By Claudia Douglas, MD, FAAP and Annie Hoopes, MD, FAAP
The three core values of reproductive justice are the right to have a child, the right to not have a child, and the right to parent one’s child or children in safe and healthy environments. While reproductive rights have historically focused on legal rights to abortion and contraception, the reproductive justice movement emphasizes that having legal rights does not mean equal access. Many factors (and often, the intersectionality of these factors) such as race, ethnicity, age, income, sexual orientation, gender, gender identity, immigration status, ability, and geography can affect an individual’s ability to access comprehensive reproductive health care.
The Supreme Court decision in June 2022 that overturned Roe vs Wade has caused frustration, confusion, and fear among many adolescents, families, and healthcare providers about the future of SRH care. Currently, in Washington state, individuals of any age can consent or refuse birth control services, abortion and abortion-related services, and prenatal care. However, it is important to recognize that even in a state with such protective reproductive rights, legality does not equal access. Adolescents face unique and significant barriers to sexual and reproductive health care (SRH), including lack of access to both SRH education and SRH services.
In 2018, Washington State Legislature conducted a literature review on disparities in access to reproductive health care. Barriers experienced by adolescents were highlighted in the study and included economic barriers (insurance status and cost of care), structural barriers (provider availability, medically accurate sexual health education, distance/transportation, lack of culturally and linguistically appropriate services, and difficulty navigating health system), and social barriers (lack of perceived confidentiality, provider stigma and bias, and lack of social support).
While Washington State is taking steps to acknowledge and address the barriers often faced by adolescents seeking SRH care and education (e.g., passing Senate bill 5395 which mandates comprehensive sexual health education in public high schools), there are still significant inequities experienced by adolescents in the state, particularly among those who are racial or ethnic minorities, live in rural areas, or experiencing poverty. Although adolescents in Washington State may have the legal right to consent for SRH services like STI testing, contraception, and abortions, they may not have access to local providers who can offer these services in a logistically feasible, low-cost, or confidential setting. Even when adolescents are able to find a skilled provider, they may experience overly biased and directive counseling that prioritizes the provider’s personal views, even if these are not aligned with the patient’s preferences and goals. Pediatricians may be motivated to navigate our new post-Roe reality by strongly advising our patients to choose LARC methods (e.g., intrauterine device or contraceptive implant) over other forms of contraception. We may express understandable frustration when our “at risk” patients miss appointments or are unwilling to engage in conversations about contraception or reproductive health. However, it is crucial that we as pediatric providers provide person-centered, reproductive-justice-informed sexual and reproductive health care.
Actions to promote youth reproductive justice
Unbiased, person-centered and reproductive justice informed education and SRH care requires multi-level interventions. Pediatric providers working with adolescent patients should strive to provide equitable and developmentally tailored SRH counseling and care. This includes anticipatory guidance and routine pregnancy intention screening, comprehensive contraception counseling and provision, health care navigation support, and access to confidential care if indicated. Providers should support and communicate with parents about the importance of 1:1 time between adolescent patients and healthcare providers. Additionally, providers should serve as advocates to legislators in ways that continue to advance protections for adolescents seeking SRH, digital health information related to reproductive health, and clinicians who provide this care.
Most importantly, as providers, we must listen to our adolescent patients. This will require us to reflect and acknowledge our own personal biases that may result in inequitable reproductive care for our patients, including encouraging or discouraging a patient’s contraception preferences or expressing reluctance to stop or remove contraception at our patient’s request. Negative healthcare experiences during adolescence can reinforce health inequities and mistrust of providers, and can affect future health-seeking behavior, especially among adolescents of color and other marginalized communities. We must remember that reproductive coercion is not always about the provider’s intent, even when well meaning, but it is about the adolescent’s perception.
Now more than ever, it is imperative that pediatric health providers remain engaged and center reproductive justice in this dynamic landscape of reproductive health rights and access.