In the past decade, religious conservatives in Congress have blocked even mild reform. Even if a new president is elected, Brazil’s abortion rights movement will fight an uphill battle.

“The Ambivalent Activist”

Lauren Groff Published in Fight of the Century: Writers Reflect on 100 years of Landmark ACLU Cases (2020)

Before Roe v. Wade, abortion regulation around the country was spotty. 37 states still had near-bans on the procedure while only four states had repealed anti-abortion laws completely. In her essay, Groff summarizes the case in accessible, engaging prose. The “Jane Roe” of the case was Norma McCorvey. When she got pregnant, she’d already had two children, one of whom she’d given up for adoption. McCorvey couldn’t access an abortion provider because the pregnancy didn’t endanger her life. She eventually connected with two attorneys: Sarah Weddington and Linda Coffee. In 1973 on January 2, the Supreme Court ruled 7-2 that abortion was a fundamental right.

Norma McCorvey was a complicated woman. She later became an anti-choice activist (in an interview released after her death, she said Evangelical anti-choice groups paid her to switch her position), but as Groff writes, McCorvey had once been proud that it was her case that gave women bodily autonomy.

“The Abortion I Didn’t Want”

Caitlin McDonnell Published in Salon (2015) and Choice Words: Writers on Abortion (2020)

While talking about abortion is less demonized than in the past, it’s still fairly unusual to hear directly from people who’ve experienced it. It’s certainly unusual to hear more complicated stories. Caitlin McDonnell, a poet and teacher from Brooklyn, shares her experience. In clear, raw prose, this piece brings home what can be an abstract “issue” for people who haven’t experienced it or been close to someone who has.

In debates about abortion rights, those who carry the physical and emotional effects are often neglected. Their complicated feelings are weaponized to serve agendas or make judgments about others. It’s important to read essays like McDonnell’s and hear stories as nuanced and multi-faceted as humans themselves.

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About the author, emmaline soken-huberty.

Emmaline Soken-Huberty is a freelance writer based in Portland, Oregon. She started to become interested in human rights while attending college, eventually getting a concentration in human rights and humanitarianism. LGBTQ+ rights, women’s rights, and climate change are of special concern to her. In her spare time, she can be found reading or enjoying Oregon’s natural beauty with her husband and dog.

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Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020

Racial and ethnic disparities in reproductive health are prevalent and can be reduced through policy-level strategies and by confronting bias and racism.

Racial and ethnic disparities in women's health have existed for decades, despite efforts to strengthen women's reproductive health access and utilization. Recent guidance by the American College of Obstetricians and Gynecologists (ACOG) underscores the often unacknowledged and unmeasured role of racial bias and systemic racial injustice in reproductive health disparities and highlights a renewed commitment to eliminating them. Reaching health equity requires an understanding of current racial–ethnic gaps in reproductive health and a concerted effort to develop and implement strategies to close gaps. We summarized national data for several reproductive health measures, such as contraceptive use, Pap tests, mammograms, maternal mortality, and unintended pregnancies, by race–ethnicity to inform health-equity strategies. Studies were retrieved by systematically searching the PubMed (2010–2020) electronic database to identify most recently published national estimates by race–ethnicity (non-Hispanic Black or African American, Hispanic or Latinx, and non-Hispanic White women). Disparities were found in each reproductive health category. We describe relevant components of the Affordable Care Act (ACA) and the Preventing Maternal Deaths Act, which can help to further strengthen reproductive health care, close gaps in services and outcomes, and decrease racial–ethnic reproductive health disparities. Owing to continued diminishment of certain components of the ACA, to optimally reach reproductive health equity, comprehensive health insurance coverage is vital. Strengthening policy-level strategies, along with ACOG's heightened commitment to eliminating racial disparities in women's health by confronting bias and racism, can strengthen actions toward reproductive health equity.

Despite significant strides in women's reproductive health, disparities in access and outcomes remain, especially for racial–ethnic minorities in the United States. 1 – 4 Reports document decades-long racial–ethnic disparities in several areas of reproductive health, including contraceptive use, sexually transmitted infection care and human papillomavirus vaccination among younger women aged 18–25 years, 5 reproductive cancers, 6 preterm deliveries and low-birth-weight neonates, and maternal morbidity and mortality. 7 Data suggest that the disproportionate risk for women of color for reproductive health access and outcomes expand beyond individual-level risks and include social and structural factors, such as fewer neighborhood health services, less insurance coverage, decreased access to educational and economic attainment, and even practitioner-level factors such as racial bias and stereotyping. 1 , 4 , 8 The Center for Reproductive Rights describes this racial–ethnic gap as a human rights issue and suggests that, “several U.S. policies may exacerbate these disparities by disproportionately burdening access to health care for women of color.” 4 Solutions that lead to increased access for women must remove these social and structural barriers so that women, especially underserved racial and ethnic minority women, may access and utilize reproductive health services as needed without clinician bias or other obstacles. 9

Healthy People 2020, the science-based national guidance document, considers improved health care access by making the elimination of health disparities and improvement of health for all groups an overarching goal for the United States, including for reproductive health. 10 Policy-level interventions, which are often based on political will, can help move the needle toward health equity by leveling the field and reducing how often subjective bias, including individual racial bias and structural racism, factor into health care accessibility, acceptability, decision-making, and affordability. 11 The Patient Protection and Affordable Care Act (ACA) is an example of a social-structural-policy–level intervention that helps facilitate national prevention goals by increasing health care access for millions of previously uninsured and underinsured persons. 12 – 14 Although legal challenges continue to threaten the potential for fully expanded reproductive health access and services for women (Appendix 1, available online at http://links.lww.com/AOG/C152 ), the ACA has provided large gains for women who would otherwise be without health care or have copays as an access barrier. 12 – 14 However, because federal and state rulings continue to diminish portions of the ACA that allow access to contraceptives, optimal health parity for reproductive access and services will require a fully comprehensive national health insurance reform strategy that removes barriers and strengthens access. In some cases, even when medical insurance is available among women in the same socioeconomic strata, persistent, unexplained disparities persist and suggest that racism and other social and clinician-level issues are factors; life-course approaches to understanding women and their contexts are needed by clinicians and care systems to optimize care.

The health of persons of color in the United States has been adversely affected by centuries of social and structural factors, such as unequal access to educational and employment opportunities, lack of health care access, redlining (structural racism in the U.S. housing system that forced people of color into specific neighborhoods and has contributed to stark and persistent racial disparities in wealth and financial well-being), distrust of physicians, a segregated health care workforce, negative perceptions of the health care system, and disproportionate engagement with a legal–justice system that is rooted in racism and that disproportionately incarcerates non-Hispanic Black or African American and Hispanic or Latinx compared with non-Hispanic White (hereafter referred to as Black, Hispanic, and White) peoples. 2 , 4 , 7 , 8 , 15 – 19 These all negatively affect reproductive health outcomes and require multipronged anti-racist approaches to tear away these centuries-old systems of racism. Women of color must be listened to with empathy and solidarity, so that care and treatment responses can be appropriate; this requires a more racially and ethnically diverse workforce, anti-racist education at every level of clinical training, and increased inclusion of doulas and other patient advocates in maternal care. Additionally, clinicians should ensure that patients are fully informed regarding treatment and care options. This requires cultural humility, mindfulness, transparency, and acknowledgement of the historical injustices that have occurred and a commitment to relegate them to history. Educational trainings of all obstetrician–gynecologists (ob-gyns) regarding these social and historical contexts are warranted to strengthen patient care. Therefore, the purpose of this commentary is to update regarding reproductive health disparities in the United States and inform national health-equity efforts.

REPRODUCTIVE HEALTH DISPARITIES, ACCESS, SERVICES, AND OUTCOMES

Nearly one in three women aged 19–64 years, approximately 27 million women, were uninsured, and another 45 million delayed or avoided health care because of cost in 2010, before the ACA was implemented nationally. 20 By 2018, after implementation of the ACA, an estimated 10.8 million women were uninsured, a decrease compared with 2010. 21 However, gains have stalled in recent years. Having health insurance improves the chances that women will have a regular source of care and access. 22 – 25 By including a package of women's preventive services as recommended by the Department of Health and Human Services, 14 access through the ACA includes Pap tests, mammograms, and some contraceptives without copays for women; this improves comprehensive care and access for all women and may ultimately help reduce reproductive health disparities. A recent review confirmed that, since implemented in 2010, the ACA has resulted in improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes for women. 23 – 25 However, huge challenges to coverage, access, and affordability remain for women throughout the country, and particularly in 14 mostly southern states that have not expanded Medicaid eligibility and continue to lack access through the ACA. 26 – 28 This coverage gap disproportionately affects disenfranchised populations in the southern states and likely contributes to the wide racial–ethnic health disparities in health access and several health outcomes for women. 27 , 28

For this commentary, we reviewed and summarized (Table ​ (Table1) 1 ) recent national estimates for several reproductive health measures using a PubMed review (2010–2020), including services (contraceptive use, 29 – 37 Pap tests, 38 – 40 mammogram screening, 39 – 45 late or no prenatal care, 46 – 48 chlamydia screening, 49 – 54 human immunodeficiency virus [HIV] treatment 55 – 60 ) and outcomes (unintended pregnancy, 61 – 63 induced abortions, 64 – 66 preterm births, 67 – 69 breastfeeding initiation, 10 , 70 – 73 maternal mortality, 15 , 74 – 82 cervical cancer, 83 – 85 endometrial cancer deaths, 86 , 87 HIV diagnoses 88 , 89 ) by race–ethnicity (Black, Hispanic, and White, as classified by the authors of the studies, and examined, because we are exploring racial–ethnic disparities). By highlighting the current racial–ethnic disparities in reproductive health, our goal was to show that there are opportunities to strengthen access and care for women, toward improved reproductive health equity (Fig. ​ (Fig.1), 1 ), as underscored recently with a renewed commitment from the American College of Obstetricians and Gynecologists to eliminate these disparities. 8 For the three topics below (contraceptive access, maternal mortality, and HIV diagnoses), we considered focused strategies using multilevel approaches, including addressing racism, which may work synergistically to improve clinician awareness, and access and outcomes for women. If time reveals improved access and outcomes for women of color for the three issues discussed below, lessons learned could inform other reproductive health disparity issues summarized in Table ​ Table1 1 and ultimately lead us toward reduced reproductive health disparities.

Estimated Rates of Selected Reproductive Health Measures by Race–Ethnicity, 2020

Sutton. Racial and Ethnic Disparities in Reproductive Health. Obstet Gynecol 2021.

Focused Strategies

Contraceptive access and use.

Cost is a known barrier to contraceptive access and use for some women. 29 , 30 High contraceptive costs affects consistent use, which subsequently affects risk to reproductive autonomy 31 and rates of unplanned pregnancies. Highly effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device and dermal implants, have higher upfront costs. 29 , 30 , 32 Providing contraceptive access by removing cost barriers can be a highly effective means of increasing reproductive autonomy for all women regardless of race–ethnicity and social status. 33 , 34 Pharmacy-level barriers also exist and can lead to some women not obtaining even prescribed or over-the-counter hormonal contraceptives. Increased reproductive access–focused training for pharmacists is important as part of expanded access for women. 35

Having health insurance is associated with an increase in the likelihood of receiving family planning services, 36 which can strengthen reproductive autonomy 31 and decrease unplanned pregnancies. Contraceptive use among females aged 15–49 years is statistically more common among White females (67%) compared with Black females (59.9%). 37 Strengthening access to comprehensive health insurance can help close this gap in contraceptive access and use (Fig. ​ (Fig.1), 1 ), as evidenced by data from a state with expanded Medicaid access. 90

When considering LARC and permanent sterilization, clinicians must be aware of the historical legacy of abuse and eugenics in which women of color have been disproportionately sterilized without their consent (compared with White women) as a result of explicit bigotry. Data suggest that women of color are offered LARC more often sometimes owing to implicit biases. 91 Awareness of historical and modern-day racial injustices often contribute to the lower rate of contraceptive use among Black and Hispanic women; there is a distrust by some patients that has yet to be acknowledged by many clinicians. 92 To combat this, patient-centered shared decision making is a vital component of all contraceptive counseling. 93

Laws that have restricted women's access to family planning and reproductive health services have also contributed to rising maternal mortality rates. 81 Policy-level interventions are warranted to save women's lives. Especially with as many as 50% of pregnancies in the United States being unintended, preventing unintended pregnancies will help prevent maternal deaths. The Preventing Maternal Deaths Act, signed into law in 2018, supports state maternal mortality review committees to review every pregnancy-related death and, based on their findings, develop recommendations for how to prevent future maternal deaths; this will allow care gaps can be identified and closed. 15 , 82 (Fig. ​ (Fig.1 1 ).

Maternal Mortality

Maternal mortality disparities have been documented for decades in the United States. 74 These disparities are a public health failure that have recently generated increased attention and policy shifts, especially because approximately 60% of pregnancy-related deaths are preventable. 74 Persistently, women of color have been disproportionately affected by maternal mortality; Black women and American Indian or Alaska Native women are 3.3 and 2.5 times more likely to die from pregnancy-related causes than White women, respectively. 74 When individual recent cases were reviewed, clinician-level biases and racism often contributed to delayed or absent care that led to deaths. 75 – 79 Establishment of management protocols by hospitals and medical practices for the management of conditions such as postpartum hemorrhage, 80 hypertensive disorders of pregnancy, and maternal cardiovascular disease will lessen the disparate care provided to women of color, increase standardized care, and improve maternal morbidity and mortality. Such protocols are necessary in both the inpatient and outpatient arenas, at the hospital or health care system level, as well as in independent medical practices.

Human Immunodeficiency Virus Diagnoses

In women, those who are Black and Hispanic account for 75% of new diagnoses of HIV. 55 Given that 85.2% of women diagnosed with HIV acquire it through heterosexual contact, comprehensive and accessible gynecologic care, including HIV and sexually transmitted infection prevention and treatment programs, are essential to decrease the rates of HIV infection. 55 – 60 Barriers to accessing such care by Black and Hispanic women need to be eliminated by providing high-quality, culturally sensitive, accessible care in local communities.

Multiple approaches are needed to address these alarming HIV diagnosis disparities, including addressing disproportionate poverty through microfinance interventions, ensuring equitable access to educational and career opportunities and reproductive health care access, and increasing access to biomedical prevention interventions, such as pre-exposure prophylaxis. 88 , 89 Data show that Black women are less likely to be prescribed pre-exposure prophylaxis, a known, evidence-based approach to HIV prevention, compared with White women and men. 94 Increasing pre-exposure prophylaxis bias-awareness is one additional strategy to increase pre-exposure prophylaxis uptake among at-risk Black women who are HIV-negative. 95 Improving linkage and retention in HIV care for Black women who are HIV-positive are also important strategies to address HIV disparities. Educational strategies regarding HIV-prevention tools with clinicians and also with all sexually active women are warranted. 91 Although HIV screening for sexually active women during gynecology visits is supported without copays, fewer than 20% of sexually active women reported receiving an HIV test during the past year in a recent report. 96 Offering routine HIV screenings should be fully incorporated during obstetrics and gynecology visits; early diagnosis is vital for timely treatment and decreased morbidity and mortality (Fig. ​ (Fig.1 1 ).

Racial–ethnic disparities in reproductive health access, services, and outcomes are prevalent and require heightened awareness and strategies to close these long-standing disparity gaps. Specifically for contraceptive access, preventing maternal deaths, and decreasing HIV infections, developing and strengthening policies and laws that include a focus on dismantling structural racism and implicit bias are crucial as part of the solution. Because race and ethnicity are social constructs, dismantling the structures developed based on race–ethnicity will require social solutions. 97 Upstream federal-level solutions for structural racism will require the Departments of Justice, Education, Labor, and Housing and Urban Development to dismantle current systems that are rooted in a legacy of unequal treatment and move toward anti-racist judicial, educational, income (especially with hourly, low-wage jobs, which disproportionately decrease flexibility and access for women, especially women of color), and housing solutions; legislative advocacy by local and national clinicians will be vital to these efforts. 98 – 102 Commitment from downstream leadership, followed by implementing policy-level platforms, will help strengthen the ability of ob-gyns and other clinicians to provide necessary services, improve outcomes for women, and reduce racial–ethnic reproductive health disparities.

In addition, these persistent disparities will require multiple levels of partnerships and collaborations to improve outcomes for women of color. For communities, including schools and community-based service organizations, increasing awareness and empowering women through peer education and media campaigns that are transparent regarding historical injustices while also informing regarding evidence-based services, are vital. Some community-based approaches have successfully engaged low-income Hispanic and Black women in accessing cervical and breast cancer screening services. 103 – 106 Health care and professional organizations should hold clinicians and hospitals accountable by encouraging standardized, patient-informed approaches for clinical care and developing strategies to measure and reduce racial–ethnic disparities by linking services provided to measurable health outcomes and performance standards. At the systems level, this can help reduce reproductive health disparities by providing incentives 107 for identifying and removing clinician barriers, with the goal of improved access and outcomes for patients.

Finally, as ob-gyns, we must continue to hold ourselves accountable for the improved health of our patients by addressing the racism and biases that contribute to reproductive health disparities. With renewed commitment and action from the American College of Obstetricians and Gynecologists, 108 we can help facilitate the dismantling of systemic racism that contributes to reproductive health disparities by helping to strengthen the current national health plan for women's health provisions or advocating for a more comprehensive universal health care system or both, increasing the diversification of our workforce, training our residents and fellows to understand the role of racism as it affects patients' care and how to address it, understanding our own biases, and advocating for our patients to help them feel safer in their communities that may be unjustly affected by structural racism and health inequities. 9 By doing so, we will greatly improve reproductive health equity and decrease the excess burden for Black, Hispanic, and Native American women in the United States.

Financial Disclosure The authors did not report any potential conflicts of interest.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at http://links.lww.com/AOG/C153 .

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• If Marc is Suzanne’s father, does it follow that Suzanne is Marc’s child? An experimental philosophy study in reproductive ethics
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• http://orcid.org/0000-0003-1062-7918 Kristien Hens 1 ,
• Emma Moormann 1 ,
• http://orcid.org/0000-0002-9752-6302 Anna Smajdor 2 ,
• Daniela Cutas 3
• 1 Department of Philosophy , University of Antwerp , Antwerpen , Belgium
• 2 IFIKK , University of Oslo , Oslo , Norway
• 3 Clinical Sciences , Lund University , Lund , Sweden
• Correspondence to Professor Kristien Hens, Philosophy, University of Antwerp, Antwerpen 2000, Belgium; kristien.hens{at}uantwerpen.be

In this paper, we report the results from an experimental reproductive ethics study exploring questions about reproduction and parenthood. The main finding in our study is that, while we may assume that everyone understands these concepts and their relationship in the same way, this assumption may be unwarranted. For example, we may assume that if ‘x is y’s father’, it follows that ‘y is x’s child’. However, the participants in our study did not necessarily agree that it does follow. This means, at the very least, that we need to make sure all parties in a debate have the same relationships in mind when talking about reproduction and parenthood. Moreover, it gives us reason to explore more carefully the conditions which support or undermine the connections between these concepts. This cannot come from purely theoretical reasoning, nor from empirical research alone, but from the alliance between the two.

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https://doi.org/10.1136/jme-2023-109808

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Introduction

Reproductive ethicists commonly rely on concepts such as ‘sibling’, ‘parent’, ‘child’, ‘donor’, ‘genes’ or ‘biology’. Such concepts are assumed to be reasonably reliable: in using them, we can be confident that we are talking about the same thing. These apparently stable concepts can then serve as a basis for discussing, for example, the rights and duties of biological versus social parents. Once we commit to one or another interpretation (eg, biological vs social ties as indicators of parenthood), we may take ourselves to be consistent in our use of these concepts and assume that they fall into a specific relation to each other. For example, if Marc is Suzanne parent, then it must also be true that Suzanne is Marc’s child. We also tend to assume that we share an idea of what it means for someone to have reproduced. These choices have normative repercussions. If ‘having reproduced’ and ‘being a biological parent’ are taken as meaning more or less the same thing, this implies that the duties and rights of reproducers are the same as the duties and rights of biological parents. For example, Velleman has claimed that the people who reproduce genetically are the parents of the children thus created, and that therefore donor conception is unethical because it intentionally alienates children from their parents. 1 Choices such as these have practical, legal and ethical implications for how we think about donor conception.

Reproduction and parenthood

Since the 1970s, with the development of bioethics as a distinct discipline and the advent of in vitro fertilisation (IVF), questions about ethics and reproductive technologies have proliferated. As new biomedical possibilities emerge, terms such as ‘mother’, ‘biological parent’ and ‘reproduction’ have come under scrutiny. Concepts that were previously regarded as biologically given are now increasingly recognised as negotiable, or underdetermined, or partly/wholly socially constructed.

Accordingly, new avenues of research have emerged in the literature. In particular, questions about parenthood and reproduction have become a prominent feature of the discourse. There are a number of philosophical accounts of parenthood. 2 3 Some of these privilege biological connections, while others focus on the intentions of prospective parents; others take the causal processes involved in conception to be a key component of parenthood. Still others may highlight the Lockean approach, whereby parenthood is viewed as a status that one acquires through one’s activities—especially caring activities—in relation to a child. On the biological accounts, parenthood may be construed as a fixed genetic relationship, which is necessarily connected with reproduction. A good deal of work has been undertaken in various areas of ethics on these topics, both conceptual and empirical. 4–10 We add to this broader discussion an analysis of a very specific relationship between reproduction and concepts of parenthood. Our work in this paper aims to yield insights into how people construe the relationship between genes, reproduction and fatherhood, by using scenarios where the genetic relationship is slightly altered in each iteration.

Experimental philosophy

It was a common flaw of analytical philosophy of the past to assume that philosophers’ intuitions were the same as those of any ‘reasonable’ person. New approaches to philosophy seek to go beyond these assumptions and intuitions. Cannold has warned of a failure of moral philosophers adequately to understand and respond to lay reasoning in the abortion context. 11 Empirical approaches, such as that espoused by Cannold herself, offer ways of engaging and interacting with the public that aim to reveal new insights into ‘philosophical’ problems. The use of such methods may help philosophers to avoid becoming, to borrow from Wittgenstein, a wheel that turns by itself. 12

The approach we adopt in this paper is commonly known as experimental philosophy. 13 14 A typical study in experimental philosophy involves the design of multiple vignettes which present a particular scenario where one variable is altered in each iteration of the vignette. The vignettes are then presented to a sample of respondents. Using this method, unexpected associations or inconsistencies in people’s interpretations of certain concepts may be revealed. In turn, these help philosophers to understand the ways in which people construct concepts and their relationships. XPhi studies have also fruitfully made apparent cross-cultural differences in intuitions. 15 Many XPhi studies have been conducted in epistemology, free will, moral philosophy and aesthetics. 16 17 Recently, several studies in experimental philosophy of medicine and experimental philosophy of bioethics have also been undertaken. 18

In the context of reproductive ethics, empirical studies such as interviews, focus groups and surveys to investigate people’s opinions and experiences have been increasingly common since around 2000. 11 However, the specific methodology of experimental philosophy has not been widely used. There is some overlap between empirical ethics, qualitative research and experimental philosophy. 19 Given that ethicists are already undertaking empirical work, it might be argued that there is no special need for yet another empirical methodology. However, experimental philosophy, in the sense in which we use the term, is a different endeavour from the studies undertaken by empirical ethicists and qualitative researchers.

Experimental philosophy is in some senses narrower in its scope than other empirical approaches. In most experimental philosophy, especially when vignettes are used, the focus is on the specific concept in question; participants cannot share views, observations or feelings other than those allowed for in the response options. Thus, the overall aim is very different from, for example, that of a qualitative researcher who undertakes semistructured interviews to explore participants’ experience of fertility treatment or runs focus groups in order to elicit participants’ ethical concerns about a particular phenomenon. Often, the main aim in experimental philosophy is to identify those variables that influence participants’ concept of a particular phenomenon. As such, experimental philosophy, especially the flavour that uses vignettes, perhaps has more in common with conceptual engineering than it does with empirical ethics and qualitative research.

Experimental philosophy gives us an additional tool with which to probe the questions we are interested in. Moreover, it can tell us things that do not emerge from other methods of enquiry. For example, the emerging field of e xperimental philosophical bioethics aims to ‘make sense of the eliciting factors and underlying cognitive processes that shape people’s moral judgments, particularly about real-world matters of bioethical concern 14 ’. Experimental philosophy of medicine investigates intuitions regarding concepts of disease, health and disability. 18 As with any other empirical methodology, there may be weaknesses in experimental philosophy that can make its findings questionable, or limit its validity in particular cases. 20 We acknowledge these risks and suggest that the vital thing in the context of experimental philosophy is to be concise in pinpointing the concepts to be analysed, to be cautious in interpreting the data and to avoid leaping too quickly from the findings to normative conclusions. Therefore, we deem the method fruitful to analyse concepts in reproductive ethics, which are often fraught with vagueness and uncertainties.

In this experimental reproductive ethics study, we set out to investigate whether our respondents consider reproduction as necessarily entailing parenthood, and whether ‘x being y’s parent’ entails that ‘y is x’s child’. We also wanted to find out the degree to which genetic contribution is perceived as being necessary or sufficient for reproduction, parenthood and ‘being someone’s child’. More broadly, we aimed to explore the potential of experimental philosophy as a tool with which to shed light on important issues in reproductive ethics. We wanted to answer the following research question:

Do people’s opinions on who has reproduced/is a parent/has a child differ depending on the degree of genetic relatedness between the parties involved?

In the following, we will present the vignettes that we used, our methodology, and discuss our findings.

Methodology

We designed three vignettes. For each vignette we created three separate sets of questions. Each set consists of four questions, with a 5-point Likert scale answer (from ‘completely disagree’ to ‘completely agree’). We recruited 450 participants using Prolific, an online research platform facilitating the recruitment of participants. 21 We calculated the sample size using the Qualtrics online sample size calculator, with as parameters a confidence level of 95%, 1 000 000 as population size and error margin of 5%. This yielded an ideal sample size of 384 participants. We increased this to 450 participants, so that we could deploy a 9×50 (between subjects) design. This means that each of the nine possible combinations of vignette and question sets were presented to 50 respondents. The only requirement that we used as a pre-screener in Prolific was that participants had English as a mother tongue, and that the sample was gender balanced. We did not collect further demographic information besides age and gender. The participants were distributed among all age ranges, although most responses were within the 25–44 age range. Both the geographical location of the participants and their age may have relevance for the responses. We consider this a pilot study, and we encourage its reproduction in different geographical regions and with younger and older respondents. Figure 1 gives an overview of the flow of the vignettes.

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Flow of the vignettes.

Ethics review was not required for this study. We collected no identifying information and drew up a carefully designed consent process to ensure participants understood the nature of the study and chose to participate freely.

We designed vignettes in which the genetic relatedness between a sperm donor and the social father (‘Marc’) varied in several ways. The child could be (a) conceived with sperm donated by someone unrelated to Marc, or (b) from sperm donated by Marc’s younger brother or (c) from sperm donated by Marc’s identical twin brother. We then asked four questions about the degree to which respondents agreed with statements such as ‘Marc has reproduced’, ‘The sperm donor/brother/identical twin has reproduced’ and ‘The fertility doctor has reproduced’. We also manipulated the type of question: either ‘has reproduced’ or ‘is a parent of’ or ‘is a child of’. Here is the vignette:

Maria and Marc are a couple in a long-term relationship. They have always wanted to become parents. However, Marc is infertile. A fertility doctor uses Maria’s egg and [sperm from a sperm bank/sperm from Marc’s younger brother/sperm from Marc’s identical twin brother] to create an embryo. The embryo is transferred to Maria’s womb and Maria becomes pregnant. Marc and Maria finally see their dream come true: their baby Suzanne.

The data were analysed using SPSS 29. We assumed that the answers on the 5-point Likert scales can be treated as continuous variables. First, descriptive statistics (minimum, maximum, means and SD) were done. Next, one-way analysis of variance (ANOVA) tests were used to (1) compare the three groups (unrelated/brother/identical twin) and (2) compare the three formulations (reproduced/parent/child). We performed a Tukey post hoc test. As a multiple testing corrective, the false discovery rate (FDR) method was used on all p values of the ANOVA tests. We found that all initially significant p values survived this FDR correction. Since the Tukey post hoc tests were only used to find those pairs of means significantly different in the case of significant ANOVA results, no multiple testing correction was performed on the Tukey p values. Thus, all p values <0.05 are reported as being significant. Further details can be found in the online supplemental appendix .

Supplemental material

We first investigated whether people’s opinions on who has reproduced/is a parent/has a child differ depending on the genetic contribution. Two significant differences between the parent and child questions can be observed in the younger brother donor scenario. In this scenario, people seemed more inclined to say that Marc is a parent than that Suzanne is his child (p<0.001) ( figure 2 ). Conversely, they were more inclined to say that Suzanne is the donor’s child than that the donor is Suzanne’s parent (p<0.001) ( figure 3 ). Participants were somewhat more likely to agree with the statement ‘Marc has reproduced’ in cases where an unrelated sperm donor was used than in cases where the sperm of Marc’s younger brother or his identical twin brother was used (although this difference was not significant).

The mean answers to the three formulations of the question about Marc for each genetic contribution scenario. (Answers were given on a 5-point Likert scale, with 1=completely disagree, 3=neither disagree nor agree and 5=completely agree.)

The mean answers to the three formulations of the question about the donor for each genetic contribution scenario. (Answers were given on a 5-point Likert scale, with 1=completely disagree, 3=neither disagree nor agree and 5=completely agree.)

We then investigated whether people have different intuitions in judgements about ‘is Suzanne X’s child’, ‘is X a parent’ and ‘has X reproduced’, where X is either Marc, Maria, the sperm donor/brother/identical twin or the fertility doctor, depending on whether and how the intended parents and donors are related. Here we found significant differences in answer means for the questions regarding Marc in the child and parent formulations (parent p=0.013, F=4.439; child p<0.001, F=7.339) and the donor (parent p=0.003, F=5.958; child p=0.001, F=14.515). When we look closer to find out how genetic contribution plays a role here, we find that for the father, significant differences can be found between the unrelated donor and twin scenarios (parent p=0.010, child p=0.007) and between the unrelated donor and younger brother scenarios (child p=0.002) ( figure 2 ). For the donor , significant differences can also be found between the unrelated donor and twin scenarios (parent p=0.002, child p<0.001) and between the unrelated donor and younger brother scenarios (parent p=0.082, child p<0.001) ( figure 3 ).

Our study yielded some expected and some surprising results. In particular, the ‘closeness’ of the donor to the social father seemed to have implications for the attribution of parenthood in a way that goes beyond mere genetic contribution. The discrepancy between ‘reproduce’ and ‘is parent’ and ‘is child’ was expected. That there is in some cases a difference between ‘is y's parent’ and ‘is x's child’ was not expected. Our respondents were less likely to agree that someone has reproduced than that someone is a parent in the case of donation by a (younger) brother. Surprisingly, they were also less likely to say that Suzanne is Marc’s child than that Marc is Suzanne’s parent in these cases.

This might suggest a number of things. It is possible that some participants in the survey assumed that an anonymous donor would play no further role in the child’s life. Thus, he is merely a genetic contributor. In contrast, respondents may regard a sibling or identical twin of the prospective father as being likely to play a role in the child’s upbringing. If the presumption of an ongoing social role affects people’s perceptions, this may help to explain why the brother or identical twin are more likely to be seen as a parent than the unrelated donor.

Looked at in this way, the genetic relationship between Marc and the donor may be regarded by our respondents as a proxy indicator of a future relationship between the resulting offspring and the sperm donor. If so, it is not obviously the genes themselves that are the significant feature here. A follow-up study could yield interesting results if it included, for example, a friend of Marc’s or an adoptive sibling as a sperm donor. In such a case, one might also assume an ongoing relationship, but one which would lack a close genetic connection between Marc and the sperm donor.

The emergence of an asymmetry between the respondents’ interpretation of the child/parent relationship may also indicate that people view parenthood as something that has a variety of components. Parent can be a verb as well as a noun. It is not just what one is, but also what one does . In contrast, the word ‘child’ is not a verb, and does not function in the same semantic way as the term ‘parent’. To be x’s child is thus interpreted in one particular relational sense, which is primarily biological: participants regard the offspring as being the child of the sperm donor, even where they also regard Marc as the father.

However, to be y’s parent can be understood in a variety of ways, some of which are static and biologically given, while others are dynamic and active. It may be this that leads to the apparently inconsistent ‘x is y’s parent, but y is not x’s child’. This apparent inconsistency, though, seems not only explainable but perhaps justifiable if one takes a Lockean view of what makes someone a father: ‘So little power does the bare act of begetting give a Man over his Issue, if all his Care ends there, and this be all the Title he hath to the Name and Authority of a father.’ 22 For Locke, being a father is something that emerges from the activities of caring. By implication, fatherhood is a status that can be gained or lost and is not fixed biologically.

When interpreting the results of this study, it is important to avoid claiming too much. All the versions of our vignettes feature sperm donation, and none features egg donation. Accordingly, our data relate to fatherhood directly, and parenthood only partly. Since these concepts are gendered, we cannot extrapolate from our findings to parenthood in general (even though we acknowledge that the necessary connection between sex and fatherhood is open to question). In terms of reproduction, biology and motherhood, people’s intuitions might be very different. In addition, there are several ways in which biological motherhood can be subdivided that would add complexity to vignettes such as ours. This would make for a fruitful avenue for further research.

In summary, possibilities created by reproductive technology challenge norms and understandings of intrafamilial relationships in a variety of ways. Not least, it seems that the existence of a genetic relationship between Marc and the sperm donor makes respondents less likely to say that Marc has reproduced. This is surprising, since we might otherwise think that more genetic relatedness between the social father and the offspring would make people more likely to think that the social father has a claim to have reproduced. For example, in discussions of mitochondrial transfer, the fact that a mitochondrial donor only transmits mitochondria and no or little nuclear DNA has formed the basis for denying the mitochondrial donor the status of a biological parent. One might wonder what the result would have been if we had included a sister as a mitochondrial donor in our vignettes: would that have made participants less likely to say that Maria has reproduced? This remains to be seen in further studies.

Ethics statements

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Ethics approval

• Velleman JD
• Smajdor A , et al
• De Proost M ,
• Nekkebroeck J , et al
• Pérez-Hernández Y ,
• De Proost M
• Archard DW ,
• Kostenzer J ,
• de Bont A ,
• Wittgenstein L ,
• Anscombe GEM ,
• Hacker PMS , et al
• ↵ "Moral theorizing and intuition pumps; or, should we worry about people” by James McBain . Available : https://digitalcommons.pittstate.edu/phil_faculty/37/ [Accessed 15 Dec 2023 ].
• Dranseika V , et al
• Machery E ,
• Rose D , et al
• Alexander J
• De Block A ,

X @kristienhens, @acsmajdor

Contributors KH, AS and DC initiated the study and designed the vignettes. KH collected the data. EM did the statistical analysis. All authors (KH, EM, AS, DC) contributed substantially to the content, approved the final submission, and take responsibility for the content.

Funding This study was funded by Marcus och Amalia Wallenbergs Minnesfond (MAW2020.0074).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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