Structural Racism and Sexual and Reproductive Healthcare Experiences: A Qualitative Study among Undocumented Asian and Latina

Abstract

Structural racism in sexual and reproductive healthcare (SRH) has been linked to poor quality of maternal care among Black and Latina groups. Few studies have captured this from the perspective of undocumented female-identifying individuals, who experience compounding barriers from their intersecting minoritized identities including immigration status, race, and gender. This study aims to: 1) reframe Hardeman and colleagues’ Racism and Maternal Healthcare framework to center the voices of undocumented Asian and Latina female-identifying individuals; 2) identify historical and contemporary examples of the impact of structural racism on their SRH access; and 3) describe manifestations of structural racism that lead to poor quality of SRH care for this group. Between February and July 2022, 30 semi-structured interviews were conducted with undocumented female-identifying Asian (n=14) and Latina (n=16) individuals. Both deductive and inductive thematic analysis of transcripts were conducted in Dedoose. Lack of health insurance, fear of seeking care instilled by immigration enforcement, and mistrust in the healthcare system due to historical and present-day experiences of racism in obstetrics and gynecology emerged as factors impeding access to SRH. Manifestations of structural racism in the health care setting included disrespectful care, ignored pain, dismissed concerns, lack of informed consent, bodily violations, and lack of person-centered SRH education and resources. This study provides valuable insights into how structural racism shapes SRH seeking behaviors and experiences of Latina and Asian undocumented female-identifying individuals. Findings will help guide healthcare providers’ and policymakers’ decision-making in addressing current barriers that stem from structural racism.

INTRODUCTION

There are an estimated 10.5 million undocumented immigrants living in the United States who face a multitude of barriers to healthcare access.¹ For instance, the Affordable Care Act (ACA) deems undocumented immigrants ineligible for enrolling in Medicaid, nonemergency Medicare, and purchasing health insurance through the ACA marketplace.² Even for those who are eligible, a “chilling effect” resulting from the Public Charge rule discourages immigrant communities from enrollment.³ This rule denies advancements in legal status to those considered likely to become “primarily dependent on the government for support” based on their use of certain public benefits. In California, undocumented immigrants can access family planning and reproductive services through the Family Planning, Access, Care, and Treatment (PACT) Program and are eligible for full-scope Medi-Cal as long as they meet income eligibility.^4,5 However, the Public Charge Rule causes immigrants to become fearful of utilizing such resources due to potential status repercussions.^6,7 Stark contrasts in uninsured rates between nonelderly undocumented individuals (46%) and nonelderly US citizens (8%) are a direct result of the Public Charge rule and ACA exclusions, which systematically disadvantage immigrants.² Restrictive anti-immigrant policies, also referred to as criminalization policies, further reflect policymakers’ intentions to restrict rights for noncitizens by criminalizing their day-to-day activities through heightened surveillance and policing.⁸

Inequities in sexual and reproductive health (SRH) are perpetuated by the historical context of racism in the field of obstetrics and gynecology. Dating back 150 years, the United States’ history of medical experimentation and reproductive coercion continues to permeate the experiences of female-identifying individuals of color.^9–11 In 1845, Dr. Marion Sims conducted unanesthetized obstetric and gynecologic experimentation on Black enslaved female-identifying individuals.¹⁰ Between 1919 and 1953, approximately 20,000 individuals deemed “feeble-minded,” “defective,” and of a “lower racial level” were sterilized in California’s state institutions under the eugenic laws.¹¹ After analysis of eugenic records, Novak and colleagues concluded that Latinas were disproportionately targeted under the eugenics sterilization program.¹¹ More recently, between 2006 and 2010, female-identifying individuals in California state prisons were forcibly sterilized without required state approvals.¹² In 2009, cash benefits were denied to families who had more children while receiving assistance, disproportionately affecting Latina and Asian families, the two largest immigrant groups in the US.¹³ Rooted in racist ideologies, this historical context continues to undermine immigrant trust in broader public institutions, shaping current experiences with healthcare institutions.^14–16

There is a growing body of literature demonstrating how racism leads to poor SRH care access and quality of care among Black and Latina groups.^17–19 A recent survey capturing 2,138 patients’ maternity care experiences indicated that female-identifying individuals of color reported higher rates of mistreatment compared to White individuals. This included violations of privacy, forceful treatment, and physical and sexual abuse.²⁰ However, there is very little data capturing this from the perspectives of undocumented female-identifying individuals. Given that undocumented female-identifying individuals possess multiple minoritized identities concerning immigration status, race, and gender, they experience compounding barriers to high-quality, respectful, and patient-centered care exacerbated by policies of exclusion and fear of the immigration enforcement system.^8,21 This study adapts Hardeman and colleagues’ Racism in Maternal Health framework, centering Asian and Latina undocumented voices to demonstrate how structural racism impacts their SRH care experiences.

Conceptual Model - Adaptation of the Racism in Maternal Health Model to Immigrants

Hardeman and colleagues’ conceptual model examines how historical and contemporary forms of racism impact maternal health. We reframed this model to center on SRH, recognizing that maternal health lies within the broader SRH continuum and that both, maternal health and SRH, are shaped by shared structural components.²² This model is novel and of high utility in that it provides specific manifestations of racism in the maternal health care setting, which can be adapted to other SRH services (see Figure 1). The conceptual model makes the following assumptions: 1) it acknowledges the legacy of racism and how it is perpetuated in current maternal healthcare delivery, and 2) it provides a specific definition of structural racism and how it manifests in the healthcare setting. This allowed us to standardize the identification of structural racism among our coders.

Figure 1.

Adapted from Hardeman’s et al. Racism in Maternal Health Framework¹

In their model, Hardeman and colleagues highlight how the historical context of racism in the United States is a major contributor to maternal mortality and morbidity, especially for Black birthing people.¹⁷ For undocumented Latina and Asian female-identifying individuals, this includes the long history of medical experimentation and reproductive coercion against minoritized female-identifying individuals in the field of obstetrics and gynecology.^9–11 Their model specifically outlines how structural racism manifests in healthcare settings. Hardeman and colleagues define structural racism as “the systems of power based on historical injustices and contemporary social factors that systematically disadvantage people of color and advantage white people through inequities in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, etc.”¹⁷ They leave institutional racism out as a discrete contributing factor to racial disparities in maternal health outcomes, and instead conceptualize it as a form of structural racism, given that structural racism is upheld by the synergies of racist policies and practices across institutions. The model provides examples of manifestations in healthcare that both result from and perpetuate racist ideologies.¹⁷ It is worth noting that Black maternal experiences of structural racism may overlap with the experiences of other minoritized groups like the undocumented. For example, both groups oftentimes live in communities where the physician workforce does not reflect their cultural and linguistic backgrounds and where local hospitals lack sufficient resources to provide quality care.^23–25 For these reasons, we used the manifestations listed in their model such as ignored pain, failed shared decision-making, and ignored symptoms to guide our analysis. In addition to these manifestations, we also included lack of informed consent and lack of person-centered care. In informed consent, the provider explains the risks, benefits, and alternatives of a medical service to the patient in a manner they can fully comprehend, protecting the patient’s autonomy, bodily integrity, and well-being.^22,26 In person-centered care for reproductive health equity, individuals’ values, decision-making, and cultural backgrounds are placed at the center.²⁷ Particularly, person-centered care acknowledges existing challenges in healthcare settings to engage subgroups like undocumented female-identifying individuals who may have low educational attainment, low cultural health capital, and experience heightened language barriers.²⁷ Lastly, the model elucidates how historical and contemporary forms of racism work together to perpetuate racial inequities in maternal care. We hypothesize this is also true for undocumented Latina and Asian female-identifying individuals – that is, the historical and contemporary forms of racism in SRH care result in racial inequalities in SRH.

Based on the framework, the objectives of the study are to: 1) reframe Hardeman and colleagues’ Racism and Maternal Healthcare framework to center the voice of undocumented Asian and Latina female-identifying individuals; 2) identify historical and contemporary examples of the impact of structural racism on their SRH care access; and 3) describe manifestations of structural racism that lead to poor quality of SRH care for undocumented Asian and Latina female-identifying individuals.

METHODS

Recruitment and Eligibility

We leveraged the community-engaged BRAVE Study (Building communities, Raising All immigrant Voices for health Equity: PI: Sudhinaraset). Between February and May 2022, online surveys were sent to approximately 158 study participants who were recruited through community partners. The survey asked participants if they would be interested in being contacted again for future studies. For those who responded with interest, an invitation to an interview was sent to those who met the current eligibility criteria. Participants were also recruited through peer referrals. Eligibility criteria for this study included individuals who lived in California, were undocumented, between the ages of 18 to 40, self-identified as female, and were of Asian and/or Latina background. Purposive and snowball sampling were used to recruit 14 Asian and 16 Latina undocumented female-identifying individuals.

Study Procedures:

Interviews were conducted between February and July of 2022 over Zoom or phone using a semi-structured interview guide co-developed by a team consisting of undocumented immigrants and experts in the subject matter. Informed consent was first obtained, followed by eligibility verification. At the beginning of the interview, we collected demographic information, including information on the SRH service(s) participants have accessed in their lifetimes. We then delved into their experiences seeking SRH services, exploring the different factors that led to positive and/or negative experiences. Guided by the study framework, we explored how personal experiences and knowledge of past discrimination and mistreatment of undocumented immigrants shaped trust in healthcare institutions when accessing SRH care services. At the end of our interview, we asked for recommendations on how to improve access to and quality of SRH care services for other undocumented, female-identifying individuals. Participants received a $50 gift card. The interviews were transcribed; Spanish transcripts were translated into English. All transcriptions were reviewed by a study team member for accuracy.

Analyses:

Transcripts were coded in Dedoose. Codes were developed deductively using the study’s conceptual framework, as well as inductively to allow the participants’ descriptions to inform our understanding of the experiences of undocumented female-identifying individuals and how immigration status intersects with SRH. Coding occurred in three different phases with three coders for reliability. During phase 1, two team members blindly coded five of the transcripts. A third person reconciled the codes. During phase 2, one team member coded another subset of the transcripts while another member reviewed and provided feedback. In the final phase, the remaining transcripts were coded by one study member only. Final themes and codes were discussed with the full study team to ensure that the codebook matched the sentiments expressed within interviews.

Trustworthiness of data:

The interviewers either identified as undocumented themselves or had ample experience working with undocumented individuals, creating an environment of empathy and understanding where participants felt safe to share.

RESULTS:

Demographics

Descriptive characteristics are reported in Table 1. There was a total of 30 participants, with 14 identifying as Asian and 16 as Latina with the following countries represented: Vietnam, China, Philippines, Mexico, Guatemala, and El Salvador. One interview was conducted in Spanish and 29 in English. The participants’ ages ranged from 18 to 37 years. The highest educational level included ninth grade (n=1), high school diploma (n=4), community college (n=2), bachelor’s degree (n=19), and master’s degree (n=4). The majority had legal protections to reside in the United States with a valid work permit under the Deferred Action for Childhood Arrivals (DACA) executive action of 2012. Their marital status ranged from single (n=12), in a relationship, not living with partner (n=10), living with partner (n=3), to married (n=5).

Table 1.

Demographics

	N = 30	%
Ethnicity
Asian	14	46.67%
Vietnamese	2	6.67%
Korean	9	30.00%
Chinese	1	3.33%
Philippine	2	6.67%
Latina	16	53.33%
Mexican	14	46.67%
Guatemalan	1	3.33%
Salvadorean	1	3.33%
Education
9th Grade	1	3.33%
HS Diploma	4	13.33%
Community College	2	6.67%
Bachelor's	19	63.33%
Master's	4	13.33%
DACA Status
Yes	20	66.67%
No	10	33.33%
Children
Yes	5	16.67%
No	25	83.33%
Marital Status
Single	12	40.00%
In a relationship, not living w/ partner	10	33.33%
Living w/ partner	3	10.00%
Married	5	16.67%
Employment Status *
Employed	20	66.67%
Unemployed	9	30.00%
Participants have accessed the following:
Contraception	24	80.00%
Pap smear	26	86.67%
Pelvic exam	21	70.00%
STI Services	23	76.67%
Pregnancy test	18	60.00%
Prenatal care	6	20.00%
Postpartum care	6	20.00%
Abortion services	5	16.67%
HPV vaccine	22	73.33%

^*Participant 2 did not report.

Impacts of Structural Racism on Sexual and Reproductive Health Care Access

Fear of seeking care instilled by immigration enforcement, lack of health insurance, and mistrust in the healthcare system all exemplify the impacts of structural racism on access to SRH care. Although the following examples may not all be immigrant-specific, they each reflect the intricate and compounding intersectional barriers faced by undocumented female-identifying individuals.

Fear of immigration enforcement segregates undocumented female-identifying individuals from SRH services

Most participants described feeling deterred from seeking SRH services due to fear of the immigration enforcement system. Many felt that they had to protect their status out of fear of deportation or other status repercussions. For instance, when sharing why she delayed seeking necessary reproductive care, one participant stated:

“I think it was harder to access reproductive care, because I felt like I had to keep it a secret, but then at the same time, I felt like I had to keep my undocumented status a secret too, because I always felt like it was an impediment to whatever service I could receive.” (Mexican, age 25)

Fear of deportation is felt across generations, communities, and families. Two participants felt that social isolation, including from healthcare, was a form of protecting their families from being outed as undocumented. One of these participants shared how her mother instilled the idea that undocumented people should not use any government-funded resource out of fear of receiving future punishment, an example of the “chilling effect.”

“My mom has also instilled in me the idea, like, we don’t want to avail for these funds, because we don’t want the US or the government to think that we’re piggybacking, you know, and I feel like that’s a really common thing, like, many undocumented immigrants don’t want to use the services because they don’t want it to be feel like they’re gonna get punished in the long run,and that’s also my fear—I don’t want to avail for something that is going to punish me in the long run,like, if I get like a pap smear.” (Filipina, age 20)

Lack of access to health insurance

Limited or lack of health insurance shaped access to and experiences of SRH care. Many participants compared personal and familial experiences with various insurance statuses, including being uninsured, having state-sponsored insurance like Medi-Cal, and having private insurance with Kaiser Permanente.

The majority of the participants did not have continuous access to health insurance until enrolling in college. In the absence of health insurance, some participants did not seek necessary treatment and lived with gynecological conditions such as yeast infections and irregular menstruation for extended periods. One participant stated that she endured bleeding every day, only being able to address it upon entry to college and enrollment in school health insurance.

“I learned a lot of things from going to school and having access to a lot of those things, because growing up, I didn’t have access to any of that…I was just dealing with the bleeding. I was just like whatever, it is what it is. I was bleeding every day. Yeah, I didn’t get help with that aspect until I was in school.” (Mexican, age 25)

Faced with ineligibility for public insurance and high costs for other insurance options outside of the higher education setting, school health insurance is often the most easily attainable for undocumented individuals. In light of uncertainty about post-graduation coverage, one participant reported “maximizing” their school health insurance while they maintained student status.

“I think it’s challenging as an undocumented person to even have health insurance. I’ve been pretty fortunate in that I’ve been in school for quite a long time, so I’ve always been covered by school insurance, but every time I do have insurance, my friends always tease me that I maximize my health insurance—I will go to the doctor for every service that I can.” (Korean, age 32)

The same participant discussed how the expiration of her health insurance after graduation limited her opportunities to obtain vital SRH preventive care. Consequently, she was unable to complete the three-dose vaccine series recommended for optimal protection against HPV.

“The reason I couldn’t get that third one [HPV vaccine] is because my insurance—I had graduated, and my insurance expired, so there was no way for me to get the third shot.” (Korean, age 32)

Another participant accepted her recurring yeast infections as a part of everyday life in the prolonged absence of health insurance coverage. Rather than seek medical care, she self-managed uncomfortable symptoms like pain and itching, which briefly subsided only during menstruation.

“I can talk about the time I had a yeast infection, because that was when I was not covered by health insurance. I thought that was part of my normal existence, and I just had to deal with this pain and itching for the rest of my life every month with some relief when I was getting my period.” (Korean, age 25)

Other participants who lacked health insurance reported turning to Planned Parenthood to fulfill some of their SRH care needs, namely periodic check-ups and STD testing. The free and low-cost services offered by Planned Parenthood filled in care gaps for uninsured individuals who would have otherwise been subject to high out-of-pocket costs for the same services elsewhere.

“There was a period of maybe two years after graduating college where I didn’t have health insurance, I was working, but I was working in [the] service industry, and they didn’t cover health insurance. I was using Planned Parenthood at that time, and I feel supportive of their services, because I think without them, I definitely wouldn’t have been able to have those periodic checkups when I felt the need for it, or—I’m like forgetting exactly all the services I used at Planned Parenthood but I know that it felt like the only option for me to access sexual care at that period of my life.” (Korean, age 27)

“I didn’t have health insurance, at this time, so I would always go to the (Planned Parenthood) clinics, and they would also give me condoms and then that’s where they would check my woman’s health there too and test me for STDs and stuff. So (Planned Parenthood) was actually very helpful for me when I couldn’t access health insurance.” (Filipina-German, age 30)

However, participants acknowledged that Planned Parenthood alone is unable to fulfill all SRH needs. For instance, the availability of prenatal care varies among Planned Parenthoods, resulting in differential access based on location. One participant stated that their Planned Parenthood’s limited pregnancy-related services beyond pregnancy testing meant that they had to seek care from an OB-GYN for prenatal care, childbirth, and postnatal care, which necessitated health insurance.

“I went to Planned Parenthood, and they gave me the urine test and they’re like, okay, yeah, ‘You’re pregnant,’ and after that, they tell you that they can’t see you anymore because you’re pregnant, you have to be seen by an OB-GYN, so they only give you like a little paper slip that says positive pregnancy that you can send to the insurance or whoever so they can get you in as soon as possible.” (Mexican, age 25)

Those without insurance are often limited to low-income facilities. One participant contrasted her experiences at state-sponsored versus privately owned facilities. She noted how these low-income state facilities often lack the resources available in more upscale facilities located in wealthier areas.

“Based on the healthcare experiences where I had MediCal, and then I had Kaiser and, or like a private insurance just in general,and they’re not the same,or like, you go to the low-income facilities, and like, you don’t have the same resources that at Beverly Hills.” (Mexican, age 29)

When sharing her experience with the healthcare system as an uninsured patient, a participant discussed how individuals who lack both insurance coverage and the capacity to pay out-of-pocket medical costs are placed at the bottom of the hierarchy of who receives care:

“Either you have money or you have some sort of insurance, and you’ll be okay to be seen, but if you don’t have any of the two, then you’re kind of left there as a last priority.” (Mexican, age 30)

Historical and Contemporary Mistrust

Several participants shared their mistrust in the healthcare system, particularly related to obstetrics and gynecological care, given the history of and present-day experiences of coerced care within the undocumented community. This mistrust prevented them from seeking SRH services for themselves.

When asked about how undocumented immigrants have been treated in the past within the healthcare system and how this affects her current healthcare decisions and experiences, one participant cited the history of forced sterilization in detention centers as her source of mistrust, sharing:

“I mean, now you like really got me thinking about like, like detention centers, and like, just women that, you know, like healthcare workers have, like, done the hyrestectomies [hysterectomies]. I don’t even know how to say that.” (Mexican, age 27)

This participant emphasized how coercion continues in the present day, naming its impacts on the level of trust they have in healthcare institutions. They stated that such mistrust causes undocumented individuals to avoid healthcare interactions by managing their own symptoms.

“It’s so hard for us to seek healthcare services,and once we’re already there, and we give our consent to not give consent, they still do that to us. It’s just like, there’s so much—I don’t know. I feel like the mistrust. That’s what we don’t trust, like these types of institutions, and we’d rather just find alternative ways to take care of ourselves, because things like that make us not want to trust the healthcare system.” (Mexican, age 27)

When asked how past treatment of undocumented immigrants in the United States impacts her personal healthcare decision-making, one participant discussed the lack of rights granted to undocumented immigrants despite their substantial contributions to society and the economy. They highlight that despite health care being a human right, this right is not granted to the undocumented:

“I think that undocumented people are taken advantage of. To be honest, I think that is just not the way that they’re treated in society. They are kind of like a second [class-citizen]. I don’t know what it is or how it’s used, but they’re kind of not treated the same way. Regardless, at the end of the day, a person is human, and they should have access to healthcare, they should have access to their own reproductive rights. Today, I feel like it’s more seen as what can these undocumented people do for us or how can they contribute to society and economically, but let’s not give them their rights.” (Mexican, age 22)

Another participant disclosed how her mother’s fear of having her personal information shared with ICE was passed down to her and now deters her from seeking SRH services. Although she did not quote a specific example of ICE obtaining undocumented individuals’ information from institutions, undocumented communities collectively understand their lack of protection from deportation based on historical occurrences shared within and across generations, even if they cannot name specific events.

“Because just growing up with my mom, she was very fearful, and she passed on, passed on a lot of her fears to me. She didn’t trust the medical system because she thought, ‘Oh, well, if we go there, we’re gonna be charged,’and ‘If we don’t pay those bills that are being piled up, they might send them to ICE and they might come looking for us because we are giving them personal information,’so maybe it does also stem from childhood experiences and just like being fearful of them sharing our personal information with ICE, so maybe I still bring that on with me. It’s still part of me, maybe it’s with me, and I don’t even realize it when I’m like, ‘I don’t trust them,’ and it’s maybe something that’s been with me since I was a child when my mom didn’t trust the healthcare system.” (Mexican, age 28)

When asked how the evolving laws around abortion impact undocumented individuals, another participant expressed how these compounding barriers to accessing abortion impact not only the health, but also the lives of these individuals, exemplifying the broader impacts of these restrictive policies.

“I think it really puts us at a high risk…. even with this question, I’m not even thinking about myself, I am thinking about my mom, I am thinking about, you know, family members and friends that are undocumented, that have already had very limited access, and very little information, and then with everything going on, even more is being stripped like I think that just really puts, not even the well-being, but like the life of individuals at risk, and so for me it’s a very, very scary time to be living, because so much is being taken away, when we already had so little.” (Mexican, age 26)

Manifestations of Structural Racism in the Healthcare Setting

Structural racism indirectly shaped the SRH experiences of study participants by vastly limiting their affordable healthcare options to settings with suboptimal care. Overall, participants described negative SRH experiences with providers and healthcare staff. These included feeling disrespected by providers, having their pain ignored, having dismissed concerns, failing to obtain informed consent and consequently feeling violated, and receiving care in facilities that lack person-centered resources for the undocumented. Although not all experiences shared here are immigrant-specific, they each demonstrate the poor quality of care that undocumented female-identifying individuals repeatedly face.

Disrespectful care, ignored pain, and dismissed concerns

Many participants shared experiences in which they felt disrespected by healthcare providers or staff, leading to mistrust and cautiousness when accessing SRH services and looking for providers. One participant felt she was being questioned excessively and “harassed” about her immigration status during her care, making her feel othered. When comparing her and her friend’s interaction with the same SRH provider, she stated:

“But for me, it was more like, ‘Oh, …where [do] you come from, or where were you born? Do you have any type of ID?’ and I was like, ‘Well, why do I need an ID?’ It was just a little bit harder for me… it took more than what I thought. So it’s the difference between someone that’s actually a US citizen to like undocumented person to, like different kind of, you get more attacked, more question…I felt harassed in a way.” (Mexican, age 29)

Another instance of disrespectful care occurred when a participant’s provider blatantly violated her privacy by disclosing the news of her miscarriage in the waiting room area where many other individuals were seated at the time. This experience not only made her feel dehumanized but also created significant trauma, negatively impacting her thoughts on future fertility as she later mentioned she did not have any intention to attempt pregnancy again.

“He told me in the waiting room too…I told my husband, it’s kind of, it was frustrating, because he just told me [in the waiting area] like, it was nothing, like if I was not supposed to feel anything.” (Mexican, age 24)

Beyond such overtly disrespectful provider behaviors, care can be compromised in more subtle ways, for instance, through microaggressions. One participant perceived discrimination when her provider suggested she get tested for STDs in a manner that conveyed suspicion and moral judgment. This encounter, which illustrated how implicit provider bias can be communicated nonverbally, undermined the participant’s trust in their provider and impacted their willingness to seek future SRH care.

“I felt discriminated [against] because she did mention, well, maybe you need to get tested too…for STD or HIV, and the way that she said it, [it] was her face expression…that just made me feel uncomfortable and embarrassed.” (Mexican, age 37)

Implicit bias also leads to instances where healthcare providers fail to adequately acknowledge, validate, and treat undocumented individuals’ pain. Three participants discussed traumatic SRH encounters where providers undermined or ignored their pain. From the moment one pregnant participant stepped into the triage room, she felt ignored by multiple hospital staff. Despite her obvious discomfort and labor pain, the staff made her wait over 40 minutes before checking in with her. Her pain was belittled even during her labor experience, where her provider failed to employ any methods to minimize discomfort during the excruciating stitching process.

“I don’t remember them ever asked me if I was in pain. I was just very sweaty, and they were just trying to get through the intake form….but I think the part that was kind of traumatizing was after the birth, and after delivering the placenta, I had a lot of bleeding, and she was putting her hand in my vagina and scooping out the bleeding to see where it’s coming from, so she was like, ‘I’m gonna have to pack you. You have a hematoma and you, you’ve tore a second-degree tear, so I’m gonna have to stitch you,’ but to be completely honest, I don’t remember ever them giving me any kind of numbing thing for down there,so they stitched me up like that. I was yelling bloody murder the whole time.” (Mexican, age 25)

Similarly, three participants voiced experiences where they felt that their SRH providers dismissed their gynecological concerns. One of these participants even felt that certain treatments were being forced on her. Although treatment was offered, the provider failed to employ a shared decision-making process where the patient’s concerns were fully addressed, failing to make her feel heard. Ultimately, the participant felt uncomfortable and unwilling to try the suggested treatment:

“So I actually went into gynecologist for PMDD [pre-menstrual dysmorphic disorder], which is a severe form of PMS [pre-menstrual syndrome], but the gynecologist was very dismissive and her answer was to get me on birth control, and I asked her, ‘How do you know what birth control to give me if you don’t know what’s going on with my body?’ and her answer was, ‘Oh, it’s just trial and error. We’ll see. We can give you a dose. If it doesn’t work, we’ll give you another dose,’ and I told her like, ‘Isn’t that dangerous? Like, you’re giving me all these things that I don’t know how my body will react, and you’re refusing to do tests for me?’ So, yeah, she was just very dismissive, and I decided to not do it because I just felt uncomfortable.” (Chinese-Hispanic, age 27)

Violations in SRH care and lack of informed consent

Informed consent is vital for ensuring that patients have full knowledge of the risks, benefits, and alternatives of any medical service. A few participants shared experiences where informed consent was not obtained. Retrospectively, participants remembered signing forms but not fully understanding what they signed. When describing their pap smear experiences, four participants recalled feelings of being violated and ignored during the procedure, as if they were another instrument to practice on. Providers often did not walk the participants through the different pap smear steps, leaving them with feelings of assault and trespass against their bodies.

“Throughout the entire experience, she didn’t explain to me what was happening. She inserted the tool inside of me, probably 10 times and it was very, very painful, and I felt they were talking about me, and it was kind of abrasive. Yeah, and I ended up having to put in a grievance for that, because I literally felt violated from that experience.” (Chinese-Hispanic, age 27)

“But they didn’t explain the procedure, what they were going to do to me…and they inserted the [speculum] and I’m like, what is happening? … And I actually felt like abuse…Like, I feel I was raped.” (Mexican, age 28)

Such harmful experiences, and feelings associated with them, can reverberate through social networks and be passed intergenerationally. One participant disclosed that her undocumented mother experienced sexual assault by a healthcare provider. This knowledge created a sense of fear that prevented her from seeking SRH services for herself.

“I honestly, feel it comes from my mom’s own experience because I know that before, she was sexually assaulted by a health administrator.” (Filipina, age 20)

Lack of person-centered SRH education and resources

Tailored health education and resources are a key component of person-centered care. Undocumented female-identifying individuals continuously face SRH care where these needs are unmet. For example, many healthcare facilities currently lack language-friendly educational and financial resources to inform undocumented patients about their rights to access SRH services and their options to pay for or cover these services.

A few participants shared that as undocumented individuals, they did not know whether they were able to access SRH services or have the financial means to pay for them, illustrating how the current healthcare system has failed to outreach to this group to inform them of their rights.

“I’m not aware if I have to pay for it.” (Filipina, age 20)

“Because I feel many people don’t know, or are unaware that just because of your status, they maybe think they can’t, you know, so they don’t even ask for stuff.” (Salvadorean, age 22)

Another participant discussed the lack of translation services for her parents when receiving information about the HPV vaccine. Had its importance been properly communicated in the correct language to her parents, her mother may have prevented her from forgoing the third dose.:

“They were like, ‘This is a vaccine you should take’ and my parents were like, ‘Why?’ because they didn’t know what it was. It’s all in English, and there were no translation services, and they’re like, ‘You should get it, it’s for cancer,’ and I was like, ‘Okay.’ I don’t know, but I was like, ‘That sounds pretty serious, I guess we’ll get it,’ so I got the first shot when I got my physical exam done for me to continue with tennis PE class. From the tennis team, I got my second dose of the vaccine three months later, and then I didn’t get the third one even though I was supposed to, because I was like, ‘Mom, this hurts, I don’t want to go back,’ and they never explained the importance of the vaccine to me, and neither did my parents know.” (Korean, age 25)

Other participants felt they had to search for educational resources themselves, as their providers failed to explain SRH services in a way that satisfied their needs. A few participants did their own research online.

“I did most of like my research online because I didn’t really- like they just told me how to take it and stuff but they didn’t really [explain], you know, so I kind of just started going online to look at everything.” (Mexican, age 22)

After completing her pap smear, one participant was hoping to have a conversation with her provider about starting contraception. Instead, she received a brochure and left the office with questions that she would later investigate on her own.

“So I first got a pap smear, and that’s when… I wanted to know, maybe what’s better for me? She just gave me a brochure with all of them, and she was not necessarily taking the time to ask, oh, like, ‘What is it that you’re looking for?’... I can look things up on my own and understand what they mean, but I’m just thinking, if I didn’t have the knowledge that I have, then I would feel very dismissed.” (Mexican, age 24)

For one participant, lack of awareness and proper education about pap tests caused her to rely solely on information from friends, which ended up instilling fear that caused her to avoid the preventive service altogether:

“I didn’t know what a pap smear was at the time, and people made it sound really scary. So I was like, ‘Okay, I’ll just avoid this as much as possible.’” (Korean, age 25)

DISCUSSION

This study, adapting Hardeman and colleagues’ Racism in Maternal Health framework, underscores how structural racism continues to impact the SRH experiences of Latina and Asian undocumented female-identifying individuals, resulting in disproportionate barriers to high-quality, respectful, and patient-centered care.¹⁷ Although the stories shared are not unique to Latina and Asian female-identifying undocumented individuals, this group often faces exacerbated barriers due to their multiple intersectional identities, including their undocumented status, female sex, and primary language.

Our study identifies several forms of structural racism impeding access to SRH care. Structural racism in the form of inequitable access to health insurance was pronounced in participant discussions about seeking and obtaining SRH care. Punitive policies excluding undocumented individuals from health insurance coverage reinforce a hierarchy of citizenship statuses, aligning with participant experiences of differential access to health insurance based on their status.⁸ Additionally, the Public Charge rule continues to instill fear and taint feelings of social belonging for noncitizens, creating a “chilling effect” that was evident in participants’ attitudes about using government-funded resources.³ One 2018 study found that one in seven adults in immigrant families either avoided or knew a family member who avoided a federal program like SNAP or Medicaid out of concerns about immigration ramifications.²⁸ High uninsured rates among undocumented immigrants correspond to lower odds of having a regular source of healthcare and decreased utilization of preventive services compared to documented immigrants and US-born citizens.²⁹ This was prevalent among our participants, who avoided crucial preventive SRH services such as the HPV vaccine and endured conditions like chronic yeast infections and irregular menstruation due to lack of health insurance. Aside from policy, other structural barriers include limited resources to combat the fear, confusion, and language/literacy challenges commonly experienced by immigrants when enrolling in health insurance.³⁰

Our study also highlights how the history of obstetrics and gynecology and unfair treatment of undocumented immigrants in the United States leads to mistrust in the healthcare system, impacting SRH care use. According to a recent systematic review, many participants of existing qualitative studies have reported mistrust due to historical injustices faced by the marginalized communities they belong to.³¹ Quantitative studies in this systematic review demonstrated that such medical mistrust impacts the care-seeking behaviors of these marginalized populations, which may in turn affect their health outcomes.³¹ Understanding past and current undocumented treatment, one Mexican participant expressed fear regarding new restrictive abortion laws, citing the latter may place undocumented lives at risk. Another Mexican participant cited historical mistrust, specifically referencing forced hysterectomies performed on immigrants in detention centers, as a reason why undocumented immigrants like herself prefer to seek alternative methods of care that do not require the healthcare system. Such instances of reproductive coercion have surfaced to light in more recent years, for example, in the 2020 whistleblower report by Project South regarding high rates of forced hysterectomies performed on immigrant women in the Irwin County Detention Center.³² However, these practices persisted long before being brought to the public’s attention, considering how the field of obstetrics and gynecology was built off of medical experimentation and reproductive coercion of people of color.¹⁰ These stories of coerced obstetric and gynecologic care are being passed within and across undocumented generations, ultimately leading to reduced uptake of SRH care.

As a direct result of structural racism where high-quality healthcare access is limited, female-identifying undocumented individuals are forced to resort to suboptimal healthcare facilities where their needs are constantly unmet. Encounters where participants experienced ignored pain, dismissed concerns and disrespectful care were prominent among the stories shared. Prior studies have shown how healthcare providers’ biases and behaviors and racial and cultural discordance have the potential to negatively impact patient/provider relationships, especially for female-identifying individuals of color.^23,24,33 As cited by Peek et al., constraints set forth in clinical settings (time pressure, limited resources, high cognitive demand), especially in underserved areas, may cause healthcare providers to act on their racial biases unconsciously such as interpreting patient behaviors and symptoms based on racial stereotypes.³³ This particularly impacts uninsured patients whose lifelines are community clinics and/or safety net hospitals, and health centers that are under-resourced and over-stretched.²⁵ A recent study of in-depth interviews with Latina immigrant female-identifying individuals during COVID-19 concluded that racism and xenophobia by providers negatively impact the female-identifying individuals’ ability to access and engage the healthcare system, often resulting in avoidance of healthcare services.³⁴ This was reflected in the stories of our study participants. Participants were aware of the low quality of SRH care, with many voicing their concerns about returning to the same clinic that instilled fear or did not cater to their needs.

Lack of informed consent and violations in SRH care emerged as another major manifestation of structural racism in the healthcare setting. Informed consent begins with a strong patient/provider relationship. In cases of racial or cultural discordance, as with many of our participants, this relationship may be tarnished from the beginning.³⁵ Higher rates of mistreatment in maternity care have been reported among female-identifying individuals of color compared to White individuals, including violations of physical privacy (6.4% among Hispanics, 7% Asians vs 4.4% Whites), providers threatening to withhold treatment or forcing patients to accept treatment they did not consent to (5.9% in Hispanics, 6.7% in Asians vs 3.6% in Whites), and physical abuse such as inappropriate sexual conduct (2.1% among Hispanics vs 1.1% in Whites).²⁰ Similar experiences were reported among our study participants. The systematic reproductive violence committed against female-identifying individuals of color and undocumented individuals stems from a society that deems them as less worthy of reproductive autonomy and respect – factors that should be inherent human rights.³⁶ Maternal mortality is the ultimate price that such individuals in this current system pay. A recent qualitative study interviewed 11 key informants on their perspectives of barriers and pathways to SRH care for Black, Indigenous, and People of Color (BIPOC) during the COVID-19 pandemic.³⁷ When discussing quality of care, one participant reflected on the impact of immigration status on maternal safety – “This is an undocumented family. They’re not going to go up against this hospital that killed their loved one.”³⁷ This violation of reproductive justice led to the patient’s death, and the family did not seek any justice out of fear. Structurally racist policies continue creating an environment of fear and mistrust, perpetuating health disparities for Latina and Asian undocumented female-identifying individuals.

Lastly, structural racism manifests as healthcare institutions’ lack of person-centered, culturally sensitive SRH education and resources to access SRH care. As indicated by our participants’ experiences, the lack of linguistically- and culturally-appropriate education about the importance of SRH services leads to decreased utilization of SRH care and contributes to inequitable health outcomes.³⁸ This is supported by a recent study that found that language discordance leads to disengagement and reduced access to SRH care among immigrant youth.³⁹ Participants noted inadequacies of phone and paper translation services and difficulties in identifying with their providers because they didn’t look like them.³⁹ Current healthcare administrators may feel that they have addressed language barriers by having paper or phone translations, when the reality is that these methods may fail to address patient needs.⁴⁰ This underscores the critical need for person-centered resources for navigating the intricate healthcare system, including resources for informing undocumented female-identifying individuals about their rights to accessing SRH care and assistance in handling the financial aspects of obtaining SRH care. Failure to acknowledge these deficiencies in the system often contributes to victim blaming, where individuals are held responsible for decreased healthcare utilization and poorer health outcomes solely based on their behavior rather than factors out of their control, such as the availability of personnel to guide them and lack of proper SRH education and resources.

There are limitations to this study worth noting. The study sample is small and only examined perspectives of Latinas and Asians in California. We also did not inquire about sexual orientation or gender identities, which may exacerbate mistreatment in the medical setting. We acknowledge that the undocumented community is diverse. Thus, these findings may not be representative of the broader undocumented community, particularly in other states outside of California that may have even more restrictive immigration and reproductive health policies.

Based on these study findings, we make a number of recommendations. Structural racism is enacted and reinforced at multiple, interconnected levels, including policy, institutional, and interpersonal.⁴¹ Therefore, dismantling structural racism requires targeting these lower levels, which provide tangible entry points for structural transformation.⁴¹ At the interpersonal level, diversifying the provider workforce where providers reflect the patients they care for, can positively impact the provider-patient relationship as patients will more easily identify with and trust their providers.^23,24 This can also address providers’ biases and create an environment where care is given in a culturally sensitive and person-centered way.^31,42 At the institutional level, hospital administrations should revisit their current norms and implement policies that are intentional about addressing barriers to care for undocumented populations. This may entail limiting police presence on hospital grounds so that patients feel welcomed; assigning case managers to work with foreign-speaking patients to orient them to their right to healthcare; and ensuring all hospital departments have language-friendly educational and financial resources to inform undocumented patients about their right to access services and their options for covering these services. Furthermore, at the policy level, funding can be increased for communities with large immigrant populations where efforts can be centered around public health campaigns to improve comprehensive SRH education and literacy. Policymakers can also push to expand healthcare insurance like the Affordable Care Act to include the undocumented and eliminate policies like the Public Charge Rule. Doing so can drastically improve undocumented immigrants’ willingness and ability to access SRH services, including their ability to seek safe abortions, a topic that warrants further research. Lastly, a purposeful and thoughtful intention to acknowledge how medicine has historically been a source of oppression for the undocumented can lead to a place where this no longer impedes access to care for the undocumented.³⁷ To begin doing so, every SRH healthcare administrator and provider should learn about this history so that it can guide their healthcare delivery. We urge policymakers and healthcare providers to deepen their understanding of the Latina and Asian undocumented SRH experience and create avenues to address current barriers that stem from structural racism. Further, given the deep permeation of structural racism across all sectors and at multiple levels, it is impossible to dismantle it through a single strategy.⁴¹ Instead, structural transformation necessitates the implementation of coordinated, multifaceted approaches that lead to simultaneous changes in policies, practices, attitudes, and norms across social institutions and systems such as healthcare, housing, education, and employment, among others. While this study’s recommendations are focused mainly on decreasing racism as it pertains to SRH care access and quality, future work should expand on these recommendations to inform the development of comprehensive, multisectoral approaches to dismantling structural racism and advancing SRH equity.

Highlights:

• Structural racism in OBGYN care impede access to sexual and reproductive health.

• Structural racism includes fear of seeking care instilled by immigration enforcement.

• Manifestations of structural racism includes dismissed concerns and bodily violations.