Who deserves to have a baby?

Medicine has long used scientific methods to justify racism—particularly when it comes to reproduction

Years ago, I interviewed for a residency position at The Johns Hopkins Hospital in Baltimore. Standing before the domed Victorian building at the campus entrance, I couldn’t help but be in awe of the history of the place, the great doctors who had once walked the halls and the scientific discoveries they had made in those very rooms.  

Medicine is a profession that loves eponyms—every gynecologic surgeon, for example, is familiar with the Sims retractor, Sampson’s artery, and Meigs syndrome. Once residency training begins however, there is little time to dwell on the people behind the names, let alone the context in which their discoveries took place. 

I ended up doing my residency at a different hospital in Boston. But for much of that time, I carried a ghost from Baltimore with me. 

Richard Wesley Te Linde was the first Chair of Gynecology at Hopkins—and the first Chair of Gynecology anywhere. He published Te Linde’s Operative Gynecology, in 1946, a hefty textbook that still remains a mainstay for ob/gyn residents nearly 80 years later. Most nights I would pore through Te Linde’s instructions to prepare for my surgical cases the next day, the well-worn pages replete with meticulous attention to detail—and timeless wisdom. Or so I thought.

At the peak of his career, Te Linde co-authored a seminal paper in the Annals of Surgery, summarizing his observations of 516 gynecological patients, from his own upper-class private practice as well as the primarily Black population of the public hospital ward. He titled this paper, External Endometriosis: The Scourge of the Private Patient. 

“Corrupt blood”

Endometriosis is a common gynecological condition that has perplexed clinicians for centuries. It can cause debilitating pain and it can cause difficulty getting pregnant. The exact prevalence is unknown but it is thought to affect at least 10% of all women, and potentially up to 80% of those who experience infertility. 

Under a microscope, endometriosis looks like misplaced implants of “endometrium,” the tissue that normally composes the lining of the uterus. During the menstrual cycle, this lining is designed to proliferate and thicken to prepare for an embryo. If no embryo arrives, it sheds itself only to rebuild anew the next month, a process that repeats 500 times during the average woman’s life. 

There are several modern theories on how exactly endometrial tissue, which has clear purpose inside the uterus, also ends up outside the uterus, responding to the same cyclical hormones to proliferate, shed, bleed, and wreak havoc. The true cause, like everything about endometriosis, remains mysterious. During surgery, endometriosis can appear red, blue, purple, black, clear—or merely, as one 17th century physician described it, “an aggregation of corrupt blood.” It can be found on the pelvic walls, inside the ovaries, attached to the bowels and as far flung as the lungs. 

The symptoms it causes can be mild or severe. It can first appear in girls who have just started to menstruate or in middle-aged women who have menstruated for decades. Even after being surgically excised it can stubbornly recur. 

But for Te Linde, despite its many confounding manifestations, there was one property of endometriosis that stood out. In his seminal paper, he postulated that it was unlikely to affect Black people.

A (very) brief history of fertility and racism 

For all his attention to detail, Te Linde was a product of the social and political context of his time. He observed that the well-to-do white women in his private practice had pathologic evidence of endometriosis much more than the “colored” patients in the public wards. Never mind that Black people in Baltimore were less likely to have their pain or fertility struggles recognized in the first place–let alone treated. His widely cited paper quickly became firmly embedded as fact, in the minds of clinicians and in the minds of the general public. To this day the stereotypical image of a person struggling with infertility is an upper class white woman.

Te Linde’s claims remained uncontested until 1967 when Dr. Donald L. Chatman, a Black gynecologist in Chicago, found that 20% of his Black private-practice patients demonstrated evidence of endometriosis, and that 40% of those patients with endometriosis had been falsely diagnosed with pelvic inflammatory disease—an infection usually associated with unprotected sex. 

(I’m not sure what is less surprising: that physicians opted for blaming Black women’s pain on a notion of promiscuity, or that it took a Black clinician to correct the record). 

In recent years much necessary attention has been paid to the fact that Black people who are pregnant are significantly more likely to suffer morbid outcomes. Less attention has been paid to the stark disparities Black people face in getting pregnant, and in staying pregnant. 

Black women are twice as likely to experience infertility compared to white women, and half as likely to seek treatment. Black patients have a significantly higher rate of miscarriage when undergoing IVF, and a 30% lower rate of live birth—even after adjusting for factors like income, age, weight, and preexisting health conditions. 

The Mothers of Gynecology

In the heart of American medicine lies a disturbing contradiction. On one hand, the bodies of Black people are treated as biologically different, despite evidence to the contrary, often to justify disparities that are actually driven by inequitable circumstances. On the other hand, Black bodies have also been treated as similar enough to exploit for the benefit of white people.

Te Linde himself was a one-man paradox. In the case of endometriosis, he and others used scientific methods to conclude that Black pain either didn’t exist or else was the result of lascivious behavior, a long-held racist trope. Yet he also collected tissue samples from a Black woman named Henrietta Lacks, without her consent, for his studies on cervical cancer. These samples were ultimately used to establish lucrative medical breakthroughs that Black people seldom had access to. 

On a spring day almost exactly six years ago, a crowd gathered in the northeast corner of New York City’s Central Park to observe as a bronze cast statue of J. Marion Sims was pulled down. Celebrated as the “Father of Gynecology,” in the 19th century, Sims conducted cruel experiments on enslaved women on his Alabama farm, performing surgeries without anesthesia to perfect his technique. He parlayed this experience to become the most prominent gynecologist of his time, moving to Manhattan for the duration of his career. 

Three years ago, on a different spring day in Montgomery, Alabama, three statues were erected of those enslaved women–Anarcha, Betsey, and Lucy, larger than life, composed of recycled scrap metal and painful symbolism. Their sculptor, activist Michelle Browder, calls them the “Mothers of Gynecology.” 

I asked Dr. Tiffany Green, a nationally recognized expert in racial disparities in reproductive health at the University of Wisconsin, how our country is faring in reconciling our history of racialized medicine. With an arched eyebrow she pointed to the recent scramble to protect IVF access in Alabama. Restrictive policies in the state had already caused disproportionate suffering among Black people, earning Alabama a failing grade on the March of Dimes report card. It was not until IVF was threatened, a service primarily accessed by white people, that local legislators took action and the nation as a whole seemed to pay attention. 

Freeing the Black body

From its inception, medical education established hierarchies between races to justify economic structures that benefited some while enshackling others. In her book Killing the Black Body, University of Pennsylvania legal scholar Dorothy Roberts points out that the will (and resources) to address racial inequity in reproductive medicine is based in tacit views on who deserves to have a baby. 

Structural barriers persist in cities and towns in every part of the United States, gating some people more than others from access to the care they need. Black people are less likely to possess the necessary wealth to receive fertility care and if they do, it is often at a much later stage, making procedures like IVF less likely to be successful. Dr. Green tells me she is currently conducting a study that uses mortgage denials as a proxy for structural segregation, examining how this exposure impacts fecundity, starting with how long it takes someone to get pregnant who is trying to conceive. 

Digital health alone will not solve structural racism. At Maven, we use technology to work around structural barriers where possible, while also advocating for their removal. We enable ready access to digital experts, and we work with sponsors of health benefits to ensure people have the financial means to reach in-person experts. We aspire to a care model in which every person with painful periods or difficulty getting pregnant receives a diagnosis and a treatment, alongside the holistic care and support they also deserve. More on that next time.

April marks two observances in reproductive health: Black Maternal Health Week (April 11-17) and National Infertility Awareness Week (April 21-27). 

Here’s what we are reading, considering, and building against:

• One of the best papers I found on how social, structural, and political context can explain racial disparities in endometriosis is this systematic review from Dr. Erica Marsh and her colleagues at the University of Michigan.

• For a better understanding of how endometriosis affects people, watch Below the Belt, an excellent film on PBS directed by the relentless and inspiring Shannon Cohn, and executive produced by Rosario Dawson, Hilary Clinton, and other amazing women.

• For a strong dose of hope that endometriosis will soon be understood much better—and potentially even unlock a new era of regenerative medicine—read this profile of Linda Griffith, the MIT professor and winner of the MacArthur Genius award who is afflicted by the condition herself.

• Anti-Black ideology in medicine is rooted in chattel slavery, a shameful time when physicians were called upon to evaluate the fertility of Black women to ensure their purchase was a good investment. Medical Bondage, a powerful book by the great historian Deirdre Cooper Owens, explores how physicians like Sims could at once deny Black women their full humanity while also valuing them as “medical superbodies,” suited for experimentation.

• Finally, check out the BMHW event calendar at Black Mamas Matter Alliance and follow #BMHW2024. Going forward, paid subscriptions to the Preprint will support maternal health equity through our MPact for Families program in partnership with March for Moms.