This edition of the Recently Published Book Spotlight is about Jill Delston’s book Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care. Jill B. Delston is an associate teaching professor of philosophy at the University of Missouri-Saint Louis. She co-edited a textbook with Larry May entitled Applied Ethics: A Multicultural Approach (editions 5 and 6). Medical Sexism: Contraception Access, Reproductive Medicine, and Health Care is her first monograph.
Why did you feel the need to write this work?
One reason that I thought this project was worth exploring in a book length treatment was the parallel I found between contraception restrictions and other related areas of medicine like abortion restrictions. In the paper-length version of this idea, I was only able to touch on this connection and point in its direction. In fact, in the paper, I merely listed potential implications including abortion policy. Writing the book allowed me to address those issues head on.
I also found that I had to discuss contraception in order to make sense of abortion, and that I had to discuss abortion in order to make sense of medical decisions in prenatal care, labor, and delivery. In the end, I spent about as much time on issues outside of contraception access as I did on contraception access itself and found all these areas incredibly interconnected. Because infantilizing female patients explains how overriding their autonomy with paternalistic practices could become so widespread, I was able to use the motivating case study as a lens to view a much wider array of issues.
For example, when it comes to abortion policy, many argue that limitations on the bodily autonomy of predominantly female patients is required due to the moral status of the fetus. But we see the same behaviors, reasoning, and restrictions in contraception access, before the fetus exists. I argue that a common thread exists between these policies, and it shows that abortion policies are not about the fetus at all. This discussion of abortion also sets the stage for an analysis of phenomena surrounding labor and delivery, in which the fetus is also used as justification for overriding patient preference. If advocacy for legal abortion in the first trimester were to rely on the idea that fetuses in the first trimester have no moral status, that argument may lead not only to the idea that abortion in other trimesters is impermissible but also that we can override patient preference in labor and delivery, in which the status of the fetus looks a lot more like born babies.
Thus, neither abortion policy nor labor and delivery policy are actually about protecting the bodily autonomy of the pregnant person. These restrictions do not arise because pregnant person has bodily autonomy in the beginning of a pregnancy and loses it at some point, but rather reflect the view that respect for bodily autonomy never existed. I then use these arguments in turn to shed light on policies overriding patient preference surrounding contraception.
How is your work relevant to everyday life?
I think medical sexism is profoundly connected to everyday life. First, medical sexism is an instantiation of broader societal problems many vulnerable populations face. Hence, belonging to one of those groups makes the topic of direct personal relevance. Second, reproductive autonomy is closely connected to other issues of liberty, from security and economic well-being to the right to refuse treatment and bodily integrity. The current pandemic might even demonstrate some of these inequities. If doctors find greater risks in bringing patients into the office for yearly tests than in prolonging a prescription, then decisions to prescribe contraception highlight the fact that the tests in question were never necessary or standard of care. Or, decisions to continue requiring patients come in for these tests despite apparent risks further highlight the need for other options. Third, I found medical sexism in every area of health care I explored, so no matter what issues arise in the medical field or what preventative measures are needed when healthy, these issues are bound to connect to individual experience.
In fact, these issues are so woven into the fabric of our society that while medical sexism makes certain problems seem intractable, it also means that a highly focused attack on injustice can have far-reaching implications. I hope that this consideration will help readers interpret my message as empowering rather than diminishing. Identifying injustices and naming them as such can give us the tools to remove obstacles to patient autonomy and solve these problems. The fact that injustices in contraception access can relate to abortion access and labor or delivery care might make the issue seem too complex to solve. However, the interconnected policies also mean that opposing the injustice in one area of reproductive care can have positive impacts on other related areas.
Your reference to bodily integrity and economic well-being introduces the importance of relative material equality to overcome sexism. What practices make this hard to achieve, and does your book offer any solutions to it?
One consideration that makes the intersection between classism and sexism problematic is that they reinforce each other. A precarious economic position makes sexist treatment difficult to overcome because it limits options for recourse and leaves patients at the mercy of unfair treatment. Sexist treatment can also have negative financial implications. I argue that sexist treatment can lead to both overtreatment and undertreatment, and both have negative financial repercussions. Overtreatment can lead to expensive and unnecessary testing, but undertreatment can also be expensive because it can lead to greater and more expensive medical problems at a later stage. Similarly, it is easier to economically exploit populations that are already vulnerable. For example, a larger share of minimum wage earners are women even though men make up a larger share of the work force overall. Longer and more expensive appointments burden hourly workers more than salaried ones. Shopping around for a doctor and dealing with extra tests are easier for more economically privileged patients. Thus, medical sexism can exacerbate poverty and poverty can exacerbate medical sexism.
I find people often pit these concepts of sexism and poverty against each other rather than view them as connected. In other words, a concern is that a particular unfair action cannot possibly be sexist because it is instead classist. I make the case that many such unfair actions are both. These connections are ultimately what attracted me to study intersectional feminism, since it offers a unifying theory rather than attempting to solve societal injustices in distinct silos and is also sensitive to the complexities in injustice.
That is one reason why neat solutions are going to be difficult. Gaining reproductive autonomy is not going to magically solve poverty; people are not poor because they have too many children but rather because of structural injustices. Still, I argue that some injustices continue in part because we do not realize that they are injustices at all and so philosophical analysis can help make progress on a solution. For example, doctors continue requiring cancer tests for contraceptive prescriptions without realizing this action exemplifies a paternalistic attitude toward patients. Similarly, patients typically view cancer screenings as a normal part of care without realizing that they are getting tests at a far more frequent rate than the science suggests is valuable or without asking why such screenings are paired with birth control.
If I can make the case that these practices violate medical malpractice law, informed consent, patient autonomy, the doctor -patient relationship, and human rights, then it will be much easier to eliminate them. And, if I can further show how these same violations are at stake in other areas of health care, demonstrating the pattern of medical sexism, then we can better address the cause of mistreatment rather than the symptoms.
Do you see any connections between your professional work and personal life? I find personal stories can be more compelling, inasmuch as it helps us to connect abstract or impersonal statistics to the events we see everyday. Would you be willing to share one of your stories, or an example of medical sexism you’re aware of, in order to illustrate more clearly how sexism manifests itself in the medical field?
The first few times I got this question, or variants on it, I didn’t directly answer. I think I avoided answering it for a few different reasons, even though I found trading stories with people who shared their experiences of medical sexism with me with me in private to be a bonding experience. My medical history is deeply personal and for that reason hard to share. One worry I had is that sharing my experience of medical sexism would undermine my authority. Would my book be seen as a personal vendetta, or could it even be viewed as a memoir instead of a piece of philosophical argumentation if I shared the medical sexism I faced? That tension between research and memoir is one that scholars, and perhaps especially feminist philosophers and other philosophers working on matters of social justice, grapple with and discuss a lot. For example, Julia Serano in Whipping Girl, bell hooks in Ain’t I A Woman, Betty Friedan in The Feminine Mystique and others discuss this issue explicitly and differentiate their own scholarship from memoir or autobiography. In fact, I think some people might feel a double bind when answering this question, in which they are damned if they do and damned if they don’t. If they do not answer, they are dodging the question, being defensive, minimizing personal experience, or making their research less relatable or less accessible. If they do answer, their work is discounted as merely anomalous, subject to confirmation bias, or they are discounted as another angry feminist.
Another concern I had about personalizing my work was that it would make it seem like my book was anecdotal instead of based in data. The fact is, I did not write the book because of my personal experience. I wrote it because medical sexism is a large and systemic problem. In fact, my own experience is really a distraction from the issues of the book. Sharing what happened to me in the labor and delivery room, for example, which I experienced as medical sexism, might lead people to debate whether what I experienced there really was wrong. But ultimately, the determination on what happened giving birth to my children is not relevant to my argument, because I’ve collected work and studies on this issue, and subjected it to moral analysis. Data, not anecdotes, are what justify the conclusions I make.
In addition, suggesting that it’s relevant that I experienced medical sexism might imply that this issue is only relevant to those who have personally experienced it. There is also a danger of suggesting that a phenomenon is only a problem if you have experienced it; the implicit flip side of that suggestion is that if you have not experienced it, it must not be a problem. And sometimes I hear comments phrased in just that way (“I have not experienced this, so it must not be a problem”).
With that long preface, the answer is yes, I have experienced many of the phenomena described in the book. Even deciding to have children in a state as restrictive as Missouri felt extremely dangerous. If my pregnancy threatened my life, would an ambulance take me to the nearest hospital instead of one that would protect my rights? Would doctors at the hospital allow me to die instead of giving me a life-saving abortion if I wanted one? These questions worried me particularly in the middle of my pregnancies—after the first trimester but before the fetus is viable and delivery could remove the medical threat.
It took me a long time to see how the issues I noticed in the medical field could possibly be incorporated into my research. Doctors have required me to get a Pap test and a pelvic exam before they would prescribe birth control to me in every state and in every city I’ve ever lived. But I remember on one particular occasion, lying awake thinking about it, indignant, and I ended up writing the entire first draft of the paper in the middle of the night. That paper became a talk at the APA Central, which in turn became a book proposal and a journal article. Ultimately, that’s why I am answering the question here, even though it’s difficult to talk about. The fact that I have experienced medical sexism shows the need for a diverse faculty in philosophy to draw attention to the diverse set of moral problems that philosophy can elucidate.
How has your work influenced your teaching?
The semester my book came out, I was teaching a biomedical ethics class, a feminism class, and two applied ethics surveys. Each of these classes cover topics connected to the themes of the book. I enjoyed teaching related issues, and judging by the final paper submissions, my presentation of certain dilemmas was reflected in student interests. That’s not to say it was easy. Students often ask me my opinion on the topics I teach—what’s my view of abortion, am I vegan, which moral theory do I subscribe to, and the like. I take these questions as a compliment, but I don’t want students to think they are being judged on their conclusions instead of their arguments. I believe there are right answers to these moral dilemmas and that the answers are incredibly important. But for teaching philosophy, the conclusions they come to are less significant than the reasons they offer to get there. And, as the motto of my philosophy department at UMSL says, “we have the questions for all your answers.” If my students think I will judge their essays on the conclusions they come to instead of the arguments they give, then the class becomes a less effective tool in teaching critical thinking, moral philosophy, and arguments. I love pointing out in class how Mary Anne Warren and Don Marquis, who are on opposing sides of the abortion debate, both spend time arguing against people who come to the same conclusions they do. Warren, who is pro-choice, argues against popular pro-choice positions because it’s not enough for her that someone comes to the same conclusion as she does. If they do so for the wrong reasons, she wants no part of it. Marquis engages in the same exercise, arguing against other common antiabortion views. The time they spend arguing against people who agree with them shows how significant it is not just to come to the right conclusions, but also that those conclusions are justified in the right way. In my book, I argue that both of these articles get the abortion debate wrong, but I still teach them in the classroom. Similarly, I also enjoy the exercise in the classroom of taking two authors who are seemingly on opposite sides of the political spectrum and who hold opposing views and showing how much they are in at least partial agreement. So, writing a book on the very issues I teach, especially one that could be perceived as incendiary, certainly could have posed obstacles, but I found it fun.
More than the ways in which my work has influenced my teaching, however, my teaching has influenced my research program on a very deep level. I set out to write exclusively on social and political philosophy, but as a teaching professor, I felt I had a responsibility to work on the issues central to my teaching. I was also spending more time thinking about the issues I teach than I would have otherwise. And once I started working on bioethics and other applied ethics issues, I found it interested me more than I anticipated. I love teaching applied ethics classes because I think the questions matter and that they matter a great deal. What if the whole world hangs in the balance over what you eat for breakfast? What if we get human rights wrong because we have not taken a multicultural approach? I enjoy teaching these issues for the same reason I enjoy exploring the answers to the questions in research: I care about the answers. The bibliography for this book reads at times like the reading lists in my syllabi. The time I spent teaching some of the sources I use in the book was enormously helpful in understanding the issues I set out to explain. I don’t think I could have or would have written the book I did without my teaching.
What’s next for you?
I have other projects in feminist bioethics that I am pursuing and that are connected to the themes of the book. For example, I’m running an empirical study with a local Ob/Gyn, Dr. Amy Ravin, that seeks to test the accessibility of patient access to contraception. I am also using the topics in my book to help gain traction on related areas of biomedical ethics, specifically the ethics of precision health. On the one hand, ethical considerations might limit opportunities for research in precision health by ruling out proposed studies as exploitive or otherwise morally problematic. On the other hand, ethical considerations might open up new opportunities for research by showing what types of questions have been historically overlooked for morally questionable reasons.
I’m also interested in other issues of applied ethics. Right now, I’m also working on a paper on microinequities. Specifically, I’m interested in the ethics and politics of microaffirmations. I hope that by drawing attention to the unjust distribution of microaffirmations in addition to the more commonly discussed unjust distribution of microaggressions, I can show how some populations are disproportionately impacted and harmed in ways that are sometimes overlooked. I hope that I can spend more time on research related to that topic, both quantitative and qualitative.
You can ask Jill Delston questions about her work in the comments section below. Comments must conform to our community guidelines and comment policy.
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The purpose of the Recently Published Book Spotlight is to disseminate information about new scholarship to the field, explore the motivations for authors’ projects, and discuss the potential implications of the books. Our goal is to cover research from a broad array of philosophical areas and perspectives, reflecting the variety of work being done by APA members. If you have a suggestion for the series, please contact us here.
