DifferenTakes is an investigative series of issue papers, published by the Population and Development Program at Hampshire College, providing alternative information and analysis on a wide range of reproductive rights, population, environment and social justice issues. This spring we are launching a special series of DifferenTakes focusing on 'Reviving Reproductive Safety' in movements for women's health and reproductive justice.
We are pleased to send you the third issue in the series, "Depo-Provera: Old Concerns, New Risks" by Amy Oliver and Diana Dukhanova. This issue discusses the ramifications of new research suggesting a link between Depo and increased susceptibility to several Sexually Transmitted Infections (STI's).
- Betsy Hartmann and Amy Oliver Co-editors, DifferenTakes
By Amy Oliver and Diana Dukhanova A Publication of the Population and Development Program at Hampshire College • No. 32 • Spring 2005
The Summer 2000 issue of DifferenTakes provided an introductory glance at the injectable contraceptive Depo-Provera (or DMPA), and why many women's health advocates are concerned with its use and misuse around the world. 1 Approved for use in the U.S. in 1992, Depo has only become more controversial as its image as a hassle-free contraceptive clashes with the reality of possible side effects such as irregular bleeding, weakness, depression, weight gain, nausea, loss of libido, darkening of skin, abdominal pain, headaches and hair loss. 2 Side effects can be so numerous and severe that over 70% of American women who have ever used Depo discontinued their use within the first year. 3 Injected into the arm or buttock, Depo's effects last for three months and its effectiveness rate is an impressive 99.7%. 4 But with alarming new risks added to these worrisome side effects, the contraceptive deserves closer scrutiny.
Depo-Provera Receives "Black-Box" Warning
The Food and Drug Administration (FDA) recently mandated that Depo carry the "black box" warning label, the agency's most severe warning. Based on new data from Pfizer, Depo's manufacturer, the new label will inform users of recent findings that Depo causes a loss in bone mineral density that may not be completely reversible. The warning also suggests that Depo use should be limited to two years unless other forms of birth control are insufficient, and in this case women should be evaluated while taking the drug long-term.
These findings have special relevance to young women who are in the critical period of bone growth. Studies are conflicting as to whether or not bone loss can be completely recovered once use of the drug is discontinued. 5 Clearly, the FDA black box label poses a red flag that more research is needed on Depo's long-term effects on women's bone loss and future risk of osteoporosis.
Increasing Risks of STI's and HIV/AIDS
Other recent studies show that Depo-Provera users are at an additional risk of contracting Sexually Transmitted Infections (STI's). A joint study funded by the National Institute of Child Health and Human Development (NICHD) and the U.S. Agency for International Development (USAID) recently found a strong correlation between Depo use and a woman's chances of contracting chlamydia and gonorrhea. The study, published in the journal Sexually Transmitted Diseases , followed over 800 women in Baltimore, MD, who had the choice of using Depo-Provera, oral contraceptives, or a non-hormonal contraceptive.The study found no correlation between taking oral contraceptives and contracting the infections, and did not conclude why Depo users were more likely than women using other hormonal contraceptives to contract these STI's, indicating further research is needed on the subject. 6
The findings clearly have important implications for women's reproductive health and call into question the widespread promotion of Depo-Provera in family planning programs in the U.S. and overseas. Yet there is already an attempt by some agencies to downplay them. Family Health International's (FHI) August 2004 report on the findings states that "while of concern...this new research does not call for changes in the provision or use of DMPA." 7 The report goes on to assert that women in monogamous relationships are at no additional risk of infection, and that the results of the study "are of little concern for DMPA users who use condoms consistently and correctly, since such condom use only rarely fails to provide protection..." 8 The fact that the report virtually ignores such significant findings is alarming. The results clearly state that the use of Depo-Provera only , not hormonal contraceptives in general, increases the risk three-fold of contracting chlamydia and gonorrhea. 9 In lieu of an in-depth look at the implications of these findings, FHI quickly puts the responsibility on correct and consistent condom use and monogamous relationships to prevent the spread of STI's.
Encouraging condom use is of course important, but as a consumer choosing a safe, reliable method of birth control in addition to condoms, one might think twice about choosing Depo given that condoms can fail or one's partner might be unwilling to use them. Moreover, many women who are at risk for contracting STI's because of their partner's promiscuity most likely believe (or would like to believe) that their partner is faithful. The point at which a woman finds out her partner isn't faithful is far too late to decide to switch birth control methods, particularly if she just received her three-month shot. Meanwhile, she could have been putting herself at an addition risk of contracting STI's from her partner simply because she used Depo .
New studies show conflicting evidence over whether Depo-Provera increases the risk of contracting HIV, transmitting it to others, and increasing the rate at which the virus progresses once in the body. A study published in January 2004 in The Journal of Infectious Diseases found a correlation between taking hormonal contraceptives (both injectable and oral) and acquiring HIV. 10 The study further concluded that the use of Depo at the time of HIV transmittal hastened the rate of disease progression. 11 In terms of contracting HIV, skeptics point out that the research yielding these results used sex workers in Kenya, who would have more frequent exposure to HIV than the average person. 12 Only a handful of prospective studies have addressed injectable hormonal contraceptives in particular and their effect on HIV, and findings are mixed. 13 Some found no correlation between Depo use and HIV, and suggest further research is needed. The National Institute for Child Health and Human Development (NICHD) is currently conducting a larger study inclusive of subjects who are at a lower risk of HIV infection, and results are expected some time this year.
Although Depo's manufacturer was mandated to add the "black-box" label concerning bone loss, it seems less concerned with adequately informing women of other new risks. While promoting their product as ultra-convenient and period-free, Depo's current distributor, Pfizer, claims "There is no proof from clinical studies that shows Depo-Provera increases your risk of acquiring a sexually transmitted disease, or STD." 14 This claim was found on the official Depo-Provera website seven months after the findings were released (and reported in popular U.S. news sources) 15 concerning women's increased risk of contracting STI's. While Pfizer does remind women that Depo does not protect from STI's and HIV/AIDS, it thus far ignores this recent finding.
In informational materials (mainly targeting college-age women) put out by Depo's former distributor, Pharmacia, sweeping statements are made that "while most sexually active young women use condoms to protect themselves against sexually transmitted diseases, they don't often think to protect themselves against pregnancy as well." 16 Pharmacia's materials go on to claim that the condom's failure rate is as high as 14%, compared to Depo's 99.7% effectiveness. 17 The materials neglect to mention that condoms, used with withdrawal, can be up to 98% effective, as reported by Planned Parenthood. 18
With the rate of HIV infection rising to pandemic levels among the youth population -- half of all HIV infections in the U.S. occur in people under 25 19 -- promoting a birth control method to youth that downplays condoms as ineffective will only contribute to the crisis. In light of the recent findings that Depo increases the risks of contracting STI's and possibly HIV, it is critical that women receive accurate information regarding the risks of solely relying on hormonal contraceptives.
At What Risk?
Because of the particular circumstances in which Depo-Provera is used in the U.S. and abroad, new risks associated with Depo should not be taken lightly. Long-acting contraceptives such as Depo and Norplant (a contraceptive placed under the upper arm) have a history of being coercively targeted at poor women and women of color, often without informed consent, despite the current promotion of Depo as a white, college woman's contraceptive. 20 Anecdotal evidence shows that Depo is disproportionately promoted to women on welfare as a population control measure, 21 and there is a pressing need for more research in this area. New risks associated with bone loss, contracting STI's and possibly HIV pose great concern for women who are already less likely to have access to basic services such as healthcare.
With many questions left unanswered, widespread research is needed on the safety of Depo-Provera. A study conducted in India in 2003 explored women's experiences with obtaining and using Depo (banned in 2002 from India's Family Welfare Program after much pressure from women's groups). The study profiled a sample of 50 women, most between the ages of 21 and 30, who received Depo from a public hospital. Goals were to measure how informed the choice was to take the drug, women's knowledge of risks and benefits, medical screening tactics, personal health risk factors, and physical setting of medical facilities. The study found some alarming results: over half of the women were given no other contraceptive options besides Depo, 42 out of 50 were not informed of the probable side effects, and more than half received no screening. 22 The study made women's first-hand experiences a central focus of the research, an approach severely needed in the U.S.
Depo has for years served as both a subtle and blatant tool for population control in developing countries despite the fact that risks are aggravated in places where medical monitoring is difficult or impossible. 23 Under apartheid in South Africa, Depo was typically given to women without adequate screening and health services, which were virtually inaccessible to rural populations. Many black South African women were coerced into using Depo and were sometimes forced to use it in order to keep their jobs. 24 Although this does not mean Depo is always misused in developing countries, its vast history of abuse by population control programs and potential for further misuse (particularly in areas of high HIV risk such as South Africa) call into question its ultimate safety for women.
Despite recent concerns about a link between Depo-Provera and HIV/AIDS, there is little evidence that new risks will be taken seriously by those who consider reducing Third World birth rates a higher priority than women's health. In a report on the recent findings concerning Depo and HIV risk, Timothy Wilkin, M.D., M.P.H., (Instructor of Medicine at Cornell University and writer for a popular website on AIDS research), states "It is difficult to say what this means for women's reproductive health. Because women in developing countries such as Kenya are much more at risk for dying during childbirth...it is unclear whether this increase in HIV infection is more important than the risk of unwanted pregnancies." 25
While it is true that because of poor living conditions and lack of prenatal care, a woman's chance of dying during childbirth is generally higher in developing than in developed countries, it is a cruel trade-off to pit the risks of an unwanted pregnancy and childbirth against using Depo (with possible increased risk of contracting HIV) as a woman's only two options. If we are really concerned with reducing death rates related to childbirth, we instead should focus on improving overall standards of living and prenatal care for women in Kenya and elsewhere. Further, the risk of contracting HIV can greatly be reduced by increased condom use and there are other contraceptives women can use besides Depo. Indeed, given present concerns about Depo causing increased risk of acquiring STI's and possibly HIV/AIDS, it is questionable whether Depo should be used at all in vulnerable populations. We may be witnessing the beginning of a major public health crisis.
A Broader Vision for Contraceptive Choice
Despite the new FDA black box warning about bone loss, evidence of increased risk of contracting STI's among Depo users, and concern that Depo may be linked to increased HIV infection, Depo-Provera continues to be used by many of the most vulnerable populations in the world. Seen at first as a hassle-free contraceptive that would answer women's prayers, new findings raise serious questions of the usefulness of this drug as a safe option for women. While many advocates for reproductive choice argue that more contraceptive options automatically empower women, we must raise the question of how important a choice is if the safety of the method is in serious doubt. A broader movement for reproductive health looks beyond a narrow definition of choice to the assurance that available options are safe as well as effective. Moreover, women need to be completely informed of the array of contraceptive options available to them, and the risks associated with their use.
Amy Oliver is the Program Coordinator for the Population and Development Program at Hampshire College, an organization dedicated to promoting reproductive rights, economic justice, and social equality for women. Diana Dukhanova is a fourth-year student at Hampshire College concentrating in Russian literature. She has been working for the Civil Liberties and Public Policy Program and Population and Development Program since her first year and her primary activist interests lie in reproductive rights.
1 Littlecrow-Russell, Sarah. “Time to Take a Critical Look at Depo-Provera,” DifferenTakes, Population and Development Program at Hampshire College, No. 5, Summer 2000. 2 Unveiled Realities: A study on women’s experiences with Depo-Provera, and injectable contraceptive, Sama Resource Group for Women and Health, New Delhi, India, 2003. 3 Ibid. 4 “Different Needs at Different Times,” Pharmacia Corporation, 2001. 5 “Black Box Warning Added Concerning Long-Term Use of Depo-Provera Contraceptive Injection,” http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01325.html, Last visited February 17, 2005. 6 “Depo-Provera Appears to Increase Risk for Chlamydial and Gonococcal Infections,” http://www.nichd.nih.gov/new/releases/depo-provera-risk.cfm, Last visited February 22, 2005. 7 “Depo study USAID Guidance,” FHI News email:
, August 31, 2004.
8 Ibid. 9 “Depo-Provera Appears to Increase Risk for Chlamydial and Gonococcal Infections,” http://www.nichd.nih.gov/new/releases/depo-provera-risk.cfm, Last visited February 22, 2005. 10 “Hormonal Contraception and HIV: an Update by Dr. Charles Morrison and Kim Best,” August, 2004. http://www.fhi.org/NR/Shared/enFHI/PrinterFriendly.asp, Last visited February 16, 2005. 11 Ibid. 12 Ibid. 13 Ibid. 14 http://www.depoprovera.com/vc-prospect-user.asp, Last visited March 7, 2005. 15 Rubin, Rita. “Contraceptive is Linked to High STD Risk,” USA Today, Gannett Company, Inc., August 23, 2004. 16 “Different Needs at Different Times,” Pharmacia Corporation, 2001. 17 Ibid. 18 http://www.plannedparenthood.org/pp2/portal/files/portal/medicalinfo/birthcontrol/pub-contraception-choices-5.xml, Last visited February 23, 2005. 19 “Adolescents and HIV/AIDS,” http://www.advocatesforyouth.org/publications/factsheet/fshivaid.htm, Last visited March 2, 2005. 20 “Beyond Pro-Choice Versus Pro-Life: Women of Color and Reproductive Justice,” Smith, Andrea. NWSA Journal, Vol. 17 No.1 Spring 2005. 21 Littlecrow-Russell, Sarah. “Time to Take a Critical Look at Depo-Provera,” DifferenTakes, Population and Development Program at Hampshire College, No. 5, Summer 2000. 22 Unveiled Realities: A study on women’s experiences with Depo-Provera, and injectable contraceptive, Sama Resource Group for Women and Health, New Delhi, India, 2003. 23 “Depo-Provera Deadly Attempt At Population Control,” Reproductive Rights Newsletter, Reproductive Rights National Network, Summer 1981. 24 Hartmann, Betsy. Reproductive Rights and Wrongs, Hartmann, Betsy. South End Press, Boston, MA, 1995. 25 “Hormonal Contraceptives Increase HIV Risk; Vitamin A Levels Unrelated to Viral Load,” http://www.thebody.com/confs/retro2003/wilkin2.html Last visited February 9, 2005.
Reproductive Health and the FDA: Buffeted by Political Battles
By Amy Allina
Since its inception, the Food and Drug Administration (FDA), the U.S. government’s main watchdog agency over the pharmaceutical industry, has been subject to political pressures that undermine its mission to ensure drug safety and protect consumer health. In the last several years, these pressures have intensified as the FDA is buffeted by the Bush administration’s right-wing agenda and an ever more powerful pharmaceutical industry. More often than not, women’s reproductive health and safety are caught in the crossfire of these political and economic agendas.
The Religious Right and the Battle over Emergency Contraception In 2002, the Bush administration set off a powerful reaction when it tried to install W. David Hager as chair of the reproductive health drugs advisory committee responsible for advising the FDA on questions relating to contraception and abortion. The outrage of women around the country – expressed by more than 10,000 protest email messages to the FDA – led to a close public scrutiny of Hager’s record. Hager had been the lead spokesperson for the Christian Medical Association’s petition for a ban on mifepristone,1 the drug approved by the FDA for abortion. He had spoken publicly of his reluctance to prescribe contraception to patients who are not married.2 And as headlines across the country proclaimed, he was co-author of a book recommending prayer as treatment for PMS.3
In the face of this storm of public opposition, the Bush administration backed off from the original plan of putting Hager in charge of the committee, but they did make him a member. And they provided him with like-minded colleagues, appointing Joseph Stanford (who has written that he is unwilling to prescribe contraception even to married patients because of his belief that any interference between sexuality and fertility is detrimental to marriage4) and Susan Crockett (a board member of the American Association of Pro-Life Obstetricians and Gynecologists) to the committee as well.
Reproductive rights advocates and FDA watchers saw these appointments as a sign of the Bush administration’s allegiance to the religious right and pointed out that they set the stage for a fight over the pending FDA decision on whether to make emergency contraception (EC) available over-the-counter. Following that discouraging development, feminist activists and reproductive health advocates cheered the triumph of science a year later when the committee voted unanimously that emergency contraception was safe for use in an over-the-counter setting. In the face of overwhelming scientific evidence, even the three staunch opponents of reproductive rights on the committee had to acknowledge that this after-the-fact contraceptive method could be used safely without a prescription requirement. Among the doctors, scientists and activists who had been working for years to expand women’s access to EC, most had expected far worse from the committee.
The victory was short-lived, however. Despite the overwhelming recommendation from FDA’s science advisors, opponents of contraception prevailed and the FDA denied the EC over-the-counter application.*
Scientists and medical experts joined reproductive rights advocates in criticizing that decision, pointing out that by bowing to anti-choice political pressure, the FDA has denied women access to a safe and effective contraceptive and has undermined its own credibility as a scientific agency around the world. An editorial in the New England Journal of Medicine lamented the loss of FDA’s “enviable international reputation” and pointed out that the decision was “likely to mean that both physicians and patients will wonder whether future drug-approval decisions are based on the evidence with regard to efficacy and safety or, rather, on political considerations.”5 Mission in Flux The EC controversy was not a typical, everyday occurrence at FDA. The FDA usually operates behind-the-scenes, unnoticed by most people – even those concerned about health. Yet, despite being out of the public eye, the FDA is still under constant pressure from political forces of a different kind than the very public battles that take place over reproductive rights. The standard battle at the agency is between the interests of the companies that make the drugs and devices it regulates and consumer advocates concerned about the safety of those products.
Since the FDA was first created early in the twentieth century, there have been struggles between businesses, determined to fight off government interference, and consumers and their advocates, working to establish a role for the federal government in protecting the public health.6 At its start the FDA was made up of a handful of scientists who worked in an obscure bureau of the Department of Agriculture; as the scope of drugs and medical devices in the world has expanded, the FDA has grown as well, now responsible for regulating over a trillion dollars worth of food, drugs and medical devices, more than a fifth of the U.S. economy.
This growth has taken place in spite of industry resistance. It has taken fierce fights between consumer advocates and industry, and all too often, national and international tragedies to expand the scope of FDA regulation. Sadly, many of the events that have persuaded Congress of the need for better regulation of drugs and medical devices have specifically involved damage to the life and health of women. Only after thalidomide, given to pregnant women to reduce morning sickness, was found to have caused nerve damage in the women who took it and sometimes fatal birth defects in their children, did Congress mandate that FDA must review evidence of a drug’s safety and efficacy before a company could begin to sell it. And pre-market review of medical devices came even later. In the United States alone, 17 women died and thousands more had emergency hysterectomies to save their lives as a result of using the unsafe Dalkon Shield IUD before the FDA was given the authority to require those reviews.
In the last decade, however, the trend has gone in the opposite direction. When conservative lawmakers won control of Congress in 1994, they went to work on a broad reform agenda that reflected the wish lists of industries from financial services to pharmaceuticals. The FDA Modernization Act of 1997 reshaped the agency in response to the drug industry’s long-held desires. The new law speeded up drug approvals, scaling back safety requirements, and even redefined the agency’s mission statement to commit it to working in consultation with “manufacturers, importers, packers, distributors, and retailers of regulated products.”7
Recent news about drug safety problems with widely prescribed pain relievers, however, has led to a growing public understanding that FDA’s ability to protect the public has been eroded. Public outrage has already translated into Congressional interest, and these developments may lead to drug safety reform legislation to restore some of FDA’s capacity to ensure drug safety.
The False Choice Between Speed and Safety Over the years as these trends have evolved, drug companies have not always been alone in criticizing FDA for its slow approval process. Patient activists have sometimes made common cause with industry, pushing for faster drug approvals even at the expense of rigorous safety testing. Early AIDS activists, in particular, urged FDA to dispense with stringent safety requirements to give dying patients access to new treatment drugs. Later, as more AIDS drugs became available, many of these same activists responded to the changed circumstances and urged the FDA to reprioritize the need for evidence of long-term effectiveness and safety in its consideration of AIDS drugs.
Women’s health advocates similarly urged faster approval for the female condom and other barrier methods of contraception that hold the potential to protect women from HIV infection and other sexually transmitted diseases. The question of how to balance safety concerns with the urgent need for a product will again be at center stage when FDA eventually considers approval of microbicides now in development – topically applied products that help prevent the transmission of HIV and other infections. Drug companies and device manufacturers have watched these developments carefully and learned from them. Industry-funded patient groups now often play a very public role in companies’ plans for obtaining FDA approval; in some cases these patient groups have been found to be wholly created by the companies whose products they are demanding access to. But activists who are accountable to real-life patients suffering from illness are learning as well. They have learned to reject the false choice between faster approval and safer products. The demand for efficient consideration of urgently needed products does not have to result in the elimination of safeguards for the public health.
Addressing Safety Concerns and Overcoming Division When it comes to contraception, the political battles sometimes converge, subjecting these critical women’s health products to the complicated tensions of the safety/access balance as well as the bruising assaults of the anti-choice, anti-family planning right wing. In the past, this convergence has created division within the reproductive health community, as was seen with Depo Provera, the contraceptive injection, and Norplant, the contraceptive implant. Women’s health advocates who asked the FDA not to approve a contraceptive because of safety concerns have been seen by family planning advocates as unwitting accomplices to anti-choice efforts to block access to products that improve women’s ability to control fertility. Family planning advocates who have urged approval of new contraceptive products in spite of unanswered questions about safety have been seen by consumer health advocates as unwitting accomplices to an industry agenda that promotes fast approval without adequate safeguards for women’s health.
These controversies (as well as the fact that the Baby Boomers, who drive so many marketing choices in the United States, need less and less contraception as they age) have sometimes led major companies to shy away from contraceptive products, except in cases where they expect very high levels of profitability to counterbalance their concerns about political controversy. Both mifepristone and EC fell into this category, failing to attract the interest of the big pharmaceutical companies and only advancing to FDA approval with the support of smaller companies committed to providing women access to these products.
It is interesting to note that in the case of both mifepristone and EC, the companies involved worked closely with the reproductive rights and women’s health communities to make sure that women’s safety concerns were seriously addressed. This cooperative approach headed off the potential for internal controversy and created a united front of women’s advocates to face the anti-choice opposition which was thus effectively marginalized. Lack of Credibility Undermines FDA’s Ability to Protect Women’s Health Last fall, a new development in the regulation of Depo Provera proved the truth of the New England Journal of Medicine editorial warning that FDA’s motivation for future decisions would be called into question.
Women’s health advocates have raised concerns about the safety of Depo Provera for decades. Over time, research has laid to rest some but not all of the questions about the effects of this drug. One uncertainty that had remained was about Depo’s effect on the strength of the bones of women using it; some preliminary research indicated that women using Depo experienced a loss of bone density.8 Health advocates have continually called for better information on this and other possible risks of long-term use of the method. The kind of cooperative approach that created unity among women’s advocates on EC and mifepristone has not yet evolved with respect to Depo Provera. Meanwhile, the FDA – its credibility weakened by the Bush administration’s appointment of unqualified candidates like David Hager and by denying women improved access to safe and effective EC – announced labeling changes for Depo Provera that revealed the fault lines in the women’s community.
Based on new data, submitted by the company that makes Depo, the FDA has instructed the company to add information to the drug label about bone loss and to recommend that clinicians limit use of Depo to two consecutive years. This new information is being conveyed in the form of a black box warning on the label – FDA’s most severe label warning, commonly although not exclusively, used for life-threatening conditions. Many women’s health advocates have been pleased to see the FDA requiring that the bone loss information be provided to women.9 But at the same time, the agency’s recent history of manipulating and suppressing scientific data for political ends and the Bush administration’s track record of attacks on family planning cannot help but raise questions about what is really behind this label change. Is it a genuine effort to protect women’s health by sharing new scientific evidence? Or is it a politically motivated attack on contraception, using science as a smokescreen for an anti-choice agenda? Just as the editorial warned, FDA’s distorted decision on EC has undermined the agency’s credibility and led even those who support its role as a protector of the public health to question the motivations behind these actions.
Amy Allina is Program Director of the National Women’s Health Network, a national organization that is committed to ensuring that women have self-determination in all aspects of their reproductive and sexual health. Prior to joining the NWHN in 1999, she worked on women's health policy issues at the consulting firm of Bass and Howes and as the Political Organizer for the Maryland affiliate of NARAL. She serves on the board of directors of the Reproductive Health Technologies Project and the Alan Guttmacher Institute.
* While this is being written, a revised application to make EC available over-the-counter is still pending and may eventually be approved, but it’s been seriously weakened by a plan to restrict over-the-counter access to women 16 and older, setting up a two-tiered system of access based on age and denying improved access to younger women.
Ten Years After Cairo: The Resurgence of Coercive Population Control in India
By Rajani Bhatia [pdf version] In 1994 at the U.N. International Conference on Population and Development (ICPD) in Cairo, world leaders reached a new consensus on population. Although the ICPD Program of Action (POA) legitimizes demographic goals set by national governments, it recommends policy approaches based on the promotion of reproductive health, informed free choice, and gender equity. The document specifically rejects the use of coercion in family planning programs and discourages the use of social and economic incentives and disincentives to reduce fertility.
However, today after commemorations of the tenth anniversary of the ICPD have taken place around the world, population control is still with us. While the negative effects of China’s one-child policy have received much attention, recent two-child norm policies in India have also had devastating consequences for women and the poor. It is important that women’s health and reproductive rights activists remain vigilant about the continuing impact of population control.
During the last 15 years, population control in India has moved away from a tightly connected system of policies imposed by the central government mainly involving pressure on the poor to be sterilized.1 Instead, individual states are devising their own schemes to enforce a two-child norm. Designed to deter parents of two children from having a third, these policies employ disturbing new incentives and disincentives that trample on the rights and health of the country’s people. Disincentive penalties prohibit parents of more than two children from holding posts in local village councils or seeking government employment and deny or circumscribe access to public provision of education, health insurance and other welfare benefits. Working in the reverse, new forms of incentives give preferential access to anti-poverty and employment schemes to individuals who accept sterilization after two children.2 Emerging studies show how these population control policies have increased socio-economic and political disparities as well as gender-based violence in the country.
Oddly, most of the two-child norm policies came about either concurrent to or just after the national government of India made significant policy changes consistent with the ICPD Program of Action. First, a Target Free Approach (TFA) was adopted in April 1996, which officially removed targets related to contraceptive acceptance.3 In February 2000 the government announced a new National Population Policy (NPP 2000) that upheld the principles of voluntarism and informed consent in reproductive health care provision. However, many of the new strategies never had a chance to get off paper and on the ground. Health Watch, a watchdog coalition formed to monitor the government’s commitments made in Cairo, conducted surveys in nine states and found the new approach poorly implemented.4 In those areas where the TFA was tried, many officials doubted its merits and too quickly interpreted the subsequent fall in sterilization rates as system failure.5
When India’s population crossed the one billion mark on May 11, 2000, alarmism around the need to reduce population further undid what little progress had been made toward upholding ICPD and NPP principles in state health policies. M.K. Raut, a government official from Chattisgarh state, for example, expressed this common sentiment, “We can’t wait forever. The empowerment route advocated by the Cairo declaration is a long process and we would have added another billion by then…Yes, it is coercion. But with a billion-plus people, family size is no longer a personal matter.”6 The current national government led by the newly elected Congress Party has thus far taken no action to pressure states into adhering to NPP 2000 principles. As recently reported by the Washington Post, officials of the Indian Ministry of Health and Family Welfare describe population issues as an area now mandated by states without central regulation.7
Among the most controversial disincentives are electoral laws that since 1992 have sprung up in eight states. These debar anyone with more than two children from holding office in local government bodies or village councils known as panchayats. As a result over 4000 panchayat members have been forced to vacate their posts upon having a third child.8 State officials say they devised electoral disincentive laws in order to force village council members to act as role models in encouraging smaller families.9
In July 2003 the Supreme Court of India gave a national stamp of approval to the state two-child norm policies by upholding the constitutionality of the electoral disincentive law of Haryana state. In its ruling the Supreme Court stated, “Disqualification on the right to contest an election for having more than two children does not contravene any fundamental right, not does it cross the limits of reasonability. Rather, it is a disqualification conceptually devised in the national interest.”10 Emphasizing India’s “burgeoning population” as a national problem causing everything from congestion in urban areas to shortfalls in food grains and reduced per capita income, the Supreme Court further observed, “Complacence in controlling population in the name of democracy is too heavy a price to pay, allowing the nation to drift towards disaster.”11 Critics of the two-child norm and the Supreme Court decision have likened current policies to the 1970s Emergency Period in India’s political history remembered for massive forced sterilizations and suspension of democratic rights.12
A study conducted by the Bhopal-based NGO, Mahila Chetna Manch, between July 2001 and March 2002 clearly reveals how state policies have adversely impacted local communities and their village councils. Commissioned by the Ministry of Health and Family Welfare with support from the U.N. Fund for Population Activities (UNFPA), the study covered the states of Andhra Pradesh, Maharashtra, Madhya Pradesh, Orissa and Rajasthan. It found that 75 percent of those disqualified from their panchayat posts for having a third child belonged to economically and socially disadvantaged groups known as Scheduled Castes and Tribes. People resorted to a variety of means in order to evade the law including forced abortion, desertion of pregnant wives, divorce, extra-marital affairs, denial of paternity, hiding babies or children (for example by not allowing them to attend school), child abandonment, tampering of birth and immunization records, and giving away of children in adoption. The laws also resulted in a marked rise in the number of prenatal sex determination tests and abortion of female fetuses. In the case of a male fetus, most mothers were pressured into having a third child with the consequence of losing her own or her husband’s post in the panchayat.13
Meanwhile, the traditional system of incentives has not disappeared entirely. In the state of Andhra Pradesh, for example, Health Watch documented the use of gold chains to entice women to get sterilized after having two children.14 States have also employed a range of new incentives to allow individuals accepting sterilization preferential access to subsidized housing, food, government jobs and the like. In addition, some states have implemented group or community incentive schemes that give preferential access to development grants for housing, sanitation, school buildings, etc., based on collective family planning performance. As in the past, Madhya Pradesh, Andhra Pradesh and Maharashtra provide performance awards to service providers who meet family planning targets.15
Most shocking is a guns-for-sterilization scheme put into place in three districts of Uttar Pradesh. The policy mirrors past incentives for family planning “motivators,” but is directed at harnessing the exploitive power of rich, land-owning farmers. Bringing in two people for sterilization gets you a single-barrel shotgun; five people a revolver license. The London Guardian recently reported a case of five poor farmers who in July 2004 were lured by a rich farmer’s offer of work and then forcibly sterilized.16
Some states employ population policies to address social issues such as low age at marriage, son preference and lack of male responsibility in contraception – but unfortunately by punitive or preferential means. Uttar Pradesh, Rajasthan and Madhya Pradesh, for example, deny individuals married before the legal age of 18 access to government jobs, thereby further disempowering women forced against their will to marry early.17 Similarly ill-conceived is a policy in Andhra Pradesh that awards three couples selected by a “lucky lotto” dip 10,000 rupees. In order to qualify for the lotto, couples must either adopt a permanent method of family planning after having one child or two girl children or by adopting vasectomy after having one or two children.18 Neo-liberal economic and deregulation policies of the past ten to fifteen years have also had a negative effect. Resource allocations to the health sector have fallen at both federal and state levels. The research of Health Watch revealed that many women in India do not have easy access to basic health care or even minimum reproductive health care services. The context of population control has become decentralized as a host of different actors including state and local government bodies, NGOs, corporations, and lending sources for micro-businesses implement separate strategies to instill a two-child norm.
Another recent development in Indian population rhetoric is the influence of Hindu right wing alarmism that posits a Hindu majority threatened by a rapidly growing Muslim population. While announcing the new state population policy in Uttar Pradesh in 2000, the Hindu Nationalist Chief Minister, R.P. Gupta, spoke unsubtly, “There are groups and communities which feel that if they go on increasing their number they will capture power one day. Such a way of thinking has to be disincentivised.”19
Women in India have raised their voices against the latest resurgence of coercive population control. On March 6, 2003, a group of women representatives from local government bodies in different states spoke out at the National Human Rights Commission. They denounced the two-child norm policies as both anti-women and anti-poor.20 Immediately following the Supreme Court ruling to uphold the two-child norm policy in Haryana, the All India Democratic Women’s Association released a statement condemning the decision and demanding that the national parliament take action to force states to adhere to Cairo and NPP principles.21
On the other hand, many mainstream women’s and population organizations in the West have been slow in responding. Their efforts in recent years have mainly focused on defending the Cairo POA against conservative anti-abortion forces and reinstating their government’s monetary commitments made at the conference. The accomplishment of the Cairo declaration with its gender progressive content seems to have blinded many to the continuing reality of population control abuses. While the POA is worthy of support, much more must happen to counter trenchant population control ideology and abuse internationally. The UNFPA and the Population Council in India have openly condemned two-child norm policies.22 Women’s groups internationally must also take action. The U.S. Agency for International Development, for example, ought to be confronted for its silence, as it has influenced the formulation of some state population policies in India, including in Andhra Pradesh and Uttar Pradesh.23 The September 2005 International Women and Health Meeting in Delhi will provide an opportunity for women around the world to join their sisters in India in opposing population control and building action steps to stop abusive policies. Let this not be a missed opportunity for solidarity.
Rajani Bhatia is a member of the Committee on Women, Population and the Environment (CWPE). She is an activist and writer in the international movement for women's health, reproductive rights and justice. She is a contributing author in Jael Silliman and Anannya Bhattacharjee, eds., Policing the National Body: Race, Gender and Criminalization, Boston: South End Press, 2002, and Abby L. Ferber, ed., Home-Grown Hate: Gender and White Supremacy, Routledge,2004.
Endnotes 1 For an excellent history of population control policies in India and their present incarnation, see Mohan Rao, From Population Control to Reproductive Health (New Delhi and London: SAGE, 2004). 2 HealthWatch, “State Population Policies,” Seminar, 511, March 2002. 3 Mallik, Rupsa and Jodi Jacobson, “The Far Right, Reproductive Rights, and U.S. International Assistance,” Center for Health and Gender Equity, August 8, 2002. 4 Sharma, Kalpana, “Forget Targets, Remember People,” The Hindu, February 27, 2000. 5 Mallik, Rupsa, “The Two-Child Norm and Incentives and Disincentives in Population Policies in India,” unpublished, May 12, 2002. 6 Lakshmi, Rama, “A Choice Between Politics, Progeny in India,” The Washington Post, October 31, 2004. 7 Ibid. 8 Ibid. 9 Farah, Francois, “The two-child norm is a loaded dice,” The Times of India, August 2, 2003. 10 Quoted in Venkatesan, J. “ SC upholds two-child norm,” The Hindu, July 31, 2003. 11 Quoted in Rajalakshmi, T.K., “Population Policy: Children as disqualification,” Frontline, Volume 20, Issue 17, August 16-29, 2003. 12 Hariharan, Githa, “A New Emergency,” The Telegraph, August 2, 2003. 13 Mukul, Akshaya, “Two child norm cripples women,” The Times of India, March 7, 2003; Special Corresondent, “Two child norm brings little relief for women,” The Hindu, July 2, 2003. 14 Sharma, Kalpana, “Forget Targets, Remember People,” The Hindu, February 27, 2000. 15 HealthWatch, “State Population Policies,” Seminar, 511, March 2002. 16 Ramesh, Randeep, “Outrage at Guns for Sterilisation Policy,” The Guardian, November 1, 2004. 17 Hariharan, Githa, “A New Emergency,” The Telegraph, August 2, 2003. 18 HealthWatch, “State Population Policies,” Seminar, 511, March 2002. 19 Tripathi, Purnima S., “New U.P. Population Policy targets minorities,” The Asian Age, Vol.3, No.5, March 6, 2000, p.1. 20 Mukul, Akshaya, “Two child norm cripples women,” The Times of India, March 7, 2003 21 Staff Correspondent, “SC ruling on two-child norm criticized,” The Hindu, August 2, 2003. 22 Lakshmi, Rama, “A Choice Between Politics, Progeny in India,” The Washington Post, October 31, 2004; Mukul, Akshaya, “Two child norm cripples women,” The Times of India, March 7, 2003. 23 Mallik, Rupsa, “A Less Valued Life: Population Policy and Sex Selection in India,” Center for Health and Gender Equity, October 2002.
Andrea Dworkin, for almost four decades a campaigner, writer, and feminist activist who helped break the long standing taboo against violence against women, has died at her home here. She was 59.
She was called the "eloquent feminist," by the syndicated columnist Ellen Goodman, while Gloria Steinem, her friend and fellow activist, was even more lavish with her praise. "Every century there are a handful of writers who help change the world. Andrea is one of them."
Ms Dworkin's agent, Elaine Markson, said the cause of death was not known, but she had become increasingly frail as her knees had weakened and she suffered a series of falls. She died at the home in Washington DC she shared with John Stoltenberg, her partner of 30 years and husband since 1998.
Andrea Dworkin was born in Camden New Jersey. Her father was that American rarity, a committed socialist who was appalled by racism and discrimination, and was an unwavering supporter of organised labour. A teacher and a post office worker, he became her quiet inspiration: "it would be hard to overstate how much he taught me about human rights and human dignity, how to talk and how to think," she said years later.
Her public life as a political activist began in 1965, as a 19-year-old protester against the Vietnam war ? long before suich protest became commonplace. She was arrested outside the US mission to the United Nations, and sent to New York City's Women's House of Detention. After she was subjected to a crude internal examination, her description of the experience created headlines worldwide.
But she did not come to feminism until several years later, in her mid 20s. Her outlook was shaped by years during which she had worked as a prostitute, married, and then experienced spousal abuse at first hand. Increasingly, she grew horrified by the indifference with which women were treated - an indifference, she came to believe, in part brought about the pornography, brutalising and degrading the act of sex, in which a woman was an object to be exploited, enjoyed, abused, and at the end cast away.
Thus began the crusade against pornography that shaped her career, and for which she became internationally famous. Her first book, 'Woman Hating,' was published in 1973 when she was 27. Thereafter Ms Dworkin campaigned tirelessly on the subject, helping draft the pioneering Minneapolis and Indianapolis ordinances that define pornography as a civil-rights violation against women.
That law, since repealed, formed the basis for a civil rights suit on behalf of Linda Marchiano, better whom as Linda Lovelace, contending that she had been coerced into pornography. Quickly she became an authority on the issue testifying before the US Attorney General's Commission on Pornography and before the Senate Judiciary Committee.
The case became a precedent that would exercise legal thinkers and inspire a generation of grassroots feminist activists.
Thereafter her fame only grew, on both sides of the Atlantic. She appeared on national television shows including Donahue, The MacNeil/Lehrer NewsHour, 60 Minutes, CBS Evening News, before featuring in an hour-long documentary titled "Against Pornography" on the BBC. For her admirers, Ms Dworkin was a visionary. For her critics (mostly male) she was a tiresome scold, a man-hater and an undisguised advocate of censorship.
In addition to her crusade against pornography, Ms Dworkin wrote 13 books of fiction, nonfiction, and poetry, including Ice and Fire, and Mercy, as well as Life and Death: Unapologetic Writings on the Continuing War Against Women. She was a featured speaker at universities, conferences, and, for an event she helped create, Take Back the Night marches.
A speech to the University of Chicago Law School in 1993, summed up her philosophy as well as any. "Dehumanisation is real. It happens in real life, it happens to stigmatized people. It has happened to us, to women. We say that women are objectified."
"We hope that people will think that we are very smart when we use a long word. But being turned into an object is a real event; and the pornographic object is a particular kind of object. It is a target. You are turned into a target. And red or purple marks the spot where he's supposed to get you."
In the words of Dworkin
'Heterosexual intercourse is the pure, formalised expression of contempt for women's bodies'
'Erotica is simply high-class pornography; better produced, better conceived, better executed, better packaged, designed for a better class of consumer'
'Men know everything... no matter how stupid or inexperienced or arrogant or ignorant they are'
'Women?s fashion is a euphemism for fashion created by men for women'
Film Detailing US Human Rights Abuses in Afghanistan
Report by Charlie Pottins Published: 23//01/05
In May/June 2004, Walkley-award winning investigative reporter Carmela Baranowska was embedded with U. S. Marines in one of the most dangerous and remote parts of Afghanistan, beyond the reach of UN and aid agencies.
Frustrated by the limitations imposed on what she could report, Baranowska decided to travel back to Oruzgon Province independently of the U. S. Marines and Afghan militia that she had journeyed with up to that point. Western media outlets reported her kidnapping by the Taliban; a ‘fact' the documentary dispels. (The source of reports of an abandoned vehicle and Taliban abduction of a western woman has never been uncovered.)
More importantly, Baranowska's footage offers disturbing first-person accounts of the treatment being dealt Afghans by U. S. marines in the war on terror and has led to three US military inquiries and the controversial "firing" of the US Marine operational commander in Central Afghanistan. Despite these results none of the US military inquiries have been made public.
Camila Baranowska, touring Europe and the US with the film will be in the UK from Monday 24th - Sunday 30th January. She is available for interview.
Screenings organized so far:
Tuesday 25th Jan SOAS Student Union, Khalili Lecture Theatre, Thornhaugh Street, WC1 7-9pm
Thursday 27th Jan Goldsmiths College, Room 137, University of London, New Cross SE14, 7. 30pm - 9pm
Friday 28th Afghan Association of London Meeting Room, Community Premises, 27 Northolt Road, South Harrow 6 - 8pm *Private Screening*
Please email Carmela directly at
or call 0044 7749 421 576 to arrange interviews and further screenings