The Patient Protection and Affordable Care Act (ACA) has many implications for Asian Pacific Islander American (API) women’s reproductive and sexual health, including provisions calling for preventive services, increased funding for mental health and community health centers, and ethnically disaggregated data collection. The political climate following the passage of the ACA has given rise to increased interest in anti-abortion policymaking that capitalizes on rallying conservative opposition to the law. Anti-choice political actors use racial divisions to target women of color, especially API and Black women, as evidenced by a rise in sex-selective abortion legislation and the use of billboards evoking “Black genocide” in predominantly African American communities. While bans on sex-selective and race-selective abortions are touted by anti-abortion groups as “anti-sexist” or “anti-racist”, such policies have important implications for the reproductive freedom of women of color, the unity of groups that advocate for reproductive rights, and the ability of providers to care for women of color. This article discusses the rise of sex-selective abortion bans in the wake of ACA implementation; offers a gendered perspective on son preference in Asian American communities; and reviews ongoing organizing efforts by API women along the framework of reproductive justice, concluding with recommendations for ensuring reproductive freedom especially for API women.
REPRODUCTIVE AND SEXUAL HEALTH POLICY FOLLOWING THE ACA
The ACA, signed into law in 2010, has had many well-documented improvements for Asian American and Pacific Islander American (API) women’s health. API women face disparities in reproductive and sexual health including disproportionately high cervical cancer rates in Vietnamese women[i], high rates of breast cancer mortality in Filipino women[ii] and high uninsured rates in Korean women.[iii] Complicating the identification of reproductive health disparities among API women for purposes of intervention is the dearth of ethnically disaggregated data that accurately reflects the diversity among APIs in terms of income, socioeconomic status, language proficiency, immigration status, and generation in the U.S. Moreover, while it is known that most abortions in the U. S. are obtained by minority women, most data on abortions are currently disaggregated only along strata of non-Hispanic white, Black, and Hispanic women.[iv]
The ACA addresses these disparities by increasing access to preventive services and expanding eligibility for Medicaid in states who choose to accept federal funds to do so. Additionally, Title IV of the ACA calls for the collection of ethnically disaggregated data in order to better understand health disparities.[v] The Centers for Disease Control and Prevention (CDC) released the Native Hawaiian and Pacific Islander (NHPI) National Health Interview Survey in 2014, and a public use data file is expected to be available in 2015.[vi]
Following 2010 and the subsequent 2012 Supreme Court ruling upholding the ACA while making the Medicaid expansion optional, the political climate in the United States has been increasingly polarized.[vii] Anti-abortion political actors have capitalized on this polarization by rallying conservative opposition to the ACA in order to promote policies restricting access to reproductive and sexual health care. In just two years after the ACA was signed, over 1,100 provisions related to restricting reproductive health access and rights were introduced at the state level. Of these, 209 passed, exceeding the number passed in the entire preceding decade (Figure 1).[viii]These include bans, waiting periods, ultrasound requirements, insurance coverage restrictions, clinic regulations, and limitations on medication abortions.[ix] The most recent midterm elections in November 2014 saw three abortion-related measures appearing on state ballots: “personhood” measures (defining a human embryo as a person from the moment of fertilization) in Colorado (Amendment 67) and North Dakota (Measure 1), which were both defeated, and an amendment to the Tennessee constitution (Amendment 1) denying legal protection of the right to an abortion, which voters approved.
RECENT RISE OF SEX-SELECTIVE ABORTION LEGISLATION AND PROFESSIONAL OPINION
In the last half-decade, anti-choice political actors have shown a rising interest in targeting women of color through restricting abortions conducted on the basis of the sex or race of the fetus. Since 2009, over 60 bills that would ban sex- and/or race-selective abortions have been introduced at the federal and state levels.[x] Oklahoma, Arizona, Kansas, North Dakota, Pennsylvania, and Illinois all have bans on sex-selective abortion, all of which were passed between 2010 and 2013 with the exception of Pennsylvania and Illinois.[xi] Arizona’s statewide ban also includes language banning race-selective abortion. Sex-selective abortion bans were introduced in eleven additional states within the same time period, where they failed to pass.[xii],[xiii]
At the federal level, Representative Trent Franks (R-AZ) has introduced a sex- and race- selective abortion ban four times in the House, first as the “Susan B. Anthony Prenatal Nondiscrimination Act” in 2008; the following year as the “Susan B. Anthony and Frederick Douglass Prenatal Nondiscrimination Act”; and as the “Prenatal Nondiscrimination Act,” or PRENDA, in 2011 and 2013, when it was last defeated. Senator David Vitter (R-LA) introduced a similar bill in the Senate in January 2013, which also failed to pass. In September 2014, the San Francisco Board of Supervisors unanimously approved a city resolution opposing sex- selective abortion bans, the first and only local policy of this kind in the U.S..[xiv]
In terms of professional medical opinion, the American College of Obstetricians and Gynecologists (ACOG), a professional organization representing most physician providers of fertility and reproductive health services, and the American Society for Reproductive Medicine (ASRM), another professional organization for providers of reproductive care, have both weighed in. In an ethics committee opinion authored in 2007 and reaffirmed in 2011, ACOG stated its opposition to meeting requests for sex selection “because of the concern that such requests may ultimately support sexist practices.”[xv] At the same time, the ACOG ethics committee affirmed that information on a fetus’s sex “should not be withheld from the pregnant woman who requests it…because this information legally and ethically belongs to the patient.” ASRM expresses similar concern for sex selection as a gender-discriminatory practice that should be “discouraged,” while also upholding that “the Committee does not favor its legal prohibition.”[xvi]
Starting around the same time as the legislative campaigns, media campaigns also began to surface attempting to paint the disproportionate number of abortions obtained by minority women as a racist attack by abortion providers on Black babies (Figure 2). These campaigns fail to consider socioeconomic and individual factors that may limit the ability of women of color to access effective contraception, carry a fetus to term, and raise a child under ideal circumstances. Just as banning race-selective abortion fails to address the social and economic factors that drive disproportionate rates of abortion in Black communities, banning sex-selective abortion fails to consider factors that lead to son preference in API communities. To understood root causes, race and gender cannot be de-coupled when discussing race- and sex-selective abortion.
GENDER ANALYSIS OF SON PREFERENCE AND API AMERICANS
The association of sex selection with API communities hinges on son preference. In many societies including the United States, men enjoy an elevated social status that confers, among other privileges, higher socioeconomic earning power, greater political influence, and relative safety from the threat of sexual violence. Additional gendered cultural norms in many API countries of origin include traditions requiring sons to care for aging parents and carry on the family name. Some API women experience information barriers to contraceptive use, pressure to prove fertility soon after marriage and pressure to bear sons, all factors that may lead to son preference resulting in sex selective abortion.[xvii] A cultural value placed on gender balance between children within families may also lead to sex selection in second and higher order births, and evidence of son preference in second and third children is in fact seen in data on Chinese, Indian, and Korean American families.[xviii]
Social policies affecting API women in the United States are another potential driver of sex selection. Immigration policy that confers derivative status on dependents, usually wives, of foreign workers holding H visas leads to an environment of vulnerability among many API immigrant women in relation to male spouses.[xix] Refugee resettlement policy and fear of losing social welfare benefits have been identified as barriers for API women to reporting intimate partner violence.[xx] As API women are aware of the effects of these policies on their lived realities, it is not implausible that they may make their reproductive choices motivated in part by fear of gender discrimination and violence against potential daughters.
Given the reality of son preference in API communities, anti-abortion-rights political actors portend the protection of unborn female fetuses from gender discrimination through the banning of sex-selective abortion. Rather than combating gender discrimination, however, sex-selective abortion bans promote gender discrimination in a racialized way. Bans on sex-selective abortion require medical providers to racially profile patients for further scrutiny of their reproductive choices, reinforcing racial stereotypes and impeding objective medical care of women of color. Linguistic barriers increase the chance of miscommunication between API patients and their providers, which may lead to denial of abortion care to API women based on misunderstandings or assumptions about the reasons behind their reproductive choices. Furthermore, these policies pit mainstream pro-choice groups against communities of color through a purported cause of racial “anti-sexism,” targeting API women’s reproductive freedom while failing to address systemic causes of gender discrimination in either API cultures or U.S. society.
THE REPRODUCTIVE JUSTICE FRAMEWORK AND API WOMEN’S ORGANIZING
Up to and since the Roe v. Wade ruling in 1973, the rhetoric around reproductive health has traditionally been framed as one of individual choice and the need to protect and preserve the right to contraception and abortion. However, many factors other than legal access to birth control affect a woman’s ability to choose when and under what circumstances to raise a child. Beyond individual factors of rights and access, true reproductive freedom requires systems-level policy analysis and advocacy.
For the last two decades, API women have been organizing cross-racially at the systems level under the framework of reproductive justice, a term that was coined at a 1994 conference for the Black Women’s Caucus.[xxi] In 1997, the Black Women’s Caucus and other women’s groups, including National Latina Health Organization, Native American Women’s Health Education Resource Center, and Asian Communities for Reproductive Justice (now Forward Together), formed the SisterSong Women of Color Reproductive Health Collective “to educate women of color and policymakers on reproductive and sexual health and rights”. The groups in this coalition work under a framework that extends beyond protection of access to contraceptives and abortion, linking abortion with issues of economic justice, the environment, immigrants’ rights, disability rights, labor, housing, and discrimination based on race and sexual orientation, as all of these things affect the health of a woman and her ability to choose when and under what circumstances to parent a child.
Member groups of SisterSong and other API women’s organizations have since been at the forefront of working to protect reproductive freedom against legislation targeting women of color through bans on race- and sex-selective abortions. The National Asian Pacific American Women’s Forum (NAPAWF), Forward Together (formerly Asian Communities for Reproductive Justice), and Khmer Girls in Action are three examples of organizations created by API women and girls that currently actively organize around API women’s policy at national, state, and local levels.
NAPAWF, formed in 1996 by API activists, is a multi-issue advocacy and organizing body for API women and girls with chapters in eight states and Washington DC. Taking a reproductive justice framework approach to organizing for API women’s issues, NAPAWF has been active in engaging in evidence-based advocacy around health care reform including the ACA, the HPV vaccine mandate, race- and sex-selective abortion bans, civil rights, immigration reform, and nail salon worker health and safety. NAPAWF’s Executive Director, Miriam Yeung, was the only testimony allowed at congressional PRENDA hearings in 2013.
Forward Together, a multi-racial organization based in Oakland with chapters in Oregon, New Mexico and New York, started in 1989 as Asian Communities for Reproductive Justice. Forward Together currently does reproductive justice advocacy work through youth organizing campaigns for sexual education in Oakland Unified School District; Echoing Ida, a program for promoting Black women’s thought leadership in media communications around race and gender issues; and APD Forward, a campaign to reform police-community relations in Albuquerque, New Mexico. Concern for disproportionate rates of police violence against young men of color fits into a reproductive justice framework by affecting the ability of women of color to parent their children safely.
Khmer Girls in Action (KGA), based in Long Beach, California, was started by Cambodian American women and girls in 1997 as HOPE for Girls. In addition to leadership development and academic support programs for youth, KGA also engages in local policymaking advocacy in the form of campaigns for school-based health in Long Beach, a community with a disproportionate number of Black, Latino, and Southeast Asian youth as well as high rates of lack of health insurance, truancy, and teenage pregnancy, issues that are causally linked under the reproductive justice framework.
RECOMMENDATIONS AND CLOSING REMARKS
The preceding analysis outlines the political climate framing the rise in sex-selective abortion legislation; contextualizes sex selection within gender constructs in API communities and U.S. policies that lead to son preference; and describes organizing work that is currently being done by API women and other women of color under the framework of reproductive justice. The following recommendations are based on addressing the systemic factors leading to sex selection at multiple levels.
First, organizations that work in the interest of women and API communities should actively commit to increased dialogue to maintain unified opposition to restrictions on abortion rights. Mainstream women’s movements have invited criticism in the past for failing to acknowledge issues that disproportionately affect women of color, and many mainstream pro-choice organizations have remained silent when sex-selective abortion legislation has been introduced. At a time when anti-choice sociopolitical actors acknowledge using race and sex selection as a faux “anti-racism” and “anti-sexism” wedge to divide women’s organizations on the issue of abortion, it is important that women’s and API groups be conscious of this intention and actively work together to resist it. In the context of media messages and legislative action specifically targeting Black and API women, the intersections between race and gender cannot be ignored by groups that work in the common interest of women’s health. The medical community as well as mainstream women’s groups should consider the perspectives and research offered by API women’s organizations when formulating professional opinion and policy around race and sex selective abortion.
Second, full advantage should be taken of ethnically disaggregated data to conduct research on the reproductive needs of API women. Policy change must be driven by data, and one of the many ways that the ACA is expected to improve health inequality is the provision that enhances data collection to address the diversity of communities of color. New ethnically disaggregated data specific to API communities, including data on abortion, contraception, and sexual and reproductive health, must be harnessed for analysis in order to identify and assess community- specific needs. The ACA is instrumental in improving the collection of data on API communities, and the resulting analyses should be used to drive evidence-based interventions at all levels of policymaking and community programming.
Finally, a reproductive justice framework should be adopted in approaching research, advocacy, and reproductive health services delivery for API women. Organizations such as NAPAWF, Forward Together, and Khmer Girls in Action have been using reproductive justice principles to inform their work on issues affecting API women and other women of color. The same framework can inform research, policymaking, and coalition building to affect policy surrounding API issues.
Sex selection must be addressed by targeting systemic gender bias, including domestic violence, immigration reform, environmental justice and the wage gap. Only by addressing these and other factors underlying root causes of son preference in API communities can sex selection be reduced. Targeting API women’s reproductive freedom serves to exacerbate gender discrimination, not to eliminate it. Restricting reproductive rights by targeting API women further stigmatizes women of color and adds to the legal barriers that women of color already face in accessing reproductive health care. Open dialogue between women’s and API groups, research using data made possible by the ACA, and a reproductive justice framework will be instrumental in guaranteeing not just reproductive health, but reproductive freedom of API women and other women of color.
Vicki Chia is a fourth-year medical student at the University of California San Diego School of Medicine and a Master of Public Health student at the Harvard T. H. Chan School of Public Health studying Health Policy with a concentration in Women, Gender and Health. Since 2011 Vicki has been engaged with the medically underserved through direct service delivery, community health education and outreach, political advocacy, and research on global health systems strengthening. She completed a medical student clerkship with Planned Parenthood of the Pacific Southwest in 2014, and in 2016 she will begin residency training in obstetrics and gynecology.
[i] National Asian Pacific American Women’s Forum. “HPV, Cervical Cancer, and API Women: Eliminating Health Disparities,” Issue Brief, January 2009.
[ii] Miller, Barry A; Chu, Kenneth C; Hankey, Benjamin F and Lynn AG Ries. “Cancer incidence and mortality patterns among specific Asian and Pacific Islander populations in the U.S.” Cancer Causes Control 19:227-256. 2008.
[iii] National Asian Pacific American Women’s Forum. “Health Coverage and Asian & Pacific Islander Women.” Fact Sheet, April 2008.
[iv] Cohen, Susan A. “Abortion and Women of Color: The Bigger Picture.” Guttmacher Policy Review 11(3):2-12. 2008.
[v] Alberti, Phillip M., Bonham, Ann C. and Darrell G. Kirch. “Making Equity a Value in Value-Based Health Care.” Academic Medicine 88(11):1619-1623. 2013.
[vi] Centers for Disease Control and Prevention “Surveys and Data Collection Systems.” Last modified July 15, 2014. http://www.cdc.gov/nchs/nhis/nhpi.html
[vii] Blendon, Robert J., and John M. Benson. “Voters and the Affordable Care Act in the 2014 Election.” New England Journal of Medicine 371(20). 2014. doi: 10.1056/NEJMsr1412118
[viii] Boonstra, Heather D., and Elizabeth Nash. “A Surge of State Abortion Restrictions Puts Providers—and the Women They Serve—in the Crosshairs.” Guttmacher Policy Review 17(1):9-15. 2014.
[ix] Guttmacher Institute. “States Enact Record Number of Abortion Restrictions in 2011.” Last modified January 5, 2012. http://www.guttmacher.org/media/inthenews/2012/01/05/endofyear.html
[x] National Asian Pacific American Women’s Forum. “Race and Sex Selective Abortion Bans: Wolves in Sheep’s Clothing.” Issue Brief, July 2013.
[xi] “Replacing Myths with Facts: Sex-Selective Abortion Laws in the United States.” 2014. International Human Rights Clinic at the University of Chicago Law School; National Asian Pacific American Women’s Forum; and Advancing New Standards in Reproductive Health.
[xii] National Asian Pacific American Women’s Forum. “Race and Sex Selective Abortion Bans: Wolves in Sheep’s Clothing.” Issue Brief, July 2013.
[xiii] Liss-Schultz, Nina. “San Francisco Lawmakers Could Pass Resolution Against Sex- Selective Abortion Bans.” RH Reality Check, September 10, 2014. http://rhrealitycheck.org/article/2014/09/10/san-francisco-lawmakers-pass-resolution-sex- selective-abortion-bans/
[xiv] Gandhi, Lakshmi. “Fight Against Sex-Selective Abortion Ban Successful in San Fran.” NBC News. September 17, 2014. http://www.nbcnews.com/news/asian-america/fight-against-sex-selective-abortion-ban- successful-san-fran-n205356
[xv] American College of Obstetricians and Gynecologists. ACOG Committee Opinion Number 360: Sex Selection. Washington, DC. 2007 (reaffirmed in 2011).
[xvi] American Society for Reproductive Medicine. Sex Selection and Preimplantation Genetic Diagnosis. Birmingham, AL. The Ethics Committee of the American Society of Reproductive Medicine. 2004.
[xvii] Najafi-Sharjabad, Fatemeh; Yahya, Sharifah Zainiyah Syed; Rahman, Hejar Abdul; Hanafiah, Muhamad and Rosliza Abdul Manaf. “Barriers of Modern Contraceptive Practices Among Asian Women: A Mini Literature Review.” Global Journal of Health Science. 5(5):181-192. 2013. Doi: 10.5539/gjhs.v5n5p181
[xviii] “Replacing Myths with Facts: Sex-Selective Abortion Laws in the United States.” 2014. International Human Rights Clinic at the University of Chicago Law School; National Asian Pacific American Women’s Forum; and Advancing New Standards in Reproductive Health.
[xix] Kelkar, Maneesha. “South Asian Immigration in the United States: A Gendered Perspective.” Asian American Policy Review 22:55-60. 2012.
[xx] Warrier, Sujata. “(Un)heard Voices: Domestic Violence in the Asian American Community.” The Family Violence Prevention Fund. 2002.
[xxi] Smith, Andrea. “Beyond Pro-Choice Versus Pro-Life: Women of Color and Reproductive Justice.” National Women’s Studies Association Journal 17:119-140. 2005.