Four on Friday: Let’s Talk About Sex, Baby!

1. CARAVAN, which is my new favorite Indian magazine, has a new piece out on sex selection by desi parents. I know I’ve covered this topic on my blog before, but this article—actually, it’s an excerpt from a book—makes a historical link that’s news to me: the connection between Western foundations and the World Bank in the 1960s and ’70s and population control using sex selection.

It started in the 1950s, when India was regarded as a “cauldron” to test population control measures; the thinking was, if it worked in India, it would probably work everywhere else. Rockefeller and Ford Foundation money started flowing into the country, along with funds from the World Bank and even the United Nations. The world population was growing fast, and one of the places it was growing the fastest was India. This was dangerous, because poor people were seen as more likely to lean toward Marxism. Mara Hvistendahl, the author of Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men, from which this article was adapted, writes:

The population control movement arose at the precise moment that Western powers were losing their grip over Asia, Africa and Latin America. Around the world, colonies were gaining independence, with Cold War tensions replacing imperialism. Many early population activists thus belonged to the US business and political elite. Big names included Hugh Moore, the millionaire inventor of the Dixie Cup; John D Rockefeller III, heir to the Rockefeller family fortune; Lewis Strauss, head of the US Atomic Energy Commission; and Will Clayton, former undersecretary of state. Rising birth rates, as this group saw it, would make countries more susceptible to communism at a time when the US urgently needed allies in Asia and Latin America. “We are not primarily interested in the sociological or humanitarian aspects of birth control,” Moore and Clayton once confided to Rockefeller. “We are interested in the use which communists make of hungry people in their drive to conquer the earth.”

So Indians became proxies in this Cold War battle. They started with the All India Institute of Medical Science, or AIIMS, in Delhi, the country’s most prestigious medical center. The Western envoys began teaching the doctors there how to perform amniocentesis, an invasive procedure which carries the risk of miscarriage. But it became so popular for sex determination that parents began calling it the “sex test.”

In their remarkable openness about the tests, it wasn’t simply that the physicians neglected to consider the ethics of sex selection in the face of widespread patient demand. No: not only did the doctors believe sex selection acceptable, they believed that by culling female foetuses they were making the world a better place. Shortly after the amniocentesis tests began, several AIIMS doctors published a paper in the journal Indian Pediatrics explaining the project as an experimental trial with potential to be introduced on a larger scale. Indian couples clearly desired sex selection, wrote Dr IC Verma and colleagues. And that interest, if tapped more widely, could be a boon for India—and the world:

“In India cultural and economic factors make the parents desire a son, and in many instances the couple keeps on reproducing just to have a son. Prenatal determination of sex would put an end to this unnecessary fecundity. There is of course the tendency to abort the foetus if it is female. This may not be acceptable to persons in the West, but in our patients this plan of action was followed in seven of eight patients who had the test carried out primarily for the determination of sex of the foetus. The parents elected for abortion without any undue anxiety.”

While the doctors defended their actions with cultural relativism—“This may not be acceptable to persons in the West”—their logic was a variation on Malthusianism, which India inherited from Europe. Verma and his colleagues aborted female foetuses in the name of population control.

The article goes on to detail the power and influence that the envoys from the Rockefeller Foundation and other wielded on India’s population policy—so much so that they were able to redefine the priorities for the country’s director of family planning and shift it from a holistic consideration of maternal and child health and population control to a focus on only the latter. And in 1975, when the then-Prime Minister Indira Gandhi declared a state of emergency and began forcibly sterilizing poor men in vast numbers, these scientists and philanthropists lined up to empty their pockets for her program.

Western experts later distanced themselves from the excesses of the Emergency, but records from the time show that many advisers supported, if not cheered, India’s fling with despotism. A World Bank official in Delhi at the time the Emergency began returned to Washington to urge that the bank increase its support for India’s family planning programme. The Indian government asked for $26 million from the bank, explaining it would use a portion of the money to build sterilisation camps in remote areas. The committee that considered the proposal turned it down—not because committee members were alarmed at the human rights violations being perpetuated with World Bank money, but because $26 million was, as one employee wrote to a colleague in the bank’s population division at the time, “disappointingly conservative”. Money came instead from UNFPA, which in 1974 had issued its largest grant yet to India, and the Swedish International Development Authority, which in 1976 contributed $60 million toward family planning in India. And World Bank money continued to flow into India. Between 1972 and 1980 the bank doled out $66 million in loans to the country for the express purpose of population control.

A few months after the committee considered India’s proposal, World Bank President Robert McNamara flew to India to make the bank’s support for the Emergency explicit. Arriving in Delhi as men were being forcibly rounded up for vasectomies, he met with Health and Family Planning Minister Karan Singh, who admitted the sterilisation campaign had entailed a few abuses. Still, McNamara was apparently unfazed, writing in a summary of his trip: “At long last, India is moving to effectively address its population problem.” When the archives of Western population control organisations were finally opened, the scholars who sifted through them might be forgiven for overlooking the role the organisations played in bringing sex-selective abortion to India. At a time when the president of the World Bank endorsed the forced sterilisation of millions of men, a few thousand voluntary abortions must have seemed like nothing.

2. About 10 days ago, the Institute of Medicine released a much-awaited report with their recommendations on how to strengthen preventive care for women, as asked by the U.S. Department of Health and Human Services (HHS). If the HHS approves these measures, then starting in January 2013, insurance companies would be required to cover them, without passing on the costs to their customers. The eight preventive health services the report recommends are:

• screening for gestational diabetes
• human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
• counseling on sexually transmitted infections
• counseling and screening for HIV
• contraceptive methods and counseling to prevent unintended pregnancies
• lactation counseling and equipment to promote breast-feeding
• screening and counseling to detect and prevent interpersonal and domestic violence
• yearly well-woman preventive care visits to obtain recommended preventive services

Importantly, it also stresses, “To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS consider adding the full range of Food and Drug Administration-approved contraceptive methods [my emphasis] as well as patient education and counseling for all women with reproductive capacity. Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy. Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.”

The Guttmacher Institute, a nonprofit dedicated to advancing sexual and reproductive health in the United States, said in its release about the IOM report:

Making contraceptive counseling, services and supplies—including long-acting, reversible methods (the IUD and the implant), which have high up-front costs—more affordable acknowledges the reality that cost can be a daunting barrier to effective contraceptive use. The evidence strongly suggests that insurance coverage of contraceptive services and supplies without cost-sharing is a low-cost—or even cost-saving—means of helping women overcome this obstacle.

In a year when the same Institute mapped the amount of restrictions on abortion that U.S. states enacted in the first half of 2011—162!—the IOM report comes as a relief. Now all the HHS has to do is approve it.

Abortion restrictions in 2011 by the Guttmacher Institute

3. In all the inflammatory talk among right-wingers of abortion and those who perform it as “murderers” and “baby-killers,” it’s worthwhile to go back to a 2010 article supported by The Nation Institute’s Investigative Fund—where I work—that just this past week won the Planned Parenthood Maggie Award. “Not A Lone Wolf,” by Amanda Robb, was published in Ms. magazine last May, and investigated the case of Scott Roeder, the man who killed abortion provider Dr. George Tiller in his Wichita, Kansas church for his work. The anti-abortion brigade’s chatter after the murder centered around Roeder being a “lone wolf,” i.e., acting alone, without the support of the larger anti-abortion community. But Robb showed that he relied on a network of supporters to carry out the killing, from longtime connections with members of the Army of God—a secretive organization that has bombed abortion clinics and carried out murders and attempted murders of doctors who provide abortion services—as well as with James Kopp and Paul Hill, both of whom have killed abortion doctors.

Kopp was the murderer of Dr. Barnett Slepian, the abortion provider whose death in 1998 shook Buffalo and the national pro-abortion community. It also prompted (my friend and colleague) Eyal Press to write a book, Absolute Convictions, about the killing and the movement behind it, and the death threat to his own father, Shalom Press, who also performed abortions in his Buffalo practice. After the killing of Dr. Slepian, Dr. Press was the only doctor left in the upstate city who offered abortion services—which he continued to provide as part of his normal gynecological practice, despite the danger. I highly recommend it.

4. Did anyone read the recent New York Times article about the progress in male contraception? There are several methods that are being tested, and some of them will be presented at an October conference by the Gates Foundation. Different methods use progestin and testosterone hormones, some use a male contraceptive pill that results in nonfunctional sperm, and others are testing a drug that blocks the production of retinoic acid, which is important for sperm production. (Funnily enough, this drug also acts as one that helps curb alcoholism; if you drink while you’re taking it, it will make you sick. Dr. Amory, who is one of the scientists behind this particular method, quipped to the Times, “The joke is if it weren’t for alcohol, no one would need contraception.”)

Wow, to imagine a day when women don’t bear the brunt of contraception. Right now, there are exactly two methods of male contraception: the condom and the vasectomy. Women have the birth control pill, the nuvaring, the patch, the IUD (intra-uterine device), the diaphragm, and tubal ligation. Am I missing any? The pill, the ring and the patch all have side effects, some serious, as they interfere with a woman’s hormones; the IUD is not recommended for everyone, and the diaphragm is no longer easily available and is hardly used by American women. When it comes to sterilization, vasectomies are much easier procedures than tubal ligations. The former can be accomplished in an outpatient procedure that takes 30 minutes and has a minimum of risk, as well as being up to four times cheaper than tubal ligations. Tubal ligation for women, however, requires hospitalization, general anesthesia, and is more often than not an intra-abdominal procedure with a longer recovery time. It also carries serious risks such as perforation of the intestine, infection, complications from anesthesia and even pulmonary embolism. It’s also way more expensive than a vasectomy.

So why is it that in the United States, according to a 30-year Center for Disease Control report from 1995 (couldn’t find a more recent government study, sorry!), women get tubal ligations one-and-a-half to two times more often than men get vasectomies? I’m sure a chunk of the blame lies with unwilling men, but it’s also incumbent on clinics and doctors to include men in discussions about contraception. (Informal poll of readers: How many of the women reading this blog took your male partners along to the doctor’s office when you discussed methods of contraception? And for the male readers—how many of you asked to accompany your partner, or were asked by her, on such a visit? And did you in fact go with her? This question, of course, assumes that you went to the doctor to discuss contraception when you were in a heterosexual relationship. Do let me know your answers in the comments.)

This discrepancy in responsibility was rather humorously captured in this Washington City Paper blog post last year by Amanda Hess. The post begins:

Allison, 26, and her boyfriend were having sex—an activity they had engaged in many times over the six months they had been dating—when her contraceptive vaginal ring fell right out of her vagina. Her boyfriend paused. He developed a sudden concern over the efficacy of the couple’s method of birth control. “He was like, ‘Oh, no. How is it going to catch my semen?’” Allison recalls.

Allison, it seems, had had ignorant partners before.

“I was dating a guy in college who knew that I was on the birth control pill. Of course, he was concerned about me getting pregnant,” says Allison. “So he said, ‘You know, you should take four or five of these a day—just take as many as you need to,’” she says.

And then there was Jenna:

Jenna had been living with her boyfriend for several months when he floated his own contraceptive theory. Jenna was taking her birth control pills continuously, meaning that she was skipping the pack’s built-in placebo pills in order to stop her period. At some point, her boyfriend discovered how she had managed to avoid the monthly ritual. “I was thinking you were just magical, like a unicorn,” he told her. “I mean, you hope one exists somewhere, but you never think you’ll get to live with one…a cool chick with no period drama that has sex all month long.” He added, “The guys thought I was making it up.” (Boyfriends could not be reached for comment for this story).

Hess quotes a study by the National Campaign to Prevent Teen and Unplanned Pregnancy, which surveyed single Americans of both sexes between the ages of 19 and 29 and found that men in general were much less informed about methods of contraception than women were. And the discrepancy in knowledge widened when it came to female contraceptives, so that 78 percent of men said they were clueless about birth control pills, as compared with 45 percent of women.

Contraceptives

Women shouldering the burden of contraception means more than just remembering to swallow a small pill every day. It is accompanied by a host of other responsibilities and costs: co-pays for gynecological visits, annual check-ups, the financial cost of contraception (and don’t forget that Viagra is covered by insurance companies, but not always birth control pills—though that might change if the HHS implements the IOM’s recommendations), not to mention the side effects, which can be myriad and major.

This has an impact on men, too. Their lack of choices for a long-acting, reversible contraceptive (LARC) means they must trust their female partners to take care of the contraception. And if it fails, as contraceptives sometimes do, they are supposed to be responsible for their children, whether they wanted offspring or not. I would think men would cheer a pill that gave them more control over reproduction. (And, it seems, they do. According to this 2009 article from Science Progress by Lisa Campo-Engelstein, a study showed that 55 percent of men would be willing to use contraception.)

But though the medical research community has been making noises about contraceptives for men for years, there is still nothing on the market. Campo-Engelstein suggests that this has to do both with gender perception (contraception is “women’s work;” women’s bodies are less complex than men’s; that men will not be willing to use methods that have side effects on their bodies, the way that women do; and more) and with the funding available for research.

The distribution of research and development money in the 1990s was as follows: 60 percent to high-tech female methods, 3 percent to female barrier methods, spermicides, and natural fertility control methods, 7 percent to male methods, and 30 percent to multiple methods, though mostly for women.[12] Researchers who would like to study male contraception often cannot due to a lack of funding. For example, Richard Anderson, a professor of clinical reproductive science at Edinburgh University, says that “most of the work [on male contraception] has been initiated by university investigators and the World Health Organisation. There has so far not been a lot of money from corporate companies.”[13]Despite positive findings on a male contraceptive pill, Anderson has not been able to conduct trials because no pharmaceutical company will financially support them.

In Hess’s post, Allison said, “I’ve been dating since high school, and it feels like the men that I date now have a very similar idea of birth control as the men I dated who were high school students. They get a preliminary idea in sex ed, and then there’s not really any education after that. Nothing ever changes.”

Let’s all, men and women, hope that this time, something will.

Tags: abortion, barnett slepian, birth control pill, condoms, contraception, eyal press, george tiller, guttmacher institute, healthcare, indira gandhi, institute of medicine, nuvaring, population control, scott roeder, sterilization, tubal ligation, vasectomies