One Key Question: Why “Would You Like to Become Pregnant in the Next Year” is a Bad Idea

Note: I wrote this last year when the One Key Question initiative in Oregon was being discussed, and pitched it to an appropriate publication. Unfortunately, the editor of that publication somewhat maliciously string me along and sat on it until it was no longer timely, and it’s been sitting in my sads folder since. With the recent CDC recommitment to the notion of pre-pregnancy, I decided this should at least be published on my blog.

A “simple, routine question” advocated by the Oregon Foundation for Reproductive Health is a great way to alienate and further disenfranchise women who are childfree.

A new piece on Slate discusses one of the most alienating ideas I’ve read in a while, and I wrote about the Hobby Lobby SCOTUS decision last week. In a nutshell, it argues that for effective and proactive reproductive health care needs, primary care physicians should ask a woman, at every visit, if she would like to become pregnant in the next year.

OKQOn the surface, the One Key Question Initiative, by the Oregon Foundation for Reproductive Health, may seem like a good idea. Many women have access to a primary care provider, but do not see OB-GYNs with any regularity. And of course, discussing reproductive and contraception options with a patient should be a basic of yearly, preventive, or wellness exams. The problem is not in discussing reproductive and contraception options, but instead in the framing of the question: would you like to become pregnant in the next year?

If I heard this from my doctor at every visit, I would change doctors. I expect my doctor to listen to me, and expect my doctor, after the first time I explain that I am childless by choice, to respect my decision. Asking me, repeatedly, if I would like to become pregnant in any time frame ignores my stated preference and decision. It falls into the cultural stereotype that women must want children, and that if they’re asked enough, if they get old enough, if they just meet the right man, they’ll change their minds.

Statistics indicate that I’m not alone in my desire to not have children. In fact, a third of women in the “acceptable childbearing age” bracket of 20-44 don’t have children,[note]US Census Bureau, Current Population Survey, June 2010. Table 2. Children Ever Born per 1,000 Women, Percent childless, and Women Who Had A child in the Last Year by Race, Origin, Nativity Status, Marital Status, and Age.[/note] and 20 percent of women won’t have children.[note]Livingston G. Childlessness Up Among All Women; Down Among Women with Advanced Degrees. Pew Research Center, Washington D.C.; June 25, 2010.[/note] Many of these women are involuntarily childless, either for medical reasons or circumstance, but a recent survey by DeVries Global suggests that as many as 36 percent of those who are childless are voluntarily childless.[note]DeVries Global. Shades of Otherhood: Marketing to Women Without Children.[/note] As such, medical appointments should not be used as an opportunity to emphasize the stigma of the choice not to have children.

And make no mistake: there is still a significant stigma to choose to not have children. (One of my favorite paper titles ever is “Women without Children: A Contradiction in Terms?”) Women are judged for not having children; they are selfish, immature, refuse to grow up. The crazy cat lady has become a modern boogieman to scare women with. Headlines scream “The Trend of Not Having Children is Just Plain Selfish” (The National Post), women are assured it’ll be different when it’s your child, and assured they will regret their choice to remain child-free. Some of these beliefs are so deeply engrained into culture that women under the age of 30 have a difficult time finding doctors who will tie their tubes; a persistent, paternalistic attitude that doctors know better than women about their reproductive desires, which Slate itself covered in depth in 2012.[note]Lowder JB. “Sterilize Me, Please.” Slate, July 2012.[/note]

We’ve had this conversation before, when 2006 federal guidelines resulted in women of reproductive age being labeled “pre-pregnant” and treated as if they could fall pregnant at any moment. As bioethicist Rebecca Kukla noted, the idea of pre-pregnancy literally treats the non-pregnant body as on its way to pregnancy, with non-pregnancy seen as a fleeting and temporary state; it also reinterprets primary care for women into reproductive care.[note]Kukla R. “Preconception Care” and the Transformation of Women’s Health Care into Reproductive Medicine.” Presentation, Aston University, September 16 and 17, 2009.[/note] The One Key Question Initiative brings us right back to the pre-pregnancy focus on what some people have dubbed “bikini medicine” – all attention on a woman’s reproductive organs first and foremost – creating a strong pro-natalist, coercive discourse about women’s healthcare, and shifting the focus to future outcomes (pregnancy and children) rather than the immediate patient at the appointment.

This is not to say that the ultimate goal of the One Key Question Initiative, to “ensure that more pregnancies are wanted, planned, and as healthy as possible,” is wrong. In fact, I firmly come down on the side of every child a wanted child, and as authors Julie F. Kay and Michele Stranger Hunter note, “about 85 percent of couples not using contraception will become pregnant in the next year, whether they intend to or not.” Primary care physicians should ask their female patients about childbearing and reproduction; the physician should know the patient preference and note that in her chart. In following visits, it’s more than acceptable to ask a woman who indicated she is not interested in bearing children if her contraceptive choice is working as desired, if there are any side effects, even if the woman wants to make any changes to that contraception. What isn’t okay is to make “would you like to become pregnant in the next year” a mandated question operating from a presumption that pregnancy is always a possibility on the horizon.

Not a Privilege but a Right

A version of this post should have been up before Christmas, but technology decided to take a holiday a bit before the rest of us.

…and then there was the time the WordPress wasn’t actually publishing posts, and things got behind, and then it all just seemed like such a big mountain to crawl out from under. Also known as “what I like to call the last two weeks.”

First and foremost – and with apologies, since I did really drop the ball on notifying people – I did receive word that my biopsy results were negative and I am, thankfully, cancer-free. My doctor was also able to rush the results, so I found out prior to the holidays, which was also a relief.

It was a very strange experience, though, in that it forced me, for a week, to once again contemplate mortality and the specific desires I have for life. Also, as a friend of mine noted, it was one of the instances where, all things wrong with the American health system that there are, the fact that I was being treated here and not in the Canadian health system was a blessing, because it was a fast process.

And actually, still is a fast process. There are obviously still “body is not functioning right” issues going on, and this afternoon will hopefully resolve a lot of that. So I’ve gone from concerned issue to ultrasound to biopsy to results to treatment inside a month – that’s a time frame that really is enviable…and it’s a time frame made possible by virtue of having startlingly good health insurance and living in a place where, while I do have to pay for that health insurance, one of the benefits is access.

That access is an important thing, because just a few years ago, I didn’t have that access. I didn’t have health insurance for a few years, and prior to those years, what I did had didn’t even cover a wellness health visit outside a very overcrowded campus health center that wasn’t equipped for anything but colds, flus, and sexually transmitted diseases. I shudder to think of the process then – deciding whether or not to seek out care, or if this is just a discomfort I could live with. What if the biopsy result had been positive? In my current position, it would have sucked, but I have family nearby and loved ones willing to come take care of me, and access to top-of-the-line hospitals and people who will make sure that I receive excellent care (or else).

A few years ago, none of that was necessarily the case – especially the access to care.

I am privileged. I didn’t have to live with the stress and concern and fear that happens when you get a bad test result back and fall into that wasteland of waiting. I knew that, should the result be a bad one, I would have excellent and aggressive health care waiting for me, and that I would ultimately be in charge of the decisions made, and that what happened to me wouldn’t be based on limited services or access or my ability to pay (or not). These are the sorts of privileges a lot of women don’t have – especially low income women living in states where legislature is actively working to shut down what is often the only existing source of women’s healthcare: Planned Parenthood.

I was able to usher in the start of the year with toasts of “fuck cancer” – and it is the memory of that relief and that privilege that, in part, continues to motivate my political activism, support of the Affordable Care Act, and donations to various women’s health and activism organizations, including Planned Parenthood.

Because no woman should have to wonder “cancer” without knowing that, if it is, there is easy access to care and support. “My body is broken and needs fixing” should not be a privilege but a right.

Yet Another Rape Apologist in a Position of Power

It’s been a banner year for rape in the media, and apparently December just felt left out. Joining the likes of:

is Orange County Superior Court judge Derek Johnson, who said that the following litany of amazing things when refusing a heavier sentence for a man convicted of rape by a jury of his peers:

I spent my last year and a half in the D.A.’s office in the sexual assault unit. I know something about sexual assault. I’ve seen women who have been ravaged and savaged whose vagina was shredded by the rape. I’m not a gynecologist, but I can tell you something: If someone doesn’t want to have sexual intercourse, the body shuts down. The body will not permit that to happen unless a lot of damage is inflicted, and we heard nothing about that in this case. That tells me that the victim in this case, although she wasn’t necessarily willing, she didn’t put up a fight. And to treat this case like the rape cases that we all hear about is an insult to victims of rape. I think it’s an insult. I think it trivializes rape.State of California, Commission on Judicial Performance

Of course, in some ways it’s unfair to lump Johnson in with the above quotes, because his ruling actually happened in 2008. That’s okay, though – there’s an awful lot of horrible that’s been spouted off in the past, too, and he’s just clearly gravitating towards his own:

  • Stephen “rape causes women to ‘secrete a certain secretion’” Freind (1988 Rep, R-PA);Freind’s Rape-pregnancy Theory Refuted
  • Henry “the facts show that people who are raped–who are truly raped–the juices don’t flow, the body functions don’t work and they don’t get pregnant. Medical authorities agree this is a rarity, if ever” Aldridge (1995 Rep, R-NC);Lawmaker Says Rape Can’t Cause Pregnancy
  • Clayton “if ‘[rape] is inevitable, just relax and enjoy it” Williams (1990 Texas Republican gubernatorial nominee);Texas Candidate’s Comment About Rape Causes a Furor
  • James Leon “concern for rape victims is a red herring because conceptions from rape occur with approximately the same frequency as snowfall in Miami” Holms (Federal Judge, 1997);In Judicial Twist, Republicans Seen Stalling Bush Pick
  • John C. Willke, a physician who was once president of the National Right to Life Committee, whose statement is astonishing and bears repeating in full:

    Finally, factor in what is is certainly one of the most important reasons why a rape victim rarely gets pregnant, and that’s physical trauma. Every woman is aware that stress and emotional factors can alter her menstrual cycle. To get and stay pregnant a woman’s body must produce a very sophisticated mix of hormones. Hormone production is controlled by a part of the brain that is easily influenced by emotions. There’s no greater emotional trauma that can be experienced by a woman than an assault rape. This can radically upset her possibility of ovulation, fertilization, implantation and even nurturing of a pregnancy. So what further percentage reduction in pregnancy will this cause? No one knows, but this factor certainly cuts this last figure by at least 50 percent and probably more.Rape Pregnancies Are Rare

People being horrible about rape, since forever.

With thanks to Katie J.M. Baker for her Jezebel post Fuck You, Rape Culture, which served as a comprehensive list of spoken justifications for rape that made the news this year.