National Partnership for Women & Families

Monthly Women's Health Research Review

Researchers explore how U.S. television combats, perpetuates stigma against abortion providers

Summary of "Doctors and witches, conscience and violence: abortion provision on American television," Gretchen Sisson and Katrina Kimport, Perspectives on Sexual and Reproductive Health, Sept. 26, 2016.

Research showing that media portrayals of "reproductive health are particularly stigmatizing and inconsistent with evidence-based medical care" indicates "that television's depictions of fictional abortion providers might contribute to the stigmatization of actual providers," according to Gretchen Sisson and Katrina Kimport, both of whom work at Advancing New Standards in Reproductive Health at the University of California-San Francisco.

However, the researchers wrote that other research "identified media channels -- and 'popular entertainment' specifically -- as potential tools for normalizing abortion within public discourses," which indicates that "television could potentially create positive frames that counter real stigma."

According to the researchers, "Understanding the role that popular culture plays in the production and contestation of provider stigma is contingent on understanding how providers are portrayed onscreen." The researchers conducted the study to assess "fictional representations of abortion providers on American television to identify patterns in these portrayals and to theorize how such patterns influence stigma toward abortion providers."

Methods

For the study, the researchers searched the Internet Movie Database (IMDb) and Google between December 2012 and February 2015 to find English-language plotlines "appearing on American television between January 2005 and December 2014 that depicted abortion provision." The researchers coded all relevant plotlines to "captur[e] general characteristics of the program," such as genre and time period, as well as the depiction of abortion care, including providers and locations.

Results

Overall, the researchers "identified 52 abortion provision plotlines on television over the period 2005-2014, depicting 44 unique spaces and 36 provider characters." According to the researchers, "The depiction of an abortion space or provider did not mean that these plotlines portrayed an abortion procedure: Only 11 percent of provider characters performed abortions on-screen."

The researchers identified abortion plotlines in 40 television programs, with the majority (75 percent) appearing in dramas, particularly medical dramas, and the rest "spread across the genres of comedy-drama, horror, science fiction, comedy and soap opera." They found that 20 percent of the shows, predominately medical dramas, depicted multiple instances of abortion care. Overall, according to the researchers, 46 percent of the abortion storylines were presented on network television shows, 33 percent on cable television and 21 percent on subscription channels.

Abortion spaces

The researchers found that the "most frequently depicted abortion spaces (75 percent) were medical facilities," including abortion clinics (58 percent), hospitals and private offices.

According to the researchers, "In 54 percent of the depictions of medical spaces, the scene showed the examination or operating room in which an abortion would take place." They noted that the majority of such spaces "were portrayed as clean, safe and comfortable, with visual counterpoints to the stigmatized framing of abortion as dirty and unsafe." The researchers cited one outlier to this trend in the horror show Hannibal, but they noted that the ominous depiction of abortion care in that show "must be contextualized within the show's genre."

The researchers noted that in relevant medical dramas, "abortions were presented within hospitals and physicians' offices, which were the shows' primary settings." According to the researchers, such depictions "normalized abortion spaces, both within the context of the shows' other plotlines and within the provision of other medical care."

Even shows that did not portray the room in which an abortion was provided depicted other medicalized spaces, such as waiting rooms, the researchers wrote, which "reinforc[ed] the idea that abortions occur within an accepted medical context." For example, Parenthood depicted a quiet, full waiting room at a Planned Parenthood facility. Further, the researchers noted that two shows depicting time periods when abortion care was illegal -- Downton Abbey and Mad Men -- also portrayed medicalized waiting rooms, "reinforc[ing] ideas of professional legitimacy even within a context of illegality" and "communicat[ing] the acceptability and propriety of an abortion space."

However, the researchers also found that some shows "portrayed nonmedical spaces for abortion provision that were less clean and implicitly less safe than medical settings," perpetuating the "stigmatized frameworks of abortion as being dirty and unsafe." According to the researchers, "The 25 percent of depicted abortion spaces that were nonmedical spaces included bedrooms, a women's prison, a kitchen, a bar and the outdoors." Citing examples of such nonmedical abortion spaces as depicted on shows like Reign, Salem and True Blood, the researchers continued, "These nonmedical spaces were situated on the edges of the fictional worlds in which they took place, apart from the shows' typical settings, suggesting that abortion should be secretive and that such spaces should be isolated."

Abortion providers

The researchers found that most (61 percent) abortion providers portrayed on the relevant television shows "were featured in a single episode," and "[a]mong recurring characters involved in abortion plotlines, most performed or offered to perform an abortion just once." According to the researchers, "Only 14 percent were both recurring characters and ongoing providers."

The researchers found that on the television shows, "effective abortion provision -- meaning care that conclusively ended a pregnancy -- was squarely situated within a medical context." They wrote that about 75 percent of providers "were doctors or nurses, most working in contemporary medical settings," while almost "all completed abortions were done using surgical methods (94 percent) and performed by a physician (87 percent)." In addition, the researchers wrote that "all physician characters who unambiguously attempted to perform an abortion" were successful, "thereby presenting doctors using medical methods as effective practitioners."

However, citing abortion portrayals on Call the Midwife and The Knick, the researchers noted that "a character did not need to be a medical professional in order to perform an effective abortion, as long as the methods and practices employed were similar to ones that a medical professional might use." The researchers added that in those two shows, "these nonphysician characters were established providers."

Nonetheless, the researchers found that most "nonmedical providers were shown as ineffective." For instance, they cited three shows -- True Blood, Salem and Orange Is the New Black -- in which characters tried and failed to provide abortion care via "supernatural" methods. Further, noting that the nonmedical providers in Salem and Orange Is the New Black concealed the continued pregnancy from women seeking abortion care, the researchers wrote, "These providers were not merely ineffective, but also deceptive." Adding that those characters "may have been ineffective [providers] by intent, rather than inability," the researchers noted, "This pattern reinforced the framework that abortion must take place within a medical context to be trustworthy and effective."

The researchers also cited a "final exception to this pattern linking medical practitioners with efficacy" in ER. In that show, a medical provider at one point provided a procedure that "merg[ed] ... the medical and supernatural approaches, with ambiguous efficacy."

The researchers also found that while "safe abortion provision most commonly occurred in a setting where abortion was legal," more than 25 percent of storylines "involved illegal provision, either because they took place in a historical setting in which abortion was illegal or because illegal providers were functioning in settings in which abortion was otherwise legal." Citing abortion storylines on Downtown Abby, Reign and Call the Midwife, the researchers wrote, "Most illegal abortions were depicted as unsafe, and fears over safety led several characters who were seeking abortion in illegal contexts to change their minds."

Further, the researchers noted that while "[t]here were exceptions to the pattern of linking illegality and unsafe abortion" in The Knick and Boardwalk Empire, both of those shows conveyed "that illegal abortion was generally unsafe, and that these providers -- able to perform safe abortions -- represented exceptions." In comparison, the researchers found that "legal providers were portrayed as offering safe abortions, with no insinuations made regarding their qualifications or ability to perform the procedure safely." According to the researchers, "All of these legal providers were depicted within medical settings," such as Grey's Anatomy and The Fosters.

The researchers also found that "illegal providers were portrayed as having little concern for their patients' well-being, while contemporary, legal providers were depicted as being more compassionate." Citing instances of "unsympathetic" nonmedical providers on Reign and Call the Midwife, the researchers wrote, "Negative portrayals of illegal providers were tied to safety; because they were performing unsafe procedures that would be risky and detrimental to patients' health, they could not be overly concerned with their well-being." Meanwhile, in portrayals of legal abortion care on Grey's Anatomy and The Fosters, providers were depicted as compassionate.

The researchers also found that "most medicalized abortion care [depicted on screen] was provided in the same spaces and by the same characters as was other care, contesting that abortion should be marginalized." They noted that while "abortion clinics were the single most frequently depicted type of space, for plotlines in which the provider was shown, the majority (52 percent) were set in facilities that provided other medical care." Further, "[a]ll recurring provider characters who were physicians were shown providing other types of care in addition to abortion, and none worked in a designated abortion clinic," the researchers wrote. According to the researchers, "These representations, in fact, integrated fictional abortion care into other medical care more often than actually occurs in the real world, where 70 percent of abortions are performed in specialized abortion clinics and the majority of providers have high abortion caseloads."

The researchers found that characters who provided abortion care had a wide variety of motivations. Overall, 25 percent of characters who provided abortion care "articulated their motivations for providing care; these reasons portrayed them as courageous, even heroic, and as performing a social good, thereby countering provider stigma." For instance, a provider character on Battlestar Galactica counsels a woman so she can access abortion care, the provider character on The Knick "viewed her work as saving lives" and a physician on Private Practice was motivated by her own abortion experience, as well as "a sense of obligation regarding the scarcity of providers and of bravery in the face of the risk of violence." According to the researchers, "These motivations challenged the stigmatization of abortion providers by presenting [the physician on Private Practice] as heroic and presenting abortion provision as a necessity." However, the researchers also cited two nonmedical provider characters -- on Call the Midwife and Salem -- who "were portrayed as providing abortion for more dubious reasons, hence legitimating the stigmatization of abortion providers by presenting them as greedy or evil."

Violence and abortion care

The researchers found that 10 percent of television storylines "included violence against a provider or a clinic (four murders of providers or other clinic staff, and one clinic bombing)." According to the researchers, "The occurrence of violence produces stigma by linking abortion to danger and, often, by framing such violence as a consequence of abortion's being a moral wrong." They wrote that in such storylines, "the inclusion of violence presented abortion work as inherently dangerous and signaled a consequence for characters for their abortion provision; yet, at the same time, it underscored providers' bravery."

The researchers cited Law and Order, Copper and Orange Is the New Black, all of which depicted the aftermath of a provider's death. According to the researchers, two of them -- Law and Order and Copper -- villainized the provider. Further, the researchers found that "[b]eyond the actual incidence of violence, plotlines tied abortion provision to danger by depicting providers who took measures to ensure their safety." The researchers noted that the portrayals "suggested that these characters anticipated violence and prepared for it in their daily lives, in a way accepting it as an expected part of abortion provision."

The researchers added that in the study sample, "the only abortion provider shown taking safety precautions without encountering violence was Audra, from Weeds (2009), who wore a bulletproof vest." According to the researchers, "In this plotline, the safety measures and impending threat of violence were used to portray Audra as noble and self-sacrificing."

Discussion

The researchers wrote "Overall, our sample of on-screen representations of abortion provision upheld medical authority in abortion care." However, they noted that while most shows combatted abortion stigma by depicting "effective, safe and compassionate abortion care ... provided by physician characters working in legal, medical settings," the depictions of "nonmedical and illegal abortion care were consistent with a stigmatized understanding of abortion provision." The researchers wrote, "That legal and illegal abortion providers were portrayed so differently suggests that while abortion provision remains stigmatized, modern medical contexts work to contest stigma."

Citing an earlier study by Norris et al., the researchers wrote that such portrayals "illustrate why [abortion] provision is stigmatized." According to the researchers, "The omission of providers and clinical rooms in abortion plotlines contributes to the invisibility of the actual procedure," while the depiction of "illegal abortion spaces as unclean and risky reinforces the idea that abortion is detrimental, which is a central premise of abortion stigma." Moreover, they noted that "the overall negative depiction of illegal provider characters supports Norris et al.'s contention that legal restrictions on abortion not only are a consequence of stigma, but also contribute to stigma." The researchers wrote, "Such restrictions, and in some cases prohibitions, on abortion provision reinforce the idea that abortion is dangerous and morally wrong, and so work to produce stigma."

Nonetheless, as proposed in the study by Norris et al., the researchers also found that "onscreen depictions contest the stigmatization of abortion provision, particularly when stories are set in medical spaces and when providers are physicians." According to the researchers, the depiction of clean, medical abortion spaces directly challenges "stigmatized understandings of abortion as dirty and risky," while portrayals of providers who offer a range of medical care, including abortion care, "contests the isolation of abortion from mainstream health care and the marginalization of abortion providers within medicine" and "counters the fundamental idea that abortion provision devalues a provider's identity."

Further, the researchers wrote that the depiction of providers' positive motivations and compassionate attitudes "contests the stigma-supported concept of abortion providers as 'murderers' committing a moral wrong." According to the researchers, "In many ways, the motivations of these fictional providers reflect the motivations of real providers, who feel compelled to provide abortion care out of concern for women's health, lives and ability to control their own reproductive futures."

The researchers noted that the "contributions and challenges these plotlines make to the stigmatization of abortion provision must also be understood within the context of their shows' genres." For instance, they explained that most of the shows portraying abortion were dramas, so "it was unsurprising that plotlines portrayed abortion provision in dramatic ways."

However, the researchers expressed concern over the "fairly narrow band of genres" that depicted abortion care. They wrote that while "television horror programs are far fewer than comedies, abortion provision appears more often in horror shows than in comedies, suggesting some preexisting association between horror and abortion -- or lack thereof between comedy and abortion." According to the researchers, "This pattern begs the question of why such shows are portraying abortion provision in the first place, and how this may contribute to the stigmatization of abortion." Such depictions have "potential consequences in regard to real-world abortion provider stigma," the researchers wrote, including fostering suspicion of nonmedical abortion care and of abortion provided outside of increasingly onerous, medically unnecessary restrictions.

Noting that most television "portrayals of [abortion] provision challenged ideas that serve as root causes of stigma," the researchers concluded, "These findings indicate that there is indeed potential within popular culture to contest stigma and contribute to improved cultural narratives about abortion provision specifically, and abortion care and access more broadly."