Evidence-Based Advocacy is a monthly column seeking to bridge the gap between the research and activist communities by profiling provocative new abortion research that activists may not otherwise be able to access.
Ask anyone to tell you who’s doing the most innovative research on abortion provider stigma and they’ll tell you it’s Dr. Lisa Harris and her interdisciplinary team at the University of Michigan. Together they pioneered the Provider Share Workshop, a pilot project testing the possibility that a support group for abortion providers could help reduce the negative impact of stigma. She writes about topics that others in even the most pro-choice communities shy away from—the need to have open and honest conversations about second trimester abortion provision, how stigma affects abortion complications, and, recently, the need to recognize conscience as a motivating factor in abortion provision. Now, Dr. Harris and her team, which includes social worker Jane Hassinger, and public health PhDs Michelle Debbink and Lisa Martin, have gone a step further and actually mapped out how abortion providers experience abortion stigma, coining a new term: the legitimacy paradox.
Based on their interviews with abortion clinic staff who participated in the Provider Share Workshop, Dr. Harris and her team theorize that the combination of stigma and silence perpetuate a vicious cycle:
“When abortion providers do not disclose their work in everyday encounters, their silence perpetuates a stereotype that abortion work is unusual or deviant, or that legitimate, mainstream doctors do not perform abortions. This contributes to marginalization of abortion providers within medicine and the ongoing targeting of providers for harassment and violence. This reinforces the reluctance to disclose abortion work, and the cycle continues.”
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A visualization of the legitimacy paradox, by Dr. Lisa Harris et al.
The marginalization of abortion providers within medicine and society at large is not a new issue. In fact, as Dr. Harris and others have written, negative portrayals of abortion providers go back at least two centuries in the United States. In the nineteenth century, the American Medical Association opposed abortion in part because non-physicians (such as midwives, osteopathic doctors, and others) were the majority of abortion providers at that time and took away valuable business from physicians. The AMA sought to criminalize abortion to push these competing practitioners out of business, and thus began the association of abortion provision with “deviance” from mainstream medicine.
As the women’s liberation movement made the case for safe and legal abortion in the mid-twentieth century, abortion providers were depicted as “back alley butchers.” This portrayal and the grotesque images associated with it communicated the very real dangers of illegal and unsafe abortion, but neglected that many thousands of safe illegal abortions that were provided by both clinicians and lay-people during this time. While the use of the “back alley butcher” imagery certainly helped to legalize abortion in the United States, Dr. Harris argues that it did so while further stigmatizing abortion providers.
To track how abortion providers experience stigma today, Dr. Harris’ team conducted a focus group with abortion clinic staff in a Midwestern abortion clinic. She documented that all abortion clinic staff, including clinicians, counselors, front desk workers, and others, feel the negative impacts of doing stigmatized work. Providers commented on encountering stigma in public discourse, such as in political rhetoric, from institutions, such as hospitals and churches, as well as in their every day relationships with family, friends, and even their patients. As a result of this stigma, providers often have to choose if and how to disclose their involvement in abortion provision, weighing the possibilities of relationship conflict and threats to their safety if they decide to disclose, or isolation and disconnection if they keep their work a secret.
What are the consequences of this stigma? One possibility is that it may contribute to violence and harassment of abortion providers. Dr. Harris and her team explain:
“Stigma dehumanizes its subjects, and dehumanization is a step on the path to violent acts…When underlying prejudices, attitudes, or mental health conditions intersect with degrading rhetoric…some individuals may be incited to acts of violence.”
It shouldn’t come as a surprise to anyone that stigma can lead to violence, and that as a result, abortion providers decide not to routinely disclose the nature of their work in everyday situations. And that’s where the legitimacy paradox comes in: this (understandable) silence from abortion providers allows others to define abortion provider’s work and character for them. Many highly trained physicians provide abortion care, but abortion providers continue to be stereotyped as substandard doctors.
Why should we care about abortion provider stigma and the legitimacy paradox? Dr. Harris explains that it most likely affects the availability and accessibility of abortion services in several ways. The prevalent negative images and stereotypes of abortion providers may deter medical students from seeking abortion training and may discourage clinicians already in practice from providing abortions. For clinicians who already provide abortion care, being stereotyped as a “substandard” provider may cause them to provide abortion for only a short time in their careers. Additionally, the legitimacy paradox may impact people seeking abortion services—that is, patients may assume that doctors at an abortion clinic are “low-quality” physicians because they provide abortion services.
What can we do to address abortion provider stigma and the legitimacy paradox? The solution isn’t to push abortion providers out of the closet—considering the safety risks of publicly identifying as an abortion provider, this would be an irresponsible and perhaps even dangerous solution. Dr. Harris suggests that advocacy and medical organizations as well as institutions and clinics implement structural interventions to address abortion stigma and provider stereotypes. We must demonstrate that we value the work of abortion providers by challenging the harmful assumption, from anti-abortion legislators as well as some in the medical community, that abortion providers are sub-par clinicians. Understanding and addressing the legitimacy paradox will enable us to better support abortion providers and people who seek abortion services.