Opinion | Preventing Contraceptive Coercion in the Post-Roe Era

Racism and classism — and the related prejudices about who can and should bring a child into the world — have shaped our country’s history of birth control. Contraceptive care providers and systems have all too often reflected and perpetuated the oppression infusing our society as a whole.

While most healthcare providers would condemn the most blatant injustices — such as researchers using Puerto Rican women as test subjects in birth control trials without informed consent, doctors performing “Mississippi appendectomies” sterilizing Black women without their knowledge, and judges coercing people to use birth control to avoid jail time — the reality is that this history continues to be reflected in the care we provide today. I’m concerned this is becoming even more true with the fall of Roe.

My team’s research, published in the American Journal of Obstetrics and Gynecology in 2010, found that providers were more likely to recommend long-acting intrauterine devices (IUDs) to low-income Latina and Black patients. Other research shows that Black women are more likely than white women to report that a clinician pressured them to use birth control. Additionally, policymakers and advocates often tout birth control programs not as ways to increase autonomy, but as tools to prevent young people or people without money from having children.

It takes a tremendous effort to realign our work away from a shameful history of reproductive coercion.

Belatedly and imperfectly, providers who offer contraceptive care have been engaging for years in a conversation about this historical and ongoing reality. More of us are firmly rejecting eugenic policies that targeted communities of color. We’re identifying the vestiges of those policies that persist in reproductive healthcare and policy, and working to shift them. We’ve been working toward a future informed by reproductive justice advocates that honors the right of every person to have or not have a child, and to raise that child in a safe community. That means recognizing our role of shifting the contraceptive care we provide to be centered on reproductive autonomy and individuals’ needs and preferences.

And then a bomb went off in the reproductive health field with the Supreme Court’s decision stripping millions of Americans of a constitutional right to abortion. We’re only beginning to see the devastation of the many ways this ruling interferes with reproductive autonomy.

In states that have banned abortion, fear hangs over people’s reproductive decision-making. Media report stories about people rushing to get IUDs and other long-acting birth control. In my team’s research (still ongoing), we’ve seen an uptick in people interested in permanent sterilization. Even some people who want to have a baby are holding off out of fear of everything that could go wrong, such as the horror stories about hospitals denying life-saving care.

Providers and health systems are under intense stress trying to provide care in these hostile environments. They fear for their patients. This pressure could make it very easy to slip back into old habits, letting fear of potential negative outcomes take precedence over someone’s own ability to make informed decisions in this new context.

Providers might look at the hurdles ahead and think that a patient simply can’t afford to have a baby. They might make judgments that they aren’t ready to parent, leading them to push the patient toward a particular birth control method. But we can’t decide for someone else what an undesired pregnancy means in their lives. There is a serious danger that providers will ignore the needs and desires of patients of color and those with low incomes — as well as those with disabilities or chronic medical illness — continuing to devalue their ability to make informed decisions about their bodies and reproductive lives.

Acting on these biases also ignores the fact that there are plenty of valid reasons someone might not want to use a particular form of birth control. While there have been major pushes to get more people using long-acting contraceptives because they’re easy and effective, many people do not want to use these methods for a range of reasons, including the fact that they have less control over them. People who are unhappy with their IUDs have complained about providers refusing to remove them, inspiring a slew of online videos on how to remove it yourself. People can also experience all kinds of unpleasant side effects of hormonal birth control. Those reasons don’t change because abortion laws change. A provider might feel like avoiding pregnancy at all costs is the top priority. A patient might feel differently.

Our patients know their lives best. Our role as healthcare providers is to give them information about the options available, and the very real constraints they face in states that ban abortion. Then we need to trust our patients to make the decisions they see as best within that reality. That includes if they don’t want a pregnancy, or if they would risk one and figure out what to do.

It’s time to chart a new path forward: one that recognizes the cataclysm that Dobbs caused while still putting patient values front and center. All healthcare providers and systems must work to provide patients with every possible option, and then trust that they are the experts in their own lives. We must speak out against the inequality and structural oppression that constrains their choices to parent or not to parent. We cannot allow this tragic ruling to cause us to inflict more harm on the people who bear the brunt. This is a test of our commitment to autonomy and reproductive justice. We cannot and must not lose the essential progress we’ve made, even in the most dire of times.

Christine Dehlendorf, MD, MAS, is a family physician and director of the Person-Centered Reproductive Health Program at the University of California San Francisco.