The Need for Reproductive Justice in Pediatrics

As pediatricians, we set the stage for our patients’ future relationship to healthcare providers; nowhere are the stakes higher than sexual and reproductive healthcare. Listening to teens and respecting their priorities imparts a valuable lesson about self-advocacy within healthcare. In one of the most important aspects of our patients’ personal lives, we should model respectful, compassionate, and evidence-based care. This means integrating reproductive justice into our clinical practice.

Reproductive justice asserts that every person has “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”¹ Developed in 1994 by Women of African Descent for Reproductive Justice, this framework answers the call for a more expansive understanding of reproductive freedom than the ability to postpone childbearing. In contrast to reproductive health (the direct provision of clinical services) and reproductive rights (the legal protection to access clinical services), reproductive justice brings a societal and structural lens to “understand and root out reproductive oppression to achieve human rights and social justice.”¹ This broader view recognizes that communities who historically have been marginalized bear a disproportionate burden of constraints on reproductive autonomy – both limited access to contraception and abortion care as well as forced and coerced sterilization, carried out by medical providers and government institutions in the name of public health and reduction of poverty.²

As pediatricians, comprehensive contraceptive counseling has become the standard of care and many clinicians have focused on increasing access to long-acting reversible contraception (LARC) and promoting its use via tiered-efficacy counseling.^{3, 4} Many pediatricians express concern about the age of their patients making reproductive choices and, as such, advocate for LARC in all adolescent patients. While this may be discussed flippantly, real harm is perpetuated by prioritizing public health goals over an individual patient’s reproductive goals and bodily autonomy. The paternalistic belief that an adolescent’s top priority should be to delay childbearing is fraught with the potential for implicit bias and further entrenchment of stratified reproduction, by which the fertility of certain patients is valued over others.

While institutionalized policies of forced sterilization are no longer legal, more subtly coercive attempts to influence contraceptive decision-making still occur by providing financial incentives, pressuring patients to choose specific contraceptive methods, or refusing to remove LARC until after a trial period.⁵ Multiple studies have found that people in communities who were historically targeted for temporary or permanent sterilization continue to identify racist and classist biases in provider counseling.⁵ As a medical profession, we have not acknowledged our institutional untrustworthiness with respect to populations who historically have been and continue to be marginalized. This acknowledgement is a first step towards change. Reproductive justice provides a framework for the healthcare profession to align with communities and offers a foundation for individual providers to build rapport with patients.

As pediatricians, shifting our orientation to prioritize patients’ autonomy can be challenging given our role for younger patients often entails deciding what is best for them. Many of us do start introducing young patients to the importance of bodily autonomy with scripts around good touch and bad touch, although parents maintain authority over medical decision-making. And yet, while in many ways we are uniquely attuned to the developmental needs of our patients, we are behind when it comes to awareness of reproductive needs. We can support our patients’ growing autonomy by providing anticipatory guidance around the adolescent confidential visit and naming the transitions that young adolescents are experiencing. We can normalize open conversations about gender and sexual identity, affirming normal exploration and development. We can offer accurate and nonjudgmental counseling around sexual activity, breaking the ice for families to continue these conversations outside of the provider’s office. We can demonstrate to young people, especially those living at the intersection of multiple identities that are marginalized, that we honor their lived experience.

Reproductive justice asks providers to explore our patients’ priorities and, even more importantly, asks us as pediatricians to trust that young patients do know themselves better than we can when it comes to this deeply personal aspect of their life. Rather than focusing on contraception as a band-aid solution for poverty and disparities that are often correlated with teen pregnancy, reproductive justice “[recognizes] that the main reproductive challenge facing young and poor women of color is not unintended pregnancy by itself, but rather socio-economic and cultural inequalities that provide some people with easier access to self-determination and bodily autonomy than others.”⁶ Control over reproduction has been used as a tool to enact and entrench structural violence against people who are poor, Black, Indigenous, immigrants, disabled, queer, trans, neurodivergent, and incarcerated. Standing for the reproductive autonomy of young patients, especially those from communities which are marginalized, is a unique opportunity for pediatricians to be partners in these broader intersectional movements for justice.

Other specialties, namely family medicine and obstetrics/gynecology, have integrated reproductive justice into their family planning training. In contrast, pediatric trainees overall report limited experience and low confidence with contraception counseling; exposure to the framework of reproductive justice is rare.⁷ Moreover, the realignment that reproductive justice asks of providers can feel particularly challenging for pediatricians. This is a different type of shared decision making than we are used to but is part of an important transitional process that we should be engaging in throughout the course of our care relationship with families and patients. More broadly, reproductive justice sets forth a structural analysis of the complex power dynamics between physicians and our patients, offering tools for prioritizing self-actualization. As pediatricians, we owe it to our patients to model justice-oriented, patient-centered care that affirms their autonomy and dignity.