From Suffrage to the Senate: Expanding Inclusion in Women’s Rights to Achieve Women’s Health Equality

Women’s rights movements have evolved significantly since the early 20^th century. From the right to vote to basic reproductive rights, women acting together have caused major social change, which has improved women’s health equality (WHE).

While we applaud our progress to date, we also acknowledge that these efforts have focused on the priorities of women with socioeconomic privilege. And while all women have benefited from this progress, it is also clear that the women’s movement agenda must be broadened to include women who don’t come with all of the advantages.

Leading and speaking for the women’s movement has become a prominent issue. As the US populace continues to gain understanding of the colorful quilt that comprise all women’s experiences, we can no longer allow the movement’s focus to be solely that of privileged (and predominately white) women.

Women represent 51% of the US population, but we are not a homogenous group.¹ In a recent article of Missouri Medicine, female genital mutilation (FGM) was brought up as a call to action for providers to recognize this injustice inflicted upon women, to support survivors and to prevent further FGM. Unfortunately, FGM is just one of many WHE issues. If our goal is sustainable WHE, we must consider the many health challenges confronting women who are not in the spotlight, and ensure those so afflicted are aggressively engaged in the leadership of a diverse and inclusive movement.

As providers we have a unique exposure to the challenges faced by our female patients. We see firsthand how health issues can limit their ability to lead full lives and how social inequalities directly impact health inequality.² We have an opportunity to advocate for their voices. Our goal is to be their ally, not just their physician.

So how do we advocate for and alongside our marginalized female patients to achieve health equality? How do we actively work to overcome the diverse injustices faced by women infrequently represented on the covers of magazines, or the pulpits of change? Our current national women’s rights leaders have been effective advocates for protected maternity leave, equal pay and access to contraception – all of which are vitally important to WHE. But it’s important to remember the other disparities that affect large portions of the female populace.

While an exhaustive list of the unheard constituencies is beyond the scope of this article, there are several groups we can start to help today. How? By engaging with them in our own clinical spaces and in local public advocacy. We need to understand not only on the experiences they face, but also how we contribute to perpetuating these inequalities. Who are some of these groups?

Women of Color

Black women are three to four times more likely to die from a pregnancy related complication than white women.³ Even when controlling for economic status, infants born to black women in the middle class are more likely to die prior to their first birthday compared to infants born to white women in poverty with less than a high school education.⁴ While baby friendly hospitals and lactation suites at work advance our WHE agenda, we must also institute programs to address racial disparities and to support black women in accessing safe and affordable care. It also means supporting programs that help health care providers address their own unconscious bias so they can help build unbiased systems of care.

Black women are leaders of the civil rights movement.Source: Johnny Silvercloud, Flickr

Undocumented Women

WHE means ensuring that undocumented women have protected access to health care resources, regardless of documentation status (including signage and verbal support that documentation will not impact their access to care).⁵ Undocumented women are at increased risk of sexual assault and intimate partner violence, human trafficking, poverty, and denial of health care.^6,7 Fear of deportation or discrimination further limits their desire to access existing resources. WHE means providing interpretations services and education for staff on cultural competency and trauma informed care, in order to help create welcoming, safe clinical spaces that include incorporating understanding of the journeys they have made.

Gender and Sexual Minorities

Included in these welcoming spaces should be an acknowledgement that people who are impacted by women’s rights and WHE, have diversity of gender and sexuality. This means that conversations about WHE should include discussions about disparities faced by all persons who are gender and sexual minorities including lesbian, bisexual, transgender, and intersex persons. WHE means understanding that reproductive access is not just sought by persons who identify as women, but by transgender and intersex persons as well. ^8,9 It means understanding as clinicians that not every woman has a uterus and not every person with a uterus identifies as a woman.^10,11 WHE means removing provider bias regarding perceptions surrounding our patient’s gender identity, sexuality, or anatomy. It means advocating for inclusive insurance coverage, posting nondiscrimination policies and adapting our clinic aesthetic, and changing workflow and medical records to be inclusive of gender and sexual diversity patients.

Sex Workers

Another population to be considered is one that for generations has been pushed to the background of conversations: sex workers. Sex workers predominately identify as women, and are disproportionately the targets of violence, sexual assault, and murder.^12–14 Because of the US criminalization policies on sex work, these individuals are often reticent to work with the legal system. Consequently they are often reticent to disclose their employment status to health care personnel due to fear of mistreatment, including harassment, discrimination and refusal of services.^15,16 WHE means providing sex workers with equal access to care, creating safe spaces for open conversations about sex, and supporting their voices in legislation targeted at their protection.¹⁵

Survivors of Violence

One cannot address sex workers without also speaking about survivors of violence. The “me too” movement, started by Tanara Burke, has educated the nation on the sweeping effect sexual violence has on our citizens. Despite this, the movement has evolved into a discussion highlighting the powerful and famous women who bravely have come forward. It has seemingly left in the shadows the women for which it was initially created: disenfranchised women, especially, women of color and women experiencing poverty. Discussing violence against women means acknowledging that the same populations disproportionately targeted by sexual violence are also at higher risk for violence in general, including intimate partner violence, gun violence, stalking and homicide.^17,18 Providers should have resources ready to help patients exit unsafe situations, and utilize harm reduction and trauma informed models of care to decrease re-traumatization in the clinical setting.¹⁹

Women with Disabilities

Another critical constituency are women with mental and physical disabilities. WHE needs to be accessible to all persons of varying abilities. Women with disabilities need to be included in the conversation when creating health care spaces, workflows and competency trainings. Supporting this diverse part of our community means thinking about how individuals with sensory processing forms of autism might not feel supported in loud, crowded spaces, about how your clinic is laid out to be easily accessible in persons with ambulatory disabilities. WHE means not centering their health care solely on their disability (e.g. persons with disabilities reproductive needs have often been placed on the backburner by clinical providers).²⁰ Women with disabilities are also at higher risk for abuse, including sexual abuse, in the home and in hospital care settings.²¹ Assumptions should not always be made that caretakers are safe guardians.

Women Who Are Incarcerated

Perhaps the least engaged women are those who are incarcerated. While only ten percent of persons currently incarcerated identify as female, over half of them have experienced sexual violence prior to incarceration, and one in five to one in six are sexually assaulted while incarcerated.^22,23 Over two thirds are incarcerated for nonviolent offenses, and the majority identify as primary care takers for dependents. WHE means not only supporting decriminalization of many of these offenses but also ensuring women who are incarcerated are receiving appropriate health care and safe access to providers when they disclose prison abuse or assault.²⁴ This includes supporting hiring practices for persons with a history of incarceration since women who were formerly incarcerated are also more likely to end up in poverty and unemployed after release.²⁵

Women Who Are Poor

Overarching all of the above is the reality of poverty. Over half the individuals living in poverty are women. Roughly one in four black and Hispanic women live in poverty, compared to one in nine to ten white women. All of these rates are higher than men of the same race.²⁶ Wages directly contribute to health quality as part of the social determinants of health.^27,28 By supporting living wage policies, providers can directly engage in improving their patients’ quality of life. Financial stability contributes to higher rates of medication continuity, follow up visit compliance, and decreased rates of utilization of emergency rooms for primary health care.^29–31 As providers who believe in WHE, we need to recognize the challenges often linked to poverty, such as accommodating those who are late due to public transit limitations and offering social support resources for patients seeking stable housing, access to food and employment.

So What Can We Do?

Supporting WHE means not only listening to women’s voices, but also thinking about how to promote those voices into leadership roles. As providers, we can do so much. Show up to events sponsored by the groups listed above. Support organizations run by these women (Figure 1). Bring in speakers to hear their experiences as our patients, to help us improve our clinical care. A few simple steps but ones that demonstrate our understanding and commitment.

Figure 1.

Examples of women-led local, state and national organizations addressing above disparities

In addition, think about who is presenting you with information on WHE, on the struggles of these constituents. I am a white, economically privileged female. I cannot speak for women whose life experiences are so different from my own. This piece is not a desire to usurp their voices. Rather it’s a desire to rally those providers with my background to be allies to these under-represented constituencies. To actively work to bring their voices to the forefront.

Nor is it the intention of this piece to beat up the leadership of today’s women’s movement. Their accomplishments resurrecting the movement have been critical to reenergizing discussions about key topics like WHE. But there is much work to be done. Broadening the movement’s leadership to include the constituencies discussed above will not be easy, and it will not happen quickly. Becoming active supporters of this process is a critical first step. One we are uniquely positioned to take.