Public health Indigenous women face extra barriers when it comes to reproductive rights Across Indian Country, advocates claim Indian Health Service is failing Indigenous women.

Indigenous women who experience sexual violence are finding little to no support at Indian Health Service (IHS) facilities, despite the fact that Indigenous women are twice as likely to experience sexual assault as other women in the U.S. Some IHS facilities lack rape kits altogether, and until recently, birth control was not widely available. Meanwhile, there are significant barriers to obtaining an abortion. Advocates argue that IHS is failing to live up to its federal responsibilities, but despite lawsuits, reprimands and regulations, the agency continues to drag its feet in achieving compliance.

“They don’t care,” said Charon Asetoyer, executive director of the Native American Women’s Health Education Resource Center (NAWHERC). “They don’t want to have federal agencies with any kind of abortion services.”

Jolene Yazzie/High Country News

A 2002 study published by the Native American Women’s Health Education Resource Center, a South Dakota-based nonprofit that advocates for Indigenous women, found that only 25 abortions were performed in the IHS system since 1976, when the Hyde Amendment was passed. (The Hyde Amendment prevents the use of federal funds to pay for abortion services, with rare exceptions.) That 2002 study is one of the few to track abortion statistics specifically among Indigenous women. High Country News filed a Freedom of Information Act request for more recent data from the Indian Health Service, but it has gone unanswered.

When clinics are able to provide an abortion, it comes with strict conditions: The procedure can only be performed in the case of rape or incest or when a woman’s life is in danger. Furthermore, IHS policy states that rapes must be reported within 60 days in order for women to receive abortion care.

“We know that most rape victims don’t report at all,” said Sarah Deer, a citizen of the Muscogee (Creek) Nation, who has been recognized for her work on reauthorizing the Violence Against Women Act. “So if they don’t make that report within 60 days, then they are no longer eligible for even that exception.”

IHS also requires signed documentation from a law enforcement agency and a health-care facility, along with a police report filed within 60 days of the incident. “Additionally, the incident in question must meet the definition of rape or incest as defined by law in the state or tribal jurisdiction where the incident was reported to have occurred,” the policy states. The Bureau of Justice Statistics, which tracks crime nationally as well as in Indian Country, reported that in 2016, Alaska Native and Native American women experienced higher rates of sexual violence than their white and Latinx counterparts did.

Access to contraceptives such as Plan B, commonly known as the “morning after pill,” is also an issue at IHS clinics. Plan B, which acts as emergency birth control when other methods fail, is an over-the-counter medication available at pharmacies like CVS or Walgreens. Native women sometimes don’t use those pharmacies, choosing instead to obtain their medication at IHS clinics. “Every other woman in this country has access to it except for Native women,” said Asetoyer. “We jump through all kinds of hoops to get it.”

The Plan B pill wasn’t available at IHS clinics until a 2010 lawsuit from the Native American Women’s Health Education Resource Center forced IHS to make it available. Two years later, NAWHERC found that more than half of tribally run health centers were out of compliance when it came to providing the medication. Even after those findings, NAWHERC found that barriers remained. Some clinics still required a prescription, while almost a third failed to stock Plan B at all.

“Why should we be denied access to Plan B when it is perfectly legal?” said Asetoyer.

Some of the facilities that did not provide Plan B were in Oklahoma, particularly in the Creek, Chickasaw and Shawnee nation health centers. Emergency contraceptives were not available, allegedly because they were not in stock.

The treaties that tribal nations signed with the United States specifically stated that, in exchange for land cessions, the federal government would provide medical care and supplies for tribal members and citizens.

The Indian Health Service maintains that it is understaffed, and that every year, the amount of money the federal government allocates to hire, train and staff its clinics shrinks. Long waiting times and delayed care are part of Indian health care. Asetoyer says that, even with budget cuts, this lack of care is a violation of the federal government’s trust responsibility. The treaties that tribal nations signed with the United States specifically stated that, in exchange for land cessions, the federal government would provide medical care and supplies for tribal members and citizens. The Indian Health Service did not comment for this story by publication.

The Indian Health Service was cited by the Government Accountability Office in 2011 for its slow response time to sexual assault. The GAO examined the ability of the Indian Health Service and tribally operated hospitals to collect and preserve the medical evidence needed for criminal prosecution in cases of sexual assault and domestic violence. It also analyzed what, if any, special challenges these hospitals face in collecting and preserving such evidence, and what factors besides medical evidence contribute to the decision to prosecute such cases.

The Government Accountability Office made three recommendations: Develop a new plan and policies for treating sexual assault; provide better training for hospital staff who handle sexual assault victims; and update the process followed when medical staff are subpoenaed to testify.

In 2017, Amnesty International stepped in and filed a Freedom of Information Act request asking about the number of rapes and sexual assaults reported each year, as well as the number of rape kits clinics had on hand and how often they were requested. The group also asked how often Indian Health Service staff were asked to testify, and how many had done so on behalf of a client. If a request to testify was declined, Amnesty wanted to know on what grounds. The worldwide human rights organization also inquired about the number of sexual assault nurse examiners and whether victims were offered emergency contraceptives at the time of their visit. But according to Tara Dement of Amnesty International, this request was denied.

Despite this setback, Amnesty and NAWHERC continue to lobby for more accountability when it comes to these essential services. Recently, they met with members of the staffs of Rep. Deb Haaland, D-N.M., and Sen. Elizabeth Warren, D-Mass., urging them to keep pressure on IHS to provide requested information and make sure these services are available to Indigenous women.

“This is not a fulfillment of U.S. obligations under its own treaties or under international human rights standards,” Dement said.

Allison Herrera is Xolon Salinan from the Central Coast of California and serves as editor of climate and environment for Colorado Public Radio. Follow @alisonaher

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