RESEARCH BRIEF:

Background

Abortion stigma is the idea that “abortion is morally wrong and socially unacceptable” (Cockrill & Biggs, 2018), and it defies all leading medical understandings of abortion as a safe, common intervention. The World Health Organization (2021) holds that “lack of access to safe, affordable, timely and respectful abortion care, and the stigma associated with abortion, pose risks to women’s [and birthing people’s] physical and mental well-being throughout the life course.” As a social phenomenon, abortion stigma affects people who have abortions, supporters of people who have abortions, and people who work in abortion care in deeply contextual ways (Norris et al., 2011).

In order to restore and expand access to abortion care in the U.S., there needs to be a focus on how stigma harms not only people seeking abortion, but also the healthcare workers who provide abortion care. In this study, I use “abortion workers” to broadly refer to this group, which includes anyone who has regular, direct interactions with patients in the provision of abortion care. Even before the Dobbs decision, abortion workers have long experienced an intense stigma that manifests in cultural discourse, law, politics, communities, institutions, patient care, and interpersonal non-work relationships (Harris et al., 2011). These stigmatizing messages force a social separation between a stigmatized group of people (i.e., abortion workers) and everyone else. The degree to which a person accepts the public’s valuations of a stigma and applies the stigma to themself informs what communication scholars conceptualize as stigma management communication (SMC; Meisenbach, 2010). This research study contributes to scholarly understandings of SMC by exploring the theory’s utility in interpreting the experiences of U.S. abortion workers who experience a unique and highly politicized occupational stigma linked to stress, burnout, harassment, physical threats, violence, and even death (Medoff, 2014).

Methods

Qualitative interview data was collected between July and November 2023. Study participants (n = 24) included U.S. healthcare workers who were currently working in abortion care or had done so within the last two years (2021–2023). I spoke with each participant for 51-122 minutes; the average interview was 59 minutes. Once fully transcribed, the video recordings were permanently deleted. The interviews resulted in 25 hours of recorded conversation and 418 single-spaced pages of transcripts which were analyzed using Tracy’s (2020) phronetic iterative approach.

Participants’ time spent working in abortion care ranged from four months to 11 years, with an average tenure of 1 to 2 years. Two-thirds of participants (n = 16) reported working in roles and in clinics that only provided abortion. One-third (n = 8) worked in settings where 28 abortion care was offered alongside a wider range of health services. Two participants (8%) worked in family practice, and three participants (12%) worked in both abortion clinics and hospital settings. The study intentionally included workers (n = 6) who were not working in abortion care at the time of their interview. Participants’ self-reported job titles included care or clinic coordinator, certified nurse-midwife, doula, family planning fellow, health center assistant or medical assistant, medical support, nurse, operations officer or coordinator, patient advocate, patient educator, patient navigator, and social worker. While varied, participants’ responsibilities all included some form of patient contact and support, which could include performing or assisting with medical procedures, administrative support (such as front desk work), informational support (such as patient education), emotional support (such as counseling), practical patient support (such as assistance with funding or travel to the appointment), or some combination of these responsibilities.

Results

RQ1: How abortion care workers experience stigma

The study revealed that workers experience stigma from directly stigmatizing messages, stress compounded by stigma, and socioemotional impacts.

• Stigmatizing messages are verbal and nonverbal communication that reinforces a negative attitude toward abortion, people who have abortions, and/or people who work in abortion care. Sources of stigmatizing messages can include clinic protest activity, patients themselves, coworkers, and friends/family/acquaintances.

• Stress compounded by stigma refers to the unique or additional psychological burdens that workers experience because they perform a stigmatized job, which intensifies the impact and contributes to a more challenging workplace. Examples of these stressors include barriers to abortion access, stressful working conditions, difficult patient behavior, and the criminalization of abortion in some parts of the country.

• Socioemotional impacts are the negative effects on workers’ physical health and emotional wellbeing as a result of performing a stigmatized job. These impacts include anxiety, emotional drain, burnout, and enmeshment.

RQ2: The role of community, organizational, and identity level factors

The study revealed that workers navigate stigma among many intersecting situational factors, upholding that experiences of abortion stigma can vary widely across contexts. That said, several salient themes emerged in the data set, revealing specific nuances about the experience of stigma in this political moment.

• State laws: All participants were required to be providing abortion legally within the confines of their state laws, which can shape patient access and work conditions by imposing restrictions (e.g., gestational limits, mandatory counseling, wait times, stricter licensing and/or reporting requirements, different criteria for medical exemptions).

• Service delivery: The specific dimensions of an organization’s abortion care services are not always the same. While most participants in this study were involved in both medication and procedural abortion care, some participants worked for providers who were only offering pills and others exclusively performed in-clinic procedures. Gestational limits (whether imposed by the state law or by the providing physician) make a difference for some workers, particularly as clinics in protective states look to offer care later in pregnancy. Workers can also be affected when more effective pain management (such as IV sedation) is not available to patients.

• Organizational culture: An employer’s values, attitudes, systems, policies, and rules (both spoken and unspoken) all influence workers’ experiences of their organizational culture. Five important sub-themes emerge here: social hierarchy, expectations of self-sacrifice, values (mis)alignment, formal and informal workplace support, and unionizing.

• Community attitudes: The laws of a state do not necessarily reflect a local community’s attitude towards its abortion providers. Participants in protective states named where negative community attitudes could still interfere with clinic practices, while many participants in restricted/banned states felt their local communities were actually somewhat to quite supportive of the clinic and/or abortion overall.

• Regional identity: Participants in this study reflect a diverse geography, and regional identities were particularly emergent around areas with heavily restricted or no abortion access, shaping the way participants relate to the larger abortion access landscape. Language like “hostile and haven” states can add a layer of stigma for workers serving these communities.

• Privileged and marginalized identities: Intersecting axes of race, ethnicity, gender, sexual orientation, age, education, socioeconomic status, religion, and (dis)ability inform the way workers experience stigma. Privileged pieces of identity may be protective against stigma, while some marginalized pieces of identity can contribute to feelings of isolation in the workplace and/or motivate targeted stigmatizing messages (e.g., harassment that is both anti-abortion and also racist, homophobic, transphobic, etc.).

• Reproductive experiences: Workers’ own individual experiences with abortion, miscarriage, fertility, and childbirth influence the way they relate to the work, while upholding that respect for all reproductive choices is fundamental to a healthy organizational culture.

RQ3: How abortion care workers manage stigma

The study revealed that workers enact a variety of strategies to manage stigmatizing encounters. Under the framework of stigma management communication (SMC; Meisenbach, 2010), strategies fit into four broad categories:

• Accepting strategies: When a person accepts a public perception of a stigma and applies that stigma to the self, they may enact strategies that focus on coping rather than challenging stigma. Accepting strategies include forming enclaves or social “bubbles” of people who are like-minded about abortion; using humor to cope with stress; deferring agency or reflecting a sense of helplessness around changing the causes or consequences of stigma; and passive acceptance when another person expresses stigma.

• Passing strategies: When a person accepts a public perception of a stigma but does not apply it to the self, they make seek to avoid detection or create distance from the stigma by “passing.” Passing strategies include concealing one’s job in order to avoid conflict, protect oneself, or preserve a relationship; changing roles within the organization to reduce stress or feelings of stigma; and exiting the organization.

• Transcending strategies: When a person challenges a public stigma but still applies that stigma to the self, they may enact strategies that seek to shift perceptions of the stigma or their relationship to it. Transcending strategies can include framing the work through a positive lens (e.g., emphasizing positive outcomes or the satisfying elements of one’s job), recalibrating the standards by which abortion care is judged, depersonalizing by focusing more on the way stigma harms others more than oneself, and refusing to engage in specific interactions when stigma is present.

• Challenging strategies: When a person both rejects the public perceptions of a stigma and does not apply the stigma to the self, they may enact strategies to challenge that stigma altogether. Challenging strategies include disclosing one’s job in order to normalize abortion; engaging in unapologetic displays of abortion support; resisting stigma by choosing to engage in interactions around abortion when stigma is present (e.g., using logic and facts to detract from anti-abortion arguments); using cognitive reframing to make (potentially) threatening situations seem less scary; and ignoring stigma and going about the work anyway.

These findings reveal that abortion workers use a mix of communication strategies to manage stigmatizing encounters and maintain a positive self-image. Working in healthcare can create an inherent tension between prioritizing the needs of patients (who also experience an intense stigma) and tending to one’s own needs around stigma management. Additionally, there were tensions for workers who see abortion care as a form of political advocacy for a cause they deeply care about but who are lacking support to advocate for themselves as employees navigating real or perceived organizational inequities, misalignment of values, and mistreatment by their employers. Workers’ ability to choose their own stigma management strategies is impacted when their own needs are overshadowed by the needs of patients, organizations, and/or the larger movement. These dynamics can put workers into tension with the care that they deeply want to provide.

Discussion

Seeing stigma through an intersectional lens

The findings uphold that working in abortion care can be a particularly turbulent and stigmatizing experience that affects a healthcare provider’s mental and physical wellbeing, economic livelihood, and interpersonal relationships. By examining stigma in the context of social forces at play, this study helps to theorize differences or similarities among the impacts of stigma and resources needed for stigma management communication. Black feminist scholars have long used what Collins (1990) called the “matrix of domination” to highlight the constraining, overlapping forces of white supremacy and patriarchy. Participants in this study shared experiences that also speak to the forces of cisheterosexism, ablism, classism, and spiritual abuse. This study further found that occupational abortion stigma is not a “one-size-fits-all” experience; rather, it is a nuanced communication phenomenon influenced by how oppressive forces coalesce via state laws, service delivery, organizational culture, community attitudes, regional identity, privileged/marginalized identities, and reproductive experiences.

Applying an intersectional lens further reveals the way structural stigmas can exacerbate tensions for people who perform different types of clinic work. Most participants in this study fell into roles that could be considered medical assisting or patient support, meaning there was not enough variation to assess how stigma management might vary among clinic administrators, physicians, clinicians, nurses, and medical staff. However, the data did include some insights into the way that participants experienced stigma differently depending on their specific job responsibilities. For example, discussions of handling pregnancy tissue arose among medical assistants, and there were data points about the added fatigue for workers who had to be on-call for patients. Social workers, patient educators, and patient navigators reported higher amounts of emotional fatigue compared to nurses and clinicians. Participants who had the ability to work remotely discussed being shielded from protest activity and having added flexibility, but also named that they felt more isolated from their coworkers. Overall, more research is needed to fully address if there are consistent patterns in stigma management among groups of abortion workers by role.

Structural stigma, emotional labor, and burnout

The enforcement of abortion bans has put a great strain on the entire reproductive health care system. Participants’ reports of increasing patient volumes are backed by national abortion data which identified both an overall increase in the total number of abortions between July 2022-June 2023 and “surge states” that experienced the largest cumulative increases in the total number of clinician-provided abortions (Society of Family Planning, 2023). While social and economic barriers to access exist in nearly all realms of healthcare, abortion workers know that many of the additional barriers their patients encounter—including informational barriers and being forced to travel—would not exist if abortion was not so stigmatized.

In some organizations, scarcity is then used to justify poor employment conditions, like low wages, lean staffing, and scant benefits. For example, participants described the way some organizations have used scarcity to justify a culture of self-sacrifice, which exacerbated negative socioemotional impacts like emotional drain, burnout, and enmeshment (Tracy, 2009). These participants described a phenomenon akin to “passion exploitation” in which employers seek to legitimize unfair management practices by assuming that the work is its own reward, and that “passionate” workers would volunteer for it if given the chance (Kim et al., 2019). Passion exploitation, or the myth of the “labor of love,” is especially common within helping professions that are viewed as feminine, disproportionately harming and exacerbating the pay gap for women and people of color (Jaffe, 2021). However, participants reported some abortion clinics have begun to recognize the harms of the self-sacrificing model and instead implemented formal workplace supports for staff to be able to care for their mental and physical health through paid time off, on-site counseling, and/or wellness stipends. The benefit of these policies is supported by research suggesting that healthcare providers’ perceived support from their organizational is associated with lower burnout and greater well-being (Reitz et al., 2021).

Burnout is a pervasive impact of care work that can have serious health consequences for providers, particularly employees who have frequent, intense interpersonal contact with others (Tracy, 2009). This study suggests that symptoms of burnout can onset incredibly fast in a high stress environment, particularly when compounded by stigma, and there are limits on how much individuals can practice “self-care” to manage their own burnout (Tracy, 2009). Rather, burnout is an issue that organizations need to take seriously in relationship to their processes, structures, expectations, and culture. As one participant bluntly put it, “It’s not burnout when a broken movement is lighting its workers on fire.”

Stigma management communication

Findings support that SMC strategy use is situational and relationally dependent (Noltensmeyer & Meisenbach, 2016). The results suggest that workers make several “mental calculations” throughout a given day that inform their use of SMC strategies, a finding that Harris and colleagues’ (2016) “screening process” for deciding when to tell someone about their abortion work. Many participants felt conflicted or guilty that they did not feel safe or have the energy to disclose their occupation in all situations; most identified that they were still trying to find the right “balance” of their safety and being “an ambassador” to their work. These findings illustrate how participants engage in safety planning when selecting their stigma management strategies; every participant identified instances when they needed or wanted to pass as nonstigmatized by lying, avoiding, or only disclosing “half-truths” about their work. Participants also described situations where they had to ignore protesters or passively accept stigma directly from a patient in order to remain “professional.” These findings reveal that even workers who both “challenge public perceptions of the stigma and its applicability to them as individuals” will sometimes enact other strategies because of their own safety calculations or because of external constraints. While most participants agreed that disclosure can be a powerful strategy for destigmatizing abortion, concealment behaviors do not necessarily indicate acceptance of a stigma. Rather, episodic concealment can be indicative of past trauma or threats to one’s personal safety, interference from one’s social network, and/or managing limited emotional and cognitive resources for stigma resistance.

Additionally, findings support the most current understandings that patterns of SMC strategy use do not fit neatly into Meisenbach’s (2010) original four quadrants (Meisenbach et al., 2019; O’Shay-Wallace, 2020; Romo & Obiol, 2023). Participants enacted multiple strategies across quadrants, challenging Meisenbach’s (2010) proposition that individuals who challenge public perceptions of a stigma are likely to mostly, or exclusively, engage in resistance strategies. This empirical evidence supports the revision of the SMC model to better reflect how stigmatized individuals enact multiple strategies and frequently blend (Romo & Obiol, 2023) SMC strategies as situationally and relationally appropriate across interactions with patients, friends/family, professional networks, strangers/acquaintances, and anti-abortion protesters.

Recommendations

Take burnout seriously.

The literature is clear: burnout recovery is incredibly difficult, if not impossible (Tracy, 2009). Unaddressed, burnout has many negative individual and organizational impacts including mental and physical illness, interpersonal conflicts, higher rates of absenteeism from work, higher rates of job turnover, lower morale, and lower productivity (Teffo et al., 2018). The best way to help providers recover from burnout is to prevent burnout in the first place. Organizational leaders—particularly those who have decision-making power over clinics and clinic staff, but whose day-to-day work is relatively removed from clinic flow—are advised to genuinely empathize with the experiences of frontline workers. Making sure that staff needs are prioritized alongside the needs of patients is a more effective way to ensure that an organization can retain its providers and challenge stigma more effectively in the long run. When organizations talk to workers about self-care, it is critically important that they are designing the work in such a way that staff can actually take care of themselves (Gomez-Salgado et al., 2019). A benefit, like unlimited paid time off or paid family leave, is not really a benefit if workers do not feel like they can access it without harming their coworkers and/or patients (Kirby and Krone, 2002). One of the most important things a reproductive health organization can do is voluntarily recognize, support, and engage in good faith negotiations with their labor union(s). While this sample has limited generalizability, it is worth noting that participants who successfully unionized report that this strategy has been the most effective in improving their working conditions and securing the resources to manage stress and resist stigma more effectively.

Rethink hierarchies.

Hierarchy is a feature of most, if not all, healthcare systems (Ehrenreich & English, 2010). True to form, participants discussed their work and their role in relationship to others, painting a consistent picture of a social hierarchy that divides “leadership” and/or “administration” from clinic staff. There also is a medical hierarchy that ranks nurses, medical assistants, and clinic support below physicians and clinicians (Noyes, 2022). This hierarchy both implicitly and explicitly denigrates the important emotional labor and medical care that nurses and “support roles” provide (Ward, 2021), which is intertwined with long histories of racism and sexism in all medicine broadly and reproductive healthcare specifically (Roberts, 1997). As a result, physicians are typically the only people with access to the prestige of being an abortion provider, which can be an important resource for stigma management (Ashforth & Kreiner, 1999; Ward, 2021).

In light of the way that different roles encounter and experience stigma, it is really no surprise that when many workers feel burnt out in their clinic roles, they look to “move up” into administrative positions that come with higher paychecks, more prestige, more flexibility, and much less stress. The value that organizations seem to place on certain types of administrative work, like fundraising, versus the way they treat entry-level clinic jobs as almost disposable reinforces classist ideas about “skilled labor” and devalues the very necessary labor of frontline clinic staff.

Additionally, in the wake of Dobbs, the movement has developed a particularly problematic binary shorthand for describing the abortion access landscape (e.g., red state/blue state, hostile/haven, restrictive/receiving). At the highest abstraction, the clustering of “red states” with abortion bans presumes that there is far less support for abortion in many areas of the country than there actually is—and also presumes that access is virtually a non-issue in “blue” states. Speaking with participants on the ground in rural, Southern, Midwestern, and Appalachian communities reveals the depth of these workers’ passion for destigmatizing abortion, holds that local knowledges are powerful, and contributes understanding that what communities need is an equitable distribution of resources, not more disenfranchisement (Smith et al., 2023). At the same time, speaking with participants in receiving states shows that stigmatizing messages are ubiquitous and that there is currently no abortion law shielding workers anywhere from the destructive effects of stigma and its compounding stressors.

What does this mean for the reproductive health movement and its members? This study suggests that the project of resisting abortion stigma is not served by discursive binaries or hierarchies. It holds that abortion seekers and medical providers—all medical providers—are the experts on their own experiences and deserve both discursive and practical support to effectively manage stigma. It implores both movement and organizational leaders to take care with the content of their messages and to shift power to the folks on the ground who are experiencing the intersections of systems of oppression and movement disenfranchisement.

Build shared pro-abortion understandings.

One important finding of this study was how much participants can experience stigmatizing messages from their coworkers and how workers in abortion care are often navigating complicated feelings about their own stigmatizing views, particularly around abortion later in pregnancy. Since the Dobbs decision, many clinics in receiving states have expanded their gestational limits to accommodate the barriers that are pushing patients further into their pregnancies before they are able to access care (Society of Family Planning). Family practice providers in receiving states can help ease the burden on abortion clinics by incorporating abortion care–even just medication abortion–into their scope of care so that more abortion seekers can simply be seen by their primary physician. However, the experiences of participants in this study underscore how stigma can and will show up in even the most “progressive” workplace. Organizations that are endeavoring to institute or expand abortion care must equally be mindful and intentional about building a shared pro-abortion understanding and supporting workers in managing abortion stigma. This study suggests that recoding understandings of pregnancy and abortion stigma can be a slow process and that stigma management will be ongoing, but that this is necessary work to demystify and build support for abortion throughout the healthcare system and to lessen the stigma on abortion providers.

References

For full text and references, access this thesis project in Proquest or email becca.lee@colostate.edu to request a PDF copy.