‘What Happens Next?’: What Is Reproductive Justice?

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Susan Carland: Welcome back to What Happens Next?, the podcast that examines some of the biggest challenges facing our world and asks the experts: What will happen if we don't change? And what can we do to create a better future.

I'm Dr Susan Carland. Keep listening to find out what happens next.

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Danielle Mazza: It's really important that, when it comes to something like contraception, that women really make a choice that's best for them.

Louise Johnson: I think it's really important that women's reproductive health and men's reproductive health is talked about freely in the media.

Tania Penovic: So we are beginning to recognise reproductive healthcare as a corollary of women’s equality, central to women's equality, but we haven't dismantled all healthcare barriers.

Susan Carland: Before we begin, I'd like to mention that although we use the word “women” throughout the series, these matters are not restricted to cisgender women alone. All people assigned female at birth are affected by these issues and often face even greater challenges because of them.

Last week on the podcast, the future of women's reproductive rights seemed a bit bleak, not to mention the history and current state of those rights. But I promise it's not all bad news!

Today we'll talk to the healthcare providers and advocates working tirelessly to educate people about their health options, ensure that we don't lose ground in the global fight for reproductive justice, and dismantle the systems that have left women's healthcare on the back burner.

Keep listening to find out what happens next.

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Danielle Mazza: So my name is Professor Danielle Mazza, and I'm the head of the Department of General Practice at Monash University, and I'm the director of the SPHERE Centre of Research Excellence in Women's Sexual and Reproductive Health and Primary Care. And most importantly, I'm a general practitioner and I'm involved in the delivery of clinical care. Susan Carland: Danielle, welcome to the podcast.

Danielle Mazza: Yeah, it's great to be here.

Susan Carland: Can you tell me, do you think women's healthcare is behind men's healthcare? Are they at the same point? Where are we?

Danielle Mazza: I don't really like to compare, to be honest, because I think it's a lot of different issues that goes on in women's healthcare.

There's really so much work to do. Women's healthcare in Australia is not ideal, and the areas that I'm focused on are around sexual and reproductive health, where we know that healthcare services are not currently being delivered according to best practice. And that's the work that I'm involved in trying to address.

Susan Carland: When you say that women's healthcare isn't always being delivered in a way that's best practice, what do you mean?

Danielle Mazza: Well, best-practice women's healthcare means that it is affordable, and accessible, and high quality. So particularly if I take the example of availability of contraception, for example, we know that about only 11 per cent of women of reproductive age in Australia are currently using intrauterine devices and implants.

I've just come back from Sweden and over there, it's about 20 to 25 per cent. And I think some of the reasons for that are probably around women's lack of knowledge about those products and how they might benefit them, and also that they're not being necessarily offered them by medical practitioners and we don't have services available to deliver them. So they're the kinds of gaps.

Susan Carland: So when you say only about 11 per cent of women are using those devices or products, what would the rest of the women be using?

Danielle Mazza: Well, in Australia, women mainly rely on the pill –

Susan Carland: Mm.

Danielle Mazza: – as their mainstay of contraception. And that's because that's often, as I said, what's being offered to them. Or when they come in asking for contraception, they just immediately go to what they know, or what they know their friends are taking, their peers. So there's a lot of change, cultural change, knowledge improvement that needs to go on.

Susan Carland: And is that relevant because implants are more effective, or have fewer side effects? Is that why it would be preferable for more women to be on that sort of birth control?

Danielle Mazza: Yeah, so it gets back to the underlying problem of unintended pregnancy rates.

And I was just doing a conference presentation this morning and explaining that in Australia, the estimates are that around 45 per cent of all pregnancies are unintended.

Women these days have fewer pregnancies, and those pregnancies are very precious. And they want to be able to optimise the pregnancy outcomes and ensure that they're in the best possible health going into a pregnancy, and that it's a wanted pregnancy. And so we need to ensure that in order for women to achieve their reproductive goals, to really get what they want, the outcomes that they want, the number of children that they want, and healthy children, that we have available really effective contraception so that they can plan and optimise those pregnancies that they do have.

And it's interesting, I was also talking to these health professionals this morning, explaining that average age of first intercourse in Australia is around 16 at the moment. The average age of first pregnancy is 32. The average age of menopause is 51.

So if you think about that, and if you think about the average woman having two children, she might spend five years of her life trying to become pregnant, pregnant, or recovering from a pregnancy, but that's 30 years of her life that she spends trying to avoid a pregnancy, or wanting to. And so we need to try our best to help her to do that.

Susan Carland: Louise Johnson spent 16 years doing just that as CEO of the Victorian Assisted Reproductive Treatment Authority. She spent a lot of time correcting the misconceptions around, well, conception.

Louise, thank you so much for joining us today.

Louise Johnson: Thank you. I'm delighted.

Susan Carland: Louise, I want to start by asking you what are the biggest factors that affect a woman's ability to conceive?

Louise Johnson: Age is the most important factor that affects a woman's fertility. It's not only the age of the woman, it's the age of her partner, and also lifestyle.

And it's the obvious things that everybody talks about in the media: it's not smoking, it's being a healthy weight. And that's not easy for everybody, but even losing five kilogrammes can make a difference in relation to conceiving.

Susan Carland: There are so many misconceptions or misunderstandings about the relationship between age and fertility for women. Even now I speak to female friends who are in their 30s who still seem quite surprised to hear just how much a woman's fertility declines as she gets older.

Why do we still not really seem to know about this?

Louise Johnson: I think we'd like it to be different, and I think much as we'd like to have it all at any age, our biology hasn't changed. Our fertility still declines, or starts to decline, in our early 30s and accelerates more rapidly in the late 30s.

And we read about celebrities that are having babies in their 40s, and often they've used donor eggs and not their own eggs to try and conceive. So reading about women who've been able to have babies at a later life, I think, creates unrealistic expectations of what's possible. And we go through menopause – the age the women go through menopause hasn't changed over the last few decades, so much as we'd like our biology to be different, it really hasn't changed. Susan Carland: Purely from a biological point of view, what is the ideal age for a woman to conceive?

Louise Johnson: It's much, much easier to conceive in your 20s and in your early 30s compared to later on.

But unfortunately for many women, they don't partner until later. They may be with a partner who's hesitant to have children, and the decision to have children gets delayed. And so sometimes women find themselves between a rock and a hard place in relation to having babies.

And there's not only partnership issues that are a huge factor, but there's also financial factors as well. For many women in their early 30s, they're still paying off HECS debt through doing tertiary study, and there's a number of other factors. And we've recently had a lot of coverage in the media about the cost of living.

I think it's a really tough decision for men and women to decide when to try for a baby.

Susan Carland: We seem to be in this really difficult tension between the demands of biology and social demands. They seem to be crashing into each other at the moment.

Louise Johnson: Absolutely, and I think there's been a number of companies that have subsidised the cost of egg freezing. But egg freezing for women is really only something that people with a really high income can afford. And it's no guarantee. It certainly incurs the costs of IVF treatment and all the risks and all the lottery that goes with that. So that's a very difficult option for women as well.

And there's very few women that really have access to the sort of money that's required to freeze eggs. So it's really only an option for the well-off and there's no guarantee of success. And you've got the expense and the rollercoaster that goes along with IVF treatment down the track.

So it's quite a challenging issue for many women that do want to have children, and some women don't. And all those choices are great. There's lots of things you can do with your life.

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Susan Carland: It's vital to improve access to contraceptives for those individuals who don't want children, or who may not be ready for them quite yet.

That's where pharmacist Dr Safeera Hussainy and team step in. They're working on removing barriers to emergency contraception methods, and they're doing that by – and you'll never believe this – actually listening to the people who need them.

Safeera Hussainy: Hi, my name is Safeera Hussainy and I'm a pharmacist. My main area of research is women's health and sexual and reproductive health, which I'm very passionate about. And my main role has been to advocate for enhanced access to emergency contraception.

Susan Carland: Safeera, can people just walk into the pharmacy and access emergency contraception?

Safeera Hussainy: So initially when one of them came on the market in 2004, you could get that over the counter without a prescription, and prior to that, you had to get a prescription for it. But since then, with the introduction of the newer product as well, you can get that also over the counter. So both of them over the counter without a script, you have to request it from the pharmacist, which also means having a conversation with them about your need for emergency contraception. A lot of pharmacies might hand you a checklist to complete, but that practice is quite outdated and we've been advocating to phase that out.

Susan Carland: What sort of questions would be on the checklist that you feel are outdated?

Safeera Hussainy: Yeah, sure.

So I just want to preface this by saying that the checklist was introduced to, I guess, protect both parties in a way, because just in case the woman did fall pregnant later on, everything was documented.

The types of questions are around where she's at in her menstrual cycle, how long the cycle is, what the date of unprotected sexual intercourse was, what medications she might be taking, and what medical conditions she has, because these can influence the choice of the product that you recommend.

Susan Carland: Mm. So why is it that pharmacists started to feel that maybe these questions were no longer appropriate to be asked?

Safeera Hussainy: I'm not sure that pharmacists felt that the questions weren't appropriate to ask. It was women who told us in our research that those questions are not exactly the right time to be asking them, and they're too personal. And they come across as the pharmacist gatekeeping women's access to these products that they absolutely need.

And also the data so far has shown us that emergency contraception is a very, very safe medication to take. There's really no contraindications to taking it. If anything, if your body mass index is over a certain value or if you're taking certain medications, then the pharmacist needs to know that in order to recommend a different product or refer you to the doctor to get a copper IUD inserted, which is also a form of emergency contraception.

Susan Carland: Do pharmacists ever feel that they could be put in positions that they feel uncomfortable with? And I wonder how that bumps into the needs of female patients.

So if there is one pharmacist who happens to work in a rural community, there's only one pharmacy, and this pharmacist for whatever reason feels uncomfortable with dispensing medication that can bring on abortion, what happens in that situation?

On the one hand, we don't want to have a pharmacist doing something against their own conscience, but on the other hand, these women have nowhere else to go and they deserve to have access to the medication that they need and want. Can that happen? And if it does, what happens in that situation?

Safeera Hussainy: Yes, it can happen. Where there is only one pharmacy and you know everyone in the town, it's always a big risk that you feel like you're taking, going into the pharmacy to get that script dispensed. And the pharmacist might even be a family friend, who knows?

But it's definitely a balancing act that pharmacists do face, and it's an ethical dilemma. On one hand, they do have the right to conscientious objection. And on the other hand, the professional guidelines, or the clinical guidelines, around emergency contraception in particular, and around the supply of medical abortion, do say that you need to facilitate access.

So if you are not able to dispense the medication and there's no other pharmacist who's working in the pharmacy who'd be willing to, you have to facilitate supply. So that means you have to be able to refer the person to another pharmacy who might dispense it.

But in a rural or regional area that might be 50 kilometres away. It's just not good enough. So that is increasing the time, again, to accessing these vital medications for time-sensitive conditions.

Susan Carland: And what about emerging medications? That's a question for pharmacologist Dr Sab Ventura.

Tell us about the male contraceptive pill you're working on.

Sab Ventura: So our idea is a non-hormonal, non-spermatogenic one. So the way it works is we interrupt the message from the brain that normally moves sperm from where it's stored, to where it needs to go to be ejaculated out of the body. So when ejaculation occurs, there's no sperm there.

Susan Carland: Ah-ha. And is that quite a difficult thing to configure?

Sab Ventura: No, not really. It was just something we thought of during an experiment and we did a particular experiment in an isolated tissue and we thought, “Oh, that might be useful for male contraception.” And that was about 30 years ago, though.

Susan Carland: Oh, wow. So 30 years on, where are you now in the development of this contraceptive pill?

Sab Ventura: So we know the proteins that we need to block to do what we want to do, but we need a chemical to block one of those proteins, which we don't have yet. So we're in a drug discovery phase at the moment.

Susan Carland: OK. And if men do end up taking this pill, or tablet, or whatever it is, how often would they need to have it?

Sab Ventura: Well, we're not really at that stage yet. There's a couple of options. I think that taking a daily pill, much like women do, is probably the easiest way for men to remember to do it. It could be an option to just take it prior to sex and have it only then. But yeah, we're not at that stage yet.

Susan Carland: Although there are clinical trials underway for other male contraceptives, including a gel that Sab says is promising, he also believes the chances of getting anything to market soon are low because pharmaceutical companies aren't in a rush to change the status quo.

Is there a way for the average person at home to try to do anything to change the attitudes of pharmaceutical companies, or at least make pharmaceutical companies aware that they would like access to these sort of things?

Sab Ventura: Yes, I don't know how they’d do it, but they’d just have to make the pharmaceutical companies and the government bodies aware that there's a demand for it. They have to say, “We really want one.”

Susan Carland: So send an email to mrpfizer@gmail.com. [Laughter]

Sab Ventura: Yeah, that's right! And get a few million of your friends to do it as well.

Susan Carland: Right. OK. So if there is a sense that there is enough groundswell of community support, the money might follow.

Sab Ventura: If the pharmaceutical companies think, “Hang on, people are going to use this. We're going to make a lot of money out of this, so let's do it.”

I think at the moment they feel like, “If we made a male contraceptive, all we are going to do is just eat into our female contraceptive market. So we're not going to make extra money, we're just going to move it from one place to the other.”

Susan Carland: So you really would need a significant community push for something like this to happen.

Sab Ventura: Yep, yep. Or you need someone with a lot of money to fund this sort of thing.

Susan Carland: Yeah. Mr Pfizer. [Laughter]

Sab Ventura: Well, there's philanthropic organisations. There's one in particular in the US called the Male Contraceptive Initiative, and they sort of collect donations from people.

And apparently there's a lot of quite rich people who are interested in developing a male contraceptive, particularly young people who have become rich through the tech boom and things like that, and have suddenly got billions of dollars. And they're very keen to develop a male contraceptive, probably because they've seen people, or seen their generation, go through pregnancies and have children, and would've liked to have had some sort of male contraceptive to have stopped that happening.

Susan Carland: While we wait for those Silicon Valley investments to pay off, there are a few things we can do in the meantime to defend reproductive rights and health.

Here's human rights law expert, Dr Tania Penovic.

When Roe versus Wade was overturned in the US, there were an outpouring of protests even in places well outside of the US, like Australia. From a legal or human rights perspective, do you think those protests outside of the US help? Do they achieve anything? Or is it just an understandable outpouring of emotion that needed some way to channel itself?

Tania Penovic: I think those protests are certainly not futile. So first and foremost, they're a mark of solidarity with people in the US who have lost a constitutional right of five decades standing, and that's significant. Those shows of solidarity are significant.

But what that kind of protest can also show is our commitment to reproductive rights, our understanding of reproductive rights as central to women's equality and autonomy.

And it also illuminates deficiencies in our system. So we've been on a trajectory of decriminalisation in the past 20 years, but our system is not perfect. We've got a patchwork of laws. Western Australia has a lot of work to do in order to bring its legislation into line with the rest of the country.

And quite apart from the law, we have a lot of residual barriers to access, particularly for marginalised communities, people who experience intersectional discrimination. So there are women in Australia now who still cannot receive the healthcare that they choose and need.

And so these protests draw attention to all of those things. So they're definitely valuable.

Susan Carland: Although the headlines seem to be blaring bad news these days, progress is being made around the world. And happily, here in Australia, too.

Tania Penovic: Period poverty is the inability to access sanitary products, which is more widespread than we may think, and it impacts on school attendance, employment, and health more generally.

And it's been really recognised increasingly in recent years. So a number of Australian states have introduced free sanitary products in state schools. So Victoria, I'm pleased to say, was the front-runner in 2020, followed by New South Wales, South Australia, and most recently, Queensland.

And hot off the press, Scotland has just enacted legislation requiring the provision of free sanitary products in public-facing facilities such as libraries and community centres. And also local government can take the initiative too. So the city of Melbourne has a pilot program providing free sanitary products in libraries, community centres, and other facilities.

Susan Carland: We seem to be talking so much more openly about menstrual health and access to menstrual products than certainly when I was younger, and probably when you were younger as well. But there's still, I feel, a long way to go.

I read an article recently about how difficult it is for female scientists to go to Antarctica because of access to menstrual products, that the way the treks are designed, when they can stop, when they can use the bathroom, having to bring things with them, made it almost impossible for female scientists to go on these trips, and no one was talking about it.

Beyond Antarctica, where are the other frontiers that we need to address in reproductive health for women?

Tania Penovic: [Laughter] Well, we have an androcentric legal system, we have an androcentric medical system, and these all impact on our ability to discuss and deal with issues such as menstruation.

So we have a long way to go, but we are starting to talk about it, and I think that's a wonderful thing.

Susan Carland: When you think across your career and the areas you've worked in, do you generally feel hopeful about the way things are going for reproductive rights, human rights, gender-based violence?

Tania Penovic: We've made huge strides in dealing with gender-based violence under international law. So in 1979 when the Convention on the Elimination of Discrimination against Women was adopted, there was no mention of gender-based violence. And that's because at that time, in the late 1970s, this was not considered to be part of international human rights, and we've really advanced since that time where the prohibition on gender-based violence is embedded in customary international law and treaty law. So that's a huge advance.

Now, reproductive rights are related to the prohibition on gender-based violence, as I've discussed. So bans on abortion, coerced abortion, sterilisation, mistreatment in the context of reproductive healthcare, these are all understood to be gender-based violence.

And I think we've made huge advances at the international levels. So restrictions on abortion, for example, are understood to be inconsistent with fundamental rights such as the right to privacy, autonomy, the right to health, the right to life, freedom from cruel, inhuman, degrading treatment, freedom from discrimination, et cetera.

So this is all now well understood, and consistently with that, in the past 25 years, we've had more than 50 countries decriminalise, liberalise abortion. So that is a huge advance.

So we are beginning to recognise reproductive healthcare as a corollary of women's equality, central to women's equality, but we haven't dismantled all healthcare barriers, and obviously this progress has been challenged. It's been challenged by the religious right at the international level, and now this religious right has very much embedded itself within Republican administrations in the US.

So if indeed we invested the time and the money in securing evidence-based healthcare for women and girls and other pregnancy-capable people, we would have solved problems of access. But unfortunately, we've got a long way to go, and there's a backlash that really needs to be met with constant vigilance and commitment for advancing rights.

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Susan Carland: Reproductive rights are human rights, and it's incumbent upon all of us, pregnancy-capable or otherwise, to protect and advance human rights. This concludes our series on reproductive health. Thank you to all our guests on these episodes: Dr Tania Penovic, Dr Paula Michaels, Dr Sab Ventura, Dr Safeera Hussainy, Louise Johnson and Dr Danielle Mazza.

For more information about their work, visit our show notes. This is the final episode of our season. We'll be back in a few short months with a new series investigating new challenges and how each of us can make a difference. In the meantime, be sure to explore our back catalogue of episodes on your favourite podcast app.

You can also dig deeper into many of the topics we've covered in this season by visiting Monash Lens at lens.monash.edu.

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