“Shame, Stigma, Silence”
The Social and Moral Dimensions of Gynecology
Limits to reproductive healthcare availability aren’t always legislated. Often, there are concentric layers of stigma, shame, and silence shrouding access to information and care, especially the kind unrelated to childbearing. We often feel shame around contraception, STI testing, and even the most basic needs of our reproductive systems. All too often, we’re uneducated about our vulvas, squeamish about our menses, and ashamed of our bodies in general.
The moralizing and shame aren’t always internal or family-based; we sometimes hear it from our care providers, too, when their personal opinions enter the professional setting. In this way, judgment comes at us from all sides: ourselves, our families, our institutions, our communities, and our laws. And this is why many women don’t seek out any sort of reproductive healthcare—they are afraid of being judged. And thus, common conditions go undiagnosed, untreated, and ignored.
There is no effective treatment for sexual health without addressing stigma first. Yes, our reproductive organs are affected by viruses, bacteria, cancers and more; but stigma is the most pernicious disease of all.
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Karli Fairbanks
Layers of Stigma
Individual (internalized):
A 40-year study of women of reproductive age found a correlation between restrictions on abortion access and increased suicide rates, translating to more than 5,000 suicide deaths in that time, and an even greater number of women struggling with mental anguish and suicidal ideation who didn’t ultimately take their lives. [1]
Suicide is one of the most common causes of death among adolescent girls, and the risk increases with unwanted pregnancy, death being seen as the resolution to the problem. Factors include family rejection and social isolation and stigma. [2]
“For a failure of contraception, death was my Plan B.”
Pregnant teens between ages 15-19 were three times more likely to experience suicidal ideation, attempt, or self-harm than any other age category. [3]
One study in 2002 showed that girls were 68% less likely to tell a doctor or nurse about past sexual history due to stigma. The same study also showed stigma was related to a 71% decrease in girls seeking STI-related care. Another study in 2009 showed that stigma caused a 50% decrease in the probability of someone getting tested for STIs. [4]
“I declined the STD screening, and I continued to do so for the next eight years. I was afraid of what the results might say about me. Ignorance, here, was not so much bliss as it was better. An ignorant slut is better than a herpetic one.”
Interpersonal (partner, parent):
58 percent of women have felt a sense of embarrassment simply because they were on their period.
42 percent of women have experienced period-shaming
51 percent of men believe it is inappropriate for women to openly mention their menstrual cycles in the workplace. [7]
In the U.S. today, the gap between the age at first sex and first marriage is 8.7 years for young women and 11.7 years for young men. [5]
Abstinence-only education frequently employs outdated gender stereotypes, portraying girls as naturally chaste and casting them as the gatekeepers of rampant male sexuality. [6]
“Nosebleeds are acceptable, vaginal bleeds are not”
“I’m so disappointed in you,” said my father, shutting the bedroom door on me. Thus began my punishment for becoming a sexual being—as evolution had intended.”
Institutional (physicians, schools):
One in two sexually active people will contract an STI before age 25. That’s half of all sexually active people! [8]
90% of survey respondents said that their sex education left them unprepared for real-world sexual experiences.
“As the nurse emerged from between my legs, she said, ‘Now, there’s no reason why we need to test a nice girl like you for sexually transmitted diseases, right?’”
Subpar sex education leads to gaps in knowledge for women about their own reproductive health. For example, 38% of women said they felt unprepared for changes in their menstrual cycle. One-third said the same about fertility and conception (34%) [9]
Studies have shown that women who receive comprehensive sex education are more likely to make informed decisions about their bodies and health. This includes making choices about using contraceptives, seeking medical care when necessary, and understanding their sexual anatomy. [10]
“The doctor was a middle-aged man armed with an air of weariness surrounding the treatment of irresponsible co-eds. It was his tone, more than anything, that belied his disgust with my sexual ignorance and actions.”
“Researchers have theorized that concealing abortion is part of a vicious cycle that reinforces the perpetuation of stigma.” [11]
Recent research indicates that two out of three women having abortions anticipate stigma if others were to learn about it; 58% felt they needed to keep their abortion secret from friends and family. More than two-thirds of women talked about their abortions “only a little bit” or “not at all.” [12]
“The receptionist’s reaction told me that my actions would have ramifications back home.”
Community (church, media, schools):
“Our results lead us to conceptualize slut shaming as a form of gender-based violence that takes place from adolescence onwards and is likely to generate physical and psychological suffering among young people.” [13]
One study found that women are routinely exposed to slut-shaming, most often online. Such judgments may lead to negative self-perceptions and fear of being ostracized, even though the woman may not be the target of slut-shaming herself. [14]
“That was my knowledge of sex. STDs and condoms. Nothing about pleasure or pregnancy, communication or consent. I wasn’t ready educationally, but I was primed emotionally and biologically. There was a gap. I inserted my newfound sex life into it. My ignorance fit like a glove, so tightly, I didn’t know it was there.”
In the ’90s, Choosing the Best was a widely used abstinence-only curriculum that used a Russian roulette theme, stating that "there is a greater risk of a condom failure than the bullet being in the chamber." The curriculum included a video, entitled No Second Chance, in which a student asks, "What if I want to have sex before I get married?" The student's teacher responds, "Well, I guess you'll just have to be prepared to die. And you'll probably take with you your spouse and one or more of your children." [15]
Only 9% of health education certification programs require students to take a course in how to teach sexuality, and none requires a course on HIV and AIDS education methods. Thus, most teachers enter the field with no idea how to teach sex ed and feel just as uncomfortable as their students during lessons. [16]
“This was the air I breathed as an adolescent: woman + sex = whore. Thus, when I found myself awakening the morning after getting drugged and raped by my date, I blamed myself.”
“Religious commitment is associated with decreased sexual activity, poor sexual satisfaction, and sexual guilt, particularly among women.” [17]
“My parents had witnessed the pointed shame of premarital sex and took the shame to be as natural and inevitable an outcome as the pregnancy itself.”
Public Policy (laws):
We see an important intertwining of law, morality, and stigma. Legal restrictions (e.g., parental consent requirements, gestational limits, waiting periods, and mandated ultrasound viewing) in the United States make it more difficult for women to obtain abortions and reinforce the notion that abortion is morally wrong. Stigma is a barrier to changing abortion law. This is of particular concern because severe legal restrictions are correlated with unsafe abortion, which contributes to morbidity and mortality. [18']
“They did everything they could to stop me from exercising a constitutional right, while making me feel morally bankrupt about exercising that right so I wouldn’t do it again.”
Rep. Greg Delleney (R) of South Carolina says mandatory ultrasounds help a woman "determine for herself whether she is carrying an unborn child deserving of protection or whether it's just an inconvenient, unnecessary part of her body."19 But studies show that ultrasound viewing has little measurable impact on the abortion-seeker. Her mind, once at the clinic, is already made up. [20]
“Statements like these, when codified, trickle down through the strata of shame—through our communities, our institutions, our families, and our psyches—reifying the notions that our bodies and their functions are shameful.”
Shame: One Body, Five Acts
Essay by Jen Jackson Quintano, illustrating the layers of shame depicted above.
As a 12-year-old menstrual neophyte, tampons were terrifying, the accompanying pamphlet confusing, and Toxic Shock Syndrome a new kind of adult-sized monster hiding under the bed. Which is to say, I started off with pads.
I knew to spiral fold my sanitary napkin’s contents into submission—a kind of shame-based origami—and put them in the trash, but it was a new art. I didn’t yet know about the necessity of toilet paper entombment. Thus, during my uncle’s visit, one pad unfurled slightly from its coil in the bathroom wastebasket. The bathroom I was sharing with him.
My mother was the first to spy it, in all its gory glory.
(Not so gory, really; I was mostly spotting at the time.)
She hissed at me to better conceal my mess while my uncle was around. It was disgusting. No one wants to see that. This was Menstruation 101: nosebleeds are acceptable, vaginal bleeds are not.
I was horrified. I was disgusting. I failed the class.
To this day, I mummify the evidence of my menses. No one wants to see that. It’s disgusting. That fluid from my body that will come roughly 480 times in my life. That fluid which flows from roughly half the population. Blood that we all carry within our beings, that cradled us all in the womb.
Disgusting. Keep it hidden. Nothing to see here.
It’s your hushed dialog with the moon, Kotex, and no one else.
* * *
“Sex is when a man inserts his penis into a woman’s vagina.”
Inserts. I remember that clearly from the Sex Talk when I was still small—maybe six? eight?—riding in the passenger seat of my mom’s red Fiat. All difficult conversations are easier when both parties are allowed to gaze anywhere else but at one another.
Inserts. I remember the word feeling like instructions found in a step-by-step assembly guide: Insert Flap A into Slot B. This was a description of a mechanical operation, one that two soulless mechanisms might engage in, cogs turning the wheel of life.
I don’t remember feeling uncomfortable about The Talk, however brief it might have been. I do remember feeling curious about that word. Inserts.
It didn’t sound interesting. But all the banter about sex I’d been hearing on the playground made it sound very interesting.
“Mommy! Turn on your headlights and open your gate! '
Cause here comes Daddy with a Z-28!”
“George: Martha, can I stick my finger into your belly button?
Martha: Sure, George.
Martha: Um, George, that’s not my belly button.
George: And that’s not my finger.”
So much dancing around the topic. To allow for a dance of that magnitude, the topic must be very big, indeed. Bigger than inserts might allow.
As the schoolyard jokes dissipated, the family talks picked up again in my teenage years, mostly as a means of checking in on my friends’ promiscuities and making sure that I didn’t follow suit. The sex talk once again came down to one word in my mind, this one even shorter and less interesting: Don’t.
As in Don’t have sex. Period.
I grew up in a home informed by generations of Catholicism, strict dogma fertilizing both sides of the family tree. One of my aunts had been sent to the city for the duration of her high school pregnancy, the infant spirited away as if she’d never happened. An uncle and his high school sweetheart did not marry or hide but adopted out their baby. Another aunt did marry—unhappily and abusively—rather than bear an illegitimate child.
My parents had witnessed the pointed shame of premarital sex and took the shame to be as natural and inevitable an outcome as the pregnancy itself. The events were a Church-sanctioned stain on the family. Grief and discomfort—and the desire to avoid further familial improprieties—informed their fears for me. The safest option was don’t.
Don’t. Rather than, Here’s how to be safe, or, let’s talk about consequences and options. I received an impossible directive rather than a toolbox. Close your eyes (and legs) and pray, rather than, Here’s how to build your life raft. Rather than, And I will be in that life raft with you, if it comes down to it. No matter what.
When my parents found out I was having sex at age 17, that Talk was also short.
I’m so disappointed in you, said my father, shutting the bedroom door on me. Thus began my punishment for becoming a sexual being—as evolution had intended.
I was crushed.
Disappointed. Even though I’d waited until I was ready and had a long-term boyfriend willing to wait years for our joint readiness. Even though it was a considered decision, one made soberly and deliberately, planned well in advance. Even though it was love and the natural manifestation of it. It was not an insert. It was not a disappointment. It was my adult self flowering forth in a space of safety, pleasure, mutual respect, and wonder.
It was natural. It was inevitable. I was lucky. It was perfect.
When my mom found out we were using condoms, she was similarly disappointed. How could you be so stupid? She spat while angrily flipping through the phonebook to find the number for Planned Parenthood. Apparently, it was time to get on birth control.
Her anger came from a protective fear—for my future, for my freedom—but it read as rejection.
How could you be so stupid? Condoms break. You should know that.
I didn’t know. No one told me. I only knew condoms from their mention while viewing slides of raging STDs in health class. And I knew that when a kid in my class tried to substitute saran wrap for a condom in the heat of the moment, his girlfriend walked out. Then she publicly broke up with him, broadcast the reasons why, and enlisted friends to saran wrap his car during third period.
Saran wrap is bad. Condoms are good.
(But condoms are bad, too?)
Don’t.
Insert.
That was my knowledge of sex. STDs and condoms. Nothing about pleasure or pregnancy, communication or consent. I wasn’t ready educationally, but I was primed emotionally and biologically. There was a gap.
I didn’t know women could orgasm.
I didn’t know about the range of birth control methods.
I didn’t know to pee or wash after sex to prevent UTIs.
I didn’t know about ovulation or times of peak fertility in my cycle.
I didn’t know to ask for what I wanted. I didn’t know what I wanted.
There was a gap. I inserted my newfound sex life into it. My ignorance fit like a glove, so tightly, I didn’t know it was there.
My parents and I didn’t talk about sex again until I was raped three years later. That talk, too, was brief. There, too, was a gap in knowledge. For all of us. How to respond, who was at fault, what to do next, where to place one’s emotions. The questions silently puffed out of us, like down from a leaky comforter, then quietly settled under the bed unseen, undisturbed.
Me, a little less full. Less comforted.
* * *
Some weeks after my rape, I visited the on-campus clinic at the urging of my roommate. I scheduled it as an annual exam, not as treatment for an act of violence. I was casual about it. Nothing to see here. Just being the responsible owner of a vagina.
The kind nurse asked about whether I was currently sexually active. I hedged. I didn’t know what to say. Did one partially-remembered night count as “active?” Does “active” hinge on who chose to act? Or who was at fault? Who was at fault? Was I? Was I a slut? Did I deserve whatever I got in this room? What would I get in this room? A reprimand? A diagnosis?
She sensed my hesitation. She delicately prodded. Without naming it as rape or me as victim, she gently asked if I wanted to be tested for STDs or pregnancy. Just in case.
I declined.
When we talk about being STD-free, we say we are clean. I wanted no concrete proof of my filthiness. I wanted no positive test.
Ignorance, here, was not so much bliss as it was better. An ignorant slut is better than a herpetic one.
I declined the STD screening, and I continued to do so for the next eight years.
I was afraid of what the results might say about me.
It was better to remain silent, unseen. The filth swept under the rug of my expansive shame.
However, I knew maintaining ignorance was irresponsible. The guilt eventually gnawed through the resolve of my shame. Four years after my rape—it took me four years—I made an appointment at the health district in my conservative, rural town. I made the appointment on World AIDS Day. It was terrifying to face my demons, especially the possibility of the biggest boogeyman of all.
I shook as I put on my paper gown, feeling that I might walk out of this room a different person entirely.
My pelvic exam went fine. My cervix looked normal. As the nurse emerged from between my legs, she said, “Now, there’s no reason why we need to test a nice girl like you for sexually transmitted diseases, right?”
As if on marionette strings, my head slowly shook from side to side.
Nope. Nothing to see here.
I wanted to remain a nice girl. I didn’t want to imply that I wasn’t by requesting a test not otherwise freely offered.
I walked out of that room knowing less about myself than I did before the appointment.
Was I not a “nice” girl? What is the opposite of a “nice” girl? An informed one?
Eve was punished with childbirth pain and body shame upon gaining wisdom. And I am her heir.
It took me four more years to return to that same clinic and ask for what I needed, and that was only because a new boyfriend wanted to make sure we were both “clean.”
Despite the rape and the trauma-informed licentiousness that followed, I emerged clean.
A clean slate. It was as if my shameful past had never happened. Not to me. No, that was another girl—a not-nice girl—who was now crying in her paper gown, her expansive shame unable to keep up with all those wicked hens coming home to roost.
* * *
I lived for years feeling decidedly unclean. Immoral. Bad. I came of age during the slut-shaming ’90s and internalized much of what the religious right and pop culture had to say about women’s sexuality. Which was, Sex sells—and we will gladly consume—but giving us what we want makes you a slut.
Monica Lewinsky, a 22-year-old intern having an affair with the most powerful man in the world, was called a “predatory girl who had set her sights on the president.”
Anita Hill, who described the sexual improprieties of would-be Supreme Court Justice Clarence Thomas, was described as “a little bit slutty, a little bit nutty.”
Madonna, one of the most celebrated entertainers of all time, was introduced on The Late Show as having “slept with some of the biggest names in the entertainment industry.”
A teenaged Britney Spears was repeatedly asked by the press about the authenticity of her breasts, the status of her virginity, and why she exposed so much skin. One media outlet proclaimed her “a big skank” and mocked her as, “I am woman, hear me whore.”
This was the air I breathed as an adolescent: woman + sex = whore.
Thus, when I found myself awakening the morning after getting drugged and raped by my date, I blamed myself. It was a cheap hookup, and it was my fault. I didn’t dissent. I let it happen. I made all the mistakes, and this was on me: I went to his house, I let him make me a drink, I told no one where I was going, I strayed too far from campus safety.
I must have wanted it, on some level.
He told me that I liked it, after all.
He called it making love.
And so as someone who “made love” without the prerequisite of love, I took up the mantle of slut-dom. It was easy to follow the script. Especially when my male partners continued to ignore the boundaries that “no” suggested.
Rather than simply dabble in my newfound identity, I soon embraced it with gusto. It felt powerful. I owned the term. No one could define me if I was in charge of the narrative. And if I never said no, I didn’t risk the pain of having boundaries transgressed. I was invincible.
After one night of too much booze and too little caution, I awoke unaware of the means of protection used the night before. I decided to do the responsible thing and go to the campus clinic to get the morning-after pill. Just in case. At that time, emergency contraception was only available by prescription. One had to appease the gatekeepers before being rewarded with peace of mind.
My gatekeeper did not seem pleased or appeased.
The doctor was a middle-aged man armed with an air of weariness surrounding the treatment of irresponsible co-eds. I was but one of a number of young women challenging his continued faith in humanity.
When did you last ovulate?
I have no idea.
What was the date of your last menstrual period?
I don’t know.
Did you use protection?
I’m not sure.
He briefly put his palms to his temples, hinting at his level of exasperation.
Do you know how the timing of ovulation relates to your chances of getting pregnant?
No.
He declined to elaborate.
I don’t know if you need this, but I’m going to give it to you anyway.
Okay.
Next time, be more responsible.
Okay.
It was his tone, more than anything, that belied his disgust with my sexual ignorance and actions.
I accepted the prescription and felt, not just like a slut, but a dumb slut. Uneducated and unclean.
* * *
After years of embracing the bad-girl narrative, I was ready to switch lanes. Yet, I didn’t know how. Two measly letters—N-O—were little more than speed bumps in intimate encounters, and it was always easier to acquiesce than to resist and lose.
So I hitched my wagon to an older man who obviously had much in the way of maturity to offer. Maturity, as in control. Control, as in protection. Protection, as in from myself.
My first husband and I got engaged within two months of meeting. My sexuality was now safely ensconced within the confines of matrimonial commitment. My intimacies were safe from scrutiny.
But our intimacies could have used a bit more scrutiny, for a few months later, I was pregnant. Our path out of the predicament was never a question—as my fiance had taken part in seven abortions previous to my unplanned pregnancy, he knew the drill—but such certainty hadn’t always been the case.
In college, I once told my longterm boyfriend that, if I were to fall pregnant, I would probably kill myself. This was before the era of the morning-after pill, before there were a few stops on the rail line leading either to suicide or abortion.
It turns out, that’s one sure-fire way to pump the brakes on sex. He refused to touch me again until I worked through my malignant moral qualms with sex’s potential side effects.
At the time, I was still close to my parents, still their shining star—high school valedictorian and team-leading athlete, recipient of a full-ride scholarship and honors college admission—and the thought of losing that approval in such an inglorious way was more than I could bear. If they were so upset about me having sex, how might they react to me having irresponsible, pregnancy-inducing sex? Better to shed this mortal coil than bear the opprobrium of those closest to my heart.
For a failure of contraception, death was my Plan B.
Thankfully, I never had to test my resolve on that front, but the fact that the idea ever blossomed in my young mind speaks to the depths of my shame's roots.
Fast-forward a number of years, and I was no longer as close to religion or my parents, no longer in need of their approval. In fact, my family’s disapproval of my engagement was one of the wedges driven between us. I did not fear losing their esteem; it was a bridge I’d already crossed. Pregnancy no longer warranted death.
My fiance and I had to travel out of state for the abortion. There were no clinics in our rural corner of our ultra-conservative state, and this was well before telemedecine and abortion pills by mail. We drove for hours. We had to stay overnight to abide by the unnecessary state laws making abortion harder to obtain: mandatory waiting periods, counseling, and ultrasound viewing. Such was the needle I had to thread: take time off work, drive for hours, pay for gas and food and lodging, stay multiple days away from support networks, consult with multiple providers—then finally to look my embryo in the eye and say no, thank you. All so I could get some pills plunked into my palm along with a cup of water. All so I could get a paper bag with more pills to take home.
All of this, and then I was on my own for the actual termination of the pregnancy—the cramping and clots and profusion of blood.
All of this, not for my own well-being, but to make anti-choice legislators feel better about living a pro-choice reality. They did everything they could to stop me from exercising a constitutional right, while making me feel morally bankrupt about exercising that right so I wouldn’t do it again.
All of this because the potentialities of the tiny dot on the ultrasound screen are more important than the actualities of your existence.
When I first arrived at the Planned Parenthood clinic, a familiar face greeted me at the reception desk. She had lived in my town for years, recently moving to this new state for a new life.
Her eyes widened into the same surprised O-shape as her mouth.
She leaned across the desk and spoke to me in a whisper.
Don’t worry. I won’t tell anyone back home that I saw you here. Your secret is safe with me.
It hadn’t yet occurred to me that anyone beyond my family would care. That an acquaintance—with connections back home—now held dirt on me. And that dirt could damage me. It could make me appear unclean.
I hadn’t, until that moment, emerged from the bubble of the experience itself to consider its ramifications. The receptionist’s reaction told me that my actions would have ramifications back home.
And so I told no one. For years. I remained silent so I could remain clean.
But now? Now, I tell people. Because now, my path to getting abortion care—fraught and roadblocked as it was—is no longer available to others in my state. My state’s legislators, along with the United States Supreme Court, have declared abortion a crime. A sin. A deplorable act. Statements like these, when codified, trickle down through the strata of shame—through our communities, our institutions, our families, and our psyches—reifying the notions that our bodies and their functions are shameful. They should remain hidden and silent.
I will not remain silent. I will not remain hidden. I will be seen. I will be heard.
My body and my life are intertwined. The functions, needs and desires of one must be honored and embraced to support the other.
Maggie Nelson writes, “I want to live in a world where the antidote to shame is not honor, but honesty.”
I want to live in that world, too.
This is as honest as I know how to be. Consider me shameless. Consider that freedom.
References
1 https://news.harvard.edu/gazette/story/2023/01/abortion-law-suicide-rate-study-adds-to-raging-debate-but-are-we-missing-point/
2 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236269
3 https://www.publichealthpost.org/databyte/unspoken-pregnancy/
4 https://www.reneecottermd.com/blog/stigma-and-misconceptions-about-sti-testing
5 https://www.publichealth.columbia.edu/news/abstinence-only-education-failure
6 https://hrp.law.harvard.edu/wp-content/uploads/2013/03/sexlies_stereotypes2008.pdf
7 https://menstrualhygieneday.org/nearly-half-us-women-experienced-period-shaming/
8 https://www.reneecottermd.com/blog/stigma-and-misconceptions-about-sti-testing
9 https://www.forbes.com/sites/debgordon/2023/10/21/90-of-americans-feel-unprepared-by-sex-education-new-survey-shows/?sh=1fdfa1fc4646
10 https://www.allohealth.care/healthfeed/sex-education/sex-education-for-women
11 https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/Abortion-Stigma.pdf
12 https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/Abortion-Stigma.pdf
13 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296320/
14 https://huichawaii.org/wp-content/uploads/2018/01/Perryman-Mandy-2018-AHSE-HUIC.pdf
15 https://www.guttmacher.org/journals/psrh/1998/07/school-based-sexuality-education-issues-and-challenges
16 https://www.guttmacher.org/journals/psrh/1998/07/school-based-sexuality-education-issues-and-challenges
17 https://link.springer.com/article/10.1007/s12119-016-9374-x
18 https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/Abortion-Stigma.pdf
19 https://www.guttmacher.org/gpr/2007/11/state-abortion-counseling-policies-and-fundamental-principles-informed-consent
20 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8958634/
21 https://menstrualhygieneday.org/nearly-half-us-women-experienced-period-shaming/