When it comes to freely-chosen parenthood, we sometimes miss the big picture.

Imperfect people and imperfect contraceptives and imperfect pregnancy processes fail; and when they do, access to abortion is a moral good.

Like health knowledge and birth control options, the power to end an ill-conceived pregnancy helps young people to form the families of their choosing with the best timing and circumstances available to them—improving health and wellbeing for kids and families and whole communities.

But family planning tools and services lead to human flourishing only when people are truly free to make their own decisions, and that is more complicated than it sounds.

Picture a multiracial teen who is a high school junior in Tuskegee, Alabama—let’s call her Jean. Jean’s evangelical church condemns women in leadership roles while glorifying motherhood. Her working-class parents, who married young because of a surprise pregnancy tell her, “Don’t make our mistakes.” They want her to go to college, but she lacks role models of relatable professional women. Her soft-spoken boyfriend gets teased about being queer and pushes her to have sex without condoms. Her state forbids sex ed teachers to talk about anything other than abstinence and STIs. While visiting a doctor for a soccer injury, Jean asks hesitantly about the pill, and the doctor waxes eloquent about why she should get an implant instead. But her black grandmother—traumatized by the infamous Tuskegee experiments—has warned her against medical procedures. For a young woman like Jean, the cacophony of images and voices in her head can make it almost impossible for her to know what she wants or how best to take care of herself.

Relationship dynamics, authorities, social institutions, biases, or life circumstances can create pressures that overwhelm a person’s ability to live by their own heart, mind, and conscience. When these pressures strongly push a person to have or not have a child, they are called reproductive coercion.

Reproductive coercion takes many forms, each of which can make it difficult or even impossible for young people to create the family of their choosing with the partner of their choosing at a time of their choosing.

Provider Coercion—For many reproductive health professionals and advocates, what comes to mind when they think about coercion is concern that a health provider may pressure someone to have a procedure they don’t want, like an IUD or tubal ligation—or just any kind of birth control. This can happen because a provider is overly enthusiastic about the good that can come from family planning or overly judgmental about a person having babies under adverse circumstances.

Provider coercion is top-of-mind for many  because it is a kind of coercion that can be readily addressed and because of bad history linking it to race and class. At different times and places during the 20^th century, including in the U.S., doctors sterilized handicapped, poor, or minority women without their consent, or with consent given under duress, or at times when a woman might be foggy—like in the immediate aftermath of giving birth. Violations like these, though now rarer, still happen; and they have left some communities with a deep mistrust of reproductive health care. Though modern long-acting contraceptives are swiftly and reliably reversible, tubal ligations are not, and traumatic stories of unwanted sterilization hang over all birth control types and providers.

While forced or pressured sterilization has traumatized victims and entire communities, it is not the most common kind of provider coercion. More often women of all races and all around the world have been denied birth control, either certain methods or all methods, by doctors, pharmacists, nurses or other practitioners who had their own opinions about whether a woman should be having sex—especially a teen or unmarried woman. Older women in the U.S. tell of doctors in the 1960s refusing to give them the pill without a husband’s permission. More recently, pharmacists have refused to give emergency contraception to women with valid prescriptions. In conservative cultures today, many single women dare not even try to buy contraceptives because they expect to be scolded, refused and maybe outed as sexually active. In other words, young women who want one of life’s most cherished experiences, sexual intimacy and pleasure, are forced to roll the dice on mistimed or unwanted pregnancy.

Religious or Ideological Coercion—The world’s biggest religions arose during the Iron Age, and all of them to a greater or lesser degree indoctrinate women into traditional gender roles and childbearing. If you look closely enough, women in the Hebrew Bible are chattel—economic assets belonging to first a father and then a husband—and their primary value lies in their ability to produce offspring of known paternity, especially male heirs. The New Testament book of 1 Timothy says that “women will be saved through childbearing.” Some Christian sects, including conservative Catholicism and the Protestant Quiver-full movement exert tremendous pressure on women to “let go and let God” manage their family planning, even if that threatens a woman’s health or a family’s ability to make ends meet.

Forced Marriage—One way religions and other cultural institutions coerce women to breed is by giving a young woman’s parents the right to “give” her in marriage—often to an older man, which further increases the power differential. Absent birth control, early marriage means early childbearing, and young wives who don’t get pregnant immediately may be seen as defective. Some Muslim leaders have fiercely defended the right of parents to marry off their adolescent and even pre-adolescent daughters, arguing that Mohammed married his wife Aisha at age 6 or 7 and consummated the marriage at age 9 or 10. For child brides, consent is not even a consideration. Forced marriage means forced sex and, in the absence of birth control, forced pregnancy.

Partner Coercion—Because children were long counted as economic assets of their fathers, traditional cultures sometimes view a large family as a form of wealth or a sign of status. When manhood is associated with virility, a woman who actively manages her fertility may be seen as denying her husband his due. For this reason, women sometimes request “clandestine” contraceptives, methods like the shot or IUD that can’t be detected by a controlling husband who sees procreation as his prerogative. Even in more egalitarian cultures, men sometimes seek to prove their manliness by getting a woman pregnant; and pressure from a male partner may win out when a woman has mixed feelings or is unsure whether she feels ready.

Partner coercion can and does cut both ways. In modern Western cultures young men increasingly care a lot about fatherhood, meaning engaged, tender relationships with their children. Many who enjoy sex in their late teens or early twenties, also want to wait and become fathers when the time and partnership feel right. Since women have better contraceptive options than men do by far, many men depend on their female partner to manage birth control. And some women violate this trust either because they want a baby or they want to lock the man into a partnership.

While women are particularly vulnerable to unconsented sex, men are particularly vulnerable to unconsented parenthood because their birth control options are shamefully limited. One in eight couples relying on condoms will face a surprise pregnancy within twelve months (contrasted with one in a thousand couples relying on the female implant); and abortion decisions—though often made together—default to the most affected person, the woman. When women are denied access to abortion they can be forced into motherhood. When partners disagree about whether to have an abortion, men can get forced into fatherhood.

Violent Coercion—Rape isn’t just about sex. Through history, men have raped women not only because aggression is arousing, but also to force pregnancy and childbearing. Chieftains, sultans, and kings kept harems of concubines—sex slaves—not just for pleasure, but also to produce hundreds or even thousands of offspring. Slave owners raped slaves to produce more slaves.

During tribal conflict and wars, rape of the enemy group’s women is used by men to assert dominance over other men and to humiliate them. But it has also been used to “spread the seed” of the aggressors, imbedding their genetics among the conquered people. In the Bible’s Midianite story, the Israelites are commanded by God’s messenger to keep virgin girls as booty of war. They are given specific instructions on how to ritually purify them before sex. But God’s messenger commands them to kill the non-virgin females, presumably because they can’t be counted on to produce offspring of the right lineage.

State Coercion—Governments sometimes treat the child-bearing power of a woman’s body as a strategic asset of the state, using pro-natalist rhetoric or policies to out-populate competing groups or increase the supply of cannon fodder and cheap labor. Blogger Jack Matirko recently quipped that “Abortion bans are a socialist takeover of the means of production of the labor force by the state.” Anti-abortion motives vary, but Matirko is not altogether wrong. In 1966, in an attempt to swell his country’s population, Romanian dictator Nicolae Ceaușescu made abortion illegal and offered financial incentives and hero status to women who bore large families. With birth control almost impossible to obtain, orphanages swelled with unwanted children, causing immense suffering. Peru under Fujimori took the opposite tack, pressuring or physically forcing tubal ligations on thousands of poor, mostly indigenous mothers.

China has engaged in reproductive coercion on both sides of the equation. The one child rule, which brought with it coerced sterilizations and abortions, is now being replaced by policies that press women to bear more children. Why? Because the country is struggling to manage a demographic shift that was sped up by the earlier rule. Administrators can’t figure out how to support old people in the absence of an intergenerational Ponzi scheme, so they have fallen back on pushing women to have babies.

Structural Coercion—Structural coercion refers to institutional or economic factors that deny women in particular, but also men, the means to manage their own fertility. Most commonly this mean a lack of accurate reproductive health information and affordable, reliable contraceptive options—or lack of access to safe abortion. It can also mean a lack of pre-conception and pro-conception support for healthy pregnancy when a couple desires a child. For young people who have access to good birth control but who are otherwise struggling to make ends meet, lack of economic opportunity can erect barriers to parenthood. More often, poverty pushes in the opposite direction. Around the world, structural coercion forces millions of young women to have mistimed or unwanted babies and denies others the ability to have wanted children.

In the United States, for complicated reasons, conservatives promote both kinds of structural coercion—fostering conditions that make it harder for young people to prevent or end unwanted pregnancy while at the same time denying affordable support for wanted pregnancies and parenthood. Progressives generally support reproductive freedom, but some advocates are so anxious to avoid provider or state coercion that they foster structural coercion by making it harder for vulnerable women to access to the most reliable contraceptives—IUDs, implants, and tubal ligations. (IUDs and implants are twenty times as effective as the pill but also are difficult to self-remove so more suceptible to abuse than woman-controlled methods.)

Making Space for Choices

When we talk about choice, we often mean access to safe, legal abortion. Abortion access may be a moral good—I deeply believe it is—but choice is about more than abortion. Reproductive freedom means being free from coercion, but some young people, instead of being free, are getting buffeted on all sides. The bad news is—it’s complicated. The good news is this: There are lots of ways we can work to reduce pressures that might otherwise drown out a young person’s ability to form and fulfill their own dreams about parenthood.

Valerie Tarico is a psychologist and writer in Seattle, Washington. She is the author ofTrusting Doubt: A Former Evangelical Looks at Old Beliefs in a New Light and Deas and Other Imaginings, and the founder of www.WisdomCommons.org.  Her articles about religion, reproductive health, and the role of women in society have been featured at sites including The Huffington Post, Salon, The Independent, Free Inquiry, The Humanist, AlterNet, Raw Story, Grist, Jezebel, and the Institute for Ethics and Emerging Technologies.  Subscribe at ValerieTarico.com.