Rachael Lorenzo works to address reproductive health disparities in Native communities. In 2018, they founded Indigenous Women Rising, a fund that provides financial help for Native people seeking an abortion.
Historically, the federal government has restricted Native people’s reproductive autonomy. Between 1973 and 1976, more than 3,500 Native people were sterilized without their consent.
Today, the chronic underfunding of the Indian Health Service (IHS) and remote location of many reservations create barriers for Native people to access testing for sexually transmitted infections, prenatal care, and contraception.
Lorenzo is determined to fight for their community.
“My people deserve accessible health care, and I will make it happen no matter what, because this is our land,” they said.
Episode 7 explores efforts to protect and expand access to comprehensive reproductive and sexual health care in the face of historical and contemporary efforts of the government to control Native people’s fertility.
Season 4 of “American Diagnosis” is a co-production of KHN and Just Human Productions.
To hear all KHN podcasts, click here.
American Diagnosis Podcast
Season 4 Episode 7: Fighting for Reproductive Sovereignty
Air date: June 28, 2022
Editor’s note: If you are able, we encourage you to listen to the audio of American Diagnosis, which includes emotion and emphasis not found in the transcript. Transcripts are generated using a combination of speech recognition software and human transcribers and may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.
[Light, bouncing instrumental music plays softly]
Céline Gounder: Rachael Lorenzo was in the bathroom when the phone rang.
Rachael Lorenzo: I saw it was from Arizona and I was like, OK, OK. I can do this. I can do this. I was so excited and nervous and scared.
Céline Gounder: Rachael is Mescalero Apache from Laguna Pueblo near Albuquerque, New Mexico. They’re the executive director of the reproductive rights organization Indigenous Women Rising.
Rachael Lorenzo: I didn’t even pull my pants up. I was, like, washing my hands and had the ear to my phone like this, and yeah. I was like, ‘I’m not going to lose this first caller.’
Céline Gounder: Indigenous Women Rising runs a fund that provides financial help for Native people seeking an abortion. When Rachael answered the phone, the caller was skeptical.
Rachael Lorenzo: She wanted to know if it was a scam [laughs] because people … You don’t hear about abortion, let alone abortion funds, let alone abortion for, for Native people specifically.
Céline Gounder: Rachael tried to reassure the caller. Yes, this is real.
Rachael Lorenzo: And by the end of her procedure, when I checked in with her and was like, ‘Hey, how did everything go? How are you feeling? Do you need anything?’ She was like, ‘I’m kind of surprised that you all sent the money to the clinic.’
Céline Gounder: Rachael could only provide that first caller in 2018 with $50. Today, Indigenous Women Rising can pay for most, if not all, of the costs associated with helping a Native person get an abortion.
Rachael Lorenzo: We help with airfare, gas, lodging, child care, food, menstrual hygiene products. If people can’t pay for their prescriptions, we’ll pay for that.
Céline Gounder: Helping with the costs associated with an abortion is only one part of what Indigenous Women Rising does. For women planning to have a child, the group connects Native women with midwives. Indigenous Women Rising also developed a sex education curriculum with a Native perspective.
Rachael Lorenzo: We didn’t always have discussions about sexual health, about consent, about pregnancy, abortion, breastfeeding, and I realized it’s support that so many of my community members want to have.
[American Diagnosis theme music plays]
Céline Gounder: In this episode, we’re looking at sexual and reproductive health disparities on reservations. Native women are among the groups most likely to die in childbirth. Far-flung reservations and chronic underfunding of the Indian Health Service (IHS) make it difficult to access basic health care, things like testing for sexually transmitted infections, prenatal care, and contraception. We’ll hear how the federal government tried to control Native women’s fertility …
Sarah Deer: There are many Native women who recall in the 1960s and 1970s that they were sterilized without their consent.
Céline Gounder: What Native women on reservations face when trying to access the health care they need …
Sunny Clifford: It’s not like there’s another pharmacy 5 miles down the road and I could just get help there. No. These places are very remote, very isolated.
Céline Gounder: And what a post-Roe America means for the future of Indigenous reproductive care.
Rachael Lorenzo: My people deserve accessible health care, and I will make it happen no matter what, because this is our land.
Céline Gounder: I’m Dr. Céline Gounder, and this is “American Diagnosis.”
Céline Gounder: Elizabeth Rink is a professor of community health at Montana State University. She’s been working with the Assiniboine and Sioux tribes on the Fort Peck Reservation for 16 years.
Elizabeth Rink: Our very first study at Fort Peck was all around identifying how we could empower young men to take more accountability for their sexual decision-making and in their relationships.
Céline Gounder: Over the years, the tribes asked Elizabeth to study the sexual and reproductive health of young women, too. Elizabeth noticed that historical events were a driving force behind many of the sexual risk factors on the reservation.
Elizabeth Rink: So traditionally, families would come together to raise people and you would have young women being raised by their aunties or their grandmothers, and there were teachings around how to take care of yourself as a young woman.
Céline Gounder: But these traditional pathways were interrupted. Things like family separations, child sexual abuse, and a loss of cultural knowledge about sex due to colonization.
Elizabeth Rink: Prevalences of depression and anxiety, certainly substance use can come into play when you’re … when you’re talking about high-risk sexual behavior that can lead to poor sexual and reproductive health disparities. So I think it’s a mix of issues that are contributing to the challenges that we see today.
Céline Gounder: One of the most urgent is sexually transmitted infections, or STIs.
Elizabeth Rink: Especially after covid when young people were not able to access sexual and reproductive health care, we are starting to see these upward trends of STIs, including syphilis.
Céline Gounder: Syphilis is on the rise across the United States, according to the Centers for Disease Control and Prevention. And with that has come an increasing number of babies born with the disease. A CDC report this spring found that between 2016 and 2020 American Indian and Alaska Native women had the highest rates of congenital syphilis in the United States. Many of these cases originated with women who did not receive prenatal care.
Elizabeth Rink: There’s no prenatal care available at Fort Peck at the moment. So women need to go either to Williston [in North Dakota] or down to Billings or over to Glasgow [in Montana] if they want prenatal care.
Céline Gounder: And how far would that be?
Elizabeth Rink: Um, well, Billings is about three and a half, four hours away. Glasgow or Williston, I think in either direction, depending on where you are, could be about an hour. Maybe 45 minutes to an hour.
Céline Gounder: Wow. And that’s the closest prenatal care?
Elizabeth Rink: Yes.
Céline Gounder: Wow.
[Somber instrumental music begins playing quietly]
Céline Gounder: The vast distances some Native residents on reservations have to travel creates barriers to sexual and reproductive health care.
Sunny Clifford: It’s not like there’s another pharmacy 5 miles down the road and I could just drive down there. No. These places are very remote, very isolated.
Céline Gounder: Sunny Clifford is a member of the Oglala Sioux. She grew up on the Pine Ridge reservation in South Dakota.
Sunny Clifford: So, on Pine Ridge, we have one major hospital, and it’s under the Indian Health [Service, or IHS]. The hospital is located about 75 miles from my hometown in Kyle. And I remember one day calling up to the Kyle clinic to ask if I could get Plan B.
Céline Gounder: Plan B is emergency contraception. It’s a pill that can stop a pregnancy if it’s taken within three days of unprotected sex.
Sunny Clifford: And they told me that I would need to see a provider, or a doctor, and that I would have to make an appointment in Pine Ridge because there wasn’t one there in Kyle that day. And I got off the phone and was dumbfounded.
Céline Gounder: It was 2012 when Sunny made that call. Plan B was available across the United States without a prescription for women over the age of 17. Some IHS clinics would offer it and others, like Sunny’s, didn’t.
Sunny Clifford: So, it was like, ‘Why are they making me jump through hoops for this emergency contraception?’ Like, ‘I don’t have a ride to Pine Ridge. I don’t even have gas money to Pine Ridge.’ So, it was like … it was enraging to have to go through that
Céline Gounder: Sunny was struggling to access emergency contraception in 2012, but back in the 1950s, IHS did offer contraception.
Sarah Deer is a lawyer and professor of women and gender studies at the University of Kansas. She studies violence against Native women and federal Indian law. Sarah is also a citizen of the Muskogee Creek Nation in Oklahoma.
Sarah Deer: One of the tactics that the federal government began to use in the latter part of the 20th century, so let’s say the 1950s and beyond, was one of limiting the size of Native families. ‘If we can limit the size of Native families, then we will be able to control, uh, we’ll be able to have more control over the lives of Native people.’ Um, and so, many family planning services were targeted to Indian Country.
Céline Gounder: But the contraception provided to Native women at this time often was not yet approved by the Food and Drug Administration. Take the case of Norplant.
[Intense instrumental music begins playing in the background]
Céline Gounder: Norplant is a series of matchstick-size silicone capsules inserted in a woman’s upper arm. The capsules release small amounts of a synthetic hormone that can prevent a pregnancy for up to five years.
Sarah Deer: The consent issue was not clear, because I don’t think some of these young women knew exactly what it was they were being asked to do. And the other thing is that Native populations have high rates of the co-morbidity issues such as obesity, smoking, and some of those other factors that make long-acting hormonal birth control options not a great choice.
Céline Gounder: Sarah remembers speaking with Native women in South Dakota who experienced negative side effects from Norplant, but when they asked to have the implants removed …
Sarah Deer: They were told that the doctor who had implanted them was no longer available and that the health care facility lacked the ability to even remove the implants, much less undo a shot, which you can’t do.
Céline Gounder: IHS was also sterilizing Native women during this time.
Sarah Deer: There are many Native women who recall in the 1960s and 1970s that they were sterilized without their consent either shortly after childbirth, and some who went in for one procedure and while the procedure was happening, the doctor also sterilized them.
Céline Gounder: The Government Accountability Office conducted a study into these sterilizations. It found that between 1973 and 1976, IHS sterilized more than 3,400 Native women and 142 Native men without their consent.
Sarah Deer: And in that study, they found that there were consent forms missing and there were consent forms that were very poorly worded, especially for someone who might be under the influence of anesthesia or just coming off anesthesia.
Céline Gounder: The report was far from comprehensive. It only looked at the years between 1973 and 1976. And in those years, it only reported information from four IHS facilities. Sarah thinks the problem was much bigger than just poorly worded consent forms.
In 1978, a Lakota scholar named Lehman Brightman used the rate of sterilizations in the four facilities studied to extrapolate a national figure. He estimated that during that three-year period, as many as 15,000 Native women could have been sterilized. The exact number of sterilizations is unknown.
Sarah Deer: In fact, I think there were some intentional efforts to sterilize Native women, especially Native women who have substance abuse issues or who are struggling with trauma, depression, those kinds of things. Those women were targeted and sterilized without meaningful and full consent.
[Intense music swells, then fades to silence]
[Hopeful, soft music starts]
Céline Gounder: Fast-forward to 2012, when Sunny Clifford was on the Pine Ridge reservation, trying to get Plan B.
Sunny Clifford: People in my circle were also experiencing the same hoops. I remember a sister had to see a midwife and then the midwife actually berated her for her, uh, wanting Plan B. So it was like she had her religious biases in play with her services to, to an Indian woman on a reservation, you know, like not knowing anything about our lives or what we have to go through.
Céline Gounder: Sunny’s talking about the disproportionately high rates of sexual assault on reservations.
Sunny Clifford: I myself have experienced child sexual assault and sexual violence in my, um, my teens and my adolescemce. And, you know, that experience there was also a driving factor.
Céline Gounder: Sunny didn’t want others to be forced to carry a pregnancy that originated from rape or assault. So she got organized.
Sunny Clifford: Being able to own who you are, especially after something like that happens to you, right?
Céline Gounder: That spring, she started a petition demanding IHS provide emergency contraception in all its facilities. The petition grew to over 100,000 signatures.
Sunny started working with the Native American Women’s Health Education Resource Center too. She became the public face of the campaign.
Sunny Clifford: Social media, newspaper, magazine interviews, phone interviews, yeah.
Céline Gounder: Together, they successfully pressured IHS to make sure all its clinics were providing emergency contraception.
Sunny Clifford: So today, any young woman can go to their local IHS pharmacy, walk up there to the window, say ‘I need a Plan B’ and they’re supposed to hand a pill over with no questions asked and that’s it.
[Bright electronic ping sound]
Céline Gounder: This spring, Sunny got a news alert on her phone.
Sunny Clifford: I saw that they were talking about overturning Roe v. Wade and it sparked that feeling again. The feeling like I need to fight. And I messaged my twin and I said, ‘Are you ready to fight again?’ And she said, ‘I’ve been waiting.’
Céline Gounder: When we come back, we’ll hear about how some abortion rights supporters think reservations may be crucial for abortion access in the future.
That’s after the break.
[Light, bouncing instrumental music plays briefly, then stops]
[Minor instrumental music begins playing in the background]
Céline Gounder: Roe v. Wade created a constitutional right to abortion in 1973, but that right essentially stops at the door of an Indian Health Service clinic.
Sarah Deer: When I’m often talking to Native women about abortion and Roe v. Wade, uh, the response is often, well, Roe v. Wade doesn’t apply to me because I get my health care through Indian Health Service.
Céline Gounder: That’s Sarah Deer again, the lawyer and gender studies professor.
Sarah Deer: The reality is that Native women have … really haven’t had access to abortion due to the Hyde Amendment.
Céline Gounder: The Hyde Amendment is a rider attached to federal appropriations bills. It’s been included in every one since 1976. It prevents federal dollars from paying for abortion services.
Sarah Deer: So the Hyde Amendment is named after Henry Hyde.
Céline Gounder: Hyde was a U.S. representative from Illinois. Here he is defending his amendment on the House floor.
Rep. Henry Hyde: Providing a constitutional right to an abortion does not mean society has to subsidize the exercise of that constitutional right.
Sarah Deer: He was determined after Roe v. Wade to make sure that taxpayer dollars did not go to fund abortions
Rep. Henry Hyde: We are going to subsidize the slaughter of the innocents and make people to whom abortion is morally repugnant, millions of people, be complicit in that terrible action.
Sarah Deer: So that meant Medicaid, um, other federal funding sources, and includes the Indian Health Service, which is a federal agency and uses federal dollars.
Rep. Henry Hyde: My amendment simply provides that no funds may be used to pay for abortions except where three conditions exist: life of the mother would be endangered or the pregnancy was caused by rape or incest.
Céline Gounder: Sarah says that even when these terms are met, IHS rarely provides abortion care. Between 1981 and 2001 IHS only performed 25 abortions. That’s according to a study in 2002 from the Native American Women’s Health Education Resource Center. IHS serves more than 2.5 million people. That same report found that 85% of IHS facilities either didn’t have abortion services available or didn’t refer a woman for abortion care, even when she met the Hyde Amendment’s criteria.
[Dramatic instrumental music fades to silence]
Céline Gounder: Not being able to use federal funds for abortion care puts an undue financial burden on Native women, Sarah says.
Sarah Deer: Native women are among the poorest in the nation. $400 is a lot of money. So, without the federal funding and without, you know, access to, uh, other dollars to support reproductive justice, Native women are really left with very few options.
Céline Gounder: This is why groups that offer financial assistance, like Indigenous Women Rising, started to appear. Founder Rachael Lorenzo says that since 2018, when the funds started, the needs of Native women seeking an abortion have changed.
Rachael Lorenzo: One of the biggest ones that’s starting to trend more is the need for people to, to travel even further.
Céline Gounder: Native women have always had to travel off reservation if they wanted abortion care. But a slew of increasingly restrictive abortion laws, most notably in Texas and Oklahoma, are making it more difficult for Native women looking for abortion care.
Rachael Lorenzo: If they won’t be able to get an abortion for another month, they could be pushed into a new trimester and that’s a whole different procedure, a whole different length of time, a higher cost.
[Low- pitched music begins playing]
Céline Gounder: In 2006, South Dakota’s governor signed what, at the time, was one of the strictest abortion laws in the country. Sunny Clifford remembers it.
Sunny Clifford: South Dakota tried to pass an abortion ban without any exceptions for rape or incest.
Céline Gounder: The Pine Ridge reservation, where Sunny grew up, had just elected its first female president, a woman named Cecilia Fire Thunder.
Sunny Clifford: So when South Dakota says we’re going to ban this abortion, Cecilia said, ‘I will open a clinic here.’
Céline Gounder: It would have been the first clinic on tribal land to provide abortion care.
Sunny Clifford: So Pine Ridge Indian Reservation, any of the other Indian reservations make their own laws and they do not have to abide by state laws.
Céline Gounder: The Pine Ridge reservation is sovereign. If it chose to, the tribe could open an abortion clinic on its land, even if it were illegal in the rest of the state.
But not everyone welcomed the idea. Cecilia Fire Thunder was getting pushback. Some members of the tribe were upset with the idea of putting an abortion clinic on the reservation. In the end, the tribal council impeached Fire Thunder. She was forced to leave her post as president two years early.
[Fast-paced, building instrumental music plays]
Céline Gounder: Cecilia Fire Thunder’s idea of opening an abortion clinic on tribal land is getting attention again.
Sarah Deer: Yes, in theory, a tribal nation could open a clinic and possibly get around state bans or state regulations.
Céline Gounder: Tribal law and gender studies professor Sarah Deer again.
Sarah Deer: With criminal law, the interesting thing about that is the state is not going to have authority to prosecute crimes on an Indian reservation when there’s a Native person involved. So if it’s a patient or a health care provider, if they are Native, it’s gonna be real difficult for the state to actually prosecute and penalize that activity.
Céline Gounder: But that protection doesn’t extend to non-Native people.
Sarah Deer: So you can see that even in the first, like, minute or so of trying to even describe the problem, it’s very convoluted.
Céline Gounder: And just because a tribe could open an abortion clinic, doesn’t mean there’s the desire to do it. So Sarah says the conversation about health care access should go well beyond abortion.
Sarah Deer: The full range of reproductive justice, particularly prenatal care, where Native women have less access.
Céline Gounder: She says cultural competency is an important step to achieve this.
Sarah Deer: If we can have counselors or, or supporters or health care providers who are Native themselves, I think that there would be more likelihood that people could get the care that they need. There’s a fear of white medicine. There’s a fear that white doctors don’t have your best interests at heart. And those are not fears that came from nowhere. Those are fears that were passed down from generation to generation.
[Fast-paced music fades to silence]
Céline Gounder: Rachael Lorenzo’s personal experience with reproductive health care influenced their decision to create Indigenous Women Rising. Rachael had one child already and was pregnant with another, but there were health complications and then a miscarriage.
[Soft instrumental music begins playing in the background]
Céline Gounder: Rachael had a dilation and curettage, a procedure used to manage the complications of miscarriage.
Rachael Lorenzo: After that, there was just so much shame, and that is seen over and over again with callers to our abortion fund. They are just so ashamed of this decision that they’re making, even though they know it’s right for them. They can’t tell their grandma, they can’t tell their mom, or their sister, or their partner, and they are going through this process alone. And they don’t have to.
Céline Gounder: Rachael’s group provides space for Native people to talk about these issues. The fund can help someone pay for a medicine man or woman to perform a healing ceremony after the procedure.
Rachael Lorenzo: Since fetal tissue or human remains can’t be released by a medical facility to an individual, we will pay for the funeral home to take custody of the human remains so that way services and ceremonies can be provided for that individual. So whatever our people need in relation to their abortion care, this fund covers.
Céline Gounder: Rachael says Indigenous Women Rising will continue to operate, whatever the law of the land, but the fund may operate differently in the future.
Rachael Lorenzo: I think dedicating more time to understanding our legal risk and our responsibility, what kind of data we shouldn’t be asking for, how are we potentially putting our callers at risk, and then doing an education push by prioritizing Indigenous people in states that we serve the most.
Céline Gounder: Rachael says whatever happens they’re committed.
Rachael Lorenzo: This is something I am so passionate about and my people deserve accessible health care, and I will make it happen no matter what, because this is our land.
[Music builds, then fades to silence]
[American Diagnosis theme music plays]
Céline Gounder: This season of “American Diagnosis” is a co-production of Kaiser Health News, and Just Human Productions. Additional support provided by the Burroughs Wellcome Fund and Open Society Foundations.
This episode of American Diagnosis was produced by Zach Dyer and me. It was engineered by Ameeta Ganatra.
Special thanks to Charon Asetoyer and Jonnette Paddy.
Our editorial advisory board includes Jourdan Bennett-Begaye, Alastair Bitsóí, and Bryan Pollard. Taunya English is our managing editor. Oona Tempest does original illustrations for each of our episodes. We’re powered and distributed by Simplecast.
Our theme music is by Alan Vest. Additional music from the Blue Dot Sessions.
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I’m Dr. Céline Gounder. Thanks for listening to American Diagnosis.
[Music fades to silence]