Women, especially marginalized women, face unique barriers to participate in and access health care. There is a substantial body of evidence that shows how access-to-care bans in any form directly worsen health outcomes for patients. These bans also drive medical students, residents, and physicians away. By exploring both the historical backdrop and the present-day political determinants of health that influence health inequities, primary care clinicians can become better equipped to make person-centered, evidence-based decisions with patients about their health.
Key points
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Women, particularly marginalized women, historically and presently face increased barriers to routine medical care.
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The 3 political determinants of health are voting, government, and policy; together, these create the social determinants that exacerbate health inequities.
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Overall health outcomes, especially those for women and children, are worse in states with access-to-care bans.
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Legislative and judicial decisions regarding women’s health care directly affect residency applications and physician retention.
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Physician advocacy for patients’ access to equitable care is a powerful tool in the health care landscape.
Introduction
Among the many imperatives of modern-day primary care clinicians is to understand the historical context and modern-day political determinants of health that influence the positionality and lived experiences of their patients. One constant, dating back to the beginning of record keeping itself, is the drive for control over marginalized groups through political, socio-cultural, moral, and religious means. The oppression of women, particularly Black, brown, indigenous, disabled, and queer women, by limiting economic and political power, autonomy over one’s body, and choice in life’s pursuits, has wide-ranging roots across time and culture. This system of power and oppression is often exercised through expressly political means and for expressly political gains, and has far-reaching consequences over nearly every aspect of women’s lives, including the provision of women’s health care.
Formalized political control over women can be traced back centuries. In the 1700s, for example, governments began to develop a political rationale that conceived of “populations” as entities to be managed by the state. This concept effectively catapulted the traditional regulation of women’s bodies to a legally sanctioned necessity in service of birth rates and fertility. , Michael Foucalt, a French philosopher and historian, coined the term “biopolitics” to describe this practice and ideology, defining it as the political mandate for a government to “to ensure, sustain, and multiply life”.
Another lasting legacy of the intrusion of politics into women’s health is the construct of biology as destiny. This construct proliferated in colonial America and found its foothold in “natural truths” created by those in power to maintain systems of oppression. One “natural truth,” the “racial construction of whiteness,” rose to prominence in the United States, as well as biological gender differences grounded in the belief that women were innately inferior due to their reproductive physiology. , This nineteenth century “logic of difference” held that white, middle class women were delicate, less intelligent than men, and unsuitable for the public sphere. Even worse, the qualities attributed to women of color emphasized their racial difference over concepts of feminity, allowing for stereotypes of “bestial, promiscuous” Black women to foment and consequently provide justification for the enslavement, rape, and mistreatment of women of color. , These socially constructed differences imparted easy logic for ongoing oppression, and inevitably led to coercion and control across multiple spheres of women’s lives. Unsurprisingly, women’s health was and is no exception.
| Political determinants of health | Voting, governmental, and policy decisions that determine how systems are structured, resources are distributed, and power is administered. These decisions create the social conditions that drive health disparities. |
| Social determinants of health | Non-medical factors, including the conditions in which people are born, grow, work, and live, that affect health outcomes. Includes broader forces and systems that shape everyday life conditions. |
| Autonomy | The capacity and ability to make an informed, uncoerced decision. |
| Self-determination | A person’s ability to make choices and manage their own life and health care decisions. |
| Coverture | Common law concept in which a married woman is included in her husband’s legal status and therefore lacks independent legal rights, such as the right to own land, the right to her own bank account, and the right to vote. |
| Eugenics | The practice or advocacy of controlled, selective breeding of human populations to alter a population’s genetic composition. |
| Maternity care desert | A county where there is a lack of maternity care services and/or barriers to access. |
Politics, policy, and power
Political Determinants of Health
There are 3 primary categories of political determinants of health: voting, government, and policy. The uneven distribution of political power across these 3 spheres lays the groundwork for health inequities that have existed in the United States since its inception and persist to this day.
For example, the inability of women to participate in all 3 spheres of the aforementioned political determinants of health—voting, government, and policy—in the early days of the United States severely limited their ability to control their own health. Preventing women from accessing any means of political power was justified by the legal doctrine of coverture, which prohibited women, particularly married women, from having their own legal and political identity. Coverture also reinforced the notion of biology as destiny: because women were traditionally viewed as remaining in the home to raise children, policies were rarely crafted with women’s needs in mind. Today, though women have left the home and entered the workforce in droves, the vestiges of coverture linger in myriad ways. For instance, the lack of universal paid family leave reflects the long-held view that women remain in the home and therefore do not need protected or paid time to care for children or other family members.
At the same time, the predominantly male medical profession did not research women’s health and therefore understood little about how women’s bodies functioned. Most women sought care from non-physician health practitioners, the ranks of which were primarily made up of women. However, with the formation of the then exclusively white male American Medical Association (AMA) in 1847, physicians sought to “professionalize” medical practice. One of the first acts of the AMA in their work to “elevate” physicians above other societal healers was to advocate for nationwide restrictions on abortion. Their movement gained widespread political traction, and ultimately consigned women’s health to the shadows. An additional consequence of this movement was that women were also discouraged from becoming physicians.
The effects of this have reverberated for generations. The American Association of Medical Colleges (AAMC) previously noted that women did not start applying to medical school at even close to the same rates as men until 2003, and men continue to far outpace women in the upper levels of medical leadership. A consequence of this phenomenon is that there have been relatively few women in the medical field to champion women’s health-based research. As recently as the year 2020, only 10.8% of NIH research funding was allocated to women’s health research. The consequences of this are severe: women are underrepresented in clinical trials, meaning that medications are frequently less effective for women. Additionally, the lack of overall research into women’s health, as compared to men’s health, means that women spend 25% more of their lives in poorer health than men.
Women of color have faced additional barriers in achieving autonomy and self-determination over their bodies throughout history. The story of Henrietta Lacks is a commonly cited example of how women, particularly women of color, have been prohibited from making their own choices, highlighting how physicians have historically ignored principles of informed consent. In 1951, Lacks died of cervical cancer, mere months after presenting to the Johns Hopkins Hospital with vaginal bleeding. Without consent, her doctors collected and studied her cervical cells, finding that they thrived in the laboratory environment; her cells, named the HeLa line, have since underpinned a substantial amount of medical research. Lacks and her family never consented to the use of her cells for research, and have never received compensation for said use.
Court rulings further reflect the lack of autonomy women have over their bodies. In the 1927 case Buck v Bell , the Supreme Court upheld a Virginia statute allowing the state to sterilize institutionalized people it considered genetically unfit, paving the way for 30 additional states to enforce such laws. Coming at the height of the Eugenics movement, the ruling led to an estimated 60,000 people in the United States being forcibly sterilized between the 1920s and the 1970s.
The Women’s Health Movement and Roe v Wade
Starting in the 1960s, the tide began to change with the second wave of the Women’s Health Movement, a nationwide grassroots movement for women to gain control of their reproductive rights. An early success of the Women’s Health Movement was the Supreme Court ruling in Griswold v Connecticut (1965), which struck down the Comstock Act’s ban on contraceptives and ruled that the law violated a couple’s right to make private decisions.
A primary aim of the Women’s Health Movement was to legalize abortion. In the 1960s, approximately 1 million illegal abortions were performed yearly. Nearly one-third of women obtaining illegal abortions suffered complications requiring hospital admission, and 500 to 1000 women died annually as a result. With Roe v Wade (1973), the US Supreme Court ruled that laws banning abortion were a violation of the 14th Amendment’s implicit guarantee of the right to privacy, thereby making all US laws banning abortion unconstitutional.
Importantly, both Griswold and Roe were based on the right to privacy, a right that is not explicitly guaranteed in the 14th Amendment, but rather extrapolates from the right to liberty and due process. Furthermore, neither case was predicated on the equal protection clause of the 14th Amendment. For this reason, Roe not only became vulnerable to future court decisions that could reverse its precedent, but it also ignited an anti-abortion and anti-women’s health fervor in the decades after its passage. In the subsequent 50 years post- Roe , the anti-abortion movement successfully lobbied for a range of policies restricting abortion, including waiting periods and gestational age restrictions. Their goal was always the overturning of Roe , and their long-time efforts culminated in Dobbs v Jackson in June 2022.
Rather than settling the legal question, Dobbs v Jackson ’s reversal of Roe v Wade sparked a patchwork of state laws surrounding women’s health, shown in Fig. 1 from The Guttmacher Institute. Furthermore, since the US Supreme Court overturned Roe with the Dobbs decision, more and more data unequivocally demonstrate that the impacts on medical training and physician access are severe and worsening.
