Abortion Clinics: U.S. Politics Controlling Women’s Reproductive Healthcare

Architecture has an integral role to play in the built environment and by extension, in engaging and improving people’s lives. Architecture shapes a person’s daily experiences and directly participates in the politics of space — both reinforcing power dynamics that often disenfranchise certain groups and more importantly, supporting and empowering others. To locate one’s architectural practice on the side of improving the lives of others, not as an added benefit but as a primary concern, be this through design work, research, or somewhere in between, is a political act. And this act forces architecture into current social, cultural and economic debates. For the discipline to be more responsive and engaged, architects must become more politically invested in the world.

Within the United States, there is not a more politicized space of healthcare than abortion clinics. Although abortion access is a federally guaranteed right by the Supreme Court Roe v Wade 1973 decision, clinics, as a space, have experienced inordinate numbers of protestors with sometimes fatal consequences over the past four decades. Due to the politicized nature of the spaces of abortion, I was drawn to examine what role architectural thinking could have on such spaces, and how space is defined, legislated, policed and accessed within such constraints. The research questions what architecture’s roles are in respect to these spatial conflicts. It reveals the invisible systems that have created uneven access across the country through state legislation. Depending upon where a person lives and her socio-economic

level, a woman’s ability to first reach to a clinic and second, afford the procedure, has developed into a radical patchwork of access for the more affluent and quite difficult, and sometimes, quite limited access for the remainder of women seeking care. States in the South and Midwest (Alabama, Mississippi, Kentucky, Louisiana, Texas, Oklahoma, New Mexico, North and South Dakota, Nebraska, Kansas, Utah, Pennsylvania, Virginia, Arkansas) have passed numerous and onerous laws that make abortion access more difficult: requirements from biased counseling, mandatory waiting periods, to physician-only laws legally requiring only physicians to provide the procedure and in some states, counseling, ban on publicly-funded buildings as a space for care, and most recently the change in building codes from medical facilities to ambulatory surgical centers (ASC). And these are only a few of the almost 30 plus laws that have been enacted since 1973. These Targeted Regulation of Abortion Providers (TRAP) laws legislate only the spaces of abortion. Medical practices that perform more invasive procedures such as dentistry, dermatology, colonoscopy, liposuction, and miscarriage care are not held to ambulatory surgical center requirements or have been grandfathered in so as not to have to meet these requirements altogether. Therefore, abortion is regulated to a greater degree although the procedure is far less invasive and statistically a safer procedure than other medical procedures.

Case Study: Texas ///

Texas has a long history of not supporting women’s reproductive healthcare beginning early in a young woman’s life. In middle and high school the sexual education standards only promote abstinence with limited state supported contraceptive services, resulting in the state having high rates of teen pregnancies and sexually transmitted diseases. Over the past several years, the state has become one of the most extreme examples of how geography radically affects access. According to Kinsey Hasstedt of the Guttmacher Institute, the situation is only compounded by one-quarter of all adult Texas women living below the federal poverty level and having the highest proportion of uninsured women.

Texas provides an important case study demonstrating how, through the rewriting of building codes, the built environment was manipulated by politicians, and used for political gain. Texas is not the only state enacting such laws; these tactics have also been used in several other states including Virginia, Louisiana and Alabama. These building code changes precipitated closures of almost half of the clinics throughout the state. During the 2013-2014 Texas legislative session, Texas passed some of the most severe abortion laws in the country. One aspect of House Bill 2 (HB2) that had a profound affect on clinics was the Texas state legislature mandating all abortion clinics to become ambulatory surgical center facilities — essentially requiring clinics to upgrade to hospital-like spaces. Some of these changes require renovations to create wider hallways, new or larger supply closets, full surgical suites with required clear floor areas, pre and post-operative spaces, circulation of patient flow in a one-way direction, more sophisticated heating and ventilating systems, as well as the installation of sprinkler systems. When added up, these are significantly expensive changes that shuttered almost half of the clinics across the state. Due to the extreme hardship and undue burden HB2 placed on Texas abortion providers and women seeking abortion care, Whole Women’s Health brought a suit against the state’s Department of Health Services to overturn the legislation. This case was closely watched because of its potential to have radical consequences for the future of women’s access to reproductive healthcare services across the United States. If the law were upheld, then other states that have been following in the footsteps of the Texas legislature would further disenfranchise millions of women across the country by creating such extensive difficulties in accessing abortion care if not almost entirely preventing access for the most vulnerable and economically challenged women. Therefore, much was riding on this decision.

Matrix of Texas Building Code ///

After speaking with several lawyers who argue before the courts on behalf of abortion providers, it became apparent that a series of diagrams visually illustrating what changes these rewritten building codes were creating would be useful material for lawyers to use in their support of reproductive healthcare providers. These diagrams are for the general public, laypeople and those not familiar with the language of building codes, and therefore, needed to be drawn in a quite simple and clear visual language. The newly required legislated spaces are listed, proximity of spaces that have been dictated by HB2 are drawn with minimum square footage requirements as well as stipulated circulation clearances. These changes were argued by both the Texas legislature and former Governor Rick Perry as ways to increase the safety of women’s healthcare, yet this has not been proven to be the case. These new restrictions only created greater hardships, severely reducing access. Nor did these code changes improve the life and safety of the built environment – something codes are required to do. In this research project, basic architectural analytic and diagramming skills are used for political engagement to counteract erroneous information and to provide a public service.

On the June 28, 2016, the Supreme Court decision for Whole Women’s Health et al v Hellerstedt, found Texas HB2 unconstitutional. The Court’s opinion (579 U.S. No. 15-274) states that the “two requirements [ambulatory surgical centers and admitting privileges for doctors] erect a particularly high barrier for poor, rural, or disadvantaged women.” The “surgical-center requirement “imposes an undue burden on the right of women throughout Texas to seek a previability abortion.” The Court wrote “risks are not appreciably lowered for patients who undergo abortions at ambulatory surgical centers as compared to nonsurgical-center facilities [and] women will not obtain better care or experience more frequent positive outcomes at an ambulatory surgical center as compared to a previously licensed facility.”

They also found that the state was requiring different spatial standards for abortion facilities than other medical facilities and would not waive any part of these requirements as has been done for almost two-thirds of the other covered facilities. The cost of renovating an existing clinic to meet ASC requirements is, as the Court states, “[…] significant […] undisputedly approach[ing] 1 million dollars,” and “most likely exceed[ing] 1.5 million dollars,” with “some […] clinics” unable to comply due to physical size limitations of their sites.” Additionally, the Court argues that the statistics on safety of abortion compared to other surgical procedures proves that the “surgical-center provision imposes “a requirement that simply is not based on differences” between abortion and other surgical procedures “that are reasonably related to “preserving women’s health”that “many of the building standards mandated by the act and its implementing rules have such a tangential relationship to patient safety in the context of abortion as to be nearly arbitrary.” In Supreme Court Justice Ginsberg’s concurring opinion, she writes that TRAP laws such as HB2 “do little or nothing for health, but rather strew impediments to abortion.”

Architectural expertise expanding potentials for practice ///

This example clearly demonstrates precisely why it is critical for architects to be involved in all aspects of the built environment — not only design but also its codes and regulations. In some states, those with no formal education or training in the built environment are the ones rewriting building codes. Why aren’t all architects in the US up in arms about those with no expertise are writing new building codes? Why is the profession just sitting by and letting this happen? The profession must becoming engaged in the politicization of space, otherwise we give away yet another aspect of our expertise.

The practice of architecture is much broader than just designing and constructing buildings. This ongoing research uses architectural knowledge to engage pertinent social and political issues. There are many ways we can use our knowledge, whether this is through design, drawing, code analysis, mapping or diagramming to make evident how the build environment is being changed and to what affects. What initially began as a research endeavor more concerned with the broader social and political issues of space, became a series of first design analysis and then opportunities for design. These tangential engagements became clear ways to address certain spatial problems I observed through site visits and interviews. Although this was not the intention of the project as I set out, one focused on extensive research, intervening in and designing within the built environment became a possible necessity and eventual outlet of the research process. I would be irresponsible if I did not follow through in responding to the design needs of two particular clinics or create the building code analysis. This process demonstrates the critical role research participates in uncovering design’s potential — especially when it is not evident it is even needed in the first place.

As discussed earlier, clearly abortion is one of the types of healthcare spaces at the forefront of the politics of healthcare in the United States. Bathrooms are another currently contested space. This past March 23, 2016 the North Carolina state legislature passed House Bill 2, Public Facilities Privacy and Security Act, requiring the use of public building bathrooms and changing facilities to be “designated for and used only by students based on their biological sex.” The law defines biological sex as that which is stated on a person’s birth certificate. People who identify differently than their birth certificate, the trans community, cannot use the bathroom based on one’s gender identify.

Because this law discriminates on the basis of sex, it is not upholding the 1964 Civil Rights Act. As the National Center for Transgender Equality has made public, there are a number of states attempting to do create similar legislation including Illinois, Kansas, Massachusetts, Missouri, Mississippi, Tennessee and Wisconsin. The US Department of Justice has stated that these laws are unconstitutional and will not be tolerated.

The discipline of architecture has much to offer in cases such as these. Not only can architects work with providers to create more well designed and supportive medical spaces, but also in this example of reproductive healthcare, architects provide ways to visualize spatial injustices. We can make these issues more apparent through our representational abilities. Through making such efforts visible, those arguing in support of women’s reproductive healthcare (or access to bathrooms) have a greater ability to describe and make evident how the alteration of the built environment may further disenfranchise millions of people across the country creating socially unjust spaces.