Elsevier

Contraception

Volume 87, Issue 1, January 2013, Pages 11-16
Contraception

Commentary
Physicians, abortion provision and the legitimacy paradox

https://doi.org/10.1016/j.contraception.2012.08.031Get rights and content

Abstract

Physicians who provide abortion care are targets of stigma, harassment and violence. As a result, many providers do not speak openly about their work. We hypothesize that stigma and silence produce 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 reluctance to disclose abortion work, and the cycle continues. We call this phenomenon a “legitimacy paradox.” The paradox is that although many highly trained, legitimate physicians provide abortion care, abortion providers continue to be depicted as illegitimate, deviant or substandard doctors. The legitimacy paradox has adverse consequences for abortion human resources, for women's experiences of abortion care and for abortion law and policy.

Section snippets

Two centuries of marginalization and negative representation

Depictions of shady, disreputable and greedy “abortionists,” date back to at least the 1800s when such images were deployed in the effort to make abortion illegal [6], [7]. As historians have documented, physicians were among the most vocal advocates for the criminalization of abortion [6]. The American Medical Association (AMA) opposed abortion in part because unsafe practices harmed women but also because it was a good business strategy. Midwives, osteopathic doctors, homeopathic doctors and

Contemporary stigma and stereotypes of moral and technical deficiencies

The stereotypes embodied in contemporary law also impact physicians’ day-to-day provision of abortion care. In the course of our efforts to understand the meanings of abortion work for those who do it, we carried out a series of six 2-h focus groups over a 3-month period in 2007–8, at a Midwestern reproductive health clinic that offered abortion care. The methods for this study have been previously described in detail [1]. Briefly, seventeen workers in all job categories participated, including

Consequences of stigma: violence and silence

Stigmatizing, negative images of abortion providers may also contribute to violence, harassment and other acts of domestic terrorism. Since the National Abortion Federation began collecting data in 1977 in the United States, eight abortion workers have been killed, and there have been 17 attempted murders, over 400 death threats, 41 clinic bombings, 175 arsons as well as other kinds of attacks on clinics and providers [17]. Sociologists and psychologists tell us that stigma can lead to violence

Stigma+silence=legitimacy paradox

We suggest that stigma and silence work together to distort the image of abortion providers, and to create a vicious cycle in which erroneous, negative images of providers are perpetuated, and rarely or never dispelled. We base this assessment in part on Kumar et al.'s [2] conceptual work on the distorting effects of stigma and silence for women who seek abortion. As they describe, women's silence about abortion experiences leads to the broad misperception that abortion is unusual or deviant.

So what?

The significance of the legitimacy paradox needs to be measured by its potential impact on women and families who use — or may at some time use — abortion services. Indeed, the legitimacy paradox likely impacts the availability of abortion services in multiple ways: Negative images of abortion providers in popular culture (or negative internalized self-image) may deter some physicians from providing abortion care, contributing to provider shortages. For those who ultimately do provide abortion

Acknowledgment

The authors would like to thank Emily Youatt, Meghan Eagan and Stephen Harris for helpful comments on earlier drafts of this manuscript. This paper was based upon research funded by the Society of Family Planning. The views and opinions expressed are those of the authors and do not necessarily represent the views and opinions of the Society of Family Planning.

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      Doctors who perform abortions have long been targets of harassment, threats, and violence to deter them from providing their services and discourage others from entering the field [1,2]. These doctors have also been subjected to inaccurate, inflammatory rhetoric about their competence [3]. Online platforms and public records laws present additional avenues for harassing and vilifying doctors and disseminating their personal information [4,5] in a practice known as doxing.

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    The work was funded by the Society of Family Planning (SFP). The views and opinions expressed are those of the authors and do not necessarily represent the views and opinions of SFP.

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