Abortion stigma, abortion exceptionalism, and medical curricula

ABSTRACT

While it is well established that medical student learning about abortion is inadequate and lacks systemisation, there is little research on why this might be the case. This exploratory study draws on a survey sent to 438 medical educators at Australia’s 21 accredited medical schools through March–May 2021. Forty-eight educators responded to the survey. In this article, I examine their responses alongside policy and research on medical education to consider how curricula are determined. I conceptualise abortion exceptionalism – the singling out of abortion from other areas of medicine on the grounds that it is special, different, or more complex or risky than is empirically justified – as a mode of ‘stigma-in-action’, arguing that medical curricula are powerful sites for its reproduction and undoing.

KEYWORDS:

• Abortion
• medical education
• stigma
• abortion exceptionalism
• the hidden curriculum

Introduction

Abortion should be systematically integrated into medical school curricula. It is a common procedure that is integral to sexual and reproductive health (Steinauer & DePineres, 2021). Teaching medical students about abortion can increase the number of future providers, helping to reverse the downward trend in providers threatening access in the developed world (Doran & Nancarrow, 2015, p. 125). Further, including abortion content signals that it is a routine medical procedure, performing a corrective function to abortion stigma.

Studies in diverse contexts find that the inclusion of abortion in medical curricula is inadequate, uneven, and unsystematic, and that medical students want more education and, particularly, training opportunities in abortion care (Cheng & de Costa, 2021; Steinauer & DePineres, 2021). Extant studies of abortion in medical curricula are generally based on surveys sent to medical students (Cheng & de Costa, 2021; Cohen et al., 2021; Steinauer et al., 2009; Steinauer & DePineres, 2021), trainees in family medicine (Myran et al., 2018; Romero et al., 2015; Summit & Gold, 2017; Weidner et al., 2019) and obstetrics and gynaecology (Brown et al., 2020; Cheng et al., 2020; Greenberg et al., 2012; Macfarlane & Paterson, 2020; Roy et al., 2006; Turk et al., 2014), currently practicing clinicians (Cheng et al., 2020; Greenberg et al., 2012; Steinauer et al., 2008), and clerkship and residency directors of obstetrics and gynaecology programs (Espey et al., 2005; Steinauer et al., 2013; Steinauer et al., 2018). Most are quantitative and map the degree and nature of abortion training, the participants’ attitudes toward abortion, and, where relevant, their intention to provide abortions in their future careers and their competency in performing abortions. Qualitative studies examine medical students’ reactions to observing a first trimester abortion (Rivlin et al., 2020) and the stigmatising language they use to describe abortion (Smith et al., 2018).

This study centres medical educators. Educators are at the coalface of medical education; they hold important insights into the feasibility and significance of including abortion in medical curricula, and often make these curricula decisions themselves. The focus on medical educators turns attention away from what is taught to how curricula are determined, locating this research in studies of the ‘hidden curriculum’ – those ‘cultural and organizational forces – outside of the explicit learning agenda – that influence how students develop professional identities during medical training’ (Smith et al., 2018). As Zaidi et al. write, investigation of the hidden curriculum situates medical education in the structural, cultural and historical conditions of its existence, and ‘call[s] into question: Who decides what is to be included and prioritized in the curriculum? Who is charged with curricular development and assessment, and how do they make decisions about what is included’ (2021, p. 458)?

The article begins with a background section that briefly describes Australian abortion law and practice and introduces ‘abortion exceptionalism’, a core concept for understanding the continued marginalisation of abortion in medical curricula. After detailing the project’s materials and methods, I draw the survey results into discussion with policy and extant research to demonstrate how curricula are determined at the intersecting levels of systems, institutions, and individual educators. The discussion section draws the results into dialogue with abortion exceptionalism to highlight the social and cultural production of medical curricula, and medical knowledge and practice more broadly.

Background

From 2002 to 2021, abortion was decriminalised in all Australian jurisdictions except Western Australia. Abortion laws in all but two jurisdictions (South Australia and Victoria) limit the provision of abortion to medical doctors. Therapeutic Goods Administration (TGA) Guidelines only permit obstetricians-gynaecologists (ob-gyns) and general practitioners (GPs) who have specifically registered for the purpose to prescribe medical abortion, and 10% of GPs are currently registered (MS Health, 2022). Most abortions are performed in private clinics, with significant out-of-pocket costs to patients (Baird, 2017).

Abortion exceptionalism is a useful concept to describe Australian abortion law and practice. Joffe and Schroeder (2021, p. 5) define abortion exceptionalism as ‘the idea that abortion is regulated both differently and more stringently than other medical procedures that are comparable to abortion in complexity and safety’. Abortion exceptionalism, they argue, ‘encompass[es] the highly politicised and stigmatized status of abortion in American society’ (Joffe & Schroeder, 2021, p. 5).

Instead of viewing abortion exceptionalism as encompassing stigma, I see abortion exceptionalism as a mode of stigma-in-action. Here, I rely on my previous definition of abortion stigma as ‘a socio-cultural process tied to the categories of difference upon which power relations are produced and legitimated’ (2020, p. 6). Socio-cultural norms, including those pertaining to binary gender, are productive of abortion stigma, which often manifests as abortion exceptionalism in health care systems, medical institutions, and individual attitudes toward, and experiences of, health. Abortion exceptionalism signals the various discourses and practices that differentiate abortion from routine medical care. Over-regulation is a notable means by which this distinction is operationalised. Examples of this over-regulation include the continued legal regulation of abortion in standalone acts, when existing health law and policies would ensure patient safety and allow for conscientious objection (Dwyer et al., 2021), the special drug status of medical abortion despite its well-established efficacy and safety (de Costa et al., 2019); and law and policy that prevents nurse and midwife provision. Abortion exceptionalism frames abortion primarily as a moral rather than medical issue and as more complex, risky or specialised than it is in practice, involving a form of boundary crossing where, as Joanna Erdman writes, ‘moral and material hazards merge’ (Erdman, 2017, p. 34).

Abortion exceptionalism reached its ultimate expression in its criminalisation, which prevented medical schools from including curricula content on abortion (Sifris & Penovic, 2021). Most Australian medical schools now include some abortion content, but they do so unevenly and unsystematically (Cheng & de Costa, 2021). This is partly attributable to accreditation standards which, as is true internationally, only cover sexual and reproductive health topics indirectly (Steinauer & DePineres, 2021). The Australian Medical Council (AMC) ‘does not prescribe core curriculum content or any particular model of training’ (Glasgow et al., 2010, p. 4), and precise learning outcomes are ‘largely left to each medical program to determine’ (Symonds, 2018, p. 491). The Confederation of Postgraduate Medical Education Councils (CPMEC) recommends that, by the end of their prevocational training (two years post-graduation), medical students acquire several skills relevant to abortion provision, including the capacity to provide ‘non-discriminatory patient-centred’ and ‘non-judgmental’ care, and to respect the decision-making autonomy of patients (CPMEC, 2012). As with many specialist medical colleges internationally (e.g. Association of Professors of Gynaecology and Obstetrics, 2019; RCOG, 2020), the Royal Australian College of Obstetrics and Gynaecologists’ (RANZCOG) Undergraduate Curriculum recommends student instruction in abortion law, non-directional pregnancy counselling, the ‘methods, indications, contraindications and complications of’ abortion, and in how to discuss ‘history and management issues in ways that respect and empower women in their care’ (2018, p. 24).

Materials and methods

The results communicated in this article represent part of a 23-item survey sent to 438 medical educators at Australia’s 21 accredited medical schools through March-May 2021. Eligible participants included degree coordinators, subject coordinators, tutors, and coordinators of clinical placements. Potential participants were identified through searching the websites of medical schools and they were recruited via an email invitation, which linked to an online survey administered through the survey platform QuestionPro. Ethics approval was provided by La Trobe University. Consent was taken as implied by participation in the survey. Forty-eight educators completed the survey.

Participants comprised 28 (59.57%) women and 19 (40.43%) men (one participant did not disclose their gender identity). The survey was generally completed by specialists most directly involved in abortion provision – general practitioners (GPs, family physicians) (n.17, 35.42%), ob-gyns (n.9, 18.75%), and bioethicists (n.5, 10.42%) – and those who teach abortion content directly (n.27, 64.29%). Most participants (n.34, 70.83%) were subject coordinators.

The response rate (10.96%) is similar to the only extant study of abortion curricula content in the Australian context (Cheng & de Costa, 2021), and, although relatively low, yielded sufficient ‘meaning richness’ (Braun & Clarke, 2022, p. 17) to use for the purposes of a thematic analysis. The survey consisted of closed and open questions. This article focuses on the responses to open questions, which asked educators whether and why they taught (or did not teach) content on abortion and their views as to whether abortion should be included in medical curricula more broadly. Individual survey responses were imported into NVivo 12 for initial coding. A coding frame was developed around the a priori research question – ‘how do educators make decisions to include abortion in curricula content?’ Thematic analysis was conducted to address how each participant rationalised decisions to include content on abortion, within their own courses and medical degrees generally. I employed a ‘constant comparative approach’ (Glaser & Strauss, 1967) to ‘identity thematic patterns and develop explanations of differences’ in the survey responses (Purcell et al., 2014, p. 1143). From this descriptive stage I moved to a conceptual stage, identifying latent themes (Braun & Clarke, 2022) that captured the framing strategies participants used to make abortion meaningful. My interest in framing strategies emerged from my initial coding, which confirmed that educator attitudes toward abortion played a significant role in determining whether abortion is taught in medical schools. It was further directed by the only extant study of the hidden curriculum in abortion education (Smith et al., 2018), which notes that informal discourse and discussion can fill the gap left by the exclusion or marginalisation of abortion from the formal curriculum. Qualitative data are at times supplemented with a descriptive statistical analysis of quantitative data. Participants could skip questions and the given statistics were calculated according to response patterns for the specific survey item (rather than total number of participants).

Results

Systemic and institutional contexts

Curriculum guidelines are critical to the systematic integration of abortion into the curriculum and incentivise educators to include content on abortion (Cohen et al., 2021). Because they are not pinned to the accreditation of medical schools in a binding or formal way, however, the integration of abortion in medical curricula lacks systemisation. This was reflected in survey results. One educator, for example, said that, although abortion is in the ob-gyn curriculum, it is neither taught formally nor examined. Further, because RANZCOG’s guidelines have most bearing on ob-gyn teaching, educators in other relevant disciplines – such as in general practice, which is especially significant because GPs perform most abortions in Australia (Baird, 2014) – do not have even these unbinding guidelines to inform their practice. Consequently, as one GP educator noted:

Termination of pregnancy and observing the procedure is NOT listed in the curriculum handbook, it's not a requirement … it's not listed as a core condition in the GP section of the handbook either. [GP, female]

Most respondents did not know whether abortion was included in subjects they did not teach themselves, and abortion seems to be rarely if ever discussed at a discipline or school level: ‘I never hear it mentioned during talk of assessment, teaching and learning’ [no specialisation, female].

Such responses reflect disciplinary siloing within medical schools (Geffen, 2014), and the perception that abortion content belongs to specific fields, particularly ob-gyn, bioethics, and professional development. Many participants did not teach abortion content themselves because they believed that ‘Abortion is not relevant to any subjects that I teach’ [emergency medicine, female] or it is ‘not part of my portfolio of teaching’ [GP, female]. This included two GP specialists, one anaesthetist, and two specialists in emergency medicine – fields that are involved in the provision of abortion or after-abortion care in some way. Educators who did not teach abortion content directly sometimes assumed it was covered in disciplines more closely tied to abortion:

We only have 6 weeks to cover the whole content of general practice, and assume that the ethics of abortion law will be covered in second year, and hopefully the [obstetrics and gynaecology] term in 4th year will cover abortion. [GP, male]

The systems and institutions of medical education and provision limit clinical training opportunities. Educators noted that the ‘Public hospital system is not that involved with TOP [Termination of Pregnancy]’ [ob-gyn, male] and medical students have ‘limited access to facilities that provide abortions’ [GP, male]. Clinical exposure to abortion rarely occurs predictably or by design, but ‘may or may not occur opportunistically on rural, GP, obstetric or medical terms’ [no specialisation, female]:

[Access to clinical training] depends on whether suitable cases present while students are on their Women's Health rotation. This could differ between students and rotations and over various cohorts over time … They might get exposure in GP land, e.g. if GPs do medical TOP [termination of pregnancy]. [No specialisation, female]

Surgical abortions at our teaching hospital are performed at the private hospital and the med students do not attend this as part of their rotation, however occasionally surgical abortions are performed in the public teaching hospital (e.g. patients with anaesthetic risks) in which case students would be allowed to attend and observe procedure. [Ob-gyn, female]

The shadow of abortion criminalisation continues to fall on medical education. One educator queried ‘the legality of including this [abortion] in Medical education’ [Aboriginal Health, female], indicating confusion about the current legal status of abortion. Participants noted difficulties with changing the curriculum: that ‘The whole thing needs to be rethought’ now that abortion is decriminalised [bioethics and medical ethics, male]; that it is ‘out-dated and undergoing a review’ [ob-gyn, male], ‘does not evolve regularly and is not current’ [no specialisation, female], and that sexual health is treated as ancillary to the main curricula, when it ‘should be in all Medical curriculum and as such a proportion of the subject should be dedicated to abortion’ [sexual health medicine, female].

The over-regulation of abortion in government law and policy affects educational opportunities. The TGA’s regulation of medical abortion limits the number of GP providers and, in turn, clinical training opportunities:

Historically, Australia sought to stymie the provision of Mifi/misoprostal [medical abortion]. The result is teaching medical abortion […] has been taken out of the hand of medical schools and it is a kind of specialist add one can do as a GP. Thus I think info about medical abortion is absent from [name of university] and, I expect, other Australian medical schools. [Bioethics and medical ethics, male]

Conscientious objection laws increase the validity of individual practitioners and medical institutions opting out of abortion provision (Keogh et al., 2017). Catholic teaching hospitals – including one of the two major maternity hospitals in Brisbane, Australia’s third largest city – ‘prohibit abortion for religious reasons’ [no specialisation, female]. The head of a large clinical school noted the lack of access in rural areas as a major barrier to training opportunities – this reflects the number of rural and regional hospitals that opt-out of provision, to the extent that some have turned away patients with post-abortion complications (Rushton, 2019). Educators at a Catholic university noted that their institution ‘does not approve of abortion under any circumstances’ [GP, male]. Educators that worked at this university did not generally teach about abortion, but one introduced students to moral debates about abortion, including in a module titled ‘It’s just the two of us: Beginning of life’, indicating that students may be exposed to content that frames abortion exclusively in terms of autonomous foetal personhood. One educator made note of students who expressed anti-abortion views in the classroom, suggestive, perhaps, of an anti-abortion institutional culture.

Individual decision-making

Given the systemic and institutional barriers to including abortion in medical curricula, individual educators are often responsible for providing students with learning and training opportunities.

Some educators ‘made the decisions by myself to include [abortion in] the relevant sessions’ [no specialisation, male], commented that abortion was integrated into curricula, sometimes with institutional support, because of other peoples’ advocacy work, and noted that ‘the teaching is variable and depends on the personal experiences and beliefs of academic and clinical supervisors’ [GP, female]:

The current and immediate past academic co-ordinators for the medical students’ women’s health rotation (Reproductive and Neonatal Health) both share an interest in abortion and have done significant work in this field of women’s health. The university and teaching hospital support this as an important aspect of women’s health that should form part of the core curriculum for medical students. [Ob-gyn, female]

Abortion-providing supervisors open up clinical training opportunities, with students attending ‘my practice which provides MS2step [medical abortion]’ [ob-gyn, GP, sexual health medicine, male] and observing the work of ‘a maternal fetal medicine subspecialist’ whose ‘work involves termination for maternal or fetal concerns’ [ob-gyn, male].

Educators taught about abortion because it is ‘vital’ to reproductive health care (they used words including ‘important’, ‘key’, ‘essential’, ‘central’ and ‘core’ to communicate this); they noted the frequency of abortion (e.g. ‘surgical TOP is the commonest surgical procedure performed on women in Australia’ [ob-gyn, male]), its overlap with several specialisations, and that medical school is often the ‘only exposure many students will have to this area of medicine’ [ob-gyn, female]:

Because it’s part of healthcare, we wouldn’t be asking whether prostrate exams should be a part of medical education, why are we asking whether terminations should be? [Bioethics, female]

Given my students will ultimately work with women of reproductive years who may be faced with an unplanned pregnancy I want them to have both knowledge of services available and to be able to approach these women with empathy and respect. [Ob-gyn, female]

Educators cited the ‘reality’ that unplanned pregnancies and abortions occur (‘It happens and is legal. Part of quite a few women’s and doctors’ lives’ [ob-gyn, no gender identity recorded]) and that abortion is ‘a necessity’. These statements seemingly respond to a perception that abortion is rare, exceptional, or non-essential (as expressed by one anti-abortion educator who reasoned that ‘I don’t think it’s an area that needs a lot of essential education’ because of ‘[the] relevance to the entire course of medicine, [and] paucity of practice compared to other procedures’ [anaesthesia, emergency care medicine, male]).

Educators that supported including abortion in medical curricula emphasised the importance of delivering patient-centred care. They noted that students must recognise that ‘they have a legal obligation to deal with abortion – directly or by referral’ [sexual health medicine, female] in order to:

minimise the risk of harming the patient because of how they are discussing or approaching the issue in conversation. It is important that they learn the law and start thinking about their position on these issues in medical school so that they are better prepared to be confronted by conversations with patients in the future. [No specialisation, female]

Many believed that ‘This topic [abortion] should be no more taboo than teaching many other topics a small minority of students may fundamentally disagree with’ [GP, female]. Compulsory learning about abortion was deemed particularly important for those students ‘who enter medical school with attitudes that raise specific barriers to their learning and ability to provide care, and could present risk for their patients’.

Educators commonly used pro-choice language when explaining the function of medical education. They noted abortion stigma and access issues – including ‘financial barriers associated with accessing abortion services’ [GP, female], barriers to access in rural areas, in public hospitals, and obstructing doctors – and viewed including abortion in medical curricula as necessary to expand abortion access, ‘normalise abortion and break down stigma around this’ [No specialisation, female]:

It is a core issue of justice for women that they be able to choose what happens with their bodies. Doctors and other healthcare workers are uniquely prepared to support women in this issue. If they are not at least provided with the opportunity to learn about this, then as a society we undermine the ability of women to access a crucial medical intervention. [No specialisation, male]

Some educators taught students explicitly pro-choice content, setting readings that champion law reform and the extended use of medical abortion (De Costa, 2007, 2010), ‘focus[ing] on reproductive autonomy’ [medical ethics, female], and teaching ‘the history of women’s reproductive rights’ [GP, female].

More women than men responded to the survey (participation may indicate interest in the topic), taught abortion content, and strongly agreed that abortion should be included in medical curricula. Sixteen (69.57%) women and 10 men (55.56%) taught content on abortion. Seventeen women (60.71%) and 9 men (47.36%) strongly agreed that abortion provision should be part of medical education in Australia. No women, and 4 (21.55%) men strongly disagreed with this statement. These gendered patterns reflect larger surveys, which find that more women than men support legal abortion in all circumstances (Cations et al., 2020), underlining the significant role individual educator’s attitudes and values surrounding abortion play in determining curricula content.

Respondents that defended the exclusion or marginalisation of abortion in medical curricula commonly referenced an overcrowded curriculum and the ‘constant struggle to cover all necessary content as new things are constantly added’ [Bioethics, female]. Many educators believed that, although medical schools should discuss the ethical and legal dimensions of abortion, clinical training in abortion requires ‘higher level skill’ and is too specialised for a generalist degree:

The curriculum is very crowded. We focus on content that will be relevant to generalist doctors (rather than specialists). We also focus on preparing students for the next stage of their career journey – ie internship. Specialist training is where I imagine knowledge and skill re abortion would be more timely – eg GPs (who refer) and gynaecologists, who perform the procedure. [Emergency medicine, female]

the main focus at medical school level is awareness of the reasons women seek abortion, how to assist with shared decision making, how to support regardless of the choice they make. Focussing on how to actually perform the procedure is beyond the scope of undergraduate training. [GP, female]

Participants (n.4, 8.33%) who strongly disagreed with including abortion in medical curricula worked at a Catholic university that prohibits teaching and clinical training in abortion. They were clearly anti-abortion, expressed in statements such as ‘I do not believe in abortion’ [GP, male], and abortion amounted to ‘taking the life of an innocent human being’ [GP, male]: ‘Doctors take a Hippocratic oath to not kill (please re-read Oath and realise what it says) and medicine has never been about the killing of human beings and never should be’ [anaesthesia, emergency care medicine, male].

The educators who disagreed (n.1), somewhat disagreed (n.2), or neither agreed nor disagreed (n.2) with the inclusion of abortion in medical curricula were not explicitly anti-abortion, but generally characterised abortion in negative terms. They all rationalised their position with reference to hypothetical student objectors:

it is important for students to be able to opt out of participating in abortion related work if they have a conscientious objection to it, and they should be told that it is ok to opt out and that they will not be penalised … Our commitment to diversity and inclusion should extend to individuals with such beliefs. [Emergency medicine, female]

One stated that ‘participating in abortion procedures may or may not be appropriate for medical students’ [no specialisation, female]; and another did not ‘think that students are emotionally mature enough to manage this type of education’ [Aboriginal health, female]. By presenting abortion as potentially ‘inappropriate’ and as requiring a level of emotional maturity beyond the undergraduate level, these educators recited the moral framing of abortion that leads to exceptionalism in health care provision.

Framing abortion

Educators drew on established linguistic tropes when discussing abortion – oppositional tropes, stigmatising associations, and negative language. In their thematic analysis of media coverage of abortion in the UK, Purcell et al. (2014) argue that these stigmatising themes were prevalent in media coverage of abortion, while the presentation of ‘abortion as a positive and legitimate choice’ (p. 1144) was marginalised. In contrast, stigmatising themes were marginal in the educators’ responses, but nevertheless hold important insight into how some educators talk about abortion in the classroom and make decisions as to how and whether to include formal content on abortion.

Participants constructed abortion (or particular abortions) negatively through drawing it within a hierarchical opposition. Some educators repeated the common distinction between ‘desired’ and ‘required’ abortions, which, as Smith et al. write, perpetuates abortion stigma by reifying a ‘broader societal phenomenon of women being afforded a higher moral and social status for desiring motherhood’ (2018, p. 32):

when the life of the pregnant woman is at risk … [and] in cases of FFA [fatal foetal anomaly] or Severe life limiting disability [abortion] is basic healthcare … surgical abortion for other reasons involves a value laden judgment that rightly belongs to the pregnant woman. [Bioethics, medical ethics, male]

abortion should only be considered if it is life threatening (medical condition of the mother or an unhealthy baby that is proven medically) otherwise abortion is a crime killing an innocent life. [GP, emergency medicine, male]

Educators contrasted abortion with ‘normal healthy pregnancies’ (emergency medicine, GP, male) to explain why they do not teach abortion, or only teach abortion fleetingly:

I teach the Reproductive Medicine and Sexual Health module … The main focus is on normal pregnancy and puerperium, and normal fetal development … In the areas I teach (Yr 1 and 2), we focus on fundamental concepts and normal processes, whereas pathology/clinical decision making/ethical tensions etc develop as students go further in the Program. [No specialisation, female]

I teach and coordinate in the foundational years of our program and the focus in my area is normal anatomy and physiology. [No specialisation, female]

The presentation of abortion as ‘abnormal’ is central to abortion stigma (Kumar et al., 2009). In the statements above, educators reiterated a normative distinction that presented pregnancy ending in birth as unproblematic and pregnancy ending in abortion as involving ‘pathology’, complex decision-making, and/or ethical tensions.

Some educators aligned abortion with ‘widely discredited, “deviant” and/or sometimes unlawful practices’ (Purcell et al., 2014, p. 1146). One pro-choice educator associated abortion with domestic and family violence (‘It is also a very important aspect relevant to domestic and family violence’ [no specialisation, female]). Although forced abortion and forced pregnancy are important instances of reproductive coercion, this educator’s choice to underline the importance of educating future doctors about abortion by drawing a discursive association between abortion and violence is significant because it associates abortion with negative life events, thus fitting a broader pattern of abortion stigma. Another educator compared abortion to ‘other controversial areas of healthcare – e.g. assisted dying, body modification of normal healthy bodies, unnecessary plastic surgery’ [emergency medicine, female], inferring that abortion, too, was ‘unnecessary’ and a ‘modification’ of the healthy norm (i.e. pregnancy resulting in birth). One anti-abortion educator likened doctors who perform abortions to ‘veterinarians, bikie gang members or murderers’ on the basis that ‘Doctors should not kill’ [anaesthesia, emergency care medicine, male].

There was a propensity to frame abortion as inherently controversial, which, as Purcell et al. explain, presents abortion as ‘unusual, atypical … [and places] conflict centre stage’ (2014, p. 1144). Three educators explicitly used the word ‘controversial’ to describe either how abortion is or is commonly perceived (e.g. ‘[I t]hink abortion still seen as a controversial topic when discussing with students with a range of beliefs on the subject’ [Bioethics, female]). Some educators viewed abortion as divisive: one educator pointed to ‘stakeholder groups who would have a conflict of interest and be opposed to this type of education being included. It is a political issue’ [Aboriginal Health, female]; another emphasised that the topic needs to be taught by ‘organisations without vested interests … we need unbiased clinicians to teach about abortion’ [GP, female].

Discussion

The systemic, institutional and individual drivers of decision-making about curricula content on abortion reflect, reproduce, and challenge abortion exceptionalism.

The historic criminalisation and continued over-regulation of abortion (for example, in TGA limits on who can prescribe medical abortion), as well as the exclusion of most abortions from the public health care system, limits providers and the opportunities of students to observe abortion on clinical placements. Abortion exceptionalism at the level of medical institutions, law and policy stems from and reiterates the view that abortion is ancillary, rather than integral, to health care practice and delivery.

Within medical schools, disciplinary siloing, the absence of centralised systems for curriculum setting at the medical school level, and the lack of formal processes that translate the curriculum guidelines set by specialist colleges into teaching practices, help explain the uneven and unsystematic nature of abortion education. Together with the institutional and systemic contexts that work against including abortion in medical curricula, they combine to grant individual educators notable influence over curricula content.

Educators who propound that abortion should not be taught at medical school, or only taught in a cursory way, generally believe that abortion belongs to a niche area of medicine (e.g. one educator relegated abortion to ‘women’s health’ as though this was a specialised topic), that it is outside the scope of routine medical practice, and/or that its technical demands are too advanced for undergraduate students. These views reflect abortion exceptionalism. Abortion is common and (in most cases) not overly technical – nurses and midwives can provide most abortions as safely as physicians (Mainey et al., 2020). Abortion care involves a sweep of medical professionals. Anaesthetists, for example, are essential to surgical abortion care, yet have little contact with patients beyond the procedure and can be challenged by this work, especially in relation to later abortions (Flowers, 2020, p. 7). Medical school, as some participants noted, provides an opportunity for the broad engagement of future medical practitioners with abortion, and this opportunity is critical while abortion remains stigmatised, and services threatened by a lack of providers.

The discursive attachment of abortion to conscientious objection impacts on curriculum decision-making. Anti-abortion educators elide the capacity of students to conscientiously participate in abortion care. Those who support the inclusion of abortion in medical curricula emphasise that students should be exposed to learning (not necessarily training) in abortion so they are better equipped to deliver patient-centred care. Educators who fall on the spectrum between strongly disagreeing and agreeing prioritise the perceived learning needs of students who would object to learning and training in abortion. Extant evidence suggests that medical students want more, not less, education in abortion and rarely absent themselves from training in the area when they are presented with the opportunity (Cheng & de Costa, 2021; De Costa, 2019). Further, conscientious objection laws in Australia (and elsewhere) relate specifically to the performance of, and referral for, abortion in non-emergency situations (Davis et al., 2022). They do not extend to cover student learning in abortion (although would likely extend to clinical experience). Yet privileging the conscientious objection of students represents more than a potentially erroneous generalisation about the student cohort or problematic reading of the law; it reflects abortion exceptionalism, framing abortion as primarily a moral rather than medical issue and, flowing from this, emphasising (future) doctor, rather than patient, autonomy.

Educator attitudes about abortion can seep into and frame how abortion is discussed – or given meaning through a lack of formal discussion – in the classroom. The exclusion of abortion from medical curricula – and the absence of training opportunities in abortion care – would likely reproduce abortion exceptionalism, encouraging students to view abortion as separate to mainstream medical care. The teaching of abortion as a legal and moral issue – but not as a medical issue involving clinical knowledge and skills – reinforces populist framings of abortion, encouraging future doctors to view abortion as outside the scope of their medical practice (consequently, this type of learning is also unlikely to increase the number of future abortion providers (Myran et al., 2018; Steinauer et al., 2009)). The distinction between ‘desired’ and ‘required’ abortions encourages future doctors to determine the validity of abortion based on a pregnant person’s decision-making in the area. The view that abortion is contrary to ‘normal’ pregnancy, its discursive association with conscientious objection and other stigmatised practices, and its framing as a ‘controversial’ moral issue may serve to reinforce abortion stigma.

The reasons educators give for including abortion in medical curricula provide a powerful counter-narrative to abortion exceptionalism, viewing abortion as an essential component of healthcare and within the scope of a generalist education. Many educators drew on the rhetoric of bodily autonomy and decisional security to communicate the importance and function of abortion education, which they hope will not only equip medical students with necessary skills and knowledge, but combat abortion stigma, normalise abortion, and expand access.

A notable feature in survey responses was preference for ‘termination of pregnancy’ over the term ‘abortion’, which was used in the survey, and is used in this article; one educator criticised this choice:

Framing it as ‘abortion’ requires defining. This sets up the research and findings to be controversial. I know we have had to clarify with students (and staff) why we choose to use the term ‘termination of pregnancy’ – I would suggest thinking about this when reporting findings. [Health ethics, female]

Over the last fifty years, medical professionals have moved away from using the word ‘abortion’ to ‘termination of pregnancy’, which Kavanagh et al. describe as a ‘euphemistic tool; it’s “gentler” than the “harsh” term “abortion”’ (2018, p. 126). Kavanagh et al. note that, in their consultations with patients, some doctors who would generally use ‘termination of pregnancy’ deliberately revert to ‘abortion’ in order ‘to emphasise the seriousness of the procedure where they felt it was necessary, for instance to patients presenting who had previously had an abortion’ (2018, p. 125). The distinction between these two terms, thus, is a means whereby some doctors make a distinction between ‘good’ and ‘bad’ abortion patients depending on the patient’s moral and emotional stance toward the procedure. My use of the term ‘abortion’ reflects a political stance aimed to destigmatise the term through its repetition rather than avoidance: if the term ‘abortion’ were destigmatised, there would be no need to revert to the euphemistic language of termination; and the use of ‘termination of pregnancy’, which might be intended to destigmatise the practice, leaves the word ‘abortion’, with its negative connotations, untouched. The naming of abortion/termination of pregnancy is political, and, as Kavanagh et al. (2018) conclude, its effects on patients, abortion provision, and abortion stigma warrant further examination.

Educators (and RANZCOG’s curriculum guidelines) almost exclusively used ‘woman’ when describing the people who have abortions (the exception was one educator who noted that ‘many people will seek this procedure’ [no specialisation, female]). This indicates that the relatively recent push within academic and activist spaces (Sutton & Borland, 2018) to use inclusive language when speaking about abortion patients has not yet reached the domain of medical education in Australia. The exclusive use of the term ‘woman’ when describing the people who have abortions may facilitate models of care that further exclude and marginalise trans and gender diverse patients.

This article has drawn attention to systemic, institutional and individual-level forces that determine whether and how abortion is taught in medical schools. Because abortion exceptionalism – a mode of stigma-in-action – animates these forces, medical curricula about abortion is embedded in the ‘structural inequalities and injustices that produce and sustain stigmatising categories’ (Millar, 2020, p. 6). Curricula content on abortion demonstrates how medical knowledge and practice in embedded in, rather than absented from, culture, and indicates the cultural change required for ensuring health care delivery that meets the needs and expectations of the people it serves.

Acknowledgements

I would like to thank the 48 university educators who gave up their time to complete the survey. The survey was reviewed by doctors who currently perform abortions in Australia as well as Barbara Baird from Flinders University. I would also like to thank Alonso Casanueva Baptista, who scrolled through the website of each Australian medical school to identify potential participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings can be made available to the editors on request.

Additional information

Funding

This project was funded by the Australian Research Council [grant number DE210100151].