Ask an Expert: Jill Delston examines sexism in contraceptive access, medicine

In her new book, "Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care," Associate Teaching Professor of Philosophy Jill Delston examines medical sexism through the lens of contraceptive access. (Photo by August Jennewein)

In her new book, “Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care,” Associate Teaching Professor of Philosophy Jill Delston examines medical sexism through the lens of contraceptive access. (Photo by August Jennewein)

Medicine, historically, has had some ridiculous ideas about women.

In the 1800s, for example, doctors used to think running would cause a woman’s uterus to fall out.

Though contemporary medicine’s treatment of women is less obviously absurd, problems persist. Flip through the country’s newspapers and a myriad of problematic stories arise: women charged more than men, disbelieved by providers, required to endure excess testing, the diminishing availability of abortions and more.

In her latest book, “Medical Sexism: Contraceptive Access, Reproductive Health, and Health Care,” University of Missouri–St. Louis Associate Teaching Professor of Philosophy Jill Delston uses contraceptive access as a case study to get at the root cause of what women face in the health care system. UMSL Daily sat down with Delston to learn how pervasive medical sexism is and what might be done about it.

What is medical sexism?

By medical sexism, I just mean sexism in the medical field. For example, when doctors treat female patients in ways that would be considered discriminatory if done in the treatment of male patients, that would be medical sexism. A feature about the definition I use is that it doesn’t require any intent by the person who is engaging in medical sexism.

When we think about disproportionate impact, that’s an example of a sexist cause that may not have a sexist intent. For example, if I were to come up with a policy that hurt pregnant women, I’m not singling out women necessarily when I say that, except for the fact that it’s going to disproportionately harm women because women are disproportionately the ones who get pregnant.

Are there certain areas in medicine that we see sexism?

My goal in the book was originally to talk about one case study, which is contraception access. But what I found through my research is that this really opens the door to see how those same attitudes and beliefs and actions are found in all these other areas of medicine: abortion, labor and delivery, heart disease, autoimmune disorders and breast cancer. Turns out it’s unfortunately very pervasive.

How is requiring testing before prescribing contraceptives sexism?

What happens is that a doctor will say, “We’re not going to refill your prescription until you come in for this cancer screening to see if you have cervical cancer.” Cervical cancer is a life-threatening, dangerous disease. Patients ought to be tested for it to protect their health, but it’s not connected in a fundamental way to birth control. The doctor wants to incentivize testing, and they want patients to undergo this test, so they’ll withhold something that the patient really wants, like a birth control prescription refill.

The problem with that is that it’s actually illegal to withhold somebody’s ongoing medical care, even if it is in their own best interest, even if it is paternalistically going to help them in the long run. That’s medical negligence.

Why do the majority of doctors tie birth control prescriptions to these unrelated tests? Why do they test patients too frequently based on the medical evidence? Why do they threaten to withhold needed medical care or the continuity of treatment based on these tests? I think what’s going on there is a violation of autonomy, of informed consent, of the best interest of the patient. Because this policy is directed primarily at women, because it overrides female choice in this really powerful way, because it has this disparate impact on women, I think that medical sexism is occurring.

What do you mean when you say autonomy?

Autonomy is this notion that we can pursue our own goals and interests and values in our lives. Suppose I have limited funds to devote to my health care, and I have to make a choice between several needed tests. My values and goals and my own evaluation of my health suggest that I should be able to make those tradeoffs and have more information than other people about how to make those tradeoffs. We often say the power should be placed in the hands of the patient, and patients have a right to refuse treatment. These ideas appeal to autonomy.

What do you think about selling birth control over the counter at the pharmacy?

I think that selling birth control over the counter is a great idea. It’s done safely in at least 75 countries. The majority of doctors say that it would be beneficial. There have been a lot of studies that show the safety and efficacy of over-the-counter birth control prescriptions.

There are a couple of dangers that I see. One is that right now birth control prescriptions, post-Affordable Care Act, Obamacare, are covered by insurance as free preventative care. If you were to take something which was very expensive for many decades, and then, right when it becomes free or low cost, say, “Oh, we’re going to offer it over the counter,” it can actually decrease access for some patients with health care because it can mean that their insurance won’t cover it anymore. We have to take that into account.

The other danger I see is that medical sexism is just going to morph. If we were to solve the contraception case, then medical sexism could still persist because maybe patients can’t get their autoimmune disorders diagnosed or maybe patients can’t get pain medication to the same extent or maybe patients can’t get their labor and delivery choices respected. Addressing the symptoms of medical sexism without addressing the underlying cause could lead to other problems down the line.

Would an example of that be women being told that their problems are psychiatric rather than grounded in physical pain?

I think that the phenomenon of doctors not trusting patients is connected to the contraception access case. It’s the same attitudes, beliefs and behaviors. It’s saying that the patient is not trustworthy to report on their own condition, to look out for their own best interests. When doctors discount patient self-reports, then patients as a result may be misdiagnosed or fail to receive treatment.

What kind of effects does this have both on an individual level and on society?

On an individual level, contraception is central to a lot of people’s lives. I think half of all pregnancies, and a third of all births in the United States are unwanted. That can significantly impact your life. When people’s birth control access is hindered, or threatened, even if the doctor doesn’t go through with the threat, that’s still a stressful experience. That idea that you need to go in for an extra, unrelated test can negatively impact an individual’s life, and they might feel disempowered in that moment as well. I think that there might be a connection between the experience individuals have at a doctor’s office and a general distrust they may then go on to have later of the medical establishment.

Sexism exists in our society, so we shouldn’t be surprised that it also exists in the medical context. Doctors are not somehow magically above other societal influences, but identifying the discrimination that patients face as sexism can be really powerful way to oppose it and put us on that path toward improvement.

That reminds me of a study in the introduction of the original Freakonomics book that looked at when abortion was introduced in United States and then correlated that to crime rates.

There are a lot of reasons to think that poverty is not caused by lack of contraception access. Poverty has very complex causes and complex influences and so classism and racism and sexism are all kind of tied up in the issue and they intersect. This is what intersectional feminism is about. I don’t think that we can say, “Oh, look, if you have an unwanted child, you will therefore neglect them, and they’ll therefore have all these problems,” but our decisions to become parents are really integral to our lives and to our personal identities. Being able to make that choice voluntarily, deliberately and at the time in your life that you want that to happen is central. It’s not the whole story but definitely part of it that there can be these broader, unintended side effects of having people get pregnant when they don’t want to be. The best solution to that would be respecting choice and patient decisions as much as possible.

Supposedly, the Planned Parenthood’s license hearings happening now in St. Louis are not about abortions but patient safety. How can we understand those motivations?

One of the considerations that goes into these decisions about whether or not to keep places like Planned Parenthood open from a legal context is will it cause an undue burden on the person who seeks an abortion if that abortion is a legal right.

So sometimes it almost doesn’t matter what the reason is for trying to close Planned Parenthood. If it violates somebody’s rights, it doesn’t matter because it may still be sexist in its impacts. It may still violate the constitution, given our current legal framework, or the current interpretations that the Supreme Court has given of the constitutional precedent. It may be that the intent is to restrict abortion access. If that’s the case, we should look at why people want to restrict abortion access and whether those reasons are permissible.

Why should men care about sexism that women or non-binary persons face?

One reason is that sexism negatively impacts men. There are at least three reasons for thinking this. When there is a hierarchy of maleness and masculinity over femaleness and femininity, then femininity wherever it’s found – even if it’s found being expressed by men – is devalued, and men can suffer from that. If you have a male child who’s being teased about having some feminine characteristic, and if men are criticized for or denigrated for taking on traditionally considered female roles, then their decisions and choices are restricted. Another way that sexism can hurt men is that trans men can be the recipients of some of the discrimination I discuss in the book.

Lastly, Martin Luther King said, “Injustice anywhere is a threat to justice everywhere.” We have good reason for opposing discrimination, oppression and injustice where we find it, even if we’re not the direct recipients of it, because those sorts of hierarchical attitudes or attitudes of domination can end up hurting society more generally. When we see innocent victims, we ought to oppose that injustice.

What changes would you like to see in the medical field?

I want doctors to be more aware that medical sexism exists and that they might be unconsciously perpetuating it without realizing it. I want doctors to see their female patients as fully autonomous agents. Doctors also have governing bodies like the American Medical Association that can be influential in self-regulation. But I don’t want doctors to see my book as a threat. I want doctors to see it as a way for us to improve the medical field with the help of philosophy.

How would you like to see politicians help this process along?

I think that politicians can hold doctors accountable where they’re not holding themselves accountable. The Affordable Care Act tried to explicitly address sex discrimination, and that had a really positive impact that led to birth control being covered as preventative health care and the elimination of female patients being charged more for insurance coverage than male patients.

Any closing thoughts?

An objection that I often hear is, “This might be bad, but it’s not sexism.” It might be something else, classism or racism or have financial causes or something like that. But if somebody is already in a vulnerable category, like a female patient, then it’s easier to exploit that person for those other reasons. So, the other causes are compatible with sexism, not necessarily exclusive of sexism. In addition, there are lots of ways in which doctors deny patients needed medical care that aren’t financially motivated. The common thread there is the sexism, not the classism or the financial reward. I don’t think we’re going to find a solution unless we correctly identify the cause.

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