Exploring the Identity-Related Experiences of Asian and Asian American OBGYNs through Narratives

By Angela Yan

My project explores Asian and Asian American obstetrician-gynecologists (OBGYNs) identity-related experiences through narratives. These narratives discuss culturally competent care, changes in care due to COVID-19 and Tennessee’s abortion ban, and the impact on providers’ well-being.

Background

Asian American healthcare workers face pervasive discrimination and microaggressions, which were heightened during the COVID-19 pandemic. We can view Asian American OBGYNs’ experiences through two frameworks: (1) the environment and inequality and (2) restorative environmental justice.

Asian healthcare workers experienced pervasive discrimination and microaggressions during the COVID-19 pandemic. In a qualitative study of Asian Canadian and Asian American healthcare workers, Shang et al. (2021) found that most respondents’ workplaces did not communicate about the racism and violence against the Asian community at the peak of COVID-19, which increased feelings of isolation among Asian workers. They also found that most Asian healthcare workers they surveyed learned to deal with microaggressions. Most providers chose not to correct patients when patients used racialized terms to describe COVID-19, even when those terms attacked the providers’ identity. Aggregated data on Asian healthcare workers exacerbates the invisibility of Asian issues in the healthcare sector. Using data on COVID-19 deaths among Filipinx healthcare workers, Escobedo et al. (2021) found that Filipinx died at a disproportionate rate because of COVID-19, but the disparity between Filipinx to Asian American COVID-19 mortality is lost in data reporting. AAPI experiences working in healthcare during COVID-19 are invisibilized both at the systemic level in data and the individual level in interactions with patients.

            Ethnicity, gender, discrimination, and stigmatization affect Indian American physicians’ experiences. Indian American women physicians reported facing pervasive gender discrimination in the workplace, including being discouraged from pursuing lucrative medicine specialties such as surgery because management assumed they would value family over work (Bhatt, 2013). In addition, perceptions of these Indian American physicians as perpetual foreigners who will always be “others” limited opportunities for promotion (Huynh et al., 2021).

            Indian American women physicians also face stigma when they bring their occupational status to a public setting, outside of the workplace. When these women achieve career success that rivals white men’s success, they defy the gendered and racial image of submissive, non-white immigrant women (Bannerji, 1993). In turn, society stigmatizes these Indian American women as aggressive and authoritative, which is deemed undesirable. Indian American women risk losing social acceptance if they disclose their medical career success (Murti, 2012). Thus, Indian American women physicians straddle an impossible line between facing barriers to promotion and overcoming the stigma of them being too successful when they overcome these structural barriers.

  • The problems brought about by COVID-19 and Tennessee’s abortion ban are intertwined with the environment and inequality. If we define the environment as where we work, where we play, and where we learn (Shah, 2012), then COVID-19 and limited access to reproductive healthcare impacts all aspects of the environment through changes such as the shift to remote work and telehealth, limited social contact, and school closures. COVID-19 specifically impacts the environment for AAPI OBGYNs through increased pressures on the healthcare system and a higher risk of COVID-19 exposure.

  • Julie Sze (2020) defines restorative environmental justice as a call for solidarity focused on the search for bodily autonomy amidst racism, capitalism, and technology. AAPI healthcare workers navigate providing reproductive healthcare amidst COVID-19 anti-Asian hate, COVID capitalism that intensifies inequality, and technological inequalities (Stevano et al., 2021). These structural forces make using a restorative environmental justice framework necessary when analyzing COVID-19’s impacts on AAPI OBGYN’s well-being and the quality of care delivered.

I interviewed three Asian or Asian American-identifying OBGYNs, all of whom currently practice in Tennessee to construct the following narratives of their experiences working in reproductive healthcare.

  1. Obstetrician-Gynecologist, identifies as Vietnamese

  2. Obstetrician-Gynecologist, identifies as Indian-American

  3. Obstetrician-Gynecologist, identifies as Indian-American

Note: I use pseudonyms throughout to protect my interviewee’s privacy.

Obstetrician-Gynecologist, identifies as Vietnamese

Jessica

Jessica has called many places home throughout her life. She was born in a rural suburb of Canada, where she and her sister were the only Asians in her community. She experienced a stark change at age 9 when her family moved to East Asia, where she grew up around a much more diverse population. Finally, she moved to the U.S. for college, where she attended university and medical school in the Northeast before moving to Tennessee to practice as an OBGYN.

            Jessica’s multi-country upbringing influences her approach toward providing culturally competent care. Because of her experience witnessing racial disparities in health care across a multi-country context, she emphasizes meeting patients where they’re at and considering patients’ diverse cultural, family, and financial backgrounds.

“It's really important to try to meet the patient halfway. Using your interpreter services as much as you can if you don't speak the patient's language. But sometimes the interpreters are not necessarily doing their job because it's not just literally translating the words, it's also translating the specific expressions that we use. Or there's a lot of cultural factors that go into why patients may or may not trust their provider or may or may not want to use specific medications.”

            Jessica’s views on culturally competent care align with the literature on barriers to Asian Americans accessing reproductive healthcare. Her mention of a possible lack of trust in providers among Asian American patients speaks to the cultural stigma regarding sex and sexual health in Asian American communities (Zhao et al., 2016). Asian physicians were nearly 90 percent less likely to have sexual health discussions with adolescent patients compared to White physicians (Alexander, 2014). AAPI patients are also hesitant to bring up these conversations with Asian healthcare providers. Asian American adolescents were more hesitant to discuss their sexual history with Asian healthcare providers out of fear that their providers would judge them or disclose their sexual history with the patients’ parents (Zhao et al., 2016). A hesitancy to talk about sex, sexuality, and abortion in the Asian American community could contribute to patients’ hesitancy to trust providers or use a specific medication.

            COVID-19 produced anxieties among Jessica and her colleagues because of the nature of reproductive healthcare work. Pregnancy care is not a service that can be provided remotely, which meant that Jessica and her fellow OBGYNs still saw patients in person, increasing their COVID exposure. She describes her experience at the start of the pandemic:

“So when I first started, when the pandemic first started, I was in D.C. and you know, everybody was scared just because there was no good protocol in place, and every hospital kind of made up its own protocols and made it up as they went.”

            Tennessee’s ban on abortions produced safety concerns among Jessica and her colleagues, except these concerns shifted from health to legal concerns. Working within a Tennessee hospital, Jessica feels the pain of seeing patients who are carrying unsafe or unsustainable pregnancies but cannot provide adequate medical care because of Tennessee’s ban on abortions. She recounts a specific case that demonstrates the moral conundrum that OBGYNs in Tennessee face daily when providing care to patients seeking abortions.

“There are going to be pregnancies where patients really want to be pregnant, really want to have a baby. But for some reason, their baby ends up having lethal anomalies or birth defects that are not compatible with life. And so now those patients are being forced to carry or continue those pregnancies knowing that their baby isn't going to be able to live.”

            Jessica faces a legal threat herself if she were to provide abortions to save a patient’s life.

“Because the laws in Tennessee would say that you are committing a crime if you're delivering that patient and could go to jail if somebody reports you and then you would have to go to the court and defend yourself and say, ‘Hey, I was doing it to save the mother's life, because it is a life-threatening situation.’ But the first, you know, the first response is that you're committing a crime, and I think that's a really scary thing for providers to feel.”

            The reproductive healthcare climate among OBGYNs, and especially Asian OBGYNs seeking to provide culturally competent care, has become more dangerous. Through all the anxiety, she leans on her colleagues within her hospital to empathize with her experiences navigating COVID-19 and Tennessee’s abortion ban. She, along with her colleagues continue to “fight for their patients every single day.”

Obstetrician-Gynecologist, identifies as Indian-American

Daya

Daya grew up in a conservative household in Long Island, NY. She spent most of her life in the Northeast before coming to Tennessee to practice as an OBGYN. She connects her experience working in reproductive healthcare to her childhood growing up in an Asian, conservative household. Her family did not discuss reproductive healthcare, and “abstinence was the unspoken expectation.”

“I grew up in a very conservative household and I know that quite a few of the friends that I've grown up with, who are also minorities have grown up in similarly conservative households where, you know, education and career are kind of at the forefront and then everything is done in an order, essentially. There are some things that are a little bit sensitive for patients to talk about. I’m trying to find the words to express this, but there are certain things that are expected in Asian American households, and I think understanding that has quite a bit of value to it.”

            Daya’s experience growing up in this environment helped her provide culturally competent care and partially influenced her to become an OBGYN. She knew she wanted to go into medicine since undergraduate. Once she started medical school rotations, she discovered that she enjoyed OBGYN surgical procedures. She liked how the procedures were relatively short but made a large impact on patients’ lives and well-being. She takes a special interest in contraception and contraceptive care for teenagers, driven by her experience growing up in Indian American in a conservative household.

            To Daya, providing culturally competent care entails understanding the cultural contexts of the patients she serves. Her position as an Asian American OBGYN allows her easier access to these cultural contexts such as a cultural stigma surrounding sex or sexual health (Zhao et al., 2016). For example, she phrases questions differently based on the patients’ age, identity, or whether a parental figure is in the examination room. If a parental figure is accompanying a patient who is a minor, she asks the parent to step out of the examination room to allow the patient to answer some questions without the parents present. Lastly, she applies care to what she documents about her teenage patients to minimize the risk of parents discovering information about their child’s reproductive health that the child was not comfortable sharing. Daya’s approach allows her to provide culturally sensitive care, especially to AAPI patients, given that over half of young AAPI women surveyed felt uncomfortable talking to their mothers about reproductive health (2018). When OBGYNs cultivate this standard of privacy among their young, Asian American patients, reproductive healthcare can better meet these patients’ needs.

            COVID-19 increased stress in Daya’s work environment. These stresses stemmed from anxieties over her and her coworkers’ health safety and changes to providing care for reproductive healthcare patients.

“I was training for oncology cases where I had a full N95 and full PPE for four or five hour surgeries. I was on the labor floor where we had patients who were coming in, you know, from triage, and they had been checked in at the emergency room. We didn't know if I had COVID. We didn't know if we were exposing everyone.”

“From a family planning perspective, we had a lot of patients who wanted to have permanent sterilization or have terminations of pregnancy, and we tried really hard. We weren't necessarily able to bring them into the operating room because there was a shortage of ventilators for quite a while… And so we tried to convince patients who wanted permanent sterilization to have IUDs placed or have other forms of birth control that were more easily accessible. And then for our terminations, we tried to have everyone who was under 10 weeks gestation to have a medical termination if that's what they wanted.”

            When I asked Daya how Tennessee’s trigger ban on abortion affected her abortion, her voice grew noticeably more filled with emotion as she described the situations in which she has had to refer patients out-of-state or been unable to provide the care they needed because of Tennessee law. She recognizes referring patients out-of-state to obtain abortions, which poses a financial barrier she understands disproportionately impacts minority patients. She recounts a challenging case in which she expressed frustration for not being able to provide abortion care for a patient who needed it. Having attended medical school in New York, Daya sees the contrast in the care she would have been able to give a state that permits abortions.

“I had a patient who wanted to have an IUD placed, and her pregnancy test came back positive. She had to travel out of state in order to get the termination. Obviously, she was trying to get an IUD. She was done with childbearing. She was in a very safe, you know, relationship, had children with the same partner, but had just completed her family and did not think that she would be comfortable having another child. And so she had to travel out of state for it, which was a little bit frustrating for both her and myself. Because if I were still in New York, I would have been able to offer her medical management, which she would have happily taken me up on, and did not have had to go travel out of state to have a surgical procedure.”

            This example of Daya’s patient seeking an elective abortion resonated with me because had she been unable to travel out-of-state and had to carry out a pregnancy she was not comfortable with carrying out, her ability to live in an environment where she can control her reproduction would have been compromised. Under the environmental justice framework, her bodily autonomy was under threat (Sze, 2020).

            Daya’s experience working in reproductive healthcare demonstrates her ability as an Indian American OBGYN who grew up in a conservative, sex-averse household, to empathize with her minority patients and provide culturally competent care. COVID-19 and Tennessee’s ban on abortion also limited Daya’s ability to provide care to her patients.

Obstetrician-Gynecologist, identifies as Indian-American

Riya

Riya was born and raised in Louisville, Kentucky, before moving to Nashville for college. She has the unique experience of spending her whole life in the Southeast but living in “relatively liberal cities within conservative state[s].” Growing up in Louisville, she remembers access to abortion and sex education units in high school. She and her friends’ pediatricians talked openly about sex and contraceptive options. Louisville’s liberal environment contributes to that culture of discussing sex and abortions.

“I think growing up as a kid, I never felt like any ideas were forced upon me. I definitely felt like I think people were pretty open-minded in that regard.”

            Her family’s openness to discussing reproductive health was a different story, however.

“Both of my parents are doctors, actually, and we never really had conversations about that. I remember when I was like 12 or 13 and I first started having periods, my mom just took me to the library and helped me find a book about it, and she was like, “This will help you.” But other than that, my family never really talked to me about what it meant to be having periods or anything like that… My parents are both Indian and in Indian culture, that's just not really something that parents talk about as openly with women, with their daughters, and so I think I think it's because for my parents, culturally that was really not something that they even broached.”

            Riya carries her experience as a young Asian American woman facing barriers to reproductive health care into her work as an OBGYN. She pursued the OGBYN field because she feels passionate about women receiving the “health care and reproductive care they deserve.” The prevailing attitude among her and her colleagues is that they support women having access to contraception and abortion services.

“I was really fascinated with the fact that there are so many conditions that women face every day that we just knew so little about. And to me, that was fascinating and interesting at the same time, and I felt really motivated to hopefully get to be a provider that could further understand what causes some of these conditions and how to help women have a better quality of life.”

            After her residency, Riya plans on going into oncology, where she will be focusing primarily on cancer. She will have fewer direct interactions with family planning or providing abortions, but she hopes to integrate expanding access to contraceptives and abortion into her work as an oncologist. Her approach to providing culturally competent care ties back to her identity and experiences as an Indian American woman. She strives to destigmatize discussions about sex, sexuality, and abortion and be the OGBYN she never had growing up.

“I try to relate to [my Asian American patients] and think about maybe how they were raised and what their family was like regarding women's health care and how much they know.  I think for me, that's a huge soft spot. Whenever I see patients that I can identify with on that level where I can tell they haven't really grown up in a family that's talked about these issues as openly, I try to be a safe space for them, a place where they feel like they can open up and never be judged and have those resources in women's health care.”

“I have a lot of friends who are Indian, who I've already said, “You have children, please just come to me.” I'm happy to talk with them and make it so that it's less of an uncomfortable topic for everyone, just for them, for their children, but also for their parents.”

            Riya was in her first year of residency when COVID first started. Seeing the hospital shut down and working in the COVID ICU unit changed the nature of her day-to-day work and affected her mental health as a trainee. She described feelings of isolation, extreme burnout, and extreme anger.

“One of the hardest parts is just not being able to see family and see friends in those moments and times when we really needed people to support us.”

Through the mental health challenges, she also describes a feeling of community with her fellow residents.

“I think one of the helpful things was that we were all going through it together and the whole world was going through it together. So it was very isolating. But in that way, we were all still kind of experiencing it at the same time.”

            Riya’s experience of feeling isolated among her fellow residents emphasizes the importance of community in navigating environmental changes. Her work environment and her feeling associated with working as an OBGYN resident drastically changed because of COVID-19. Amidst those changes, Riya relied on her colleagues experiencing the same situation to navigate her feelings of isolation, burnout, and anger.

            Tennessee’s ban on abortion also impacted Riya’s feelings of anxiety and conflict towards providing care to patients. Like Jessica and OBGYN2, Riya found herself caught between wanting to provide women with safe, medical abortion care and facing legal danger if she provided it.

“I have a couple of patient encounters that I can recall where really it was really difficult to help get them set up for an abortion in another state because it's very hard for women to have to leave everything and drive and pay for all of that. So I think we had to learn how to get creative in supporting our patients. Through that, we also had to deal with a lot of new paperwork for every procedure that we did and this constant fear that just providing safe medical care for women was going to get you put in jail like providing care for an ectopic pregnancy.”

            Beyond fears for her safety, Riya highlighted a feeling of powerlessness in advocating for and supporting her patients. She came into OBGYN work wanting to cultivate a safe environment for women to access reproductive health care. However, Tennessee’s ban on abortion limits her ability to cultivate that environment, contributing to that feeling of powerlessness.

“There are many times when I feel powerless and I feel like I can't be the right advocate for patients. And we, unfortunately, see some of the downstream consequences of lack of access to abortion care, which are women who are very ill or women who have babies that are very ill, who have to continue pregnancy. And we see what that's like on labor and delivery, and that can also be very, very hard.”

            Riya’s openness about the mental health challenges she and her colleagues faced when navigating COVID-19 and Tennessee’s ban on abortion stuck out to me. When we view her experience through an environmental justice lens, defined as the right to a safe, productive, and sustainable environment, we can see COVID-19 and Tennessee’s restrictive abortion law as environmental injustice (Sze, 2020). Both COVID-19 and Tennessee’s abortion law limits Riya’s and OBGYN’s ability to work in a safe environment, free from fear of lawsuit for providing safe, medical care to patients.

            The challenges Riya has endured as an OBGYN resident have strengthened her resolve to provide life-saving care alongside her colleagues. When I asked her about her feelings on Tennessee’s abortion law, her motivations for going into OBGYN work shone through in her response.

“I know that we have very good providers here at [my hospital] that constantly fight for their patients and fight for what's right. And I think through all of that adversity, it's at least brought our providers closer together and aligned us all on this mission to provide the care that women need when they need it.”

Conclusion

Jessica, Daya, and Riya’s interviews all demonstrate the link between reproductive justice and environmental justice. Reproductive justice encompasses the right not to have a child, the right to have a child, and the right to raise a child in a healthy environment (Ross & Solinger, 2017). Advocating for people’s autonomy to make reproductive decisions is part of environmental justice, which seeks to reduce the environmental burdens that marginalized groups face (Sze, 2020). Reducing barriers to marginalized groups accessing reproductive health care can help these group members “live with dignity in safe and healthy communities,” which is the goal of reproductive justice (Ross & Solinger, 2017).

Jessica, Daya, and Riya all spoke about their passions for serving marginalized women as OBGYNs. Their identities as Asian and Asian American OBGYNs equip them to provide culturally competent care to Asian American patients because they share similar experiences of growing up in households hesitant to talk about sex, sexuality, and abortions. COVID-19 and Tennessee’s abortion law limited their capacity to provide the life-saving care they wanted to provide. They described feelings of isolation, anger, and helplessness as COVID limited their services and Tennessee’s abortion law put them in the difficult position of choosing between providing care themselves or facing legal threats. They navigate these challenges with their colleagues and rely on their coworkers, family, and friends for support.

Jessica, Daya, and Riya’s stories exemplify both the challenges Asian and Asian American providers face in the field of reproductive healthcare but also the resiliency they demonstrate in the face of these challenges. COVID and Tennessee’s abortion law made their work as OBGYNs more difficult but did not stem their passion for supporting patients.

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