Bedside Manners

This month’s column features our first guest-post from Liz Borkowski, MPH. Liz is the managing editor of Women’s Health Issues and a researcher at the George Washington University Milken Institute School of Public Health. She focuses on reproductive health, paid leave, and US health policy, and is a regular contributor to the public health blog The Pump Handle.


What’s the best way to help lesbian and bisexual (LB) women lose weight, when their communities may question the very goal of weight loss? That’s a question behind the “Healthy Weight in Lesbian and Bisexual Women: Striving for a Healthy Community” (HWLB) initiative. The answer they came up with was to focus the program on physical activity and nutrition, rather than numbers on a scale. Their findings suggest that this can be an effective approach for helping lesbian and bisexual women adopt healthier habits. Nearly all (95%) of participants achieved one or more of the health objectives, which included nutrition and physical activity goals as well as weight reduction. That included 57% of participants increasing their weekly physical activity minutes by 20% – habits that, if sustained, could contribute to years of improved health.

041/365 - April 29, 2009

The Women’s Health Issues supplement about the study contains lessons for healthcare providers who serve lesbian and bisexual women. As Natalie Ingraham and her colleagues explain in an article about provider interventions, lesbian and bisexual women may not disclose their sexuality to providers who seem to presume heterosexuality; lack of disclosure can lead to inadequate care. Weight bias can also be common among healthcare providers:

“…stigma and discrimination related to sexual orientation and gender identity may be compounded by stigma related to weight and body size.”

To address this, the researchers developed and evaluated two curricula for providers to enhance their ability to provide high-quality care to LB “women of size” (overweight or obese). Focus group participants explained that they wanted providers’ help in overcoming barriers to healthy habits, not providers making them feel shamed or blamed for their weight. Based on this feedback and prior studies, the team developed two curricula that involved cultural competency training and motivational interviewing (MI) techniques:

“Rather than trying to convince clients to change, providers trained in MI elicit arguments for change from the clients themselves…These techniques help clients to explore and resolve ambivalence, develop self-efficacy, and set personal goals.”

The team pilot tested the “academic format” training with physicians, residents, and medical students at universities in Washington, DC and Nashville, Tennessee. They pilot tested the “clinic format” training with staff and providers at Lyon-Martin Health Services, a Program of HealthRight360, which provides care to LGBT clients in the San Francisco Bay Area. Ninety-six participants completed tests before and after the trainings; results showed the most change on questions about patient-provider interactions and LB women’s avoidance of care.

Specifically, after the trainings, more participants (correctly) agreed with the statements “Lesbians and bisexual women may avoid health care because they don’t trust the practitioner to be culturally competent” and “Overweight and obese women often delay or avoid health care if they feel their health care provider holds a bias against women who are large.” More participants also (correctly) disagreed with the statement “Physicians/nurses should always instruct their overweight/obese patients to lose weight.” There was also more (correct) agreement with this statement, which encapsulates what providers can do to help overweight clients:

“Patients who are advised by their physician how to modify their behavior to lose weight are more likely to lose weight than those who do not get this advice.”

While the authors of this article note the need for additional research on these curricula – including studies to see whether they improve clinical practice – their findings, combined with the findings of the overall HWLB study, have some clear implications. Instead of instructing all overweight or obese lesbian and bisexual patients to lose weight, providers should offer advice on adopting healthier behaviors. It is key that this advice be presented in ways that don’t contribute to stigma on the basis of larger size or sexual orientation.  To better serve lesbian and bisexual patients, health care providers should familiarize themselves with cultural norms and problematic stigmas that LB women may face. Then, during patient interactions they should make sure to sensitively include “open and positive acknowledgement of sexual orientation.”

This month’s column features our first guest-post from Dana Benyas. Dana followed the pre-med track at the University of Michigan, graduating with honors in Sociology when she earned her Bachelor’s Degree in 2014. Interested in increasing access to preventive healthcare, especially reproductive health care, Dana reports on the findings from her undergraduate thesis.


Women who have unplanned pregnancies or contract sexually transmitted infections (STIs) are often incorrectly stereotyped as being promiscuous, poorly educated, from a minority group, or as having low self-esteem. It is dangerous but easy to indulge the rhetoric that “those kinds” of women have unplanned pregnancies or STIs because they made poor decisions.

Engaging in unprotected sex is fairly common among all women, with about one-third of U.S. women at risk for unplanned pregnancies reporting that they do NOT consistently and correctly use contraception. However, given sexual stereotyping of “at-risk” women, I questioned if social status would influence a woman’s autonomy in making sexual-safety decisions. In other words, would privileged, highly educated, and motivated women make risky sexual safety decisions when labeled with a diminished status in an isolated social status system?

I conducted interviews and anonymous surveys for my undergraduate thesis on how social status influences the sexual safety patterns of sorority women at an elite public university in the Midwest. At this university, the fraternal system has well-known rankings, whereby a woman’s sorority affiliation equates with a social status ranking (1 being the highest and 5 being the lowest). These rankings supposedly indicate coolness, greater wealth, attractiveness, and gregariousness. The vast majority of the 23 women I interviewed were from upper-middle class and upper class families. All were obtaining Bachelors degrees from an elite institution, and many planned to pursue Masters or Doctorate programs. They were born into a privileged status, but, within Greek Life, they did not necessarily feel privileged.

Sorority women’s sexual experiences varied greatly depending on their sorority’s rank. Women in lower ranked sororities felt more pressure to have sex and/or have unsafe sex with higher-ranked fraternity men:

We were at [a tier 1 fraternity]… It was my first time there and I was talking to this kid. My friends thought we were going to hook up. We ended up not… The next morning my friend was like, “Did you ever hook up with that kid?” and I was like, “No” and she said, “But he was in [a tier 1 fraternity]!

Generally, the women preferred condoms to be used, unless they were in exclusive relationships. Conversely, all women assumed that all men did not want to use condoms. These conflicts of interest were exaggerated since men, not women, were expected to carry condoms. Another interviewee elaborated on how power imbalances may translate to condom use.

It’s a hierarchy, so the [people] in the higher tiers have more power. I think that definitely manifests itself within their personalities and their actions…[fraternity guys] would think that they can just not use a condom if they don’t want to, especially if it’s a girl from a lower tier. It’s like her opinion doesn’t matter as much.

With these assumptions in mind, engaging in unprotected sex signified a woman’s concession to take more sexual risk than she preferred.

Unable to measure frequencies of unprotected sex, I measured women’s Plan B emergency contraception use and STI diagnoses as proxies. A limitation of these measures is that I did not control for timing or type of STI testing, so some STIs may have been underreported. In addition, Plan B use and STI diagnoses do not equate with unprotected sex: Plan B may be used to quell concerns of condom breakage, and some STIs may be contracted even with the correct and consistent use of male condoms.

The 71.4% of all STIs reported came from tier 2, compared to an even spread of the remaining 28% of STIs across all tiers. Additionally, 38.5% of all Plan B use was in tier 2, compared to an even spread of Plan B at 20% per tier. Women in tiers 2, 3, 4, and 5 saw men give preferential treatment to higher ranked women (i.e., invites to fraternity events and notably greater interest/effort by men in one-on-one interactions). Tier 2 women were invited to a few top tier fraternity events, so they witnessed the preferential treatment tier 1 women received: revered status felt like a missed opportunity. Contrastingly, lower ranked sororities had difficulty getting invites from fraternities of any rank. Those in the second highest tier being most marginalized aligns well with literature on high school cliques, where second tier “wannabes” put aside their own wishes to appease higher status peers.

Women in the lowest status, tier 5, were openly teased in social settings and excluded from romantic opportunities in Greek Life. The majority of tier 5 women I interviewed did not have intimate relationships. Therefore, it is difficult to say whether these women would have succumb to sexual pressures from men to have unprotected sex or have rejected the tier system to preserve self-esteem. To feel more power in sexual decision-making, women in tiers 3 and 4 commonly dated outside the fraternities or dating lower-tiered fraternity men.

Similar results come from studies about people with inferior status not negotiating sexual safety. Green’s research on gay hook-up culture found status rankings based on “erotic capital,” or a sense of power and skill within the sexual-social marketplace. High erotic capital provided men more desirability, more power, and therefore the right to select the kind of sex they wanted—protected or unprotected. Their partner was complaisant, because they felt lucky to have been selected for the sexual experience. England found women’s ability to stay on course with family planning depended on college enrollment, a  representation of socioeconomic status. She found that women with higher socioeconomic status more commonly followed a consistent contraception regimen, compared to women with lower socioeconomic status. Lower socioeconomic status made it more difficult to find suitable and affordable birth control, making consistent contraceptive use unrealistic. Also, women in a lower socioeconomic status felt they had less autonomy and became accustom to altering their lives to deal with challenges.

My study shows a correlation between diminished social status and greater likelihood of unprotected sex. Concession to unprotected sex is not a result of amoral character or a lack of sex education; rather it is a response to negotiating status imbalances between romantic partners.

Yet, there is a distinct difference between the women I studied who had unprotected sex and stereotypes about the kind of women who have unprotected sex. The majority of women I studied were diligently on oral contraceptives or LARCs, diminishing risks of unplanned pregnancies, but not of STIs. Those not using oral contraceptives or LARCs either identified as “virgins” or were in tier 1 sororities, where male partners easily consented to condom use. Finally, access to healthcare was unanimous across tiers: they could all easily manage the cost of oral contraceptives, emergency contraceptives, and STI testing. Coming from affluent families, health insurance and comprehensive sex education were norms in their communities.

Unwanted pregnancies and untreated STIs can negatively impact women and society at large. Without the luxury of high-quality, affordable healthcare, women who seem to fit negative stereotypes may simply lack access to contraception, abortion, STI testing, and treatment. Let’s stop inappropriately categorizing women who have unprotected sex, and instead work towards increasing access to sexual health education, reproductive health care, and birth control resources for all women.

Photo Credit: Jennifer Rothchild

This month, I bring you a guest post which sheds light on current events, events that literally hit home for me when the Planned Parenthood clinic closest to my university was attacked by arsonists. I welcome back Jennifer Rothchild, Ph.D. Associate professor of Sociology and Coordinator of the Gender, Women, & Sexuality Studies (GWSS) Program at the University of Minnesota, Morris, she is one of the founders of the American Sociological Association’s section on the Sociology of Development. She currently researches gender and development, health, childhoods, and social inequalities by examining the intersections of gender, sexuality, and reproductive health in the United States and abroad.


“Choose mercy! While there is still time!” A man shouted to me as I walked into a Planned Parenthood office. I couldn’t see him, which made the comment oddly affecting. I kept my eyes forward and pushed through the front door.

More than 20 years ago, my friend Kat had told me about her first trip to Planned Parenthood. As she left that building, a woman standing outside approached her, grabbed her shoulders, and cried, “‘DO YOU KNOW WHAT YOU HAVE JUST DONE? DO YOU KNOW WHAT YOU HAVE DONE?’”

I will turn 45 this February, and yesterday was my first visit to Planned Parenthood. Shame on me: a self-proclaimed activist, and a gender and sexuality scholar. Until now, my privilege had allowed me to get all the women’s health care I needed through medical clinics and private practice physicians. All covered by insurance. But I knew Planned Parenthood was always there, should I ever need their services.

I had a health problem, and this time I chose Planned Parenthood because that is what it is: a health clinic. The woman at Planned Parenthood who booked my appointment warned me: “You should know that this clinic will have protesters. Turn into the parking lot, and a volunteer will help you get by the protesters, and then park.”

There are many misconceptions about Planned Parenthood; here are some facts:

  • Planned Parenthood services include STD/STI (sexually transmitted disease/sexually transmitted infection) testing and treatment for both men and women, cancer screenings, contraception, abortions, and other health services.
  • Abortions make up less than 3% of the services provided by Planned Parenthood.
  • Federal funding for Planned Parenthood is only for Title X: restricted to family planning and STI testing.
  • Planned Parenthood clinics that provide abortion services do not receive any federal funding, even if those particular clinics also provide services that meet Title X criteria.

On a rainy, cold morning, I arrived at Planned Parenthood, and a volunteer waved me into the parking lot. Next to this volunteer stood a protester, holding a sign about texting a certain number before “aborting.” I wondered if these two women talked to each other as they stood together in the rain?

Once inside, I was overwhelmed by a need to express gratitude to everyone I met. I assumed that most Planned Parenthood patients felt same way, if not always vocalizing their sentiments. But I was wrong. My intake nurse told me that just that morning a patient told her, “I hate who you are. I hate what you do. I don’t want to be here, but I need birth control pills.”

Her story made me wonder about the level of denial and disconnect that must be actively maintained to keep those ideas working side by side. In 2012, Frank Bruni wrote in the New York Times about a doctor who performed abortions:

He shared a story about one of the loudest abortion foes he ever encountered, a woman who stood year in and year out on a ladder, so that her head would be above other protesters’ as she shouted ‘murderer’ at him and other doctors and ‘whore’ at every woman who walked into the clinic.

One day she was missing. ‘I thought, ‘I hope she’s O.K.,’ he recalled. He walked into an examining room to find her there. She needed an abortion and had come to him because, she explained, he was a familiar face. After the procedure, she assured him she wasn’t like all those other women: loose, unprincipled.

She told him: ‘I don’t have the money for a baby right now. And my relationship isn’t where it should be.’

‘Nothing like life,’ he responded, ‘to teach you a little more.’

A week later, she was back on her ladder.

That morning, security was at a premium at the Planned Parenthood clinic: a guard stood at the front door, and I needed to show him identification. I was given a name tag that read only “Jennifer.” A few minutes later, “Jennifer R.” was summoned from the waiting room. I wondered how much money could be saved and put to better use if Planned Parenthood didn’t feel compelled by threats and attacks to spend on security measures.

In the waiting room I saw young and old women, white and black and Latina. There were men, too. I couldn’t imagine the individual stories that brought them to Planned Parenthood. But, I might have assumed they all shared was a lack of access and means to the kind of health care that should be their right. According to a 2012 report from the Government Accountability Office, 79% of people receiving services from Planned Parenthood lived at 150% of the federal poverty level or lower (that comes out to around $18,500 per year for a single adult). These people live in vulnerable conditions, where an unplanned pregnancy could result in future burdens, unfair and disproportionate in consequence.

If Planned Parenthood clinics are shut down, we will see not only tremendously diminished reproductive health but also epidemic numbers of unplanned pregnancies and unsafe abortions, as well as greater needs for social services such as WIC. Concerns for women’s health aside, Planned Parenthood delivers mercy upon people who benefit from its services.

The nurse practitioner spent time talking with me, getting to know me. I told her how grateful I was for the work she did. She graciously explained, “I started working here 15 years ago to educate women about their bodies. Women don’t know their bodies.”

Driving out of the parking lot, I stopped and rolled down my window to thank the same volunteer who had stood in the rain when I arrived, waving me into the parking lot. There was now a different protester. This woman was young, white, blonde, and wearing a pink raincoat. She could have been a twenty-something version of me. In her hand, she clutched a brochure limp from the rain. Her sad gaze followed me as I drove away. I wish she saw and knew the things I understood.

I also wish everyone understood that Planned Parenthood volunteers, nurses, and doctors risk their own safety and well-being because women’s health—and women’s lives—hang in the balance. These women and men are standing up and fighting for me, fighting for you.

“Choose mercy.” Yes, we should.

This month, I bring you a guest post that reminds us of a prevalent crime which is often kept secret, causing both physical and mental health issues for survivors. I welcome Jennifer Rothchild, PhD, to Girl w/Pen. She is Associate Professor of Sociology and Coordinator of the Gender, Women, & Sexuality Studies (GWSS) Program at the University of Minnesota, Morris. One of the founders of the American Sociological Association’s Sociology of Development section and author of the book Gender Trouble Makers: Education and Empowerment in Nepal (Routledge, 2006), she researches gender and development, families, childhoods, and social inequalities.


One in five women will be assaulted in their lifetime. But in my story, it was 3 out of 5 women.

I was one of the lucky ones. There are five of us best friends.  Three were raped. Their stories are their stories, and not mine to tell. But I will and want to tell you, as I tell my students when we talk about intimate violence, it could have very easily been me. My friends’ stories and mine are exactly the same: Our families and home lives were similar, we went to school together and had the same classes. We went to parties together, and we more often than not drank at those parties. We wished for the same boys to notice us, to like us. We all flirted with the really cute ones. Our lives were mirrors of one another. The only difference: One other friend and I just got lucky. She and I do not have our own story of rape.

That was the 1980s and 1990s. Flash forward to today: Those women and I are still best friends. We are professionals, partners, mothers. Are my friends who were assaulted “over it?” No. They are happy and successful, but they never will be “over it.”  The White House Council on Women and Girls (2014) reports that sexual assault victims often suffer from a wide range of physical and mental health problems that can follow them for life – including depression, anxiety, chronic pain, diabetes, sexually transmitted diseases, eating disorders, and post-traumatic stress disorder.  They are also more likely than non-victims to develop alcohol and substance abuse problems and attempt or consider suicide.

Again, 1 in 5 women – or nearly 22 million – have been raped in their lifetimes. In calculating the prevalence of rape, The Centers for Disease Control and Prevention (CDC) counts completed forced penetration, attempted forced penetration, or alcohol/drug facilitated completed penetration.  Like other researchers, the CDC considers attempted forced penetration to fall within the definition of “rape” because that crime can be just as traumatizing for victims.  As the CDC further explains, the most common form of rape victimization experienced by women was completed forced penetration: 12.3% of women in the United States were victims of completed forced penetration; 8% were victims of alcohol/drug facilitated completed penetration, and 5.2% were victims of attempted forced penetration. These are lifetime estimates, and a victim might have experienced multiple forms of these subtypes of rape in her lifetime.

By now, most of us have heard the story of “Jackie” who claims to have been gang-raped at a fraternity house at the University of Virginia and the fallout from her story in Rolling Stone magazine now under dispute. Less well known is the story of Emma Sulkowicz, a visual arts major at Columbia University, who is carrying around her dorm mattress until her rapist is removed from campus. Sulkowicz says she was raped in her dorm room bed when she was a sophomore, and as her senior thesis project, she carries her mattress everywhere as a visual representation of the violence she bears.

What’s happening here?

As a sociologist who focuses on gender and sexuality, I argue that there is a confluence of sex and violence. Specifically, the way we socialize girls and boys about sex has deep and intractable roots in violence. I assert that in order to address and understand this we need to put our sociological imaginations to work.

C. Wright Mills’ “sociological imagination” begins with his concept of “a personal trouble,” what one thinks of as a private matter, exclusively their own and not experienced by anyone else. For my best friends, my students, and the women whose stories have been splashed all over the news and the sexual violence committed against them—each woman could think of her story as a personal trouble of her own. Mills notes:

…people do not usually define the troubles they endure in terms of historical change and institutional contradiction… Seldom aware of the intricate connection between the patterns of their own lives and the course of world history, ordinary people do not usually know what this connection means for the kinds of people they are becoming and for the kinds of history-making in which they might take part.  (1959:3-4)

But the troubles for these women are not only their own. Mills would contend that they are also “public issues,” reflecting just one of many such “troubles” that comprise a complex organization “of an historical society as a whole… [troubles that] overlap and interpenetrate to form the larger structure of social and historical life.” As such, personal troubles such as “Jackie’s” are connected to public issues, such as gender inequality and the way we define sex in our society.When we situate individual stories like “Jackie’s” in a broader social-historical context, we can visualize the intersections of individual biographies within social structures. We are then, as Mills argued, better equipped to not only understand society, but also to transform it.

In my individual biography, I was lucky, and still feel lucky. I am also angry. I am angry that my friends were hurt. I am angry that people I care about are still being hurt. I teach about intimate violence, and every year, I talk about trigger warnings and offer students an “out” if the material is too painful for them. I  Every single year, I have at least one or two students come forward and explain that they have been victimized—either directly or as a secondary victim—and would like to not participate in my section on intimate violence.

And just last week, a student in another class came to my office to tell that she had been gang raped last year, and also a former student emailed me to share the story of her having been recently sexual assaulted.

Clearly, these stories do not happen in isolation. Sexual assault is a public issue. The sexual assault epidemic is real, even if sometimes reporters get it wrong.

I was lucky, but whether or not individuals are sexually assaulted should not be about luck. Not just sociologists, but all of us need to think critically about how we socially construct both gender and sexuality and how we socialize youth to think about sex and violence. Using our sociological imaginations we can move towards positive social change. Because, in the case of sexual assault, one is too many.

This month’s column features a guest-post by Mary K. Assad, Ph.D.: she critiques recent health debates on nutrition and encourages us to question the science behind medical claims being made about heart disease.  Assad is a Lecturer in the English Department at Case Western Reserve University who studies medical rhetoric, with a focus on health communication aimed at the general public.


In The Big Fat Surprise (2014), investigative journalist Nina Teicholz “lays out the scientific case for why our bodies are healthiest on a diet with ample amounts of fat and why this regime necessarily includes meat, eggs, butter, and other animal foods high in saturated fat.” She argues that current medical guidelines are based on unproven hypotheses about dangers of saturated fat.

Teicholz’s book echoes arguments of writers including Gary Taubes, who in a 2002 New York Times essay and subsequent books urges that medical recommendations for a low-fat diet have caused America’s obesity epidemic. Multiple sources have condemned low-fat approaches and urged Americans to consume more fat and fewer carbohydrates: e.g.,  Dr. Peter Attia’s Eating Academy, Mercola Products and PCC Natural Markets.

As a medical rhetorician and writing instructor, I care about how health messages aimed at the general public transform medical information into public knowledge. We learn about our bodies and health through such discourse. However, distinguishing fact from fiction within these conversations is often more challenging than deciphering the original research studies because writers with competing arguments all cite “science” as their evidence.

While researching women’s heart health for my dissertation, my professional and personal worlds collided: I learned I had high cholesterol at age 29 despite a low BMI and regular exercise. Based on my doctor’s advice (which resembled the American Heart Association’s guidelines), I drastically revised my diet and realized that “burning off” calories is not the same as preventing arterial blockages. Yet, what if my doctor’s advice was misguided? What if reducing cholesterol and saturated fat would hurt rather than help me? The Big Fat Surprise and similar texts call into question decades of medical guidelines. They aim to do more than stir controversy: they seek to persuade us to change our approaches to healthy eating and to distrust medical advice that, presumably, was based on faulty science.

However, close inspection of these texts reveals that they often misrepresent medical research when translating it for the general public. For instance, Attia asserts: “Eating cholesterol has very little impact on the cholesterol levels in your body. This is a fact, not my opinion. Anyone who tells you different is, at best, ignorant of this topic. At worst, they are a deliberate charlatan…To see an important reference on this topic, please look here .” The linked abstract states, “the relation between dietary cholesterol and the risk of CHD [coronary heart disease] is not clearly understood.” Nowhere does the source state that ingesting cholesterol has “very little impact.”  Further, this article raises the possibility that 15-25% of the general population are “hyperresponders,” meaning that dietary cholesterol affects their measured LDL cholesterol more than usual. The researchers urge the importance of examining the relationship between dietary cholesterol and CHD among this group. Attia acknowledges none of this information.

By providing a link to a medical journal, Attia points to medical authority to support his argument without acknowledging how this source complicates or contradicts his claims. This tendency to draw on medical evidence by gesturing toward research, rather than actively conversing with it, is problematic: readers may be drawn in by liberating claims (eat as much red meat as you want!) because they believe them to be scientifically supported.

Indeed, the summary for Teicholz’s book proclaims, “science shows that we have needlessly been avoiding meat, cheese, whole milk, and eggs for decades and that we can now, guilt-free, welcome these delicious foods back into our lives.” In a culture where we are conditioned to feel guilty for eating indulgent foods, promises of dietary freedom may be persuasive because they tap into social — and particularly female — anxieties about weight, food, choices, and guilt.

As a woman, I am conscious both of the social pressures to “watch what I eat” and the medical guidelines that advise the same. However, navigating competing claims to scientific truth requires interrogation of not only the claims but also the ‘means of persuasion’.  A rhetorical approach creates a critical distance between health messages and our decision-making processes.  When reading an article, book, or website, we must ask several key questions: What is this text trying to persuade me to believe or do?  How does it go about accomplishing this task? What evidence is offered, and how is it presented?

Over the past year, I’ve read about cholesterol from many sources but have been most persuaded by a friend who told me how a vegan diet reduced his cholesterol. In closing, then, I ask: who or what has persuaded you to make a health-related decision in your life, and what made the claim convincing?  Conversations about health need to include attention to language and persuasion. Only then can we begin to make sense of what we’re being told and determine how to respond.

In honor of Mother’s Day, I ask readers to consider the ramifications of a new law about pregnant women which has dangerous implications for the health of mothers and babies. The author of this guest post, Chelsea Carmona, is a writer and drug treatment activist whose writing has been featured in major media outlets like Time, The Washington Post, The Guardian, and Al Jazeera English. She works for The OpEd Project, a social venture founded to increase the range and quality of voices we hear in the world.


107729240_3278d325a5_mCan you imagine being prosecuted and potentially incarcerated for taking an FDA-approved, legally prescribed medication – a medication both the World Health Organization and the Institute of Medicine agree is the most effective treatment for your affliction?

Starting July 1st, this is a real possibility for pregnant women in Tennessee undergoing methadone maintenance, an evidence-based pharmaceutical therapy known among experts as the “gold standard” of treatment for opioid addiction.

The bill, signed into law on Tuesday — despite avid opposition from addiction experts, reproductive health advocates, and virtually every major medical association — authorizes the arrest and incarceration of women who use illegal drugs while pregnant.

The law does nothing to expand treatment options for addicted women, but proponents maintain the intention is to help pregnant women struggling with substance abuse get into programs. Considering only 19 of Tennessee’s 177 addiction treatment facilities provide any form of care to pregnant women, this is going to be a challenge.

Targeted women can avoid criminal charges if they complete state-approved treatment, but the Tennessee penal code doesn’t specify what constitutes an “addiction recovery program.” In 2007, the 9th Circuit Court ruled that forced attendance in 12-step programming (Alcoholics Anonymous) is unconstitutional, but this model still reigns supreme in treatment today, leaving methadone maintenance highly suspect.

Advocates for pregnant women share concerns that the widespread ignorance of maintenance treatment could leave pregnant women on methadone vulnerable to prosecution, even though such treatment is widely considered the standard of care for opioid-dependent, pregnant women. The language of the new law does not specifically exempt these women from prosecution, making following doctors’ orders a potential crime.

Sadly, this can’t be surprising to anyone familiar with maintenance treatment. Although advances in science have helped us to establish a more comprehensive understanding of the disease, we have a deeply entrenched narrative of drug addiction in our culture. This new law, which will only scare women away from seeking the prenatal and addiction care they so desperately need, is the result of this misguided and moralistic view.

Opponents of the law also worry that it will result in disproportionate jailing of poor pregnant women and pregnant women of color, particularly those living in rural districts where there is significantly less access to treatment. And they are right to be concerned.

According to The National Center on Addiction and Substance Abuse at Columbia University, even though women fare just as well in treatment as men, 92% of those in need do not receive it. This is in large part due to practical reasons: Women are more likely to live under the poverty line and therefore less likely to be able to afford costly inpatient programs and the childcare services that may be necessary for them to attend.

Women were actually mobilizing to advocate for feminist-based solutions to the problem of addiction as early as the late 1960s, but locating and gaining access to effective treatment is still infuriatingly difficult. Few treatment programs have separate women-only programs, and even fewer offer programs for pregnant or post-partum women.

With the shrinking gender gap in addiction, it’s time we take into account the gendered experiences that occur throughout addiction and cultivate a more compassionate, comprehensive perspective, one that is actually conducive to helping women achieve sobriety.

For example, detailed, individual aftercare is a critical service for all addicts, but it is particularly important for women in using relationships. Women are often introduced to drugs and drug using rituals by a significant other, and rather than causing conflict, the use becomes a way to strengthen the bond. Although treatment stresses the importance of social networks, the loss of a using companion is always difficult — sometimes much more difficult than the loss of the addictive substance itself. By providing feminist-based aftercare — like housing-assistance, vocational counseling, and community development programs — recovering female addicts are much more likely to sustain sobriety and achieve autonomy.

No one supports the use of illegal drugs among pregnant women, nor does anyone wish to see a newborn show signs of neonatal abstinence syndrome, but incarceration isn’t the answer. Instead, politicians should be forming natural alliances with feminist scholars and health advocates so we can collectively address the basic needs of newly sober women. These are the ways to truly celebrate Mother’s Day.

Looking ahead to Mother’s Day and Father’s Day, I encourage readers to check out Chloe Bird‘s latest post for The RAND Blog. In “Assessing and Addressing Women’s Health and Health Care,” Bird explains the knowledge gaps and emphasizes the benefits of changing our approach to health research:

Gender-stratified research can produce more effective decision tools and interventions, and in turn improve both women’s and men’s health and health care.

I have featured her work on women’s cardiovascular health in a past post: it’s an excellent example of why we need to pay attention to sex/gender differences when aiming to improve health care.  Bird cautions of the dangers of failing to make the necessary revisions:

Until access, quality, and outcomes of care are tracked by gender, inequity in treatment will remain invisible and consequently intractable.

As we move forward with the Affordable Care Act, it is important to pay attention to the new assessments and tracking of the quality of care.  In the words of Bird, “This tracking should take gender into account so that disparities in health care and outcomes become visible and get the attention they deserve.”


Valentine’s Day is not the only reason to think about hearts in February, a.k.a. American Heart Month.  This guest-post on women’s heart health by Chloe E. Bird, Ph.D. — senior sociologist at the nonprofit, nonpartisan RAND Corporation and professor at the Pardee RAND Graduate School — discusses findings from a recent RAND pilot study.*  In our email exchange, Chloe emphasized, “…please don’t assume that you, or the women in your life, are too young to be concerned.”


High-quality routine care for both cardiovascular disease (CVD) and diabetes is at least as relevant to women’s health and survival as it is to men’s.  Yet evidence suggests that women continue to face gaps in even low-cost, routine aspects of care.


CVD is the leading cause of death for women, as well as for men. More than one in three adult women has some form of CVD.  In fact, since 1984, more U.S. women than men have died of CVD, and 26 percent of women over age 45 die within a year of having a recognized heart attack, compared with 19 percent of men. Diabetes is a major cardiovascular risk factor, and it increases risk of CVD more so in women than in men.

Despite improvements over recent decades in care for CVD and diabetes, evidence suggests that the care women receive—and their health outcomes—continue to lag behind those of men, even for routine care such as monitoring and control of cholesterol. Although the American Heart Association’s “Go Red for Women” campaign and efforts by Sister-to-Sister and WomenHeart have done much to raise awareness among both women and their clinicians about CVD, there is still too little attention devoted to preventing heart disease in women.

Part of the problem is that quality of care is not routinely measured and reported by gender. Conventional methods of measuring quality of care focus on average “quality performance scores” across the overall population. Separate assessments and reporting by gender are rare, so the care received by women is generally assumed to be equal to that received by men, despite evidence to the contrary. As a result, the quality gap in care remains largely invisible to individual women, providers, payers and policymakers, even among those seeking to improve women’s health and health care. In cases where gender gaps in care have been monitored and targeted, such as in recent initiatives by the Veterans Health Administration, marked reductions in gender disparities in CVD and other types of care have been achieved; though some gaps persist.

In an examination of gender gaps in cholesterol screening among adults in one large California health plan who had been diagnosed with CVD or with diabetes, we found larger gender differences on average in care for CVD (5 percentage points) than for diabetes (2 percentage points). Although the gaps may appear small among the 30,000 CVD patients and 155,000 diabetes patients whose care we examined, they translate into a significant number of women who were not screened, but who might have been had they been men.

We focused on screening because clinicians agree that CVD and diabetes patients should receive annual screenings for high LDL cholesterol.  Such screening is also the first step in assessing quality of care.  Moreover, research on disparities in care often finds that gaps in screening are associated with larger gaps in treatment and poorer intermediate outcomes.

In our study, gender gaps in cholesterol screening varied geographically and favored men far more often than women. Among CVD patients, there were gaps favoring men in 79 percent of counties. In 35 percent of counties, those gaps were moderate (from 5 to less than 10 percentage points) or large (at least 10 percentage points). In 12 percent of the counties there were small gaps (from 1 to less than 5 percentage points) favoring women. Among patients with diabetes, which has not traditionally been viewed as a man’s disease, there were moderate gaps favoring men in 17 percent of counties and small gaps favoring men in another 40 percent of counties. In contrast, there were large gaps favoring women in 4 percent of counties, moderate gaps in 2 percent, and small gaps in another 12 percent.

Lessons from areas with the highest quality of care and from areas with the fewest gender disparities can motivate efforts to improve care and reduce disparities. Mapping quality of care at specific geographic levels and focusing on the areas of interest to specific stakeholders may prove to be essential to efforts to tackle disparities efficiently and meaningfully.

Without gender-stratified reporting of quality of care, gender gaps are invisible and intractable. Such reporting is essential if health plans, health care organizations, and policymakers are to ensure that overall improvements in care narrow gender gaps.

Health plans should use gender-based analysis and mapping to address gender gaps and to motivate improvements in care, treatment and outcome measures. Similarly, analyses of pooled data from multiple health plans could be used to assess gender disparities in care for CVD and diabetes for managed care patients and determine whether the size and patterns of disparities differ across plans.

Closing the gender gap is crucial if women are to benefit equally from improvements in care for CVD and diabetes.  At the same time, focusing on gender gaps can inform a broader discussion of the prevalence and burden of CVD in women and the need for improvements in prevention, diagnosis and treatment.


*For more information, check out the online report and videos of her presentation and other researchers’ talks from RAND and UCLA’s recent women’s heart health event.

A new book, The Polyamorists Next Door: Inside Multiple-partner Relationships and Families (Rowman & Littlefield Publishers), takes readers beyond the myths to explore the true lives of real families.  For this month’s column, I had the chance to find out more from the author, sociologist Elisabeth Sheff, Ph.D., an expert witness, educator, speaker, and consultant on polyamorous families with children who also writes for Psychology Today.

PolyamoristsNextDoorAdina Nack: When I think of non-monogamy I think of pop culture portrayals of polygamy or men with some sort harem. Is it a common assumption that non-monogamy is simply an excuse for one man to have many female sexual partners?

Elisabeth Sheff: The media rarely portrays the full variety of non-monogamy. I study polyamory, a style of openly conducted non-monogamy that emphasizes emotional intimacy, honesty, and negotiation. In polyamory, both women and men can have access to other partners, which is very different from polygyny, the most common form of polygamy in which one man can have several wives. In contrast, polyamorists, with intentions of creating emotionally intimate relationships, differ from mainstream swingers who emphasize sexual variety with emotional exclusivity. In fact, many couples who swing set boundaries that expressly prohibit people from developing strong feelings for someone outside of the committed couple. Then, cheaters have non-monogamous relationships but lie about them or keep them secret, which runs counter to the polyamorous emphasis on honesty and negotiation.

AN: It sounds like polyamory is a very different experience, especially for the women?

ES: Yes, poly women say that they relish the opportunity to have multiple partners. The equality of allowing everyone access to multiple partners, regardless of gender, means that polyamory has a significantly different impact on women than polygyny. Women in poly relationships tend to be highly-educated and able to be financially independent if circumstances require – a significant departure from women in polygynous marriages who are typically denied education and access to paid work. Poly women generally chose the relationship style as adults, rather than entering arranged marriages as adolescents who may not have even been consulted about their wishes. Results of this gender parity are evident at the community level, in which most of the high-visibility leaders, activists, writers, and researchers are women.

AN: With more gender equality among poly people, how does this impact the division of labor in households?

ES: Even though poly people are often liberals who try to avoid sexism, their families tend to be surprisingly traditional when it comes to the division of household, paid, and emotional labor. Some of this is because the gendered wage gap that makes it easier for men to earn enough money to support a lower or non-paid worker.

AN: What are the experiences of children in polyamorous families?

ES: Children in the poly families who participated in my 15-year study are generally in great shape: they were articulate and intelligent, precocious and thoughtful, poised and self-confident. Not that kids from poly families are perfect – they can be just as obnoxious, defiant, and irritating as children in other families. Even so, kids from poly families are a strikingly robust group, in part because their parents’ racial and class privileges give them advantages in life. Having all of the extra attention and resources that come with multiple-adult families helps as well.

AN: During different ages, what are some of the experiences that tend to be common for children growing up in poly families?

ES: Young kids, up to 7 or 8 years old, who are growing up in poly families often don’t even question their family form, partially because little kids generally take their families for granted as the norm anyway, and also because the adults save the sexual interaction until the kids are in bed. In families with openly polyamorous parents, tweens from 9 to 12 are often more aware that their families are different and will frequently ask their parents what is happening. Parents who are divorced or fear losing custody of their children for some other reason (surveillance from in-laws or authorities) if they are outed as polyamorists tend to either dodge their children’s questions or hide their sexual interactions so the kids think their partners are “just” friends. Poly parents who are not worried about legal threats generally respond to their kids’ questions with truthful and age-appropriate answers, avoiding oversharing by waiting until the children ask for clarification before providing more information.  Teens are generally aware that their families are polyamorous and, in true teenager fashion, tend to be defiant against outsiders who scorn the family style. Very few of the teens I interviewed had decided to be polyamorous themselves, most often because they felt they were too young and inexperienced to make that kind of decision.

AN: How do kids in poly families talk to their peers and other people about their families?

ES:  Because divorce and serial monogamy are so common, many kids have multiple parents which allows kids from poly families to simply blend in. If children from poly families did not correct their peers’ and other adults’ assumptions, then they could pass as “normals” fairly easily. When the kids from poly families have close friends they can trust, they will often tell their friends about their poly families. Sometimes poly kids would use ‘filter’ questions — asking friends what they thought about same-sex marriage or some other issue pertaining to sexual minorities — to gauge the safety of disclosing their poly family status on the basis of friends’ reactions to these questions.

AN: Thanks for taking the time to share more about your research. During the holidays, there’s a lot of focus on “the family,” and your book is an important addition for those who want to better understand and support healthy families who may deviate from mainstream norms.

This month’s column features a guest-post by Adrienne Trier-Bieniek, Ph.D.: she critiques a recent pop culture debate and encourages us to question the impact of imagery and songs on healthy sexuality.  Trier-Bieniek is an assistant professor of sociology at Valencia College.  She studies pop culture, gender and healing after trauma; she also wrote the book Sing Us a Song, Piano Woman: Female Fans and the Music of Tori Amos (Scarecrow Press 2013).


A few months ago I was sitting in the Philadelphia airport waiting to fly home to Orlando when I got a Facebook alert on my phone.  One of my college friends had tagged me in a post, a news story, with the headline “Michigan University Removes Pendulum Statue.” What followed was an E! News article featuring a large wrecking ball that hangs in the campus of my alma mater, Grand Valley State University.  The ball was being ridden by a naked person, seemingly an imitation of Miley Cyrus in her video for her song Wrecking Ball where she sings about heartbreak while naked and swinging on a wrecking ball.  As I read through the short blurb what struck me (beyond the naked student) was E!’s statement that “Miley Cyrus, the tongue flickering demon… Has set her sights on your college students!”  This was probably meant to be tongue in cheek (pun intended), but the message was clearly connected to the dangers of feminine sexuality.

mileywreckingA few days later, Sinead O’Conner wrote an open letter to Miley about the music industry’s penchant for over-sexualizing female pop stars and kicking them to the curb once executives have made their money.  This lead to an exchange between Cyrus and O’Conner in which Miley Cyrus attacked Sinead O’Conner’s history of being treated for bipolar disorder and her attempts at suicide.  Then Robin Thicke appeared on Oprah’s Next Chapter to discuss his performance with Cyrus at the performance with Cyrus at the Video Music Awards (VMA’s). In case you are not familiar, the routine included Miley Cyrus wearing a gold two-piece outfit, seemingly to make her appear close to nude, while “twerking” in front of Thicke’s groin while also getting sexual with a foam finger.  Thicke said that, when he is performing, he doesn’t pay attention to who is touching his body because he is focused on his music and vocals.

I study gender and music and I have spent a lot of time thinking about this series of events and their connection to sexuality and body privilege.  No doubt the video for Wrecking Ball was created to get Cyrus some attention, it couldn’t be more obvious that she was literally shedding the image of Hanna Montana as she swung on the ball.  Yet there was a vulnerability to the performance that got lost in the reaction to her appearing naked.  Most people seemed to be so caught up in gazing at her body that the expression of loss and heart-break she sang about was missed.  Perhaps this is just the media doing what it does best, finding the most alluring part of a story and exposing it.  Or, maybe the reactions to the song are found in the age-old assumption that nudity, particularly nude women, are objectionable.  Except, in 2013 women’s nude bodies not only battle the puritan stance on nudity, they also are attacked with judgments on weight, symmetry, skin color and expectations of perfection.

Sinead O’Conner is right, the music industry sets up young and attractive people in order to cash out on their youth and beauty.  It creates a standard for what young women must do in order to get noticed and to keep the audience’s attention.  Thicke’s comments about not noticing how sexual Cyrus’s dancing was at the VMA’s demonstrates a privilege that is specific to masculinity and male bodies.  How can he not realize that there is a half-naked girl grinding on him?  I find this hard to believe. What Thicke did in this moment was affirm that Cyrus’s body was the object and the subject of the performance and that his body didn’t need to be a part of the discussion.  This is a privilege granted to the person in power, most women who are performing cannot escape the objectification of the male gaze.

While I am not sure if Cyrus should be flattered by people riding naked on a wrecking ball at my alma mater, I will give them the benefit of the doubt and assume that a handful of them were hoping to connect with the vulnerable side Cyrus showed in the video.  Later this month, when I return to campus to speak, I hope to find out if this is true. Much like the famous feminist mantra that floats around “If I had a hammer I would smash patriarchy”, in this case what we need, ironically, may be a wrecking ball.