A total of 18 healthcare providers took part in this study (refer to Table 1 for specific demographics).
The findings are structured around three primary themes, illustrating how healthcare providers, through refusals, biases, and oversight may both intentionally and unintentionally perpetrate and perpetuate RC and undermine reproductive autonomy.
When refusals turn into roadblocks to reproductive autonomy
In this theme, we explore participants’ accounts of explicit refusals by healthcare providers to support patients’ reproductive choices. These reflections emerged when participants were asked whether they had observed instances of medical coercion in clinical practice and what forms it took. Most participants, as strong advocates of reproductive autonomy, primarily described the actions of other providers. Some reflected on their own practices in contrast, emphasising what they would do differently to uphold patient autonomy.
Many participants expressed concerns about how conscientious objection to abortion was handled in clinical practice, particularly when it resulted in a refusal to refer patients to alternate providers. While they acknowledged that healthcare providers have the right to refuse to perform certain procedures based on personal or religious beliefs, they stressed their ethical responsibility to ensure that patients are not left without viable options. From their perspective, absence of mandatory referral mechanisms could lead to significant delays, compromising patient autonomy; and in the context of abortion care, increasing the risk that patients would miss the window for a medical abortion (available up to nine weeks’ gestation in Australia), thereby facing a more invasive surgical procedure instead. Most participants viewed conscientious objection, when not accompanied by appropriate referral, as a form of RC. They felt that such delays in accessing an abortion can be especially harmful when it is sought as a safety strategy by women also experiencing coercion from partners or family members, and that refusal to provide or refer could further entrench women in unsafe environments.
Interviewer: The idea of who the perpetrator is has broadened, not just partners, but also carers, parents, and other family members. But something else that has come up is healthcare providers. For example, if they only talk about one type of contraception, or if they deny abortion. So those kinds of situations are sometimes seen as healthcare provider-perpetrated reproductive coercion. I’d like to hear your perspective on that, does this come up in clinical practice, and how?
ID9 (GP, 13 years of experience): Oh yeah, I have heard, for this patient, this doctor was very negative [about] abortion. They just told me so. And they said, ‘I’m not going to refer you on, so just follow up’. Whereas I know health professionals have an obligation to refer on if they don’t agree with it. I’m just sort of like, you’re not supposed to agree what’s supposed to happen with the patient’s body. You wouldn’t send a patient [away] that way, they might be coerced to keep the pregnancy.
Interviewer: In your opinion, is there a role for the GP to identify and support patients experiencing reproductive coercion?
ID12 (GP, 6 years of experience): Definitely, I do think there is a role for GPs… But the reality is that we can’t really address reproductive coercion without looking at the other elements of coercion that facilitate it. So, for a woman to be able to get to a GP, for example, that would be very difficult. And then to be able to get to a GP that was not going to do more harm. That would be more difficult as well…Think of a woman who might just be able to get to a clinic because she happens to be in town for some other thing, or she’s hiding it from her abusive partner. And all of a sudden, you’ve got that [conscientious objection] barrier. Or it could be the only GP in the town, if it happens to be a Catholic GP who’s there, they might have to wait till next week when someone else comes through.
One participant contrasted this with an example of conscientious objection being handled appropriately, describing a colleague who, despite being a religious objector, facilitated referrals efficiently to ensure patient needs were met.
ID16 (Sexual health nurse, 16 years of experience): I have a GP at my clinic who is a religious conscientious objector, she’s very explicit about that. I don’t have a problem with that, we don’t have a problem with each other. Um, she refers patients to me regularly because she’s also a preferred women’s health GP, so a lot of people go to her with um unplanned pregnancies, and she knows exactly what to do. She does all the right things, and then if that person decides they want termination, she refers them directly to me, quickly, efficiently, no issues um, and I don’t understand why everyone can’t do that.
Some participants described the denial of sterilisation procedures, such as tubal ligation, as another example of coercion imposed by healthcare providers. They noted that providers sometimes refused requests for sterilisation based on assumptions about patients’ future reproductive desires. In their view, these refusals, often couched in paternalistic language about protecting patients from future regret, deprived women of their autonomy over their own reproductive choices.
Interviewer: Any examples of denying a tubal ligation, has that occurred?
ID13 (GP Obstetrician, 15 years of experience): So, look, doctors are really guilty of that [refusing sterilisation]. So I’ve often had patients that I’ve seen through the antenatal period, you know, we’ve discussed tubal ligation, we’ve counselled around it and then I say, it’s not me doing the surgery on the day and dare I say it, it’s usually a male doctor who comes in and says, ‘Oh, you’re too young to have a tubal ligation, let’s not do it during the cesarean section’. And I’ve seen that quite often, you know, and the person has pre-consented. They’ve been through that journey with their care provider, we have a continuity model and then I see them at their postnatal check, and they’ve not had their tubal ligation, and so doctors can be quite guilty of that as well.
Interviewer: Have you encountered any situations regarding forced or coerced sterilisation, like tubal ligation or vasectomy?
ID8 (GP and Medical educator, 15 years of experience): Um no, not forced. Actually, I see more situations where women are being turned away from having a tubal ligation, which is actually a form of coercion by the medical field, in my opinion. So, I have a patient, she’s in her 20s and she’s got five children. She definitely wants to have a tubal ligation, and they will not do it in the public system. And she doesn’t have private health insurance. So that could even be viewed interestingly as a form of coercion. They are not respecting her bodily autonomy.
One participant reflected on how explicit refusals could occur within structured clinical processes, particularly in later-term abortion care. They described situations where two doctors’ disagreement led to patients being denied termination after 24 weeks, leaving continuation of the pregnancy or adoption as the only options. This participant acknowledged that while the system was designed to distribute responsibility, it still limited patient choice. Reflecting later on these cases, the participant questioned whether denying access in some situations had ultimately served the patient’s best interests, and whether different decisions might have better supported patient wellbeing.
ID18 (OB/GYN, 12 years of experience): So especially when we are supporting terminations beyond 24 weeks, because it has to go through two doctors and a panel. There have been times that two doctors have not agreed, and then [the patient] doesn’t access the service. They have to continue with the pregnancy or choose adoption. We’re limiting what the end pathway is. And there have been times that, a year down the track, I’ve reflected on a situation and thought, wow, did we really make the best decision at the time? Are they okay now?… We always talk about trusting the system, that two independent doctors have to agree. So, it takes away the sense that I individually changed someone’s trajectory. But it does make you think: if I’d said yes, would they have been better off with that termination?
Some participants also described situations where other providers have dissuaded patients from having their IUDs removed, even when patients requested removal due to side effects or personal preference. They viewed such practices as undermining reproductive autonomy by privileging provider opinions over patient choice.
ID11 (GP and Sexual Health Registrar, 10 years of experience): I’ve had a number of patients whose doctors wouldn’t take out their IUDs and really were trying to dissuade them from having their IUDs removed. So those are two times when I’ve definitely heard of, I would say, medical coercion. And even if I think that an IUD is actually doing great things for a person. If they want it out, I will take it out straight away. It’s their body. It’s their choice. But I’ve heard that not uncommonly….
One participant expressed concern over how explicit refusals by providers could contribute to mistrust in healthcare providers and the overall system. They noted that when there was discord between a patient’s reproductive intentions and those of their partner or family, patients might fear that providers might side against them. In their view, this fear and anxiety could prevent individuals from seeking care or disclosing reproductive concerns, particularly if they had prior experiences of being judged by providers or denied support.
ID16 (Sexual health nurse, 16 years of experience): Certainly, in my line of work, access to care is a real fear issue. So, a lot of people come in to see me worried about how I will interact with them, worried about what I might make them do in order to be allowed care. I think one of the worries is, if there is discord between the pregnant person and the pregnancy partner, I think there’s always worry that I will have a side. I get a lot of patients who have experienced trauma associated with seeking support from a GP they thought they could trust, and then they end up with me already you know, feeling shitty and worried about how I’m going to respond to them.
How implicit provider bias shapes reproductive decision-making
In this theme, we explore how implicit bias from the perspective of healthcare providers can subtly shape reproductive care. Some participants recognised their own biases, while others described behaviours, either theirs or others, that suggested unconscious assumptions, even if not explicitly identified as bias. These biases, shaped by clinical training and societal values, appeared to influence how providers framed reproductive options and, in some cases, limited patient autonomy in decisions about contraception, pregnancy, or abortion.
Some participants acknowledged that their clinical training and professional norms implicitly shaped their counselling, leading them to promote certain methods as more effective or responsible. As reflected in the quote below, such practices were recognised as unintentional but potentially constraining, especially when discussions were not grounded in patients’ individual preferences.
Interviewer: So, we’ve discussed reproductive coercion in the context of partners, family members, friends and others. Something else that comes up is health providers, and how patients perceive that. I’d like to hear what you think about that.
ID5 (GP registrar, 4 years of experience): Yeah, that’s interesting. And I can see how that would happen. We all have our own biases as health care providers. Yeah, I guess the western model of medicine and health, probably we say certain reproductive, or contraception options are more successful than others. So, I think, yeah, often maybe they’re the first that we recommend rather than actually opening up the discussion and asking more broadly, ‘what would you like, what have you heard of?’ And offering all those solutions rather than just necessarily pushing them onto a pill or, or not even asking? Yeah. I wouldn’t say it’s done intentionally.
Another participant reflected on how their initial approach to contraceptive counselling was influenced by training that emphasised LARCs as the optimal choice. Although they did not label this as bias, they recognised that it shaped how they guided patients, often prioritising effectiveness over individual preference. Over time, their perspective shifted from equating success with LARC uptake to understanding that patient-centred care means supporting the method that best aligns with each individual’s values and circumstances.
ID11 (GP and Sexual Health Registrar, 10 years of experience): And then in my own practice, I’ve been reflecting over the last couple of years on the way that I was kind of taught to present contraceptive choices to women. I just remember being taught kind of a really LARC heavy perspective. I felt like that teaching was almost pushing LARCs on people. I used to kind of worry a lot that, oh, you know, they’re making the wrong choice. And it’s really hard to look at how you’re perceived by patients. I do worry that that could have been seen as like trying to influence someone one way or the other. But I definitely know now that I’m like, as long as they have all of the facts, then they make whatever choice they want to make and that is right for them in that moment. Whereas I would have felt like I had failed if I hadn’t got them on the most effective method previously.
When discussing tubal ligation, one participant noted they were more inquisitive when the request came from younger patients without children. Although they described using an open approach, their reflection suggested a higher level of scrutiny in these cases. While not framed as bias, this reflection suggests the influence of implicit assumptions about age and reproductive norms on how such requests were approached and responded to in practice.
Interviewer: So, we spoke about contraception and abortion, and I wondered about pressure for a tubal ligation or vasectomy, has that come up in your practice?
ID6 (GP and medical educator, 15 years of experience): Yeah. Yeah. So, I’ve seen people with tubal ligations. I guess it’s really interesting. I find most of the tension seems to be around people who are younger, who’ve never had children. And because it can be hard to access that. I often use a very open approach. ‘And so, tell me what you think and why you want this’. Um, I would hope that would allow people to at least give me a sense of what’s happening in the relationship. But you’re right, with tubal ligation, I’m probably less likely. I’m probably more interested to know why that person wants a tubal ligation….
Some participants reflected on how their counselling was shaped by clinical familiarity and personal preference, noting they were more likely to recommend methods they had greater success with or regularly used. While not intended as coercion, they recognised that these preferences could shape patient choices. The following reflection highlights how implicit bias towards contraceptive methods can arise from provider comfort and subtly steer patient decisions.
Interviewer: Something else that has come up is the role of the health provider in perpetrating or exacerbating reproductive coercion. I think you touched upon it as well, so you know not talking about a particular contraception or missing something and the patient perceives it as reproductive coercion from the provider. What are your opinions on that and how has that come up in your experience?
ID13 (GP Obstetrician, 15 years of experience): Happens all the time. Often, you’ll have your own personal preference. Like, for example, I’ve taken out way more Kyleenas than I have Mirenas, so therefore I’m more likely to suggest to someone to have a Mirena because I’ve had greater success with it. The Implanon, the way that I explain it, it has a higher chance of causing mood side effects than something like the Mirena, which has a very localised effect and therefore a lower dose of circulating hormone. So, it’s also what I’m comfortable with. Like, if I wasn’t an IUD inserter, I probably wouldn’t talk to my patients that strongly about IUDs. I’d probably push Implanon more. So, it’s really, really challenging. You want someone with no skin in the game about what contraceptive method you recommend to someone. Yeah. It’s so common….
ID4 (OB/GYN, 15 years of experience): So, with contraception choice, I’ve seen patients who’ve been told that they can’t have a long-acting contraceptive because they’re nulliparous, because they haven’t had children. Whereas they can, but it might be a bit more uncomfortable. So that’s really what the counselling should be like. But this may be related to the practitioner’s confidence in surgery. But rather than saying how about I send you to somebody who can do it, they say, maybe it’s better just to have an implant instead. So that can happen. I’ve seen that happen.
Several participants acknowledged the difficulty of providing medical guidance without crossing into coercion, especially when patients perceive recommendations as biased. They noted that even when unintended, bias may still be interpreted as coercive by patients. This challenge was seen as especially pronounced when discussing contraceptive options that may be medically contraindicated. For instance, although a contraceptive option might be contraindicated, participants recognised that a failure to present and discuss the method may still be perceived by the patient as coercive or as limiting their choices.
ID13 (GP Obstetrician, 15 years of experience): Sometimes it is really tricky and sometimes there is coercion because the doctor may make a judgement, and it might be a judgement on experience, or it might be that they’ve actually just ruled something out because the patient has a contraindication, but they don’t actually discuss it. A patient might say, ‘Oh, I’ve got migraine with aura’. And so, you go, ‘Okay, well you can’t have the pills, so let’s discuss these other things’. And then that person says, ‘Oh, they didn’t discuss the pill. They were trying to get me to have an IUD’, you know. It can be quite complex because actually that clinician has already done a triage in their head. But then somebody may not feel that they’re fully informed with the choices that they’ve been given.
Some participants observed how other providers made judgements about which patients were “suitable” for certain contraceptive methods. One participant described coercion as being embedded in provider opinions, such as discouraging IUD use among young people or those with multiple sexual partners. These practices appeared to reflect implicit bias, where outdated or unfounded assumptions replaced individualised assessment and limited access to LARCs.
Interviewer: Since we’re on the topic of medical coercion, there’s also medical coercion towards particular types of contraception. Have you encountered that and what do you have to say about it?
ID8 (GP and medical educator, 15 years of experience): So, with contraception, I guess if you could extend coercion into opinions. So, there’s a lot of opinions about certain types of contraceptive methods which will detract young women from having a certain type. I take outside referrals for IUD insertions and sometimes I’ll see somebody down the track, who hasn’t been able to find anybody who will refer them or will insert it because they haven’t had children before. Or the other possibility is if they’ve had multiple sexual partners, you know, some might say, ‘Oh, an IUD is not suitable for you because you might get PID (Pelvic Inflammatory Disease) and then you’ll be infertile’. Whereas again, having multiple sexual partners is no reason to not insert an IUD. So, I guess the extended definition of coercion, perhaps that could be included in that, is kind of deterring women away from having LARCs as well.
Another participant described instances where providers could respond judgmentally to other often stigmatised healthcare decisions, particularly multiple abortions. They reflected that such reactions could contribute to stigma and a failure to recognise the complexity of patients’ circumstances. While not labelled as bias, the accounts point to how assumptions about pregnancy and abortion can shape provider attitudes and potentially limit empathetic, patient-centred care.
Interviewer: As a GP, what would you say about how reproductive coercion can be perpetrated by a GP?
ID6 (GP and medical educator, 15 years of experience): Yeah, I mean it comes back to if you’re not listening and not looking for signs…I think also that GPs can add to stigma…I think people can be quite judgmental, oh, you’re having another abortion instead of thinking about why is this person having another abortion? So, I think doctors can treat pregnancy like all pregnancies are wanted.
Participants also shared that, in their view, certain populations, particularly those experiencing homelessness or substance use, were more likely to be steered toward “more effective” methods like LARCs. They did highlight that such practices reflected broader societal biases about who should and should not have children, and suggested that this paternalistic approach was evident in decisions surrounding pregnancy as well.
ID14 (GP registrar, 5 years of experience): I think probably also the other group that might be more likely to be pushed towards super effective long-acting contraceptive and really try to make them keep it in and not take it out would be like people using substances. Um, anyone who society thinks, oh, you shouldn’t have children.
Participants suggested that a key strategy to mitigate personal implicit biases would be to personalise care and make collaborative decisions about reproductive healthcare with the patient. They emphasised that individualising discussions, rather than relying on general assumptions about effectiveness, was key to ensuring that care was truly patient-centred. By focusing on each person’s lifestyle, needs, and circumstances, participants felt that providers could better support reproductive autonomy and avoid reinforcing preconceived notions.
ID1 (Registered Nurse, 13 years of experience): It’s having that discussion about what options are available, what’s suitable. So, you know, young people like the pill, but it’s just, are you gonna remember to take a pill?… What might work for the person you saw before is not going to work for this person, because, you know, they’re a shift worker, blah, blah, blah. I think it’s good to really personalise contraception, and have that discussion about their lifestyle and their expectations…So, even though you can say, oh, yes, they are the most effective, but are they going to suit that person? And their lifestyle?
How oversights and misinformation enable and obscure existing coercion
In this theme, we present participants’ perspectives on how gaps in provider awareness, oversight, and access to accurate information and training can contribute to enabling or obscuring RC. Participants described both their own and others’ practices, acknowledging how, even with good intentions, providers may overlook coercive dynamics or make assumptions that inadvertently restrict patients’ reproductive choices.
One participant reflected on their own oversight in not raising contraception with patients in supported accommodation or those attending with carers, expressing concern that these issues may have been missed in routine care. They questioned whether key aspects of reproductive health had been considered at all, highlighting a retrospective awareness of how such omissions might affect patients.
ID11 (GP and Sexual Health Registrar, 10 years of experience): I have seen people who’ve been in supported accommodation, um, and I can’t even think, did I ask them if they need contraception? Like, I don’t even know if it was ever brought up, which is not good because it should be okay. I haven’t had many people [with disability] attending with carers. Just the odd 1 or 2 and the supportive care, you have to do an annual health check or something. Oh, was that [contraception] on there? Like did we even consider that at all? Like did I ask them about their periods? Honestly, I have no idea, which makes me think probably we didn’t. Um, but that sounds crazy.
Another participant reflected on a past consultation in which they accepted a young woman’s decision to have an abortion without exploring the possibility of coercion. In hindsight, they questioned whether the decision had been influenced by the patient’s partner and whether they had overlooked signs of pressure. This reflection highlights the participant’s concern that, despite aiming to support autonomy, their assumptions may have led to an oversight that limited their understanding of the patient’s situation and potentially missed signs of RC.
Interviewer: Have you seen patients who are adolescents who have come in with their parents? And how did that manifest in terms of reproductive coercion?
ID12 (GP, 6 years of experience): I don’t know that I’ve actually seen that in my practice. Well, actually, if I think about it, I remember one girl, she was 19 or 20 young, but technically an adult, and I’m quite sure that her boyfriend influenced her to get an abortion that she didn’t really want to have. And then, like, broke up with her straight afterwards. So, at the time I kind of thought, oh, well, this is probably the best choice for you anyway. You know, you don’t have a job. You know, she’s telling me she wants to make this decision, and I think it’s a good decision, so I’m going to help her with this. But looking back, I’m like, Oh, I don’t know if that was truly her decision. I do think that the partner influenced her to make that happen.
Some participants reflected on the complexity of supporting reproductive decision-making, describing the challenge of empowering patients without inadvertently influencing them. One participant questioned whether decisions they had supported, such as proceeding with a termination, were truly aligned with the patient’s needs, acknowledging the difficulty of distinguishing support from paternalism. This reflection highlights the uncertainty providers may face after a consultation, particularly when coercion may not have been apparent at the time.
ID18 (OBGYN, 12 years of experience): We carry all this decision-making support with the patient. But then afterwards, how do we make sure that they’re still okay, and do they still feel like that was good for them? And maybe sometimes we don’t get it right by saying, ‘Yeah, this is a good idea to have a termination’. There’s two branches there because you want to be as supportive as possible. But also, you want to help people make the best decision for themselves. So where does that crossover with you know, a paternalistic approach? There’s so many gray areas. Yeah, and sometimes I think you reflect on the ones that don’t quite you know, get on the mark.
Many participants reflected on their own lack of awareness or preparedness to identify coercive dynamics within reproductive healthcare encounters. They described how limited experience, lack of training, or uncertainty about how to navigate complex situations could lead to missed opportunities to recognise or address RC, particularly when working with vulnerable or marginalised communities. Several participants acknowledged that in hindsight, they would have handled certain situations differently to create safer and more open environments for patients to express their true needs.
ID3 (Advanced practice registered nurse, 20 years of experience): This particular situation, the woman was new to Australia and [of] non-English speaking background. And so, I didn’t have much experience working with that community. And he [partner] was often in the room as an interpreter, which is another element to that equation, which now I’m like, ohhh. Because I was in a rural setting, we rarely had people from non-English-speaking background. And I felt I didn’t know how to be non-judgmental. I was worried about being judgmental. I should have got the interpreter earlier. There’s a whole heap of things that I should have done that I didn’t do, because I think I was lacking experience and knowing where to find that information. I was inexperienced and I didn’t know how to handle that.
ID17 (Sexual health nurse, 10 years of experience): Years ago, I remember a client, we’ve seen her a few times, she usually presented with her partner. And I didn’t have my kind of red flag, I didn’t have my lens on trying to look at why this person was always in the room. And when we’d seen her before, she was always telling us that they were planning a pregnancy and that was when the partner was in the room. And then one of the consults she came on her own. And that’s when she was able to tell us that she actually didn’t want to have a baby. And yeah, I feel that I should have done a bit more. If I had an awareness back then, I think I would have created that situation earlier where I would have asked the partner to leave the room.
Participants also reflected on how misinformation among other healthcare providers could inadvertently contribute to coercive dynamics. They described instances where inaccurate contraceptive advice with certain methods compromised reproductive autonomy for patients.
ID6 (GP and medical educator, 15 years of experience): I’m a medical educator and you know, there’s still a lot of doctors there that are really misinformed and miseducated around contraception. One example is the doctor’s told the person they need a break from the pill because they’ve been on the pill. So, then they come back to me to have an abortion because they’re pregnant, because, of course, they didn’t need a break from the pill. So, there’s still a lot of education that needs to happen in that space.
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