Healthcare as an institution and some healthcare providers do not always deliver a positive experience for patients. Violence in healthcare happens in many ways, from physical assaults by a physician or denial of a patient’s needed care during a mental health crisis. Violence in patients’ lives also negatively affects their health outcomes. “Women in the US are more likely to be murdered during pregnancy or soon after childbirth than to die from the three leading obstetric causes of maternal mortality” (Lawn and Koenen 2022).

Childbirth in the media is presented as a joyous experience, and it is for many women, yet violence in childbirth does happen as well. “Obstetric violence is the physical, sexual, or verbal abuse, bullying, coercion, humiliation, or assault that occurs to laboring and birthing people by medical staff, including nurses, doctors, and midwives.“ (Terreri 2018). Violence in healthcare does not occur only on the interpersonal level. Institutional violence can occur through laws restricting a patient’s ability to receive needed care or through patterns of policies that provide for poor patient outcomes.

9.6.1 Governmental violence

Currently, states with the most restrictive measures on pregnancy termination have legislatures with a White male majority. Women, especially young women, are severely negatively impacted by the lack of rights regarding their pregnancies, yet the least likely to be represented in the decision-making process on abortion rights. “In West Virginia, 18 of 134 lawmakers are women — and 13 of them, all Republican, voted for the near-total abortion ban. In Indiana, 35 of 150 legislators are women; 14 voted for the bill there. In South Carolina, 29 of 124 legislators are women; seven voted for bans” (Willingham 2022).

States with the most severe restrictions on abortion are found to be the ones with the poorest health outcomes for women and children. They have the highest infant and maternal mortality rates and the highest numbers of children in poverty as seen in figure 9.17. They also have the most stringent healthcare supports, restrictive family leave policies, and typically do not mandate more than the federal minimum wage (Badger, Sanger-Katz and Cain Miller 2022).

Variations in state laws can also impact a pregnant woman’s right to a divorce. Divorce is denied to couples in some states if one of the partners is pregnant. Such laws force victims of abusive relationships to continue interactions with and marriage to the abuser until after the birth.

How States Rank on Measures of Well-Being for Women and Children

Figure 9.17a  States with some of the most number of mothers and babies dying during pregnancy, childbirth, or within six months of birth are also states with some of the highest uninsured rates for women and highest rates of children in poverty and are least likely to have access to abortion.

Figure 9.17b States with some of the lowest numbers of mothers and babies dying during pregnancy, childbirth, or within six months of birth are also states with some of the lowest uninsured rates for women, lowest rates of children in poverty and are most likely to have access to abortion. (Ranks with asterisks are based on fewer than 20 deaths and may be unreliable. States with identical values are assigned sequential rankings in alphabetical order. )

9.6.2 Violence Against Transgender People

Violence in the transgender community can take many forms. Being the victim of bullying and teasing can negatively impact health. One study found that “compared to adolescents who identified as straight, odds of weight-based teasing from both family and peers were higher for those who identified as gay, lesbian, bisexual, queer, pansexual, asexual, and other” (Puhl, Himmelstein, and Watson 2019: 9).

The US Transgender Survey in 2015 (James et al. 2016) found that transgender people were eight times more likely to be experiencing psychological distress. Poor outcomes for health, including physical and psychological, manifest in many ways for transgender people, including high rates of suicide. These negative societal experiences, especially in healthcare, mean transgender people attempt suicide at nine times the rate of the U.S. population. The intersectionality of transgender people, including their race, poverty, and employment, can amplify negative experiences in the medical setting (James et al. 2016).

9.6.3 Forced Sterilization

The practice of forcibly preventing people from becoming pregnant or impregnating someone is known as forced sterilization. As discussed earlier in this chapter, eugenics was the basis of this practice, supported by politicians, communities, and medical professionals. During the early to mid-1900s, “more than 60,000 people were sterilized in 32 states” (Stern 2020). Discrimination of people based on race, sex, physical abilities, and mental health was the basis of this practice. These practices targeted those with little to no formal education, predominantly people of color and those with disabilities.

Coerced or forced sterilization are examples of racist legacies and eugenics in the wider birth control movement. The language of “overpopulation” was commonly used in reference to Puerto Rico, especially regarding the poor, rural population. This racist narrative was distributed by the U.S media, including the New York Times and birth control advocates alike. Margaret Sanger, a famous birth control activist and founder of what eventually became Planned Parenthood, also advocated for the testing of birth control methods on poor, uneducated women. The use of this idea, the promotion of birth control methods to “improve the genetic pool of the population,” were policies promoted by the United States and Nazis in Germany.

Eugenics projects are still in effect today. Sterilization is still coerced or forced on women and girls, especially disabled women and girls, in several countries (Guterman 2011). Women in California prisons continue to be forcibly sterilized, as recently as 2010 (Campos 2013). As of April 2017, 20 countries require sterilization for trans people to obtain legal gender recognition (Transgender Europe 2017).

Social Change and Activism

There are many ways to address inequity in health on local and global levels. Access to food, healthcare (including medicines), and stable income will increase women’s and children’s health in society. Also, “Patriarchal societies often concern more about the well-being of their progeny than that of their women. The relationship between their gender inequality and the survival of their children should be highlighted in every possible way to make them feel the need for a social change” (Brinda 2015).

Women are significantly more likely to be affected by lack of healthy food due to living in impoverished areas which are also food deserts. They are more likely to be single head of households which include dependent children, have less education, and access to well-paying jobs. So, how do we get food to people who may live in a food desert? To address lack of access to full-service grocery stores with healthier food choices in Portland, Oregon, “the Oregon Food Bank has partnered with Lyft to give people who live in food deserts a car ride to the grocery store for the price of a bus ticket” (Herron 2019).

9.6.4 A Resurgence of Doula and Midwifery Care

As childbirth became more common in medical settings, the incidents of non-medically necessary interventions increased. Recently though, there has been a resurgence of pregnancy and labor care by doulas and midwives. Doulas, pictured in figure 9.18, are trained to provide physical and emotional support to pregnant women before, during, and after childbirth. Although they do not have formal medical training, they undergo a certification process, including an exam to be considered a doula. Doulas are different from midwives.

Midwives have formal medical training as registered nurses with master’s degrees in nursing. They are licensed to deliver babies inside and outside the hospital setting. Regulation of the training and certification of midwives occurred as the practice became popular again in the mid-1970s through the 1990s (Registered nursing.org 2022). Midwives are valuable resources to women with low-risk pregnancies who choose to deliver outside the hospital setting. They are sometimes a lower-cost alternative to obstetricians. “Only 8 percent of births in the United States are attended by midwives. In the UK and other countries, they attend over two-thirds of births” (Stephens 2018). Some women find using midwives positively affects their birth experience. Midwives and doulas provide emotional and physical comfort during what can be a scary, exciting, and isolating experience.

Figure 9.18. shows a doula supporting a woman in labor. Historically, family or designated community members helped women through childbirth. Today, some cultures still rely heavily on family support, yet in other cultures, pregnant people can find emotional support during labor through paid services.

9.6.5 Gender-Affirming Healthcare and Informed Medical Care

Social change has influenced medical research and technology. Advancements in medical technology have also influenced the ability of transgender and intersex people to connect to their internal and external identified selves. The World Professional Association of Transgender Health (WPATH) provides guidance for care to transsexual, transgender, and gender non-conforming people by medical and academic professionals. Organizations like this work to ensure gender-affirming surgeries and informed medical care is possible for the betterment of patients. Gender-affirming care encompasses topics such as sexual health, reproductive health, hormone therapies, and mental health.

Gender-affirming surgeries, sometimes called sex reassignment surgeries, may include breast implants or tissue removal, facial reconstruction, and genitalia reconstruction. People born intersex or with indistinguishable genitalia may have gender assignment and medically necessary corrective surgeries throughout their lifetimes. One organization advocating for intersex youth is the Intersex Society of North America (ISNA). They are “devoted to systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female” (ISNA N.d.).

Organizations such as WPATH and ISNA also seek to provide all aspects of support to transgender, nonbinary, and intersex people. Addressing medical needs and mental, emotional, and social support will positively influence their life outcomes.

9.6.6 Reproductive Justice

Efforts to address inequity in healthcare for all genders, but especially power over one’s ability to reproduce, have strengthened in the last 50 years. Many people choose to reproduce voluntarily, others are forced to reproduce through rape or have the decision to reproduce forcibly taken from them through sterilization. Reproductive justice is defined as the “human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities” by the Sister Song Women of Color Reproductive Justice Collective (N.d.). Sister Song is one organization dedicated to assisting women’s reproductive choices. Their specialized focus on women of color and indigenous women provides these women the opportunity to control their own bodies, thus giving them control over other life outcomes such as education, employment, and family structure.

Groups such as Planned Parenthood are known for general health needs such as cancer screenings, yet included in general health is reproductive justice. Figure 9.19 shows a doctor holding an intrauterine device (IUD), a form of birth control implanted in the uterus to prevent pregnancy. According to the World Health Organization (WHO), the global organization devoted to ensuring people’s well-being, reproductive rights are part of a person’s mental, physical, and social health. The WHO maintains that “reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so” (WHO N.d.).

Figure 9.19. Doctor holding an intrauterine device used to prevent pregnancy.

9.6.7 Intact Penis Movement

The cutting and removal of parts of male genitalia is a globally debated topic. As discussed earlier in this chapter, male circumcision is common in only a few parts of the world. Two-thirds of males globally are not circumcised while only about 20% of adult males in the United States are not circumcised (Guevara et al. 2021). Many groups seek to end what is considered needless medicalization of a natural male body part through male genital mutilation. The activist group, Intact America, is one group striving to eliminate it. They view circumcision on male babies as “medically unnecessary surgeries carried out on them without their consent in the name of culture, religion, profit, parental preference, or false benefit” (Intact America N.d). Society, including medical professionals and activists, currently debate medical necessity and bodily integrity issues through the legal system. Conversations surrounding male circumcision also encompass how societal views and laws prohibiting female genital cutting influence societal views and legalities of male genital cutting.