A dual reality: Contraceptive choice and coercion can co-exist
People's stories about their experiences accessing contraceptive care reveal how health care systems harm people and limit their opportunities to exercise reproductive autonomy. Despite clear evidence of these occurrences, health care providers often deny that they contribute to this reality. Some providers insist that they don't coerce patients, that their patients are empowered to make their own decisions, and that they (the provider) are just a guide, a resource to patients during health care encounters. While I believe that some providers employ truly person-centered approaches to sexual and reproductive health care provision, research shows that providers claim to offer contraception in person-centered ways, but unexamined and intersecting oppressions of racism, bias, paternalism, and discrimination limit their understanding.
Data from several recent qualitative studies exploring people's perceptions and experiences of sexual and reproductive health care (contraceptive care, HIV prevention care, and pharmacist-prescribed hormonal contraception) uncovered concerns about provider (mis)treatment. Specifically, people are concerned that providers will "push" methods on them or people in their community, especially long-acting reversible contraception (LARC), or that providers will shame or mistreat them for their contraceptive decisions. The "push" people describe is a form of contraceptive coercion – any effort to impede someone's reproductive choices or desires (intervening actors include intimate partners, parents, health care providers, policies, or practices). People's concerns about contraception coercion may be even more pronounced if they identify as Black, Indigenous, or a person of color (BIPOC), members of minoritized racial groups that have long been targeted for public health interventions related to fertility control.
Early in the LARC-first promotion phase, people used beautifully colored charts to start contraceptive conversations between health care providers and patients (especially in communities of color or those with lower incomes) with LARC methods. These conversations inherently emphasized the importance of contraceptive efficacy in people's decision-making, indicating to patients the "right" way to consider their options. Not only did contraceptive conversations include these tiered-effectiveness charts, providers may have also stated that these were the methods they preferred patients to use. Additionally, providers may have discouraged some people from choosing other methods, even if these recommendations were subtle. For example, a provider may have overemphasized how difficult it was to remember a daily pill despite someone indicating a preference for oral contraceptives or how many patients miss their next hormonal injection and become pregnant. Furthermore, systems helped to reinforce constrained choice through specific funding for LARC methods exclusively. People with low incomes or those who did not have health care coverage may have been offered subsidized contraceptive methods through LARC-only programs and such assistance may have been touted as significant savings to the patient as LARC methods are costly (range $800-1200). These examples highlight the nuance and complexity of reproductive autonomy within the context of the U.S. health care system and interrogate how we determine if someone has free choice or if they have experienced coercion.
Findings from my previous work of young cisgender Black women's contraceptive care experiences revealed how contraceptive care visits are mired in confusion. Despite some patients not being aware of all the contraceptive methods available, they expected their provider to inform them yet described feeling as though their provider did not give them enough information to make an informed decision. Women also questioned providers' motives when they encouraged or discouraged specific methods, especially LARCs. When reflecting on their contraceptive care experience, some women said they felt unsupported or that the health care visit did not meet their needs. Although several people left their health care visit with a chosen contraceptive method or no method if they did not desire one, some may assume that these individuals made choices without pressure, constraint, or coercion.
On a structural level, health care and its associated policies may create and distribute disadvantage. For instance, people without health insurance have fewer contraceptive options, and where people access care may create differential care experiences. Intersecting reproductive oppressions function within the existing health care system to ensure that BIPOC folks, queer, trans, and non-binary people, youth, people with low incomes and less education, ultimately have fewer resources. Providers may also be less likely to view and include members of socially marginalized groups as partners during health care encounters.
Contraceptive options constrained by people's engagement with the health care system or through structures like policies and practices maintain the illusion that most people can exercise reproductive autonomy in contraceptive decision making if they have obtained a method of birth control. However, what is critically important to understand is that contraceptive choice and coercion are intertwined in our current health care system, and often people are not able to make contraceptive decisions free of harm or coercion.
This blog post is the first in a three-part series on contraceptive coercion. The following entries will examine the history of contraceptive coercion and solutions to facilitate and protect reproductive autonomy.