Abstract
Although it remains an underresearched topic in the field, counseling psychology can and should play an important role in enhancing individuals’ sexual and reproductive health (SRH), as well as promoting reproductive rights at the systemic level. SRH issues affect virtually all people, especially those whose sexual and reproductive behaviors and identities are stigmatized. In this article, we make the case for the importance of SRH and rights in counseling psychology, and introduce the reproductive justice framework as a means to incorporate these issues into research, training, practice, and advocacy for social justice. We introduce four case studies with a focus on the ways in which restrictions on SRH differentially affect individuals across dimensions of social inequality including race, class, and sexual orientation. Next, we assess the state of scholarship on SRH in counseling psychology. Finally, we offer an action plan for incorporating reproductive justice principles into counseling psychology.
Although it remains an underresearched and underdiscussed topic in the field, counseling psychology can and should play an important role in enhancing individuals’ sexual and reproductive health (SRH), as well as in promoting reproductive freedom at the systemic level. SRH represents a constellation of issues that affect virtually all people, especially those whose sexual and reproductive agency is threatened by stigma, legal action, and policies intended to limit reproductive rights or discriminate against certain sexual behaviors and identities (World Health Organization [WHO], 2009). In this manuscript, we make the case for the importance of SRH and rights in counseling psychology and introduce the reproductive justice (RJ) framework as a means to incorporate these issues into counseling psychology research, training, practice, and advocacy for social justice.
RJ has come to signify a social movement and critical perspective for promoting a comprehensive vision of reproductive agency that links issues of SRH to racism, heterosexism, and economic injustice, among other intersecting forms of oppression. Notably, mental health is central—not ancillary—to RJ. The Asian Communities for Reproductive Justice (2005) group foregrounded mental health in their commonly cited definition of RJ: …the complete physical, mental, spiritual, political, economic, and social well-being of women and girls [that] will be achieved when women and girls have the economic, social and political power and resources to make healthy decisions about our bodies, sexuality and reproduction for ourselves, our families and our communities in all areas of our lives. (p. 1)
SisterSong (2016), the activist collective that founded the contemporary RJ movement, defined RJ precisely as: …the human right to have children, not have children, and parent the children we have in safe and healthy environments. Over the years, we have expanded RJ to include the human right to bodily autonomy from any form of reproductive oppression (“What is Reproductive Justice?”).
Many women and women of color with low incomes face tangible barriers to having and raising healthy children throughout the United States (U.S.). These barriers include the stress and mental health consequences of mass incarceration (Alexander, 2010), targeted neighborhood policing and disinvestment (Lipsitz, 2006; Rios, 2011), discriminatory lending (Chakravartty & da Silva, 2013; Nero, 2005), and environmental racism (First National People of Color Environmental Leadership Summit, 1991; Taylor, 2014). Accordingly, RJ activists’ vision of social justice demands a comprehensive understanding of mental health and health equity in the context of intersecting inequalities.
We argue that counseling psychologists should view themselves as integral to RJ movements because of our field’s focus on individual empowerment, as well as its investment in social transformation (Vera & Speight, 2003). Counseling psychologists have skills that can both address impediments to RJ and promote SRH care as scientists, practitioners, and advocates (Mallinckrodt, Miles, & Levy, 2014). To illustrate the potential role of counseling psychologists as RJ proponents, we introduce four case studies with a focus on the ways in which restrictions on SRH differentially affect individuals across dimensions of social inequality including race, class, and sexual orientation. Next, we assess the state of scholarship on SRH in mainstream counseling psychology. Finally, we offer an action plan for incorporating RJ principles into counseling psychology.
From Reproductive Rights to Reproductive Justice
Both classic and recent political and academic work that falls under the umbrella of “reproductive justice” has contextualized reproductive rights within the matrix of structural inequalities that constrain women’s sexual and reproductive freedom (Collins, 2000; Davis, 1983; Luna & Luker, 2013). Historically, reproductive rights activism in the U.S. focused on women’s ability to not reproduce. Reproductive rights activists campaigned for access to safe contraception and abortion, and much of this activism happened in court cases. Most notable is the 1973 Roe v. Wade U.S. Supreme Court decision that solidified women’s rights to seek an abortion vis-à-vis privacy law. In the wake of Roe v. Wade and continued legal and extralegal attacks on abortion and reproductive health care, affluent non-Latina/o White activists have continued to campaign for access to birth control and abortion—in other words, for the ability not to have children and to engage in family planning, so as to resist efforts to keep women in the household and solely in positions of unpaid domestic labor (Luna & Luker, 2013).
Meanwhile, federal and state governments engaged in various tactics to limit poor women and women of color’s ability to achieve pregnancy and to raise children (Silliman, Fried, Ross, & Gutiérrez, 2004). Eugenics-informed forced sterilization policies, miscegenation laws criminalizing interracial reproduction, and “abstinence only until marriage” curricula (Fine & McClelland, 2006) have all limited women (and men) in their rights to reproduce or have access to scientific information about reproduction, which hinders health literacy. Numerous so-called “neoliberal” (Brown, 2015; Duggan, 2003) policies (e.g., Clinton-era welfare reform, regressive tax policies), which attempted to address social problems with market-focused solutions, have actually exacerbated income inequality. The neoliberal agenda, which has included the privatization of social services, deregulation, and government disinvestment in social welfare programs, has concentrated wealth and produced massive social and economic costs for society’s most vulnerable (see Grzanka, Mann, & Elliott, 2016, for an overview). These policies, in turn, coincide with increased infant and child poverty rates and increased removal of these children from their parents’ care, effectively limiting or eliminating opportunities for women to care for their children. More recently, so-called “fetal assault” bills have criminalized women who are addicted to illegal drugs and controlled substances, disproportionally impacting women of color (Bach, 2016). Despite evidence suggesting that White people use illicit substances at equal or greater rates than people of color, Paltrow and Flavin (2013) determined that people of color are more frequently prosecuted for failing to sufficiently “protect a [sic] fetus,” and the discrepancy in prosecution rates is greatest in the Southeastern U.S.
Reproductive rights frameworks have been criticized for taking a single-axis, gender-first approach (Dill & Kohlman, 2012) that ignores the ways in which reproductive rights are distributed unfairly and asymmetrically among women (SisterSong, 2016). Mirroring women of color’s critiques of mainstream (White, middle-class) feminism (Moraga & Anzaldúa, 2015; Smith, 1980), RJ activists have insisted that reproductive rights and SRH care must be examined and advocated in the context of intersecting systems of oppression that affect women in different ways, particularly women who are multiply marginalized in terms of race, gender, class, sexual orientation, nationality, ability, and other dimensions of difference (Luna, 2016). RJ is both a social movement and a conceptual framework for both (a) examining the weaknesses of single-axis (i.e., gender-first) reproductive rights advocacy, and (b) advancing a comprehensive, radical, and transformative agenda for reproductive freedom.
RJ connects systematic marginalization and disenfranchisement in multiple domains of social and civic life to restrictions on reproductive freedom while highlighting the limitations of narrowly construed reproductive rights advocacy to actually deliver on the promise of reproductive autonomy. For example, RJ work frequently underscores the limitations of reproductive rights’ emphasis on privacy—the right to make medical choices free from public (i.e., government) oversight or intervention. RJ activists argue that privacy itself is a privilege and one that is increasingly scarce in what feminist legal scholar Bach (2014) called the hyperregulatory state, in which “[the state’s] mechanisms are targeted by race, class, gender and place, to exert punitive social control over poor, African American women, their families and their communities” (p. 2). The ability to access SRH care from a private physician privileges the concerns of middle class women seeking contraception and abortion, as opposed to the needs of low income women, who are disproportionately women of color, are chronically under-insured, and whose fertility itself is viewed as a public health problem. In sum, RJ rejects a gender-first approach to reproductive rights that views social justice solely in terms of access to abortion and contraception; instead, RJ prioritizes the intersectional ways in which the freedoms and life chances of women and families are differentially constrained by interlocking structural inequalities, that is to say, reproductive oppression. In the next section, we explore four interconnected issues in one U.S. state. In doing so, we aim to (a) illuminate reproductive oppression, (b) explore these issues’ relevance to counseling, health literacy, and mental health promotion, and (c) introduce ways for counseling psychologists to participate in RJ as a movement and academic framework.
Reproductive Injustice: Four Case Studies
The following case studies are drawn from the state of Tennessee. We focused on these RJ issues in Tennessee for two main reasons. First, although Tennessee certainly has unique characteristics—it is located along the historical border between the U.S. Civil War’s Confederacy and the Union, it has a large population living in poverty in rural areas as well as urban centers, and it is traditionally divided into three distinct regions from East to West—it is in many ways an exemplar of the SRH issues that affect people across the U.S. For example, many states have laws targeting abortion providers, but none has also had a “fetal assault” law like the one in Tennessee. In addition, many states have introduced or passed conscience clauses, yet Tennessee was the first to pass a bill that affects licensed counselors as opposed to trainees. Second, both authors live and work in Tennessee as members of a counseling psychology PhD program (one faculty member, one doctoral student) and as activists in the community. Accordingly, we draw upon our lived experience engaging with these issues academically and in organizing against these laws and regulations in our activist lives to provide both a scholarly and embodied account of these controversies. Although these RJ issues have all manifested in one U.S. state, we explore their consequences with a focus on how they reverberate on a national scale, and how counseling psychologists may use their positionality and unique skills to influence change.
Fetal Assault
In July 2013, the Tennessee General Assembly made it legal to prosecute pregnant women for use of illegal narcotics, punishable as an assault (Tenn. Code Ann. §§ 39-13-107, 2014), which carries a maximum sentence of 15 years in prison. This law, which was the first of its kind to criminalize this behavior (Jeltsen, 2016), has since expired (Burke, 2016) and is no longer active. This law dictated who can and cannot reproduce and on what terms, and produced several negative consequences beyond the threat of incarceration. A RJ lens helps to illuminate how the Tennessee “fetal assault” law and similar juridical efforts harm different women in intersectional ways (Collins, 2000). This law was limited in scope, sanctioning women specifically for use of narcotics while pregnant, despite the well-documented, pervasive use of amphetamines (e.g., crystal meth) within rural Appalachia (Brown, 2010; Tennessee Bureau of Investigation, 2016). American Indian and White people use crystal meth at far greater rates than African Americans and Latina/o within Appalachia (Brown, 2010; Iritani, Halfors, & Bauer, 2007). By targeting narcotics users to the exclusion of amphetamine users, the law may have influenced which women were actually arrested and prosecuted.
The law did include an exception for women who sought treatment before giving birth and completed the treatment (Tenn. Code Ann. §§ 39-13-107, 2014). However, low income women seeking treatment are at a significant disadvantage. There are 177 licensed residential addiction treatment facilities within Tennessee, yet only two provide prenatal care to women and housing for older children of the mothers receiving care. Only 19 of these facilities provide any type of addiction care for pregnant women. Furthermore, many have waiting lists, require women to travel a great distance, and offer only a short, 30-day treatment program (Culp-Ressler, 2014). Fewer still accept the statewide Medicaid program, TennCare. Inadequate access and disparities in access to care place pregnant women using illegal or controlled substances in the state of Tennessee in a double-bind: if they can access treatment at all, they do so with severe limitations—or risk incarceration. The law’s clause allowing for exceptions based on treatment was also troubling because it violates the American Psychological Association (APA) Ethics Code (APA, 2010), which requires psychologists to provide care after informed consent (Hall, Friedman, & Jain, 2015). Women who are compelled into treatment in order to avoid prosecution (and the many collateral damages that occur from incarceration) are not necessarily providing “informed consent” when and if they engage in treatment services. The ethical implications of mandated treatment and right-to-refuse treatment have been debated in medicine and other applied social sciences (Caplan, 2006; Dworkin, 1993; Regehr & Antle, 1997). No consensus has been reached, but it is essential to acknowledge the ethical implications. Although we recognize the responsibility of counseling psychologists as mandatory reporters, we also acknowledge the disproportionate consequences of these laws for people of color. Privacy issues are abundant insomuch as medical facilities can share patient information with law enforcement agencies (Bach, 2014), potentially deterring women from seeking necessary medical services. These laws further violate privacy by giving authority to public health institutions treating pregnant women (Goodwin, 2014). No longer are individual reproductive decisions viewed as a private, individualized matter, but instead as a public health issue to be addressed within political arenas. Women with greater access to privatized health care are less likely to be subjected to these discourses and surveillance of their private decisions than women without access to this care (Bach, 2014). Global RJ issues should be included in public health discussions, yet the specific decisions of individuals should remain private.
Relying on criminal justice systems to solve public health problems has additional implications for women and families. Women who seek medical treatment from their physicians may now have to consider if they will be required to submit to “random” drug tests, and whether the results of these tests will be used to build a legal case against them. Not only does this blur the lines of privacy and confidentiality, but it may deter pregnant women from seeking appropriate and necessary prenatal care for fear of retribution (De Ville & Kopelman, 1999; Hall et al., 2015).
This violation of APA ethics, the inherent violation of privacy and confidentiality for women, and the blurred lines between criminal justice, public health domains, and individual rights to privacy are but a few of the critical reasons that counseling psychologists should be involved in challenging fetal assault laws, as well as supporting the women and families targeted by these laws. These laws represent an opportunity for counseling psychologists to empower women to advocate for themselves by helping them to negotiate complex bureaucratic health care and legal systems. This legislation also highlights the lack of substance use treatment facilities and services for pregnant women in Tennessee. As researchers, we must question why this shortage in treatment providers exists; as advocates, we must seek to increase access to treatment for individuals who are seeking it; and as practitioners, we can increase our own scope of practice to include marginalized groups who otherwise do not have access to care. Furthermore, practitioners must inform themselves about the unique legal and social barriers encountered by pregnant women who are dealing with substance abuse issues to ensure that the care they provide is sensitive to these women’s needs.
Targeted Regulation of Abortion Providers
Targeted regulation of abortion providers (or “TRAP” laws) are policies designed specifically to limit access to abortion. Nearly one-third of women in the U.S. have had an abortion by the age of 45 (Jones & Kavanaugh, 2011), and 21% of pregnancies end in abortion (Jones & Jerman, 2011). In 2015 alone, 57 restrictions were placed on women’s reproductive rights (Markens, 2016), and as of this writing, 44 U.S. states and the District of Columbia have measures in place that subject abortion providers to regulations not imposed upon other kinds of medical professionals (NARAL, 2016). Politicians and antichoice advocates often promote TRAP laws using rhetoric about women’s safety. However, the expressed intent of these laws are to restrict access to abortion, most often by implementing burdensome regulations on abortion providers and clinics, sometimes resulting in clinic closures. The logic undergirding TRAP laws is that, so long as abortion remains legal, regulations can be used to make safe, medical abortion nearly impossible to access for most women.
TRAP laws have been effective in garnering public support because of how they can be discussed in terms of safety and regulation. Although abortion is a safe and legal medical procedure (e.g., fewer than 1% of surgical abortions result in post-operative complications; Totenberg, 2016), TRAP advocates frame these laws in terms of both making abortions safer and protecting women. For example, 26 states now restrict abortion services to hospitals and other specialized clinics (e.g., ambulatory surgery centers). Many other states require abortion providers to have admitting privileges at a local hospital, which are difficult to obtain and nearly impossible to maintain because abortion doctors so rarely admit patients to a hospital. This may sound inconsequential, but the effects of these laws drastically limit abortion access because most abortions are performed in regulated outpatient clinics. In Texas, for example, regulations associated with that state’s House Bill 2 forced at least 22 clinics to close; 10 of the remaining 19 clinics would have closed if the Supreme Court had not struck down the law as unconstitutional (Totenberg, 2016). Because Tennessee is one of the only states in the Southeast to not implement the most aggressive forms of TRAP laws, women throughout the region travel hours to Tennessee to undergo the procedure (Stiller, 2014).
Abortion opponents in Tennessee were successful in implementing a 48-hour waiting period for abortions, which is based on the idea that women seeking abortions have not fully considered their decision and should be forced to wait 48 hours, presumably in the hope that they will change their minds about the procedure or be unable to return for the procedure. We are not aware of any empirical research to support this argument. However, these kinds of waiting periods have been passed in many U.S. states and have profound effects on women seeking an abortion. For example, in large rural states like Tennessee, a woman may drive hours to a clinic only to have to return after 48 hours in order to actually undergo the procedure. By exceptionalizing the procedure, this form of TRAP law can have the unintended effects of increasing the number of surgical (as opposed to pharmaceutical) abortions, because these laws inherently extend the amount of time of the pregnancy. The wait time may also force women to try to abort a fetus using dangerous and unregulated methods.
From a psychological perspective, these laws are based upon, and exacerbate, abortion stigma. Abortion stigma refers to the culturally pervasive ways in which abortion and women who have abortions are devalued, marginalized, and pathologized (Norris et al., 2011). According to Pew Research Center, 49% of individuals in the U.S. think abortion is immoral (Lipka, 2016). TRAP laws—particularly ones in the 28 states that mandate waiting periods after an initial counseling session that may involve providing the woman with unscientific and medically inaccurate information (Richardson & Nash, 2006)—reinforce the idea that women cannot make responsible choices about their bodies. Although abortion can sometimes be a stressful and emotional experience for women, TRAP laws arguably exacerbate these stressors and may have psychological consequences that have yet to be explored empirically (Norris et al., 2011). Some psychologists have researched the psychosocial dimensions of abortion stigma (e.g., Press & Cole, 1999), but more work in this area is needed, particularly work that is guided by the RJ framework. Further, existing research has focused on three primary constituencies affected by abortion stigma: women who have had an abortion, abortion providers and clinic staff, and friends or family of women who have had an abortion (Norris et al., 2011). Virtually no research has explored how abortion stigma affects the reproductive choice-making of women who have not had abortions.
Counseling psychologists can produce valuable research to address these gaps and illuminate the harmful consequences of TRAP laws and the concomitant effects of abortion stigma. In the therapy room itself, counseling psychologists should be aware of TRAP laws that may affect their clients. Being informed about TRAP laws can help therapists anticipate issues that their clients may encounter when seeking an abortion or accessing other kinds of reproductive healthcare. Because abortion is already so stigmatized in the U.S., discriminatory events that occur in the context of TRAP laws may produce shame and humiliation among abortion seekers. Furthermore, therapists adopting an RJ framework should be sensitive to how TRAP laws affect diverse women differently. Poor women, women who work hourly jobs (as opposed to salaried positions), women in rural (vs. urban) areas, women in the Southeastern U.S., young women and girls, and women whose religious communities condemn abortion, may all be differently impacted by TRAP laws.
Long-Acting Reversible Contraception Promotion
Long-acting reversible contraception (LARC), a category of contraceptives that includes intrauterine devices and subcutaneous implants, refers to contraceptive technologies that are inserted in the body for the purpose of preventing pregnancy for up to 10 years (Gubrium et al., 2016). Heralded as a “first line option” for preventing teenage and unintended pregnancy, groups such as the American Academy of Pediatrics (2014), the Centers for Disease Control and Prevention (2015), and the WHO (2014) have issued policy statements promoting LARC, particularly in light of newer, cheaper, and safer forms of the technology that are becoming widely available (Gubrium et al., 2016). Because LARC devices must be inserted and removed by a trained medical professional, do not require the user to do anything besides consent to LARC insertion, and essentially eliminate human error from the contraception process, many perceive LARC to be preferable to other forms of birth control. From this perspective, LARC offers women the freedom to prevent pregnancy affordably and safely, without the burden or responsibility of having to take a pill every day or to use a condom, for example.
RJ advocates have raised concerns about LARC promotion efforts, particularly those that may inadvertently restrict women’s reproductive agency by targeting low income women. For example, as of this writing, 25 U.S. states plus the District of Columbia have developed policies to encourage immediate postpartum insertion of LARC among Medicaid recipients (American Congress of Obstetricians & Gynecologists, 2016). Furthermore, family planning agencies in Colorado and Missouri have received private funding to reduce barriers to LARC among low income, young women by training providers in LARC counseling and insertion, financing LARC provision, and increasing patient caseloads (Secura, Allsworth, Madden, Mullersman, & Peipert, 2010; Secura et al., 2014; Ricketts, Klingler, & Schwalberg, 2014). Little is known, however, about the institutional histories of these policies or how they are implemented. For example, Georgia’s Medicaid policy mandates that the LARC must be inserted within 10 min of childbirth for the service provider to receive full reimbursement for the procedure (ACOG, 2016). The “LARC FIRST” program in St. Louis, for example, describes “patient choice” as a priority, but contradictorily espouses contraception counseling practices that emphasize LARC as the “first-line option” for all women (LARC FIRST, 2016). These and other initiatives raise important questions about the degree to which informed and noncoercive consent is being obtained, as well as the motivation behind the policies themselves. In interviews with states’ Medicaid representatives, Moniz et al. (2015) found that budget concerns, policy implications, and physicians’ guidance were influencing decisions about whether to adopt immediate postpartum LARC insertion reimbursement policies. Notably absent from these interviews were discussions of actual LARC recipients’ experiences both with the technology and with postpartum insertion procedures. Furthermore, by targeting low income women’s reproductive capacities, these policies invoke a painful history of eugenics and forced sterilization in the U.S.
Although LARC promotion discourse is generally characterized by well-intentioned appeals to help young women and families, these efforts warrant investigation of the state’s and nongovernmental agencies’ role in regulating reproductive practices, particularly for society’s most marginalized groups: young, poor, racial or ethnic minority women (Gómez, Fuentes, & Allina, 2014; Gubrium et al., 2016). For example, some LARC promotion efforts (e.g., Memphis-based A Step Ahead Foundation) explicitly distance themselves from other kinds of family planning healthcare, such as surgical and pharmaceutical abortion, whereas others emphasize how LARC reduces abortion (LARC FIRST, 2016). In this case, the desire to help women access contraception but not abortion services may contribute to abortion stigma (Cockrill & Nack, 2013) by signaling that contraceptives are socially acceptable but that abortion is not. Feminist scholars and activists routinely wrestle with these issues and have made important contributions to understandings of reproductive freedom and the policies and practices that best engender women’s reproductive agency. Counseling psychologists are poised to contribute to this work, which has emphasized the complexity of reproductive freedom, including issues of housing, health care, education, race and racism, and social support (that are sometimes reduced into a simplistic conceptualization of freedom of choice; Solinger, 2005). Specifically, because actual and potential LARC users’ voices are so often absent from research and policy debates about LARC (e.g., Moniz et al., 2015), counseling psychologists can and should use their skills in person-centered, strength-based, multiculturally competent, and social justice-focused research to foreground these perspectives where they are otherwise omitted or ignored. In terms of therapeutic practice, counseling psychologists can act as RJ advocates by empowering clients to question physicians’ guidance about LARC and other forms of contraception and to seek information from multiple sources or outlets, including ones that are explicitly feminist (e.g., the New View Campaign) and antiracist (e.g., SisterSong). We do not mean to suggest that psychotherapists should promote skepticism about medical professionals; however, our own anecdotal experiences suggest that health care providers routinely provide misinformation about contraception, including LARC. Amid increasingly pervasive LARC promotion, informed skepticism about LARC—which is not the same as blanket opposition to LARC—may indeed be one strategy for promoting RJ in direct service provision settings.
Conscience Clauses
In 2016, Tennessee joined the ranks of several other states (Tenn. Code Ann. § 63-22-302, 2016) to indoctrinate alleged “conscience clauses,” laws that allow therapists to refuse services to a client if they can demonstrate a conflict with their own “sincerely held principles” (Tenn. Code Ann. § 63-22-302, 2016), as long as they refer the client to another provider. This law, and others like it, is of paramount concern as it directly enables discrimination of particular populations, hinders the client’s access to appropriate and necessary care leading to injustice in care, and makes it difficult for training programs to produce competent practitioners.
Tenn. Code Ann. § 63-22-302 (2016) and similar laws contribute to the discrimination of already marginalized groups, allowing professionals to withhold and refuse services from individuals or groups on the basis of personally held principles, including religious beliefs. Although the conscience clause in Tennessee demands that a referral to an alternative provider be made, there is no guarantee that a referral can be made to a reasonable, affordable, and geographically proximal provider. Given the considerable rural population in Appalachia, this can have even greater implications. Insurance regulations and lack of insurance or other financial resources make it difficult to find affordable counseling and psychotherapy. This issue is compounded if the client is seeking a therapist who shares a marginalized identity or who specializes in issues affecting members of marginalized populations. These practical implications that can impede individuals’ ability to obtain services, coupled with the stark contradictions between the law and the ethical code presiding over many of these service providers, make this law inherently unjust. Due to the discriminatory nature of these laws, national organizations including APA (2016) and the American Counseling Association (ACA, 2005; Rudow, 2011) have issued statements rebuking the direct conflict with their ethics codes, specifically the ethical obligation of nondiscrimination and avoiding harming a client (APA, 2010).
As we noted previously, the WHO (2009) found that agencies that provide reproductive health services for women rarely include mental health services within their treatment models, despite the fact that there is evidence to suggest that many areas of SRH intersect with mental health. We know that there are many links between SRH and mental health, but much of this information comes from studies of married women of childbearing age living in developed nations (WHO, 2009). There is a dearth of research on the connections between mental health and SRH for low income, single, heterosexual women, and there is even less evidence about the relationship between LGBT-identified individuals’ and heterosexual men’s SRH and mental health. Counseling psychologists, therefore, should be well-versed in SRH issues and should be open to addressing (and contributing to the empirical literature) on the lesser-known but still relevant mental health issues related to sex and reproduction. Although research indicates that women who choose to have abortions do not have increased mental health concerns compared to women who do not make this choice (APA Task Force on Mental Health and Abortion, 2008), the sheer frequency with which women in this country have abortions (Jones & Jerman, 2011; Jones & Kavanaugh, 2011) also demonstrates the increased need for mental health professionals to be competent in SRH issues.
Abortion stigma is considered a “concealable” stigma that is unknown to others unless otherwise disclosed (Quinn & Chaudior, 2009). This concealable identity also complicates issues related to the conscience clause laws. The conscience clause may be invoked by a therapist upon the initial meeting with a client, but it is possible that a therapist may not realize the conflict between their own beliefs and the client’s concerns until several sessions into the relationship. It is unethical to discriminate against any client (ACA, 2005; APA, 2010), but it becomes even more unconscionable to terminate an existing client-therapist relationship. Refusal of treatment for any individual who has made a choice to have or is considering an abortion not only contributes to discrimination but also serves to perpetuate the cycle of abortion stigma and discounts the importance of multicultural competency and strengths-based counseling that is so integral to counseling psychology. Furthermore, the current law (Tenn. Code Ann. § 63-22-302, 2016) creates discrepancies between previous laws that give public education institutions the freedom to determine pedagogical protocols and curriculum standards free from political interference (Ward v. Polite, 2012; Ward v. Willbanks, 2010). The Tennessee law and others like it also serve to widen the gap between mental health and SRH, a gap that counseling psychologists should already be working to reduce.
Integrating Reproductive Justice in Counseling Psychology: A Plan of Action
Prior to developing our recommendations for integrating RJ into the field of counseling psychology, we conducted a theoretically driven review of the literature by analyzing all articles (N = 46) published in Journal of Counseling Psychology (JCP; n = 18) and The Counseling Psychologist (TCP; n = 24) that included the word “abortion” as of July 2016. Although RJ is not just about abortion, abortion research offered a place to start to consider the place of SRH issues in counseling psychology. The vast majority of these articles were not about abortion per se, but included the word, usually in parentheses, in reference to a controversial issue in counselor training (e.g., Mintz et al., 2009; Williams, Judge, Hill, & Hoffman, 1997) or to a spiritual and/or religious conflict for clients (Cragun & Friedlander, 2012; Frieberg & Bridwell, 1975; Illfelder-Kaye, Lese-Fowler, Bursley, Reyes, & Bieschke, 2009; Rose, Westefeld, & Ansely, 2001). Other articles reference (e.g., Boyraz, Horne, Owens, & Armstrong, 2013) or analyze abortion as a form of trauma (e.g., Anders, Frazier, Shallcross, 2012; Freiberg & Bridwell, 1976; Kahn-Edrington, 1979), even when the authors acknowledge that not all women may experience trauma (Frazier et al., 2009). Referencing abortion as a form of trauma or framing research questions so as to infer a traumatic experience ignores the empirical research indicating that the vast majority of women report that they made the correct decision in choosing to abort (Rocca et al., 2015), and perpetuates abortion stigma.
Two articles (Goodyear, Newcomb, & Locke, 2002; Newcomb et al., 1998) in JCP that either reference abortion or abortion statistics focused on Latinas’ reproductive and sexual practices, particularly rates of HIV contraction, sexual risk-taking, and teenage and unintended pregnancy. Both articles reproduce ideas about Latinas’ reproductive practices that are challenged by the RJ framework. For example, Goodyear et al. (2002) focused on psychosocial factors impacting whom Latinas select to have children with, but failed to address racism, xenophobia, or other forms of structural inequality that shape Latinas’ social locations in the U.S. (what they reduce to “neighborhood”). They reiterated widely circulating statistics about pregnancy rates among Latina girls, but failed to attend to critiques of the ways that public health- and ethnic studies-informed research has problematized the meanings derived from these statistics (see Gómez et al., 2014; Mann, 2013).
Four older articles published in the 1970s explicitly stigmatize abortion. One article (Freiberg & Bridwell, 1976) suggested that some women may not be able to effectively negotiate their reproductive health care choices, ignoring the complexity of emotions that women may experience around deciding to have an abortion by implying that women who are “assuming a very nonchalant posture” (p. 50) toward the decision may be denying the pregnancy ever existed. Another article posited a priori that abortion is a fundamentally difficult decision to make (Luscutoff & Elms, 1975), whereas similar publications during this time period further perpetuated abortion stigma by stating that women who have had multiple abortions “have less favorable personality structure” (Kahn-Edrington, 1979, p. 38) and describing a woman’s search for birth control as a disguised search for “counsel as to whether she should be sexually active” (Freiberg & Bridwell, 1975, p. 110). It is unfair to critique historical research by contemporary standards, but we should still engage the academic work that precedes us and interrogate the ideological underpinnings of science. Each of these articles devalues women as autonomous beings and oversimplifies inherently complex issues.
In sum, the scant literature in two of the field’s leading journals fails to substantively engage SRH as an issue central to counseling and mental health, much less as a social justice issue that affects women and families in differential ways according to stratified access to safe, affordable, and nonstigmatized health care and SRH knowledge. This does not mean that counseling psychologists are not doing any of this work, but it does mean that it is not being published in the mainstream venues of the field. Notably, we also searched more explicitly the social justice-focused journals in counseling (e.g., Journal of Social Action in Counseling and Psychology) and found similar results, namely an absence of research on SRH. Based on our review of the issues and our identification of a substantial gap in the mainstream counseling literature on SRH issues, we assert that counseling psychologists should turn their attention to SRH as an important social justice issue that implicates mental health and intersecting social inequalities. Furthermore, we contend that the RJ framework—which links abortion access and reproductive freedom to other social and economic issues affecting marginalized women and their families—offers a path forward that is consonant with counseling psychology’s commitment to empowering clients and promoting positive social change. In order to begin integrating RJ into counseling psychology, we offer several action items in the section that follows.
Challenge Multidimensional SRH Stigma With an Intersectional Lens
Take an intersectionality-first approach
In order to integrate RJ into the field, counseling psychologists must fully integrate intersectionality into their understanding of SRH (Grzanka, 2014; Grzanka & Miles, 2016; Moradi, 2017). SRH is typically discussed as a woman’s issue, despite the obvious fact that (a) no individual woman’s behavior occurs without interconnectivity with other individuals in her social networks (e.g., parents, other children, spouse or partner, friends, treatment providers); (b) cisgender women are not the only people who get pregnant, contract sexually transmitted infections, plan families, etc.; and (c) SRH issues intersect with race, socioeconomic status, religion, and other dimensions of difference. We must recognize that any individual seeking mental health services has potentially been impacted by SRH stigma, and we should have the appropriate knowledge and skills to treat the great variability in clientele seeking to discuss heterogeneous SRH issues. Once again, it is critical to review our preconceived ideas about SRH issues and expand these preconceptions to include cisgender men and women, as well as transgender and gender nonbinary individuals. Likewise, research on SRH can and should be expanded to reflect the diversity of experiences different individuals, not just (White) women, may have with reproduction. Even among the many women who have an abortion, for example, the experiences vary greatly (Major et al., 2009). As researchers and therapists, counseling psychologists are uniquely situated to recognize and challenge the intersecting systems of oppression constraining reproductive choice making. This means acknowledging not only clients’ multidimensional identities, but that cultural competency in an RJ framework means gender- and sexuality-related issues may not always be the exclusive or even central issues affecting clients’ reproductive decision making, and that gender and sexuality are always coproduced by other dimensions of privilege and oppression (Collins, 2000; Luna & Luker, 2013).
Give voice
Much of the literature about abortion in particular, including several articles from JCP and TCP (see previous section), reference abortion briefly as a controversial issue or potentially traumatic experience, despite research to the contrary (APA Task Force on Mental Health and Abortion, 2008; Pope, Adler, & Tschann, 2001; Reardon et al., 2003; Reardon & Cougle, 2002; Rocca et al., 2015; WHO, 2009). Abortion stigma, not the abortion itself, can contribute to negative mental health outcomes (Crocker, Major, & Steele, 1998; Major & Gramzow, 1999) and can be experienced as internalized stigma, felt stigma, and enacted stigma (Cockrill & Nack, 2013) that exists within a system of inequality (Kumar, Hessini, & Mitchell, 2009). This pervasive stigma creates a cycle of discrimination and marginalization for many affected by abortion (Cockrill, & Hessini, 2014; Coyle & Rue, 2015). However, abortion is just one aspect of SRH-related stigma. As counseling psychologists study and teach about SRH, it is paramount that we carefully analyze our language so as not to perpetuate stigma about SRH, including sexually transmitted infections and non-normative sexual practices. Practitioners may also incorporate narrative approaches to therapy to help change the stories of stigma to ones of agency and empowerment, as advocates have done via storytelling (e.g., abortion storytelling projects, including the 1 in 3 Campaign and the Tennessee Stories Project). Indeed, with an explicit RJ focus, Perry (2015) referred to storytelling as a tool for intersectional mobilization. Furthermore, storytelling is consonant with social justice principles in counseling that emphasize giving voice to clients’ experiences, especially to clients whose voices have been systematically ignored (Goodman et al., 2004).
Promote and Advocate RJ
Centralize SRH in training
A general commitment to resisting abortion stigma in therapy, research, and teaching is not enough to actualize RJ. Psychotherapy training, including continuing education, should include SRH issues comprehensively and multidimensionally, because otherwise we may inadvertently contribute to SRH stigma through silence and ignorance. SRH issues are constantly changing across legal, structural, systemic, medical, and cultural registers of social life (Jozkowski & Crawford, 2016). To be competent therapists, teachers, supervisors, researchers, and advocates, we must understand the contemporary landscape of SRH issues that affect women and families as well as be sensitive to inevitable changes in this landscape. As we have outlined previously, we assert that SRH issues are central—not marginal—to mental health and to a social justice-focused counseling psychology.
Expand our competencies
Development of multicultural competencies has been a hallmark of counseling psychology (Vera & Speight, 2003) and continues to be a guiding principle in training (Toporek, Gerstein, Fouad, Roysircar, & Israel, 2006). APA adopted the multicultural competencies proposed by Sue, Arredondo, and McDavis (1992) and emphasized that multiculturally competent counselors have the ability to appraise their own values and attitudes, are knowledgeable about diverse populations and treatment approaches, and have developed skills for working with a wide range of clients. Arredondo and Toporek (2004) discussed these competencies as necessary for ethical treatment in practice, while also providing recognition that the competencies are and should be an evolving list to include necessary sociopolitical changes. Accordingly, we recommend that an intersectional perspective on SRH be considered a new competency under the multicultural umbrella, because the RJ movement has demonstrated both (a) the ways that systems of inequality shape individuals’ experiences of SRH, and (b) the pervasive ways in which SRH informs virtually all areas of social life (Luna & Luker, 2013). In short, we cannot opt out of SRH issues if we hope to provide genuinely competent and affirmative counseling and psychotherapy.
Clients often seek information from counseling psychologists given our positions of authority. In the interest of empowering clients and promoting health literacy, it is vital that the information we provide is accurate and comprehensive, and that we can refer clients to accessible resources that offer other perspectives. Counseling psychologists should also work to normalize SRH and conversations about these issues through careful attention to word choice and terminology that does not make assumptions. As with all our clients, we should wait to hear their individual story, normalize their cognitive and affective responses, and share information with clients about the frequency with which SRH issues occur and the responses that they are having. This can also aid in the destigmatization of SRH within the therapeutic context (e.g., Ely, 2007) and in social life more broadly. As we continue to use appropriate, unbiased language, we may also focus on a nonjudgmental and compassionate stance. Stigma develops from the sociocultural context of the issue (Major et al., 2009), and counseling psychologists can help clients understand this context and how it has helped to develop internalized stigma.
Promote SRH across our roles
It is well documented that many people who are seeking SRH care often are unable to receive comprehensive health care, including care for both SRH issues and mental health (WHO, 2009). Often, individuals seeking mental health care must find these services from other providers, if they can find them at all. Recent conscience-clause legislation allowing therapists to discriminate on the basis of strongly held beliefs further limit individuals’ opportunities to find appropriate counseling services (see previous section). In advocating for the inclusion of SRH issues as a component of multicultural competency development for all practitioners, we are attempting to affirm counseling psychology’s commitment to discrimination-free counseling and psychotherapy. Conscience clauses and right-to-deny-services legislation are attempts to write discrimination into the discipline. Regardless of any counseling psychologists’ “deeply held beliefs,” we must actively challenge the normalization of stigma and discrimination in the field, including abortion stigma. Although advocacy around the counseling discrimination law in Tennessee focused on potential discrimination against LGBT clients, we recognize that this law (and similar legislation in other states) also enables discrimination against women who have had or are seeking an abortion or other SRH care services. We must be vigilant in opposing any attempts to further entrench stigma in society and in our field. Just as counseling psychologists routinely speak out about issues of racial injustice (e.g., Adair et al., 2015), we should work to support the RJ movement. We occupy privileged positions as academics and therapists and we recognize that community work is fraught with complex power negotiations (e.g., Luna, 2016), yet these are not reasons to excuse ourselves from this work. Just as lawyers and physicians have been vocal advocates for expanding reproductive freedom, counseling psychologists should join the conversation and leverage our skills and expertise in the interest of RJ.
Collaborate With Other Health Professionals and Activists
Forge interdisciplinary coalitions
Consonant with widespread trends in health care that signal a move toward integrative care, counseling psychologists should conceptualize themselves as integral rather than ancillary to SRH care concerns. Because of rampant stigma about contraception use, family planning, and women’s sexuality more broadly, as well as the persistence of abstinence-only education that obstructs health literacy (Elliott, 2014; Fine & McClelland, 2006), counseling psychologists should work with other health care professionals, including community health organizers and activists (Luna, 2016), to combat reproductive oppression. Treating SRH and mental health services as distinct may exacerbate reproductive oppression for a number of reasons. Often, agencies providing SRH services do not include mental health care (WHO, 2009), even if they involve some form of state-mandated preabortion counseling (Richardson & Nash, 2006). Social workers have investigated how a feminist approach to preabortion counseling can transform the experience into one that is nonpathologizing and even empowering (Ely, 2007). Likewise, many counseling psychologists are now trained to (a) contextualize health care issues in terms of intersectionality, (b) focus on women and girls’ strength and agency in the family planning process, and (c) depathologize sexual and reproductive practices that may otherwise be misunderstood or stigmatized within the health care system (e.g., gynecological and obstetric services for transgender men, unique issues facing LGBT people of color). Collaboration with social workers, community psychologists, and RJ activists can illuminate the ways in which counseling psychologists can leverage their skills in both familiar (i.e., clinical) and unanticipated settings.
Learn from our clients, participants, students, and each other
Although access to safe, legal, and nonstigmatized abortion is certainly paramount to reproductive freedom, RJ perspectives illuminate how abortion access is not the only dimension on which reproductive agency is stratified. For many women, especially low income women and women of color whose reproductive practices have been historically surveilled, regulated, and controlled by the state (Bach, 2014; Davis, 1983), access to family planning services and the ability to have a child may be just as important as access to safe abortion services. Counseling itself may be part of RJ for women who need a safe and nonjudgmental space to discuss their goals, fears, and hopes for having or not having children (e.g., Ely, 2007). Our clients, students, community members, and research participants (particularly those who are members of multiply marginalized groups) are key informants whose experiences of reproductive oppression can inform counseling psychology’s place in the RJ movement—which leads us to our final point and conclusion.
One of the best ways to actualize these goals is to start producing critical, RJ-informed knowledge about SRH and reproductive oppression. Psychologists have done some of this work already, yet little of it is grounded in a critical, social justice-oriented perspective, which counseling psychologists can offer. Our hope is that RJ will not only inform counseling psychologists’ work with women and families encountering obstacles to reproductive freedom, but that more counseling psychologists will ultimately become change agents and active contributors to the movement for comprehensive RJ.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.