ADDRESSING SYSTEMIC AND PERSONAL BIAS
Adapted from UCSF Bixby Beyond the Pill CME Course # MMC20087
Introduction
As providers, it is imperative to understand the historical context in which we practice so that our care is responsive to people’s needs and desires. The healthcare system has a history of systemic bias and discrimination against marginalized communities. Armed with this knowledge, providers can interrupt their own bias and empower people to make self-determined health decisions.
History of Systemic Bias in Health Care and Scientific Establishments
Several historical, structural, and interpersonal factors impact the reproductive and sexual health and well-being of communities. The fraught history of eugenics and non-consensual health care experimentation has caused lasting harm to marginalized communities, leading to valid mistrust towards health establishments. People with disabilities/disabled people, Black, Indigenous, and People of Color (BIPOC), poor people, and incarcerated people have all been targets of eugenic projects. These communities have historically been denied reproductive autonomy as they were believed to be “unfit” to parent, with their children “burdening” society, and continue to experience structural barriers to building self-determined futures and families today (National Council on Disability 2012, National Institutes of Health 2022, Metraux 2025).
Eugenics grew from a fringe idea of a British demographer in the 1860s to a global movement within decades (Brookes 2004). While Nazi Germany may be the most dramatic example of eugenic thought in action, the scientific basis for racism was supported by elites, governments, and health professionals of many countries, including the United States (U.S.).
U.S. eugenic precursors were seen in the treatment of reproduction of enslaved people, and later underpinned the 1927 Buck v. Bell Supreme Court of the U.S. (SCOTUS) decision, which found that forcible sterilization of people with disabilities was constitutional. The Court notoriously stated in its decision,“it is better, if… society can prevent those who are manifestly unfit from continuing their kind…three generations of imbeciles are enough” (SCOTUS 1927). This decision was never explicitly overturned, and >30 states still have laws allowing for the forced sterilization of people with disabilities (NWLC 2022). BIPOC, disabled, and incarcerated people are more likely to be sterilized without their consent (NPR 2017, Stern 2020). These procedures became so common across the South that they were called “Mississippi appendectomies” (Ko 2016, Pearce 2020). California forcibly sterilized more than 20,000 individuals, a huge share of the national total. Sterilizations without consent in immigration detention facilities have been reported as recently as 2020 (Manian 2020).
Eugenic thinking also fueled some early contraceptive access advocacy, as well as non-consensual experimentation on marginalized communities, such as the 1950s Puerto Rican contraceptive trials and the 1930-70s U.S. Public Health Service Untreated Syphilis Study on Black men at Tuskegee (CDC 2022, Simon 2016). Coercive practices in the use of Long Acting Reversible Contraceptives (LARCs) have targeted low-income people, for example through the conditioning of receipt of welfare benefits on LARC use and authorization of Medicaid coverage for LARC placement but not removal (Cappello 2021, Dehlendorf 2010).
With this historical knowledge, clinicians can proactively disrupt discrimination and improve systems. The starting point is considering personal biases and incorporating person-centered reproductive care. Additionally, person-centered performance measures can improve care provision (Dehlendorf 2023, Wingo 2023).
Personal Reflection on Bias
Bias refers to attitudes or stereotypes affecting our understanding, actions, and decisions. These stereotypes can be unconscious and don’t necessarily align with our declared beliefs (Blair 2011, Marcelin 2019, Zestcott 2016), or they can be conscious. It is easier to see biases in others than ourselves. Bias has been shown to contribute to racial health disparities and to impact pregnancy options counseling, childbirth, pain management, and contraceptive care (Saluja 2021,Hirsh 2015). Both unconscious and conscious biases can result in discrimination and health disparities, especially in communities subject to marginalization.
Bringing awareness to the influence of these biases on our care can minimize harm. To begin self-reflection, consider the following questions:
- To what marginalized groups (e.g., low-economic status, immigrant, non-English language, person who uses substances) and privileged groups (e.g., white, educated, heterosexual, cisgender, nondisabled, citizen) do you belong?
- Do you find yourself wanting people in specific groups to make particular contraceptive or pregnancy decisions?
Some best practices to consider:
- Listen more than you speak; people are the experts in their own lives and bodies.
- Practice cultural humility and attunement rather than imposing your beliefs.
- Cultivate partnerships with local justice and advocacy groups.
- Avoid assumptions reflecting cultural stereotypes.
- Contribute to efforts in your organizations and communities that reverse structural aspects of racism (Green 2020, BMMA 2020).
- Commit to lifelong self-evaluation (Waters 2013).
Additional Resources: