 Good afternoon. Good afternoon. On behalf of the Clayton Center and the Department of Obstetrics and Gynecology and the Bucksbaum Institute, it's a pleasure to welcome you back to the spring quarter lecture series continuing our year long lecture series on reproductive ethics. It is a great pleasure to introduce today's speaker, Melissa Gilliam. Dr. Gilliam is serving as vice provost for academic leadership, advancement, and diversity. This is a role in which she supports the provost in activities relating to faculty development and institutional diversity. Dr. Gilliam is a professor of obstetrics and gynecology and of pediatrics here at the university. She holds the Ellen H. Block Professorship of Health and Justice. Melissa serves in addition as chief of the section of family planning and contraceptive research, directs the fellowship and family planning in the Department of Obstetrics and Gynecology. Melissa holds a bachelor's degree from Yale, a master's degree in philosophy and politics from Oxford, her medical degree from Harvard, and a master of public health degree from the University of Illinois at Chicago. She's also a member of the National Academy of Medicine that was formerly known as the Institute of Medicine. Here at the university, Dr. Gilliam heads CI3, which is a university-wide interdisciplinary research center. CI3 works with and on behalf of young people marginalized by race, class, and sexual orientation and takes an asset rather than a risk-based approach to addressing sexual and reproductive health, educational attainment, physical safety, and economic security. Within the Department of Obstetrics and Gynecology, Dr. Gilliam leads the NIH contraceptive clinical trials network, conducts qualitative and quantitative studies, and develops clinical and community health interventions to promote reproductive health and rights. Today, Dr. Gilliam's talk is entitled Not Much Choice, Reproductive Justice and Women of Color. Please join me in giving a warm welcome to Melissa Gilliam. Good afternoon. Thank you so much, and thank you for that introduction, Mark. So today, I'm going to move my bag so I don't trip. This afternoon, I'm going to talk to you about the topic of reproductive justice. And this is a topic that is really near and dear to my heart and something that I've grappled with throughout my career. And the reason why is that when I first started training in obstetrics and gynecology, we learned a lot about all of these different contraceptive methods, and I was so excited about it. And one of my earliest studies was a qualitative study with young Latinos on the west side of Chicago. And their understanding and thoughts about contraception were so different from what I was learning. They had a lot of concerns, absolutely opposed to many forms of contraception, and really were very concerned about not so much about, I want to prevent pregnancy in order to have all of these other outcomes, but really thinking about, if I use these methods, what are the effects on my future fertility? And so it gave me a lot of pause. I thought, I have all of these tools, and it's not clear that people actually want to use them. And so I had to start to rethink a lot of what I had learned, and that's how I came to the topic of reproductive justice. So what I'm going to do today is talk to you a little bit about the history of reproductive justice. Then we'll talk a bit about how it's particularly related to issues of contraception and sterilization. And then I'll actually turn to my own work and how it's been informed by the topic of reproductive justice. And then we'll talk very specifically about a project that I'm working on right now in India with a number of you in the room as an example of how these principles of reproductive justice have really changed the way that I am thinking about and conducting research. What is reproductive justice? If we think about reproductive health, and as you heard in the introduction, part of my training is in public health, think about it as this big population level impact. This is incredibly important. Thinking about the role of clean water and other big systemic interventions and how it can change the health of a population. This was just an absolutely eye-opening way for us to think about health and the way that we can transform the health of many, many people. And so a very important concept, public health. Reproductive rights. I think this is kind of a good image. It's sort of thinking about the individual and the dignity of individual human beings. And often we talk about the issue of choice, the ability to choose and for each person being able to choose what is right and what is wrong for them. And yet there seems to be the need for a third term, which is reproductive justice. And the way that I started thinking about it, and this quotation has meant a lot to me and so I've used it a number of times. But it was somebody writing actually about the city of Chicago. And what they're saying is that things are separate and unequal. And in this quotation, Warren moves from the ideas of school dropout rates, school segregation, but then gets into health, obesity, asthma, cancer, and then into reproductive health, pregnancy, breast cancer, and that somehow all of these different structures and processes are related. And so this is the idea behind reproductive justice, that we need something more than talking about the big public perspective or the individual perspective, but we also need to add the systems level thinking. And people have taken this even further to kind of think about this as more of a dynamic process. So this is work by Paul Farmer, who is a practitioner of public health, who really talks about how the privilege of some is associated with lack of privilege, lack of access for other people, and that lack of access actually is not just neutral, right? It almost has a violent effect. It almost has a harmful effect on other people. And so another way of thinking about it is that we can't just simply think about people's rights if we don't actually think about the larger structures or systems that they live in. And this is a picture of a community on the south side of Chicago, and that access to all of those things, whether we look at Warren's example of school, school, healthcare, all of those things actually impair people's rights. And so when we think about reproductive justice, we need this sort of broader conception. We need to think about people's access to being able to safely raise their children. It's not only about the right not to have children, it is the right to have children. And when you have children, it's about the right to be able to raise them in a place that is healthy and safe and supports their well-being. So reproductive justice might also look like this. So I think one of the best definitions I've seen comes from a group called Asian Communities for Reproductive Justice. And now you'll often see them talking about their current work as families forward. And what they say is that reproductive justice exists when all people have the social, political, and economic power and resources to make health decisions about our gender, bodies, sexualities, and families for ourselves and our communities. And what's important about this is that this is moving beyond an issue that is specifically about women. It is not specifically about a certain color of women or a certain class of women. It is really a very universal idea. So where did this come from and what's the need for it? So there are many reasons why reproductive justice is such an important concept for me, but you'll see that it's really ineluctably linked to the history of obstetrics and gynecology. And then specifically family planning. And we'll talk a bit about that today. So Marion Sims, any OBGYN in the room or aspiring OBGYN will probably know about Marion Sims. And Marion Sims has been considered the father of modern gynecology. And he was born in 1813 and he's really, he was one of the most famous American surgeons of his time and of the 19th century. And if you go to what we call ACOG, the American College of Obstetricians and Gynecologists, you'll see pictures of Marion Sims and we have devices that are still named after this person. And Sims became really well known for his treatment of the vesco vaginal fistulas. This is a really debilitating condition that happens after childbirth where there's a fistulous track between the rectum and the vagina and it can really change people's lives and it continues to be a problem today. But one of the things that, one of the ways that Sims learned how to repair fistulas was actually by working with African American slaves. And so he would keep in his, behind his house, he had a hospital where he was practicing and treating these surgeries. And this is, I'll let you all dive into this history and make your decisions about the ethics of it. So on the one hand, he was really heralded because these were techniques that people didn't know how to do. And because of the surgical advancement and he has kind of an interesting history, he was kind of a mediocre student and kind of a mediocre doctor. And then suddenly he discovered all of these innovations in surgery. And so these are things that are practiced to, some of the things are practiced to this day and really change the practice of gynecology. But on the other hand, the women who he performed these surgeries, there were people who were operated on as many as 30 times. And this idea of what we think of in the modern times of consent and what it means to the complications of surgery. And I told you we're talking about the 1800s so we're not talking about antibiotics and the safety of those procedures again. So much of what we benefit from today are really happened at the expense of people who didn't have a lot of autonomy. The one of your earliest speakers was a friend and colleague, Dorothy Roberts. And Dorothy Roberts is an amazing person, but her book, Killing the Black Body, it just had an incredible impact. And one of the earliest things she describes is slave women. They would dig a hole in the ground, lay the women on top of it, but that hole would protect the pregnant belly, would protect the fetus. And so then when she was whipped, there wouldn't be harm to the fetus. And so this idea is, what Dorothy argues is that you're already seeing the separation of a woman from her child and a differential interest in the offspring in the mother herself. And this idea is kind of this beginning of thinking about women and women of color as somehow not being valued in the same way that the fetus is, that somehow the interest of the mother is different than the interest of the fetus. And she brings this forward to even think about some of the lectures that you've also heard in this lecture series where women are being prosecuted for having an exposure to drugs. Sometimes these are very weak exposures, they're past exposures that happen before pregnancy, but somehow the woman can be incarcerated because of potential harm to the fetus. And so these were, these are some of the historical examples, but these are things that actually come into the present. And because this idea of access to healthcare, this idea of thinking about the children of African-American women or women of color or poor women differently, then we might think about the wellbeing of other children. There was a group of women as they returned from the conference on population and development in Cairo, which was an incredibly important time for women and women's rights, they said we are not hearing the needs of women of color being met in the same way. Our needs are different and they have to do with much more systemic and structural violence and inequities. And so they said, you know, we need another term that is beyond rights and beyond health and this is a term reproductive justice. And one thing that's particularly wonderful about this topic is that it originated here in Chicago. It was a group of women activists working in Chicago who coined this term and really are the owners. And so again, this other connection. So the topic of reproductive justice is actually very salient within the field of family planning. And I wanna just give you some examples of both historical and present about how that has worked. One of the things that got a lot of attention is the contraceptive device, norplant. It's modern, it's not that ancient history, but it's modern successor is the single rod implant, implant on or next one on. But at the time when norplant came along, it was really revolutionary because it could be placed and stay in the arm and provide protection for five years and was highly effective. And so people started thinking about it from a public health perspective. My gosh, we can do all of these things around the issue of unintended pregnancy. But this is a article from the Philadelphia Inquirer because, and the editorial board said, you know what, I just, we had one article about approving norplant. And then we had this other article about how many poor women there are who are having children. Let's put the two things together and can norplant really solve the problem of the underclass? And this went on in multiple settings just to give you a few examples in these, some of which come from Dorothy Roberts' work, that there were people who were introducing legislation to give financial incentives for people to use norplant and giving more money for each year you kept it in. So if you got the full five years that would prevent women from having children. Other people were saying, okay, I'll let you out of jail if you agree not to have children. And so this idea of somehow linking this public health goal to contraception is something that was established fairly early on. This is what norplant looks like, and this is important because you'll see that it actually has six rods and there was not a lot of training for people to put them in. And so when I was finishing residency, I was part of the cohort of people who had to take them out. And it was really hard. It could take an hour and you could find them in lots of different places. And so you're kind of at the end of clinic doing a minor surgical procedure, trying to identify all of these rods that were somehow in someone's arm. And so it ended up there, there ended up being a number of lawsuits. None of them that were actually won by the way, but there were a number of lawsuits including a large class action lawsuit. And so by the time that there was a lot that did not have adequate drug levels, again, no pregnancies resulted in it, but they were concerned about the bioavailability of drugs. They actually ended up saying enough, it's coming off of the market. And so norplant is no longer available. But yeah, so it's an interesting story. Sheldon Siegel is really one of the greats in contraceptive development. And before he passed, he actually came and gave a talk here at the University of Chicago. And he said, you know, I never wanted to make it with six rods. I didn't think that was the best thing for women, but that kind of technically that seemed to be the easiest way to make sure that we had sufficient drugs. And so on the one hand, it's sort of this great method, highly effective, but the way in which it was used and sort of its association with coercive practices really made it, its distribution ended. And so by 2002, it was no longer available. And so just again, this kind of connection between social justice issues and family planning. The other area that has been a really important part and is still an active debate today is the role of sterilization. And you all had the opportunity, those of you who are here to see Don Shapiro's work on sterilization. So you have a sense of the history of sterilization and the coercive use of sterilization. But this is something that still is alive and well. This is a quotation from Senator Russell Pierce who's like, hey, let's just, you know, we wanna solve these social problems and what we need is birth control implants and tubal ligations and nore plant, right? So still in modern times, people are thinking about this as a way to address larger social issues. And so these are, this is the reaction of women and of communities of color saying, don't force sterilization. So this has been an interesting area for me and something that I started studying at the very beginning of my career with my friend and colleague, Dr. Nikki Zeit. And what happened at the time is we noticed we were, at that time, I was at the University of Illinois at Chicago. And we noticed that when we were on labor and delivery, sometimes a woman would have all the requirements to have postpartum tubal ligations and sometimes not. And because of the larger history of sterilization, there actually, we have to sign a consent forming. You have to give women adequate notice in order to, so you have, there has to be 30 days between the time the consent is signed and the time the procedure is actually performed. And so when we actually looked at the rates of sterilization, if someone had requested sterilization, we found that only about 46% of women who had requested a postpartum sterilization, about 46% actually had an unfulfilled request. And this study ended up being repeated by other people across the country. So in San Antonio, they found that about 31% had an unfulfilled request. Another study in Philadelphia showed about 44% had an unfulfilled request. Now these papers are only for women who are using Medicaid funding to pay for the cost of sterilization. So if you don't require, if you weren't using Medicaid, then you wouldn't have this request form required. And so one way of looking at this is that, my gosh, we have a different requirement for women who have lower incomes than we have for women who have higher incomes. But what I wanted to do as well was to actually look and say, well, what's the consequence? And so I also followed women longitudinally forward and said, what actually happened? So these are the women who had requested sterilization during their pregnancy, had not received it than what happened next. So about 24% ended up having a sterilization at another time and about 18% became pregnant at about a year. And so some, one way of saying is like, oh, that could be a problem. Women who had wanted to have no more children actually ended up getting pregnant again. But what was interesting is that many of them were losing insurance. Many of them actually were happy not to have had the sterilization. There was a lot of inconsistency and it was difficult to say that it was purely a bad thing that their request was unfulfilled. And that was in that one cohort. So one of the challenges is that this issue of who is having an unintended pregnancy happens. It is more common among women who are low income or women who are people of color. And so many people have said, look, if we address this issue of unintended pregnancy and this address this issue of unintended sterilization, the thing to do would be to take away that paper so that women, as it came on labor and delivery, would be able to have a sterilization. And so a lot of people have argued that we should remove that 30 day waiting period and then Sonia Barrero even estimated the cost difference, right? If you included pregnancy and all of these other things that happened, if women had repeat pregnancies, you know there's actually a cost savings. The challenge though is that when you think about things that way, either the kind of cost effectiveness or even just maybe the ethics of removing a piece of paper, you're not using the reproductive justice framework, right? And when you start to think about it more in a social justice framework, you start to realize how much choice do women really have. In our study, we were finding that women lose insurance, they lose access to medical care. They may not have the same ability or autonomy in making contraceptive decisions as other women. And when you look more closely, what you realize is that Medicaid provides coverage up into a certain time and the Affordable Care Act has improved much of this. But at the time, Medicaid provides coverage until six weeks postpartum. And so maybe some of those decisions about having a postpartum sterilization had to do with will I have further access to contraception? Other places, women don't have access to all methods of contraception. And so some very important work that's happening here would led by Lee Hasselbacker and Deborah Stahlberg are looking at the access to contraception in religiously affiliated hospitals. And so if you think about that, that you don't actually have access to contraception, you might choose sterilization at the time of delivery. The other interesting issue is around the access to financial assistance for the number of children that you have. And so under the Clinton administration, there were a series of welfare reforms. And what happened in that welfare reform was women stopped getting additional financial support as they had more children. And these were called family cap policies. So as a result, you actually didn't have the money that you needed to raise more children. So maybe that's why you choose sterilization because having additional children actually threatens the economic wellbeing of your family. And about 19 states have these policies. And so what reproductive justice does is it forces us to complicate our understanding of what could initially seem only to be an issue of unfair access to a treatment. And what was interesting when there was sort of the drumbeat of articles about sterilization and removing barriers to sterilization is that some of the most vocal people about not removing these barriers were actually women of color led organizations, right? So the people that you think you're trying to help were actually the people who were most concerned. I'll give you another example of this. So this is a chart that's often used to help to counsel women about contraception with this idea of helping them understand the most effective method. Again, that's using this public health framework, right? If contraception is to prevent unintended pregnancy, you need to know the most effective method. And it led to, and so you put those on top and you give people this graphical understanding and this is how people understand efficacy. This is just a diagram from the contraceptive choice project. This was this idea of you give women choice and you remove their access to contraception and you tell them about the most effective method first. They are more likely to choose long-acting methods, the IUD or the implant, right? So choice results in this and then they also show the reduction in pregnancies and their reduction in abortion and the reduction in birth compared to people who are not in the choice study. But what's really interesting is the response to this type of research, right? Lowering access. Actually, this is a document by Sister Song which is one of the leading organizations in reproductive justice. And it's a letter that they are asked providers to sign and it's really about restraint in the use of long-acting methods. And so what they say is we call on reproductive health rights and justice communities including clinicians and funders and others to endorse the following principles and I'll just give you an example of what these principles look like. We acknowledge the complex history of the provision of LARC and seek to ensure that counseling is provided in a consistent and respectful manner that neither denies access, nor coerces anyone into using a specific method, right? So the study is called the choice study but the reaction of women and women in the community is this feels like coercion or there is a potential here for coercion. They want people to sign something that says we commit to ensuring that people are provided comprehensive, scientifically accurate information about the full range of contraception options in a medically ethical and culturally competent manner in order to ensure that each person is supported in identifying the method that best meets their needs. And so it goes on and this is something you can find on the web but it just gives you a sense that maybe the ways in which we're thinking about it either in a research context or a clinical context is not the same way that women and activist organizations and women of color and our patients are thinking about it. So these are topics that I've kind of grappled with and thought about for a long time and one thing that's important to remember about reproductive justice is that it is considered to be a women of color led movement but it's also a movement from women who are most affected by it and most marginalized by these issues. And so in many ways, it's not about the academy, right? It's not about us in a university setting trying to be leaders in this movement. And so that was a complicated thing and trying to figure out how to think about it. So in 2008, it gives you a sense of how long we've been sort of thinking about these issues here at the University of Chicago. We hosted a conference and we called it Beyond Choice, examining reproductive justice from scholarship to activism. People like Dorothy Roberts Kane, people like Lisa Harris, a number of women of color led organizations from our local community participated and it was really an opportunity to talk about the interface, talk about the history of reproductive justice but also to begin to think about the interface between the provider community and the reproductive justice community. And this is the article that resulted in it. This is an editorial that talked about the conference but also talked about the way that clinicians can interact with reproductive justice organizations. And we were fortunate enough to get funding from the Harris Foundation to continue to have a policy program. And one of the things that we learned was the lack of access to information and to articles. And if you tried to get an article and you're not part of the university, you're often asked to pay $30, $40, $50 for a single article. And so one of the things that became really important for us to do was just be the group that read through, synthesized data and provided to organizations that were working in activist organizations or other organizations that were on the front line of actually changing unjust policies. So just to give you sort of a sense of the things that we highlighted in that conference is that it's the breadth of reproductive justice, how it's not just focused on family planning but it really is much more complicated. So for example, women who recently immigrate to the US are often closed out of access to a broad range of reproductive healthcare, whether it's breast exams, physical exams, family planning visits. We talk about the Hispanic paradox that women who come, Latina women, Mexican-American women who immigrate to the US actually have better birth outcomes than most US women. And you can see this in other colorectal cancer for other populations, but for pregnancy, this has been noted. Over time, that boost, that protective factor actually diminishes and part of that is because of the systemic discrimination, whether it's due to culture or language or fear of incarceration due to documentation status. And then unless we're thinking about these larger systemic factors, we can't just sit in our clinical environment and think that we are providing excellent healthcare. And so this is worked by a colleague, Lisa Harris who talks about the role of in vitro fertilization. And in vitro fertilization was originally developed to prevent for women who had tubal disease, right? So the fallopian tubes were blocked. And so this was a way of taking a fertilized egg and putting it directly into the uterus. Blocked tubes are actually much more common among low-income African-American women because of higher rates of chlamydia and gonorrhea. And so it really is the ideal treatment for this problem. And yet the actual access to IVF is incredibly low for these populations. And so it's actually the populations that are the least able to use it. So we have Medicaid coverage for sterilization with the barriers that I talked about, but not Medicaid coverage for fertility services. So again, this differential access to the right to bear children. So the key to reproductive justice is that it is considered empowerment of and leadership by people who have been disempowered. And what's important about that is that the idea is not only to change access, it is really to empower and to change people's ability to make changes for themselves. And so in some ways, you know, on the one hand it's this enlightening and really important framework, but as I said, it is not necessarily, it does not necessarily put academics or academic physicians at the center of the movement. And so I wanna talk a little bit about why we ended up starting CI3 and how my work has been informed by the topic of reproductive justice. So CI3 is a center with, run by those people up there. And thank you. And we started this in 2011, 2012, really with this idea of trying to think about interacting and working with communities in a very, very different way than I had been trained to do either through research or through clinical care. And I wanna talk to you about some of these projects and show you how they work. And hopefully you can kind of see the echoes of reproductive justice and how that is an outgrowth of this work. So we work in three areas, we kind of call them three verticals, and then throughout we combine policy and research and communications. And so one thing, and so my work is with adolescents. So one key project has been the work in the Game Changer Chicago Design Lab and that's work that I do with Patrick Chagoda and Ashlyn and Bea and her team. And the idea was to think about how we can bring people who are not experts in health, but are experts in their own health and experts in their own lives into the process of actually designing the intervention. And this is an example, it's taken us a while to kind of come up with the way to design games and interventions, but the idea is that from the very beginning we are planning and bringing young people and educators into the process of designing. Then we do a lot of play testing round and round and now really making sure that we're constantly exposing young people and ourselves to these interventions. And then we only then do we start to do the actual research and the actual scaling. And this has led to a very different approach to research, a very different approach to designing interventions, but one that both changes us and I think changes the people who interact and in many ways the process of designing it is as much the research as the outcome. So we're very interested in both the process and the outcome. So I just wanna give you a few examples. So this is sort of the CI3 approach to addressing the issue of sexual assault and sexual violence. This is a game called Bystander that with the idea that to teach young people about sexual assault and sexual violence, rather than making them the victims, we wanna make them the assets and the people, assets, we wanna make them the people who have the ability to address the issue. And so Bystander interventions are ways and kind of pro-social approaches to changing community norms around issues. And so for this game, the young person is always positioned as a person who can intervene, address and gain skills. And this is a project that we're working on right now in some of the Chicago public schools. And so this is an example of one of the modules. You have a scenario where a young person espouses a rape myth and then you as a Bystander, your job is to say, is this true or is it not? And to give advice to your colleague. And then you can get the answer wrong. You can pretend you don't know the answer. You cannot know the answer and then you get feedback. And when we did this, we had, for example, young men said we're always the bad people whenever we talk about sexual violence. And so we also included a module about young men. So this is an example of another module where the young man is actually the person who's trying to look for episodes of sexual harassment or sexual misconduct and then trying to show them the different interventions. This is another example. This is a game that we're working on right now. It's called The Test. And it's a game for young MSM to start to think about how and where to get HIV tested. And so again, we work with young people from the population and we actually bring them in constantly getting input and advice on how to design it, what works for them, what doesn't. But also creating scenarios and personas that actually reflect their actual lived experience. And so through this, the idea is to address some of the real barriers that people experience with trying to get HIV tested and embedding that teaching into the game. This is another example. This is a project being developed by my colleague, Brandon Hill, really talking about the role of pre-exposure prophylaxis for prevention of HIV. And again, having young men who are at very high risk for HIV being engaged in the development of the intervention. And this is a similar project and it's called Our Plan. Really trying to help young people start to think about using contraceptive methods, but also finding a method to prevent sexually transmitted infections as well as unintended pregnancy or undesired pregnancy. And what was interesting about this is that they felt very strongly about the use of condoms and very concerned about saying long acting methods were more effective than condoms when many of them felt that they're much higher risk for sexually transmitted infections. And so there's a huge emphasis on condoms and discussing condoms and really going through a lot of the barriers they feel they have to condom use. So that gives you an example of how we've kind of reframed and rethought the way that we do contraception research and other behavior change research in CI3. The next lab that we work through is called the Design Lab. And this is led by Amanda Geppert here. And it's really trying to bring young people into the whole process of designing interventions. The project that we're really excited about is a project working with a mobile health unit. And what's important about this is that we work with the community from the very beginning of kind of this idea of inspiration. What is the problem that we're trying to fix? Generating a lot of ideas that actually come from the communities affected and then really trying to just iterate from there on potential solutions. And so this is a project right now that we're working on with people from the mobile health unit, the Comer mobile health unit, to think about how do you provide section reproductive health in the mobile health unit? So one of the big issues for young people is transportation. Like how the heck am I going to get to the clinic and have my parent take time off? And so this idea of actually being able to bring reproductive health care to young people is really important. And I just glanced up at my friend and colleague, Lisa Massenter, because she's like, why don't we just use the mobile health unit? Why not? And so we are. And what we're seeing as young people is the mobile health unit coming today to my school because we really need to get section reproductive health care. And this was a place that really wasn't provided, was kind of focusing on school physicals and now is able to provide section reproductive health care. The third lab works in the area of narrative. And we started this work because the, a lot of times we're relegating people to surveys or even to qualitative. These are the things that we want to hear from you. But through narratives, people are able to tell you kind of what is pressing and what is most important to them. And what I'll do, just to kind of show you how all of this comes together, I'm gonna skip ahead and talk about a project that we're working on right now in India. And I think it kind of gives you a sense of how reproductive justice, these ideas of designing and making with the community in order to help them address systemic change is reflected in this project. So Kisa Kahane is a project about storytelling. It's a project that we're conducting right now in Uttar Pradesh, India in the city of Lucknow. And it came out of this, it's funded by the Gates Foundation and it came from their work and Melinda Gates' interest in family planning. And yet we were working with younger adolescents and as you know from the reproductive justice framework, it would say maybe that is not the interest of this community or we have to understand where they are and what their needs and wants are, especially among adolescents, especially among unmarried adolescents. And so yes, while you can point statistically to what you would call an unmet need for contraception, you'd also have to understand more of the community perspective. And so our idea was we could use our techniques through storytelling and research to understand more about young people. The other key thing with reproductive justice is that we have to think not just about the person clinically, we have to think about their social interactions and the larger political systems that inform their health and well-being. And so that's how you get to something that we would call a socio-ecological approach. So Kisa Kahane has lots of different components. One of it is using some of the technologies and the games that we design actually is a research tool. And this actually turned out to be a very productive approach because a lot of the topics that about section reproductive health are really taboo or things that they are told and taught not to talk about. And so by using a game-based approach where they created scenarios in many ways, this is how we learned about how young people interact with one another, what they do in their downtime. And what we learned was that by kind of creating these groups and we'd have them kind of create these different scenarios and then we'd actually kind of create a guide and analyze kind of what we were hearing. And we were really able to see some of the barriers and stigma and issues that were related to sexual and reproductive health. One of the big themes was that there was a lot of harassment of girls over social media in school, in public places that really inhibited their mobility and their activities. And so this social media, very similar to what we see in the United States was this sort of threat to put your picture online was actually a real threat to them. Again, we couldn't find this in any other parts of our research until we use this game-based method. We also found out a lot about how inhibited they are from having relationships with one another. And so, and we can talk about this at another time, but the logistics of working in groups where boys and girls are meant to be segregated was quite significant. But the idea of having, being in a relationship was really considered very stigmatized and their goal was eventually to have girls get married as a way of bringing wealth into the family. So having relationships outside of marriage was a problem. Another method that we use in Kisafahani is something called body mapping. And I'll show you images of this, but basically what we do is we have young people draw outlines of their bodies and then they narrate stories related to different experiences and put it onto the map. And then we actually ask them to interpret the body map. And from this, we really learned about what the role of adolescence, and by becoming an adolescent and becoming an adolescent girl and having a menstrual cycle, that's really the moment where it's sort of a symbol of this is a time of danger, this is a time of risk, this is a time when girls can bring shame on your family. The other thing that we found in the body mapping work was what a safe space school was, this is one of the places where girls could learn as much as they wanted to, they really felt a sense of self-efficacy. But that a lot of that passage to school actually was fraught with a fair amount of danger and again harassment and lots of reasons why girls were inhibited from getting to school. And these are images of the body mapping and how the process worked. And also some of the findings. And so one of the things that girls talked about is that when they go out, they're sort of lewd comments that are made and they're stared at and they feel as if accessing the streets is just is, and certainly going out alone is very threatening. I'm gonna skip ahead and kind of talk to you about what we did as a result. So we use these different methodologies to learn about young people. And one of the things we asked them to do is create stories and we created beautiful digital stories with the help of Marquez Ryan on our team led this work. And we took these stories that were often traumatic around issues of family and violence. And we actually, by telling a story, girls actually became, or boys became the heroine or the hero of the story and really transform what was a rather painful event into a positive event. And these stories were then entered, we've shown them in lots of different settings, but one of the things that we did was to enter them into a film festival in India. And we gave young people the opportunity to view them. And so this is a picture of the Chen Film Festival. And these are the stories as they were going around India being seen by young people all over who actually rated them and decided which ones would go into the final jury decision. And the jury decision was an international contest and we were able to present it actually at our India Center, our Delhi Center in India. And one of our young people who created a film for the digital stories, Pinky, actually ended up winning a juried award. The last thing I'll just finish is by telling you the other component is we actually worked with young people and we trained them to design their own interventions to the problems that they were identifying in their community. And so these are our research team and they're working with young women and young men, really teaching them about the human center design process so that they can identify those problems and start to find solutions. And so they started to, as I told you before, they started to kind of plan and iterate and come up with potential ideas. And this is led by Amanda and Suchi did the day-to-day work on this. And they came up with potential solutions for how they would address issues of sexual harassment, sexual violence, lack of access to reproductive health in their communities. And so these projects are ongoing with a number of the young people in the NGOs that they are working with. So I'm just gonna end that. We've talked about reproductive justice, about a history and about the framework. We've talked about how much it's informed my approach to research and the work that we do in CI3. And then I'm gonna just end with a series of kind of what I think are recommendations for how providers and healthcare providers and people who are interested in these issues but probably, but may have a privilege that might make it so that you're not at the center of the reproductive justice movement. But there is always, when people are trying to address systems and systems that are either ingest or oppressive, there is such a role for people who are allies. And so these are the ideas that we came up with following the conference that we held in 2008. But I think there's still a resonate and are meaningful today. One of our roles is advocating for policies and practices that enable people who are marginalized to access clinical care, childcare, housing stability and transportation. And in our center, this is work that's led by Lee Hasselbacker, really trying to identify barriers that we're seeing, whether it's in our clinical setting or in our research setting and thinking about how we can be part of the support that changes the policies that limit women's access to care. Really addressing some of the limits of access to abortion, whether that's around stigma or shame or access to care, but not, but also how we as providers promulgate some of these negative aspects. Really promoting policies that expand coverage to contraception and that's something that we've been very involved with here in the section of family planning and also at CI3. I'm really thinking about the role of violence and sexual violence screening regularly in clinic and having the tools and ability to help people find resources. And this goes to many other social issues that I think we often as clinicians ignore because they're difficult to solve. One of the things that we did in the section of family planning is we have the privilege of having a social worker who sits in clinic with us because these were social problems that we weren't addressing. My colleague Candace Norcott just left but we also have a psychologist who sits in clinic because there are so many other mental health and behavioral health issues that our patients face that we were not addressing because we didn't have the ability. So again, just change in the way that we practice care and then removing barriers and limits to reproductive health for women with disabilities and a very large part of my practice in Julie Core and Amber Trueheart's practice is working with girls with disabilities because they have the same reproductive health and aspirations as other young people and then promoting the investment and comprehensive sexuality, giving people as much information as they possibly can, especially trying to shift money away from abstinence-only education. So those are my thoughts for how we can be supporters of the reproductive justice movement and a little bit about my own process and pathway through this work. So I thank you for your time and welcome any questions. Thank you for a really interesting talk. You focused mostly on issues that I care about a lot which is access to care. But I also wonder if in the current political climate, stop working. Oh, okay, thanks. I just stopped hearing the echo. We need to, you know, in a climate where a US representative can stand up and talk about other people's children as though they're terrorists or a drain on the economy, if there might be more danger currently going in the other direction that is more coercion of women of color, minorities, immigrant women, not to have children, if we might be going back to that. Can you talk a little bit about what you see happening in that realm? Yeah. You know, the modern moment is a really complicated one and I think one of the, you know, this question of access, not access. It's really tricky, right? I've talked a little bit about sometimes when you give, when we sort of think about access to long-acting reversible contraception, we might go too far in one direction and it becomes coercive. Other times we put unfair barriers and unfair limits. So the first thing I would say is right now I think the biggest risk is lack of access, right? Because the Affordable Care Act gives women access to contraception without a co-pay at this moment, there are ways that that could be quickly undermined. Important work that we worked on along with Everthrive provides some protections here for women in Illinois to access to multiple modes of contraception. But I think lack of access to contraception is at risk. There is clearly, there is a real drumbeat around defunding Planned Parenthood, which would be a tremendous impact on women's access to lots and lots of forms of reproductive healthcare. And then there is still the Hyde Amendment in place which limits women's access, poor women's access to abortion services because it prevents Medicaid from paying for it and had the Republican version of affordable healthcare gone through. There would have been, there was legislation to prevent women's access to having insurance cover abortion services. So I would say right now that those contraception and family planning access issues are very important. And I have heard less direct conversation about the value of other people's children, but that is clearly an undercurrent of all of this is not wanting those people in this country, not wanting questions about whether we should still by being born in this country that you have citizenship. That is absolutely what those conversations are about is a different value. So there are two things that I think are important. One is empowering people to make their decisions about contraception, right? It is not our decision about this person should use this type or shouldn't use this type really helping people make those choices themselves with a minimal amount of coercion. That's really important. And when you have financial access to one and not to another, that forces people's choices. So we have to think very, very broadly about those issues and our role might be to limit barriers, but at the ultimate decision making has to be about these women. But I completely agree this is an incredibly vulnerable time for many, many people and populations. Did you just want to make this thing happen or not? Yeah. It seems that the question for abstinence only in sex ed just never died. Yeah. And even in 2014, I think that part of the Affordable Care Act included like $50 million dedicated towards abstinence only sex education. Even though clearly the Obama administration was pro-comprehensive sex education as demonstrated by the establishment of the Office of Adolescent Health. I think a lot of that has to do with our representation doesn't look like all of us. It's a lot of old white men, unfortunately. So what do you think can be done to maybe bridge the divide there where younger people of color and young women and men are able to show these representatives that this is what matters to us and that these are decisions that really impact our health? So the question was about comprehensive sexuality education and one thing that the question points out is that so early on very forceful legislation around abstinence only, but even as abstinence only legislation has been rolled back, there's basically $50 million towards abstinence only education. The difference is that it required matching grants and so one of the ideas was that because there was a state matching grant requirement that it would be a disincentive to use to have abstinence only information. But, so whether it's who's the legislator and the color and the age of those people, I think there are a lot of people who believe in comprehensive sexuality education, but I think it gets at some fundamental points. I think you can kind of see it in our research in India which is there is fear of adolescence and fear of sexuality and fear of adolescence as sexual beings and so here's this kind of moment where reproduction and biologically young people are now open to the ideas of sexuality and it's biologically it's driven that way and yet we as a society are like, oh my gosh and then the sexuality of young women is particularly frightening and I think you've, I think you're touching on it. I think it goes beyond legislation. I think parents find when I talk to parents about your daughter is almost 12, they go, oh my gosh, you know, this is so terrible. It's so frightening. So there is something, there is something that is, that scares us but think about it, what problem is ever solved by making someone ignorant, right? When does ignorance actually make something better, right? You know, we are sitting here in an institution of education and so what we know is that knowledge is what makes things better and I think the last thing I might just point out is the issue of reproductive justice. So I sometimes talk about, I don't know if you need sex education or just education, right? You know, when kids are busy, when they have things to do after school, when they're in supportive, safe environments, they actually don't have very high rates of pregnancy, right? So there are all of these other systemic and social interventions and this is where it goes back to this idea of caring about other people's young people as much as you, other people's children as much as you care about your own children because working at this larger systemic level where we're worrying about safe schools, safe passage home, all of these other things, it really keeps kids, if you wanna call it, trouble out of trouble and then the second piece to remember is that it is absolutely normal and normative for young people to be interested in issues of sexuality and that if we don't talk to them about it, then they do it behind our backs. It's not gonna go away, right? It's sort of like abortion does not go away. It is just a question of is it safe and in the open or is it hidden and less safe? And so we know from studies in the Netherlands and for European countries that they have the same rates of sexual activity, the same age of onset of sexual activity but not the same outcomes and so I think it's a complicated reason why we are not teaching young people about giving people information but I will tell you it's absolutely wrongheaded. Yeah. Yeah. Other questions or concerns? The other one in the back. Thank you, I'm an outside visitor. Thank you. With the Religious Coalition for Reproductive Choice, I'm Betty Holcomb and for the 21 years that I've been sitting on this board, we have consistently pushed for comprehensive sexual education and uphill battle in spite of the Hyde Amendment, et cetera, demonstrations. We did receive some grant money for a while for that but we continue to find resistance right in the communities that are impacted the most by reproductive injustice and I wonder if you've had any type of luck in outreach in predominantly black communities of faith with the resistance that continues to be put up about information on reproductive health? Yeah. Have you had any success at all? Yeah. Yeah, no. So first of all, I thank you so much for being here and thank you so much for the work that you do and you are pointing to a very, very important issue. So I think some of the most powerful work that has been done was work being done by Tony Bond and Black Women for Reproductive Justice and one of the things that they did was these sort of like kitchen table conversations, right? How do we go and start talking about, not actually starting with her agenda but talking about things like douching, right? Things that may be slightly more neutral territory just to begin to show people that we can have those conversations and I think me and many of the people in our section, in our section, in our center spend, when groups ask us to come and speak, we make ourselves available because people wanting to hear about these issues, it's really important. One thing I will say is that sometimes you don't find as much resistance as you think you will at an individual level, at a group level, everyone's like, we're not allowed to say those things but when you talk to people one-on-one, you make a little more progress but the last thing I would say and it's what we're finding in also in our work around Kisa Kahane is that sometimes you have to let what we're finding and just from our perspective and it could be very different for you as a member of the community. I often think that you're probably a more powerful voice than someone like I would ever be but one thing that we found in our work in Kisa Kahane is that letting other people set the agenda but being there to give them the information so and maybe our work is a little more around creating demand, whether it's my work in higher education trying to make as much access to educational opportunities for young people and then they start to say, oh, I need the information so my child doesn't get pregnant or this because that opportunity is now available to them so my sort of thinking is that we put all of this together not just I'm coming here to talk to you about not getting pregnant but you put it into to, these are my other hopes and aspirations for you and your children and your community but you put these things together and these are the outcomes that you could get. Yeah, thank you. Great, thank you. Appreciate it. Thank you.