Dr Richard Ma is a general practitioner in London and a clinical research fellow at Imperial College London. He has research interest and clinical experience in delivering sexual and reproductive healthcare for over 20 years. His current PhD is funded by the National Institute for Health Research and focuses on improving contraceptive care in UK general practice.
I shall start this essay with an apparently uncontroversial, if not benign statement:
“Unintended pregnancies make up an estimated 44% of all pregnancies worldwide, nearly 60% of these end in abortions (1), and up to half of unintended pregnancies are due to incorrect or inconsistent use of contraception (2, 3). Britain has among the highest teenage abortion rates in Europe (4, 5); together, these suggest significant room for improvement in contraceptive programmes in Britain and worldwide (6).”
This was taken from my own research on how long-acting reversible contraceptive (LARC) advice from general practitioners was associated with increased prescriptions of LARC and reductions in abortions (7). It is not an uncommon narrative in the beginning of many research and policies on sexual and reproductive healthcare (SRH) in high-income countries. I am a doctor actively involved in SRH practice, research, and policy for 20 years. I have come to realise framing of much contraceptive healthcare research might be problematic and we might be failing women’s health with this narrative.
In this essay, I shall argue how women’s SRH is framed, delivered, researched, and applied into policy fail to tackle the real issues that perpetuate inequality and impede advances in sexual and reproductive health rights (SRHR) movement. I shall also make a case how we as practitioners, researchers, policy makers and advocates can make changes for the better.
Framing of much SRHR Research and Policy is problematic
The first National Strategy for Sexual Health and HIV published in 2001 acknowledged sexual ill health of the nation and put SRH on the agenda (8). However, there was little detail on the structural problems that lead to poor sexual health. An updated strategy A Framework for Sexual Health Improvement was published over a decade later and although it explicitly acknowledged the contribution of complicated drivers of human action, including gender roles, inequality and norms around sexuality, there was little guidance on how to address these (9).
England’s multifaceted policy intervention Teenage Pregnancy Strategy published in 1999 to reduce teenage conception and address social exclusion of young parents was associated with a decline in conceptions in women under 18 years (10). But for all the skills, opportunities and education that were invested in this generation, the impact was not sustained into young adulthood (11). Perhaps institutional and structural barriers that were determinants of unplanned pregnancies for women in young adulthood and beyond were not adequately addressed.
Underlying much of the policy and guidance for SRH practice is an a priori assumption that women are not using the right or the most effective contraception at the right time, thus leading to unplanned pregnancies. Abortion is often depicted as secretive, shameful, regretful and cause of relationship conflict (12). A common narrative is abortion is a bad outcome, needs to be avoided and could be prevented. It is often used as a proxy metric to judge of how well women are using or accessing contraception. Perhaps we should be more critical about this assumption and be asking what this metric tells us, and if it is desirable to achieve zero rates of abortions at all. Should we normalise it more, and problematise it less? (13, 14)
Not everyone wants to use contraception for fertility control and women at different life stages have different preferences. All methods of contraception have unwanted effects and not all are acceptable to women. It would be useful to have a women centred discussion to include: what women want from contraception and what would help to make the right choices at the right time.
National Institute for Health and Care Excellence (NICE), which produces guidelines for clinical practice, have focussed mainly on access to physical facilities, medicines/devices, and clinician interaction but little on individual preferences. NICE cannot be blamed for framing the standard of women’s SRH by access and use of contraception. But given its premise on use of best available evidence, it is not surprising that the problem (scope) and solution (guideline) is framed in a medical model– which might be the root of the problem.
Medicine as an institution is bad for women’s health
Medicine as an institution could be problematic for women’s health and person-centred care. The “medical model” is the dominant “disease” model of medical practice. If someone is “sick”, they are assumed to have abnormalities with their measurable biological determinants, rather than a more biopsychosocial model of “problems with living” where other dimensions are explored (15).
The recent “evidence-based medicine” movement, based on the same philosophy of finding the one “true” or optimal way of practising clinical care, could be contributing to frustrating and unsatisfactory doctor-patient encounters. Doctors take the “presenting complaint” from a patient, look for clues in the examinations and investigations, then find a solution to their problem. Doctors get “stuck” when patients do not present or respond to treatment in a prescribed way, or as expected in our neat and rigid treatment pathways. Even the treatment guidelines can be rigid where there is no room for context or individualised care.
The discrepancies between presenting complaint and what “fits” in with a recognised medical narrative could result in “gaslighting”, a term used to dismiss women’s health problems, and reinforce stereotypes that women are “irrational and hysterical” (16). Often there is a power struggle between the clinician (often but not always male) and the patient (often, but not always female). Such power struggles can be magnified by intersecting issues of gender, age, social class, and race. Is it any wonder therefore that young women from black and minority ethnic groups often have high SRH needs and get the worst outcomes? (17-19)
Academia and epistemological trampling
The relatively high value academia places on quantitative methods and the face validity of science and “truth” can be problematic. Positivism – the philosophical basis of natural sciences, on which much of modern medicine is based, depends on quantifiable observations of phenomena, or facts, in which are empirically and objectively measured, with interpretation that is based on deduction and value-free (20).
“High impact” journals regularly publish quantitative research, which is often valued more than qualitative research. One such medical journal, the BMJ, has been outspoken about its stance on qualitative research and has been criticised by the academic community (21). The BMJ claims to work “in partnership with patients” by asking authors about patient and public involvement (PPI) when they submit their manuscripts, and by having patients as peer reviewers (22). However, unlike the scrutiny given to the rigor of scientific methods, there is no such assessment for PPI; to cynics, this might sound like a fudge, an afterthought, or even tokenism.
On its own, positivism can lead to overly simplistic ideas that prevent us from realising our potential to heal or harm people (20). Epistemological trampling of SRH research by positivist philosophy results in a reductionist framing of women’s SRH needs, with access to contraception, its uptake, and abortions as direct or proxy metrics. For example, whether a woman chooses to use contraception or not is more than prevention of pregnancy. Meanwhile we know less about why women use contraception and what they really value – which could be answered using qualitative methodologies. But such research would not be of interest to high impact journals, which means they are less likely to be published, and in turn less likely to be studied.
Given such systemic and structural issues affecting women’s health, what can individuals and organisations do to improve? Who is responsible to improve gender equality in SRH research and practice anyway? Do we, and should we expect women to claim responsibly and solve this problem? Should I as a cisgender man step aside?
Solution 1 – Involving more women in research and policy
One of the unexpected things l learned from my PhD was the value of participatory research. Indeed, the concept of patient and public involvement/engagement (PPI/E) has been an important development in research and policy recently. Research councils now ask applicants how the public were involved in their research proposal, and how they would continue to be involved and engaged including research dissemination. The public have contributed to scoping, development, and review of clinical guidelines for NICE. My PhD has a project advisory group which consists of lay people and charity representatives; they have shaped my research and engagement with the public.
The James Lind Alliance is a non-profit organisation whose aim is to bring the public and clinicians together in priority setting partnerships (PSPs) to identify and prioritise unanswered questions or evidence uncertainties that are important for them. They have already identified a list of important research questions for contraception including what interventions improve the uptake and continuation of LARC, what are the longer-term effects of contraceptive use and what new contraceptives are effective for men among the top 10.
Solution 2 – Seeing the world through the feminists’ lens
In her PhD thesis on breastfeeding support, the late Dr Heather Trickey used a feminist approach in her research (23). These approaches seek to break down barriers and flatten hierarchical relationships between the researcher and participants, and often take a participative approach to unfolding the research agenda. It recognises the power dynamic inherent in all human interactions which also relevant in research (24).
Seeing things through a feminist lens has helped me to reflect my own practice and consider the structural problems that could create barriers to good SHR. Let’s start with the very topic I am researching – contraceptive care. The oral contraceptive pill has been around for half a century, yet it is mainly women who bear the responsibility for contraception and unplanned pregnancies. There does not seem to be much appetite for research and development into contraception for men.
However, there are structural problems that need to be acknowledged and addressed for any progress. The murder of Sarah Everard has reminded young women and girls how they are taught from a young age to be “wary/mindful” of men, or they should not go out alone at night and thus perpetuating the idea that women are responsible for this threat (25). It is a failure of society that this sort of advice is still given, yet little is done to educate boys and men about appropriate behaviour and respecting women. From #MeToo movement to the murder of Sarah Evarard, these events have highlighted how society has tolerated sexual harassment of women for far too long.
Religious institutions are not free from blame when it comes to misogyny and oppression of women; the anti-abortion stance of the Catholic Church being a good example. Women have also been complicit in oppression of women as the story of Magdalen laundries demonstrate – where young women who fell pregnant out of wedlock and had their babies given up for adoption, were systematically shamed and abused by the nuns who ran such horrific instructions in Ireland. These laundries only ceased operation as recent as 1996 but it was not until 19th February 2013 that the Taoiseach Enda Kenny issued a formal state apology (26).
A patriarchal society, with its system of oppression, is harmful for not only women, but other marginalised groups including people from Black, Asian and Minority Ethnic (BAME) and lesbian, gay, bisexual and transgender (LGBT) communities. The sexual, emotional, and physical abuse often affect victims for the remainder of their lives. In my work as a GP, I see the impact of these experiences, often present as anxiety, depression, borderline personality disorders, post-traumatic stress disorders (27). Breaking this barrier is the only way to progress to sexual, gender and racial equality. But of course, this is challenging because there are too many vested interests to keep this institutional status quo.
Solution 3 – we need fewer bystanders and more allies
Many years ago, I attended a teaching session where the tutor, oblivious to my heritage, made a subtle racist remark about Chinese people. I called him out on his behaviour but why was I expected to act when I was the victim of racism? An ally might have characteristics that put them in a privileged position, and they could use that power to call out such behaviour whereas those who witness harassments and yet actively chose to be bystanders might be unwittingly condoning those behaviours.
We need more societal change to promote gender equality and justice for reproductive health rights. We need to give examples and call out behaviour that are harmful to minority groups. We need to foster development of allies to help promote the cause and create a shift in policy. Bystander interventions and ally development are key to improving social justice including the workplace (28).
In the context of SRHR, the Lancet-Guttmacher Commission aims to change harmful social norms, uphold human rights, promote gender equality, and give individuals greater control over their bodies and lives at the global, regional, and country levels (guttmacher.org/guttmacher-lancet-commission). It recently called for gender inequality to be challenged, especially in Africa, Asia and Latin America, and involvement of men in SRHR agenda – “we need innovative ideas that will systematically desensitise men from their domineering role and accept that women have right” (29). Men might be the problem, but also part of the solution.
I am grateful for my patients, PPI group, my PhD supervisor, research participants and co-workers/authors for giving me the privilege to hear about their experiences. My research journey has given me an insight into the feminist movement and how structural barriers impede the progress of sexual and reproductive rights. These patriarchal barriers also oppress other marginalised groups from attaining equality. I hope I can contribute in a small part to continue Dr Trickey’s legacy of improving women’s health. I hope this platform is a start to help make some real changes to sexual and reproductive health research, policy and practice to improve women’s lives.
- Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: estimates from a Bayesian hierarchical model. The Lancet Global Health. 2018;6(4):e380-e9.
- Finer LB, Henshaw SK. Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health. 2006;38(2):90-6.
- Ong J, Temple-Smith M, Wong WCW, McNamee K, Fairley C. Contraception matters: indicators of poor usage of contraception in sexually active women attending family planning clinics in Victoria, Australia. BMC Public Health. 2012;12(1):1108-.
- Sedgh G, Bankole A, Singh S, Eilers M. Legal abortion levels and trend by women’s age at termination. International Perspectives on Sexual and Reproductive Health. 2012;38(3).
- Statistics N. Abortion Statistics, England and Wales: 2019. Department for Health and Social Care; 2020.
- Wellings K, Jones KG, Mercer CH, Tanton C, Clifton S, Datta J, et al. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). The Lancet. 2013;382(9907):1807-16.
- Ma R, Cecil E, Bottle A, French R, Saxena S. Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study. PLOS Medicine. 2020;17(9):e1003333.
- Department of Health. The National Strategy for Sexual Health and HIV. London2001.
- Department of Health. A Framework for Sexual Health Improvement in England. London: Department of Health; 2013.
- Wellings K, Palmer MJ, Geary RS, Gibson LJ, Copas A, Datta J, et al. Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000–12: an observational study. The Lancet. 2016.
- Ma R. England’s teenage pregnancy strategy has been a success: now let’s work on the rest. The Lancet. 2016;388(10055):1981.
- Hallgarten L. Abortion narratives: moving from statistics to stories. The Lancet. 2018;391(10134):1988-9.
- Purcell C, Maxwell K, Bloomer F, Rowlands S, Hoggart L. Toward normalising abortion: findings from a qualitative secondary analysis study. null. 2020;22(12):1349-64.
- Maxwell KJ, Hoggart L, Bloomer F, Rowlands S, Purcell C. Normalising abortion: what role can health professionals play? BMJ Sexual & Reproductive Health. 2021;47(1):32-6.
- Engel GL. The Need for a New Medical Model: A Challenge for Biomedicine. Science. 1977;196(4286):129-36.
- Fraser S. The toxic power dynamics of gaslighting in medicine. Canadian family physician Medecin de famille canadien. 2021;67(5):367-8.
- Prather C, Fuller TR, Marshall KJ, Jeffries WLt. The Impact of Racism on the Sexual and Reproductive Health of African American Women. Journal of women’s health (2002). 2016;25(7):664-71.
- Love Sex Life LSL Partnership. Transforming Sexual and Reproductive Health for BAME Communities in Lambeth, Southwark and Lewisham. London; 2020.
- Wayal S, Hughes G, Sonnenberg P, Mohammed H, Copas AJ, Gerressu M, et al. Ethnic variations in sexual behaviours and sexual health markers: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). The Lancet Public Health. 2017;2(10):e458-e72.
- Thomas P. General Medical Practitioners Need to Be Aware of the Theories on Which Our Work Depend. The Annals of Family Medicine. 2006;4(5):450-4.
- Greenhalgh T, Annandale E, Ashcroft R, Barlow J, Black N, Bleakley A, et al. An open letter to The BMJ editors on qualitative research. Bmj. 2016;352:i563.
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- Trickey H. Theorising breastfeeding peer support as intervention in a complex ecological system: lessons for implementation and evaluation in a Welsh context. Cardiff, Wales, UK: Cardiff University; 2018.
- Collins PH. Black feminst tought: Knowledge, consciousness, and the politics of empowerment: Routledge; 2002.
- Ferber A. Sarah Everard’s disappearance is a horrifying reminder that women live in fear of violence. The New Statesman. 2020.
- About the Magdalene Laundries [Available from: http://jfmresearch.com/home/preserving-magdalene-history/about-the-magdalene-laundries/.
- Covington SS. Women and Addiction: A Trauma-Informed Approach. Journal of Psychoactive Drugs. 2008;40(sup5):377-85.
- Collins JC, Zhang P, Sisco S. Everyone is Invited: Leveraging Bystander Intervention and Ally Development to Cultivate Social Justice in the Workplace. Human Resource Development Review.0(0):15344843211040734.
- Adewole I, Gavira A. Sexual and reproductive health and rights for all: an urgent need to change the narrative. The Lancet. 2018;391(10140):2585-7.