How to advocate for IUDs and implants given the history of birth control coercion

Dani McClain has a great piece at The Nation today exploring the growing enthusiasm for IUDs and implants — those super-effective long-acting reversible contraceptives, or LARCs — within the context of the long history of eugenicist attempts at controlling poor women of color’s fertility in the US. 

If your sole concern is curbing unintended pregnancies, then it’s hard to argue with the data on implants and IUDs, which are more reliable than the pill (91 percent effective) or condoms (82 percent). For champions of the Buffet-funded programs, that was a major selling point. In Colorado, Governor John Hickenlooper boasted that between 2008 and 2013, the LARC initiative had reduced the infant caseload of the state’s Women, Infants, and Children program by nearly 25 percent. Republican State Representative Don Coram, co-sponsor of the bill to provide state funding to Colorado’s LARC program, told National Journal that “policywise, [the LARC program] may be the best piece of legislation I’ve ever worked on,” in part because “80 percent of teen mothers that become pregnant will be on welfare within a year.” But some reproductive-justice advocates have urged caution: They’re worried that the excitement over LARCs has obscured the fact that efficacy is not the only reason why women choose a birth-control method. And they warn that, from the misuse of Norplant in the 1990s to forced sterilizations in California’s women’s prisons as recently as 2010, contraception has often been used to reduce the fertility of poor African-­American and Latina women, often without their consent.

McClain takes a nuanced and thorough look at a complicated issue. On the one hand, LARCs are still underutilized, particularly by the most marginalized communities. The high upfront cost, lack of insurance coverage, and dearth of providers trained in inserting them has left teens, low-income women, and women of color especially without access to these most effective birth control methods. “Women with household incomes greater than $75,000 per year were almost 11 times more likely to use LARCs than those whose household incomes were less than $10,000,” McClain notes. Studies have found that when cost is removed as a consideration, many more people choose LARCs. And while they’re supposed to be fully covered under Obamacare these days, some insurance companies still aren’t complying.

On the other hand, there is a long history of coercion in state-sponsored birth control programs in this country. And by “history,” I mean present. Birth control has been pushed on low-income communities of color not as means of ensuring reproductive freedom but as “a way of reducing populations that weren’t valued,” notes Dorothy Roberts, author of Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. And there’s evidence that unconcious bias affects health care providers’ birth control recommendations to their patients. Even if it doesn’t, a birth control counseling approach that emphasizes effectiveness at preventing pregnancy above all else can leave low-income Black and Latina women feeling especially pressured into opting for LARCs.

Reproductive justice advocates say that proponents of LARCs need to acknowledge this history if they want to ensure the methods are seen as real options for everyone. “There is a context that already exists in many communities of color and low-income communities around the country, and some of that is medical mistrust based on real, lived experiences,” explains Advocates for Youth’s Aimee Thorne-Thomsen. And they urge a model of counseling that doesn’t have a “laser focus on reducing births” but instead centers the patient’s preferences when it comes to a contraceptive method.

That sounds right to me. I have been an IUD evangelist for years. I think IUDs are great and that they should be offered for free to everyone who wants one. But I don’t have one anymore myself. A couple years ago, I swapped the most effective birth control method for one of the least. It was the right move for me. And while I haven’t exactly gotten the sense from the health care providers who’ve asked since that they think relying on condoms (and, honestly, not even always) is the greatest choice, they’ve never questioned it.

I want to live in a world where everyone has enough information to make a call like that for themselves — and be supported in it.

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