Willing and Unable: Doctors' Constraints in Abortion Care

By Lori Freedman

Vanderbilt University Press

Ninety-three percent of all abortions are done in abortion clinics. Only three percent of non-metropolitan counties in the United States had an abortion provider in 2005, while thirty-one percent of metropolitan counties had at least one. After completing their residency, half of physicians who plan to perform abortions as part of their practice actually do so.

These startling facts prompted Lori Freedman to embark on the study summarized in Willing and Unable: Doctors' Constraints in Abortion Care. Freedman is a sociologist working for Advancing New Standards in Reproductive Health (ANSIRH), a collective of researchers and scholars at the University of California, San Francisco. Through this study, she “primarily wanted to find out what keeps physicians who feel positive about providing abortion from doing so.” She interviewed thirty ob-gyns—twenty-two women and eight men—who graduated between 1996-2001 from four residency programs in which abortion training is routine. The interviews, along with historical context and analysis, make up the core of the book.

While some may assume that doctors don’t “have the guts” to do abortions or are primarily afraid of violent retaliation—which is understandable given that eight abortion clinic workers and/or doctors have been murdered since 1993—the reasons are more complex and wide-ranging. The reasons Freedman uncovers include the managed care currently regulating doctors’ services, the stigma attached to being labeled an “abortionist,” the fact that abortions do not often result in a significant amount of revenue, the efficiency and quality of care provided by abortion clinics, and the extent to which physicians see providing abortion as a professional duty.

Willing and Unable begins with the introduction of Freedman’s research question and methods, establishes the various factors influencing physician autonomy, and provides context for the debate over abortion. Most notably, Freedman points out that the loss of fetal life is not, in fact, the most morally offensive element of abortion for those who rabidly oppose it—despite their propensity to wave around graphic pictures of aborted fetuses—since many support abortion in the cases of rape, incest, and fetal anomaly. Rather, the element of abortion that rankles many anti-choicers is “the notion that women can shirk the mother role. Deeply embedded in American society is the belief that women who have sex implicitly become obligated toward parenthood more so than men.” Therefore, any woman who avoids this responsibility is assumed to be irredeemably selfish.

From here, Freedman’s book covers a wide span of topics. The next five chapters trace the history of abortion care in U.S. medicine, the various ideological reasons why doctors are willing or not to provide abortions, the choices surrounding “learning, doing, and having abortions,” the various manifestation of the “institutionalized buck-passing of abortion care,” and the dynamics of miscarriage management within Catholic-owned institutions. The concluding chapter recaps Freedman’s main points and outlines ways to increase the number of abortion providers and integrate abortion into mainstream practice, both of which would lessen the stigma attached to abortion.

Freedman’s balance between analysis and physicians’ interviews is highly engaging. In chapter four, she teases apart the variety of choices involved in abortion care—not simply a woman’s choice to have an abortion or not—through the prism of Dr. Rina Anderson’s experience. After initially opting out of abortion training, Dr. Anderson chose to re-enter the program, then chose to perform abortions in private practice primarily in the case of fetal anomalies, and finally, chose to carry her own pregnancy to term despite the fact that her baby had a fatal condition and would die soon after birth. Dr. Anderson’s story is not only moving but also reveals the layers of choice involved in abortion care for both provider and patient, especially when they are one in the same.

While Freedman’s book explores a unique perspective within the abortion debate, I couldn’t help but want more—more interviews and information pertaining to a wider sampling of physicians. Perhaps I wanted more because what Freedman provides is so compelling. These are memorable portraits of physicians who find themselves confronted with the “choice” of either providing abortions or practicing obstetrics and gynecology, which—like the options available for many women faced with an unwanted pregnancy—isn’t much of a choice at all.

Review by Dr. Jennifer A. Smith

Beauty Shop Politics: African American Women’s Activism in the Beauty Industry

By Tiffany M. Gill
University of Illinois Press

In Beauty Shop Politics, Tiffany M. Gill documents the central role that Black beauticians played in the struggle against Jim Crow laws. Beauty shops were one of the few industries that offered Black women some economic stability and upward mobility in the face of segregation. The industry also offered Black women a respectable alternative to domestic labor, as well as a chance to not work for White people. As political tensions rose, civil rights organizers increasingly turned to Black beauticians for disseminating social and political information.

Initially, White English and French men dominated the hair care industry. Black men slowly worked their way in, serving as hairdressers for White women, but that period was short-lived, as the stereotype of Black men as sexual predators began to emerge. During the antebellum period, Black women began to emerge as hairdressers in greater numbers; the early twentieth century saw the emergence of Black female entrepreneurs, namely Annie Malone and Madame C.J. Walker, who played an integral role in expanding Black beauty culture.

Through hard work and sheer perseverance, the women fought for beauticians to gain the respect of the general public. The women had to fight charges that they were inhibiting racial uplift, particularly because their products appeared to straighten Black women’s hair at a time when it was culturally looked down upon. Still, the women fought to have beautician courses established at Black colleges, arguing that the industry provided Black women economic stability. They also fiercely promoted themselves to the public by contributing to various philanthropic causes.

In times of economic hardship, the beauty industry offered Black women an opportunity to enter a respectable profession that entailed a steady income and entrepreneurial opportunities. On the national level, women worked to create a national organization that would legitimize their profession. In 1912, Madame Walker argued that “hairdresser” was a derogatory term, and insisted on the use of the term “beauty culturist.” With their economic and professional status now in place, beauty culturists were quickly gaining a strong foothold and establishing their place within their communities.

Because the Black beauty industry was owned and supplied by Blacks, and catered to the Black community, Black beauticians had some insulation from the economic hardships that their peers faced. Thus, they were able to participate in civil rights activism without the fear of losing their jobs or their customer base. Some, for instance, established literacy schools so that their students would be able to pass voter registration tests. Others distributed information through their beauty shops, which had become central locations for community organizing. Gill also extends her research to the present day, noting how the focus has now shifted from civil rights to women’s health initiatives.

Perhaps the best thing about this book is its accessibility to a wide audience. Gill writes in a clear and engaging style that makes the book an excellent choice for a non-academic reader who is interested in the subject. She includes noted figures in Black women’s history such as Madame Walker, Annie Malone, and Septima Clark, and uses compelling anecdotes about women such as Mahalia Jackson and Anne Moody, author of Coming of Age in Mississippi. Most importantly, Gill introduces the reader to a roster of lesser-known figures who also played important roles during this period. The book is an invaluable resource for women’s history and African American history scholars.

Review by Melissa Arjona

The Uterine Health Companion: A Holistic Guide to Lifelong Wellness

By Eve Agee, Ph.D.
Celestial Arts

In The Uterine Health Companion, Dr. Eve Agee brings her training as a medical anthropologist and as a holistic healer to bear on the subject of life-long uterine health. She begins the book by explaining both holistic health and the structure and function of the uterus to her readers. Then she outlines a plan for optimal uterine health, with chapters on emotional/spiritual and mental health, the power of nutrition and the importance of a strong body. In part three, Dr. Agee discusses what she calls “Uterine Health Conditions” and these span from menarche to menopause and beyond. This is a book for women at every stage of re/productive life.

This is also a book for western women specifically. Dr. Agee’s training in Africa has led her to question the disproportionate distribution of uterine maladies from a global perspective. Without ever insinuating that western women have their menstrual woes all in our heads (so common to masculinist approaches to women’s reproductive health, as I’m sure most of you are aware), Agee asks why it is that PMS, endometriosis and hot flashes (to name some examples) are so prevalent in the west but comparatively minimal in the non-western world. Agee indicates that dominant western attitudes about women’s bodies and women’s reproductive systems and abilities have actually contributed to menstrual, reproductive and menopausal illness in the western world. I found that to be the most interesting thing about her book.

I can’t say I learned much about the nature of uterine health conditions or about things to do for optimal uterine health, but I’m a reproductive health geek, so I came to the book with a fair amount of knowledge. Still, the reminder to eat my orange and red veggies was a good one and encouragement to keep up on exercise is always appreciated. The part I just couldn’t do was the holistic bit: I just couldn’t bring myself to do the guided visualizations. Certainly, that had more to do with my own comfort zones. Still, I just wasn’t prepared to enter my uterus and talk to the people/things I met there (though it was fun to tell my mother do to so).

Agee’s style is engaging and easy without being over-simple. A quick read, enjoyable and timely.

Review by kristina grob

Living Downstream: An Ecologist’s Personal Investigation of Cancer and the Environment (Second Edition)

By Sandra Steingraber
Da Capo

In the original 1997 edition of Living Downstream, Sandra Steingraber was the first to compare data on toxic releases with data from U.S. cancer registries. In the last ten years since this edition was published, there has been rapid growth in the understanding of environmental links to human cancer and new published findings that corroborate the evidence Steingraber compiled in 1997. With a Ph.D. in biology and a Master's degree in creative writing, Steingraber has been the recipient of many awards, including Chatham College's Rachel Carson Leadership Award in 2001 and a Hero Award from the Breast Cancer Fund in 2006. Living Downstream is both a personal story of Steingraber's battle with cancer and her investigation into the potential sources of carcinogens released into the air, land, and water in and around her hometown of Normandale in West-Central Illinois, as well as in other areas of the United States.

Thirty years ago, when Steingraber was a 20-year-old college student, she learned that she had bladder cancer and was surprised when her urologist asked her whether she had ever been exposed to textile dyes or worked in a tire factory or the aluminum industry. The author later learned that bladder cancer was considered a quintessential environmental cancer. In other words, there was more evidence linking it to toxic chemical exposure than to any other type of cancer. However, although bladder carcinogens had been identified, they continue to be used by industry even today. The obvious question, of course, is why have these chemicals not been banned. The reader quickly discovers that cancer causation is complex, as is proving the source responsible for this disease.

The author reminds her readers that of the 80,000 synthetic chemicals currently in use in the U.S., only about two percent have been tested for carcinogenicity and only five have been banned under the U.S. Toxics Substances Control Act since 1976. We also learn that the U.S. environmental regulatory system does not require exhaustive toxicological testing of chemicals before they are marketed. Legal limits are set on chemical releases, but, as we recently learned with bisphenol A (BPA), trace amounts can be more harmful to humans than higher doses. Moreover, we are often exposed to many contaminants simultaneously in the air we breathe, the water we drink, the food we ingest, and the land where we live and work.

Often compared with Rachel Carson, Steingraber makes some compelling arguments in favor of the precautionary principle, or the better-safe-than-sorry approach to chemicals. She also advocates the principle of reverse onus, which holds producers responsible for proving that their products will not harm the public, as is the case for pharmaceutical companies.

Sandra Steingraber has the expertise in science to give her the necessary authority to present an investigation of this scope and the impeccable writing to make it accessible to a wide audience. Although some environmental texts can be dry, Steingraber's writing and personal story make for a compelling read. Her drive and commitment to finding the missing pieces of the cancer jigsaw puzzle are humbling. I only wish that she had included a map of Tazewell County, Illinois, which we repeatedly visit throughout the book. A few diagrams of some the atoms she describes would have also been nice.

In short, if you have ever thought that the environment may have played a role in the death of a loved one and would like to know more, this is the book for you.

Review by Heather Leighton

Lifting Depression: A Neuroscientist's Hands-On Approach to Activating Your Brain's Healing Power

By Kelly Lambert
Basic Books

"Depression hurts," chimes the television announcer. Most people have been depressed at some point in their lives, whether from a life-changing event or simply a bad patch of circumstance. I am willing to wager that if you haven’t been there yourself, you know someone who has suffered from depression. The pharmaceutical industry is now doling out pills to treat depression and a large portion of our population is taking them, some with marked results, some going from pill to pill searching for the perfect cocktail that will relieve them of pain and anxiety, fear and restlessness.

In her book Lifting Depression, Dr. Kelly Lambert explores the reasons why people born in the middle of the twentieth century are ten times more likely to suffer from major depression compared to people born in the early twentieth century. Why, in our modern day convenience-filled society, do people seem to be so ill at ease? Dr. Lambert is the chair of psychology at Randolph-Macon College and President of the Behavioral Neuroscience Society, and her research has been featured on ABC’s World News Tonight and in Scientific American Mind.

In one experiment she conducted with rats, some had to work hard for rewards, and some they dubbed the "trust fund rats" were simply given the treats. After five weeks, the hard working rats were sixty percent more persistent in trying to work on a new task. She describes this as "learned persistence," and theorizes that coming from our agrarian roots, the human brain receives stimulation from doing concrete tasks like working with our hands, and accomplishing something you can hold as the fruit of your labor, "effort driven rewards." Her studies find that engaging the effort driven rewards circuit of your brain appears to be equivalent to taking a dose of the most powerful antidepressants. With this in mind, she suggests that something like "behavioral activation therapy" can work to retrain your brain to be happier in the long term. With this form of therapy, a person learns how to alter their behavioral responses to situations and even change their environments to stimulate the brain into feeling more rewarded and therefore relieving the subject of their depression. She is not advocating the end of pharmaceutical intervention to lift someone out of a lethargic and depressed state. But she maintains that without some other form of therapy, or alteration in activities, a person could simply remain on these drugs, without ever being able to get out of the cycle completely.

This book is not only a valuable addition to the field of psychology in an academic sense, but it is also a readable guide book that I would recommend to anyone struggling with depression or seeking to understand how they could offer better guidance to a person who is.

It seems so simple, to engage in exercise, to take up knitting or woodworking as a way to engage the brain in a new rewards program that will assist in finding happiness. But if it is so simple, (and inexpensive!), then why are most people advised by their healthcare providers to just pop the pill and carry on as usual?

Review by Jen Wilson Lloyd