S5E20: Advocating for Reproductive Justice

Lina: Do your taxes. If you are smart enough, do it by yourself. I'm not.

Hạ: Or make friends with an accountant who can do it for you for free.

Juliette: Family friends are the best friends seriously.

Lina: All right. Hi, everyone. Welcome back to "Bundle of Hers." This is Lina speaking to you. Today, we have Ha and I, and another guest, Juliette, who you've all heard from in a previous episode. But I'll let her introduce herself again.

Juliette: Thank you. I'm really happy to be back. And this time when I'm here, I'm here in kind of a different capacity. So my new role that I just took on, I'm a regional director for a skilled nursing facility company called Ensign. And so I'm specifically director over managed care, which means that everything I do is ensuring value-based care and practice is provided to our patients within our facilities across all of the states that I cover, which is Utah, Idaho, and Nevada. And then I've also been a co-chair for inclusion/diversity with Optum and United for the past two years.

Lina: Amazing. Welcome back.

Juliette: Thank you.

Lina: Today is another special conversation about reproductive healthcare and reproductive justice. This conversation came up to me kind of through rotating through OB/GYN. I just recently finished it several weeks ago. I had a lot of good experiences through it, and I was exposed to a lot of sides of that healthcare field.

I always seek out patients that are part of my community or part of a minority community. And it's really important to me to be a part of their healthcare, and focusing on where I saw the disadvantages and where I saw a lot of the inequalities in a lot of these patients accessing reproductive care.

The populations that this affected the most is usually BIPOC communities. It's a thing. We know that it affects a lot of different sides of healthcare and specialty, but in OB/GYN specifically just how the system is built and just how OB/GYN came up, that is important to talk about and to discuss

And it's also come from looking at a lot of these communities. There's little knowledge that's available to them. There's little information that's accessed to them, and I just wanted to share those experiences a little bit more in I guess your own experience or patients that you've interacted with.

Juliette, we've talked about this before. Would you like to start?

Juliette: Yeah, absolutely. So my experience in a way kind of almost started when I was born. I would even go back saying with my mom. When I was born, she actually opted to put on my birth certificate that I was white. It's because my dad is Caucasian and she's black, and she thought that it might give me a better future for my healthcare if they have on my birth certificate that I'm white, and maybe I'll just have a better opportunity and be treated differently than she had been treated.

And so, when you fast-forward to adolescence and those teenage years, I had what everyone thought would be an amazing cycle, and then things started to kind of go wrong around the time I was 16 and I was having some really bad complications.

My mom took me to go see her OB/GYN, and she specifically sought somebody out that was pro-LGBTQ. He's just very much an ally to all groups and made that known, so it created a safe space even though he was white. She felt very safe with him because of the environment he created.

And I loved him. I thought he was great. I went to him from like 16 to maybe 18 or 19. And then when I went to college . . . so I went from having a pretty good experience my first time with someone who was an OB/GYN. Then I went to college, and I didn't have health insurance, which is very common for someone who is a black woman to not have health insurance.

So I didn't go to an OB/GYN again until pretty much like post-grad school. So it was a good five years without going and seeing a provider, unless if it was absolutely necessary. And I definitely had a lot of health issues along the way that I almost ended up in an ER, and some of them were related to whether it was bladder issues or vaginal issues.

Anyway, so post-grad school, what was interesting is this was the first time that I had insurance of my own from working, and I had to find my own provider. And I wanted to. I wanted to get back into preventative care.

For me, it's been no secret to anyone in my personal life. I've never wanted kids. I knew that I really struggled with taking the pill and talking about contraceptives and whatnot, so it was important to me to find a provider that would be willing to have those discussions with me.

And I had three different providers all refuse to give me anything more than the pill. They wouldn't talk to me about the shot. They wouldn't talk to me about an IED. They just said that, "I'm not comfortable with it," and I explained to them, "This is something I sincerely don't want."

I want to be open about my sexuality, and I would hope that my provider would create a safe space for me to be able to feel comfortable talking about that. But they all kept coming back to, "Well, you're a woman and the statistics show that some of those devices or methods that you want to talk about might be harmful, or might cause you to not have kids, so therefore I won't do it. We can do the pill, or I'll give you the ring, and that's it."

I understand that this is kind of that question of "Where does morality come or ethics within healthcare?" If you're not comfortable doing something, that's fine. But to have three providers consecutively say, "Oh, no, I don't want to do something that might jeopardize your fertility," and I'm telling them, "I have not wanted kids since I was 12" . . . I'm not future planning. I actually want the opposite. I want someone to help me be preventative with this, and I'm trying to be educated with my decision-making. And it was just being blocked. So that's kind of been my experience so far within that world.

I will say that, yet again, when I moved to Utah, I found myself in a similar situation that when my mom set me up with an OB/GYN, and it was a woman, and she gave me an IED the same day. She said, "Oh, absolutely, if this is what you want." We talked about pros, cons. We talked about all the different types and pathways that I could take, and it was just a totally different experience.

Hạ: And in an opposite way, the true confession is that my experience with OB/GYN is that I've actually never gone to an OB/GYN. I get a lot of my preventative care, like Pap smears, from my primary care provider who's a Med-Peds-trained physician.

Part of the reason why I feel that I never really looked into OB/GYN is because the topic of women's health is kind of a bit quiet/quiet, whisper/whisper within my culture.

I remember the first time I got my first Pap smear at 21, my mom, bless her soul, completely love her, but she completely freaked out. I had to do a lot of the research, and I had to explain to her everything about it because it was just something that she did not understand. Her first Pap smear that she got was when she came here pregnant with me.

It was interesting because when I started medical school, I was really open to a lot of different specialties, but the one specialty that I was always very closed off to was OB/GYN. And I was always like, "OB/GYN is not the field for me. It was not made for people like me."

And I think also part of the reason why was that especially seeing OB/GYN in Utah, I saw a lot of its work as being geared towards white women and not really women of color. I didn't really see OB/GYNs as a safe space for me to go and get my care about sensitive topics. I felt a lot more safe with my other primary care physicians.

I just saw, "This is the type of care that's not really going to focus on all of the communities that I care about." I went into medicine caring about communities of color, caring about marginalized and stigmatized communities, and that wasn't really the vision of OB/GYN that I was given growing up.

And so that's kind of a lot of my experience with it, and I feel that in opening conversations, I've realized that, yeah, it has a lot of impact in other communities, but in a way, it is very true that how it's built right now isn't as inclusive as it could be.

Lina: Yeah, Ha, I completely agree with you. And really, I think I always hear that kind of common terminology, like with what you brought up and with what Juliette brought up. People, specifically women of color, feel unsafe, don't feel comfortable with OB/GYN, don't feel comfortable with approaching that topic. And I feel part of it has to do just kind of how OB/GYN started.

Beginnings of obstetrics developed around testing on black women without anesthesia and under the assumption that they couldn't feel any pain. And even though we got that information, we have to realize that effect that had on many generations to come of black women and of communities of color.

Hạ: OB/GYN deals with something so sensitive, and it's so wild to think that its history comes from something that was not really trauma-informed, or didn't really value lives, and was very racially charged. And it's wild to think about that, but then when you realize that history, as you said, Lina, you go, "Oh, now it makes complete sense. It's just bred into OB/GYN as a field itself."

Juliette: It is really interesting, too, to say the connection that you even brought up, Ha, about how you see something and you associate it with something that's a predominantly white industry. The marketing is geared towards that. Everything you see is towards that. The pamphlets that you receive, the diagrams of the anatomy are always on white bodies.

It's just interesting to see that what founded it all was kind of the torturing and the singling out of black women and African-American women and that trauma associated with that. What's interesting is you have an industry that's profiting yet again off of that came from black culture in a way.

One, I mean, it's not something that's not taught in our history books, right? So, when you come to education, it's something that's lacking. But two, a lot of people, once they know that, fail to still see that kind of comparison of something that you're benefiting from off of the history of people of color, in this case, African-American women and enslaved women.

And yet you get to profit and have a whole slew of providers at your service and your beck and call to help you sometimes in the most confusing and isolating and hard moments of your life, especially in terms of infertility and whatnot. And yet, people don't feel the urge to say, "Huh, why doesn't this seem like it's accessible to all people?"

But I guess that's the luxury of being able to say you have a provider that looks like you, and you have a level of care that reflects what you need.

Hạ: It even pervades how . . . because OB/GYN is also a field of a lot of advocacy and activism, right? But a lot of that narrow mindset pervades even how the activism is done.

When we think about discourse regarding contraception, a lot of people forget how historically it was built off of narratives that demonized and dehumanized black and brown communities too.

Juliette: That's true because there is definitely a stigma that when it comes to sexuality within the black community, especially for black women. There was always this narrative, to Lina's point that we brought up from before when you look at the history of it, that enslaved women, one of their roles is that they're breeders. They were treated like cattle, and they could keep breeding and having babies.

And so it's created this . . . It's very taboo to talk about this in the black community. But it's created this narrative that black women are just insanely fertile. And there's a preconceived notion within healthcare too, and even within doctors, that they just assume all black people are fertile, and that's not the case. My mom couldn't get pregnant for three years before she finally did. And there are a lot of people that have similar stories to that.

But it comes off like there's something wrong, and then when you have already something that makes you feel vulnerable and society tells you, "You should be extremely fertile," and you have a provider that's saying, "Things should be fine. I'm not going to run the test that you're requesting because you should be fine just based of your ethnicity," it creates a bigger barrier to an already long-standing mistrust with providers, especially one that started off with the targeting of black women.

Lina: Yeah. Contraception is kind of provided right now as an option, but when we look at how it was originally provided, it was provided as a way to sterilize people and to decrease the number of immigrants, of poor, of disabled people. Those were the people who were given birth control. Those were the people that we wanted to make sure didn't reproduce.

And it goes back to both your points that this is established on white supremacy. And same thing with OB/GYN as a whole banning a lot of other midwifery practices and cultural practices around a woman's fertility and reproduction. It came also to ban a lot of what brown and indigenous communities knew what to do, and how to feel safe within themselves, and how to survive what they can survive. But yet, somehow OB/GYN came as a way to stop all of that.

I think we mentioned it in episodes before that the best way to kind of approach things is really consider everyone's identities, and everyone's kind of intersections of what they have, and truly giving them the power to control their own healthcare.

Juliette: I love that. And even with that, one of the research articles that I had been reading on . . . so this was from 2015, and it was called "The Silent and Infertile." It was done by University of Michigan by a psychologist and associate dean there.

So she interviewed 50 black women about their experiences with infertility, and she even says, "I was just floored that all the work on infertility was been done on white, very wealthy couples. When I learned that women of color are more impacted, it seemed like a clear injustice."

And so, when she was going through articles before they did this research study, it was just . . . you see women two to four times more likely to have extremely high morbidity, mortality rates, higher infertility rates, and yet they're not even a quarter of the people being researched in a lot of these different articles and papers.

So that's why she was saying it's kind of hard to justify what exactly is the true percentage of women being impacted because they're not been researched. And if they're not being researched, then there's not a lot to support this, right? It's still theory, but . . .

Hạ: It frustrates me because knowing the research process with IRBs and getting participants and things like that, is it a way for us to slow down progress? And also, I wonder if by depending on current systems that we currently already use and that we know aren't working, I think what we're doing is reforming things, but we're not radicalizing things. We're not actually changing things.

Because the way that OB/GYN currently is set up, it is very built on a lot of systems of oppression. But really, what OB/GYN was doing was most healing was with things that were built very much more on the collective, and on community, and on meeting people where they were at and really understanding each other.

That's why while I believe that a lot of the activist work that is happening in OB/GYN right now is very necessary, and I want to also acknowledge that a lot of people are thinking about how to change it and make it better and not a space for just white women, I also want to always challenge the ways and the tools that we're doing it. We might just be repeating a lot of the similar issues, or putting a pretty bowtie on it, and bringing people in but not really including them.

Lina: I really like that, bringing people in, but not including them. I mean, yes, there's a lot of research that's happening right now and that's great, but what's our next step? Where are we going with that?

I think including that community and involving it with "How can we be better? How can I take care of you? How can I preserve present you with all the options?" Trauma-informed care as well. How can I make you feel safe throughout this whole experience? Whatever option you want, what you need in this point for me to help take care of you.

Juliette: I love that.

Lina: And that also includes involving cultural practices and communities and what they believe in and what they would like to be part of their OB/GYN care, rather than just focusing on ABC, this is what to do, and this is what we do, a standardized measure to every patient, but making it a more aware thing, I guess.

Juliette: It's that ability to really connect with your patients, and knowing that maybe they're Christian, knowing that they're Jewish. Maybe they're Palestinian. Maybe they're black. Maybe they're Punjabi. There are just a lot of cultural norms associated with religion, with sexual orientation. There is a lot of trust that's being missed there.

It comes back to cultural sensitivity classes, right? A lot of hospitals, they're starting to invest in them, but not to the extent that they probably should. And we can't expect everyone to be a wealth of all information. I understand that. How much do you really expect? Well, we can expect our providers to be willing to be open-minded, and to be willing to learn, and to just ask the question of, "What does your family need? What do you need to feel safe?"

If I was asked that as a patient, I may not even know how to answer it, but it would sure as heck make me feel a whole lot more comfortable, more trusting in my provider that they're taking that into consideration.

It's being open-minded to having those conversations and creating spaces of trust and opportunity and cultural sensitivity.

Hạ: Such an important reminder because I do think, at least for me going through the medical training, it takes a lot out of us, and we forget about the people that we're seeing and the stories that they're living. The fact that for a lot of us, especially to reach the place that we do within medical school and residency and beyond, we've had a lot of privileges and a lot of luck and good fortune that some of our patients don't have.

At the end of the day, I like to subscribe by the patients know themselves best. They know their bodies, and our work is to kind of be a translator. It's to listen to what they're describing and help them reach the solution together.

Lina: Yeah, you brought a good point, Ha. We go through this medical school process, and we are kind of depersonalized in a way, and that can be in many specialties and not just OB/GYN. But you learn to just take in the information and the science, and just kind of not react to the stories, or not pay attention to the stories.

I think with something as sensitive as OB/GYN and as kind of the advocacy that comes with it, we need to pay attention to the stories, and we need to always be humble enough to know that we're always going to be learning something from our patients and that our patients know best.

Juliette: It's not one of the only reasons why there are barriers to trust, but it's a big contributing factor, because black women don't feel like they're heard when it comes to this area within healthcare.

When you have someone questioning what you're feeling, if there's a pain there and you're saying, "Well, I'm not seeing anything on this ultrasound," or, "I'm not seeing anything on this MRI or CT scan" . . . Because that's what happens a lot within the black community. "Well, I don't see anything on your skin. I know you're saying that there's something there, but it doesn't present itself as what I know it to be," because it's typically taught in medical books on white images.

Unfortunately, women, especially black women within the OB/GYN world, are known for having the highest cardiovascular issues, and they go undiagnosed and missed, end up being pre-diabetic. I mean, there are a lot of side effects that come and they're often missed.

Again, it could be lack of trust too where they don't feel safe even expressing how they feel because there's already . . . Black people are quick to be like, "I don't know about this person," and they get quiet real fast.

And then it's already kind of culturally known for us that we don't offer up our business. So you're expecting us to be vulnerable and be open with you, but I don't think really you're considering what I'm saying or what I'm expressing to you.

Lina: I agree with you completely, Juliette. And I think it's very, very important for us to highlight someone's cultural side to reproductive care, and that includes accessing birth control, or their thoughts even about birth control, and accessing OB services and what they've been raised at or what they believe. I think that's important to know because not everyone has the information, whether they've been taught this information or truly believe that this is something safe. It goes back to that.

I've seen it a lot in Middle Eastern communities. One, it's a taboo. It's a stigma to talk about as being a woman and talking about sensitive subjects that you can't talk about. And then, two, there's just a lot of incorrect information about what IEDs can do to you and what birth control can do to you or the baby. And it's just a lot to uncover I guess, in a sense, and we need to remember that a lot of this stuff is very, very common.

Hạ: That's a really excellent point that you brought up, Lina, and I touched about it a bit when I was talking about my experiences with OB/GYN, or a lack thereof. I feel that coming from a Vietnamese culture, issues related to OB/GYN just weren't really something that was normal to be talked about.

And there's a lot of misconception about what OB/GYN is. When I was really enjoying OB, and I told my mom I was interested in it, she had just this notion that my only role was that all I was going to do was deliver babies 24/7, which is a very huge component of OB/GYN, but there's so much more to it too.

And then similarly, a lot of our views in the Vietnamese community, we honestly don't think about birth control that much, and we don't talk about it. There are a lot of rumors that are always circulating around about how being on birth control causes a lot of health issues later on, be it with the baby if you have a future child, or even with yourself, and how it lowers your longevity and all of that. And so there's a lot of even pushback in trying to get the preventative care.

When I mentioned about the Pap smear, a lot of pushback for me to convince my mom that Pap smears were important and that there was not going to be any damage, or any major later health concerns that were going to happen to me. But it was just because it wasn't something that we talk about.

When you have your first period, it was kind of a bit of a hush-hush. "I'll tell you how to manage it, but let's keep it under wraps, and let's not make it a big deal."

Juliette: Mine was actually very similar to that too. Super embarrassing story and outing myself, but I remember when I had my first period, when I tell you I thought I had cancer and was dying. I was like, "I don't know what's happening to me. There's just all this blood. I don't know where it came from."

Lina: "Oh, my god."

Juliette: We just never talked about it. And so I went to school soiling myself for like the first two days because I was so . . . I was mortified. And I had no idea because my mom had never talked to me about it. Finally, by day two, I came whimpering to my mom and I felt shame like I had done . . . like something was wrong and I didn't know what I had done.

Of course, my mom was like, "Steve," that's my dad, "Steve, oh my god, it happened." I'm like, "Oh my god, don't bring him into this." Oh my god, I was freaking mortified. I was 12 years old, and I'm sobbing, and I'm wet, and I was like, "Ahh." The whole thing was just horrible and just humiliating.

And then my mom was like, "Okay. Well, this is what it means." I knew what a period was, but it's funny because as much as I knew, and we had sex education in school and whatnot, it's not like they show you pictures. So I just knew. I was like, "Okay. You get a period, and it means that you can now technically have a baby." But I had no idea what to expect.

They're like, "Here's a deodorant stick, and here's a tampon, and good luck." And I was like, "What do I do with this thing?" I had no idea. I'm like, "Does this go with the deodorant, or is this for down there? I don't know."

And so I can just totally relate to the taboo you just don't talk about it because with us, we never talked about it. I didn't even know that my mom never got me my HPV vaccine. I think the cut-off is you have to get it by 26. So I rushed to my PCP, and I was like, "Can I still get it?" She said, "Oh, yeah, so long as you get your first one before you're 26, you're fine." And she was fine with it, but when we talked about it, she's like, "I mean, I really thought it was never something we'd ever have to talk about or ever have to do."

I think a lot of it is within the black community, going back to Lina's point when you talk about culture, I think religion does play a bit of a component to it. Most people in the black community are some form of Christian. Not always. I mean, you still have maybe Muslim or a few that are Jewish and what have you.

But at the end of the day, the one thing across all of the religions you'll see is there's always God's plan, whoever you believe God to be. But a lot of the times you'll hear that, like, "If it's God's plan, it's there for you. Just pray about it. Hold strong to your faith."

And I'm not condemning that. I think that's a beautiful thing. But I think it prevents a lot of people, especially minorities, from going in and connecting with their providers when they feel like they need help because they're like, "Okay, maybe if pray about it." And then by the time they go in, things are either so far gone, or maybe even you can still get help, but it's a lot harder and it might be a lot more expensive than if they had come in early.

And they didn't come in early because maybe they don't either, again, trust their provider, or maybe they're putting trust in their community, or in their family, and their family is saying, "Just pray on it. God has you." Unfortunately, that can play a role into it too.

Hạ: Just another thing is a lot of in our conversation today, we talk a lot about women, and I just want to always be mindful as a final note in this conversation that a lot of people describe OB/GYN as women's health, but that's not really inclusive because OB/GYN also includes trans health too. I want to put that note for our listeners to be very aware of that and to also reflect on that too.

Juliette: I think that's great.

Hạ: Well, thank you, our dear listeners, for joining us. Thank you, Juliette, for joining and sharing your incredible insights.

As a reminder, you can listen to us on Spotify, Apple, wherever you get your podcasts. We hope that our conversation has sparked a bit more thoughts about reproductive justice. Bye-bye.

Lina: Bye.

Juliette: Bye.