Applying a Reproductive Justice Lens: Bioethical Reflections on Vulnerability, Antimicrobial Resistance, Sexual Health, and Reproductive Health

In November 2024, I had the opportunity to do a short research visit to Kenya hosted by Dr Joshua Kimani (University of Manitoba; University of Nairobi).  The visit combined the research interests of two Kone Foundation funded projects: Microbial Lives: Practices of New Human-Microbial Cultures and Technology, Ethics and Reproduction: Controversies in the Era of Normalization (ReproEthics). Deeply touched and intellectually inspired by the visit, I share some bioethical reflections on vulnerability, antimicrobial resistance, gender, and sexuality, and reproductive and sexual health in a reproductive justice framework. 

 As a queer feminist bioethicist collaborating with sociologists, I have been working with issues of gender, sexuality and health with a contribution to rethinking vulnerability. I was honored to discuss vulnerability with those who are considered the most vulnerable in global health research and management: cis-female sex workers, men having sex with men and gay men living in the Global South. However, from an ethical perspective, that vulnerability often derives heavily from internationally funded projects targeting HIV/AIDS  as they set the rationale and ethos with which resources are dispersed. Despite progress and further good intentions with using them as platform for both medical and social interventions, a more nuanced understanding of vulnerability is needed to benefit those considered vulnerable – and those currently excluded by the platform. In what follows, I discuss some observations to ground that understanding, building on ReproEthics’ collaborative thinking on reproductive justice.

What does reproductive justice mean to the intersections of gender, sexuality, health and vulnerability in a global health context? Why is sex work an issue for reproductive justice? What are the needs of queer communities from a reproductive justice viewpoint?  How do politics and ethics of gender and sexuality, reproductive and sexual health, vulnerability and  antimicrobial resistance intertwine, and why is this all very relevant to Finland?

Background: Drafting a Reproductive Justice Lens for Finland  

I had the pleasure of working in the project Technology, Ethics and Reproduction: Controversies in the Era of Normalization (2019-2024) on ethics of reproductive technologies: ethical evaluation essential to the acceptance, regulation, dissemination, participation in, and marketisation of reproductive technologies.  Ethical deliberation is done by all kinds of actors in the arena of reproductive technologies, such as policy makers, bioethicists, medical professionals, market players, patients, and donors of reproductive tissue and of reproductive labor. The project ReproEthics brought together methods, perspectives, and scholars from social science and the academic field of bioethics in order to examine ethics. Bioethics can be defined as considerations of the moral, societal, and political issues brought about by sickness, health, care, and environment: what kind of ontological assumptions these concepts build on, what kind of knowledges they entail and how should ethical issues around them be resolved.

ReproEthics explored a wide variety of cases of technological practice that have, or may in the future, become normalised as uncontroversial in some (delimited) cultural contexts. The project included four members – principal investigator, sociologist and gender studies scholar Riikka Homanen; senior researcher, medical anthropologist Mwenza Blell; PhD candidate and later postdoctoral researcher, bioethicist Tiia Sudenkaarne; and PhD candidate Sanna Poelman.  It also included three affiliate members: PhD candidate in sociology Ronja Tammi, PhD candidate Kaisa Naskali and Masters student Joren Buyck.

During the years working with the project, we developed unique case analysis on for example ethics of surrogacy, gamete donation and transgender health. We also mapped out connections between race, racism and fertility in the past and present ruins of the Finnish welfare state. Our findings lead us to galvanize a reproductive justice framework into this ethos and to interrogate bioethics and biopolitics around reproduction.

Reproductive justice is explicitly trans-inclusive and centered on the experiences of marginalised people (Blell & Sudenkaarne 2024, 606). It reorients focus from abstract freedoms, legal frameworks, and questions of access to a specific technology such as abortion or IVF. Instead, reproductive justice invites a broader view: it includes the right for families to care for one another in safe environments, free from state and personal violence (ibid). Reproductive justice keeps birthing rights, obstetric violence, eugenic practices, environmental justice, prisons, and sexual/reproductive health education in the same frame (Daniel, 2021; see also ibid.). Thus, in this framework, reproduction goes hand in hand with violence and is riddled with vulnerabilities often invisible to, or unfathomed by, white normalcy (Blell & Sudenkaarne 2024, 607).

Applying the Reproductive Justice Lens on AMR, Sex Work and Reproductive and Sexual Health

In November 2024, I was already working with Microbial Lives (2019-2024) funded by Kone foundation, thinking about antimicrobial resistance (AMR), and how in a human health perspective, some people are more vulnerable to it than others. AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death (WHO). Yet there are varied layers of vulnerability that make you more likely to experience the most damaging effects of AMR as they are most severe in extreme scarcity (MacPherson 2022). Further, it is often the case that medical and bioethics in their ethical analyses only cover some aspects of the phenomena while not taking on the dilemmic construction of these aspects. One key dilemma is the division between global North vs. South, in which racism and colonialism have integrated with hygiene and morality in the moral economy of antibiotics (cf. Meek 2024). They entangle with  AMR stewardship,  the aim for coherent set of actions to use antibiotics “responsibly” (see e.g. Dyar et al 2017). What counts as responsible is a source for ethical and practical dilemmas. At a policy level, the design of internationally salient solutions that are able to steward AMR’s interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward (Kirchhelle et al 2020; Sariola et al 2022). Yet what is at stake in AMR stewardship is too often the antibiotics while within human health alone,  the drivers of AMR are connected to social problems such as non-existing basic healthcare (Sariola et al 2022). Moreover, while HIV/AIDS continues to be a serious issue, infection-wise it is by far not the only one threatening the health of those considered key populations (Chandra 2024; Boothe 2020). While the “key” in key populations refers to groups most vulnerable to HIV/AIDS, understanding their complex vulnerabilities requires social scientific and bioethical analyses of both the conceptual and practical spheres of those vulnerabilities, a constant site of political struggle (cf. Oinas 2019; see also Luna 2019). So instead of focusing on misuse of antimicrobials by the framing of antimicrobial stewardship, the focus should be on resistant infections (Will 2018).

In a future publication, together with Microbial Lives principal investigator, sociologist Salla Sariola with whom I visited Nairobi, we discuss how gendered, sexualized, racialized and marginalized people are more prone to AMR vulnerabilities, including but not limited to drug resistant gonorrhoea, and that these vulnerabilities require a queer feminist framework. Well established in global health literature but unfairly met in policy, cisfemale sex workers, cismen having sex with men, gay cismen and transwomen are prone to sexually transmitted infections, and this should be perceived as a mix of injustices including the realms of reproductive health, sexual health, social justice and reproductive justice. 

For cisfemale sex workers, the unfair distribution of caring duties is a leading reason for sex work, in a social reality where day wages is the most prominent way of making a living, poverty subjecting them to a myriad of vulnerabilities. As there are no governmental child support or strong legal support for paternal financial liability, women with children often care for them under social and material circumstances that leave themselves desperately lacking of care. This is vulnerability and injustice stemming from cis- and heteronormativity and patriarchy, associating women with caring duties based on their gender while men, in a binary system, are free to cater to their own needs first. This also extends to caring for older relatives and friends.  Patriarchy also places the moral stigma of sex work solely on the women, making them vulnerable to violence from both their clients and the police (see e.g. Tamale 2011), despite the fact that in most African countries sex work is not criminalized per se.

In terms of antibiotics, there is a paradoxid reality of both lack of access (MacPherson et al 2022) and over-prescription (Broom et al 2023). The notion of AMR stewardship that antibiotics are vulnerable (cf. MacPherson et al 2022) formulates an ethos of antibiotics, not people as vulnerable into the moral economy of antibiotics. In this moral climate, self-medication with unprescribed antibiotics to compensate for lack of health care access (Denyer Willis & Chandler 2019) and the pressure to have sex without condoms either for the extra cash incentive clients often offer or for the threat of violence if the sex workers refuse create a dynamic of vulnerability too often failed to recognize as such. Yet moral blame for this behavior, further made complex by the use of preventive antibiotics (Doxy-PEP) for STDs,  falls solely on the sex worker, “appearing woefully ignorant about the proper use of antibiotics, an ignorance that is portrayed as threatening to the global health order (Meeks 2024, 2).    

From a reproductive justice viewpoint, untreated gonorrhea and chlamydia with pelvic inflammatory disease (PID) as their aftermath, are source of infertility for cisfemale sex workers. We spoke to a few women who were ostracized  by both families and fellow sex workers for their inability to conceive. The fact that a woman was doing sex work without the necessity of providing for her children made these women be perceived by some as sexually promiscuous, threatening the moral order of sexuality and gender and thus requiring shunning as abnormal by some sex workers. This added a double-stigma to the psychological, universally damaging effects of involuntary childlessness. Patriarchy and gender normativity further fueled by fierce pronatalism affecting all sexual and reproductive health policy, a reproductive justice lens to map out and try alleviate such vulnerabilities is crucial with one of the most intense debates among African feminists occurs around interpretations of motherhood and its relationship with patriarchal culture (cf. Udenigwe et al 2023).

The Kenya Sex Workers Alliance (KESWA) is an umbrella body for the sex workers led groups and organisations dedicated to strengthening the voices of sex workers and empowering their health and human rights in Kenya. Sex workers of Kenya are active to protest particularly against various forms of criminalization falling on their work, and raising awareness for their daily issues. With the slogan ’sex worker rights are human rights’, activists at places like SWOP Ambassador operate under constant risk of violence (e.g. Mbuyi 2016). They document violence against sex workers for criminal cases and even arrange funerals for members of the community who have been abandoned by their families.

Vulnerebilities of Queer Communities

In the key populations paradigm, cis-MSM and gay cismen are receiving services and resources through the HIV/AIDS platform while extremely scarcely in the scale of Africa as a whole. While vitally important and the platform itself financially minimized by the current changes in global politics, a similarly dedicated analysis of bioethical justice issues and a more nuanced understanding of vulnerabilities would greatly benefit both groups. The effects of lack of basic healthcare, self-medication and threat of violence are at the core of this dynamic, too. Moreover, young age and social media expose to blackmail and threat of violence from within the community, which was a substantial concern for some of the people we spoke to.  

Looking at other positions of the queer community, it is obvious that the HIV/AIDS platform, while crucial on its own right, excludes those not considered key for its spread. Particularly the organization Minority Women in Action raised the issue that lesbian and queer women are not able to access the same resources through global health funding apparatuses as they can’t make their case using the HIV/AIDS platform. Trans women are to some extent recognized as having specific health needs in terms of transition treatment that some NGO-operated clinics help with, but as the same does not go for trans men, it can be argued that this claim is also motivated by the aforementioned platform. More intersectional analysis of queer vulnerabilities  recognizing the different positions within the queer communities, is desperately needed, as is seeking queer forms of living that are locally indigenous for empowerment outside the Western paradigm.  It also worth noticing that forms of commercial sex, often a way to negotiate lack of basic needs e.g. homelessness, further complex the vulnerabilities experienced by queer communities.  

Conclusion

Alex Broom and colleagues (2023, 7) discuss how in relation to AMR and vulnerability, bodies and their vulnerabilities reflect, in nuanced and often elusive ways, histories of colonization, global capitalism, and dynamics of care throughout the life course such as access to welfare and the unfair distribution of caring duties. Hence it is crucial to consider the entanglement of  gendered, sexualised, racialised and marginalised vulnerabilities, AMR, reproductive and sexual health in a reproductive justice framework.

Despite warranting multifaceted research due to its complex, political and both local and global nature, sex work persists as an issue for reproductive justice because the realm of biological reproduction is an integral part of the dynamic that maintains the vulnerabilities within it. The moral stigma around sex work should be neutralized from sex workers and health campaigns should be targeted to the general public where their clients come from as they are more often the source for risky behavior e.g. refusing condoms. Further research is urgently needed to target involuntary childlessness among cisfemale sex workers as they are rendered vulnerable from both their assumed peers and the general community with no options to improve their situation, often leading to depression and even suicide attempts based on the experiences we encountered in Kenya. Equally urgent is the support of sex work activists and political campaigns against gender-based violence and femicide that sex workers are the most vulnerable to. All this research and support should follow the best practices of participatory research, seeing the community – in this case, the sex workers – not as a source of data but as the best authority on what their needs are and justifying research by attending to as many of those needs as possible.

Yet another urgent gap in research are the varied needs of queer communities from a reproductive justice viewpoint. Some of the people I had the pleasure talking to said they have married their queer friend – for example a lesbian woman marrying a gay man – in order to maintain the acceptance of the overall community and to be able to have children they both wanted, with equal agreement that both find sex and romance elsewhere. While this type of practice has always been around everywhere as a coping strategy for queer folks and obviously does not constitute safeguards for queer family making in the same way as equal marriage opportunities would, it is perhaps more reasonable to support these types of social arrangements and offer queer-affirming counseling to such families than to promote a Western, medicalised assisted reproductive technology model. It is also crucial to note that people make these arrangements in constant threat of criminalizing, punitive and marginalizing legislation, homosexuality punishable by death for example in Uganda neighboring Kenya. During my visit, people were fearing the advancement of the Family Protection Bill aiming to outlaw same-sex relationships, LGBTQI+ activities, “public cross-dressing” and related advocacy campaigns. There is also push to disallow the registration of LGBTQI+ organisations in Kenya, which would have detrimental effects on the work of the organizations we visited. Against this backdrop, the struggle for queer-affirmation is a burning political issue. While reproductive technologies are available in Kenya, the number of people ever being able to access them is very narrow, constituting a reproductive justice issue of its own.

Politics and ethics of gender, sexuality, vulnerability and  antimicrobial resistance are extremely relevant to Finland, too, through processes of colonization ethos and particularly racialised capitalism. As a Nordic welfare state under collapse, the dynamics of racial capitalism have become intertwined with the moral economy of antibiotics in which pharmaceuticals have come to occupy the position of innocence and purity rather than making claims for the lives of those dealing with the most dire consequences of AMR experienced in already extreme scarcity (Meeks 2024; McPherson et al 2022).  

Working in these two Kone funded projects has offered me a unique nexus of reproduction and AMR, mapping out lacunas for further research. Part of that future work is strengthening a reproductive justice viewpoint in Finland. This means for example acknowledging reproductive justice issues in sexual and reproductive health institutions and services based on current data on health disparities connected to other findings on inequality (cf. Fina et al 2021; Malmberg 2023), and promoting AMR stewardship that keeps various forms of justice –social, reproductive but also more-than-human – in the same framework.

Acknowledgements

I would like to thank Kone Foundation for research and travel funding. I would like to wholeheartedly thank MD Joshua Kimani and his team, particularly our unparallel Anto, all the NGOs I visited and everybody who took the time and effort to share their experiences. Unable to evaluate the threats even exposure through pseudonyms could cause, I have made the decision to anonymize almost all encounters and thus, am only able to publish a very small fragment of all that would be well worthy of public awareness. I very much hope I can return to this work in the future. 

References

Blell, M.  & Homanen, R. (2025). Repropolitical Anxieties and Injustice in Finland’s Haunted Data “Goldmine”. In The New Reproductive Order: Changing In-Fertilities across the Globe. Franklin, SB and MC Inhorn (Eds). New York: NYU Press.

Blell, M., & Sudenkaarne, T. (2024). Ghosts in the machine: Black feminist and queer critiques of reproductive justice in Finland. Journal of Lesbian Studies, 28(4), 603–621. https://doi.org/10.1080/10894160.2024.2393563

Boothe, M. A. S., Comé, C., Semá Baltazar, C., Chicuecue, N., Seleme, J., Chitsondzo Langa, D., Sathane, I., Raymond, H. F., Fazito, E., Temmerman, M., & Luchters, S. (2020). High burden of self-reported sexually transmitted infections among key populations in Mozambique: The urgent need for an integrated surveillance system. BMC Infectious Diseases, 20(1):636. https://doi.org/10.1186/s12879-020-05276-0  

Broom, A., Peterie, M., Ridge, D., Lafferty, L., Kenny, K., Broom, J., Kelly-Hanku, A., Treloar, C., & Applegate, T. (2023). Sex, drugs and superbugs: The rise of drug resistant STIs. SSM: Qualitative Research in Health, 4, 100310. https://doi.org/10.1016/j.ssmqr.2023.100310.

Chandra, S., Broom, A., Ridge, D., Peterie, M., Lafferty, L., Broom, J., Kenny, K., Treloar, C., & Applegate, T. (2024). Treatment ‘cultures’, sexually transmitted infections and the rise of antimicrobial resistance. Sociology of Health & Illness, n/a(n/a). https://doi.org/10.1111/1467-9566.13832 

Daniel, M. (2021). The social movement for reproductive justice: Emergence, intersectional strategies, and theory building. Sociology Compass, 15(8), e12907.

Denyer Willis, L., & Chandler, C. I. R. (2019). Quick fix for care, productivity, hygiene and inequality: Reframing the entrenched problem of antibiotic overuse. BMJ Global Health, 4(4), e001590. https://doi.org/10.1136/bmjgh-2019-001590.

Dyar, O.J., Huttner, B., Schouten, J. & Pulcini, C. (2017). What is antimicrobial stewardship?

Clinical Microbiology and Infection, 23(11): 793-798. https://doi.org/10.1016/j.cmi.2017.08.026.

Fina, S., Heider, B., Mattila, M., Rautiainen, P., Sihvola, M.-W. and Vatanen, K.

(2021). Unequal Finland: regional socio-economic disparities in Finland.

Saatavilla osoitteessa https://feps-europe.eu/wp-content/uploads/2021/04/Unequal-Finland-Regional-socio-economic-disparities-in-Finland.pdf. Viitattu 25.4.2025.

Kirchhelle, C., Atkinson, P., Broom, A., Chuengsatiansup, K., Ferreira, J.P., Fortané, N., Frost, I., Gradmann, C., Hinchliffe, S., Hoffman, S.J., Lezaun, J., Nayiga, S., Outterson, K., Podolsky, S.H., Raymond, S., Roberts, A.P., Singer, A.C., So, A.D., Sringernyuang, L., Tayler, E., Rogers Van Katwyk,  S. & Chandler, C.I.R.. (2020). Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy. BMJ Global Health 5:e003091. doi:10.1136/bmjgh-2020-003091. 

Luna,  F. (2019). Identifying and evaluating layers of vulnerability: a way forward. Developing World Bioethics 19: 86–95. https://doi.org/10.1111/dewb.1220.

MacPherson, E. E., Reynolds, J., Sanudi, E., Nkaombe, A., Phiri, C., Mankhomwa, J., Dixon, J., & Chandler, C. I. R. (2022). Understanding antimicrobial resistance through the lens of antibiotic vulnerabilities in primary health care in rural Malawi. Global public health, 17(11), 2630–2646. https://doi.org/10.1080/17441692.2021.2015615.

Meek, L. A. (2024). Shit voyeurism, anti-blackness, and the spherical: rendering antibiotic use in Africa. Catalyst: Feminism, Theory, Technoscience 10(2): 1–26

Mbuyi, M. (2016). A report on study of violence against sex workers in Nairobi, Kenya. Kenya Sex Workers Alliance https://keswa-kenya.org/keswa-profile.html. Viitattu 25.4.2025.

Oinas, E. (2019). HIV Politics and Structural Violence: Access to Treatment and Knowledge. In: T. Vaittinen, & C. C. Confortini (Eds.), Gender, global health and violence : Feminist perspectives on peace and disease. London: Rowman & Littlefield, 89-114.

Malmberg, K. (2023). “Kaikilla ei ole varaa maksaa sellaisia summia: Suomessa gynekologia tarvitsevat naiset on jätetty yksityisen hoidon varaan. Helsingin Sanomat 12.10.2023.

Manyau, S., Dixon, J.; Mutukwa, N., Kandiye, F.,  Palanco Lopez, P.,  MacPherson, E.E.,  Ferrand, R.A. & Chandler, C.I.R. (2022). Antibiotics and the biopolitics of sex work in Zimbabwe.  Medical Anthropology 41:3, 257-271, DOI: 10.1080/01459740.2022.2037083.

Sariola, S., Butcher, A., Cañada, J.A., Aïkpé, M. & Compaore, A. (2022). Closing the GAP in antimicrobial resistance policy in Benin and Burkina Faso. mSystems. 30;7(4). doi: 10.1128/msystems.00150-22.

Sudenkaarne, T. & Blell, M. (2022). Reproductive justice for the haunted welfare state: race, racism and queer bioethics in Finland. Bioethics 36(3): 328-335.

Sudenkaarne T. (2024). A queer feminist posthuman framework for bioethics: on vulnerability, antimicrobial resistance, and justice. Monash Bioethics  Review 42(1):72-88. https://doi.org/10.1007/s40592-024-00192-4.

Tamale, S. (2011). Paradoxes of sex work and sexuality in modern-day Uganda. In: S. Tamale (Ed.) African Sexualities, a Reader. Oxford: Pambazuka Press, 145-174.

Udenigwe, O., Okonofua, F.E., Ntoimo, L.F.C. & et al (2023). Seeking maternal health care in rural Nigeria: through the lens of negofeminism. Reproductive Health 20(103).  https://doi.org/10.1186/s12978-023-01647-3.

WHO. Antimicrobial resistance. https://www.who.int/health-topics/antimicrobial-resistance. Viitattu 25.3.2025.

Will, C.M. (2018) Editorial: Beyond behavior? Institutions, interactions and inequalities in the response to antimicrobial resistance. Sociology of Health and Illness 40: E1-E9. https://doi.org/10.1111/1467-9566.12735.