Introduction

Reproductive justice (RJ) is the human right to maintain personal bodily autonomy and access to safe and sustainable reproductive health services. This is achieved when individuals have social, economic, and political agency as well as the resources to make healthy decisions (SisterSong, n.d.). RJ is a restatement of individual’s rights, which integrates human and civil rights grounded in the human rights context as a moral, political, and legal structure through which goals may be eventually met (Bakhru, 2019). Intersectional perspectives on the modern-day RJ movement show how and why women of color organize around reproductive rights, which underscores the need to reframe reproductive rights as human rights (Luna, 2020).

Sexual and reproductive health (SRH) services often serve as an entry point into the medical and healthcare system. Improving access to these services is crucial to eliminate health inequities and increase educational attainment, career opportunities, and financial stability (Office of Disease Prevention and Health Promotion, n.d.) among diverse groups, including members of the lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI+) communities and individuals with different abilities and diverse ethnic and racial identities, socioeconomic backgrounds, and geographic locations. Rooted in the feminist perspective, SRH rights are human rights. The intersection of these conditions has changed from a gendered view of sexual rights to the enjoyment of many other human rights, as well as a prerequisite for equality and justice for all individual and communities (World Health Organization [WHO], 2020).

This article highlights reproductive and sexual health across the life stages and reflects on the roles of macro social work practice, including approaches and frameworks to address RJ and SRH structural barriers and to promote environmental and organizational change at a community level.

Historical Perspectives

The U.S. legal landscape has included regulation of the legislation surrounding women’s fertility, dating back to the days of the early New American colonies. History tended to focus on statutes or case law that sought to establish legitimate parentage of children and, more centrally, to avoid the birth of a child whose lack of a father would likely create a burden on the community. Native white births declined, and immigrants with higher birth rates arrived. Movements at both the federal and state levels led to restricting access to birth regulation, at least in part to encourage or coerce more white births (Luna & Luker, 2013). A different example of these coercive practices took place between 1909 and 1979, when more than 60,000 sterilizations were conducted on women of color, low-income individuals, and people with disabilities (Loder et al., 2020).

The movement to advance social reproductive health rights is informed by reproductive health rights and justice. Each has strengths and limitations, and together they establish the matrix for reproductive justice activism (Ross & Solinger, 2017). The growth of activism and scholarship production has generated a broader understanding and disrupted narrow debates, resulting in increased access to sexuality education in some spaces. However, more interventions are needed.

It was not until 1967 that reproductive health activities were established as a priority at the Centers for Disease Control and Prevention (CDC), resulting in the Division of Reproductive Health, which improved the health of mothers and children nationally and around the world. Some of the successes are listed here:

Since 1987, the Maternal and Child Health Epidemiology Program has assigned more than 35 senior epidemiologists to 36 states and 6 public health agencies and organizations. PRAMS began collecting data from 6 sites in 1986 and has since grown to collect data from 51 sites (CDC, 2017a, 2017b). Important progress in maternal and child health has been made; nonetheless, there are still significant challenges. For example, in the United States, more than 24,000 infants die in their first year of life, and too many mothers die of pregnancy-related causes that are preventable (Hoyert & Gregory, 2016). Reproductive injustices continue to occur in the United States and across the globe (Loder et al., 2020).

In the case of Roe v. Wade (1973), the U.S. Supreme Court decided to strike down criminal abortion laws against women and doctors. It concluded that inherent in the Due Process Clause of the Fourteenth Amendment is a fundamental “right to privacy” that protects a pregnant woman’s choice on whether to have an abortion. This landmark case also led to a global trend in recognizing the right to abortion and personal autonomy. New state restrictions banning abortion represent an assault on reproductive rights. In the midst of these negative developments, other states have enacted policies to protect and expand access to abortion and maternal healthcare (Nash & Cross, 2021).

The definition of sexual health and reproductive health expanded in the 1990s to include a respectful approach to sexuality and sexual relationships, and pleasurable and safe sexual experiences free of coercion, discrimination, and violence. The International Conference on Population and Development, held in Cairo in 1994, put forth a program of action titled Gender Equality, Equity and Empowerment of Women and defined these rights as including voluntary, informed, affordable family planning services; prenatal care; safe motherhood services; assisted childbirth from a trained attendant (physician or midwife); comprehensive infant healthcare; prevention and treatment of sexually transmitted infections (STIs), including HIV, AIDS, and cervical cancer; prevention and treatment of violence and torture against women and girls; safe, legal, and accessible pre- and post-abortion care; and sexual health information, education, and counseling to enhance personal relationships and quality of life (Armstrong-Mensah, 2017).

The women’s rights movement in 1994, led by and representing middle-class and wealthy white women, failed to recognize, much less defend, the needs of women of color and other marginalized women and trans people. Their exclusion prompted women of color to lead a national movement to uplift the needs of the most disadvantaged women, families, and communities. Feminists of color conceptualized reproductive rights struggles and embedded these in social justice organizing that simultaneously challenged racism and classism, among other oppressions, and they coined the term “reproductive justice” in the same year (Bagenstos, 2020). These advocates named themselves Women of African Descent for Reproductive Justice. RJ combines reproductive rights and social justice and is rooted in the UN human rights framework. In 1997, SisterSong was formed and created a national, multiethnic movement (SisterSong, n.d.) of women of color, which offered to the feminist movement salient contributions to the social and policy analysis of the politics of reproduction, transforming reproductive activism at the beginning of the 21st century (Ross & Solinger, 2017). Women of color led the movement that helped reproductive health advance.

Sexual and Reproductive Health

Sexual and reproductive health (SRH) is a state of complete physical, mental, and social well-being in all matters relating to the reproductive system (Moss, 2015; United Nations Population Fund [UNFPA], n.d.). It implies that people are able to maintain a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so. To maintain SRH, people need access to accurate information and safe, effective, affordable, and acceptable contraceptive methods of their choice, in addition to being informed and empowered to protect themselves from sexually transmitted infections (STIs). Women must also have access to services that can help them have a fit pregnancy, safe delivery, and a healthy baby. Leading organizations such as the World Health Organization (WHO) emphasize that every individual has the right to make his or her own choices (WHO, 2020).

In the United States, 700 women die annually of pregnancy-related causes, and more than 50,000 have severe pregnancy complications. Nearly 1 in 10 infants (about 380,000) are born prematurely, and the preterm birth rate has risen over the past four years. About 3,500 infants are lost to sudden unexpected infant death annually. Moreover, nearly half of all pregnancies are unintended, which can increase the risk of negative health outcomes for both women and infants. A recent report by the Centers for Disease Control and Prevention (CDC) noted that Black, American Indian, and Alaska Native women are two to three times more likely to die from pregnancy-related causes than white women (CDC, 2017a). Social and structural factors that contribute to these disparities and inequities include implicit bias and quality of care in facilities that serve women of color (Laguna & Luker, 2013).

Disparities among men and others who do not identify as women or females are demonstrated by higher rates of human immunodeficiency virus (HIV) and STIs. In addition, the needs and rights of men and boys are frequently overlooked (Moss, 2015). There are major gaps in the healthcare system, and experts agree that comprehensive preconception health and family planning services need to be embedded within preventive health services, such as medical history; health assessments; vaccines; STI services; genital examination; and screenings for cancer, cholesterol, diabetes, high blood pressure, depression, alcohol and drug use, and contraceptive methods (Gavin et al., 2014). Social workers play an important role in ensuring that policies are in place; services are available; and reproductive justice takes place.

Reproductive Justice

Race, Reproductive Oppression, and Justice

The urge to control sexuality and reproduction has been a persistent reality in U.S. policy, and decision makers have used this type of social agency to control communities. The renewal of a very subtle form of negative eugenics or desire to diminish the reproduction of some groups while encouraging the reproduction of others is an example of these controls. Some legislators police gender, race, and the proliferation of antiabortion laws. It was not until 2014 that Justice Now, an advocacy organization for women in prison, won legislation that prohibited California from illegally sterilizing incarcerated women (Ross et al., 2017). Other types of violations include forcing Native American parents to surrender their children to boarding schools and separation of children from their families and communities by a foster care system targeted to African Americans and other communities of color, destroying basic family units (Jansson, 2020; Reisch, 2019). This type of population control constitutes human rights violations, as it infringes on the principles of self-determination and harms the health, safety, and well-being of communities, thus producing reproductive oppression and generating systems of oppression based on race, ability, class, gender, age, and immigration status (Forward Together, n.d.).

Oppressions that reflect inequalities include criminalization of pregnancy; prosecuting women for behaviors that they would not be prosecuted for if they were not pregnant, like withholding medical care such as prenatal care or drug treatment; mandating a 5-year residence term for immigrants to access Medicaid prenatal and other healthcare and social services; excluding females near poverty levels from public assistance benefits; sustaining immigration, refuge, and asylum restrictions; preventing lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI+) persons from parenting; and coercing pregnant incarcerated women to have abortions. These inequalities have sequelae like high infant mortality and morbidity rates; separation of parents and children due to detention and deportation; and denial of basic health and emergency care to the uninsured, transgender people, and women with irregular immigration status (Mentz, 2019; Ross et al., 2017). Population control oppressions are not specific to women of color; poor white women have been targeted for sterilization. Women with special needs or those who are mentally and physically disabled may be subject to reproductive oppression because of discrimination.

Sexual reproductive health and reproductive justice also affect incarcerated women. Four percent of the world’s female population lives in the United States but accounts for over 30% of the world’s incarcerated women. Nationally, the number grew from 11,200 in the late 1970s to 206,000 (a rate of 127/100,000) by 2018, an increase of nearly 185%. A disproportionate percentage of these women were people of color and poor (Jones, 2020). In particular, the right to parenting affects women of color who are in jail. Women who are incarcerated have a higher prevalence of all medical and psychiatric conditions. In addition, 80% are mothers, and about 5% are pregnant when they are in prison (Swavola et al., 2016). The experience of post-incarceration is highly affected by race, age, gender, and motherhood status, among other factors. After release, women are expected to continue being caregivers within their families (Opsal, 2015).

Policies like the Hyde Amendment, prohibiting the use of federal Medicaid funds to pay for abortion, diminish the rights of poor women primarily. When the government allowed the states to make “value judgment favoring childbirth over abortion” (Ross et al., 2017) and justify restricting choices of all women through imposition of waiting periods, state-directed counseling, parental notification rules, and other constrains, it shaped the reproductive lives of millions, enforcing differences and defining privilege. Intimate partner violence (IPV) is a common reason for deciding to get an abortion, as unplanned pregnancies increase women’s risk for violence, which in turn increases risks of sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and acquired immunodeficiency syndrome (AIDS) (Bakhru, 2019; Barot & Swanson, 2015; Ross et al., 2017). Immigration policies also have a direct impact on reproductive justice.

Migrants and Reproductive Justice

Immigrants are regularly subject to discrimination associated with nativism, structural violence, racism, and economic inequality, which are considered causes and outcomes of reproductive and sexual health disparities among immigrants and communities of color. They are frequently subject to inferior healthcare services or no services, resulting in lack of health insurance and access to primary or secondary care, chronic stress from poverty, and punitive immigration policies. Lack of cultural and linguistic proficient services, coupled with structural barriers to services, makes it difficult to ensure care if they are experiencing chronic exposure to racism, poverty, and prominent anti-immigrant sentiment (Arons & Agenor, 2010). In some states, immigrants with irregular legal status are ineligible for federal funded public health insurance. The Affordable Care Act integrated most of the restrictions on coverage for immigrants and allocated funds for federally qualified health and community centers for under-served populations. The Congress cut the allocation by 25%, thus limiting care; the impacts of these policies have been detrimental on women’s health, making it difficult for low-income immigrants to get annual exams, contraceptives, prenatal care, and cancer screenings. Title X funding, the nation’s only federal program directed to provide family planning services, has been experiencing severe cuts (Center for Reproductive Rights, 2013).

Experiences of trauma, violence, and poor mental health complicate access of immigrant Latinas. They are at increased risk for intimate partner violence (IPV), as compared to other groups, placing them at greater risk for post-traumatic stress disorder (PTSD), lifelong health problems, and disparities (Galano et al., 2017). Latinas with irregular immigration status are more likely to have higher rates of IPV and involvement with the child welfare system as compared to women who are permanent residents or citizens of the United States (Ogbonnaya et al., 2015). In addition, disenfranchised Latina immigrants face the consequences of gender, class, racial oppression, and consequently poverty, resulting in a low standard of access to mental health services and social support, which could otherwise mitigate developing PTSD and revictimization (Crenshaw & Bonis, 2005). Risk is highest for IPV during pregnancy and after childbirth, and irregular status can increase dependency on a partner, leaving women less likely to report abuse and to seek asylum or legal aid, out of fear of deportation, family separation, and stigma (Galano et al., 2017). For Latina immigrants and refugees, policies that influence migration, mental health, healthcare, and poverty are essential for RJ as well as maternal health and caregiver–child well-being (Fortuna et al., 2019).

Against the backdrop of state-sanctioned violence, it is important to support and maintain activist efforts at the intersections of migration and RJ (Hinojosa-Hernandez & De Los Santos Upton, 2020). Advancing sexual and reproductive health (SRH) and making changes to the economic architecture and institutional arrangements such as financing the development of trade agreements could have dramatic impacts upon SRH and rights (Yamin & Boulanger, 2013).

Lesbian, Gay, Bisexual, Transgender, and Queer+ Individuals and Reproductive Justice

Early-21st-century scholarship transformed the reproductive health field, giving attention to the rights of LGBTQ+ populations, including transgender, nonbinary, and gender-nonconforming individuals (Hinojosa-Hernandez & De Los Santos Upton, 2020). The LGBTQ+ and RJ movements share values of sexual liberation; bodily autonomy; and the ability to decide when, how, and whether to build families and relationships of their choosing. At the core of each movement is the belief that personal decisions must be free from political interference (Gonzalez-Rojas, 2015), requiring a reimagining of a collective procreative consciousness where LGBTQ+ and other communities of color, those who work as assistive reproducers (i.e., implanters of embryos), individuals that are infertile, persons with disabilities, and nonnuclear families, have access to RJ and other rights that work in the local, national, and transnational contexts of their own identities (Smietana et al., 2018).

LGBTQ+ populations face unique sexual and reproductive health challenges. For example, gay men may lack the financial means necessary to cover the cost associated with surrogacy, just as women may lack the financial means for an abortion. In addition, lack of surrogacy agencies or abortion services near one’s home could increase the cost in terms of time and money, making those services even less available (Russell, 2018). There has been a recent push and expansion of comprehensive gender care, in particular, transgender care; however, these models of care are concentrated in major urban settings, preventing comprehensive access to men and women of trans experience living outside these major metropolitan areas. Research has also documented the need for health competency relevant to reproductive health, including the need for training, comprehensive information on gender-affirming therapy and care (Wingo et al., 2018), and addressing heteronormative barriers in reproductive health (Klittmark et al., 2019). Transgender healthcare is an important component of medical and health formation, which should include adolescent and general healthcare (Loder et al., 2020). Another important component of RJ is economic security and labor.

Policies Related to Economic Security and Labor

Women in the workforce continue to receive unstable wages and are seldom not protected by unions or government policies. Women need access to adequate wages to support families, create safe homes, and much more (Lens, 2020). In the late 1980s, Waring was one of the first scholars to document the deleterious effects that women’s nationally invisible unpaid work had on their rights and autonomy (McGee et al., 2020).

The Wages for Housework organizing was shaped by the anti-establishment movements of the 1960s and 1970s, particularly by feminists and those connected to the political shifts and critiques invoked by feminism, anti-colonial, antiracist, anti-patriarchal, and anti-apartheid movements. This movement contemplated racism and the necessity of autonomy in struggle; expanded notions of the refusal of work; questioned long-standing norms about leadership, collective organizing, and organizational forms; debated internationalism versus localism in struggle; attended to intergenerational commitments to struggle; and deepened commitments to RJ (Thorburn, 2020).

Public systems and policies crack down on the disadvantaged and fail to provide living wages and social benefits such as paid sick and family leave, denying basic human rights. Families live in unsafe and unhealthy neighborhoods and have limited access to quality schools and healthcare, making effective parenting a difficult endeavor. Because real wages have stagnated for decades, families send as many members as possible into the workforce. The workplace is highly demanding and increasingly less secure, with low wages, long hours, and often no health insurance. Thus, careers are destabilized; pregnancies and childbirth are postponed; and futures with predictable pensions and benefits are unclear (Zehelein, 2018). In the 1960s, on average, women were paid just 59 cents to the dollar as compared to their male counterparts. Nowadays, looking at full-time, year-round workers, white women are paid about 82 cents to the dollar as compared to white men, whereas Asian women are paid 92 cents, African American women about 68 cents, and Latinas 61 cents to the dollar paid to white men (O’Neill, 2016).

A quick glance at recent federal legislation reveals that the same legislators who vote to restrict women’s access to abortion care can also be relied on to oppose or withhold support for such ideas as restoring the Voting Rights Act, making the Violence Against Women Act more inclusive, outlawing employment discrimination against LGBTQ+ people, reviving the Equal Rights Amendment, or increasing the minimum wage.

Another reproductive injustice is that women of color with low socioeconomic status are disproportionately represented in the removal of their children because of the widespread social perception that they are unfit for motherhood (Russell, 2018).

The current line of attack denies women their reproductive rights, instead of focusing attention on structural inequalities, including housing insecurity, lack of a living wage, and profound histories of disenfranchisement and discrimination. This approach prioritizes individual-level behavior interventions and further perpetuates inequity by not addressing broader systemic injustices (Gubrium et al., 2016).

Safe Homes and Reproductive Justice

Mothers and fathers are at risk of losing custody of their children merely because of the effects of economic and social deprivation: lack of access to healthcare, including prenatal care, mental healthcare, and treatment for cognitive disabilities and substance abuse; inadequate or unstable housing; and unemployment. Some argue that neglect and poverty are conflated with these conditions and label child neglect as a failure of will rather than a product of poverty and social inequality. Studies have found that families are kept apart solely because they lack decent housing, yet the system is unable to ensure that families are stably housed (Ketteringham et al., 2016). Young fathers often need to address immediate concerns related to employment, housing, education, and life stress. Hence fostering trusting relationships between young fathers and more-experienced ones, engaging professionals through community‐based connections, ensuring case management services, and mentoring are essential (Dukes & Palm, 2019).

Mental Health at the Intersection of Sexual and Reproductive Health

Limitations on the reproductive autonomy of low-income women of color were inextricably linked to discrimination, poverty, forced sterilization, contraception, compulsory removal of children, the environmental contamination of land, and the like—factors that all contribute to health deterioration (McLeod, 2017). It would be possible to end preventable maternal deaths, cover all unmet needs for family planning, and put a stop to gender-based violence within a decade at a global cost of only $264 billion (UNFPA, 2019).

Macro social workers and mental health professionals empower women to advocate for themselves by helping them to negotiate complex healthcare and legal systems. Integration of intersectionality into the understanding of SRH is important when practicing social work. No individual behavior occurs without interconnectivity with other individuals in a woman’s social network. For example, cisgender women are not the only people who get pregnant, contract STIs, and plan families. SRH issues intersect with race, socioeconomic status, faith, and other dimensions of difference. Therefore appropriate knowledge and macro social work skills to address the variability of heterogeneous issues are required (Grzanka & Frantell, 2017).

Macro Social Work Practice

Social work constantly deals with social problems influenced by local and global processes. Reproductive health is no exception to these challenges and presents opportunities for learning, effective interventions, and social policy development (Moss, 2015). The National Association of Social Workers supports public policies and legislation, nationally and internationally, that recognize a woman’s authority over her sexual life and reproductive choices, free from coercion, violence, and discrimination. It is imperative to use dialectical and interactive relationships between individuals, families, and group rights and to look at public and social issues from a human rights framework (Ambrosino et al., 2015).

The RJ framework consists of agency, community organizing, and movement building, and it is therefore essential that social workers practice with individuals, families, and communities, to grow the power needed to achieve and protect their human rights. Practicing across diverse social justice issues, and engaging multiracial, intergenerational, and multi-gendered identities across differences and similarities using the human rights framework, is at the core of the profession. Moraga points out in The Bridge Called My Back (Moraga & Anzaldúa, 1983) that women of color are not an affinity group of individuals; however, they are persons who come together across painful differences, to survive supremacy. She challenges us to come together in our personal suffering and to understand how we are different from each other and acknowledge the differences as relational (Moya, 2000).

Macro social work can place the focus at the interaction of public policy and the lived experiences of women and men by pointing to the positive impact of public funding and accessible sexual and reproductive health (SRH). Every dollar invested in SRH saves more than five dollars in Medicaid costs. Investment in services is both a human right and an economic matter (Barot & Cohen, 2015). Macro practitioners could advocate for RJ in a variety of professional fields, to support knowledge and develop skills.

Training macro practitioners in RJ informed care requires knowledge, skills, and attributes on different models of care, such as person-centered care, the midwifery model, and harm reduction. Teaching these types of interventions will require a combination of apprenticeship; clinical skills teaching; didactics; simulations; and education on critical race theory, oppression, power, and bias (Loder et al., 2020).

RJ is at the core of the three levels of social work practice: At the macro level, by shifting resources such as the economy, laws, policies, technology, employment, and services as the primary drivers of large-scale norm change; at the mezzo level by investing in structural interventions for norm change, like mapping resources and identifying structural interventions to improve systems and institutions like health, education, social protection, poverty reduction, and employment, both to benefit the community and as pathways to shifting gender and power structures; and at the micro level through interventions focused on individuals, families, and communities, to link to complementary programs aimed at improving local institutions, systems, and services (Malhotra et al., 2019).

Moving Forward

Reproductive justice incorporates the intersectionality of injustices that are central to reproductive health, rights, and justice, like structural violence, environmental degradation, incarceration, migration, militarization, and violence. In addition, reproductive justice (RJ) is based on the understanding that the impacts of race, class, gender, and sexual identity oppressions are integrative. In order to achieve reproductive justice, a united human rights movement is needed, one that includes voices of those that have heretofore been excluded. Focusing on the relationship between RJ and economic justice helps to understand the relationship between the self-determination, dignity, and safety of a person; and the health and well-being of the community. An antipoverty agenda must include affordable, accessible, and available quality SRH care for all.

Economic justice goes beyond closing income gaps and responding to total lived experiences so that individuals have a chance to thrive, to move up economically and flourish. This goes hand in hand with achieving RJ, and removing financial and religious barriers to RJ are imperatives. Understanding context and honoring the individuals’ stories, including their reproductive lives, is vital. The RJ movement has a large agenda, one that builds a world in which all children are wanted and cared for, in which support exists for all configurations of families to be healthy and thrive. RJ offers an influential framework for empowering individuals and to create healthier and sustainable families and communities.

A human rights framework (Haslegrave, 2013) can help advance the field of sexual and reproductive health, both in the United States and abroad. Through the lens of human rights, reproductive justice and reproductive and sexual health rights can be advanced; respect for human dignity can be ensured; access to comprehensive health, free of discrimination, violence or coercion, can be guaranteed; and the government can be held accountable for its actions. A human rights framework ensures a comprehensive, holistic inclusion and participation of community members in decision making, as well as the generation of measurable action items to advance sexual and reproductive health.

Grounding macro social work education on integrating human rights approaches and serving the most marginalized is at the core of the profession. Our society will not be free until the most vulnerable people are able to access the resources and full human rights to live self-determined lives without fear, discrimination, or retaliation. A call for action and moving forward an agenda responsive of pressing issues and inclusive of marginalized identities is needed; all forms of oppressions affect RJ as well as sexual and reproductive health.

For example, the COVID-19 pandemic has led to the disruption of sexual and reproductive health services like contraception, abortion, sexually transmitted infections, and cancer screening. Healthcare priorities have shifted, leading to disparities in maternal and child morbidity and mortality (Hall et al., 2020; Rasmussen et al., 2020).

Comprehensive and targeted efforts, including ample training of providers, capacity building in facilities and healthcare institutions that serve women of color, and improvements in patient–provider interactions and communication are urgently needed.