15 Medicine, Health, and Reproductive Justice

We often think of medicine and medical knowledge as objective, neutral, and vitally important to our well being the well being of and society. There is no doubt that medicine has produced life-saving technologies, treatments, and vaccines. However, medicine is not a neutral field that exists independent of the cultures and societies within which it is created. Medicine relies on the medical model, which contains a number of assumptions. First, it assumes that the body is governed by laws and processes independent of culture, social life and institutions. Second, it assumes that physicians are those qualified to evaluate and define the body’s health or pathology and treat it as they see necessary. In sum, the medical model is a medical-biological understanding of the body, which constructs the systems, pathologies, or indicators of health of the body as independent of culture, ideology, economy, and the state. Feminist and critical theorists have critiqued this understanding of the body, showing both how doctors and medicine medicalize bodies in particular ways according to gender ideologies. Furthermore, feminists have argued that we need to pay attention to how race, gender, and class inequalities shape the health outcomes of differently situated groups in society.

Medical sociologist Peter Conrad (2007) defines medicalization as the process whereby human problems “become defined and treated as medical problems, usually in terms of illness and disorders” which are then managed and treated by health professionals. Medicalization constructs medical problems, which are codified in policy by governing bodies, such as the Centers for Disease Control and Prevention in the US, that recommend treatment. For example, two different diagnostic categories for the experience of low sexual desire—one for men (Male Hypoactive Sexual Desire Disorder), and one for women (Female Sexual Interest/Arousal Disorder)—newly appeared in the most recent edition of the Diagnostic and Statistical  Manual of Mental Disorders, the DSM-5 (American Psychiatric Association, 2013). Low sexual desire does not threaten a person’s health, but these categories treat low sexual desire as a problem and construct the experience as essentially distinct for women than for men. A number of the members of the work groups that created diagnostic categories in the DSM-5 had conflicting interests, such as ties to pharmaceutical companies (Welch et al., 2013). This diagnostic category followed the development and marketing of the first product to treat “female sexual dysfunction”—called EROS—by Urometrics, a pharmaceutical company. The Food and Drug Administration defines “female sexual dysfunction” as “decreased sexual desire, decreased sexual arousal, pain during intercourse, or inability to climax” (Shah 2003). This pathologization of decreased sexual arousal emerged in a specific social context in which Pfizer’s $1.3 billion profit windfall from Viagra in 2000 spurred pharmaceutical companies to develop an equivalent product to market to women, and a diagnostic category emerged next to encourage prescriptions and sales of the drug.

In this example, heterosexual women’s sexuality becomes medicalized to serve various interests other than their own health and pleasure. Feminists have been critiquing the ways in which women’s sexual needs and desires are often subordinated to men’s sexual needs and desires for decades—diagnosing the problem as stemming from exhaustion from both paid work and unpaid housework, as well as inattentive male partners. Urometrics and the doctors who developed EROS, in contrast, diagnose the problem as stemming from female bodily dysfunction. Instead of addressing the deeper social and cultural reasons for why heterosexual women may not be fulfilled sexually, EROS offers a commodified, FDA-approved, medically indicated treatment for a medically-defined “bodily dysfunction.” Relatedly, gender nonconformity transgender identity has been medicalized for the past several decades. The current diagnostic category in the DSM-5 is called “Gender Dysphoria.”

Medicalization is an aspect of bio-power. Bio-power, according to philosopher Michel Foucault (1979) refers to the practices of modern states to regulate their subjects through technologies of power. Foucault argued that in complex modern societies populations will not tolerate totalitarian uses of state power. Therefore, modern states must find less overt ways to control their populations, such as collecting data on the health, reproductive capacities, and sexual behaviors of their populations for the purpose of state regulation and intervention. For example, historian Laura Briggs shows how in the United States colonial occupation of Puerto Rico in the early 20th century, public health officials treated the problem of venereal disease as a problem of overpopulation and sexual immorality, and sought to institute eugenics policies (discussed below) to limit Puerto Rican women’s ability to reproduce. Importantly, Foucault argued that medical knowledge, combined with modern states’ collection of data on their populations, created new norms of health which populations internalize. Thus, the intended effect of bio-power is that people regulate themselves according to norms proliferated by medical knowledge and the state.

As we have argued before, not all women’s health and sexuality has been medicalized in the same ways, or with the same effects. Class and race differences and inequalities have made poor or working-class white women and women of color, along with people with disabilities, the targets of public health campaigns to regulate their sexuality and reproduction. Such was the case with the example of the United States’ use of bio-power in Puerto Rico above. In that example, working-class and poor Puerto Rican women’s sexuality and reproduction became medicalized in ways that wealthy Puerto Ricans’ and white women’s sexuality and reproduction were not.

The eugenics movement began in the late 19th century, but has had far-reaching impacts around the world. Eugenics is a medical/scientific ideology and social movement that takes the root of social and psychological problems (poverty, mental illness, etc.) to be the genetic make-up or heredity of specific groups within the population, and as a result, seeks to eliminate those groups through sterilization or genocide. Eugenics takes biological determinism and bio-power to their furthest logical conclusions. Eugenicists believe that selective breeding of those groups that they construct as “inherently superior”—nondisabled, heterosexual, white, middle-class, Northern and Western Europeans—is a rational-scientific answer to “solve” social problems. The most obvious and well-known example of eugenics in practice is the Holocaust in Nazi Germany, but what many people do not know is that eugenics-based sterilization was enforced by law in the United States for much of the 20th Century. In 1907, the world’s first first eugenics-based compulsory sterilization law was passed in Indiana, followed by 30 states soon after (Lombardo, 2011). The Nazi government widely cited a report that praised the results of sterilization in California as evidence that extensive sterilization programs are feasible and humane (Miller, 2009). Between 1907 and 1963, over 64,000 individuals were forcibly sterilized under eugenic legislation in the United States (Lombardo, 2011). The eugenics movement also took shape in immigration policies in the United States into the first half of the 20th Century (Allen, 1996). Eugenics projects are still in effect today. Sterilization is still coerced or forced on women and girls, and especially disabled women and girls, in a number of countries (Guterman, 2011). Women in California prisons have continued to be forcibly sterilized, as recently as 2010 (Campos, 2013). In addition, as of April 2017, 20 countries in Europe require sterilization in order for trans people to obtain legal gender recognition (Transgender Europe, 2017).

In addition to overt genocidal projects, social relations within conditions of inequality increasingly expose stigmatized groups to environmental and health hazards at rates higher than privileged groups, affecting birth and health outcomes. For example, according to the National Association of City and County Health Officials, in the United States, the wealthier a person is, the lower their risk of disease, cancer, infant death, and diabetes (NACCHO, 2008). However, two physicians who study premature birth—Richard David and James Collins—found that African Americans who were middle-class or upper-class did not experience the same lower risks for premature birth as their white peers. They attempted to find out if there was a “premature birth gene” specific to African Americans, through comparing newborns among African American women, white women, and African women. They found that African women and white American women had similar pregnancy outcomes, but African American women were still 3 times more likely to have premature births than both these groups—suggesting that there is no genetic basis for difference between pregnancy outcomes for white and black women. Therefore, David and Collins explain the pregnancy gap by arguing that African Americans, regardless of social class, experience significant amounts of stress due to their daily experiences with racism in the United States. For African Americans—particularly African American women—who are middle-class or upper-class, the necessity of being on the ball constantly and performing at the highest caliber at all times, in order to refute racist stereotypes, results in a continuous, accumulating amount of stress which translates into higher risk for negative health outcomes (Unnatural Causes, 2008). Such findings suggest that intersecting race, class, and gender inequalities have real impacts on the health outcomes of differently situated groups in society.

Recognition of the effects of social inequalities on women’s health motivates the activism of the reproductive justice movement . A reproductive justice framework for understanding the politics of health and reproduction highlights race, class, and gender inequalities and how these inequalities constrain the abilities of women to control their lives. It centers the necessary social and cultural conditions for poor women and women of color to be able to make choices, including equal wages for equal work, employment, affordable housing, healthcare, and lives free from violence. The reproductive justice movement was born out of the tensions between white, middle-class feminist activists and women of color activists in feminist movements. White, middle-class feminist activists framed their argument for abortion under a reproductive rights framework that relied on a language of “choice,”—an individualizing way of talking about reproductive politics that overlooked the ways that poverty, race, laws and medical authorities imposed control over many women’s reproductive lives.

Following the passage of Roe v. Wade in 1973 (the Supreme Court decision that legalized abortion), the burgeoning conservative movement of the mid to late 1970s succeeded in getting the Hyde Amendment passed. The Hyde Amendment prohibits federal funds—specifically Medicaid—from being used to fund abortions. This Amendment disproportionately affects poor women, who are disproportionately women of color. One would think that the National Organization of Women (NOW) would have rallied to block or reverse the Hyde Amendment, but they did not. This led women of color activists to critique the reproductive rights framework, arguing that this framework reflects the interests and experiences of white, middle-class feminists and ignores the broader racial and class inequalities that limit the abilities of women to actually make choices about reproduction and family.

The reproductive justice movement challenges the individualizing and depoliticizing tendencies of the medicalization of women’s bodies by arguing that social inequalities limit choice and expose differently situated female-bodied people to illness and disease depending on their social location within multiple axes of identity. As such, it shows how health and illness are deeply social and not solely determined by biology or genetics.