Structures & Self: Advancing Equity and Justice in SRH
Course Development & Description
Structures & Self: Advancing Equity and Justice in Sexual and Reproductive Healthcare is a learner-led, justice-informed curriculum designed to teach clinical learners to consider how systems of power and legacies of structural oppression impact their care for patients. Learners will consider how to leverage their privilege to create change on a clinical, community, and systemic level.
Led by Zoë Julian, MD, MPH, Structures and Self is also the result of transdisciplinary, community-engaged curriculum development process, employing novel methods of collaboration, transparency, and accountability that center Black lived experiences and scholarship. The core development team consisted of Black health professions educators, clinicians, and learners from family medicine, nursing, midwifery, and public health, as well as obstetrics and gynecology and family planning: Maisha Davis, MD, MPH; Talita Oseguera, CNM, WHNP; Ariel Hart, MPH; Sanithia Williams, MD; and Biftu Mengesha, MD, MAS. This team also worked in paid partnership with Elizabeth Dawes Gaye of Sisu Consulting, as well as reproductive and birth justice advocates of Black Women Birthing Justice, with continuous support from the staff of Innovating Education in Reproductive Health. See the acknowledgments section below for all our critical partners and mentors in this work.
*For more resources and citations click each video title in the light blue box!
If you would like to be able to assign this content to learners and track their progress, you can request a login for RHEcourse, our free online platform for SRH education, which offers additional features for users who want to engage more deeply. If you are a learner who would like to enroll in these courses for self-paced learning, you can request a RHEcourse login for self-paced learning.
IERH acknowledges the importance of inclusive language as a component of patient-centered care and we are working to improve our content. Read more here.
Pillar I: Own Our Legacy
Learners will become familiar with historical context and implications for disparities in sexual and reproductive health. This video will review how the history of oppression, contributes to current health inequities.
Own Our Legacy
Structures & Self is a learner-led, justice-informed curriculum designed to teach learners to consider how systems of power and legacies of oppression impact their care for patients.
HRD-77-3 Investigation of Allegations Concerning Indian Health Service
Prevalence of HIV and healthcare experiences among people of transgender experience
- Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006–2017. AmJ Public Health e1-e8.
- James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
Personal Reflection Questions
- Were you aware of the legacies of oppression within the medical establishment and how they connect to modern inequities in sexual and reproductive health? If not, why do you think that is?
- Were any of the statistics in this video new to you? How do they make you feel?
- Think of an example of a law, policy, or system that has treated someone differently based on their race, gender, class, or other identifying factor, in your patient population.
Pillar II: Recognize Structures of Oppression
Learners will explore how the structures of power and oppression manifest within healthcare systems and impact sexual and reproductive health outcomes.
Recognize Structures of Oppression
Racial residential segregation is associated with higher rates of preterm birth for Black women
- Salow AD, Pool LR, Grobman WA, Kershaw KN. Associations of neighborhood-level racial residential segregation with adverse pregnancy outcomes. Am J Obstet Gynecol. 2018 Mar;218(3):351.e1-351.e7. doi: 10
Physicians spend less time with clinically obese patients and fail to refer them for diagnostic tests compared to thinner patients.
- Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015 Apr;16(4):319-26. doi: 10.1111/obr.12266. Epub 2015 Mar 5. PubMed PMID: 25752756; PubMed Central PMCID: PMC4381543.
Personal Reflection Questions
- Think of the inequitable structures in your community or institution. How might they impact your patients?
- What are a few potential targets for action that would address some of these inequities?
- Did learning about these structures impact how you view your community?
Pillar III: Check Yourself
Learners will identify implicit bias, privilege, and fragility regarding patient interactions, their relationship to structures of oppression, and practices for self-reflection and self-care.
“Unpacking the Invisible Knapsack” by Peggy McIntosh
Implicit bias among providers
- FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017 Mar 1;18(1):19. doi: 10.1186/s12910-017-0179-8. PubMed PMID: 28249596; PubMed Central PMCID: PMC5333436.
Racial bias in pain assessment and treatment recommendations
- Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press; Washington, DC: 2013.
- Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med. 1997;127(9):813–816.
- Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. 2015;169(11):996–1002.
- Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301. doi: 10.1073/pnas.1516047113. Epub 2016 Apr 4. PubMed PMID: 27044069; PubMed Central PMCID: PMC4843483.
Personal Reflection Questions
- If you identified with any of the statements mentioned in this video, from “Unpacking the Invisible Knapsack”, think about which characteristics your privilege arises from. Do you feel defensive about these privileges? If so, why do you think that is?
- Can you think of a time when your implicit bias affected your interaction with a patient?
- Have you witnessed the impact of implicit bias during a patient encounter? How did it make you feel to witness that?
Read “Unpacking the Invisible Knapsack” by Peggy McIntosh
Take the Implicit Bias Test
Pillar IV: Take Action
After learners have recognized their privilege, they will identify ways to center a justice framework and structural analysis as a tool to promote optimal health outcomes.
Bronfenbrenner’s Social Ecological Model
- Bronfenbrenner, Urie (1989). “Ecological systems theory”. In Vasta, Ross (ed.). Annals of Child Development: Vol. 6. London, UK: Jessica Kingsley Publishers. pp. 187–249.
Personal Reflection Question
- What are three ways you can act at the institutional and/or individual level this week to become an agent of change?
- What are some barriers you envision to becoming a change agent? How do you think you might overcome those barriers?
- How will you encourage your peers and colleagues to also become change agents?
Sincerest gratitude to the reproductive and birth justice advocates, consultants, core development team, advisors, and production teams for their critiques and contributions to the development of this series.
Black Women Birthing Justice (BWBJ)
Elizabeth Dawes Gay – Sisu Social Justice Consulting
Core development team
Maisha Davis, MD, MPH
Ariel Hart, MPH, MD/PhD Candidate
Zoë Julian, MD, MPH
Biftu Mengesha, MD, MAS
Talita Oseguera, RN, MS, CNM/WHNP Candidate
Sanithia Williams, MD
Christine Dehlendorf, MD, MAS
Andrea Jackson, MD, MAS
Monica McLemore, RN, MPH, PhD
Jody Steinauer, MD, MAS
Executive Producers: Innovating Education in Reproductive Health
Stefanie Boltz, MPP
Cassandra Carver, MPA
Felisa Preskill, MPP
Amanda Sawyer, MA
Director of Photography, Kyle VanAuker
Post-production by BAYCAT Studios