Distinctions, Exclusionary Mediations, and Inequalities: The Reproductive Health Governance of “Difficult Patients”

Abstract

The article examines the way the categorization of patients as “difficult patients” impacts their access to reproductive care in primary healthcare clinics. Using an ethnographic approach, it focuses on three public clinics in Rio de Janeiro and analyzes 57 interviews with health professionals conducted between 2015 and 2017. The analysis draws on intersectional approaches to inequality, reproductive stigmas, and the governance of vulnerable populations to show how the “difficult” label and its semantics, primarily applied to black and poor women who depend on public services, has led to a social differentiation of healthcare users based on reproductive stigmas and service eligibility from an assessment of their behavior. The notion of “difficult” combines with inadequate rules and decision-making by health clinic teams to pro-mote discriminatory experiences through exclusionary mediations in their access to reproductive healthcare. The findings contribute to a better understanding of the way exclusionary bureaucratic mediation transforms distinctions into inequalities.