 Okay, we'll go ahead and get started. Welcome to everyone online and to everyone in the room. I am excited that we are continuing our McLean ethics lecture series, and I always remind people where we are so basically finished our, our autumn and winter quarters, and we are about halfway through our spring quarter. And after Dr. Core speaks today, we will have four left. So it's been a long and successful year of the McLean lecture series. All the recordings are online and we're excited to have Dr. Core joining us today. Next week, I'll just remind you Dr. Valerie Montgomery Rice, the president and CEO of Morehouse School of Medicine will be joining us. Followed by Paula Martin, who works in comparative human development at the college, the University of Chicago will be joining us talking about intervention, ethics and trans youth. And, and then we'll have two after that and then be done for for the year so it's been a very successful year and I am looking forward to hearing Dr. Core's talk today. Let me go ahead and introduce Dr. Core. Dr. Core is an associate professor of obstetrics and gynecology in the section of complex family planning and an assistant director of the McLean Center for Medical Ethics at the University of Chicago. After completing medical school at the University of Chicago's Pritzker School of Medicine, Dr. Core completed her OB and gynecology residency and fellowship in complex family planning and a master's degree in public health at the University of Illinois at Chicago. Dr. Core's academic and clinical work focuses on understanding and addressing barriers that adolescents and young adults face in seeking and obtaining reproductive health care. She has received private foundation and national institutes of health funding on her research. And Dr. Core is also a co editor of the book entire reproductive ethics and clinical practice preventing initiating and managing pregnancy and delivery, and serves on the ethics committees of the International Federation of gynecology and obstetrics, and the end of the American College of Obstetricians and Gynecologists. A dedicated educator Dr. Core serves as a program director for the fellowship in complex family planning, and the assistant director for the University of Chicago's OB gynecology third year medical student clerkship, and also co director for the first year doctor patient relationship course. So thank you for your service and we're looking forward to hearing your talk today. Thank you so much. Another part of my bio is I think Dr. Euler, you were like chief resident when I think I was a fourth year student so I also have had the pleasure of being educated by Dr. Euler so thank you. I have no conflicts of interest with this talk. I do want to make a disclaimer about language. This talk uses the terms woman and women throughout and discussing issues of gender equity. Recognizing that all individuals who can become pregnant and or utilize family planning services do not identify as women. The terminology that is used in these slides and in this presentation is correlates to the language that is used in the literature that I'll be citing so I use the language that is used in that literature and the research because that's, you know, thinking about surveys and the questions that are actually used in the research that's the language that is used in those in those studies. I will address issues of gender inclusion and exclusion within family planning during this talk, and I will also be focusing on individuals who are assigned female at birth throughout this talk so that's going to be the area of focus from for this lecture. So here is our slide with the CME code. I'm just going to take a pause for a second so people can put in their code get their credit. All good and hopefully someone can put it into the chat as well so it stays there. And by the end of this talk, I anticipate that you'll be able to discuss the role of contraception and abortion access and fostering gender equity. Describe areas for improvement in promoting gender equity within the field of family planning. And anticipate some potential impacts of abortion and contraception restrictions on gender equity and healthcare. And also more of a societal level as well. So we're going to start with a brief history of legal steps in terms of access to contraception abortion in the United States. And I start with this slide. I, this is my 10 year anniversary of being on faculty at the University of Chicago. And very shortly after I started at the University of Chicago, I had the incredible opportunity to hear Justice Ruth Gator, Ruth Gator, Bader Ginsburg, I can't remember, I can't believe I messed that up. But RBG speak at the law school. And this talk or it was more of like a back and forth kind of interview or dialogue has actually been cited quite a bit in terms of Justice Ginsburg's thoughts on abortion, and the role that abortion plays in terms of issues of autonomy and kind of her wishes of how the, how abortion could have been handled by the Supreme Court. And this was marking the 40th anniversary of Roe versus Wade. Justice Ginsburg said that by basing Roe on the rights to privacy rather than equal rights. Roe isn't really about the woman's choice is it. It wasn't about the doctor's freedom to practice, it wasn't woman centered. It was physician centered. So reviewing a bit of Justice Ginsburg's history because really looking at Justice Ginsburg's history. With her involvement in reproductive health law gives us an interesting perspective on the progress of law around reproductive health and equity. So starting out. Oh, no, it's hard because the, I think it's read versus. I can't see the titles. Is there a way to get rid of this. Mark, okay. Yeah. Yeah, would you mind. Awesome. Okay, I thought it was read versus read but I couldn't see in the year I can't remember so 1971. In this case overturned an Ohio law granting men preference as a state administrators. So seemingly kind of not the sexiest of cases. But really this law or this case actually was quite important in that it extended the constitutionals, the Constitution's equal protection guaranteed to women for the first time. Justice Ginsburg, not a justice then but as a younger lawyer. She wrote the brief in that case that came before the Supreme Court. Several years later struck versus Secretary of Defense. This is the case that justice Ginsburg states she wishes had been the first reproductive freedom case to come before the Supreme Court. I wish that or she said that I wish that would have been the first case I think the court would have better understood that this is about women's choice. The case involved captain captain Susan struck who became pregnant while serving as a nurse in the Air Force in Vietnam. And captain struck was given the option of either having an abortion or leaving the Air Force. Captain struck wanted to both continue her pregnancy and remain in the Air Force. And so she sued. Justice Ginsburg argued the case, and the case went to higher courts or district courts didn't make it to the level of the Supreme Court, because the Air Force through throughout this process abandoned the requirement of pregnant people to terminate in and remain in the armed forces. So, this was a great advancement, but didn't quite make it to the level that Justice Ginsburg had hoped. And really she she viewed this because she thought that this would be would have been a great case to bring up the issue of abortion as an equal rights issue. And so that Ginsburg confirmation hearing in 1993 she stated that abortion is something central to a woman's life to her dignity it's a decision that she must make for herself. When government controls that decision for her. She's being treated as less than a fully adult human responsible for her own choices. So though perhaps Justice Ginsburg may not have, you know, thought of herself as an ethicist first and foremost. I think that this really does crystallize some issues around reproductive health reproductive freedom and issues of bodily reproductive autonomy and justice. So I think she really sets the scene for this discussion. So I'm going to take you through some of the key cases and policy changes throughout the past 150 or so years that really lay the groundwork for access to and then restrictions from a use of abortion and contraception in the United States. So in the 1860s in the 1880s there was a an explosion of state level anti abortion legislation prior to that things had really been not so clear there's a lot of there just wasn't very much clarity in terms of kind of legal status of abortion. The AMA actually played a pretty crucial role in this and the committee on criminal abortion led by Horatio store, who was the committee chair and an OBGYN insisted that women must remain within their God given sphere. All states in the United States banned abortion by the eight by the end of the 19th century. The Comstock law, which you may be hearing about recently in relation to the current debate and legal issues around Mipha pristone and medication abortion. The Comstock law at the federal level was passed in 1873. And this was the act for the suppression of trade and circulation of obscene literature and articles of immoral use. And really this law and the subsequent state laws state Comstock laws criminalize the use of the postal service to send contraceptives and abortations. In 1936, the US versus one package, the US Court of Appeals for the second circuit allowed the importation of contraceptives so going against the Comstock laws to us doctors for use by their patients for pregnancy prevention. And in 1960, the FDA, again, kind of at the center of a lot of debate lately around abortion. First approved the oral contraceptive pill and no vid and this was really the first approval of an oral contraceptive or a modern contraceptive in the United States. In 1975, Griswold versus Connecticut, the Supreme Court ruled that the Constitution protects the rights of married couples, very importantly married couples to buy and use contraception without government restriction. And importantly Griswold established the concept of right to privacy and intimate practice. In 1972 and Eisenstadt versus Baird, the Supreme Court established the right of unmarried people to possess and use contraception. And this is based on the fact that the a Massachusetts law that was being brought to court violated again equal protection clauses of the Constitution. So these laws is there being passed to expand access are working around the concepts of privacy and also equal rights, but mostly around privacy. And in 1973 of course is the Roe versus Wade decision and that the Supreme Court ruled that that the Constitution guaranteed the right to abortion, and this was really based on the right to privacy as supported by Griswold and Eisenstadt. I'm skipping over a lot of legal decisions but I want to give you some of the most salient cases that really impact where we are today, and also impact people's access throughout the past few decades. In 1992 Planned Parenthood of Southwest Pennsylvania versus Casey, the Supreme Court decided that after viability a state can forbid abortion as long as it has exceptions for life and health of the pregnant person. But prior to viability states could could not ban abortion, but they can regulate it as long as the regulations do not impose an undue burden. There are many many cases and debates about what constitutes an undue burden, but I'm just going to cut to the chase by going to 2022 because this really largely negates those debates and that's the dobs versus Jackson women's health decision that was made in the summer of 22. The decision overturned Roe versus Wade and stated that abortion is not a federal right protected under the Constitution. Abortion laws and rights are to be determined at the state level. Very importantly, again when we're talking kind of in the next section of this, as I go to the next section of this talk. Thomas in his concurring opinion, wrote that in future cases we should reconsider all of this court substantive due process precedents, including Griswold Lawrence and Ogrefeld. Just to remind you Griswold was the case that expanded or allowed the right to to the use of contraception. So just to kind of put that out there and thinking about where the future may go based on this dobs decision. So not surprisingly in the wake of the dobs decision. A lot of dominoes have fallen with regards to legal access to abortion in the United States. So this current map that reflects state laws, you will see that Illinois is excuse me a blueberry in a kind of bowl of red or sea of red. And so this is kind of I'm not going to go through each state, but there have been 18 plus states that have highly restricted or banned abortion. Florida, Florida was in the news, I think just this week. There's a six week ban that was signed by the governor of Florida. But that is kind of on pause until the Supreme Court of Florida decides what they're going to do with another law on the banned abortion at the gestational age of 15 weeks. So this is kind of where we are, you know I started the very beginning of this talk at my, you know, privilege of hearing Justice Ginsburg speak on the 40th anniversary of Roe versus Wade. And here we are 10 years later at the 50th anniversary of Roe versus Wade and the world looks very, very different in terms of access. I'm going to turn more directly to the topic of modern contraception and abortion and its role in supporting gender equity. Some of the outcomes that have been examined with regard to gender equity and the relationship with family planning include educational attainment workforce participation career outcomes and wage gaps. So just thinking about what ways in which abortion and contraception may contribute to gender equity. Smaller cohort size, like a smaller family size maybe associated with increased financial resources for current and subsequent family members and even generationally delaying pregnancy may increase educational attainment and involvement in the workplace. And there's also the concept of the expectation effect, and that is one's ability to time whether and when to parent can inform a person's aspirations in life planning. And so these may impact engagement in the workforce career choices and advancement. And just to give an idea kind of pictorially, you know, sometimes a picture is worth a thousand words right so this is a graph showing, again as I stated, the FDA first approved modern contraception the birth control pill specifically in Novot in 1960. And this is a graph of live first birth rates by age of the pregnant person or mother in this graph. And you can see that the lines of those who are 18 to 24 at first birth really declined precipitously after the the FDA approval of the And then things kind of plateau and straighten out in 1976. And that was the Planned Parenthood of Central Missouri versus Danforth decision, where the Supreme Court ruled against the state's interest in regulating access to contraception based on age alone so really kind of equalizing access to contraception for those married non married, and regardless of age. Another graph that helps to illustrate changes in the wake of access to modern contraception. So this is a representation of age at first birth by cohorts, and you can see the one cohorts are the two cohorts actually that are substantially different from the rest are those who are born in 1955 and those who are born in 1960. And so these are people who grew up with access to birth control modern contraception so birth control pills so you can imagine. These changes had an important impacts on her people's ability to pursue education to engage in the workforce and so we'll look at some of this historic data. As you can imagine there are many challenges to establishing any kind of causal relationship between abortion and contraception and gender equity. In the 1960s and 1970s we didn't just have FDA approval of the birth control pill and row versus Wade. There are a number of legal and policy changes that can impact gender equity. Including 1963 equal pay act and the 1964 equal rights act that expanded legal legal rights in the workplace. 1972 title nine of educational of the educational amendments college and graduate school admissions were enhanced for women. In 1978, the Pregnancy Discrimination Act established the legal rights of women in the workplace who experienced pregnancy or childbirth, right so the kind of the family planning access. Progress was not isolated, it was within this new view of many other advancements at the policy and legal level. Again some challenges to establishing this causal relationship also include confounders. Right there are factors such as socioeconomic status race, ethnicity, age, insurance status, parents education. These are all predictors of fertility related outcomes. Not surprisingly these same factors are also associated with economic outcomes. It's really challenging to isolate the effects of contraception and abortion from socioeconomic demographic factors and legal policy advancements that also contribute to gender equity. So here's where I venture into the world of econometrics and looking at historic data to try to start to tease out the portion that may be attributable to contraception and abortion. So these approaches control for relevant or attempt to control for relevant socioeconomic factors, but they're unable to account for all. They may compare those who continue a pregnancy and those who miscarry, but miscarriage actually may be related to issues of access to care and socioeconomic factors so that's not really a perfect comparison group. As I was examining the implementation of policies that lead to differential access of contraception. I'm really focusing on contraception largely throughout the states and even at the county level. This data allows for comparison of women in same age cohorts with different access to contraception and abortion with likely much less variation with regards to the other kind of federal changes that were happening that may be impacting gender equity. So looking at family planning policy and funding heterogeneity. Some concepts that are really focused on in this literature this economic econometric and historic data is the concept of early legal access. And as I said, one of the first groups that gained access to contraception were married women. Okay, and so most unmarried women under the age of 21 did not have legal access to contraception in the 1960s. The state's legalized access for single women of the ages 18 to 20 over the next two decades. Public funding also very tremendously again from state to state county to county. And these changes rolled out also over the next two decades. So funding data at the state and county level allows for controls to allows one to control for factors and to better isolate this relationship between family planning and economic outcomes. So we're going to focus on a few of these kind of major outcomes so starting with career attainment. One in cats examined the early legal access to birth control pills and found that this actually accounted for about a third of increase in women in professional careers between 1970 and 1990. And this was, you know, a third increase sounds very substantial but actually this this overall was an increase of 5%. And one of the major limitations to their studies that they really only examined college educated women. Steingrim's daughter examined self reported career plans and found that women from more selective colleges increase their expectations for career attainment, more significantly more than those from less selective colleges. So considering early access or legal access to contraception so individuals who are in the more selective colleges felt that the access to birth control pills increase their career prospects, whereas actually individuals from less selective colleges felt that the birth control pill may have had a neutral or even potentially a negative impact on their career prospects. So really it's, it's very mixed data in terms of the impact of birth control pills for the general population so these are very limited studies. Looking at educational attainment, Edlin and Machado examine changes in marriage laws to evaluate minors access to contraception without parental consent and how that impacted educational attainment. Decreasing the minimal age of marriage, the led to increased minor access to contraception, and that accounted for about a 10% increase in the probability of women ever attaining college so people who had access to marriage in turn had access to contraception, their, their kind of data showed that that accounted for about a 10% increase. And it also accounted for about a 20% increase in women pursuing professions, including medicine and the law. And look at the impact of early legal access to contraception on educational outcomes between 1968 and 1976 1979 and found that women with early legal access had about a 12% increase in college enrollment. And they posited that about a quarter of a million women over the age of 30 obtain their bachelor's degree due to access to contraception by the year 2000. Now you can imagine, there are a lot of limitations to this data, but it does give us at least an idea of the relationship between access to contraception and increase engagement in education. You know, as I mentioned in terms of career attainment there is some differential impact based on the nature of the school that people attended. There's also differential impact and with regards to educational attainment based on baseline socioeconomic status. So Bailey and college colleagues looked at college enrollment and found that it was 20% higher for those 20 to 24 years old with early legal access in the early in the late 1960s and early 70s, but this increase was actually the greatest for those who had a baseline lower socioeconomic status. So that is in conflict with an aunt and hunger men's finding that the association with between access to the pill and increases in levels of education impacted less those with a lower socioeconomic status. So really, this just gives you an idea that there's a lot of noise and trying to establish a clear relationship between access to contraception and these outcomes. But there does appear to be some connection between access to contraception at a younger age and increase educational career attainment. Looking at the workforce Bailey looked at the relationship between early legal access and delays and parenting and found that this accounted for about a 15% increase in workforce participation and work hours in women ages 16 and 30, who grew up between 1970 and 1990. Bailey and colleagues subsequently looked at the relationship between early legal access and improved wages and found that individuals who have this early legal access compared to their peers who did not earned more both hourly and yearly, and they found that this attributed to about two thirds of the impact on gender expansion in the workforce, and also about a third of the increase in educational attainment and occupation. So differences in impact of family planning on economic advances. You know just thinking about some challenges again and looking at these outcomes contraception may have less of an impact for those with access to abortion. So there are several studies that show that really when you take into account both contraception and abortion, abortion may actually have had a larger impact on increase engagement in the workforce and educational involvement. The impact on economic outcomes may be less for those from lower socioeconomic backgrounds as I said, as I showed there are some studies that really conflict in terms of, of how contraception helped those from lower socio economic status compared to higher economic status. And importantly costs remains a barrier to access for many, both thinking about contraception and abortion. There's very limited data in terms of examining differences by race and race and ethnicity. And there's very inconsistent data when we look at actually the effect of teen pregnancy on educational and career attainment. So, again, you know this is really looking at historic data which we know is limited by nature. And recognizing that there are tremendous number of individual level confounders and also policy and legal confounders. So, you know we have some broad strokes thinking they're demonstrating that there is some positive relationship between access to contraception abortion and workplace outcomes. How about some prospective data because that's really what we always want right. And some of the best contemporary data is looking at the relationship between abortion and outcomes including economic outcomes and socioeconomic attainment. The turn away study is really a game changer in terms of looking at access to abortion specifically and long term outcomes. The turn away studies a five year longitudinal study of women presenting for abortion in the United States from 2008 to 2010. This study has a number of spin off papers looking at health outcomes, relationship outcomes so a number of outcomes but they also include socioeconomic outcomes. The three cohorts in the study include the near limits, and those are individuals who presented within two weeks under the gestational age limit of that clinic that they presented to. That was about 450 individuals. The turn aways were within three weeks above the gestational age limit at the clinic that they presented to who are not able to obtain their desired pregnancy termination. And there's a cohort of individuals in the first trimester who obtained their abortions. So compared to those who were able to obtain their desired abortion, those who are unable to obtain their abortion, looking at six months post denial of their abortion. Those who were not able to access their abortion had a higher odds of living in poverty. That's likely to be employed, more likely to receive public assistance, and these differences actually remained after four years. So again, thinking about the impact of access to methods of determining whether and when one can become pregnant and parents. I think these are probably the most concrete and methodologically the soundest data to show the role of pregnancy planning and being able to determine when wants to and is ready to parent and how that impacts engagement in the workforce. Okay, so I'm going to shift gears on this talk is entitled family planning and gender equity but I'm also going to look at gender equity within family planning. Most data and all the data that I presented thus far has really focused on the experiences and outcomes of cisgendered females and their use of contraception and abortion. So it's important to recognize and say out loud transgender non binary and gender expansive people who are signed female at birth do have sex that puts them at risk of pregnancy, of course, not everyone, but there are pregnancy risks amongst this population. So it's important for us to do some self reflection as family planners and ask, how are we providing care for transgender and gender expansive patients who are signed female at birth. There are some important unique contraception and abortion considerations for these patients. I'm just going to go through a few of some of the most notable, but use of testosterone frequently most commonly results in amenorrhea so no men's ease. This does not mean that people who are on testosterone cannot become pregnant. This is not a contraceptive. The use of transgender patients assigned female at birth found that about, you know, 15 to 30% believe that use of testosterone is a safe method or an effective method of contraception. And about 6 to 9% report being told by their provider that being on testosterone will prevent pregnancy. There are also some potential teratogenic effects to being on testosterone if one conceives while on testosterone. There are potentially gender discordant and potentially concordant effects of being on hormonal contraception. And the invasive nature of some of contraception and abortion procedures may be particularly challenging for patients who may feel alienated by their their anatomy. So any contraception is used by transgender men so about 20 depending on the studies between 20 and 60% of transgender men do report having used or using contraception. Transgender non binary individuals also do experience pregnancy. Dr. Josephson and colleagues conducted the probably the largest survey. Looking at reproductive health outcomes amongst transgender and gender expansive participants, including 1700 respondents of those they documented 433 pregnancies and that was about 12% of the study population. About 40% of those were unintended about 40% were resulted in my birth, a third resulted in miscarriage and about 20 resulted in abortion. And importantly, one in five respondents consider themselves at risk of getting pregnant when they did not want to be or were unsure of their pregnancy risk. So let's kind of focus a little bit more directly on abortion amongst transgender and gender expansive patients. There's a 2017 survey of all known abortion providing facilities in the United States. And from those results, they estimate that about 500 abortions are performed annually for transgender non binary patients. This is probably a a gross underestimation. Abortion clinics there's some later data but abortion clinics, you know, you will only know what your data is if you're asking the right questions right until a lot of clinics are not asking the right questions to get an accounting of the gender identity of their patients. But again, returning to Moses and study. And amongst those respondents 92 abortions were documented about 60% were surgical 30% were medical. And of all the respondents, there was a strong three to one preference for medication abortion, if they needed to pursue abortion in the future. Some respondents indicated that they would prefer medication abortion because it was less invasive and more private. Some respondents also said that they did not want to have to engage with the medical system out of concerns for discrimination, and being misgendered. So let's think about provider training comfort with regards to caring for our transgender non binary patients. Looking kind of the broader kind of broader scope of reproductive health providers, only about a third or less of OB guidelines who are surveyed reported being comfortable providing care for trans masculine patients. And as I indicated, only about a quarter of abortion clinics are really focused on care for transgender patients, and only a quarter provides specific transgender care. So that means that about 30% of abortion patients only receive their care in clinics that really provide transgender specific care. So what are our patients experiences with family planning providers are transgender non binary patients experiences Gomez and colleagues performed a qualitative study of 20 transgender non binary young adults were assigned female at birth. The participants described lack of knowledge amongst both themselves and providers about the impact of testosterone and pregnancy risk and interactions with contraception. They also described interactions where providers were unfamiliar with the needs of transgender non binary patients made assumptions about anatomy, gender and sexual identities, and lack knowledge to counsel individuals about contraception. One participant reported, they asked how I got pregnant, how it works, how do other lesbians do it, where do you find sperm and I was like, well, don't you work with pregnant people all day. She was well meaning but the questions she was asked in the questions that she was asking because she wanted to be a better provider but at the same time, it's not my job to teach her. So just clarifying some more specific barriers for transgender and non binary patients when trying to access contraception and abortion care. Fix that all conducted a qualitative study of sexual reproductive healthcare stakeholders, including five patients who had experienced either abortion or contraception care and 22 clinicians researchers advocates. Identify the following barriers to contraception abortion care specifically lack of gender affirming clinicians gendered healthcare environments. There's a lot of language about women and female in abortion clinics and family planning clinics being misgender discrimination and insurance coverage. You know, our transgender non binary patients seeking abortion in particular and contraception face a double challenge. Insurance coverage for abortion specifically is very hit or miss. And of course insurance coverage for transgender care is equally kind of spotty. And also once someone has legally and officially change their gender within the medical record that oftentimes can lead to challenges accessing care deemed women's care with regard to their insurance so so this can be a major major burden. And here's just one quote from the website we testify which is. I highly recommend going to the site there's a lot of really illustrative examples but one quote is it that as a non binary person I've been misgendered and healthcare settings. So if I ever have an abortion again, I would still prefer to self manage so this is someone who would self manage their abortion in the past, again out of concerns of having issues with regards to discrimination and being misgendered when coming into contact with reproductive health care. And so that clearly impacts how they engage with abortion care. Some recommendations from the study participants in terms of how to improve contraception and abortion care for a transgender non binary patients. Making sure their intake forms are gender neutral and gender affirming and affirming of all sexual orientations. And this I think can apply to most health care. Using gender gender neutral language by staff creation of evidence based and gender affirming patient education materials specifically around contraception and abortion which are very much lacking medical education continuing medical education around gender affirming care in the family planning context. Partnering with transgender non binary communities to ensure that changes that are being made in practice center the needs of this community, seeking to have staff that reflects the diversity of patients seeking care and family planning. And empowering those staff who do identify as transgender non binary to help lead shift in patients service delivery and culture, and advocating for comprehensive contraception abortion and gender affirming care coverage. Okay, so now I'm going to make another shift and try to move along expeditiously on family planning and gender equity and medicine specifically. Obviously was stated, access to contraception and abortion has been linked to increasing participation within the workforce and in the professions and specifically including medicine delays and childbearing during training and beyond in medicine imply that there is a use of contraception and abortion amongst physicians and training and physicians in practice. There is a paucity of literature looking at contraception and abortion use among us physicians. An older study, looking at the women's health study in 1993 to 94, include about 4500 participants. Female physicians were more likely to use contraception compared to the general reproductive age population, and to women who are matched by socioeconomic status with nearly three quarters of us physicians using contraception. And the body were more likely to use IUDs and barrier methods and less likely to use permanent contraception, compared to the general population and those matched by socioeconomic status. Thinking about my cohort of family planning providers and our contraceptive use. This is not going to be surprising to anyone who's ever talked to a family planning provider a 2013 survey of nearly 500 providers ages 25 to 44 compared to the 2011 to 2013 National Survey of Family Growth Respondents in the same age group. Family planners had a higher percentage of using contraception and were significantly more likely to use IUDs implants in the contraceptive ring. LARC use so use of IUDs and implants was about 42% compared to 12% in the general population. This reflects likely both differential preferences but also recognizing our access to contraception. Let's talk about our OB-GYN residents and their use of contraception. 2016 survey of OB-GYN residents at the time of their in training exam had an 86% response rate, 83% of those identified as women and more than half are married. The third of the respondents were using contraception or had a partner using contraception and again, the use of IUDs was five times higher than the general population. And amongst noliparous female participants, nearly about a third of them used IUDs and that's eight times higher than the national level. And again, this represents both increase in access financially, but also access to knowledge. Physicians and use of abortion. Just at the national level one in four people who can become pregnant will experience an abortion by the end of their reproductive years. There's really little known about US physician use of abortion. The first survey conducted by a number of individuals including our very own Vinnie Arora, Dr. Vinnie Arora, surveyed 3,800 US physicians and physicians in training with an impressive 82% completion rate. I mean they found that 11.5 of those who responded reported. But 11.5 of those who experienced pregnancy had had one or more abortions. And those who reported having had an abortion were more likely to have also reported delaying childbearing for training. So clearly abortion is common amongst us physicians, though it is a little less it is less common than the general population of 25%. So thinking about you know recognizing again family planning and use of contraception and abortion. So Vinnie plays a role in terms of how physicians and physicians and training, navigate the balance between family building and career attainment. What might the dobs decision that I spoke about earlier on this talk, how might that impact the physician workforce. The number of US residency programs are located within 18 states with banned or severely restricted abortion since dogs. Abortion restrictions and bands also impact management of miscarriage, ectopic pregnancy and infertility. This is especially relevant to physicians both in training as and beyond. Childbearing and strenuous work conditions that physicians experience are associated with increased risk of pregnancy complications now. This is this holds for many, many, many fields but you know we in this room are physicians and so that's why I'm focusing on on the outcomes of physicians, but the rates of complications and need for care for anomalies is quite striking amongst us physicians. Access to contraception and abortion has allowed physicians and physicians and training to plan their lives for 50 years. Impact of dobs on physician workforce is really three fold. As learners, it's going to impact educational content, medical school matriculation and residency ranking preferences. Dr. Euler Euler and I were just talking about the match this year. And, you know, I think we're still going to get more data on this but certainly anecdotally, dobs had a huge impact on how medical students ranked programs nationally. As providers, the changes in what can and cannot be offered and providing reproductive health care within the fields of OB-GYN and family medicine but also throughout internal medicine, pediatric surgery. This, these changes cause moral distress lead to moral injury burnout and career may impact career longevity for some in the workforce. Finally, as patients, these laws and the changes in access to abortion and potentially contraception on that's actually not that far off are going to have an impact on personal or family health and physical and psychosocial health. So, this is an ethics series, and I do think that we need to bring these issues back, kind of hone them into ethical principles, and thinking again back to Justice Ginsburg's words about where abortion fits within regulating one's own life and decisions. Clearly, these issues are tied very closely to both bodily and reproductive autonomy and undermine the principles of justice and access to both regulating one's life and life course but also impacting access and engagement with education and the workforce. So, the principles that are fundamental to safe evidence based provision of contraception and abortion are very much under attack. This is in addition to gender firming care for minors and adults and these are not coincidences. The people who are legislating or creating legislation that is resulting in abortion bans throughout the states are the same people who are creating legislation that is limiting access to gender firming care for children and now even adults. These concerted efforts threaten advances in gender equity that have been made over the past 50 years. So, I propose that it's an ethical imperative for us to advocate on behalf of patients, and especially those who are greatest risk. So in conclusion, access to contraception and abortion is contributed to gender equity, as measured through economic outcomes, not all genders receive equitable family planning care and that's an issue that we very much need to address. Use of contraception and abortion is highly prevalent amongst us position and helps find a foster gender equity in medicine and threats to access to abortion and contraception are threats to bodily autonomy and justice and undermine gender equity, both within our field of practice and beyond. Okay. And now I have eight minutes for questions. Wonderful so we're open to questions from the room. I was just reflecting as you were talking about, I was wondering if there are best practice from our international colleagues and like how that it will impact like this future in the United States going forward so any thoughts about, you know, either good or bad influences there. Yeah, you know it's interesting. A couple of years ago. At the National Abortion Federation. We had panels talking about self managed abortion and really we were learning from our colleagues in South America, where abortion had been banned countries that interestingly enough, many of whom are moving towards legalization of abortion. The United States is moving towards banning and restricting abortion. So there are a lot of best practices, but even with those best practices from countries that have long dealt with abortion and really predominantly abortion being illegal. We know that even within kind of application of those best practices, there are significantly negative health and economic outcomes when abortion is restricted and let alone contraception. So yes there are certainly many best practices, but it's just the idea that we have to reach out to countries where this has been illegal for decades is pretty striking. Any other questions in the room. So, I'm the question from Dr Siaki who is talking about this concept of women's health that has been advocated for a long time and how to address that in the current setting of gender affirming care. I hope I paraphrased that well okay. Yeah. You know there. That also that question takes me back to another conference where there was very heated vigorous debate and there have been really notable ruptures in organizations and kind of academic discussions around this topic. We're focusing on kind of expanding or kind of broadening the pool and using more gender neutral language undermines kind of issues that that have been identified as women's issues. And, you know, I think that my language really is shifted to focus around reproductive health and recognizing that that can be applied to people who are assigned male at birth. But, again, for me my language is focusing on more about reproductive health and quite honestly, to me what's most important is what the patient in front of me the language that the patient in front of me is using, is asking them what language they're comfortable with whether it be with anatomy or procedures or. So I think to me the very most important thing is at the individual level but yes absolutely when someone walks into a clinic and everything is women women women. It's challenging and so I don't think that we've arrived at like a single best practice, but I think focusing on reproductive health and more gender neutral terminology I think is more welcoming to more people. There's a couple questions in the zoom chat one is how is family planning and reproductive care for TGE patients being taught at University of Chicago for students and residents to ensure graduates are able to take care of these patients well. Great question and you know in terms of undergraduate medical education. You know I think that that is certainly something that is going to be a component that we focus on in terms of curricular reform, and certainly there is discussion, you know, I'm director of the ethics course and we had a session around ethical care for transgender and gender expansive patients. But I think that we need to actually get very much into the nitty gritty of practical aspects of providing this care. And so that certainly will be a focus as we are working on the curricular form in terms of clinical skills and more concrete. And so we have some approaches and DPR and those other courses in resident education. We have some, some leaders who are focusing on that Andrew Fisher, being one of them and so we are certainly very actively thinking about how best to do this but we are not, we certainly are not perfect and we are continuing to to work to integrate this into the curricular changes. So looking at socio demographic, you know, we have. Oh, I'm sorry, the question is about the turn away study and the two cohorts those, the turnaways and those who obtain their abortion were those, you know, were the two cohorts very different in terms of, are there some factors that made them more likely or less likely to make it to the clinic. Prior to their gestational age cut off those groups are actually quite similar in abortion care we've had a lot of challenges trying to identify what is the best comparison group right because people with unwanted pregnancies sorry my eyes watering people with unwanted pregnancies who continue a pregnancy are very different than people with unwanted pregnancies who terminate. So it's been a real challenge but this actually in terms of the two cohorts are quite well matched in most of the demographics that were collected so this study actually from a methodologic perspective in terms of really isolating the abortion as being our ability to obtain their abortion as the main difference was quite sound. I think we'll end here we'll stop the recording and, and then we'll just ask the ethics fellows to come down for our final discussion. Do you want me to end it right here. Do you want to stop the recording. That was signed in when I know when I was. So I wasn't hallucinating with. I know that's not ideal. Yeah. That's just great. Okay. Okay, well then. It still hurts. I think it was like, it was like minimized or yeah. Oh, super.