Policy & Advocacy

Stacking Stigmas:

Compounding forces crushing the most vulnerable patient groups post-Roe

Twice every month, I make the four-hour drive from New York to Ohio to provide abortion care at Planned Parenthood in Cleveland.

I can’t stop thinking about a patient I saw several weeks ago. 

She did not speak English, so her in-clinic procedure was done with the help of a phone interpreter. She laid calmly on the exam table as I went through my pre-procedure spiel. I reassured her, as I do with all my patients, that we’d keep her as comfortable as possible, and her safety was our number one priority.

An old, cordless phone – held together by duct tape – sat on the table next to her ear as the interpreter translated. My patient nodded; a lone tear fell down her right cheek. Within only five minutes, the early first-trimester procedure was complete without complication. 

After washing my hands, I returned to the exam table to check in. I leaned over her head and asked, “How are you? Do you have any questions for me?” Before the interpreter could translate, she grabbed my hand into both of hers and pulled it tightly to her chest. 

"She kissed my hand, pulled her own head close to mine, locked eyes and whispered: 'You saved my life today. Thank you. You saved my life today.' Then kissed my hand one more time." 

I didn’t probe any deeper, because it wasn’t my business and it did not impact her medical care. Our interaction was brief, but it was intentional and deliberate. She wanted me to know that for her, this service was a matter of life and death. And she needed to tell me – needed me to know – how grateful she was.

"I can’t stop thinking about this patient, knowing now – just a few weeks later – I wouldn’t be able to help her this way."

Policies that have restricted access and caused harm are now getting worse.

Given the stark differences in regulatory policies state-by-state, my journey to practice medicine across state lines has significant consequences for access to reproductive and sexual healthcare for people in need.

Getting care in states like Ohio has long been challenging: insurance coverage for the abortion pill or procedure is rare. There’s a mandatory, medically-unnecessary 24-hour wait period following an ultrasound. Patients must sign multiple state-mandated forms providing medically-inaccurate, irrelevant information. And patients routinely drive several hours to obtain abortion and contraception care. These financial, logistical and emotional barriers are formidable.

Then, last Friday – merely hours after SCOTUS overturned Roe v. Wade – a federal judge lifted a three-year injunction on a law that renders abortions illegal in Ohio once a fetal heartbeat can be detected. Just like that, a “heartbeat ban” went into effect, preventing abortion after six weeks of pregnancy. That is about four weeks after conception, before most people know they are pregnant. 

In just a few hours, with no advanced planning or preparation, access to abortion care in Ohio went from bad to grim. Providers were thrust into uncertainty and chaos, not knowing what parts of their job were now deemed criminal. This includes many medical scenarios that put the patient’s own life at imminent risk.

We see immediate, disastrous consequences of the SCOTUS ruling, and will continue to experience a cascade of repercussions as “trigger bans” snap into effect in 13+ states and additional legislation is passed to protect or prohibit abortion care – government rules that will dictate the patient-provider relationship for an estimated 40 million Americans.

Stigma upon stigma: how intersectionality impacts high-risk patients

I am concerned about all people who need access to abortion healthcare, but I am most worried about our patients with intersectional stigma.

“Intersectional stigma” is the convergence of multiple stigmatized identities within a person or a group of people. In medicine, it’s essential to recognize because it affects health outcomes and well-being. Abortion is undoubtedly the most stigmatized reproductive healthcare service. When the stigma of abortion is added to other forms of stigma, dangerous forces multiply. Thus, those most likely to be negatively impacted by this new legal landscape are Black and brown, low-income, rural, LGBTQIA+, disabled, and/or those diagnosed with substance use disorder (SUD). 

Advocates have warned for years that overturning Roe will have a disproportionate impact on Black women and pregnant people of color. A Duke study found a nationwide abortion ban would increase pregnancy-related deaths by ~21% — or 33% for BIPOC patients.

The risk of death associated with childbirth is approximately 14x higher than abortion. During a recent patient visit, a 34-year-old black woman asked me to clarify if that statistic was for all women, or for just black women. “All women,” I said. She immediately responded, “Well then it’s even higher for me. It’s scary being a black woman in a hospital nowadays. Can I be honest with you? I’m terrified to be pregnant.” 

"My patient shared that she had lost both a family member and a good friend to complications from pregnancy and childbirth in the past year. Through tears, she asked me: 'Why does [my state] hate black women?'"

Reproductive care for patients with SUD

I also serve as a physician with Boulder Care, offering virtual treatment for opioid and alcohol use disorders. Our mission is to improve the lives of people with SUD: folks who routinely encounter stigma and judgment within the medical system and society at-large. 

They face numerous challenges, including high prevalence of trauma, stigma from providers, challenges planning for the future, and a perceived lack of autonomy over their reproductive decisions. 

Additionally, many have experienced coercion, felt pressured not to have children because of their SUD, or faced court or Child Protective Services (CPS) involvement during their pregnancies due to their history of substance use. Pregnant people face having their newborn torn from their arms at delivery due to unfounded judgment based on their medical records. Policies have had the unintended effect of preventing people from seeking prenatal care, worsening outcomes for parent and baby.

In many states, battling addictive diseases while pregnant or parenting has already been criminalized. Per Georgetown Law

“Now, women with substance use disorders, a population already at greater risk of miscarriage and unplanned pregnancy than the general population, will have even less access to needed health care to manage their own reproduction. This loss of autonomy will yield higher rates of overdose, death, incarceration and destabilization of families, children, and communities.” 

What Boulder is doing

As our CEO conveyed, “The SCOTUS decision threatens the lives and safety of the people we exist to take care of and advocate for. As a company built for social impact, we defend vulnerable groups when institutions threaten their most basic rights to their own bodies and health choices. When people facing difficult healthcare decisions lack a stable, supportive force in their lives to empower them on the journey, we step in to be that force.”

The intersection of SUD and abortion stigma is, frankly, a matter of life and death. 

At Boulder Care, we are: 

  • Providing education and training to our patient-facing staff to be able to triage and appropriately counsel our patients when they have reproductive health related needs and questions. 
  • Appropriately licensed clinical providers will prescribe contraceptives, and also refer patients to trusted brick-and-mortar facilities for services like intrauterine devices (IUD’s) and implants.
  • Partnering with local, community-based organizations to understand the specific barriers our patients face when trying to access prenatal care, abortion care and contraceptive care, based on the specific county in which patients reside. 
  • Partnering with telehealth providers who offer abortion care to establish two-way referral relationships and coordinate on holistic care plans. 

Ultimately, we seek to uphold the values of Reproductive Justice (as defined here): “The human right to maintain personal bodily autonomy, to have children, to not have children, and to parent the children we have in safe and sustainable communities.”  

Though the threats are greater than ever, we remain resolved and committed to keep showing up: we will continue advocating for our patients across the convoluted intersections of stigma in America with tireless resolve, supporting others who are doing the same.

Recommended Reading