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The Impact of the Use of Norplant on Minority Communities

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The Impact of the Use of Norplant on Minority Communities

Annotated Bibliography

JEAN SPRING
3nd Year Law Student
Health Care Law
The University of Dayton School of Law
Spring 1997

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.

The following articles are included in this bibliography:

Adolescents' Use of Levonorgestrel Implants For Contraception

Class, Race, and Poverty: Medical Technologies and Sociopolitical Choices

Coercion and Long-term Contraceptives

Contraception or Incarceration: What's Wrong with this Picture?

Contraceptive Policy and Ethics: Illustrations from American History

Feminism, Social Policy, and Long-acting Contraception

Long-acting Contraceptives: Ethical Guidance for Policymakers and Health are Providers

Long-acting Contraceptives: Rationale, Current Development, and Ethical Implications

Long-term Contraceptives in the Criminal Justice System

Norplant and Irresponsible Reproduction

Outcomes of Adolescents Using Levonorgestrel Implants vs. Oral Contraceptives or Other Contraceptive Methods

Punishing Drug Addicts Who Have Babies: Women of Color, Equality, and the Right of Privacy

Reproductive Freedoms and African American Women

Requirements or Incentives by Government for the Use of Long-Acting Contraceptives

Slavery, Segregation and Racism: Trusting the Health Care System Ain't Always Easy! An African American Perspective on Bioethics

The Norplant Solution: Norplant and the Control of African-American Motherhood

The Social Meaning of the Norplant Condition: Constitutional Considerations of Race, Class, and Gender

Womb for Rent: Norplant and the Undoing of Poor Women


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 LindemannFeminism, 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 AssociationRequirements 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).

 
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