Abortion as a Social Determinant of Health

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Abortion holds a unique space in the intersection of health, law, and morality, and is thus one of the most divisive and stigmatizing medical procedures of our time. Societal beliefs about abortion are deeply influenced by cultural opinions about female sexuality and motherhood, yet abortion stigma is neither inherent to women nor essential to society, but rather relies upon power disparities and inequalities for its formation and perpetuation.1 Cockrill et al define abortion stigma as “a shared understanding that abortion is morally wrong and/or socially unacceptable” which “leads to the social, medical, and legal marginalization of abortion care around the world and is a barrier to access to high quality, safe abortion care.”2 Despite the facts that one in four women will have an abortion during her life, that 59% of those women have already borne at least one child, and that 75% cited concern for or responsibility to other individuals as their reason, women who choose abortion are routinely portrayed as selfish, irresponsible, and deviant.3 Schellenberg’s research has found that 58% of women who choose abortion feel they must keep it secret from friends and family.4 Stigma shames and silences women who seek abortion services, which in turn contributes to the myths and misperceptions about abortion that fuel legal restrictions.

Abortion opponents in the United States intentionally exacerbate abortion stigma, for example, claiming abortion is murder, as a tactic to erode public support and inhibit women from seeking this safe, legal, common medical procedure. The 1976 Hyde amendment prohibiting the use of federal funds to pay for abortion services, and over four decades of Targeted Restrictions of Abortion Providers (TRAP laws) deliberately limit women’s ability to obtain abortions, reinforcing the conservative notion that abortion is morally wrong. In doing so, they force women who choose abortion to navigate stigmatized identities and the corresponding physical and mental health challenges that navigation entails.5

An individual woman’s experience of abortion Stigma may be measured through the Individual Level Abortion Stigma scale (ILAS), which consists of four subscales: self-judgment, worries about judgment, isolation, and community condemnation.5 The first describes a woman’s intrapersonal feelings about herself, while the others describe her fears and perceptions of discrimination or judgment from others. This vicious cycle of silence is unhealthy for individuals, contributing to adverse health outcomes such as depression, anxiety, and stress, and perpetuates the institutional level stigma that fuels restrictive abortion laws.4,5,6

Reproductive autonomy has an inverse relationship with abortion stigma and, like abortion stigma, is situated within a social and historical context which affects when, how, and with whom women have sex, what family planning options are available to them, and the prevailing cultural norms surrounding reproductive health care.7 Unlike abortion stigma, women with higher levels of reproductive autonomy are more likely to discuss their abortions, which can play an important role in changing the culture of silence.

Understanding Structural Abortion Stigma through Cultural Theory and Gender Theory

In a previous paper, I applied Social Cognitive Theory analyze the way an individual woman might experience and manage individual level abortion stigma, either by attempting to conceal her abortion or by seeking social support. I then used Social Network Theory to offer insight into how reproductive autonomy may be created and spread throughout the ties of social networks. But stigma operates at multiple levels: intrapersonal, interpersonal, and structural.6,8 Thus far, most analysis of abortion stigma has occurred on intrapersonal or interpersonal levels. This is largely because it is extremely challenging to measure stigma on a cultural scale.8 The ILAS measurement tool takes into account how an individual perceives that her abortion will be responded to by her immediate social network, but cannot be used to measure the greater cultural context in which it takes place.

While stigma may be experienced on an individual level, such an analysis cannot adequately capture the deeply complex and multi-leveled production (and reproduction) of abortion stigma. In order to implement a successful intervention, we must include structural stigma in our approach. According to Hatzenbuehler et al, structural stigma refers to “societal level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and wellbeing of stigmatized individuals.”8 To analyze the structural forces that shape abortion stigma I will apply two new theories: cultural theory and gender theory.

Burke et al define culture as “the patterned process of people making sense of their world and the (conscious and unconscious) assumptions, expectations, knowledges, and practices they call upon to do so.”9 For example, by titling their position as “pro-life,” anti-abortion activists claim the moral high ground of the abortion debate. This framing of a “pro-life” sub-culture depends upon assumptions of fetal personhood, the (scientifically contested) knowledge of reproductive physiology (the beginning of life, fetal viability, fetal pain, etc.), and the expectation of the essential role of women as “nurturers.”1,6 This provides a justification to practice the stigmatization of women who have been rejected by “pro-life” culture through their choice to “end innocent lives” by abortion.

The decision to pursue abortion is highly contextual, both within an individual woman’s life circumstance and her culture and community. Oversimplifying the complex situation that leads to the decision to end a pregnancy is fundamental to creating abortion stigma. Burke et al argue that the analysis of behavior in social context “requires an understanding of the dynamic nature of culture and the processes by which it is brought into being.”9

Abortion is often framed as a “women’s health” issue, because pregnancy, childbirth, and abortion are sex-specific—limited to individuals with female reproductive organs. However, viewed through a gender theory lens, abortion stigma is far more linked to gender than to biological sex. Unlike sex, gender is a social construct that is produced and reproduced according to the dynamic, changing cultural definitions of femininity and masculinity.10 Such changes in the construction of gender can be a source of agency—in the last 50 years, women have experienced tremendous new possibilities and expectations—but also a source of constraint, as certain rigid gender roles and systematic attempts to control female sexuality persist.

Abortion stigma is the product of an ideological struggle about the meaning of family, motherhood, and sexuality. A core component of gender theory is performativity: the performance of what Kumar et al have termed “the ‘essential nature’ of women.1 Their proposed definition of abortion stigma is “a negative attitude ascribed to women who seek to terminate a pregnancy that marks them, internally or externally, as inferior to ideals of womanhood” (emphasis added).1 The three archetypal constructs of the ‘feminine’ that they argue are transgressed through abortion are: 1) female sexuality for procreation, 2) the inevitability of motherhood and 3) instinctual nurturance of the vulnerable.1 Abortion is the active subversion of the normativity of motherhood, and is therefore considered an aberration.

Structural abortion stigma is a product of power disparity and inequality. This connects to the concept of relational constructions of gender, defined by Springer et al as “a pervasive system of stratification that structures relationships and interactions between and among men and women, shapes access to resources and status, and signifies power.”1,10 An example would be the proliferation of TRAP laws to make abortion inaccessible. There is not a single law in the United States that gives the government the power to make decisions about male bodies, yet since the supreme court case of Roe v Wade in 1973, well over a thousand abortion restrictions have been passed into law.11 The unequal distribution of power and resources produces and perpetuates these differences not just based on gender, but across the intersection of race, ethnicity, class, religion, geography, and a myriad of other factors.

The cross-discipline concept of intersectionality is defined as “an approach that explores simultaneous intersections between aspects of social difference and identity.”10,12 The cultural willingness to tolerate abortion varies by the individual characteristics of the woman seeking it, including race, age, and financial circumstances. The mainstream abortion rights movement, like the larger feminist movement, is predominantly led by and represents middle class and wealthy white women and has a history of ignoring the issues that affect women of color.12 For example, black women are often cited to be at decreased risk of abortion stigma as measured on the ILAS scale because they score lower than white women on the “worries about judgement” subscale.2,5,7 This is likely associated with the fact that abortion is more common among African American women, who comprise 13% of the U.S. population but roughly one third of women who receive abortions.13 Yet these statistics do not reflect the individual, lived experiences of black women in communities with high levels of abortion stigma, especially rural and low-income black women and women in highly religious communities.

In particular, in a co-optation of the Black Lives Matter movement, a growing and particularly vocal culture of abortion stigma has emerged, which argues that abortion is a form of “black genocide.”13 The argument is founded on a shared cultural consciousness of the history of reproductive injustice and abuse of the black community by the medical community (for example, through involuntary sterilization programs). Crenshaw argues that “the experiences of women of color are frequently the product of intersecting patterns of racism and sexism.”12 By being equated to perpetuators of “black-on-black murder” African American women who seek abortion experience increased stigma, and by having this fact ignored by the larger abortion rights movement the stigma is perpetuated.

Implementing an Intervention to Abortion Stigma based in Structural Intersectionality

In my previous paper, I argued for the implementation of abortion Stigma interventions based in the principles of Social Cognitive Theory and Social Network Theory. I proposed the creation of a support network which would provide a non-judgmental atmosphere to implement simultaneous SCT and SNT interventions designed to reduce isolation and internalized stigma while increasing reproductive autonomy.2,7 However, such an approach is inherently limited. It addresses the intrapersonal and interpersonal levels of abortion stigma without addressing structural change.

Given the addition of Cultural Theory and Gender Theory to our implementation toolkit, we can design an intervention that works to combat abortion stigma on all three levels, building on our newly created social support network. Projects would start on the individual level, integrating the public story-sharing campaigns of organizations such as Advocates for Youth, Exhale Pro-Voice, and Shout Your Abortion into workshops and group projects designed to disrupt the cycle of silence and increase individual levels of reproductive autonomy and self-efficacy.

Women would be given the opportunity to act as Popular Opinion Leaders, to carry their newfound knowledge into their existing social networks, working to change cultural perceptions about abortion. Using an intersectional approach, the material would have to be culturally relevant. For example, not all women are in a position to safely “Shout Their Abortions” without personal risk. Yet they may still utilize their newfound knowledge to facilitate dialogue about abortion and counter conservative attitudes in their respective networks. Further community level projects would explore gender empowerment models and relate abortion stigma to a broader framework of reproductive justice.

The structural level project would include working with the media to change the national discourse surrounding abortion while simultaneously working to create political change. Such a project could be modeled after the #Me Too movement, but with an aim of pushing the political discourse in this country in the direction of a consensus about the permissibility of abortion. It would harness the fluid, dynamic process of cultural change over time, working as an integral part of social institutions to dismantle structural abortion stigma once and for all.


Cite this paper

Abortion as a Social Determinant of Health. (2022, May 11). Retrieved from https://samploon.com/abortion-as-a-social-determinant-of-health/

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