4 Inclusivity of Gynecology and Obstetrics: An Exploration of the Past and Present Exploitation of Marginalized people, and how the US Medical System Continues to Uphold Systems of Oppression

Present-Day Medical Inequalities within the Fields of Obstetrics and Gynecology:

Obstetrics and Gynecology within the United States are known for having extremely disproportionate mortality rates based on race, with Black women being more than three times more likely to die from a pregnancy-related complication than White women.[1] Prominent factors that drive this statistic are stereotypes of Black women having abnormally high pain tolerances, Black women experiencing more over-medicalized births in the form of unnecessary cesarean sections, and medical paternalism, mainly directed towards marginalized people.[2] Healthcare accessibility within the United States, particularly reproductive healthcare, is a frequently debated topic, especially after the overturning of Roe v. Wade on June 24, 2022. Beyond reproductive care in the form of accessible abortions, however, is the reality of how different people are treated within the fields of gynecology and obstetrics. The disproportionate statistics and mistreatment of Black women within medical spaces are created and fueled by the legacy of the exploitation of Black enslaved women, which created the field of gynecology. Surgeries done upon enslaved women without the use of anesthetics enabled White physicians to gain a large amount of information on the human body without being held accountable for mistakes or worrying too much about ethics under the belief that Black women were “less” than human.[3] Persisting health inequalities in the modern world were created and are continually informed by the historical context in which women of color were seen as subhuman, which allowed exploitation and continual mistreatment to be justified.

Another common form of medical abuse is non-consensual surgery on intersex infants to make them more closely fit into the constructed binary of biological sex.[4] Historical and contemporary exploitation of intersex individuals is essentially what created the basis upon which modern trans medicine was built. Intersex and transgender people are another category of people who are considered less than human, due to their expressions of biological sex and gender being seen as abnormal and defined as deviant. Their lived experiences are too frequently overwritten or ignored, intended to be made invisible. Meanwhile, the current language surrounding obstetrics and gynecology favors gendered terms such as women’s health or maternal health, which overlooks the necessity of the same care for those whose gender identities don’t match their sexes assigned at birth, implying that they do not deserve care due to being defined as deviant. Both Transgender and Black women are not considered to be “real” women within society at large, with trans women’s identities being wholly invalidated and Black women historically being considered female but not able to access the privileges of femininity that cisgender White women are so accustomed to. With colonial gender definitions being built around white men and women being considered the norm, women of color and anyone who does not fit into the sex or gender binary are left to be defined as deviant.  Overall these realities show that it has been a long and ongoing battle to make the United States healthcare system more inclusive and accessible to marginalized people.

While I center my research within the United States, I will apply a transnational framework and perspective that acknowledges the impact of the example that America sets for the rest of the world in its position of power, and its continuing impact with the spread of colonial knowledge and power structures. I will mainly be utilizing the concept of intersectionality, coined by Kimberleé Crenshaw, as the main framework for my research, along with the work of two Black feminist collectives, the Combahee River Collective and the Santa Cruz Feminist of Color Collective. These works are complemented by Maria Lugones writing on The Coloniality of Gender and Gill Peterson’s Gender to explore how modern definitions of gender are racialized colonial organizations.  Thus, I am to showcase how the contemporary US medical complex is an extension of the coloniality of black and intersex folk that continues to marginalize and exclude non-normative identities from receiving gynecologic care. I argue that medical professionals contribute to the ongoing oppression faced by black and trans-identifying people while illuminating Western medicine as a tool of continued oppression. Through understanding the histories of Black women’s experiences with reproductive healthcare, the histories of intersex people’s experiences with modern medicine, and the present effects that both histories have on the care of different individuals, I conclude with ways the United States medical field can be made more inclusive for transgender, nonbinary, and intersex people of color and other marginalized communities.

The Importance of Intersectionality and Contextualization:

Intersectionality has become a very important concept in social justice work in recent years. Coined in 1989 in an academic paper titled Demarginalizing the Intersection of Race and Sex, Kimberleé Crenshaw first used the term intersectionality as a legal term to take into consideration the compounded discrimination that women of color experience on the basis of both gender and race.[5] Intersectionality emphasizes the connections between different forms of oppression and brings attention to how they are deeply connected. Crenshaw’s theory was put into the Oxford English Dictionary in 2015 and gained significant attention during the 2017 Women’s March, which caused it to become mainstream. Even though the theory of intersectionality is frequently critiqued and a topic of great disdain for many conservatives or far-right politicians, it is not the idea they are afraid of but rather the potential of how it could be implemented. Taking the theory and turning it into a hierarchy in which those with the most marginalized identities are placed at the top makes conservatives afraid of straight, cis, white men being placed at the bottom of what would be an “oppression pyramid.” Overall, an intersectional framework is a very effective way to acknowledge all aspects of someone’s identity and contextualize the specific forms of marginalization different people face.

Utilizing the concept of intersectionality before and after it was defined, both the Combahee River Collective, 1977, and Santa Cruz Feminist of Color Collective, 2014, emphasize and expand the necessity of considering the ways that different forms of oppression interact and inform each other when discussing or dealing with issues that women of color face. Supported by Lugones’s writing and further articulated through both Black feminist manifestos, women of color’s experiences cannot be fully understood or discussed without the inclusion of the ways that both gender and race intersect to inform their lived experiences. Beyond the intersections of race and gender, however, both manifestos go beyond the original understanding of intersectionality to include sexual and class oppression, which provide a more holistic and encompassing view of people’s lived experiences. The Santa Cruz Feminist of Color Collective defines women of color as a political identity and “a way of acknowledging our interconnections, reflecting upon our comment contexts of struggle, and recognizing the different ways that structures impose violence, separation, and war on each of us.”[6] Women of color have historically been prevented or discouraged from joining women’s movements, especially in early US women’s movements, such as the suffragette movement, which fought for white women while ignoring women of color’s contributions to the movement, along with their rights, in order to propel their own political liberation. The Combahee River Collective makes Black women’s solidarity with Black men clear by stating that Black women “struggle together with black men against racism, while we also struggle with black men about sexism.”[7] The identity of being a woman of color is not born into but rather created and informed by the intersections of multiple types of marginalization, mainly upon the basis of gender and race.

Along similar lines, Maria Lugones argues in her article, The Coloniality of Gender, that modern definitions and enforcements of gender are social constructions based on histories of colonialism. Lugones defines Coloniality as an “all-encompassing phenomenon” which “permeates all control of sexual access, collective authority, labor, subjectivity, and the production of knowledge.”[8] The historical racialized division of gender, especially in the United States, subsequently caused definitions of biological sex and gender to become extremely racialized. Race and gender are socially constructed categories that were created to enable the marginalization of certain people. They are extremely powerful constructions, as their definitions and enforcements created during the process of colonization are currently maintained and perpetuated through systems such as the US medical-industrial complex. Gender norms in the United States, being based around the experiences of middle-class cisgender White women and men of European descent, consequently alienate anyone else of a marginalized gender identity that does not fit into that category.

Lugones includes intersex people within her explanation of gender, stating that even though 1-4% of the world’s population is intersex, laws fail to recognize intersex individuals’ existence, even permitting non-consensual surgery on intersex infants to make them more closely fit into the socially constructed colonial binary of biological sex.[9] Lugones further supports her argument that the modern gender binary is a colonial construction by noting that intersex and transgender people were recognized and sometimes even celebrated in Indigenous and tribal societies prior to colonization. For instance, the history behind the beginnings of trans medicine relies heavily upon the surgical exploitation of intersex individuals, altering their bodies to make them more closely align with the constructed binary of biological sex.[10] Oftentimes these decisions were made based on what surgeries were easier to perform, choosing a sexual identity of a child based on what gave surgeons less work. In contrast, the difference between biological sex and gender, which is integral to queer theory, was popularized in the 1960s by Robert Stoller who was known for his research on trans and queer patients.[11] While definitions of sex are based upon biological features and gender on psychology and expression, the binaries within both categories are socially and colonially constructed.

Past and Present-Day Exploitation:

Serena Williams is an extraordinarily talented and famous tennis player whose story of birthing her first daughter became famous when her provider refused to administer a blood thinner at Williams’ request. The ignorance of Williams’s provider, given Wiliam’s own knowledge of her history with pulmonary embolism, almost cost her her life.[12] Unfortunately, even though this story was widely disseminated due to Williams’s status, Black women experiencing inadequate medical care, especially within gynecology and obstetrics, is not an uncommon phenomenon. The United States medical system has a long and treacherous history involving the exploitation of people of color and those who do not fit within the sexual or gender binary. The field of obstetrics and gynecology is particularly infamous for the foundation of the field explicitly relying on the abuse of Black enslaved women and having a long-lasting legacy with extremely disproportionate mortality rates for Black mothers and infants today. Even when controlling for education and income, “Black women in the United States are more than three times more likely to experience a pregnancy-related death than White women.”[13] Black infants have a mortality rate that is twice as high as White infants, and Black women have much higher rates of preterm births.[14] Black women also suffer disproportionate morbidity and mortality rates from cervical, endometrial, and ovarian cancers, higher incidences of infertility, and worse overall survival rates for all significant gynecological malignancies compared to White women.[15] These health disparities are also exacerbated by systemic racism, resulting in phenomena such as the wealth gap in which the average Black family has one penny of wealth for every dollar average White families have, largely created by the Federal Housing Administration notoriously distributing home loans based on redlining maps.[16] Overall, all forms of discrimination are extremely interconnected and work together to maintain the power and authority of a very small portion of the country’s entire population.

Within the legal system that protected and continued the United States institution of slavery, Black people, specifically Black women, were defined as being subhuman and animalistic.[17] These opinions not only justified the exploitation of Black people under slavery but also continue to affect how they are treated within the modern-day United States. Legislature that guaranteed status to be passed down to children through their mother further endorsed the sexual abuse and rape of enslaved women as one of their main jobs was to have children, providing more slaves for whoever they belonged to.[18] Because they were treated and defined as property, Black women could not legally consent or refuse violence from White men or White physicians in their quest to learn more about the human body. Gynecology particularly emphasized exploiting enslaved women to work towards dominating a field that had been previously feminized and mostly carried out by midwives and healers.[19] Definitions of Black women being deviant, abnormal, and inferior, were created and perpetuated in order to justify their marginalization and to benefit White men and their desire to dominate the fields of healthcare and science.

Dr. Marion Sims, known as the father of gynecology, is famous for his experimentation without anesthetics on young enslaved women. He began his experiments on Black infants who had vitamin D deficiencies, but after having no success, moved on to Black women in 1845.[20] He chose three women, Anarcha, Lucy, and Betsy, who all suffered from vesicovaginal fistula, one of the most distressing gynecologic complications. Anarcha was his first patient who underwent thirty experiments starting at age 17, and he continued his experiments until he found a cure for vesicovaginal fistula.[21] When none of the white women who came to Sims for treatment could bear the excruciating pain of the procedure, the stereotype that Black women are inherently better at handling the pain of childbirth was perpetuated. Throughout the twentieth century, forced or non-consensual sterilization was institutionalized as part of the eugenics movement and routinely used against Black, Indigenous, and other women of color.[22] In more modern times, Black women are more likely to receive C-sections even when they are not necessary, which contributes to their abnormally high mortality rates. Physician paternalism, defensive practice, and educating women not to trust their own bodily knowledge all contribute to women of color receiving higher rates of over-medicalized pregnancies.[23] In order to enforce domination and maximize profit, the US medical-industrial complex, historically and continually, utilizes social justifications of marginalization and suppresses alternative and spiritual forms of medicine.

Racist stereotypes that affect the care that Black women receive from physicians stem from the exploitation that Black enslaved women were forced to endure. An example of such a stereotype is the belief that Black women possess abnormally high pain tolerances, causing their pain to be ignored or overwritten. Modern racist stereotypes such as Jezebel, which portrays Black women as hypersexual, not only enabled the sexual abuse of enslaved women, but it continues to aid in enabling the continued mistreatment of women of color within the medical field. This knowledge, paired with the history of non-consensual surgical procedures carried out upon intersex infants, exposes the colonial and imperial formations of the United States medical field and the impacts those histories continue to have upon marginalized people when they receive care.

While current statistics are significantly lower due to intentional erasure and forceful enforcements to cause intersex people to fit within colonial gender norms, intersex infants could make up around four percent of all births.[24] Advances in physiology and surgical technology allow physicians to identify most intersex people quickly after birth. In many cases, these identified infants are put on hormones or operated on in order to make them fit into the binary constructions of “normal” men and women.[25] These forceful medical procedures are done beneath a supposedly “humanitarian” guise of enabling intersex infants to fit in and live “normal” lives.[26] However, this humanitarian justification only functions beneath a society that does not question the defined normalcy of the colonial binary gender construction or heteronormativity. Looking further back in history, there were three sexes according to Plato, being defined as male, female, and hermaphrodite, which implied a combination of male and female attributes.[27] In the era of the Middle Ages in Europe, hermaphrodites were legally forced to choose between identifying as a man or woman, and to stay consistent, with death being the frequent penalty for transgression.[28] Historically, intersex infants were viewed to possess deformities that affected biological sex, a characteristic that is normalized as being foundational and extremely societally important.[29] The concept of savorism for intersex individuals from a life of misery continues to justify the non-consensual surgeries that have become considered a commonplace practice or even treatment, since being intersex is largely considered to be an unwanted condition similar to a disease or deformity.

The Profound Effects of Labels:

The United States medical-industrial complex is largely a capitalist endeavor due to the lack of universal healthcare within the United States, and the overwhelming capitalist and consumerist nature of American culture. Its long history of exploitation of marginalized bodies as well as its continuing mistreatment of marginalized people exposes the depth to which the system, as well as those that work within the system, uphold discriminatory practices and beliefs. The fields of gynecology and obstetrics were born from the direct experimentation and exploitation of Black enslaved women by White physicians, and this legacy continues to affect how women of color are treated within the modern US healthcare system. The medical-industrial complex is extremely explicit in its usage of Lugones’s concept of the coloniality of gender, basing gendered definitions and concepts off of the colonial binary model of gender, entirely based on the lived experiences of White, cisgender, middle-class men and women.[30] It is through the upholding of colonial definitions of race and gender that the US medical system acts as another form of oppression, denying equal access or quality of healthcare to trans people or people of color.

Both racial- and gender-based marginalization are based on definitions of who is considered to be deviant. Deviance can be defined as being non-normative, which is a label that can be gained from engaging in certain types of behavior, or even just being part of a group that is labeled as deviant.[31] The act of defining behaviors or people as deviant enables cultural values and norms to be created, by forming a clear distinction from what is considered normal from what is considered abnormal.[32] When a behavior or the existence of something is considered deviant, it is often sought to be controlled by the broader society by using social control in the form of sanctions. These sanctions can be positive or negative; positive to encourage or affirm conformity, and negative to attempt to discourage further deviancy or to punish the previous act of deviancy.[33] The ability to define social norms inherently involves social power, as definitions of deviancy directly affect the lives and behaviors of all individuals within a society. Karl Marx argued that law is a medium by which the powerful elite are able to protect their own interests.[34] This argument is further articulated through the concept of conflict theory. Created and largely articulated through Marx’s sociological arguments, those in power are able to maintain said power by defining anything that threatens it as deviant and punishing it accordingly.[35] Sociological theories are effective ways of understanding how definitions and enforcements of deviancy are utilized as tools of domination and social control that support and maintain the interests of the elite ruling classes.

Throughout history, there have been many ways of attempting to explain deviance, the earliest of which being biological essentialist explanations that attempted to assert deviance being rooted in biological characteristics.[36] These biological explanations included associating certain physical characteristics with a greater likelihood of displaying deviance, such as a low forehead, stocky build, prominent jaw, or any other characteristics that were associated with more primitive ancestors or primates.[37] Both scientific and physical characteristics thought to be associated with deviancy were also heavily associated with people of color, and especially Black people within the United States. These “scientific” theories surrounding deviancy aided not only to justify slavery but also the exploitation of Black women in order to propel the medical field. The interactions of both racial- and gender-based deviance defined Black women as female, but denied their personhood, viewing them only as a means of providing a larger labor force throughout slavery and beyond. Modern racist stereotypes such as Jezebel and the myth of Black women’s inherently greater pain tolerances, specifically with labor, continue to portray Black women as deviant, contributing to their mistreatment and subsequently disproportionate mortality rates and over-medicalized births.

The term of deviancy is also used against intersex individuals and justifies the non-consensual surgeries and hormone treatments that are given to intersex infants quickly after birth. The definition of intersex people as abnormal or deviant enables non-consensual procedures to be considered helpful, in protecting the affected infant from having to live a more difficult life, merely for existing within the body they were born.[38] The fact that being intersex is defined as having a deformity from the broader medical system creates an environment in which the mere existence of an intersex person is stigmatized and they are viewed as needing help or aid in order to embody conformity. Since both women of color and transgender people (specifically transwomen) are defined as deviant, they are treated as sub-human and deemed unworthy of experiencing the privileges of femininity, mainly protection and providing from men. In contrast to how intersex surgeries are viewed, modern gender-affirming healthcare and surgeries are generally defined as “bodily mutilation,” especially within conservative politics. Society’s hatred towards breaking gender norms by moving across gendered boundaries is exemplified through both the justification and positive view of non-consensual intersex surgeries, and the modern condemnation of gender-affirming care.

Physicians are not exempt from the broad biases of society, and thus the definitions of the deviance of women of color, transgender people, and intersex people, are upheld by the ideologies and practices of physicians within the US medical-industrial complex. This trend is exacerbated by physician paternalism, which gives individual physicians great power in determining the treatments of their patients, and the socialization of female patients which teaches them not to trust their own bodily instincts.[39] Overall, the hegemonic culture of the US medical system that renders bodily instinct and spirituality obsolete, creates a system in which societal biases and definitions of deviance are upheld and perpetuated through the inequitable care of marginalized peoples.

Articulated largely through the two Black feminist statements, The Combahee River Collective and Santa Cruz Feminist of Color Collective, Black women cannot be liberated without liberating their oppression on accounts of both race and gender. Putting this sentiment in conversation with the concept of intersectionality creates a broader generalization that acknowledges the interconnectedness of all forms of oppression. This interconnectedness subsequently emphasizes the reality that no form of oppression can be individually liberated. Instead, progress to challenge or eliminate one form of oppression positively affects all other forms of marginalization.

Looking Forward:

The United States failing to have universal healthcare has been recently discussed more frequently, especially in comparison to other countries’ healthcare systems. This fact, along with the systemic construction of the medical-industrial complex within a capitalist country with an extensive history of colonization, inevitably turns healthcare into another tool that perpetuates broader societal biases and discrimination. As a non-binary individual with extreme empathy and ties to both transgender and intersex-identifying people, healthcare inequalities is a topic that is extremely personally pertinent. The realities of the history of gynecology within the United States, with the experimentation on enslaved women by White physicians such as Marion Sims, continue to greatly impact the treatment and outcomes of Black women’s experiences with labor. The deviant categorization of both women of color as well as intersex and transgender people makes obstetrics and gynecology a particularly interesting field in which to study health inequalities.

The story of Serena Williams’ birth exemplifies the modern ignoral of Black women’s voices and instincts for the favor of physician paternalism and displays how legacies of slavery and systemic racism continue to impact Black women’s experiences with the US medical complex. Racialized notions of gender that caused Black women to be viewed as less than human in order to justify their mistreatment and enslavement, continue to have profound effects on the medical outcomes of Black people’s labor and births. Systemic racism, a label of deviancy, and racist stereotypes (such as the myth that Black women inherently feel less pain or are better suited for childbirth) largely explain the modern racial health inequalities that are so common and widespread within obstetrics and gynecology.

Intersex individuals, who are similarly defined as deviant, are subject to an extreme form of physician paternalism. This paternalism explains the non-consensual surgeries and hormone treatments that are imposed upon intersex individuals as infants, as aid from physicians to help them fit into societal standards and attain conformity. Definitions of deviance largely manifest as a technique for the elite ruling class to control and limit behaviors and groups of people that they perceive to be threats to their power. Through exploring the ways in which labels of deviancy affect the care that Black women, transgender, and intersex people receive, it becomes clear that language and labeling are extremely powerful examples of social control, which in many cases, help to perpetuate the power of the ruling class. In the case of the United States medical-industrial complex, physicians are also largely affected by societal definitions and biases which greatly affect the ways in which they view marginalized people and provide them with care. Generally, the large number of physicians that are implicit in upholding societal marginalization within their practice, greatly contribute to the statistics that exemplify modern gynecological and obstetric inequalities.

Two Black feminist statements, the Combahee River Collective and Santa Cruz Feminist of Color Collective, explore the inherent intersectionality that is involved when discussing the oppression of women of color, and more generally emphasize the interconnectedness of all forms of oppression. The United States medical system is grounded within European enlightenment philosophies that define rationality and empiricism to be the only true forms of knowledge. Because of this, spirituality, intuition, and other alternative forms of knowledge are devalued and broadly erased from the ways in which physicians provide care for their patients. Obstetrics and gynecology, although dominated by women, continue to be extremely disproportionate in the care that they provide for those of marginalized identities. The current silencing of Black people’s pain along with the exclusive use of gendered terminology causes many people who are in need of gynecologic care to feel intimidated, unheard, and undervalued. In order to confront and dismantle the pertinent inequalities within obstetric and gynecologic care, it is vital that the perspectives and experiences of transgender and intersex people of color are centered. Only when the true stories of trans and intersex people of color are heard by physicians and society at large, can we begin to dismantle the inequalities that are so prevalent in the modern healthcare system.

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