Researchers are not realizing the ramifications of the
study of Norplant or any contraceptives on minority
populations. From poor women in developing countries, to
poor women of color in the U.S., to inner city
African-American teenagers, the approach is to control
rather than educate. There is a call for researchers to
learn how all of these women live in their communities, and
for researchers to learn these women's values and adapt to
them, in order to allow these women respect and autonomy.
Norplant was originally developed to expand all women's
reproductive freedom. Now government agencies, and the
judiciary are using Norplant to limit freedom and control.
Feminists argue, however, that Norplant can still be used to
liberate black teenage women, and allow them greater choices
in their lives, by allowing them to break from traditional
roles. The feminist argument is in response to members of
the black community who see Norplant as another way for the
ever-controlling white majority is attempt to limit the
black population, which is in line with the history of abuse
of African-Americans in medical research. This annotated
bibliography contains 18 articles published between 1991 and
1996. The articles cover issues including the coercive use
of Norplant by offering increased financial assistance for
implantation, the use of Norplant as a condition of
probation, and the constitutional ramifications of such
uses. Further, all the articles outline how these uses of
Norplant affect poor African-American women the most and how
this is consistent with the history of discrimination and
abuse of African-Americans through medical research.Included
in the annotated bibliography are several law review
articles and several articles written to address the topic
of "Long-acting Contraception: Moral Choices, Policy
Dilemmas" by the Hastings Center which is a medical
ethics research institute. Also included are a few articles
from medical journals and one article which includes a
footnote outlining an example of abusive Norplant use in
Indonesia.
Annotations
Randall, Vernellia R., Slavery,
Segregation and Racism: Trusting the Health Care System
Ain't Always Easy! An African American Perspective on
Bioethics, 15 St. Louis U. Pub. L. Rev. 191 (1996).
In this article, Vernellia Randall gives (to me, at
least, a 35-year-old, white, middle-class, educated
woman) an eye-opening overview of historical events
that have shaped African-Americans' fear and distrust
of the health care system. The experiences of slavery,
segregation, racism and lack of power have created a
unique African American bioethical perspective. This
perspective keeps African-Americans from getting health
care treatment. Family planning initiatives have been
described as another attempt to reduce the Black
population. Beginning in the 1930's, the government
funded the first birth control clinics to lower the
Black birthrate.1 in the
1960's the government expanded the subsidization of
family planning clinics to reduce the number of welfare
recipients.2 In the 1970's
some doctors would only deliver babies or perform
abortions on African American women if they consented
to sterilization.3 Others
were threatened with loss of welfare benefits if they
did not agree to sterilization.4
In the 1970's and 1980's, officials tricked
African-American welfare recipients into having their
daughters sterilized.5
Today, the federal government still subsidizes
sterilizations for women on Medicaid, but will not pay
for abortions.6 On
December 10, 1990, the United States Food and Drug
Administration (FDA) approved the general use of
Norplant, a long-acting contraceptive. All fifty states
have incorporated Norplant into their welfare systems,
either reimbursing the cost of Norplant to women on Aid
to Families with Dependent Children, or offering a cash
bonus to those who are implanted with the device.7
Norplant proposals which condition probation on the use
of Norplant are aimed at poor, African-American women
based upon the concept that poor, Black women are
'deviant' and less deserving of motherhood than white
women.8 To have
reproductive choice, African-American women, among
other things, need freedom from coerced or ill-informed
consent to sterilization.9
[Back]
Dinerman, L. M., et. al., Outcomes
of Adolescents Using Levonorgestrel Implants vs. Oral
Contraceptives or Other Contraceptive Methods, 149
Arch. Pediatr. Adolesc. Med. 967 (1995).
This article describes a study done to answer the
question, "Which method of birth control is most
effective for use among adolescents?". The study
population included 166 sexually active
African-American adolescents between the ages of 12 and
18 at an inner-city, hospital-based adolescent and
teenaged mother and baby clinic. The percentage of
teenagers who have had sexual intercourse has steadily
increased in the past few decades. Adolescents often do
not use contraception or they use methods
inconsistently.10 The
results of this study, based on self-reporting, showed
that pregnancy rates were lower with implant
contraceptives than with oral contraceptive or other
methods, condom use was similar between the groups, and
the number of sexually transmitted diseases was about
the same for all groups. The main reason given for not
using oral or other contraceptive methods consistently
was forgetting, while the reason for having the
implants removed was because of 'bothersome' side
effects. While not found in this study, a potential
negative side effect is a reduced use of condoms to
protect from sexually transmitted diseases. The editor
of the journal notes: "Since we have not been able
to implant the good sense that would result in
abstinence until a person is mature enough to handle
parenting, implanting levonorgestrel seems to be a
reasonable, although far less attractive,
alternative".11 [Back]
Spaulding, MD, Cora,Adolescents'
Use of Levonorgestrel Implants For Contraception,
42 The Journal of Family Practice, 349 (April, 1996).
Cora Spaulding, MD, provided a one-page review of
the study summarized above from the Archives of
Pediatric Adolescent Medicine. The recommendation given
in this review is that given the effectiveness of the
implants (ie, fewer reported pregnancies, high
continued use rates) despite frequent reports of side
effects, physicians should consider implants as an
option for sexually active adolescents, particularly
with those reporting previous pregnancy or difficulty
complying with other birth control methods. Caveats
include uncertainty whether the study results can be
generalized to other adolescent populations and
remembering to emphasize condom use for sexually
transmitted disease prevention since only a minority of
teens consistently use a condom. [Back]
Callahan, Joan,
Contraception or Incarceration: What's Wrong with this
Picture?, 7 Stan. L. & Pol'y Rev. 67 (Winter,
1995-1996).
This author focuses on equal protection concerns
regarding ethnic and class discrimination. At the time
of writing this article, four Norplant cases had
occurred with issues of ethnicity and class in each.
Child abuse goes on in families of all ethnic
backgrounds and classes, and in the past, other types
of cases protecting fetal rights or pregnancies have
been more likely for African-American, Asian, or
Hispanic women. Further, the author points out risks
associated with Norplant that were not evident at the
start, making true informed consent an issue. Removal
of the implant can also be difficult, the article
quotes a Planned Parenthood Medical Director describing
Norplant removal as "It's a nightmare".12
In conclusion, what is needed is a political will to
create social conditions in which women are not likely
to produce children they are not able to care for, and
which will provide them help in caring for the children
they do have. Stress is a significant factor in child
abuse, and that a break from child care, and from a
cycle of pregnancy can relieve stress. Jail does not
provide support for developing meaningful autonomy and
good parenting skills. Education from the early years
on these topics would be a start. I think that the
medical doctors who are doing the adolescent studies
should read this article! [Back]
Moskowitz, Ellen H., et. al., Long-acting
Contraceptives: Ethical Guidance for Policymakers and
Health are Providers, 1/1/95 Hastings Center Rep.,
Vol. 25, No. 1 (1995).
Given that long-term contraceptives threaten
individual reproductive freedom and discrimination on
the basis of class, race, and gender, this article
suggests an alternative view to the issues. These
authors call for responsible decision-making in the
context of relationships; individual interests and the
interests of others can be considered together. Two
important conclusions are made: First, access to a
range of effective contraceptives is important; Second,
it is foreseeable that unwanted, mistimed pregnancies
will cause substantial harm. A woman's own interests,
as well as others' interests, will be compromised.
Counselors need to give accurate, complete information
about contraception, but not necessarily value-neutral.
Discussions must be value-laden to include the
adolescent or adult's own current and future interests,
as well as to others to whom they owe a responsibility
to now or in the future. The article concludes by
suggesting guidelines to policymakers and health care
providers concerning access to contraceptives, pricing
(Norplant kits have been sold for $365), insurance,
public assistance, research directives, informed
consent. The article also recognizes that no evidence
suggests that use of long-acting contraceptives will
rehabilitate criminal offenders, deter their future
criminal acts, or deter criminal acts of others. [Back]
Powderly, Kathleen E., Contraceptive
Policy and Ethics: Illustrations from American History,
1/1/95 Hastings Center Rep., Vol. 25, No. 1 (1995).
This article gives an overview of the history of
contraceptive methods in the United States. The theme
of this article is that from the late nineteenth
century until the present, birth control has been
subject to the abuses of poor women and women of color.
Although empowerment of women is a worthy goal in the
context of long-acting contraceptives, racism and
eugenics have been consistent issues in controlling
fertility. Programs and initiatives must be sensitive
to community concerns. Expanding women's reproductive
choices can only be achieved if we maintain an
awareness of the successes and failures in the history
of the birth control movement.13
[Back]
Brown, George, Long-acting
Contraceptives: Rationale, Current Development, and
Ethical Implications, 1/1/95 Hastings Center Rep.,
Vol. 25, No. 1, (1995).
This article gives a brief overview of the rationale
behind contraceptive research, explaining that much
research was initiated in response to international
anxiety about rapid population growth, especially in
developing countries. This anxiety received much
greater emphasis than did concerns about reproductive
health of individuals.14
It takes approximately ten to twenty years. The
long-term contraceptives which are being introduced
today are a result of these rapid population growth
concerns, and do not mirror today's concerns over
sexually transmitted disease prevention. The emphasis
was on providing poor women of developing countries
alternatives to sterilization which would be long-term,
inexpensive, non-coitus related, and few side effects.
The thought today is that a return to user-controlled
methods should be urged, to increase women's autonomy,
reduce dependence on the medical system, and to help
prevent HIV and STD's. (Increasing women's autonomy is
always a worthy goal in my book; imagine!) The article
discusses several types of contraceptives under
research now for both men and women and urges
researchers to include ethical considerations at the
country level. This article is interesting because of
the research rationale concerning poor women in
developing countries, but the author did not elaborate
on the ethical issues for which researchers should be
responsible. [Back]
Dresser, Rebecca, Long-term
Contraceptives in the Criminal Justice System,
1/1/95 Hastings Center Rep. Vol. 25, No. 1 (1995).
This article discusses the use of Norplant as a
punishment by analyzing the goals of punishment in
society. The author states that a device created to
expand women's reproductive freedom has quickly become
a potential instrument of state power. The author notes
that Norplant is not a perfect punishment but that
neither is imprisonment, in response to child abuse.
Rather, it is suggested that if the government were
truly serious about protecting children, other measures
would be implemented including high-quality counseling
and parent training programs, prenatal care and full
family health care and planning for poor women and
their families. Further, the author discusses the
disproportionate impacts of coercive use of Norplant,
certainly for women in general, and undoubtedly on
poor, women of color. [Back]
Steinbock, Bonnie, Coercion
and Long-term Contraceptives, 1/1/95 Hastings
Center Rep., Vol. 25, No. 1 (1995).
This is an interesting article which analyzes the
differences between offers and threats and applies this
analysis to the situation where women on public
assistance are offered cash bonuses if they use
Norplant. The Norplant situation is then compared with
the "Dollar-A-Day" program sponsored by
Planned Parenthood in Denver, where if teenage girls
come to a meeting once a week they are given seven
one-dollar bills.15 The
goal is to reduce repeat pregnancy in teens who are
mostly black and Hispanic. In neither situation are the
women forced to participate, but where financial
incentives are involved, some argue that financial
pressures will force individuals to make reproductive
choices contrary to their own values and preferences.
The article summarizes each side of the argument
whether it is coercive to offer financial incentives to
women on public assistance to use Norplant, in trying
to decide whether these women's liberty is being
expanded or contracted. [Back]
Robertson, John A., Norplant
and Irresponsible Reproduction, 1/1/95 Hastings
Center Rep., Vol. 25, No. 1 (1995).
This author discusses the use of Norplant in the
context of reproductive responsibility, realizing that
it is a touchy subject. The article begins by
discussing four issues involved in reproductive
responsibility of individuals: the importance of
reproduction to the person reproducing, the ease or
difficulty of avoiding that reproduction, the burdens
that reproduction will cause resulting offspring, and
the burdens or costs imposed on society and others.16This
author takes the view that the state has
responsibilities to protect citizens and to facilitate
exercise of others' rights, and in doing so the state
is often called upon to pay for the costs of
reproduction. The author discusses compulsory
contraception to prevent congenital disease, in which
Norplant is not an appropriate solution, and also
discusses compulsory contraception for the retarded, in
which Norplant may be a solution. The author states
that procreation is a basic right, but not an absolute
right, bringing along with it a moral obligation to
reproduce responsibly. However, the author concludes
that Norplant should only be made available for
voluntary choosing. I included this article because the
author seems to sideline the issue of discrimination
toward targeted groups. The author condones state
action of informing women of the Norplant option,
subsidizing its use, and offering financial incentives
to using it, and stating that this is not compulsory
action. I thought it would be good to know how people
think of the Norplant issue without thinking of the
discriminatory ramifications involved, thus the
inclusion in this bibliography. [Back]
Nelson, Hilde Lindeman, and Nelson, James
Lindemann, Feminism,
Social Policy, and Long-acting Contraception,
1/1/95 Hastings Center Rep., Vol. 25, No. 1 (1995).
This article takes the perspective that aggregating
birthgiving with a seriously disproportionate amount of
responsibility for child rearing has contributed to
women's oppression, and that society is structured to
this result.17 The
authors analyze Norplant as a condition of probation
and conclude that the Norplant offer is harmful and
disrespectful to women. However, the authors also
analyze Norplant in the schools and come to a different
conclusion. The authors outline a situation in which a
clergy group in Baltimore, speaking on behalf of the
African American community, raise serious reservations
about using Norplant with teenagers. The group puts out
a brochure which states that culture in the black
community sees the birth of a baby as a joyous occasion
and most are taken care of quite well; the majority
culture may not understand their community values; the
majority culture should leave procreation management to
their communities so that their values can be promoted.18
However, the authors take the view that the clergy may
not understand the individual narratives of these
women's lives, and that the clergy are assuming that
the young girls in the black community have the primary
parenting responsibility is to men's advantage in our
society as a whole. The authors' view is that
oppression of women is endemic in all cultures, and
that Norplant may allow teenage girls to protection
from the damaging aspects of our gender-based system in
which we live. [Back]
Burrell, Darci Elaine, The
Norplant Solution: Norplant and the Control of
African-American Motherhood, 5 UCLA L.J. 401
(Spring, 1995).
This author outlines the historical devaluing of
African-American motherhood, arguing that this is still
the case. Dominant society devalues poor
African-American mothers and sees them as a threat to
social order. The U.S. has become more and more
concerned with 'the welfare mess' and with the growth
of the Black underclass.19
Therefore, Norplant if not being used as an option to
enhance Black women's reproductive freedom, but as a
method of social control to curtail their reproductive
liberty.20Norplant is
offered to African-American women on AFDC because of
the fear that crime and violence of the inner city will
destroy America. African-American women are seen as
less deserving of motherhood than poor white women in
the Midwest, or poor, white women in the Appalachians.21
Offering Norplant as a condition for probation ignores
the conditions of pregnant addicts' lives which cause
them to abuse drugs during pregnancy. Further, Judges
may see themselves as social reformers and Norplant is
their tool of reform, used against inner city
African-Americans. When white women are more likely to
use drugs, but Black women are more likely to be tested
and reported for drug use.22
This author also discusses Norplant use in high schools
as being based on the some motives: fear of
African-American women's deviance and threat to social
order.23 Contraception is
needed, but not at the expense of losing focus on why
teenage girls engage in sex to begin with. All teens
may need a boost of self-esteem rather than a new
contraceptive. [Back]
Albiston, Catherine, The
Social Meaning of the Norplant Condition:
Constitutional Considerations of Race, Class, and
Gender, 9 Berkeley Women's L.J. 9 (1994).
This article provides an excellent review of
discrimination against poor women of color, the use of
Norplant, and the constitutional arguments against
coercive use of Norplant. The author outlines three
factors contributing to discriminatory prosecution of
poor women of color: 1) poor women of color are more
likely to be under government supervision, through
public agencies, and so their drug use is more likely
to be discovered 2) racist attitudes of health
professionals and social workers predispose them to
report women of color disproportionately 3)
prosecutorial efforts focus on drugs used by women of
color even though drugs used by white women also harm
fetuses.24 The author
argues that Norplant cannot replace the institutional
support that poor women of color need, and that poor
women of color have poor health and inadequate access
to health care, making them serious risks for use of
Norplant as a condition of probation. Further, Norplant
does not protect women from AIDS, thus sending a
message that as long as drug addicts do not burden
society by giving birth to damaged children, they are
disposable.25 The author
also points out that Norplant does nothing to prevent
abuse of children already born. This article analyzes
the fact that a poor woman of color challenging the
Norplant policy will be unable to find an equal
protection theory that allows her to argue all her
race-, class-, and gender-based claims together.26
The author argues that a new constitutional theory
should be used: poor women of color may challenge the
Norplant policy as a class as a discriminatory
infringement of their procreative liberty by
restricting their ability to have children, requiring
the state to show a compelling interest rather than
only an important one; then, equal protection should be
used to force the state to present compelling interests
justifying the burden on women but not men.27This
allows the focus to be on the classifications rather
than on the state's interest. [Back]
Vance, Jeanne L., Womb
for Rent: Norplant and the Undoing of Poor Women,
21 Hastings Const. L.Q. 827 (Spring, 1994).
The author analyzes the racial premise of Norplant
legislation concerning poor African-American women and
other poor minority women. This article argues that by
conditioning special assistance grants on Norplant
implantation, the state is impinging upon a woman's
constitutional right to have children and to choose a
contraceptive method. The author argues that these
Norplant bills should fail strict scrutiny and even the
undue burden test, as well as equal protection
challenges. The author calls for courts to discern
social realities that the legislation imposes on poor
women because they are underrepresented in the
judiciary. [Back]
Bernier, Barbara L., Class,
Race, and Poverty: Medical Technologies and
Sociopolitical Choices, 11 Harv. BlackLetter L.J.
115 (Spring, 1994).
The author argues that there is ample evidence to
show that the Hippocratic Oath has often been ignored
when patients are people of color. The article gives a
historical review of the medical abuses of African
Americans during slavery and post-slavery, including
the Tuskegee Study. The author argues that the
requirement of proof of intent before racial
discrimination is deemed unlawful under equal
protection legitimizes discriminatory policies
resulting from structural ('unconscious') racial bias.28
The author also discusses the racial politics of
procreation, including the eugenics movement, penal
sterilization, and Norplant. The media portrays only
African-Americans as being drug- and welfare-dependent
because most drug-dependent white Americans have
private insurance, therefore, they are practically out
of reach. In footnote 138, the author describes the
Norplant situation in Indonesia. The availability of
Norplant seems to be shifting from encouragement to
coercion. The Indonesian government has been sending
teams of officials out to villages to recruit women to
use Norplant, being trained to put Norplant in, but not
well-trained to remove it. Under pressure of quotas,
the safari teams do not always check to see if the
women are currently pregnant before implanting, and
failing to get fully informed consent.29
I have read brief abstracts of other articles to know
that Norplant is being used and studied in many
countries around the world, and I would be interested
to know if there are any other cases of abusive or
discriminatory uses of Norplant in other countries. I
did not find any articles detailing the use of Norplant
as discriminatory in other countries, aside from this
footnote. Perhaps a review of newspaper articles would
be useful, as this is where the information for
footnote 138 was found. [Back]
Board of Trustees, American Medical Association, Requirements
or Incentives by Government for the Use of Long-Acting
Contraceptives, 267 JAMA 1818 (April 1, 1992).
This article outlines the position of the Board of
Trustees of the American Medical Association on
court-ordered use of Norplant and federal financial
incentives for using Norplant. It is the Board's
position that court-ordered insertion probably violates
several constitutional rights including the right to
refuse medical treatment, prohibition against cruel and
unusual punishment, right to procreate. The Board
believes that there may be less intrusive ways to
protect children from abuse from their parents, and
that the state would have difficulty showing that
court-ordered Norplant is narrowly tailored to further
a compelling interest. Further, they argue that the
alternative to Norplant being incarceration prevents
the acceptance of probation terms from being voluntary,
thus consent is illusory. The Board takes the position
that child abuse may be better prevented by providing
better services such as day-care programs and
parenting-skills training. The Board also recognizes
that women who use illicit drugs during pregnancy are
more likely to be poor or black and that the poor are
disproportionately subject to child abuse reporting.
The Board also recognizes that Norplant insertion and
removal are expensive and these costs should be covered
by Medicaid in all states. The Board also takes the
position that while the government is not obligated to
provide welfare, it may not condition welfare benefits
on waiver of important fundamental rights. The article
concludes by warning that long-acting contraceptives
may be medically contraindicated and that assessing the
health risks of using Norplant is outside the purview
of the courts and legislature. [Back]
Rutherford, Esq., Charlotte, Reproductive
Freedoms and African American Women, 4 Yale J.L.
& Feminism 255 (Spring, 1992).
The article represents the opinion of advocates and
experts who persuaded the NAACP Legal Defense Fund to
address the issue of African-American women's
reproductive health. African-American women want and
need reproductive freedoms that range from terminating
unplanned and unwanted pregnancies to quality prenatal
care, and delivering babies in healthy circumstances.
Included in the list of reproductive freedoms is access
to a full range of contraceptives and sex education and
counseling. Norplant should be an available choice for
poor African-American women, but cash incentives should
not be allowed, which sets the wrong tone. Limiting
procreative rights of poor African-American women will
not eliminate the root causes of poverty which are
racism, sexism, and classism; ie., poverty will not be
solved by merely having fewer children.
30 The author also provides an interesting
discussion of Title X regulations. [Back]
Roberts, Dorothy E., Punishing
Drug Addicts Who Have Babies: Women of Color, Equality,
and the Right of Privacy, 104 Harv. L. Rev. 1419
(May, 1991).
The author argues that the government may choose to
help women have healthy pregnancies, or to punish women
for prenatal conduct, but not both. This article
provides the perspective of poor Black women and
details that prosecution of drug-addicted mothers
constitutionally violate racial equality and the right
of privacy by intruding on the women's autonomy overt
reproductive decisions and creating invidious
government standards for childbearing. The article
gives a background on the state's punitive response to
drug-addicted mothers, a history of devaluation of
Black women as mothers, and constitutional
characterizations of the state's actions. [Back]
Endnotes:
1. Randall, Vernellia R., Slavery,
Segregation and Racism: Trusting the Health Care System
Ain't Always Easy! An African American Perspective on
Bioethics, 15 St. Louis U. Pub. L. Rev. 191,
191-224 & footnotes (1996).
2. Id.
3. Id.
4. Id.
5. Id.
6. Id.
7. Id.
8. Id.
9. Id.
10. Dinerman, L. M., et. al., Outcomes
of Adolescents Using Levonorgestrel Implants vs. Oral
Contraceptives or Other Contraceptive Methods, 149
Arch. Pediatr. Adolesc. Med. 967, 967-972 (1995).
11. Id.
12. Callahan, Joan,
Contraception or Incarceration: What's Wrong with this
Picture?, 7 Stan. L. & Pol'y Rev. 67, 67-69,
75-77 (Winter, 1995-1996).
13. Powderly, Kathleen E., Contraceptive
Policy and Ethics: Illustrations from American History,
1/1/95 Hastings Center Rep., Vol. 25, No. 1, 1-6
(1995).
14. Brown, George, Long-acting
Contraceptives: Rationale, Current Development, and
Ethical Implications, 1/1/95 Hastings Center Rep.,
Vol. 25, No. 1, 1-8 (1995).
15. Id.
16. Robertson, John A., Norplant
and Irresponsible Reproduction, 1/1/95 Hastings
Center Rep., Vol. 25, No. 1, 1-10 (1995).
17. Nelson, Hilde Lindeman, and
Nelson, James Lindemann, Feminism, Social Policy,
and Long-acting Contraception, 1/1/95 Hastings
Center Rep., Vol. 25, No. 1, 1-6 (1995).
18. Id.
19. Burrell, Darci Elaine, The
Norplant Solution: Norplant and the Control of
African-American Motherhood, 5 UCLA L.J. 401,
401-408, 430-444 (Spring, 1995).
20. Id.
21. Id.
22. Id.
23. Id.
24. Albiston, Catherine, The
Social Meaning of the Norplant Condition:
Constitutional Considerations of Race, Class,
and Gender, 9 Berkeley Women's L.J. 9, 9-30,40-57
(1994).
25. Id.
26. Id.
27. Id.
28. Bernier, Barbara L., Class,
Race, and Poverty: Medical Technologies and
Sociopolitical Choices, 11 Harv. BlackLetter L.J.
115, 115-137, 143, footnote 138 (Spring, 1994).
29. Id.
30. Rutherford, Esq., Charlotte, Reproductive
Freedoms and African American Women, 4 Yale J.L.
& Feminism 255, 255-266 (Spring, 1992).
