Numerous social and political issues have influenced fertility control in the modern world.
INTEREST GROUPS AND FAMILY PLANNING. Providers of Family Planning Services. Family planning services in the United States are offered by both private and public agencies. Public providers of family planning services at the local level include public health clinics in hospitals or neighborhood health centers, school-based clinics, Medi-caid managed-care organizations and hospital-based clinics. At the county, state, regional and national levels, various arms of government are involved with the setting of policy for these publicly supported clinics and in devising formulas to disburse funding. The major conduit for public funding of family planning services is Title X of the Public Health Act of 1970. Title X has never allowed funding for abortion services, however.
In the private sector, abortion and family planning services are offered both by for-profit and not-for-profit clinics, managed care organizations and by private physicians. The not-for-profit Planned Parenthood Federation of America, Inc., with affiliates across the country, continues to be one of the most important providers of family planning services in the private sector.
In theory, the public and private components of the family planning delivery system share similar goals: the dissemination of contraceptive services and education under a public health model, which includes the prevention of HIV infection and other sexually transmitted diseases as well as services specifically rendered to control fertility. The relationship between the public and private components is quite complicated and intertwined, however. Family planning services, like other publicly provided social services in the United States, are typically delivered through a system that relies at least partly on private agencies, or "subcontractors," rather than directly by the government itself.
In addition, family planning became intensely politicized in the United States after the election of Ronald Reagan in 1980. Since then, the agendas of public and private providers of family planning services have often been at odds. Difficulties with Title X-funded programs illustrate these contradictions. A significant proportion of Title X-funded services in many communities across the country is provided by Planned Parenthood, which is also a prime target of those who are politically conservative because of the organization's visibility as an abortion provider. Political appointees within the Department of Health and Human Services, which oversees Title X and related services, have, at times, been aligned with political groups committed to the defunding of this program, because of some conservatives' opposition to family planning programs. The number of publicly funded family planning programs and clinics across the country has declined; this decline reflects the bitter ideological wrangling over the concept of publicly funded family planning (Ettinger, 1992; Scott).
In 2002, nearly five million women received health care services at family planning clinics funded by Title X. They were predominantly young, poor, uninsured, and had never had a child. Seventy-one percent of women using Title X-funded clinics are 20 years of age or older and 63 percent are white. Sixty-five percent have incomes at or below the federal poverty level. It is estimated that these clinics are the only source of family planning services for more than 80 percent of the women they serve (AGI, 2002a; Kaeser et al; Planned Parenthood).
The Women's Movement. Since the re-emergence of a visible women's movement in the United States in the late 1960s, various groups associated with the movement have been forceful advocates for family planning and abortion services. The new feminists have demonstrated a keen interest in issues of reproductive rights and sexuality (Joffe, 1986). The campaign to make abortion legal and accessible was a major focus of the feminist movement in the 1960s. During the 1980s, when a woman's right to a legal and safe abortion was threatened, women's organizations played a highly visible role in pro-choice activities, working closely with such organizations as Planned Parenthood and the National Abortion Rights Action League.
With respect to other reproductive issues, however, the relation of sectors of the women's movement to its abortion allies has been more complex. At times, the responses of some feminist health activists to prevailing contraceptive practices and new contraceptive innovations have conflicted with sometime allies, such as Planned Parenthood. These activists, for example, raised doubts early on about the safety of oral contraceptives, objected to testing new contraceptive technologies on women in developing nations and, more recently, voiced reservations about the likely social abuses of Norplant, a long-acting, implantable contraceptive device (Seaman; Gordon, 1976; Moskowitz and Jennings).
The Pro-Family Movement. Beginning in the 1970s, a movement of sexual conservatism—the "pro-family" movement—became a significant presence in family planning politics (Petchesky; McKeegan). This movement's main concern has been the breakdown of sexual morality in contemporary society, as evidenced by high rates of abortion, adolescent pregnancy, out-of-wedlock births, and sexually-transmitted diseases. For sexual conservatives, widely available family planning services—especially those supported by public funds—represent a temptation to break with traditional morality (Marshner). Though the pro-family movement is most visible in anti-abortion activity, its interests and interventions extend to a broad range of reproductive and sexual matters—contraceptive services, sex education, adolescent pregnancy prevention efforts, and HIV prevention (Joffe, 1986; Nathanson).
Family planning services for adolescents have been a major focal point of pro-family activity (Joffe, 1993). Conservative activists have persuaded legislators in a number of states to adopt parental notification and consent rules for teenagers seeking abortions, and have sought regulations that would include parental notification policies for federally funded clinics providing contraceptive services.
The "gag-rule" controversy, which has spanned the presidencies of Ronald Reagan through George W. Bush, is further illustration of the efforts of conservatives to link attacks on abortion to those on family planning. Originally written as an administrative guideline during the Reagan administration, the gag rule forbade employees in Title X-funded family planning clinics to provide counseling about abortion options, even when women asked for such information. For many within the healthcare community and the public at large, this ruling raised concerns about free speech for health professionals. In the space of several years, the gag rule was upheld by the Supreme Court, overturned by congressional legislation, and promptly vetoed by George H.W. Bush, under intense pressure from conservatives. In one of his first acts after taking office in 1993, Bill Clinton abolished the gag rule, under similar pressure from the pro-choice and family planning communities. On his first day in office, George W. Bush restored the Reagan—era gag rule for international family planning programs. This is a pattern that is likely to continue, illustrating the strong relationship between politics and women's health issues, especially those involving fertility control (Planned Parenthood; RowBoat).
Welfare Conservatives. In contrast to the pro-family movement, whose defining issue is the breakdown of sexual morality and traditional families, "welfare conservatives" are concerned about the rising welfare costs resulting from adolescent pregnancies, illegitimate births and failure of fathers to make child support payments. Welfare conservatives have made a number of policy proposals that either mandate use of contraception as a condition of receiving welfare or other financial incentives for such contraceptive use, that penalize recipients financially for having additional children and that forbid adolescent mothers from receiving welfare assistance directly, providing instead that the grant go to their parents or guardians (Nathanson; Peirce).
The contraceptive implant, Norplant, introduced in the United States in 1990, quickly became implicated in a number ofpolicies advocated by welfare conservatives. Once inserted, the implant prevents pregnancy for up to five years. Both the insertion and the removal, however, must be done by a trained health professional. After the insertion, no further "user compliance" is required, making this a far more effective contraceptive device than other birth control methods. Within eighteen months of the introduction into the United States of this new method, virtually all states approved the public funding of Norplant insertion for welfare recipients. The potential for coercion is evident. There have been instances where judges have required Norplant use as a condition of probation or child custody for women convicted on drug-related charges or of child abuse (Forrest and Kaeser). Provision of access to Norplant for adolescents has also raised ethical concerns (Moskowitz and Jennings). In addition, lack of access to providers trained to remove the implant may restrict choice for some women.
SERVICES TO POTENTIALLY VULNERABLE POPULATIONS. Minority Communities. Minority communities in the United States have long had a wary relationship with family planning advocates and services. The previously cited historical links between the founders of the birth control movement, such as Margaret Sanger, and those in the eugenics movement with an avowedly racist ideology created a lasting sense of distrust in minority communities as to the intentions of some within the family planning movement (Chesler; Gordon, 1976). Such distrust reached a height in the late 1960s and early 1970s when many of the Title X clinics appeared to be targeted specifically at African-Americans, leading some African-American leaders to accuse family planners of "genocidal" intentions (Littlewood). More recently, some community leaders—most notably, black clergy—have joined forces with the pro-family movement, arguing against such measures as condom distribution in inner-city high schools and offering Norplant to adolescent mothers (Moskowitz and Jennings).
At the same time, the rates of premarital sexual activity, sexually-transmitted diseases, adolescent pregnancy and abortion have been disproportionately higher for minorities than for others. Thus, there is a need for culturally-sensitive family planning and abortion services, and many minority organizations argue forcefully for their retention and expansion.
Adolescents. In the early 1990s, adolescents were entitled to receive low-cost or free confidential contraceptive services at Title X sites. Adolescents, as a group, did not receive any public funds for abortion. The field of adolescent medicine recognizes the need to provide education and family planning services to sexually active adolescents (American Academy of Pediatrics, 1999). The rising rates of sexual activity among adolescents, particularly young adolescents, has increased concern within the family planning community about adolescent pregnancy and this group's vulnerability to HIV and other sexually-transmitted diseases (Alan Guttmacher Institute, 1991). In the 1980s, a major response to both these issues was the establishment of school-based clinics on the theory that while few teens would make their way to a free-standing clinic, clinics located within the school would reach a much larger public. Programs were also established for pregnant adolescents and those with children to try to keep them in school. Predictably, such school-based programs were controversial from the start, strongly opposed by conservatives and just as strongly advocated by health professionals and public health advocates (Kirby et al; Moskowitz and Jennings).
A number of school districts, particularly those in large urban areas, began distributing condoms to students in response to the HIV epidemic. There has been massive controversy here as well, with many parent and church groups opposing such efforts. Generally speaking, however, HIV-related interventions in schools seem to be more acceptable to the public and to educators than specific efforts for pregnancy prevention. A national study of sex education in U.S. schools in the late 1980s found far more attention paid to HIV and sexually-transmitted diseases than to family planning education (Forrest and Silverman). While most would advocate abstinence for adolescents, particularly young ones, the alarming rate of unprotected sexual activity in this age group warrants realistic education and confidential access to safe, appropriate family planning services.
In October of 1998, there was an attempt to pass legislation restricting minor's access to family planning services. The proposed amendment would have mandated that parents of dependent adolescents be notified before their children received contraceptives from Title X-funded clinics (Congressional Record). Supporters of parental consent feel that available, confidential family planning services encourage sexual activity in adolescents and undermine parental authority. However, research has demonstrated that confidentiality is crucial to teens' willingness to seek services related to sexuality (American Academy of Pediatrics, 1999; Reddy et al; Planned Parenthood). Moreover, Planned Parenthood states that the fact that the average teen does not visit a family planning clinic until 14 months after she has become sexually active provides clear evidence that clinics do not encourage sexual activity. Requiring parental consent may not deter adolescents from having sex, but it could keep them from seeking reproductive health care in a timely fashion or at all. This could contribute to an increased rate of pregnancies as well as sexually transmitted diseases (AGI, 2000; Planned Parenthood). While the 1998 amendment was not passed, there is an ongoing attempt by political conservatives to fight access to family planning services for adolescents and even punish them for having sex. In a recent NYC case, a group of eighth graders who skipped school to attend a party where they allegedly had sex were forced to submit to pregnancy and other gynecological testing and to provide the results before they could return to school. A suit has been filed on their behalf by the New York Civil Liberties Union (Williams).
Services to the Disabled. Case law in the United States generally recognizes that developmentally disabled individuals have the same fundamental rights regarding procreative choice as those who are not disabled. There are, however, difficulties in implementing family planning services for disabled persons. The issue of informed consent for mentally disabled individuals is particularly relevant and remains ethically problematic. Is the individual capable of giving informed consent, and if not, who is the appropriate surrogate empowered to make such decisions (Stavis).
In spite of legal decisions supporting provision of such services, relatively few disabled persons are served in Title X clinics (Moore and Lieber). Few clinic staffs have received the specialized training necessary to work effectively with this population. In addition, many caretakers, particularly parents, have difficulty dealing with sexuality in this population and are reluctant to ensure that these individuals receive such services. In addition, disabled individuals and caretakers are often not aware of the entitlement of the disabled to family planning services, which implies a need for more outreach to this population.
In light of the compulsory sterilization programs of the past, the major ethical conflict regarding sterilization today is balancing the rights of a mentally retarded or mentally disabled person to sexual freedom with a protection of their best interests regarding childbearing. Many writings deal with the sterilization of the mentally retarded who are somewhat incapacitated or even totally incapable of giving informed consent (Macklin and Gaylin). The Committee on Ethics of the American College of Obstetricians and Gynecologists has issued a statement on "Sterilization of Women Who Are Mentally Handicapped," which urges all possible attempts to communicate with the person involved on whatever level is possible. Even in cases where it is clear that the individual has no ability to comprehend a pregnancy and childbirth and may be harmed by the experience, it is difficult to obtain a court order for sterilization because of the history of abuses. Perhaps it is more beneficent to take the middle ground in these cases. While routine sterilization of a mentally impaired individual without her consent is clearly wrong, restricting the sexual expression of a profoundly impaired individual who cannot comprehend her sexuality, much less pregnancy or coitus-related conception, is also not justified. In carefully considered circumstances, advocates for the patient may conclude that sterilization is in the patient's best interest. The decision should be made by an appropriate surrogate or proxy, based on the best interests of the patient after considering alternative methods of dealing with the situation. The prominence of this issue in the Senate confirmation hearings of Dr. Henry Foster as
Surgeon General in the Clinton administration illustrates the importance of this issue and the lack of societal consensus (Powderly, 1996).
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