Alexandersanger.com

Hate Speech Brings Down a Bull Moose

2009-07-02T19:30:00.008-04:00

During the election campaign of 1912, a mentally-unbalanced man fired a shot at Theodore Roosevelt, the candidate of the Bull Moose Party, at a rally in Milwaukee, Wisconsin. The bullet was slowed by TR's lengthy speech, which he had double folded in his pocket, and by his eyeglasses case, nevertheless the bullet entered his body and he was bleeding profusely. Roosevelt declined to seek immediate medical attention and mounted the podium, announcing that he had been shot but that "it takes more than that to kill a Bull Moose."

A minute later, Roosevelt delivered the following lines about his would-be assassin.

"Now, friends, of course, I do not know, as I say, anything about him; but it is a very natural thing that weak and vicious minds should be inflamed to acts of violence by the kind of awful mendacity and abuse that have been heaped upon me for the last three months by the papers in the interest of not only Mr. Debs but of Mr. Wilson and Mr. Taft.

"Friends, I will disown and repudiate any man of my party who attacks with such foul slander and abuse any opponent of any other party; and now I wish to say seriously to all the daily newspapers, to the Republicans, the Democrat, and Socialist parties, that they cannot, month in month out and year in and year out, make the kind of untruthful, of bitter assault that they have made and not expect that brutal, violent natures, or brutal and violent characters, especially when the brutality is accompanied by a not very strong mind; they cannot expect that such natures will be unaffected by it."

These words bring to mind the mendacity, abuse and foul slander that were heaped upon Dr. George Tiller by the Right Wing talk show machine, most prominently by Bill O'Reilly, but by others as well. O'Reilly called Dr. Tiller a "baby killer," who has "blood on his hands" and who is guilty of what O'Reilly called "Nazi stuff." Others in the Right Wing routinely call abortion a "Holocaust."

Bill O'Reilly and his cohorts of hate cannot expect that "not very strong minds...will be unaffected" by their inflammatory language.

Truly delusional or deranged persons need little of this sort of "foul slander" to pick up a gun in order to prevent what they are told is a Holocaust. Those with weaker minds and constitutions need more instigation, which is what the daily litany of hate, intolerance and mendacity that Right Wing talk shows provide. They also provide a justification for murder — that murdering a doctor is justifiable homicide, preventing a greater evil, saving innocent lives. In this case, homicide isn't just justifiable, it is as necessary and imperative as bombing Auschwitz.

Delusional people often commit assassinations—Hinckley shooting Reagan to impress Jody Foster, for example. But an ordinary human mind, even a not very strong one, needs to be inflamed to commit the deed. Murder is a powerful taboo, but it can be overridden by the sort of bile that TR decried in 1912.

The Right Wing talk show juggernaut is an operation that would make Joseph Goebbels or the KKK proud — first dehumanizing the enemy, as the Nazis did the Jews and as the KKK did the black man, then dramatizing their threat to the home and hearth, and finally inciting the weak, in carefully coded and deniable language, saying that whatever happens to the enemy he brought on himself.

Those defending or excusing the murder of Dr. Tiller adduce a perverse variation on the civil obedience argument of Gandhi and King and Thoreau—murder for a higher principle. They press that principle further to say that it was necessary to kill the doctor in order to save lives—the lives of unborn children he might have aborted. This is to adapt the Hiroshima/Nagasaki Greater Good justification (we dropped the bombs to end the war to save American and Japanese lives, as many as a million and more) to the abortion issue.

General George S. Patton used to give incredibly bloodthirsty speeches to his men in order to inflame them to kill in battle, believing that it was necessary get men's passions up in order to induce them to commit murder. So the atrocities they committed in war seemed to them condign revenge and (as with the murder of an abortion doctor) a morally justified preventative measure. In his famous "Blood and Guts" speech to his Third Army on the eve of D-Day, Patton said the following:

"We're not going to just shoot the sons-of-bitches, we're going to rip out their living Goddamned guts and use them to grease the treads of our tanks. We're going to murder those lousy Hun cocksuckers by the bushel-fucking-basket. War is a bloody, killing business. You've got to spill their blood, or they will spill yours. Rip them up the belly. Shoot them in the guts."

Scott Roeder, the accused murder of Dr. Tiller, upon hearing that Dr. Tiller's clinic would not reopen, said the closure would mean "no more slicing and dicing of the unborn child in the mother's womb and no more needles of poison into the baby's heart to stop the heart from beating..." I wonder which Right Wing Patton he heard that from.

Bye-Bye Gag Rule — Hello Family Planning Funding Increases

2009-06-23T15:32:00.008-04:00

As expected, on January 23, 2009, President Obama rescinded, by Executive order, the Mexico City Policy/Global Gag Rule and announced that he would ask Congress to fund the United Nations Population Fund (UNFPA), which has been denied US funding for the past eight years.

The President said in his written remarks, "For the past eight years, they have undermined efforts to promote safe and effective voluntary family planning in developing countries...For these reasons, it is right for us to rescind this policy and restore critical efforts to protect and empower women and promote global economic development."

The President added, "For too long, international family planning assistance has been used as a political wedge issue, the subject of a back and forth debate that has served only to divide us. I have no desire to continue this stale and fruitless debate."

Alas, politics being what it is, the stale and fruitless debate on this issue flared up almost immediately, and opponents brought motions before the Congress to overturn the President’s repeal of the Global Gag Rule. All these motions failed by wide margins, wide enough so that another proposed bill, which would codify the end of the Global Gag Rule and prevent its re-issuance by future Presidents, is almost certain to pass. That said, politically-motivated future administrators of United States Agency for International Development (USAID) could simply refuse to fund IPPF projects.

As for money for family planning, well, no surprise, given the U.S. financial crisis, there is none — not this fiscal year anyway. Even in the future, there will be little new money for Latin America and the Caribbean. The Western Hemisphere is not high on the list for U.S. foreign aid — the priorities being in Africa and Asia. There is a proposal before Congress from a coalition of international agencies, including IPPF, to increase U.S. funding for family planning to $1 billion a year from its current level, which is about half that amount.

In response to our proposal, on June 17, 2009, a House Appropriations Subcommittee approved $648 million for family planning programs in the 2010 fiscal year appropriations bill, including $588 million for USAID programs and a $60 million contribution to the UN Population Fund.

If enacted, this appropriation would represent a 19 percent increase over the 2009 fiscal year allotment of $545 million. It also marks a 40 percent increase in funding over the past two years.

Progress!

George Tiller

2009-06-09T14:40:00.008-04:00

In August 2004 I journeyed to Kansas City to do a benefit with George Tiller to raise funds for his political action committee, ProKanDo.

His ever present opponents knew where we were and circled the house with a truck carrying large photographs of fetuses.

About fifty brave supporters gathered. I spoke about the importance of being politically strong and giving backbone to our elected representatives.

George then spoke. He roared, "Tiller, George, First Lieutenant, reporting for duty!" George told of his days as a Navy Surgeon and, when his parents were killed in a plane accident, that he was discharged from the navy to take over his father's solo medical practice. His patients soon let him know that his father had performed abortions and pleaded with him to continue. George realized how necessary safe and legal abortion was once he heard of a patient dying from an illegal abortion. So, George continued his father's practice.

His clinic brochure said on the cover: "Kindness, Courtesy, Justice, Love, Respect." George said, "Women and families are intellectually, emotionally, spiritually, and ethically competent to struggle with complex health issues — including abortion — and come to decisions that are appropriate for themselves."

George was a hero in our Cause, but especially to all the women he helped over the years. He will be missed.

Obama-Hillary photos from the Women for Obama Breakfast at the New York Hilton on July 10, 2008

2008-12-04T19:39:00.017-05:00

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RH in Bhutan

2008-10-26T16:58:00.004-04:00

The small, Switzerland-sized, Himalayan nation of Bhutan has only recently emerged from the Middle Ages and from its Middle-Ages-level reproductive health problems.

Fifty years ago in Bhutan, there were no schools, no currency, no mail, no roads and no health care beyond what traditional healers provided. There were no clinics, hospitals, doctors or nurses. There were no modern contraceptives. There were no statistics on either health or demography. The size of the population was unknown, as was life expectancy, and infant and maternal mortality. There was a tradition of traditional medicine, although the traditional medicine practitioners I spoke to professed not to know which herbs were and are currently used for pregnancy prevention and pregnancy termination.

From a standing start in 1960, Bhutan has developed, so that now there is universal primary education (classes are taught in English, except those in Bhutanese history and language), as well as a free health care system of hospitals and rural health clinics that reaches almost the entire population. It would reach all of it, but the rudimentary road system does not come close to covering the nation, and the vast majority of the populace has to walk or rely on overcrowded and sporadic busses to reach nearby towns.

Statistical gathering remains less than scientific. For instance, the UN reports that Bhutan has a population of 2.3 million, whereas the Bhutanese report a population of approximately 700,000. See the UN State of the World Population Report for 2007. http://www.unfpa.org/swp/2007/english/notes/indicators.html

Therefore, any statistics that are reported should be taken with a grain of salt. According to the UN, life expectancy is about 63 for males and 66 for females; infant mortality is 48 per 1000 live births (it was 102 in 1984) and the maternal mortality ratio is 420 (it was 770 in 1984), both about 20% lower than neighboring India; contraceptive coverage is around 20%; the TFR is 3.9 (it was 4.7 in 2000); about a quarter of births are attended by a skilled birth attendant. Childhood vaccinations are almost universal, and as a result of reduced infant mortality and increased life expectancy, the population has been growing rapidly (at 2.2% annually the UN reports; it was at 3.1% in the mid-1990’s), yet labor is imported for road and construction work from Nepal and India.

There is not the sex ratio imbalance at birth that is seen in India and China. In schools there is a dominance of females in the later grades, after many boys are sent to monasteries or drop out to work the family farm (about 10% of the male population are monks and 90% of the population work in agriculture or forestry). In one school I visited, in the 12 year old class, there were 16 girls and 7 boys. The society operates as a matriarchy. The eldest daughter inherits the family farm, and her husband comes to live with her, and with her parents until they retire after age 50 or so to a community monastery to pray and meditate.

Modern contraceptives are widely available, with the government health clinics offering free oral contraceptives, IUD’s, Depo-Provera and condoms, as well as male and female sterilization. Oral contraceptives are also sold in pharmacies at $2 per cycle and condoms are sold for $1 and $2 depending on the brand. Condoms are also distributed for free at various non-health locations in cities and towns. Still, as noted above, there are many couples not using contraception, due to a combination of a desire for large families and lack of access.

A visit to a rural health clinic gave some perspective on all these statistics. The following statistics (for 2007) were posted on the wall of the doctor’s office. This particular clinic covered an area with 243 households and 1257 inhabitants (about 5 persons per household), with slightly more females than males (641 to 616). There were 286 females of reproductive age between the ages of 15 and 49. There were 16 infants less than 1 year old and 91 children less than 5.

There were no reported infant deaths, child deaths or maternal deaths in 2007. The doctor has a network of “informants” around the village and as soon as it is known that a woman is pregnant, this fact is reported to him, and he makes a visit to the home, where he talks about prenatal care and sees to it that the woman has at least 4 prenatal appointments. When delivery time approaches, he arranges for the woman, if she can, to go to the regional hospital a week before her delivery date, accompanied by a relative who has her same blood type in case a transfusion is needed (anemia being a major complication in pregnancy). Naturally this is not possible in every case, and in 2007, of 18 pregnancies about half were attended at home and half delivered at the hospital.

Of the 286 females of reproductive age, there were 6 IUD users, 89 Depo users and 9 pill users. There were no sterilizations performed. Condoms are kept in a box by the door that woman and men can access without entering the clinic. The balance of the women of reproductive age presumably were using condoms, were not sexually active or were, or were trying to get, pregnant.

There are HIV/AIDS awareness signs in the clinic and along the roads of the town. Sex Ed begins in secondary school, though there is health and hygiene instruction in primary school, where teachers are required to inspect the children weekly to be sure that their uniforms and fingernails are clean, and that they have a handkerchief pinned to their uniform if their nose is running.

There is testing in the clinics for sexually transmitted diseases, and the rates are unofficially reported to be high. Bhutan is not a puritanical society, although public displays of affection are frowned upon, and couples pair and un-pair with some regularity and often get married only when the female becomes pregnant.

The abortion rate is unknown. I was told that abortion was against Buddhist ethics and was illegal except to save the life of the mother. Naturally, there is a problem of unsafe abortion. In a 1999 survey, of 654 obstetric complications, 71, or 14%, were due to septic abortion. In the clinic I visited, the physician did not report any septic abortions. Bhutan is surrounded by nations that have decriminalized abortion: India and China, and Nepal, although Nepal does not technically border Bhutan. One can hope that given the difficulties of travel for most citizens, Bhutan does not think it can rely on abortion tourism (or self induced abortion) to be the only alternatives for its women for pregnancy termination.

Despite its reputation as a Shangri-La, Bhutan has a domestic violence problem. Recently, one of the Queens founded an organization called RENEW to provide shelter and counseling for abused woman. It is located in a modern facility in the capital. Additionally, RENEW is constructing a residential safe house facility for women and their children to provided temporary housing until the woman can get divorced and resettled in society. They do a wonderful job, but it was sobering that such an organization needs to exist in this otherwise peaceful nation. See http://www.renew.org.bt/

Since Bhutan has a military force of only 4,000 (the Indian Army picks up the slack), it can, and does, spend a large proportion of its budget, approximately 15%, on health care. With improving infant and maternal mortality, the results are plain and commendable. One can hope that progress continues.

The Decriminalization of Abortion Upheld by Mexico Supreme Court

2008-09-16T21:49:00.002-04:00

On August 28, Mexico’s Supreme Court by an 8-3 vote upheld as constitutional the decriminalization of abortion.

The law, passed in 2007 by the Mexico City Legislative Assembly, decriminalized abortion in the first 12 weeks of pregnancy. The law also defined a pregnancy as beginning upon implantation and required public health centers in Mexico City to provide abortion information and free services, with an opt-out for doctors with a conscientious objection. With this law, Mexico City joined Puerto Rico, Cuba and Guyana in the Hemisphere as having decriminalized abortion in the first trimester.

The law was immediately challenged by the pro-criminalization forces in Mexican society, as violating the right to life as set forth in the Mexican Constitution. The decision, finding that it did not, was a constitutionally limited one, unlike the broader Roe v. Wade decision from the U.S. Supreme Court in 1973. The Roe decision found that in the U.S. Constitution there was a right to privacy that required that abortion be decriminalized before fetal viability. The Mexican Court held that the Mexican Constitution permitted, but did not require, the state legislatures of the nation to decriminalize, or criminalize, abortion. One judge said, “It is not up to the Supreme Court to legalize or criminalize abortion.” With this decision as precedent, other states in Mexico can decriminalize abortion should they choose to do so.

The Mexico City abortion law addresses a catastrophic public health problem: unsafe abortion. There are estimates that there are between 500,000 and 1 million unsafe abortions a year in Mexico, with approximately 100,000 annual abortion-related hospital admissions. From 1990 to 2005, 21,646 women in Mexico died of maternal related causes, with abortion accounting for 537. These figures are probably understated given the illegality of the procedure. Since the decriminalization, there has been one death from abortion in Mexico City.

Additional maternal deaths in the past were in no doubt caused by lack of access to family planning services, which would have delayed pregnancies until the woman was older, spaced out a woman’s pregnancies and reduced the absolute number of pregnancies, thereby reducing the risk of death in childbirth. It was heartening to see that 58% of women seeking abortions in Mexico City ask for an IUD after their abortion to prevent their next pregnancy. Abortion decriminalization must be part of a broad public health plan to bring reproductive health care services to young, poor, indigenous, rural and uninsured women, who otherwise do not have access. About 40% of pregnancies worldwide are unintended. It is these pregnancies that result in unsafe abortion and maternal mortality and morbidity. This can be prevented only by simultaneously attacking gender inequality, gender violence, lack of information and access to contraceptive services, lack of an appropriate contraceptive method for every woman at every stage of her reproductive life, and, finally, the stigma that women face in many cultures in trying to control their bodies and their lives. A big agenda, but Mexico has shown that we can tackle it.

The U.S. Election of 2008 ― A Clear Choice

2008-09-14T13:54:00.003-04:00

As far as global reproductive health, the foreign policies of John McCain and Barack Obama are as different as night and day. More particularly, the candidates have opposite positions on the Mexico City Policy, also known as the Global Gag Rule (the “Rule”), which prohibits U.S. foreign aid for family planning programs going to any U.S. non-governmental organization that either performs abortions, counsels on abortions or advocates for legal abortion. Senator McCain supports the Rule and Senator Obama opposes it. The difference is that clear. Senator McCain has voted consistently to support the Global Gag Rule in votes in the Senate to overturn the Rule, while Senator Obama has consistently voted to overturn it. In the September and December 2007 votes to overturn the Rule, neither Senator was present to vote. However, in a prior vote in April 2006 to overturn the Rule, Obama voted in favor of overturn and McCain voted against. In five previous votes since 1991, McCain voted to uphold the Global Gag Rule. Senator Obama was not a member of the U.S. Senate for those votes. Senator Obama told me personally in January 2008 that he would sign an executive order overturning the Global Gag Rule.

In the fight to reauthorize PEPFAR in 2008, the President’s Emergency Plan for AIDS Relief, both Senators were co-sponsors. In 2003 Senator McCain voted to require one-third of AIDS funds be spent on abstinence-only programs. Obama was not a member of the Senate for this vote.

With respect to funding UNFPA, McCain voted at least five times against funding UNFPA, while Obama has voted in favor. Obama says specifically that he will work to fund UNFPA as President. McCain has been silent on this issue.

The differences between the candidates on U.S. domestic reproductive health care issues are as stark, with McCain voting and calling himself “pro-life” and Obama voting and calling himself “pro-choice”. The Planned Parenthood Action Fund, the political arm of the Planned Parenthood Federation of America, rates McCain at 0% and Obama at 100% and has endorsed Obama for President. It is likely that, based upon past votes and statements made as candidates, as President that Senator McCain would continue the reproductive health policies of President Bush, while Senator Obama would pursue reproductive health policies more akin to those of President Clinton. The difference is clear.

Remember Sanger

2008-09-14T13:52:00.000-04:00

The attached letter appeared in the Concord Monitor. I don’t think my grandmother was being arrested at that point in her long career of lawbreaking, but who knows.

http://www.concordmonitor.com/apps/pbcs.dll/article?AID=2008809080365

Health Agenda for the Americas: Where’s the Courage?

2008-05-31T10:51:00.002-04:00

In June 2007 the Ministers of Health of all Latin American nations issued a Health Agenda for the Americas: 2008-2015, (the “Agenda”) a supposedly comprehensive plan for improving the health of the people of the Americas that was anything but comprehensive. It managed to leave out many proven recommendations for improving the sexual and reproductive health of the citizens of Latin America.[1]

Infant and Maternal Mortality

If the moral soundness of a society is measured by how it treats its children, then Latin America, while better than Africa, does not measure up.

Infant mortality in Latin America is stubbornly high ― averaging 23 per 1000 live births (versus 7 in the U.S.) ― though an improvement from 81 per 1,000 live births in the years 1970-1975.[2]

Maternal mortality is far too high, with Bolivia and Peru leading at rates of 420 and 410 per 100,000 births respectively, as opposed to 17 in the U.S. Uruguay has the low at 27.

The major causes of high infant and maternal mortality are well known: poverty, lack of skilled birth attendants and deficiencies in emergency medical care. There are underlying causes as well that lead to these medical emergencies, and they all fall under the rubric of sexual and reproductive health. Health experts, and mothers, know that contraception which enables intended pregnancy can improve outcomes by 1) delaying first birth until a woman has fully matured, 2) birth spacing, permitting a mother to regain her health and to fully nurture the child she has before giving birth to the next, and 3) reduction in absolute number of births, allowing the mother to give more care to the children she has.

The Agenda, to its credit, called access to contraceptives “indispensable,” and called for continuous care to mothers before, during and after pregnancy, for increased efforts to prevent transmission of STI’s and for stronger men’s roles in all these.

While a good start, this is insufficient.

Contraceptive and Fertility Rates

The issue in Latin America is not contraceptive use; it is getting the contraceptives to those at risk for unintended pregnancy. Contraceptive prevalence in Latin America is the highest in the developing world, on average, with 75% of women in South America and 66% in Central America having access to a method (the corresponding figure in Africa is 27% and in the U.S. 73%). These rates are far less in rural and poorer areas, and thus the rate of unintended pregnancy there is higher. Increase in contraceptive prevalence (the rate was 60% for Latin America and the Caribbean in 1998) though has not translated into birth rate or abortion rate declines.

The reason is a combination of lack of contraceptive access in vulnerable populations, along with higher intended childbearing desires. In some Latin countries overall birth rates, including teen birth rates, increased during the 1990’s, while in the rest of the world they declined. On average, 20% of teens give birth in Latin America. The fertility rate for ages 15-19 is currently 78 in South America. In 1996, the South American rate was 75, indicating a 4% rise since then.

A comparison with the U.S. is instructive. The fertility rate for Hispanic teens in the U.S. is about 82 for 2005, or slightly higher than the overall fertility rate for teens in Latin America (about 76). The U.S. figure disguises ethnic variations among immigrant populations, with the fertility rate for teens of Mexican origin in the U.S. being 93. However, interestingly, the teen fertility rate in Mexico is 63, about a third less than for Mexican teens in the U.S. Hispanic teens in the U.S. in general have a higher fertility rate than Hispanic teens in their country of origin.

The reasons could include lack of access in the U.S. to contraception or more teen sexual activity. Also Hispanic culture meeting with more prosperity in the U.S. (as well as in those Latin countries that have prospered) could have led to increased teen birth rates. There are no figures, though, that I have seen as to the intentionality of these teen pregnancies.

Though adolescents especially were recognized in the Agenda as needing special attention, there was, however, no specific call for renewed sexuality education efforts and increased availability of contraceptives for adolescents. This is not dissimilar to the silence in official circles in the U.S. Government around teen sexual activity, except for calls for abstinence education.

One sure way to decrease unintended pregnancy for teens and adults alike is emergency contraception. In many Latin countries there are battles over the legality of emergency contraception, which is characterized, mistakenly, as an abortifacient. In Chile and Ecuador, cases challenging distribution of emergency contraception recently went up to their respective Supreme Courts where, alas, EC opponents prevailed. The Agenda makes no mention of emergency contraception.

Abortion

An abortion rate about 50% higher than the North American level predominates throughout Latin America, along with attendant maternal mortality and morbidity. This would indicate pregnancy rates are higher than the desired childbearing rates. Still, women in Latin America have about one more child than they say they want.[3]

Abortion is proscribed virtually everywhere in Latin America, except Cuba, Guyana and Mexico City. Four of the five countries of the world which prohibit abortion in all cases, even to save the mother’s life, are in Latin America: Honduras, Chile, Nicaragua and El Salvador. There are about 4 million illegal abortions a year, 95% of which are unsafe. About 5,000 women die a year, resulting in 20% of all maternal deaths being from unsafe abortion.[4]

There has been progress during the last year in decriminalization. Colombia’s Constitutional Court decriminalized abortion in three cases: rape, for the life or health of the woman and for fetal deformity. The Mexico City legislature also decriminalized abortion, by a vote of 46 votes in favor and 19 against, despite a threat of excommunication.

The Agenda made no mention of de-criminalizing abortion or providing post-abortion care.

STI’s and HIV/AIDS

While HIV/AIDS levels are below those of sub-Saharan Africa, HIV is still at serious levels. The prevalence rate is at or below 1% in every South American country, similar to most Asian countries, compared to rates of 25% in southern Africa. Condom use in Latin America is low ― just 4% of women in Brazil and Mexico report using condoms, compared with 13% in the U.S. according to PAHO (other sources show a higher rate of condom use of 18% in the U.S.).[5]

Approximately one-third of Latin women have never had a Pap smear. In the U.S. about 84% of women had a Pap smear within the last three years (including 81% of Hispanics), indicating that Hispanic women are not disproportionately marginalized from the U.S. health care system.

The Agenda made no specific recommendations for increasing condom use and the availability of Pap smears.

Violence Against Women

Violence against women is apparently more prevalent in Latin America than in the United States, though comparable and accurate statistics are hard to come by. In the U.S. there has been a steady decline in what the U.S. Department of Justice calls “intimate partner non-fatal victimization” (a gender neutral term) which had declined from 6 per 1000 persons to about 2 per 1000 from 1993 to 2005. The rate of violence against both Hispanic and non-Hispanic females in the U.S. declined as well and averaged about 4.2 per 1000 annually during the period 2001-5.[6]

In Latin America, the few surveys that have been done show, for example, that over 40% of women ages 15 to 49, who have ever been in a union in Peru (42%) and Colombia (44%), have been victims of partner violence. This is a cumulative figure, but it would appear that violence against women is higher in Latin America than among Hispanics in the U.S. DHS surveys in Latin America reveal that, for instance, in Nicaragua 11.9% of women experienced domestic violence in the year preceding the survey.[7]

There was not a single mention of violence against women or domestic violence in Health Agenda for the Americas: 2008-2015.

The Americas’ Health Ministers’ Recommendations… and Omissions

So, the Latin American Health Ministers made a less than sterling start in addressing the sexual and reproductive health needs on their citizens, leaving out sexuality education, teen access, condoms, safe abortion, emergency contraception and measures to combat domestic violence.

Not unexpectedly, they did call for increased spending on health. The region spends 6.8% of its GDP on health care, or about $500 per person (the U.S. figures are 16% and $7,600, respectively).[8]

How to pay for increased sexual and reproductive health care? First, decriminalizing abortion will save health care dollars. So will providing preventive health care, including family planning, emergency contraception and condoms. Passing and enforcing domestic violence laws too will reduce health care expenditures.

If funds are needed, countries might consider increasing tax revenues. Latin American taxes average 18% of GDP (in the U.S. it is about 25% and about 36% in Western Europe.[9]

Finally, the U.S. and other donor nations could also increase their ODA to the agreed-upon level of 0.7% of GDP. The U.S. ODA in 2006 was at 0.17%. Only three Scandinavian nations, the Netherlands and Luxembourg exceeded 0.7%.[10] Having healthy neighbors is in our national interest.

[1] All data that follows comes from the following sources, except as otherwise noted: Pan-American Health Organization’s (PAHO) Gender, Health and Development in the Americas- Basic Indicators 2007, and the United Nations Population Fund’s (UNFPA) State of the World Population 2007.

[2] See http://www.eclac.org/cgi-bin/getProd.asp?xml=/prensa/noticias/comunicados/6/32166/P32166.xml&xsl=/prensa/tpl-i/p6f.xsl&base=/prensa/tpl-i/top-bottom.xsl and http://www.unicef.org/progressforchildren/2004v1/latinCaribbean.php

[3] See http://www.infoforhealth.org/pr/m17/m17.ppt#289,34,Married Women (Ages 15-49) Have About One Child More Than They Want, 1990-2001

[4] See http://www.guttmacher.org/pubs/fb_IAW.html and http://www.guttmacher.org/pubs/2006/07/10/PreventingUnsafeAbortion.pdf

[5] See http://www.guttmacher.org/pubs/fb_contr_use.html

[6] See http://www.ojp.usdoj.gov/bjs/intimate/overview.htm

[7] See http://www.measuredhs.com/pubs/pdf/OD31/OD31.pdf

[8] See http://www.nchc.org/facts/cost.shtml

[9] These figures vary by source but see http://www.eclac.cl/cgi-bin/getProd.asp?xml=/prensa/noticias/comunicados/3/32253/P32253.xml&xsl=/prensa/tpl-i/p6f.xsl&base=/prensa/tpl-i/top-bottom.xsl .

[10] See http://www.millenniumcampaign.org/site/pp.asp?c=grKVL2NLE&b=274333

The No-Brainer Syndrome : the HPV Vaccine and Male Circumcision Recommendations as the Latest Weapons in the Fight Against HPV, HIV and AIDS

2008-03-16T13:25:00.004-04:00

Dr. Paul Offit, director of the Vaccine Education Center at The Children's Hospital of Philadelphia, called the new HPV vaccine, Gardasil, approved last year by the Center for Disease Control (CDC), ”a no-brainer.” Many advocates in the blogosphere use the same phrase, “no-brainer”, to describe the World Health Organization (WHO) 2006 recommendation for male circumcision as an HIV/AIDS prevention strategy, at least in sub-Saharan Africa. Most health professionals agreed, even if they didn’t use the exact phrase.

The public disagreed. A mere 10% of girls in the U.S. have been vaccinated so far with Gardasil and few men in Africa have had “the snip”. Within the past weeks the Virginia Legislature has taken steps to repeal its mandate for the HPV vaccine for schoolgirls, and the Health Minister of South Africa has refused to endorse male circumcision as part of its national AIDS program.

So, are these recommendations “no-brainers” or not?

They aren’t, for three reasons: 1) rents did not rush to get their daughters vaccinated.

Aside from safety, effectiveness and cost issues, some parents and public health officials had additional concerns:

Efficacy ― while the vaccine does protect against HPV-16 and HPV-18 (the strains that cause 70% of cervical cancer), by so doing the vaccine may be unleashing other HPV strains which can infect the woman ― thus, the ultimate efficacy of the vaccine against all HPV infections and, ultimately, against cervical cancer may be less than the initial studies indicated;
Misallocation of Funds ― money to pay for Gardasil as part of the Medicaid program or some other government program would have to come from somewhere, perhaps leading to a reduction in health prevention or treatment of HPV itself. There is an argument that whatever millions are spent on HPV vaccination might be better spent on a more comprehensive STI prevention program, including condom use and more extensive Pap screening.
Risk Compensating Behavior ― conservative groups argued, only somewhat disingenuously, that HPV vaccination would inevitably lead to adolescents engaging in more, earlier and unprotected sex, thereby causing more transmission of HPV and other sexually transmitted infections. Vaccinated, and unvaccinated, adolescents might have a reduced fear of contracting HPV, and might thus engage in more and riskier sex. This is known in the public health world as “risk compensation”, and occurs when there is a perceived change (i.e. reduction) in the risk of acquiring a disease or being involved in an accident, for instance with drivers with seat belts and air bags driving faster. The fact that there is still a multiplicity of sexually transmitted infections out there (including other HPV strains) that Gardasil does not prevent, and thus that there should be no false sense of immunity, has not dissuade these conservative groups from their campaign. This argument might be, in theory, a valid concern, but remains unproven.

Male Circumcision

In 2007 the World Health Organization announced that it was recommending male circumcision “as an efficacious intervention for HIV prevention.”

Circumcision has a long and often contested history ― socially, culturally, medically and religiously ― which the WHO was well aware of, yet in 2007 two studies, one in Kenya and one in Uganda, were halted early by medical authorities, when the preliminary results showed a 53% and 51% reduction in risk respectively in acquiring HIV infection by circumcised males as opposed to uncircumcised males. The case for circumcision was so clear that it appeared to be a “no-brainer”, even though scientists have no proof of how circumcision might actually work as an HIV preventative. Possible explanations include the keratinisation, or extra layers of skin forming on the penis, that occurs after circumcision serving as a retardant to HIV transmission, or the susceptibility to HIV in the Langerhans cells in the inner foreskin. Langerhans cells are immune cells which act as a reservoir and replication site for the HIV-1 virus. They also appear in other parts of the male and female genitals, including the clitoris. There was no suggestion by WHO that these cells, or the surrounding skin on the organs that contain them, be excised. The WHO circumcision recipe for the goose is not one for the gander.

Some policy makers raised similar objections to circumcision as those raised against HPV vaccination:

Efficacy ― the WHO itself emphasized that circumcision was not 100% effective, and that, in fact, the HIV infection rate in circumcised males in the African clinical trials was still unacceptably high. There was no evidence that male circumcision protects female partners, or the partners of men who have sex with men. Both these sad facts have been born out by subsequent trials. Circumcised men who are HIV positive transmit the virus to their partners at the same rate as uncircumcised men. In fact, there was an observed increase in infection in the female partners of circumcised men who commenced sexual intercourse before their circumcision wounds had healed, despite extensive counseling of the couples to abstain until they got a go-ahead from a nurse.
Misallocation of Funds ― some public health officials argued that a more effective use of funds was the current armament of HIV prevention strategies, such as ABC, especially the “C”. It is hard to imagine an effective public health campaign that urged circumcision and continued condom use ― why should a man go through circumcision if he still has to wear a condom?
Risk Compensating Behavior ― there is a real prospect of an increase in risky sexual behavior by those circumcised, including reduced condom use and more sexual partners. In Africa the widespread male dissatisfaction with condom use and an innate desire for multiple partners and large families would likely be the chief motivators for males to seek circumcision in the first place, so that they would have a ready excuse not to wear condoms.

A final danger for women is that there might be a conflation of male circumcision with female genital mutilation, especially if the theory of the Langerhans cells (which appear in both the foreskin and the clitoris) is proven. The conflation in some parts of the world of male and female circumcision as a cultural marker or initiation rite is already problematic. It would be horrific if the call for more males to be circumcised in cultures where it is not practiced led to more female genital mutilation.

HPV Vaccination and Male Circumcision: Case Studies in the Failure of Public Health

So, here we have two new, expensive public health recommendations relating to sexually transmitted infections, one for females and one for males. Neither is a “no-brainer.” Each is less than 100% effective, and has the real possibility of greater harm: Gardasil if the vaccination unleashes other HPV strains and circumcision if males have sex before the wound heals and if they embark on more partners without wearing condoms. Each risks draining resources from other prevention strategies, and each could harm women especially.

Cervical cancer can be caught and cured with pap smears, and HIV by a comprehensive ABC program. HIV in Africa is mostly transmitted by female prostitutes. Thailand embarked on a program to require condom use in brothels. Africa has not. The HIV prevalence rate in Thailand is now far lower than in Sub-Saharan Africa. ABC can work. The circumcision recommendation is, I believe, more a comment on the world’s failure to implement ABC than on the benefits of the procedure, just as the HPV vaccine recommendation is a sad commentary of the U.S. and the world’s failure to have a comprehensive public health system that gets Pap smears to every woman.

The foregoing is abridged from a longer article of the same title that can be found at www.AlexanderSanger.com
A citation for the proposition for the potential unleashing of other HPV strains caused by HPV vaccination is as follows: George F. Sawaya, MD and Karen Smith McCune, MD, Ph. D, HPV Vaccination: More Questions More Answers,

http://content.nejm.org/cgi/reprint/356/19/1991.pdf

This editorial states in part:

"In contrast to a plateau in the incidence of disease related to HPV types 16 and 18 among vaccinated women, the overall disease incidence regardless of HPV type continued to increase, raising the possibility that other oncogenic HPV types eventually filled the biological niche left behind after the elimination of HPV types 16 and 18."

No Brainer

2008-02-27T00:35:00.007-05:00

The No-Brainer Syndrome : the HPV Vaccine and Male Circumcision Recommendations as the Latest Weapons in the Fight Against HPV, HIV and AIDS

Nonetheless, I wondered if they were right - mainly because in my experience the words "no-brainer" usually indicates more about the state of the grey cells of the person uttering the phrase than about the state of the choice that is faced.

Then I noticed the coincidence that Gardasil and male circumcision were each targeted to a single sex: Gardasil to females, and circumcision to males (a second HPV vaccine Cervarix was approved in Europe for both sexes). Was each recommendation the result of some murky sexist plot or was it just a sexist coincidence? And what did it matter?

I also noticed that there were no lines around the block for either medical service. A mere 10% of girls have been vaccinated so far with Gardasil and few if any men have had "the snip". Within the past weeks the Virginia Legislature has taken steps to repeal its mandate for the HPV vaccine for schoolgirls, and the Health Minister of South Africa has refused to endorse male circumcision as part of its national AIDS program.

So, after all the fanfare, what is going on here, and can we learn any public health lessons?

The Two Epidemics

The HPV- Cervical Cancer Epidemic - Cancer of the cervix is the second most common cancer of women worldwide, with 555,000 new cases and 260,000 deaths annually. Most cases (80%) of cervical cancer occur in the developing world.

Almost all (99%) of cervical cancer cases are linked to HPV, the human papillomavirus. There are over 100 different types of HPV (over 30 of which are transmitted sexually) that can infect women and men. Two types (HPV 16 and 18) cause 70% of cervical cancer, and two other types, HPV 6 and HPV 11, cause 90% of genital warts. Merck's Gardasil targets these four strains, while GlaxoSmithKline's Cervarix (approved in Europe and elsewhere but not yet approved by the FDA) mainly targets HPV 16 and 18.

About 3 in 4 men and women will develop HPV in the United States during their lifetimes, but fortunately about 90% of those infected will clear their HPV infection within two years without medical intervention. Currently, 27% of women ages 14-59 have HPV. Every year, about 11,000 women in the U.S. are diagnosed with cervical cancer, and about 3,700 women die of the disease - a high a number but, compared to the number of women with HPV, a tribute to the healing powers of nature and the U.S. Pap smear screening program, even though for some populations of women the program is as porous as a cotton condom.

In the developed world, about half of women have been screened for HPV/cervical cancer within the last five years, but only about 5% in the developing world have. As a result, the death rate from cervical cancer in the developed world has plunged in the last half century but has not in the developing world.

There have been recent studies linking HPV to a rise in oral cancer in men. See http://content.nejm.org/cgi/content/full/356/19/1944?ijkey=qVEw4puuEh6zQ&keytype=ref&siteid=nejm

Men (73%) are far more likely than women to have oral cancer, which hits 35,000 people a year in the U.S. and kills 8,000. The rate for males has increased since 1973, even though there has been over a decrease in tobacco use during that time, which should have resulted in, but didn't, a reduction in the incidence of oral cancer. That leaves the rise in oral sex as the culprit. Currently, oral sex causes as many cases of oral cancer in men as smoking does. In contrast, the rate of HPV-related upper throat cancer among women has fallen since 1973. Studies do not reveal any reduction in oral sex performed by females during that time, in fact quite the opposite. So what is happening? Are women requiring condoms on their male partners before performing oral sex? No. As you might imagine, governments are not champing at the bit to fund studies on oral sex, but the few that there are say that condom use during oral sex occurs only slightly more frequently than a lunar eclipse. One British study from 2003-2005 found that 80% of 16-21 year old university students did not use condoms during oral sex, whereas most did during vaginal sex. In the U.S. a 1996 study found that 86% of high school student never used a condom during oral sex and 8% used one sporadically. One suspects that the self-reporting nature of these scientific studies exaggerated the frequency of condom use.

See http://www.guttmacher.org/pubs/psrh/full/3800606.pdf

The HIV/AIDS Pandemic - At the end of 2007 there were about 33 million people living with AIDS (about equally divided by gender), with 2.5 million persons newly infected in 2007 and 2.1 million deaths. The majority of HIV infections worldwide are transmitted by heterosexual sex.

There has been a gradual reduction over the past few years in new HIV cases globally, reflecting the natural trend of the epidemic and behavioral changes in at-risk populations. There has also been a reduction in the number of deaths annually, due mainly to greater access to more effective treatments.

The Magic Bullets

Both epidemics, HPV and HIV, have certain similarities: both are viruses, both are transmitted sexually, both have a high death toll and both flourish because of the molasses-like pace of change, or lack thereof, in the human sexual behavior needed to thwart them. The ABC (Abstinence, Be faithful, Condoms) approach has been effective in some countries, mainly resulting in more condom use, in Africa and elsewhere, but alas, condom use is not universal for many reasons - cultural, sexual, economic and otherwise, including the prosaic fact that the worldwide condom supply is both erratic and insufficient. Alas, even when condoms are available and used, they are not universally effective against HPV/genital warts. Thus HPV and HIV march on.

So why the public health establishment embrace of techno-fixes, seeming magic bullets in the fight against HIV and HPV? Why not devote the money to manufacturing and distributing more condoms along with educational messages?

A combination of factors are at work, including impatience and frustration on the part of health officials with the lack of headway against the diseases. One researcher stated, "It has been claimed that primary prevention based on an educational, social and rights-based response has failed, and what is needed is a more thoroughgoing engagement with the principles of ‘traditional' public health medicine."

There is pressure to find a solution, any solution, especially one that will attract funding. This has led to an increased emphasis on "biomedical prevention", i.e. vaccines and surgery, which involve as little human behavioral cooperation as possible, like fluoride in the water supply. For example, there have been recent suggestions that antiretroviral drugs be rolled out to otherwise healthy populations in Africa. In the past month, it was also proposed that antibiotics be given to all aboriginals in Australia to prevent the further spread of sexually transmitted infections (this was before the Australian government's apology for its treatment of aboriginals; perhaps a new apology is in order). Meanwhile, multiple teams of scientists with dreams of Nobel Prizes dancing in their heads are hard at work on the holy grails/magic bullets of a female microbicide for HIV prevention and a HIV vaccine. These appear to be far in the future, but hopefully one or both will appear before the next solar eclipse in New York (April 24, 2024). See P. Aggleton, ‘Just a Snip'?: A Social History of Male Circumcision, Reproductive Health Matters 2007: 15 (29): 15-21.

So, for starters, what science has given us are a vaccine and circumcision. Neither are 100% effective. And, just as fluoride does not obviate the need for brushing one's teeth, the WHO made it clear that the HPV vaccination and male circumcision were not cure-alls and that condoms were still needed.

Perhaps for this reason, the reception by men and women for these "new" technologies was less than clamorous.

The HPV Vaccine-Gardasil

Gardasil is recommended for young females, preferably ages 11-12, who are not yet sexually active and hence not already infected with HPV. The vaccine has been approved by the FDA for all females ages 9-26. Three doses are required over a six month period, and thus repeat visits to the doctor. The vaccine was approved for girls only, since Merck did not have enough boys in its clinical trials to prove safety and effectiveness for them. Trials for boys are continuing, and reportedly a second application to the FDA is due from Merck in 2008 to have Gardasil approved for males.

It is not known whether it was Merck's decision to concentrate on girls in its initial trials, whether there was true difficulty recruiting boys for the trials, or whether the vaccine is simply not as effective in boys as girls. There is a public health argument that since cervical cancer is the ultimate target of the vaccine that it should be targeted to girls. And, assuming that there are limits to public funds for HPV vaccination, one argument to be made against the vaccination of boys is that the cost thereof would be better spent reaching all girls ages 11-12, thereby providing, eventually, what is called "herd immunity," which occurs in a population when at least 70% of its females are vaccinated. Thus, the decision to concentrate on females has grounding in public health theory.

Alternatively of course, all funding could have been directed at immunizing males and allowing their herd immunity to protect females. The New York Times recently speculated that there would have been few takers for this among boys and their parents. See http://www.nytimes.com/2008/02/24/fashion/24virus.html?scp=1&sq=herd+immunity&st=nyt

As with any vaccination, there are side effects. The injections are painful. The CDC reports that there have been other reported side effects, including fever, nausea and dizziness, but that these and others are "relatively very rare, in the context of 7 million doses distributed across the U.S." Both Europe and the U.S. are investigating a few deaths following the administration of the vaccine, which are, at the moment, not believed to be directly related to the vaccine, but coincidental.

Effectiveness. In clinical trials for the 16-26 year old age group, Gardasil was virtually 100% effective against the four strains of HPV that it targets. Merck reported that the effectiveness lasted five years.

There are, however, certain unknowns. The effectiveness beyond five years, and thus the need for, and the effectiveness of, boosters is unknown. Also, since relatively few girls between 11 and 15 were in the clinical trials, the safety and effectiveness for that target age group is unproven. The effectiveness for women who already have been exposed to HPV is also unknown, but is believed to be nonexistent. Finally, there is concern that while the vaccine does protect against HPV-16 and HPV-18, by so doing the vaccine may be unleashing other HPV strains which can infect the woman. Thus, the ultimate efficacy of the vaccine against all HPV infections and, ultimately, against cervical cancer may be less than the initial studies indicated (Merck did not test, and the FDA did not require them to, the vaccine as a preventative against cervical cancer, just HPV infection).

Public Reception. To date, after over a year of availability in the U.S., only about 10% of women ages 18 to 26 have received at least one dose of the HPV vaccine.

Why the low numbers? Public awareness is low about HPV in general, about its connection to cervical cancer and about the HPV vaccine in particular. This lack of public awareness about vaccines is not confined to HPV. There is similar low awareness about the new shingles vaccine, and an even lower vaccination rate (2%).

Cost is another deterrent. The three doses cost $360, plus doctor's fees. However, most insurers cover the vaccine, but there are varying co-pays. Many, if not most, uninsured will be covered though various public vaccine programs. Availability of the vaccine may not be universal since the initial cost for the clinic or doctor's office is high. Cost and availability are not the only deterrents. In Ontario, where the vaccine is free and widely available, only half of girls have been vaccinated - five times the U.S. rate but not universal.

Faced with public resistance and in order to maximize its revenues, Merck embarked on an extensive lobbying campaign to have the HPV vaccine required for admission to school, like other childhood vaccines, such as measles and whooping cough. Texas, by executive order, and Virginia and the District of Columbia by legislative action responded to Merck's lobbying and made HPV vaccination mandatory for girls entering the sixth grade (though the District's law still needs Congressional approval to take effect).

Then a backlash set in. The Texas legislature recently overturned the Governor's order, and one house of the Virginia legislature passed a bill delaying the implementation of its legislation. Most other state legislatures have either rejected a mandate or are taking a wait-and-see approach, even though one chamber of the Kentucky Legislature last week passed a mandate. At least four provinces in Canada have free but voluntary HPV vaccination programs in schools for 7^th and 8^th graders.

The backlash against mandates was fueled by a combination of factors.

There were parental concerns about the long-term safety and efficacy of the vaccine, especially for the 11-15 year old age group. Merck is currently conducting more trials to study this population.
Budgetary concerns. Gardasil is expensive. Funds to pay for it as part of the Medicaid program or some other government program will have to come from somewhere, leading to a reduction in health prevention or treatment of some other disease. There is an argument that whatever millions are spent might be better spent on a more comprehensive STI prevention program, including condom use and more extensive Pap screening. It has not gone unnoticed that Gardasil protects against only 70% of HPV-causing strains, while condoms protect against all of them, plus other STI's.
There is also a growing concern with the safety of all vaccines in general, and especially with childhood vaccines, with parents demanding the right to opt their children out of any mandated vaccine (all state vaccine mandates have an opt-out provision). This deferral to parental rights did not satisfy some conservative groups, which, while they didn't openly oppose the FDA approval of Gardasil and stated publicly that they welcomed vaccines against HPV, did oppose any state mandate that all girls be vaccinated, even with a parental opt-out.
Finally, there's sex. Girl sex in particular. Conservative groups argued that HPV vaccination would inevitably lead to adolescents engaging in more and earlier sex, thereby causing more transmission of HPV and other sexually transmitted infections. They argued that vaccinated, and unvaccinated, adolescents will have a reduced fear of HPV, even though Gardasil does not prevent all HPV strains, and will thus engage in more and riskier sex. This is known in the public health world as "risk compensation", and occurs when there is a perceived change (i.e. reduction) in the risk of acquiring a disease or being involved in an accident, for instance with drivers with seat belts and air bags driving faster. The conservative argument is identical to their argument against birth control - that a reduced fear of pregnancy leads to more sex and thus more pregnancy. The fact that there is still a multiplicity of sexually transmitted infections out there that Gardasil does not prevent, and thus that there should be no false sense of immunity, has not dissuade these conservative groups from their campaign.

I suspect that it is the realization that their daughters may be sexual beings is too much for some parents to take. Their response is to bury their heads in the sand and refuse to vaccinate their daughters. This raises the question whether the HPV vaccine would have had an easier road to acceptability if it had been targeted to boys first and their epidemic of genital warts. I wonder if fewer parents would have blanched at being confronted with their sons being sexual beings and thus would not have objected as vociferously to the vaccine, which could then slowly have been rolled out for girls. Even if never rolled out for girls, the male herd effect protecting girls would have occurred after 70% of males were vaccinated. See The New York Times story referred to above.

That said, I can only imagine the screaming if Merck had filed for males first. The company clearly saw an easier path to riches by treating girls first, even though there may have been a less antagonistic conservative response if sons were called upon to be vaccinated before daughters.

Now that millions of doses have been administered in the U.S. and Europe, Gardasil will get its real world clinical trial. Preventive medicine is supposed to save lives and money in the long run. We will see if it does.

There will not be mandates, at least in the short run, in the U.S. Europe will probably lead us in that regard. It is likely, therefore, that a familiar health care pattern will repeat itself: wealthy, well-educated, more prosperous American girls who get advised to by their private physicians will get vaccinated at greater rates than lower-income and minority girls who won't. This will repeat the same disparity that currently exists with cervical cancer itself. Pap screening programs do not reach those marginalized in our society. The incidence of cervical cancer is 1.5 time higher for African American and Latina women in the U.S. than white women. Cervical cancer is highest along the Mexican border, in Appalachia, among Native Americans and in rural areas, exactly where the public health system is weakest. That is why mandates in a way make sense, especially since school drop-out rates for lower income and minority girls begin earlier than for more affluent, white girls.

Male Circumcision

In 2007 the World Health Organization announced that it was recommending male circumcision "as an efficacious intervention for HIV prevention." The CDC has yet to make a recommendation for the United States.

See http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

Male circumcision is a different medical animal than a HPV vaccination. It is surgery. It is more expensive - in the U.S. the cost is in the thousands of dollars with insurance coverage variable and no government programs to cover the uninsured (some states, including recently Florida, have dropped infant circumcision from Medicaid coverage). Medical benefits, if any, and side effects are hotly debated. The side effects include pain, shock, hemorrhage, infection, and accidental disfiguration. There is also the hotly debated issue of loss of sexual sensitivity and increased friction and pain during intercourse, not to mention other psychological complications.

Circumcision has a long and often contested history - socially, culturally, medically and religiously. It is not "just a snip," as some advocates put it. It is virtually universal among Jews and Muslims, and less so among Christians and rare among other religions. Circumcision, or the lack thereof, is a literal marker of identity, of coming of age and of maturity, of being a member of a group, tribe, nation or religion. It may have originated, some anthropologists argue, as an intra-sexual control mechanism, designed to reduce male and female sexual sensitivity, so as to better control adolescents and to confine their sexual activity to within culturally-approved bounds. Circumcision is thus nothing less than a cultural and sexual minefield. Getting acceptance for an HPV vaccine will be a walk in the park compared to getting acceptance for circumcision in some societies.

Effectiveness. In 2007 two studies, one in Kenya and one in Uganda, were halted early by medical authorities, when the preliminary results showed a 53% and 51% reduction in risk respectively in acquiring HIV infection by circumcised males as opposed to uncircumcised males. The case was so clear that it appeared to be a "no-brainer". Another earlier clinical trial in South Africa showed a 60% reduction in risk. These studies confirmed, or appeared to, earlier observational studies that circumcised males had a lower incidence of HIV. The WHO called the evidence compelling and the case proved beyond a reasonable doubt.

Interestingly, there is no agreement on how circumcision might actually work as an HIV preventative. There are a variety of theories including the keratinisation of the penis that occurs after circumcision serving as a retardant to HIV transmission. Another is that there is a susceptibility to HIV in the Langerhans cells in the inner foreskin, although one researcher published a paper a few weeks before the WHO recommendation came out arguing that langerin produced by Langerhans cells blocked HIV transmission. See http://www.nature.com/nm/journal/v13/n3/abs/nm1541.html;jsessionid=B7086F8AE0A92211B2E59C3669A60A66

Langerhans cells also appear in other parts of the male and female genitals, including the clitoris. There was no suggestion by WHO that these cells, or the surrounding skin on the organs that contain them, be excised. The WHO circumcision recipe for the goose is not one for the gander.

The WHO emphasized that circumcision was not 100% effective, and that, in fact, the HIV infection rate in circumcised males in the African clinical trials was still unacceptably high. There was no evidence that male circumcision protects female partners, or the partners of men who have sex with men. Both these sad facts have been born out by subsequent trials. In a recent study, the CDC announced that circumcision offers no protective benefit to U.S. black and Latino gay and bi-sexual men. See http://www.msnbc.msn.com/id/22096758/

The WHO took pains to point out that circumcision did not replace other HIV prevention strategies, including delay of sex, abstinence, reduction of partners, condom use and HIV testing and counseling services and treatment.

The WHO recommended that the target population be men in countries with high HIV prevalence and low circumcision rates, i.e. sub-Saharan Africa, with an emphasis on men ages 12-30 and older men with a high risk of acquiring HIV.

Public Reception. There as been no stampede for circumcision. As with the HPV vaccine, cost is a factor, as well as the lack of public education on the benefits of male circumcision. Some public health officials argued that a more effective use of funds was the current armament of HIV prevention strategies, such as ABC, especially the "C".

To date, no U.S. state has announced a circumcision campaign, much less proposed a mandate. Recently, Rwanda and a few other African countries announced campaigns to promote male circumcision, while Brazil has stated that it will not. At the moment the campaign in Rwanda is voluntary, though it has been reported that men in the army will be required to be circumcised in order to be promoted.

The WHO estimate of the efficacy of male circumcision was immediately challenged by scientists who raised the specter of risk compensation, i.e. an increase in risky sexual behavior by those circumcised, including reduced condom use and more sexual partners. Shades of Gardasil! Risk compensation is likely, some scientists believe, because of the widespread male dissatisfaction with condom use and because males, and females, they argue, have an innate desire for more than one sexual partner. In fact, the distaste for condoms, combined with a desire, in parts of Africa at least, for a large number of children, might be the chief motivators for males to seek circumcision in the first place.

While, as the WHO carefully pointed out, circumcision does not obviate the need for condoms, it is hard to imagine an effective public health campaign that urged circumcision and continued condom use - why should a man go through circumcision if he still has to wear a condom? That said, in the birth control arena there have been campaigns for dual protection, i.e., both the male and the female using contraception, though with mixed results.

There are two other major dangers for women here. It was recently reported that females do not get HIV protection from male circumcision. Circumcised men who are HIV positive transmit the virus to their partners at the same rate as uncircumcised men. In fact, there was an observed increase in infection in the partners of circumcised men who commenced sexual intercourse before their circumcision wounds had healed, despite extensive counseling of the couples to abstain until they got a go-ahead from a nurse. However, there was an observed decrease in other sexually transmitted infections in the males, but not in their partners.

See http://www.medpagetoday.com/MeetingCoverage/CROIMeeting/tb/8221

This study, which the researchers were careful to point out did not reach statistical significance, shows the intractable nature of human nature and risk compensation in action. The couples had been warned about not commencing intercourse before the wound healed and had been given condoms, and yet…. So, here we have a medical strategy designed to reduce HIV transmission, which, in fact, in this study increased it. Has the recommendation for circumcision been revisited, revised or withdrawn? No. Will it, if a larger study confirms these results?

A second danger for women is that there might be a conflation of male circumcision with female genital mutilation, especially if the theory of the Langerhans cells is proven. The conflation in some parts of the world of male and female circumcision as a cultural marker or initiation rite is already problematic. It would be horrific if the call for more males to be circumcised in cultures where it is not practiced led to more female genital mutilation. This would be compounded if Langerhans cells are seen as the culprit, since there might be a call for the removal of the clitoris which, like the foreskin, contains these cells.

As a disease preventative, circumcision has, so far, fallen short of expectations. There is some evidence in the U.S. or U.K. associating circumcision with reduced rates of sexually transmitted infections. See http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm. Studies in Africa are reportedly not rigorous enough to have a firm conclusion.

The real world experiment of the United States, which has the highest rates of circumcision in the developed world (65%) and also high rates of STIs and of heterosexually-transmitted HIV infection, should give one pause. The adult HIV prevalence rate in the U.S. is 0.6%, compared with 5% in sub-Saharan Africa. In the Middle East and North Africa, where circumcision is virtually universal, the HIV adult prevalence rate is 0.6%, though reliable statistics are hard to come by.

Circumcision, Biology and Human Evolution

There is already a concern among scientists that Gardasil, which only protects against four strains of HPV, may be unleashing the other strains to infect women. This is an example of evolutionary biology in action. Viruses will do their utmost to survive. We may be breeding new strains of HPV that will need new medicines and vaccinations. We are marching into the biological unknown with HPV vaccination, as perhaps we are with any vaccination.

Circumcision also involves unanswered biological questions. Unmentioned in almost all the debates pro and con circumcision is the question of the biological function of the foreskin in the first place. Have we evolved out of whatever purpose it once had, like a protective effect in the days of yore when humans didn't wear clothes? Is the foreskin therefore some vestigial piece of the anatomy like an appendix? If we have evolved out of its original function, why hasn't the foreskin disappeared? Parenthetically, scientists are beginning to discover biological functions for the appendix, and now believe that it is not vestigial at all, but related to the functioning of the immune system.

All primates, indeed virtually all mammals, have a foreskin or prepuce, both males and females. If the foreskin has a "pathogenic burden", why has it continued through evolutionary time and why has humanity propagated so successfully despite it? The foreskin must confer some reproductive advantage. For instance, the foreskin might contribute to the lubrication of the penis, making it easier, for vaginal intromission (penetration). It may also serve to protect and clean the penis, contributing to penile hygiene.

Not surprisingly, the debates over the usefulness, utility and importance of the foreskin quickly turn into issues of gender and the battle of the sexes. There is one school of biological thought that argues the male penis is not just a sperm delivery device, but also a sperm removal device. It has been reported that some females (one in eight in one study) copulate serially with one or more men within a 24 hour period and that, as a result, there is what is known as "internal sperm competition" to see which man's sperm gets to fertilize the egg. This battle is literally the survival of the fittest swimmer, or perhaps it is the last sperm standing that wins.

See http://www.springerlink.com/content/8nbw6ldv8r6vgqb0/

Some scientists theorize that the penis of the last man is able to remove some of the sperm of the previous male before depositing his own. A male with a penis that is designed to not only deposit his sperm but remove the sperm of the preceding male would have more offspring and thus his genital characteristics would be transmitted to the next generation. There is an argument that the shape of the male penis with its head larger than its shaft acts as a roto-rooter in evolutionary sperm competition. Perhaps the foreskin contributes to this function, though I have seen no scientific research pro or con this.

Other arguments for the existence of the foreskin involve sexual pleasure - the foreskin adds to it for the male, or so it is alleged. Studies vary on this one, and, as you might imagine, the debate is heated. See for example http://www.newscientist.com/channel/sex/mg19426015.500-does-circumcision-harm-your-sex-life.html

Assuming for the moment that an uncircumcised male has more sexual pleasure, why on earth would any male, or any parent of a male, seek to reduce his sexual pleasure? Well, lots of reasons, and argument. To the extent the lack of a foreskin retards male orgasm and thereby reduces premature ejaculation, it makes for longer intercourse and more female pleasure. There are numerous arguments and purported "studies" with some arguing there is more, and some less, male and female pleasure in circumcised and uncircumcised. The foreskin perhaps evolved as a result of female sexual choice, if more females found sex more pleasurable with uncircumcised males.

No matter what the biological or evolutionary implications are for circumcision, I suspect that males are going to be most concerned about their own sexual pleasure. They are not going to be thinking about the role of the foreskin in human evolution, alas. Circumcision is a risk. It can not generally be undone. The appendix is generally not removed prophylacticly; it is removed when infected. It is a difficult argument for males to say that any part of their body, much less one that contributes to sexual pleasure, should be surgically removed when it is not diseased. It is like saying that all males are born defective and need surgical fixing. It is a decision akin to that that some women with genetic markers for breast cancer must make in deciding whether or not to have a mastectomy. It is a drastic measure.

HPV Vaccination and Male Circumcision: Case Studies in the Failure of Public Health

So, here we have two new public health recommendations relating to sexually transmitted infections, one for females and one for males.

Even though one is a vaccination and the other surgery, each has certain common characteristics.

Cost--- Each is expensive. This is not only a deterrent but may deflect funds from other prevention measures.

Side Effects--- Each has serious potential side effects, though they are rare.

Effectiveness--- Each is not 100% effective. This may result in risk compensating behavior and either less protection than envisioned or even more infection.

Culture--- Each has cultural/gender sensitivities: each is about sex, the vaccination with the sexuality of girls and circumcision with male sexual prowess, pleasure and identity.

Public Health Impact--- Each may not be the best, or most cost-effective, way to target the disease. Cervical cancer can be caught and cured with pap smears, and HIV by a comprehensive ABC program. HIV in Africa is mostly transmitted by female prostitutes. Thailand embarked on a program to require condom use in brothels. Africa has not. The HIV prevalence rate in Thailand is now far lower than in Sub-Saharan Africa. ABC can work. The circumcision recommendation is, I believe, more a comment on the world's failure to implement ABC than on the benefits of the procedure.

Unintended Consequences--- As a biological matter, there are unintended consequences with each. HPV strains not caught by Gardasil may be proliferating when their sibling strains are vaccinated out, leading to more HPV infection. The solution is ever more vaccines for the HPV strains not currently covered. Risk compensation is a real threat to the real world effectiveness of each intervention, though I believe the problem is vastly more acute with circumcision with the real possibility of reduced condom use by circumcised men.

Just last week the oft-ridiculed South African Health Minister, Manto Tshabalala-Msimang, questioned whether the evidence was strong enough to recommend a government circumcision program as part of HIV prevention. She made the comments in the context of a meeting with traditional healers, many of whom view circumcision, along with other HIV remedies, as a Western attempt to force foreign values on South Africans. She noted that the Xhosa ethnic tribe has a high HIV rate even though almost all Xhosa men are circumcised. She failed to mention that the infection rate is even higher among Zulus, who are not circumcised. Whatever her reasoning, or lack thereof, her opposition to circumcision may be a case of a stopped clock telling the correct time twice a day.

It seems to me that male circumcision is a pretty expensive "fix" when we don't know how male circumcision works to prevent HIV transmission through the foreskin and penis in the first place. See the CDC article referred to above to the theories. If scientists could figure this out, then perhaps there is a less drastic, more cost effective or direct way to prevent transmission rather than by circumcision.

It is difficult to imagine that the path for human health and wellbeing is the removal of a part of the body (male circumcision) that nature has given us. But, given that there has been a real world experiment with Jews and Muslims for millennia, male circumcision does not appear to cause lasting harm in terms of morbidity or mortality or reproductive success, and, so far as we can tell, the Muslim HIV prevalence rate is relatively lower.

It would seem that we will continue to muddle through with a dual health care system for HPV and HIV prevention. In the developed world, there will be little demand for, or call for, circumcision and only slightly more for HPV vaccination. Preventive efforts will continue on ABC prevention - including behavior change, condom use and smarter decision making. And they will be slow to show results. In the developing world where there is less cancer screening and more sexual partners and less condom use, there will be a greater call for vaccination and circumcision. Since males in Africa, and females too, want more children than in the West, any perceived reduction of the need to wear a condom will most likely meet with favor. I suspect that there will be less than unanimous support for circumcision in general and probably too many violations of the no-sex-until-the-circumcision-wounds-have- healed guidelines.

The real world for HPV vaccine and male circumcision is a lot messier than the studies would indicate. Neither is a "no-brainer." Science not only has produced incomplete information, it may have produced wrong information for real world use. It would have been preferable in the roll out of each intervention to have it be part of a program directed towards both sexes. In the case of HPV vaccine to have it tested thoroughly on boys and girls ages 11 and up. This would have reduced the imbedded cultural/gender fears of parents about their daughters being sexual beings. Additionally, though scientifically difficult, it would have been preferable to have a HPV vaccine that worked against all HPV strains, not just a few.

In the case of HIV, since the target is Sub-Saharan Africa where prostitution is the main mode of infection, a more extensive campaign, a la Thailand, directed at female prostitutes and brothels requiring condom use would have been salutary. This is hardly easy or in itself a "no-brainer," but the alternative is waiting until the epidemic exhausts itself. Not a pretty picture.

A citation for the proposition for the potential unleashing of other HPV strains caused by HPV vaccination is as follows: George F. Sawaya, MD and Karen Smith McCune, MD, Ph. D, HPV Vaccination: More Questions More Answers,

http://content.nejm.org/cgi/reprint/356/19/1991.pdf

This editorial states in part:

"In contrast to a plateau in the incidence of disease related to HPV types 16 and 18 among vaccinated women, the overall disease incidence regardless of HPV type continued to increase, raising the possibility that other oncogenic HPV types eventually filled the biological niche left behind after the elimination of HPV types 16 and 18."

Update on Abortion and Crime

2008-02-09T01:29:00.000-05:00

Two recent articles, one pro and one con, examine the alleged relationship between legalized abortion and crime. See my post of Nov. 18, 2007.

Christopher L. Foote and Christopher F. Goetz in The Impact of Legalized Abortion on Crime refute the analysis done by John J. Donohue III and Steven D. Levitt in their 2001 paper.
See http://www.bos.frb.org/economic/wp/wp2005/wp0515.pdf

Donohue and Levitt respond in Measurement Error, Legalized Abortion and the Decline in Crime: a Response to Foote and Goetz and confirm their original findings.
See http://www.law.yale.edu/faculty/donohuepublications.htm

The debate goes on.

The 2006 Great Teen Birthrate Spike ─ The Story That Wasn't

2008-01-05T16:20:00.000-05:00

The headlines screamed: "Teen Birth Rate Rises for First Time in 14 Years!" And that was from the CDC. The newspapers were even more dramatic: "Teen Pregnancy: It's Baaaack!" read one headline.

Most newspaper stories quoted our side blaming the Bush Administration's "abstinence-only" sex-ed policy for the rise in teen births. No question but the CDC report gave us a golden opportunity to criticize this misguided policy.

But, were we right?

What did the CDC report actually say? First, the CDC press release said that the teen birth rate rose 3% from 2005 to 2006 and that this is the first rise in the teen birth rate since 1991.

Buried in the CDC press release, but in the first sentences of the actual CDC report, entitled "Births: Preliminary Data for 2006", was the revelation that all births, adult and teen combined, rose 3% from 2005 to 2006. In other words, the teen "General Fertility Rate" (to use the exact terminology) rose at the same rate as the national General Fertility Rate.

The CDC also reported that the national Total Fertility Rate (another technical measure estimating the average number of births that a group of women would have over their lifetimes) rose to 2.1, the highest rate since 1971, and the first year that the TFR has been above the replacement rate since then.

The CDC also noted that the non-marital birth rate rose 7% in 2006 to 38.5% of total births. Be prepared for next year when it breeches the 40% barrier!

So, one interpretation of the CDC report could be that teens were behaving just as the adults were ? having more babies in 2006.

But do teens always behave as adults do, baby-wise? Not exactly.

As the CDC noted, the increase in the teen general fertility rate was the first since 1991 (the teen birth rate had fallen by about one-third since 1991 until its 2006 rise). What had the adult birth rate done since 1991? Like the teen birth rate, it had fallen since 1991 (and even before) until 1997, falling 10% during those years (less than the teen rate but still a significant drop). Then the adult birth rate began a slow rise, about 1% or less a year, until the big 3% jump from 2005 to 2006. Still the coincidence, if that is was it was, of the teen and adult birth rates each rising 3% in one year after diverging for the last eight years is remarkable.

It leads one to ask why birth rates rise and fall and what might make different groups rise while others fall or, conversely, what might make an entire nation's birthrate for adults and teens rise or fall together. There was little discussion of this issue at all in the press coverage. What there was, on the part of most advocates, was placing the blame on abstinence-only sex-ed, as if this misguided policy sprung fully formed in 2005 wreaking birthrate havoc in 2006, and as if nothing else had happened that might influence the childbearing decisions of teens.

Unfortunately, abstinence-only sex-ed has been around for a lot longer than since 2005. States have had their own abstinence-only programs for years, and substantial Federal funding for these programs took off with the Welfare Reform Act of 1996. Funding has totaled over a billion dollars since then. The results? A Congressionally-mandated evaluation report released in April 2007 showed no effect on age of intercourse, number of sexual partners, contraceptive use, STI infection rates or pregnancy rates. Other evaluations have shown that abstinence-only sex-ed may deter contraceptive use.

My view is that abstinence-only sex-ed is worthless at best, and dangerous at worst, and that it is quite a stretch to say that after ten years it is responsible for a one-year 3% rise in teen pregnancy, after teen pregnancy declined for the first nine years of substantial Federal funding for the program.

As one researcher told me, "We are particularly cautious in making assumptions about the role of abstinence education in this increase because the basic trends run counter to a simple association between the two. Consider that significant funding for abstinence-only education has been around since 1997 and that most years between then and now have witnessed major declines in teen pregnancy. Thus we feel that to assign none of this earlier decrease to abstinence education while assigning all of the recent increase to abstinence education would not be well grounded in empirical evidence..."

I think it safe to say that, if abstinence-only sex-ed programs had any effect on the teen pregnancy rates, up or down, it cannot be quantified.

Virtually alone in a pro-choice sea of condemnation of abstinence-only sex-ed, the National Campaign Against Teen Pregnancy issued a statement saying that no one really knows why the teen pregnancy rate spiked in 2006. They noted, correctly, that we do not have the data for 2006 on the extent of teen sexual activity and contraceptive use, nor do we have pregnancy rates and abortion rates. All we have are childbearing rates. Hence, we don't know if the teen childbearing spike was caused by more sex, less contraception, more pregnancy or less abortion, or some combination of the above. And we don't know what might have caused each of these indices to change from 2005 to 2006.

Researchers have known for years that pregnancy rates, adult and teen alike, arise from many complex factors - socio-economic, cultural and technological. A view of teen pregnancy rates in Latin America might be instructive. In general, unlike the USA, teen childbearing rates have been on the rise in Latin America since 1990. For instance in Brazil, the largest country in the region, the proportion of women age 15-19 who have children rose from 11.5% to 14.8%. Uruguay was the worst performer in the Hemisphere, with the rate rising from 8.4% to 13.9%. For Latin America as a whole, the percentage of live births to teens is 18%, while in Africa it is 17%. In Latin America, while adult fertility continues to decline, adolescent fertility is rising.

There has been economic growth, industrialization, modernization, urbanization in Latin America, along with the spread of modern contraceptives. All this has led to the reduction in the adult fertility rate, but not the adolescent rate. From a gender standpoint, girls in Latin America are in school as much as, or even more than, boys. But there are profound cultural factors that encourage, or at least don't discourage, early childbearing. Adolescents also have difficulty accessing contraceptives (only about 20% of youth use modern contraception) and sex-ed is spotty, even worse than the USA. Meanwhile lifestyle changes have brought on earlier maturation and sexual initiation. While clandestine abortion is widely available, for the very poorest in Latin America early unprotected sexual activity can lead to pregnancy and childbirth.

One mystery is the effect of the availability, or not, of emergency contraception. In the USA it is now available "behind the counter" without a prescription. In Latin America EC availability is not uniform, but a prescription is not needed if a woman can find an agency or store that has it. In the USA EC has become increasingly available since the mid-1990's yet the spike in teen childbearing rates in 2006 occurred despite this. The change in status in the USA from prescription-only status to behind the counter status only came in August 2006, so we will have to wait to see what effect this has on teen childbearing rates, if any, in 2007 and beyond.

In conclusion, the rise in teen childbearing was the story that wasn't in 2007. We don't know what caused it, any more than we know what caused the decline in the 15 previous years. We can make educated guesses. But blaming abstinence-only sex-ed, tempting as it is, is not one of them. My guess is that there was a confluence of factors that led women, adult and teen alike, to decide that 2006 was a good time to have babies.

Abortion and Crime: An Update

2007-11-18T01:40:00.000-05:00

In Chapter Two of Beyond Choice, on pages 66-67 in the hardback, I discussed, in the section on eugenics, the abortion/crime controversy, citing the 2001 study by Donohue and Levitt, which found that the legalization of abortion resulted, twenty or so years later, in a reduction in the crime rate because potential criminals were being aborted rather than born. I also cited contradictory studies that found no effect, or the opposite effect, of abortion on crime. I concluded saying that “The best that can be said is that the case for the alleged causal connection between the legalization of abortion and a decrease in crime rates is unproven.”

Since the publication of Beyond Choice, there has been much heat and somewhat less light on the issue. Most notably there was the publication of Freakonomics by Levitt and Dubner in 2005. A reader suggestedthat I should revisit the entire issue based on Freakonomics. So, here goes.

I will spare you the gory econometric details of the argument. While I have an MBA and studied statistics and did regression analyses, that was many years ago and on a computer that took up an entire room. Fortunately for me, the American Enterprise Institute conducted a symposium on this issue on March 28, 2006. A transcript is available on the AEI website. Much of it is accessible to the non-economist.

http://www.aei.org/events/filter.,eventID.1285/transcript.asp

Since that symposium there have been papers and responses written by many of the symposium participants and by a few new entrants intothe fray. This battle is not over.

Levitt was not present at the AEI symposium, but John Donohue was, where he defended his and Levitt’s 2001 paper as well as two subsequent papers which corrected errors in the 2001 paper that had been pointed out by his critics. Virtually every economist (or their co-author) who has studied the issue was present. None agreed with Levitt and Donohue entirely, and some disagreed completely and came to the opposite conclusion. All of theten panelists were male, a comment perhaps on the state of the economics profession and/or what kind of economist wants to enter this particular debate.

The lag time between a woman’s decision whether or not to have a child (or give it up for adoption) and the time when criminal behavior becomes apparent is between 15 and 25 years. This is the first problem in trying to identify causation versus correlation. There’s many a slip between the cup and the lip during 25 years. Other antisocial or delinquent behaviors of unwanted children may be manifested earlier, such as poor school performance, alcohol and drug abuse and health problems. The challenge for policy makers andacademics is to isolate one factor― the legalization of abortion―and to calculate its impact, if any, in the subsequent anti-social manifestationsof being unwanted. The Levitt model reportedly had over 1100 different variables, including one imagines, poverty, single parenthood, peer pressure, neighborhood, family, church attendance, social programs, father’s involvement, sibling influence ― the list is almost endless.

Donohue and Levitt argue that legalizing abortion would affect the crime rate twenty years hence through two mechanisms: 1) the cohort size effect, i.e., fewer children being born and thus fewer potential criminals being alive twenty years later and 2) the selection effect, i.e., abortions will be more common for children who were unwanted. Unwanted means in this case that the parents (or mother) did not have the means or disposition to care for the child, and that there would be less of an investment (time, money, effort) in the child, who would therefore have a higher propensity to become a criminal.

On its face, the argument seems to make sense. Women who have abortions do not want to be a mother at that time, if ever. They want to invest in the children they already have or in later children born at a time when they can be a better parent. Abortion, by definition, can affect either the absolute number of children born or their timing, or both. Earlier research, though not by economists, seemed to show that unwanted children did have a higher propensity for poor school performance and delinquent behaviors.Advocates of legal abortion have in the past used this as an argument for notcriminalizing the procedure.

There is a problem with the terms “unintended” and “unwanted” however. When do we make this judgment and who makes it? Is a potential child “unintended” and “unwanted” at the time of sex, at conception, or at three or six months gestation? Is it “unwanted” at birth, at age two, at age 13? Different parents may have different answers at different times. And isn’t it possible that a parent’s idea of wantedness can change, perhaps multiple times, during a child’s prenatal and postnatal life? And which parent are we talking about? Mother? Father? Both?

Aside from upbringing, genes and all the other factors that effect a child’s decisions as to their life course, there are societal factors influencing crime levels: in the case of the US in the late 1980’s and early 1990’s there were efforts to put more police on the street, longer jail terms, better policing, the good economy and the devastating Crack Epidemic. It is a challenge to control for all these intervening effects.

In addition, there are problems of measuring abortion both before and after legalization. Pre-Roe,and pre-1970 in New York and a few other states, legal abortion was difficult to access, though there were therapeutic abortions available to a greater or lesser degree. Criminal abortion was a major enterprise. How to measure the extent of legal and illegal abortions before it was decriminalized is a major problem since statistics weren’t kept. And even after legalization, not every state has accurate records.

Then there is the people problem. People move. A lot. People go across state lines to get abortions and move to other states to live. It is hard to measure a state’s abortion rate in the first place, even the legal abortion rate after Roe, and hard tokeep track of the families who move in and out of state and to discern in all cases if a crime is committed by a person born in the state or elsewhere.

On top of these data problems, there is the issue that the legalization of abortion does more than decriminalize the procedure. Some academics argue, and I cite this in Beyond Choice, that abortion can act as an insurance policy and lead to more risky sex, thus more pregnancy, more abortion and unwanted children. These academics argue that legalizing abortion leads therefore to an increase in crime.

One economist from the Federal Reserve Bank of Boston argued that state crime levels were converging in the 1990’s and that abortion had nothing to do with it. Their regression analysis showed that it was the high crime states that were seeing their crime rates drop, not the high abortion states.They also found that property crime levels increased even as violent crime was falling.

Other analysts noted that young males between the ages of 17 and 25 commit the majority of crimes. If abortion did reduce crime, crime rates would have dropped first among young people, but they didn't. The number of crimes committed by older people dropped first in the 1990’s. Furthermore, while the rate of homicide committed by young men dropped, the rate of aggravated assaults among the young increased, and the rate of homicides committed by young females -- which should have been equally affected by abortion as males – did not drop.

The economists at the AEI symposium seemed to agree that there were all these data issues, modeling issues and econometric issues, and others too arcane to discuss here. Donohue and Levitt believe they have solved these issues. The rest disagreed. In sum, most economists present agreed that the evidence for an abortion/crime link is “pretty weak”, “really inconsequential”, not “statistically significant”, and “rather bleak”. The model that Levitt used is what economists calls “sensitive”, not “robust,” meaning that anytime one thing changes, the coefficients of the abortion/crime link change dramatically.

Nonetheless, Donohue and Levitt are sticking to their argument and producing new papers answering their critics. The moderator of the event said later, trying to be diplomatic, that: “I think the consensus position is that the abortion effect probably explains some of the crime decrease but most likely not nearly as much as Donohue and Levitt estimate and no one has much confidence in the precise size of the effect.”

My conclusion remains what it was in 2004 in BeyondChoice. The proposition that there is a connection between legalizing abortion and a subsequent reduction in the crimerate remains unproven.

It was pointed out at the AEI symposium that there is perhaps reluctance on both the Left and Right to validate the Levitt thesis: the Right because it gives societal legitimacy to abortion and the Left because it smacks using racial profiling and eugenics to support the legalization of abortion.

I framed my discussion of the abortion/crime link in BeyondChoice by saying that “eugenics disguised as social engineering wasn’t dead yet.” This comment followed a long discussion of the Norplant saga where the Philadelphia Inquirer, after stating that those having the most children are the least capable of supporting them, suggested incentives for the poorer members of society to use Norplant. And after my discussion of the abortion/crime link, I said that “At its worst, this argument is eugenics in new clothing.”

One reader has suggested that I maligned Levitt by associating him with eugenics.

The AEI conference was notably free of policy recommendations by the panelists, even coded ones. Levitt denies that his theory has racial implications. A moderator (not Levitt) did raise policy questions by saying that the debate over the abortion/crime link could inform the debate as to whether or not the states should cover abortion in their Medicaid program or whether parental consent laws should be enacted, as both these provisions affect the ease of access by the poor and the young to abortion, those whom, under Levitt’s thesis, would be most likely to give birth to future criminals. I have not read anything where Levitt or his co-author make any policy recommendations, nor any statements that sound like eugenics.

That said, the American Enterprise Institute is not an academic, non-partisan think tank. They want to affect policy in Washington. I doubt they would sponsor a symposium that would conclude with an endorsement of Medicaid-funded abortions. Economists too have political opinions, as do we all. Eugenics and the fear of eugenics lurk all around the abortion/crime debate. Only rarely does it surface explicitely.

Former Education Secretary William Bennett, hardly a supporter of legal abortion, entered the fray on his radio show in 2005. Here is the transcript of a section where he and a caller discuss Freakonomics:

BENNETT: All right, well, I mean, I just don't know. I would not argue for the pro-life position based on this, because you don't know. I mean, it cuts both -- you know, one of the arguments in this book Freakonomics that they make is that the declining crime rate, you know, they deal with this hypothesis, that one of the reasons crime is down is that abortion is up. Well--

CALLER: Well, I don't think that statistic is accurate.

BENNETT: Well, I don't think it is either, I don't think it is either, because first of all, there is just too much that you don't know. But I do know that it's true that if you wanted to reduce crime, you could -- if that were your sole purpose, you could abort every black baby in this country, and your crime rate would go down. That would be an impossible, ridiculous, and morally reprehensible thing to do, but your crime rate would go down. So these far-out, these far-reaching, extensive extrapolations are, I think, tricky.

If that isn’t eugenics in new clothing, I don’t know what is.

I end up where I began. I don’t see much of a role for economists analyzing the after-effects of biological imperatives, especially effects not seen for a quarter century. It may sell books and get academics tenure and speaking fees and air time on cable TV, but I don’t think the debateon an abortion/crime link adds much of relevance to the real world that women especially find themselves in when they need to decide between reproducing now or later or not at all. Women do the best they can in difficult circumstances. Society should be trying to make their circumstances less dire, less difficult, less fraught. Now that’s a topic for a symposium.

As Goes New Jersey… We Hope.

2007-09-20T21:55:00.000-04:00

Last week the New Jersey Supreme Court, in an unanimous decision, ruled that a doctor, prior to performing an abortion, was not required to tell his patient that the embryo inside her was “a complete, separate, unique, irreplaceable human being,” with the implication that abortion he was about to perform was the same as murder. The patient, Rosa Acuna, had filed a malpractice action against her doctor, Sheldon Turkish, after her abortion, claiming emotional distress, and asserted that he should have told her, as part of the informed consent process, that it was a “scientific and medical fact” that the abortion would result in the “killing of an existing human being.” The plaintiff claimed further that her doctor had a duty “to explain that the procedure (would) terminate the life of a living member of the species Homo sapiens, that is a human being.”

The court found that there was not even a remote consensus in New Jersey that the plaintiff’s assertions were medical facts, as opposed to religious or moral beliefs, and without this consensus the court said it would not impose this new legal duty on doctors. The court affirmed that the common law in New Jersey requires only that the physician must provide the patient only “material medical information, including gestational stage and medical risks involved in the procedure.”

The battleground in this case was the patient’s (a woman’s) right of self-determination. The plaintiff asserted that no woman can make an informed decision unless she is given the biological facts of the pregnancy. The defendants, in turn, asserted that requiring a doctor to make the statements that the plaintiff requested would place an undue burden on the woman’s right to self-determination.

The framing of the plaintiff’s arguments follows directly from the anti-choice strategy used in the Gonzales v. Carhart case decided by the Supreme Court last April. There Justice Kennedy adopted in his majority opinion the assertions by abortion opponents that abortion causes emotional harm to women:

“While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained. … Severe depression and loss of esteem can follow. See ibid.
In a decision so fraught with emotional consequence some doctors may prefer not to disclose precise details of the means that will be used, confining themselves to the required statement of risks the procedure entails. From one standpoint this ought not to be surprising. Any number of patients facing imminent surgical procedures would prefer not to hear all details, lest the usual anxiety preceding invasive medical procedures become the more intense. This is likely the case with the abortion procedures here in issue….’Most of [the plaintiffs’] experts acknowledged that they do not describe to their patients what [the D&E and intact D&E] procedures entail in clear and precise terms’)….
It is, however, precisely this lack of information concerning the way in which the fetus will be killed that is of legitimate concern to the State. Casey, supra, at 873 (plurality opinion) (“States are free to enact laws to provide a reasonable framework for a woman to make a decision that has such profound and lasting meaning”). The State has an interest in ensuring so grave a choice is well informed. It is self-evident that a mother who comes to regret her choice to abort must struggle with grief more anguished and sorrow more profound when she learns, only after the event, what she once did not know: that she allowed a doctor to pierce the skull and vacuum the fast-developing brain of her unborn child, a child assuming the human form.
It is a reasonable inference that a necessary effect of the regulation and the knowledge it conveys will be to encourage some women to carry the infant to full term, thus reducing the absolute number of late-term abortions. The medical profession, furthermore, may find different and less shocking methods to abort the fetus in the second trimester, thereby accommodating legislative demand. The State’s interest in respect for life is advanced by the dialogue that better informs the political and legal systems, the medical profession, expectant mothers, and society as a whole of the consequences that follow from a decision to elect a late-term abortion.” From Justice Kennedy’s Majority Opinion in Gonzales v. Carhart

The New Jersey case, Acuna v. Turkish, may not make it to the U. S. Supreme Court, although her lawyer says that he will file for certiorari, but a similar case from South Dakota might. In the latter case, it is a law passed by the state legislature that requires physicians to make the statements that Rose Acuna wanted her doctor to make. The South Dakota case will raise the constitutional questions that the New Jersey court was able to avoid, including questions about free speech and the extent to which the Gonzales case has gutted the Casey decision. Justice Kennedy seems to give great weight to the fact-finding judgments of state legislatures, even when they are clearly biased and one-sided. If the court acknowledges the procedural validity of the South Dakota legislature’s finding that it is a biological “fact” that an embryo is a member of the species homo sapiens and thus a human being, who is the Supreme Court, under Kennedy’s rationale, to dispute it.

I have had pro-choice obstetricians and abortion providers tell me that, medically, when a woman is pregnant, there are two patients, the woman and the embryo or fetus or unborn child. Any treatment of one must be balanced against the risks to the other. This is not remarkable. The anti-choice folks are trying to slide from this, using sleight of words, to saying that the fetus is a separate human being, a member of the species homo sapiens, that abortion is murder and that the 14^th Amendment must prohibit it. This is not a new argument, but it has been updated with arguments that the unique DNA of the fetus means that the fetus is a unique human being. This, Rose Acuna argued, she needed to know before she was able, as a woman, to make an informed decision.

In Gonzales, the Supreme Court upheld the ban on an abortion procedure without making an exception for the woman’s health. It thus ruled that states could enact restrictions on abortion to protect a woman’s mental health, while putting at risk her physical health - an interesting calculus that we have not seen the last of. Small cases that nibble around the edges of Casey, like Rose Acuna’s, will continue to rise and probably be decided in favor of ideology and morality, posing as medicine, at least if the abortion restrictions are enacted, after kangaroo hearings, by a state legislature or Congress. We can hope that not too many of these cases get to the Court until its make-up changes.

Sanger Didn't Say That

2007-07-22T23:58:00.000-04:00

Historians and others who should know better keep misquoting my grandmother. Here is the latest example from Harvard. My response comes first and the offending article follows.

Harvard Magazine July-August 2007

http://www.harvardmagazine.com/2007/07/p2-cambridge-02138.html

SANGER DIDN’T SAY THAT

In your excerpt, “An Earlier Bid for Mastery,” of a book by Michael J. Sandel (May-June, page 25), Sandel quotes my grandmother, Margaret Sanger, as saying, “More children from the fit, less from the unfit—that is the chief issue of birth control.” My grandmother never said this. The quote comes from a 1919 editorial in American Medicine that followed an article by my grandmother. This quotation has been falsely attributed to Margaret Sanger for decades. One would have thought that Bass professor of government Sandel and your editors would have checked the original source material. Is that what they supposedly teach at Harvard?

Alexander Sanger
Chair, International Planned Parenthood Council
New York City

The article my letter refers to is as follows:

http://www.harvardmagazine.com/2007/05/an-earlier-bid-for-maste.html

Harvard Magazine May-June 2007

An Earlier Bid for Mastery

New genetic knowledge may let us manipulate our nature: beef up our muscles, brush up our memory, make designer children. What’s wrong with that? Bass professor of government Michael J. Sandel proposes an answer in The Case against Perfection: Ethics in the Age of Genetic Engineering (Harvard University Press, $18.95). Along the way, he recalls the eugenics movement (and contributions to it by Harvardians Charles Davenport, A.B. 1889, Ph.D. ‘92; Theodore Roosevelt, A.B. 1880, LL.D. ‘02; and Oliver Wendell Holmes Jr., A.B. 1861, LL.B. ‘66, LL.D. ‘95). In 1910, biologist and eugenic crusader Davenport opened the Eugenic Records Office in Cold Spring Harbor, New York.

In Davenport’s words, the project was to catalog “the great strains of human protoplasm that are coursing through the country.” Davenport hoped such data would provide the basis for eugenic efforts to prevent reproduction of the genetically unfit.

Reprinted from War Against the Weak by Edwin Black

Carrie Buck, ordered to undergo sterilization

…Theodore Roosevelt wrote Davenport: “Some day, we will realize that the prime duty, the inescapable duty, of the good citizen of the right type, is to leave his or her blood behind him in the world; and that we have no business to permit the perpetuation of citizens of the wrong type.” Margaret Sanger, pioneering feminist and advocate of birth control, also embraced eugenics: “More children from the fit, less from the unfit—that is the chief issue of birth control.”
…By the 1920s, eugenics courses were offered at 350 of the nation’s colleges and universities, alerting privileged young Americans to their reproductive duty.
But the eugenics movement also had a harsher face. Eugenics advocates lobbied for legislation to prevent those with undesirable genes from reproducing, and in 1907 Indiana adopted the first law providing for the forced sterilization of mental patients, prisoners, and paupers. Twenty-nine states ultimately adopted forced-sterilization laws, and more than 60,000 genetically “deficient” Americans were sterilized. In 1927 the U.S. Supreme Court upheld the constitutionality of sterilization laws in the notorious case of Buck v. Bell. The case involved Carrie Buck, a seventeen- year-old unwed mother who had been committed to a Virginia home for the feeble-minded and ordered to undergo sterilization. Justice Oliver Wendell Holmes wrote the opinion for the eight-to-one majority upholding the sterilization law: “We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices…. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind.” Referring to the fact that Carrie Buck’s mother and, allegedly, her daughter were also found to be mentally deficient, Holmes concluded: “Three generations of imbeciles are enough.”

Attention Andover Students

2007-02-23T11:14:00.000-05:00

Please use the following link to access the complete Power Point presentation on Abortion in the United States:
http://www.guttmacher.org/presentations/ab_slides.html

Eugenics, Race, and Margaret Sanger Revisited: Reproductive Freedom for All?

2006-11-28T14:43:00.000-05:00

In winter 2001, the International Center for Photography (ICP) in New York City sponsored an exhibit, “Perfecting Mankind: Eugenics and Photography,” where posted on the wall was a quotation ascribed to my grandmother, Margaret Sanger: “More children from the fit, less from the unfit—that is the chief issue of birth control.” My grandmother never said this. The quotation actually came from a 1919 editorial in American Medicine that followed my grandmother’s review of an article. This quotation has been repeatedly and falsely attributed to my grandmother over the decades since. After I objected, the ICP promptly removed the offending quotation from the exhibit, but only after countless gallery visitors had seen it.

Misattributions, misunderstandings, and outright falsehoods about eugenics, race, and Margaret Sanger have too often been the norm in the twentieth and now the twenty-first centuries. Issues of race permeate current American arguments about abortion and reproductive rights. Abortion opponents, including some African Americans, liken abortion to slavery or the Holocaust in Nazi Germany. Such imagery is not new. My grandmother called women subject to “involuntary motherhood” slaves.

Some of the most prominent men of the early twentieth century endorsed eugenics. At the First International Eugenics Congress in London in 1912, the attendees included the type of men my grandmother wanted to win over for birth control—Alexander Graham Bell; Winston Churchill; Charles Eliot, immediate past president of Harvard University; and Havelock Ellis, her friend-to-be. While attended by an overwhelmingly white, male, well-to-do audience, the impulses of the attendees and of those who supported eugenics should not be classified as necessarily class, gender, or race based. Eugenics in its infancy was seen as a tool for societal and human improvement. Reformers saw it as a way to enlist science, biology, and genetics in service of healthy human reproduction and outcomes and thereby to improve the health and quality of all children being born. At its least offensive, eugenics called for improved prenatal care. At its most offensive, it called for involuntary sterilization. The downfall of eugenics came when reformers began to use it as a program of social control, promoting government intervention and coercion in human reproduction. This shift points to an ongoing issue in modern science—how to use science for good and how to define what that good is.

The entry point for eugenics into political discourse came from societal disapproval of certain sexual activities, specifically masturbation. Social, religious, and cultural fears and taboos, portrayed as medical “opinion,” said that masturbation was bad for the human body and psyche, not to mention sinful. Masturbation was never, however, illegal. Doctors in the late nineteenth century developed methods of sterilizing both men and women, including the vasectomy; one physician began experimenting in an Indiana prison, illegally, by sterilizing those men he diagnosed as “chronic masturbators.” The doctor, Henry Clay Sharp, performed vasectomies, circumcisions, and castrations on the inmates, presumably mostly white, sometimes doing over one hundred procedures in a year.

Sharp’s zeal for his job led him on a crusade to legalize what he was doing and to expand the class of those to whom he could legally do it. In a 1902 paper, Sharp wrote: “I therefore suggest that you endeavor to secure such legislation as will make it mandatory that this operation be performed on all convicted degenerates. It renders them powerless to reproduce their kind, and it is an undoubted fact that the progeny of degenerates becomes a charge upon the state.” In 1907, Indiana became the first of thirty states to legalize compulsory sterilization of “confirmed criminals, idiots, rapists, and imbeciles” if procreation was deemed “inadvisable” by a committee and there was “no probability of improvement of the mental condition of the inmate.”

At the same time as doctors and reformers were pushing for so-called negative eugenic legislation, some early feminists and birth controllers were also using eugenics to advance their cause. They used eugenic arguments in favor of eliminating involuntary motherhood and of permitting motherhood by choice, which in their view would produce healthier children. Late nineteenth-century feminists were of the opinion, as unscientific as it was, that unwanted children, the products of involuntary motherhood, were likely to be morally or physically defective. They argued that every child had a right to be born healthy—an argument Margaret Sanger used repeatedly throughout her life: “Every child should be a wanted child.”

While not entirely correct from a biological point of view, this argument contained the seeds of a larger valid point. Women know when they want to have a child. They know when they are ready to take on the physical and emotional burdens of pregnancy and child rearing. My grandmother argued that “women are natural eugenicists.” All women want healthy children that will survive to adulthood and have children of their own. Bringing science to motherhood and children’s health was seen as a natural extension of the so-called purity crusade in which many feminists were engaged at the turn of the twentieth century. This pursuit of mental, moral, marital, and physical health was expanded to encompass voluntarily producing healthy children. It is interesting to note that in those times many feminists talked of making motherhood a profession and more scientific. In their view, motherhood was woman’s major contribution to the human race, and improving motherhood’s status and outcomes was a method of improving women’s lives.

At this time, women’s colleges were producing a steady stream of graduates who were not only delaying childbearing but also having fewer children. President Theodore Roosevelt attacked this trend in 1905 as “race suicide,” calling it decadent and a sign of moral decline, and labeling the woman, or man, who avoided having children as “criminal against the race.” The fact that a president of the United States attacked birth control, a decade before the term had been coined and a decade before my grandmother entered the fray, made the prevention of conception a major national issue. The arguments Roosevelt and others used against birth control, in addition to eugenic ones, were similar to those first used by the Know-Nothings in the early nineteenth century that birth control would lead to the decline in Yankee hegemony and that the United States needed a growing population to fulfill its manifest destiny, as well as antifeminist and religious arguments that birth control enabled women to avoid their duty to the human race and was unnatural and sinful for both men and women.

Among the political results of eugenic thinking in the early twentieth century were immigration quotas and restrictions and restrictive marriage laws, including a resurgence of antimiscegenation statutes, which prohibited marriage between blacks and whites. Additionally, before 1920, almost one-half of the states prohibited marriage between “imbeciles, epileptics, paupers, drunkards, criminals, and the feebleminded.” Various words were used at the time to classify persons of low intelligence: for example, feebleminded, moron, imbecile, and idiot. Whether there was a hierarchy of intelligence levels understood in these words remains unclear, but they seem to have been interchangeable. Today, these terms refer specifically (and derogatorily) to persons with severe mental retardation. Then, such terms were applied across the board to persons with mental retardation, persons with other disabilities, and sometimes people whose behavior did not conform to social norms. Such people were deemed “unfit,” which became the code word among eugenicists for people who should not be allowed to reproduce. In 1913, the year my grandmother began her birth-control work in earnest, thirteen states had compulsory sterilization laws for the unfit. The number would grow to thirty.

Into this milieu came my grandmother. She was an intelligent women but not a formally educated one. I doubt she had read or studied evolution, natural selection, or genetics. She came from one of the classes that Protestant eugenicists looked down upon and discriminated against—Irish Catholics. She was also poor and female. She had married a Jew. She had a criminal record from her days as a labor organizer. She had inherited diseases. No eugenicist would call her “fit.” She had three children.

Margaret Sanger was truly committed to improving the lot of poor, immigrant, and non – English speaking woman in America. As a nurse, she saw their living conditions firsthand. She saw the abysmal poverty, unsanitary environments, and endless stream of unwanted children. She had seen all this growing up with ten brothers and sisters, a father who could not provide a steady income, and a sickly mother dying before her time. She herself had been deathly ill with tuberculosis, and repeated childbearing would have killed her, just as it had her mother. While she may have appeared to espouse elitist views about reproduction as the years passed, her views were directly descended from her life experiences in poverty-stricken upstate New York and the Lower East Side of New York City.

Margaret Sanger was an amalgam of views on reproduction. As a radical in the early years, she believed that both the inherent unfairness of the capitalist economic system and a disadvantaged environment, including poor living conditions that lead to poor health and lack of education, prevented poor people from improving their lot. And yet she believed that it was up to poor people themselves to extricate themselves from poverty—after all, she herself had done so. She believed that women wanted their children to be free of poverty and disease, that women were natural eugenicists, and that birth control, which could limit the number of children and improve their quality of life, was the panacea to accomplish this.

Eugenics at that time was not only “scientific” but also much more respectable than birth control, which under my grandmother’s leadership was seen as the cause of radical, feminist lawbreakers. Eugenics was there to be co-opted and used. At the time, it must have seemed a winning strategy, since not only would eugenics give birth control a scientific patina but my grandmother also hoped to convert eugenicists who opposed birth control into supporters. Still, substantial philosophical differences existed between my grandmother and the eugenicists, particularly around the issue of women’s autonomy.

In one of her earliest pieces on eugenics in the February 1919 issue of Birth Control Review, my grandmother laid out those differences:

Before eugenists [eugenicists were originally called eugenists] and others who are laboring for racial betterment can succeed, they must first clear the way for Birth Control. Like advocates of Birth Control, the eugenists, for instance, are seeking to assist the race towards the elimination of the unfit. Both are seeking a single end but they lay emphasis upon different methods. . . . We who advocate Birth Control, on the other hand, lay all our emphasis upon stopping not only the reproduction of the unfit but upon stopping all reproduction when there is not economic means of providing proper care for those who are born in health. The eugenist also believes that a woman should bear as many healthy children as possible as a duty to the state. We hold that the world is already over-populated. Eugenists imply or insist that a woman’s first duty is to the state; we contend that her duty to herself is her first duty to the state. . . . We maintain that a woman possessing an adequate knowledge of her reproductive functions is the best judge of the time and conditions under which her child should be brought into the world. We further maintain that it is her right, regardless of all other considerations, to determine whether she should bear children or not, and how many children she shall bear if she chooses to become a mother.

This statement outlined my grandmother’s support of some of what eugenicists stood for and her objection to other parts of their agenda. She stated that she shared the goal of the “elimination of the unfit,” but by mostly voluntary means. She asserted that a woman is best judge of whether and when to bring a child into the world. When a woman makes this determination, children will be healthier and better cared for. In other words, women are natural eugenicists.

That said, my grandmother advised, but did not mandate, that birth control be used in the following conditions:

1. If the parents have a transmissible disease such as epilepsy or alcoholism.

2. If the mother had heart or kidney disease so that the pregnancy could endanger the woman’s life.

3. If the parents already have a subnormal child.

4. There should be an interval of two or three years between children in order to give the woman time to rest from her last birth.

5. No woman should have children until she has finished her adolescent period and attained age 22 or 23.

6. There should be no more children than can be brought up decently and properly provided for.

7. Children should not be born until the young couple has two years of married life so that their marriage and relationship can mature.

Most of these guidelines are much akin to the commonsense advice a mother might give a daughter. She also claimed that birth control would improve marriages, family life, and one’s sex life. But that wasn’t enough. She went on:

No permanent peace is possible without a grasp of the population problem. Birth Control is not merely an individual problem; it is not merely a national question; it concerns the whole wide world, the ultimate destiny of the human race. . . . In his last book, Mr. Wells speaks of the meaningless, aimless lives which cram this world of ours, hordes of people who are born, who live, who die, yet who have done absolutely nothing to advance the race one iota. Their lives are hopeless repetitions. All that they have done has been done better before. Such human weeds clog up the path, drain up the energies and the resources of this little earth.

My grandmother’s reference to some of humanity as “human weeds” is among her most troubling. To call it elitist and unhumanitarian would be an understatement. Yet she also recognized the inherent biases of eugenics. When she objected to “cradle competition” between the fit and the unfit, the eugenic solution to the race problem, my grandmother said:

In passing, we should here recognize the difficulties presented by the idea of the “fit” and the “‘unfit.” Who is to decide this question? The grosser, the more obvious, the undeniably feeble-minded should indeed not only be discouraged but prevented from propagating their kind. But among the writings of the representative Eugenists one cannot ignore the distinct middle-class bias that prevails. . . . The official policy it has pursued for years has been inspired by a class-bias and sex-bias.

One can feel the tug of values here. Under strict eugenic principles, my grandmother herself would have been prevented from being born. Her father was an Irish Catholic alcoholic, her mother suffered chronic poor health, they were poor, there were already five children by the time she came along, and a subsequent child would die shortly after birth. The only eugenic factors in her favor were that they were white, spoke English, and were not a burden on the government. Some strict eugenicists of the day would nevertheless have prevented Margaret Sanger’s parents, or Margaret Sanger herself, from having more than one or two children.

All the while maintaining that birth control should be voluntary and educational, Margaret Sanger attempted to establish social norms for childbearing and motherhood and, in some instances, went beyond this to endorsing legal restrictions on childbearing. Some eugenicists endorsed the sterilization of criminals. My grandmother did not. Putting aside the fact that she was a criminal herself, having been arrested and jailed multiple times, and could be classified a repeat offender and thereby subject to sterilization, she stated:

As for the sterilization of criminals, not merely must we know much more of heredity and genetics in general, but also acquire more certainty of the justice of our laws and the honesty of their administration before we can make rulings of fitness or unfitness merely upon the basis of a respect for law. The fact that a man is for the purposes of society classed as a criminal tells me little as to his value, still less as to the possible value of his offspring.

In general, she opposed both negative eugenics and positive eugenics. She not only felt that we did not know enough scientifically to make informed judgments about reproduction but she also believed that, no matter what the law says regarding marriage and reproduction, humans will find a way around it. As she once said, negative eugenics “must resort to compulsory and restrictive legislation, which, as events prove, is ineffective and ineffectual.”

She did, however, call for the sterilization of the insane and the feebleminded. She felt that these people, however defined, were incapable of understanding birth-control information and making an informed and rational decision about whether to become a parent. She believed that the feebleminded give birth to more feebleminded, and that the only way to break the cycle was to prevent them from having children.

She also called for a ban on the immigration into the United States of various “unfit” people. She endorsed keeping “the doors of immigration closed to the entrance of certain aliens whose condition is known to be detrimental to the stamina of the race, such as feebleminded idiots, morons, syphilitic, epileptic, criminal, professional prostitutes and others in this class barred by the immigration laws of 1924.”

She further endorsed segregation of “illiterates, paupers, unemployables, criminals, prostitutes, [and] dope-fiends” as long as necessary for them to develop moral conduct so that they could return to society. It is not clear why she thought “unemployables” or poor people needed to develop moral conduct when she stated in other contexts that the environment, societal, and economic conditions were largely responsible for poverty. This belief appears to be a case of what we now call blaming the victim, but which fell right in line with my grandmother’s opinion that almost anyone could work their way out of poverty.

At her core though, she remained a feminist:

Compulsory motherhood is the cornerstone of the subjection of women and the subjection of women is the basis of all the evils of over-population. Birth is the woman’s problem, and she must be put in a position to solve it for herself. She must have the right to her own body, and the right to choose when she will bear a child. If this right be made absolutely hers, there will be an end to the bearing of children for whom the world has no room and no opportunities; there will be an end to the bearing of diseased and defective children.

The ironies of race, eugenics, and birth control are legion. So are the tragedies. Eugenics found fertile soil in the United States because of our history of competition between differing ethnic groups for political, economic, and cultural power. Eugenics did not begin as an anti-black program. The first eugenic laws were enacted because of white men masturbating. The U.S. Supreme Court upheld eugenics laws in a case involving a white woman. Margaret Sanger tried to co-opt eugenics in a bid for respectability. It failed miserably and the damage continues to this day.

My grandmother’s entire career shows that she was motivated by a desire to save the women she took care of as a nurse—the poor, the uneducated, the immigrant. There was no motivation to eliminate them. She wanted every child to have the chance that hers did—poverty combined with having too many children were the root causes of racial degeneration, not heredity or ethnicity or race. Her emphasis on childbearing served to reinforce the notion that the fertility of the poor, and by extension that of the black race, was a proper subject of social and governmental control. The dangers inherent in this view are still with us.

How Did We Do in the Midterms?

2006-11-21T16:34:00.000-05:00

The pro-choice movement is claiming victory in the 2006 Midterm Elections. We turned back a draconian abortion law in South Dakota and two mandated parental involvement initiatives in California and Oregon, all with about a 55-45 margin. Pro-choice forces picked up three new Senate seats and about 22 new House seats with some House races still undecided.

But the exit polls and the new party makeup in Congress show that the election was anything but a referendum on, or a victory for, choice in the long term.

The exit polls differ from prior years in that there was no ranking of issues asked of the voter, thus we do not know the relative importance of the issues that voters said concerned them. What we know is what voters thought about each individual issue. Voters were asked if an issue as ‘extremely,’ ‘very,’ ‘somewhat’ or ‘not-at-all’ important in deciding for whom to vote for in the House of Representatives. The ranking of the major issues was:

Issue	Extremely/Very Important
Scandals	74%
Economy	72%
Terrorism	72%
Iraq	68%
Immigration	62%
Values	57%

The two issues specifically referred to in the values question were same-sex marriage and abortion. The values vote broke down as follows:

Relative Importance	Democrat	Republican
Extremely	40%	58%
Very	51%	47%
Somewhat	61%	37%
Not-at-all	69%	29%

Voters were not asked to name their most important issue. In 2004, the voter was asked this question, and 22% said “values”. Of these voters 80% voted for President Bush. It is tempting to say that Democrats in 2006 won over more of the values voter, since Democrats won 40% of the votes of those who say values were “extremely important”. But the polling questions and methodology were different in 2004 and 2006. It has to be noted also that Democrats won gubernatorial races (Ohio) and senatorial races (Pennsylvania) by running a Methodist minister and an anti-choice candidate respectively. In some Congressional races the Democratic candidate, and victor, was anti-choice.

The Schumer-Emanuel strategy becomes clear when you look at the pro-choice results versus the Democratic Party results. As stated above, the pro-choice pick up in the Senate was 3 seats, plus one mixed-choice seat. The Democrats won 6 seats. In the House the pro-choice forces won 22 seats; the Democrats won about 30. Pro-life Democrats took the balance of the seats. These include Bob Casey of Pennsylvania in the Senate and Heath Shuler of North Carolina in the House. It is doubtful, depending on the issue, whether there is a pro-choice majority in either house, even thought here is a Democratic Party majority in both. The good news is that Democratic majorities mean that little, if any, anti-choice legislation will reach the floor.

The bigger pro-choice loss, however, was on the Republican side. The small band of Republican moderates, either partially or entirely pro-choice, dwindled even further. Lincoln Chafee lost his Rhode Island Senate seat. Two Connecticut Republicans, Rob Simmons and Nancy Johnson, lost theirs, as did Jim Leach in Iowa. Two New Hampshire Republicans, Jeb Bradley and Charlie Bass of New Hampshire, and Congresswoman Sue Kelly of New York also lost. The GOP now holds just one of 22 House seats in New England.

Choice will never be safe until both political parties subscribe to it. The loss of such stalwart defenders of choice on the Republican side is nothing short of a disaster.

Pro-choice forces can see some rays of hope in the opinion polls though. In the last Gallup Poll to ask specifically about abortion, taken in May 2006, 30% of respondents said that abortion should be legal in all circumstances, up from 23% a year earlier. This is down from 33% in September 1994, but is a heartening upward trend from more recent polls. Unfortunately, those who want abortion legal in ‘most circumstances’ were only 13%, for a mostly-pro-choice total of 43%. Those respondents who want abortion legal in only a ‘few circumstances’ or not at all were 39% and 15% respectively, for an anti-choice total of 54%.

The upshot: not a lot of pro-choice legislative initiatives will get anywhere in this Congress, and the anti-choice Trojan Horse inside the Democratic Big Tent got bigger, and the forces of moderation inside the Republican party got smaller.

The Lesser of Two Evils?

2006-06-19T13:22:00.000-04:00

Recently Democrats in Pennsylvania in a primary election overwhelmingly nominated anti-choice Bob Casey as their candidate to unseat anti-choice Republican Senator Rick Santorum. Many pro-choice Pennsylvanians called Casey “the lesser of two evils”. On the same week, the Vatican invoked the “lesser of two evils” justification to explain its investigation into the permissibility of using condoms to halt the transmission of HIV.

While the use of the principle of ‘the lesser of two evils’ is the appropriate approach for the Vatican, I wonder if it is for the Democratic Party. In Catholic theology, the principle of the lesser evil is justifiable when there is no other way to prevent the greater evil. In party politics, it seems as though the ends are being asked to justify the means.

Bob Casey is a self-described ‘pro-life Democrat,’ who thinks Roe v. Wade should be overturned. He allows that the Constitution does protect personal privacy in some situations, including the use of contraception. His candidacy for the Senate is based on his name recognition, his service as Pennsylvania State Treasurer, and his presumed electability. Senator Chuck Schumer and the Democratic Senatorial Campaign Committee pushed hard to clear the path for Casey, over the objection of many pro-choice groups and politicians. Casey’s opponent, the incumbent Senator Santorum, is, like Casey, opposed to abortion, but also opposes birth control and stem cell research, just to name a few issues of concern to women’s rights advocates. When other issues are taken into account (both support the Iraq war and both oppose restrictions on guns), Bob Casey is only slightly to the left of Senator Santorum, and way to the right of the Democratic Party mainstream.

Meanwhile at the Vatican, Pope Benedict XVI announced that various councils, theologians and scientists were studying the advisability of permitting condom use as a means of HIV prevention. The Roman Catholic Church has been on record of opposing any means of ‘artificial contraception’ since Pope Pius XI’s Encyclical, Casti Cannubii, in 1930, which was reaffirmed over strenuous opposition within the Church by Pope Paul VI’s encyclical, Humanae Vitae, in 1968. The prohibition on birth control for pregnancy prevention has included, to date, the prohibition of condoms for disease prevention. The Vatican in the face of the HIV epidemic has been adamant, up until now, that only permissible ways to prevent HIV transmission are chastity and fidelity. Now, the Church is investigating, among other cases, whether condom use by a married couple where one is HIV positive is licit as the “lesser of two evils”. Cardinal Carol Maria Martini, retired Archbishop of Milan, recently gave an interview to L’espresso where he stated that “certainly the use of condoms can constitute in certain situations a lesser evil.”

Short of enlisting Cardinal Martini run against Senator Santorum for the Pennsylvania Senate seat, what should Pennsylvania Democrats have done? 85% of them voted for Bob Casey in the Democratic primary, probably a good half of them against their pro-choice inclinations. Former NARAL President Kate Michelman reluctantly declined to run in the Democratic primary, partly because of the personal toll the race would take, but mainly because she thought that the best chance of defeating anti-choice Senator Santorum was with slightly-less-anti-choice Bob Casey. Pennsylvania Democrats obviously agreed. A few organizations stood up for principle. NOW and the Feminist Majority endorsed one of Casey’s pro-choice opponents, saying that it was important to oust Santorum, “but we must not do so by trading away our rights.” In contrast, NARAL Pro-Choice New York this week endorsed Hillary Clinton for reelection to the Senate, the same Hillary Clinton who called abortion “a sad, even tragic choice.” NARAL’s press release mentioned the word ‘abortion’ just once, in the context of seeking to reduce its number. While there are merits to broadening the issue beyond abortion to include all the reproductive issues that women face, this cannot be done in a way that avoids or obfuscates the core issue of abortion—or in a way that causes the organization to lose its soul.

If some pro-choice groups and voters are running away from the issue in a desperate effort to attract ‘moderates,’ how can the pro-choice movement expect politicians to stand with us?

While the Catholic Church will wrestle with whether, based on the principle of the lesser evil, there are any circumstances in which contraception can now be licit, so too the Democratic Party should reexamine the circumstances under which it will nominate so-called Pro-Life Lite candidates. By continuing on this path, they will continue to confuse the public about what it stands for and drive people to stay home or vote ‘none of the above.’ Similarly, pro-choice groups, intent on playing politics, and pro-choice voters eager for change, must examine their consciences. The slippery slope has taken them to a place I don’t recognize as being pro-choice.

Eugene Debs famously said, “I’d rather vote for something I want and not get it than vote for something I don’t want, and get it.”

The lesser of two evils may in some cases be progress but it does not equal the good.

Letter to the Editor of Conscience

2006-04-26T13:59:00.000-04:00

Rosalind P. Petchesky recently wrote a piece entitled On the Unstable Marriage of Reproductive and Sexual Rights for Conscience Magazine. Below is my response which Conscience printed in their current Summer 2006 issue.

March 15, 2006

To the Editor
Conscience Magazine

Rosalind P. Petchesky’s provocative article, “On the Unstable Marriage of Reproductive and Sexual Rights”, challenges us to “do the hard work of deeply analyzing their (reproductive rights and sexual rights) differences as well as their interlinkages.” She suggests three areas to be explored: the rejection of sexual hierarchies, non-gender-exclusive services, and reproductive rights of gay men.

I would suggest a more fundamental exploration first. Ms. Petchesky’s article points out, quite correctly, that in the 1970’s our understanding of sexual diversity “was at best primitive.” Alas, after 30 years of academic work, the same can be said now. What biologists, geneticists and psychologists are beginning to understand is the biological-genetic-evolutionary basis of not just human reproductive instincts and behaviors but all human sexual expression, including homosexuality and other points on the sexuality rainbow. Rather than separating reproductive concerns from sexual concerns, I would suggest we look at them together from biological and genetic viewpoints as a part of human evolution. Everyone, no matter what their sexual orientation, is a product of successful human reproduction, and everyone, conversely, is a part of the human reproductive system, whether they bear children or not. A biological analysis could bring a fresh dimension to how, what, why and to whom reproductive and sexual health services are offered and what it means to support the reproductive rights of, for instance, not just gay men and transgenders, as Petchesky correctly calls for, but all men.

The time of an “us” and “them” approach to human sexuality and reproductive freedom is in my view outworn. We are all in this struggle together. Maybe we should try to understand why.

Alexander Sanger
Author, Beyond Choice: Reproductive Freedom in the 21st Century.

South Dakota Mon Amour

2006-03-19T18:03:00.000-05:00

I’ve never been to the Dakotas, either North or South. My grandmother’s, Margaret Sanger’s, uncle, William E. Purcell, moved to North Dakota from New Jersey, practiced law and eventually represented the state in the U.S. Senate from 1910 to 1911. He didn’t care much for my grandmother’s cause. Neither do his political descendants in South Dakota, which recently passed a law criminalizing abortion.

Why, of all the states champing at the bit to criminalize abortion, did South Dakota take the lead?

Before we get to that, let’s review the bidding. Most of you have already read ad nauseam about the reactionary South Dakotan legislature under the thumb of religious fanatics (true), the effect of the law (buy oil and airline stocks—people will be traveling even more than they do now for abortions), the law being a frontal assault on Roe v. Wade (true), the likelihood of the Supreme Court hearing the case and what Justices Roberts and Alito will do (who knows), and what the law really means in practice (it will deter some abortions, but will serve to make the rest illegal, later, more expensive and more dangerous).

South Dakota’s law is the most stringent abortion law ever attempted since Roe was decided in 1973. Abortion is to be illegal except to save the life of the mother, but maybe not even permissible then. SD State Senator Bill Napoli, was quoted explaining the circumstances under which he’d be willing to grant an abortion: “A real-life description to me would be a rape victim, brutally raped, savaged. The girl was a virgin. She was religious. She planned on saving her virginity until she was married. She was brutalized and raped, sodomized as bad as you can possibly make it, and is impregnated. I mean, that girl could be so messed up, physically and psychologically, that carrying that child could very well threaten her life.” So, other than the “Sodomized Religious Virgin Exception,” abortion is now illegal in South Dakota, until enjoined by a Federal Court, which is sure to happen.

The reaction on the pro-choice side has ranged from calls for boycotts and girlcotts of South Dakota (yes), to calls for a referendum on the South Dakota ballot this fall overturning the law (most South Dakotans oppose the law), to calls for more debate and discussion of the “moral issues” involved (pulleaze!). But before we do all this, especially before we launch a referendum campaign or engage in more “moral” debates, let’s take a step back and ask ourselves, what was South Dakota trying to do here?

Were they trying to enforce their version of a religious/moral code? Make Christianity state law? Demean women? Keep women barefoot and pregnant? Bring back patriarchy?

My answer is, all of the above. But the motivation behind all this becomes clear only when we look at the demographic/societal context.

You probably haven’t read much about what the law will mean for the childbearing rate in South Dakota, because no one has focused on it. That, in my view, is what this law is all about: increasing the childbearing rate, especially the white childbearing rate.

Let’s look at the demographic context here. The population explosion worldwide is slowing down. There are still very high birth rates in much of the Third World, most of Africa, much of the Mideast, some in South Asia. The bigger news is that many countries in these regions are nearing or are below replacement birth rate for their population (the replacement rate is 2.1 children per woman). In Mexico, for instance, the birth rate has fallen from about 6.0 in the 1960’s to about 2.5 now. This pattern is repeated throughout the Third World, even if some countries like Kenya have birthrates of about 6.

The bigger demographic news comes out of Europe, Old and New (for definitions of the demographic terms I am using go to the CDC website—but you can get the gist without knowing the technical definitions). The birth rate in Europe as a whole is well below the replacement rate. The EU average is now 1.5. France at 1.94 is second only to Ireland.Germany is at 1.37. Eastern Europe, Italy and Spain are even lower.

And what do the governments of these countries with falling or soon-to-be-falling populations worry about? Grandeur? Military might? Perpetuating their culture? Yes, but mainly funding their pension systems. They fear that there won’t be enough young workers to pay the social security for the elderly. And given their current pension/retirement schemes, they are right. So, a nation has three choices: revise their pension schemes by delaying retirement and reducing benefits, import young people, i.e. immigration, or increase the native birth rate. Europe is trying to accomplish the last to try to forestall the implementing the first two alternatives. Just in the last month there have been new proposals in Germany, France Britain, and Russia, just to name a few countries, to address the birth rate problem. Defining the birth rate “problem” is not easy, nor is solving it. If women and men don’t want to have children, then it is nigh impossible for a society to lure them or force them to do so. Germany is looking at expanding its cash payments and tax breaks for additional births, more paid leave for women, mandating more time off for men to parent their children, and more subsidized child care.

What no government has figured out his how to make childbearing not a penalty for a woman’s career and her career earnings. In England it has been estimated that delaying childbearing from age 24 to age 28 will reduce the lifetime earnings loss by about $700,000. Women have figured this out all around the world, and the demographic consequence is that when you delay childbearing, the likelihood is that you will have fewer children. So women make the tradeoff, more earnings, better career opportunities and fewer children.

Is the United States immune from all this? Not a chance! Are we heading to a European demography? Yes.

What was the first thing President Bush did after the 2004 election? The very next day, when he claimed victory after Kerry conceded Ohio, Bush said his first priority was to fix Social Security. Why? Because it was going to go broke when the Baby Boomers started retiring, and there would not be enough young workers to pay into the system. Note that the President saw the need to address this even with the high immigration rates that we have in this country. Was there an anti-immigrant constituency within the Republican Party that he needed to assuage? You bet! He saw the political tradeoff—reduce social security benefits in order to reduce immigration.

But what of adopting Europe’s strategy of increasing the childbearing rate? Is the US undergoing a baby bust like Old and New Europe? Not quite. Yet.

The US population will hit 300 million this fall. We are still growing. There were a near high of 4.1 million births in 2004 (the last year for which there are figures—births were higher in 1990.). So what is the birth rate problem?

Let’s look at the fine print. The US birth rate is 14.0, or a rate halfway between France and Ireland, the two highest in Europe. The white birth rate is 11.7. What makes up the difference? The Hispanic birth rate of 22.9. This difference becomes clearer when you look at the total fertility rate. For the US as a whole it is 2.05, or slightly below the replacement rate. For whites it is 1.85 and for Hispanics it is 2.82. Hispanics are having and want to have one more child per family than whites do. Hispanics recently replaced Blacks as the largest ethnic/racial group in the country. The birth rate of the US white population is significantly below the replacement rate. There are estimates that by 2050, whites will be in a minority in the country.

These numbers are part of a long pattern in the US. The white birth rate in 1910 was 29.2. It is now 11.7. The white fertility rate has fallen from 123.8 in 1910 by over one-half to 58.5 (it was 65.3 in just 2000). The US crude birth rate is still falling, it fell 17% from 1990 to 2002; the US general fertility rate fell 9% in the same period, and the total fertility rate fell 3%. Margaret Sanger, take a bow!

So, what about South Dakota? Where does it fit in demographically?

It has a birth rate of 14.4 (in 2003), slightly above the US rate and a fertility rate of 70.8, also slightly above the US rate. That said, its population grew from 2000 to 2004 by 2.1%, less than the US growth rate of 4.3%. From 1990 to 2000, it grew by 8.5%, less than the US rate of 13.1%. South Dakota is losing the population race, but it is still growing, for now. South Dakota is one of 13 states at or above replacement rate.

BUT, there were fewer births in South Dakota in 2002 than 1990, 10,698 versus 10,999. The white births dropped from 9,076 to 8,376. Thus the white births dropped 700 while the total dropped only 300. The white birth rate dropped from 14.3 to 12.5. The only birthrate to rise was the Hispanic (the Indian and Black rates also fell). The state is 89% non-Hispanic white, one of the whitest states in the union (the US is 69% non-Hispanic white). Native Americans make up 8.3%, with Blacks, Asians and a growing number of Hispanics making up the balance.

The economic picture is mixed. South Dakota has a low household income compared to the rest of the country ($35,282 median household income versus a US median of $41,994). South Dakota has just 10 persons per square mile—the US has 80. South Dakota has undergone a massive population shift. The Great Plains there, and in other neighboring states, have become a dust bowl. Of the 67 counties in South Dakota for which there are records (4 have no records) 46 of them, or two-thirds, lost population from 1960 to 1990 (more recent figures were not available but I suspect the number is even higher now). The median age in South Dakota is 37, as opposed to 35 for the US. Just 10% of the workforce is in agriculture or similar pursuits. Education, health and social services and retail trade are bigger employers than agriculture. The family farm is dying.

The Census Bureau predicts that South Dakota’s population will grow, slowly, for fifteen more years until 2020 (from 754,000 to 802,000) and then begin declining. The US will still be growing.

So, South Dakota is: a white bastion, soon to go the way of the rest of the country demographically, relatively poor, relatively old, and with lots of space for newcomers. There are two solutions, just as in Europe (South Dakota doesn’t need any more than other states to worry about funding pensions at the state level): it can import people or grow them at home—immigration or increase the childbearing rate. And in the current context, immigration means Hispanics and Asians.

Have we seen this issue before?

Yes, in the early 19th century. Immigration patterns began to change in the 1830’s and 1840’s, shifting from England and Germany, to Ireland (it would shift later in the century to Southern and Eastern Europe). The Irish may have spoken the same (almost) language, but they were Catholic (my grandmother’s parents included). This was perceived by the Protestant elites as a challenge to their hegemony. The Protestants wanted to preserve their Puritan, Anglo-Saxon culture, the Protestant religion and their political power. As a result the Know-Nothing Party was founded. They wanted to preserve the heretofore American, male-dominated, Anglo-Saxon Protestant society. Their platform called for limits on immigration, office holding be restricted to native-born Americans, and a 21-year waiting period being imposed before an immigrant could vote. Their platform contained temperance elements as well as religious bigotry. They sought to limit the sale of liquor, to restrict public-school teaching to Protestants, and to have the Protestant version of the Bible read daily in classrooms.

A part of this nativist, puritanical vision there was a concern among Protestants about being outnumbered by the new Catholic immigrants. They noticed that Catholic women had large numbers of children, while the number being had by native Protestant women was declining. Since no new birth control methods had been introduced, the Know-Nothings concluded that their Protestant wives were making use of abortion as a method of birth control. They were right. Protestant women were making disproportionate use of abortion to limit their childbearing.

So, the Know-Nothing Party lent their support to measures seeking to criminalize abortion and birth control. They did so not because they thought birth control and abortion were immoral, or dangerous.

No, they did so to prevent their wives from using them!

The male Protestants wanted to increase the Protestant birth rate. They needed to take back control of childbearing from their wives.

They failed. The genie was out of the bottle. Birth control and abortion went underground. Women continued to use them. The birth rate in the US went from about 8 children per woman in 1800 to 4 children per woman in 1900, even though birth control and abortion had been criminalized.

Well, you might say, haven’t we learned something from history? Isn’t this just religious fanaticism on display in South Dakota and not some outworn ethnic battle? The language used in South Dakota may be religious or moral, but the underlying demographic/cultural instincts are still there.

Take the recent article in Foreign Policy by Philip Longman of the New America Foundation, “The Return of Patriarchy”.

Longman tries to make the case that patriarchy is good for society since it insures population growth. Patriarchy makes women concentrate on being mothers, raising more and healthier children, thereby contributing, as only women can do, to the future wellbeing of society. There are also in his article statements like “population becomes power”. He calls for dismantling the social security system and handing its functions back to the family, which will then need more children to support it. He concludes that patriarchal families will inherit the earth, since they will “by a process similar to the survival of the fittest, be adapted to a new environment in which no one can rely on government to replace the family, and in which a patriarchal God commands family members to suppress their individualism and submit to father.” In other words, patriarchy is the red state, God-fearing peoples way to inherit the earth.

Patriarchy is back in South Dakota. Some lawmakers there talked fondly of the day of the shotgun marriage. No abortions to get you “off the hook”. Marry young, have lots of kids. Settle the Plains. Keep out those immigrants. Keep South Dakota South Dakota.

How do I know this? Check the section on penalties. A doctor performing an abortion gets five years in the slammer. By the way, abortion is defined as murder and committing other murders in South Dakota will get you the death penalty. And what is the penalty, you might ask, for women who get the abortion, who are equally guilty with the doc? Nothing. Nada. Zilch. No time in the pen. Nope, the folks running the South Dakota patriarchal reproductive system can’t put women of reproductive age in the chair or in prison. Then they can’t reproduce! We need them in the game, as George H. W. Bush said of his granddaughter, in the game making babies.

As someone who has never set foot in South Dakota, may I make a few suggestions? First, patriarchal pro-natalism won’t work when your strategy involves criminalizing normal behavior. Second, your state is in the dumper. The people are old, the young are leaving, and there is no opportunity. And it’s not the weather, folks. I would suggest, rather than criminalizing abortion, which we know from history won’t work, why not try encouraging childbearing and family formation in some inventive ways, if that is your state’s goal. Figure out how to eliminate the economic childbearing penalty for women. Create opportunity that enables women to be workers and mothers without penalizing either role. Get the men totally involved. States are supposed to be social laboratories in our Federal system. So, South Dakota, I say go for it. Try something new, not something old like you just did. You are turning into a wasteland. Criminalizing reproductive freedom will only compound the damage to your state and to women. I remember those days when we didn’t have reproductive freedom. Believe me, you don’t want to go back there.

Two Funerals Play Dirge for Feminist Vote

2006-02-15T12:12:00.000-05:00

Last week saw the funerals of two extraordinary women, Coretta Scott King and Betty Friedan.

Each had respectful obituaries in all the papers and on TV. The similarities end there.

King’s funeral was a major media and political event. Friedan’s wasn’t. Ten thousand people attended King’s funeral, 300 attended Friedan’s. King’s body lay in state and 100,000 mourners filed by and thousands more lined the streets to the church as her casket passed by. There was no lying in state for Friedan and no mourners lining the streets.

Different styles of mourning. Different religions. Different cultures.

Yes, but also different calculations behind the two very different political turnouts.

Four presidents, including our incumbent, President George W. Bush, and his predecessors, Bill Clinton, George H. Bush and Jimmy Carter, attended King’s funeral, as did other dignitaries from federal, state and local government.

The only politician reported at Friedan’s funeral was former Congresswoman Elizabeth Holtzman.

Three dozen speakers gave eulogies for King during the six-hour service. Only a few, including Friedan’s children, did at her hour-long service.

Television cameras were at King’s, not at Friedan’s.

Both Women Contributed

This is not an argument about whether Friedan or King contributed more to U.S. life. They both did in their own way.

Friedan’s 1963 book, “The Feminine Mystique,” changed American culture. As the first of the Second Wave of feminists, she got America thinking about the problem that had no name: women’s difficulty finding identity outside of family life. Everything else that followed was built on her provocative book. King carried on her husband’s fight for justice, not just racial justice, but justice for everyone, including women. She was anti-war, like he was, when it was not popular. She advocated for women’s rights and served on the board of the National Organization for Women.

The turnout of politicians to one funeral and not another was not a measure of either woman. It was a matter of whose followings could do more for the politicians in the future.

The point is that the African American vote is perceived as being in play. Bill and Hillary Clinton are counting on it. George Bush and the Republican Party want a larger slice of it. In the last elections, African Americans went for Kerry 88 percent, Bush 11 percent.

GOP strategists think more African Americans (and Hispanics) can be swayed by the GOP’s conservative stance on social-value issues, such as keeping marriage a heterosexual institution. The African American commitment to improving the educational system for its children is also a natural match for the Republican passion for charter schools.

The women’s vote, however, is far more volatile.

Women went for Kerry over Bush by 51 percent versus 48 percent and the gender gap between Republican and Democratic candidates has fluctuated by up to 15 percentage points in the past presidential elections.

So the women’s vote is also in play.

But as Friedan’s funeral demonstrated, the feminist vote is quite another matter.

A Single-Issue Perception

The feminist vote has become detached from a broad set of interests—such as enhanced health care and child care—in which women, as a group, show particular interest. Instead, it has come to be seen as an isolated and controversial single-issue focus on abortion rights that does not translate reliably into votes.

In the 2004 election exit polls, 21 percent of voters said that abortion should always be legal, while 16 percent said abortion should never be legal. But that didn’t give pro-choice John Kerry the boost he needed. Among solidly pro-choice voters, 25 percent voted for Bush while a skimpier 22 percent of anti-choice people pulled the lever for Kerry. This works out to a swing of about 3 percent in Bush’s favor, roughly matching his margin of victory in the popular vote.

The swing in the groups that believed abortion should be “mostly legal” (34 percent) versus “mostly illegal” (26 percent) was even greater, with Kerry receiving 61 percent of the former group, while Bush received 73 percent of the latter.

Some Democrats may think the solution is to downplay the abortion issue, to run away from it, to make the party a big tent and recruit anti-choice candidates. This should be resisted at all costs.

Reframing the abortion debate, however, is mandatory, as is reframing the feminist agenda.

Swinging the Vote

To get back into political play, feminists should be looking at ways to swing the women’s vote—both in midterm elections and in 2008—by claiming the rubric of successful family life. They should represent parents’ desires to have children when it is best to have them, to raise their children safely to adulthood, to get them to adulthood in good health and educated for the jobs of tomorrow. And those jobs are just as much for daughters as for sons.

The anti-choice approach, by contrast, brings back the involuntary motherhood of old, with all the problems and suffering that entailed for women and children. Feminists should talk about abortion, as well as birth control, in terms of family formation, not just as a right or a matter of individual autonomy.

And feminists, even more than they presently do, should talk about child care, school quality, health care reform and national security in terms of the safety of families. Emphasizing these issues will get feminists out of the single-issue abortion pigeon hole and enable them to talk to U.S. women and men, on a broader set of issues about which every citizen has deep concern.

I am the third generation of a family that has been fighting for reproductive freedom, which is in peril now as never before.

Now is not the time to sweep support for abortion rights under a barrel. But new approaches must be found to persuade the American people that being pro-choice makes human sense. Since a one-dimensional approach to abortion rights has not worked, let’s try something new.

Sam Alito’s Fictional Memoir

2006-01-26T12:53:00.000-05:00

The last few weeks have been busy ones for fictionalized memoirs. Sam Alito’s performance before the Senate Judiciary Committee was a masterful display of myth-making that would have made James Frey and JT LeRoy, the newly crowned kings, or queens, of the fictionalized memoir, proud.

Why did Judge Alito feel the need to fictionalize his autobiography? His real autobiography seemed to be persuasive enough. He’s an intelligent, hard-working, family man who has risen through the ranks to the peak, almost, of his profession.

When someone fictionalizes his life, he is either selling something or trying to hide something. What was Judge Alito trying to sell? Himself. What was he trying to hide? I suspect the same answer—himself, and his real opinions about women and Roe v. Wade.

There was only one thing standing between him and the peak of his profession—his past, more specifically his dated opinions about women and Roe v. Wade. These unstated opinions were made manifest by his membership in the Concerned Alumni of Princeton (CAP). He couldn’t deny membership—after all he had bragged of his membership in a 1985 letter seeking employment with the Reagan Justice Department. It was a signal to curry favor, to get his resume to the top of the pile. It seems to have worked. Now membership in CAP threatened to be an obstacle to his long-sought goal to be a Supreme Court Justice.

CAP was an organization of alumni who were dissatisfied with Princeton’s accommodations to the realities of the late 20th century. CAP, among other things, sponsored the magazine Prospect, which in 1983 published an essay entitled “In Defense of Elitism.” Senator Kennedy quoted from the article at the hearings:

“People nowadays just don’t seem to know their place. Everywhere one turns, blacks and Hispanics are demanding jobs simply because they’re black and Hispanic. The physically handicapped are trying to gain equal representation in professional sports. And homosexuals are demanding the government vouchsafe them the right to bear children. And now here come women.”

To my recollection (I was Class of 1969), this was an accurate summary of the views coming out of CAP. They were a group of alumni seeking a return to the Princeton of their time, a white, male, straight Princeton without minorities, gays, and women only on weekends. CAP had other targets as well: the decline of the football team and the status of ROTC, but these were tangential issues.

Judge Alito had two choices: admit he joined CAP for misguided reasons which he had now repudiated, or alternatively, say he didn’t remember. Judge Alito went the latter route. Is this credible?

Every Princeton alumnus/a during the 1970’s and 1980’s was bombarded with news about CAP. It was the biggest issue that Princeton was facing—a concerted attack on co-education and minority admissions by a wealthy group of extreme conservatives, so extreme that Senator Frist, a Princeton alumnus and now the Republican majority leader, publicly rebuked them. We alumni received frequent letters from CAP, we read about CAP regularly in the Princeton Alumni Weekly, and the newspapers reported on it. In New Jersey, where Judge Alito was living and working, it was the only thing people talked about in relation to Princeton for years and yet Judge Alito said, “I have no specific recollection of that organization.” It must have been the issue of ROTC, said the judge, who was a member of ROTC at Princeton. Reportedly, ROTC was briefly banished from the campus while Judge Alito was there but returned after about a year’s hiatus. Hardly a reason in my view to join an organization dedicated to such a broad platform of opposition to minorities. There were other venues to seek the reinstatement of ROTC at Princeton.

Judge Alito’s testimony is simply not credible. But when looked at in context, it is understandable as an integral part of a fictionalized memoir.

Judge Alito had to denigrate CAP, knowing full well he would be cross-examined about it. He did it quite subtly in his opening statement by taking a deliberate swing, not at CAP, but at his alma mater:

“And after I graduated from high school, I went a full 12 miles down the road, but really to a different world when I entered Princeton University. A generation earlier, I think that somebody from my background probably would not have felt fully comfortable at a college like Princeton. But, by the time I graduated from high school, things had changed.

…

It was a time of turmoil at colleges and universities. And I saw some very smart people and very privileged people behaving irresponsibly. And I couldn’t help making a contrast between some of the worst of what I saw on the campus and the good sense and the decency of the people back in my own community.”

In the first exchange on the issue of CAP with Senator Leahy, after he talked about ROTC being the reason he must have joined CAP, Judge Alito said:

“Well, Senator, as you said, from what I now know about the group, it seemed to be dedicated to the idea of bringing back the Princeton that existed at a prior point in time. And as you said, somebody from my background would not have been comfortable in an institution like that, and that certainly was not any part of my thinking in whatever I did in relation to this group.”

So, what was Judge Alito up to here? Why the sucker punch at Princeton, referring to “very privileged people behaving irresponsibly?” Why the reference to someone of “my background” not being “comfortable in an institution like that?”

It’s all part of the fictional memoir, a la James Frey and JT LeRoy. Yes, Sam Alito came from an immigrant family, but his father was civil service and his mother a teacher, and they were solidly middle class. Sam Alito wasn’t mean streets, but he did hint at an impoverished upbringing that he had worked his way out of. He explained in an exchange with Senator Hatch that by “my background” he meant someone of Italian ancestry and “someone not from any sort of exalted economic status.” But young Sam Alito didn’t shine shoes at the Trenton train station to make ends meet or deliver groceries after school or work at McDonald’s—or he didn’t mention these in his opening statement or elsewhere, and I suspect, if he had worked after school, he would have highlighted it. So, Sam Alito’s family was well off enough so he didn’t have to work after school to make ends meet; rather he could stick to his books and study, study, study, with time off for baseball. The story was not exactly rags to riches, just middle class to modest riches—his financial disclosure now indicates a net worth of $2.1 million.

Sam Alito by his wealth alone, if not also his opinions, would seem to be on a par with those crusty members of CAP, an organization he had undeniably joined. How to disassociate himself in the public’s mind from who and what CAP was and the ugly things they stood for? Sam Alito had to set himself apart and make it clear he was not economically or otherwise privileged. So he opens with a swing at the white, male Princeton of Scott Fitzgerald and by implication those members of CAP that would make someone like him uncomfortable. Thus, he could not be tarred with the brush that the members of CAP so richly deserve. Sam Alito portrayed himself, in contrast, as a struggling outsider, fighting against the forces of privilege and repression, not someone who benefited from his family or birth. He is the underdog, a friend of the little guy. He would be the type of person that CAP would seek to keep out of Princeton, overlooking the fact that at that time about a third of the students were receiving scholarship aid. Sam Alito in his Senate testimony created an inspirational story, a fiction memoir, giving himself an up-from-the bootstraps authenticity which his middle class background didn’t give him. In this memoir he was not the guy closing the door behind him after he had made it to the Ivy League.

So, Judge Alito said repeatedly about CAP: “I have no specific recollection of that organization.” There is a Washington proverb—”it isn’t the crime, it’s the cover-up.” Judge Alito’s “I don’t remember” is simply not credible.

Why didn’t he own up to the truth? Probably because admitting to bigoted and racist views, even in one’s youth, or later, was too risky in a nomination where there was other live powder waiting to explode—his views on Roe v. Wade, for instance. These he carefully defused by stating that, even though he put in writing in 1985 that “the Constitution does not protect a right to an abortion,” he will not prejudge the issue. One can only hope. An admission of a youthful mistake in judgment would have been one indicator that, like Justices Souter and Kennedy, Alito would be actually open to changing his mind once on the court.

One doesn’t see in Judge Alito’s memoir any evidence of mistakes, learning experiences, changes, or evolution. That is what we might have learned had he owned up to his real reasons why he and his fellow members joined CAP—it wasn’t ROTC or the declining fortunes of the Tiger football team—it was minorities and women getting their place at Princeton and getting a leg up through affirmative action to get it.

Thus, Sam Alito preserved the myth, by penning a fictional memoir, the up-from-the-bootstraps guy from the inner city of Trenton. From a literary point of view, Sam Alito’s life story still fails the high memoir bar recently set by James Frey and JT LeRoy—it is totally boring. It’s bad fiction. But, unlike Frey and LeRoy, it worked. He’s certain to be confirmed as the next justice of the U.S. Supreme Court, replacing a woman, Sandra Day O’Connor.

How Are The Sexes Doing?The 2005 End of Year Report

2005-12-27T16:06:00.000-05:00

This week the Congress finished work on the Violence Against Women Act (VAWA), reauthorizing it for another five years with a healthy (20%) increase in funding as well as new programs to address and prevent the problems that domestic violence causes women and children (but not men!). Women’s groups hailed the passage of the law, and the sponsors.

Interestingly, the Republican sponsors of VAWA in the House have an abysmal record on reproductive rights issues. Representatives Sensenbrenner (WI 5), Green (WI 8), Brown-Waite (FL 5) and Pryce (OH 15) are all ranked 0% by NARAL for 2004, with the exception of Pryce who was ranked at 35% (she voted in favor of allowing women in the military to have abortions in military hospitals). Thanks to this group and their colleagues, Congress spent another year restricting access to family planning and abortion services.

There is a broader picture that needs to be looked at. The health and well-being of men and women consists of far more than their protection from domestic violence and access to reproductive health care.

At least one recent look from the male point of view painted a depressing picture. The New Hampshire Commission on the Status of Men issued its First Biennial Report (available at nh.gov/csm).

This litany of male woes was no surprise when looked at individually, but collectively, I at least, was taken aback. I have studied in some depth the depressing health disparities between men and women. See my posts of March 2005, “The State of International Family Planning in 2005”, for a discussion of the impact on women’s health of unsafe sex and that of May 2005, “Where Are The Men”, for a discussion of higher premature death and disability rates for males. Each sex has its own health problems—breast cancer for women, prostate cancer for men. It should not have been a surprise, but it was, that the New Hampshire report stated that there was more funding for breast cancer screening than for prostate screening. This combined with other factors leads to 9% more men contracting prostate cancer than women contracting breast cancer in 2005. The Federal Government spends seven times more on breast cancer research than prostate cancer research ($550 million versus $80 million)—the date for these figures was not given, not were the DALYs figures for each disease (the Disability Adjusted Life Years—the World Health Organization measure of the seriousness of the impact of a disease).

Recently, financial analysts advising insurance and pension companies reported that men are gaining in life expectancy faster than women. Women still outlive men in the USA by 4.5 years but the longevity of males has been growing at 2% over the last decade, while for females it has been growing at about 1%. The killers of modern life—working harder, smoking more, more stress—are now hitting women. Lung cancer and heart disease are heavy killers of women prematurely. Male killers like alcohol, AIDS, drugs and guns have declined in recent years. The researchers doubted that men will ever equalize with women: “Men engage in more risky behavior. It’s just our lot to die sooner.”

Violence remains a serious issue in men’s and women’s lives. Domestic violence gets the headlines and is viewed as a women’s issue. Recent research shows that DV is an equal opportunity assaulter and killer. Some research puts the rates as equal between men and women, while others put it at 2:1 male offender to female offender. Women appear more likely to be hurt by the violence because of the size disparity of the sexes. Suicide is disproportionately male with about a 6:1 ratio of deaths male to female. No figures were given for suicide attempts.

Fatherhood issues received a huge portion of the New Hampshire Report, with the most stunning figure being that in the USA 40% of children are not living with their biological father.

Paternity fraud made it into the Report, with New Hampshire, like the rest of the USA, having a rate of about 30% of paternity tests being negative—i.e. the man thought to be the father was not in fact the father. This is perhaps the only issue in the Report that is exclusively male—there being no maternity fraud, at least not yet. How would a guy get another woman’s egg into his spouse anyway? I have argued in Beyond Choice that one factor in males not committing to family life could be the rise in female controlled, as opposed to male controlled (the condom), contraception. The issue of paternity uncertainty is a serious one. Costa Rica passed a law in 2001, the Law of Responsible Fatherhood, that frames paternal obligations on the right of children to know who their parents are and to be supported by them. Paternity testing (free) is required if there is an issue. There has been a sharp decline in children unacknowledged and unsupported by their fathers from 29% in 1999 to 8% in 2003.

The educational disparities between males and females have been the latest salvo in the battle of the sexes. The gender disparities against females in math and science are matched by those against males in reading and writing skills. The math gap is less than the reading gap, proof that remedial programs are working for women. Women make up 60% of undergraduate students in New Hampshire and the rest of the USA. The same is true in graduate studies.

What does all this mean for family life? Last week the CDC reported that 35% of births in 2004 were to single women. These are by choice, since abortion presumably is accessible, if not affordable to almost every women who needs one (I know all the exceptions out there!). Is there a connection between the status of males and the marriage/cohabitation rate? There is a whole body of study on mating preferences, and it is argued that women prefer mates who have an equal educational/social attainment, or prospects thereof. The gender disparity towards females in education began in the 1970’s, right at the time of Roe. Do we see a connection here? Abortion and opportunity do go together.

But why didn’t the rates of college attendance equalize rather than go female? Lots of economic reasons I am sure: military rather than college; high paying blue collar job now versus college; the higher death rate for young males in general.

The National Center for Health Statistics announced that the rate of unwanted babies also increased. The rate increased from 9% in 1995 to 14% in 2002; unwanted being defined as “Right before you became pregnant, did you yourself want to have a baby at any time in the future?” This question measures unwanted versus mistimed pregnancies. The abortion rate also fell from 26 to 24 of every 100 pregnancies that ended in birth or abortion. Was this the result of less access to contraception and abortion? Or were women choosing not to have abortions? More research on this question will soon be forthcoming from the Alan Guttmacher Institute.

Also the CDC announced that the percent of women living with a male sex partner outside of marriage increased from 41 to 50. So as marriage declines, partnerships increase. But the high rate of children not living with a biological father, married or not to the mother, has not declined.

One totally unscientific response of females to all the above appeared in the Wall Street Journal on December 15: women reconstructing themselves to pass as virgins! What is euphemistically called “hymen surgery” or more technically “Hymenoplasty” is on the rise! This isn’t just women wanting to give their husbands a thrill on a second honeymoon; this is women doing it just before marriage to Mr. Right who, unknowingly, was not the first Mr. Right or Mr. Wrong in his intended’s love life. Hymenoplasty has long been performed in virginity-obsessed cultures in the Middle East and Latin America. It has now hit the United States big time.

The expected catcalls from the wings have begun: “fraud” say the religious groups and “female genital mutilation” say some feminists.

Virginity, and the male and female obsession with it, stems from male paternity uncertainty, and the belief that if the female is a virgin at marriage, the child conceived on the wedding night will be the guy’s. But what of the one conceived a month later or a year later? Virginity at marriage is seen by males as at least some proof that his bride is not a slut, she hasn’t slept around, and the thinking goes, if she hasn’t done it before marriage, she is less likely to do it after marriage. So, males want virgins at marriage, or some do.

Female have bought into this and female genital mutilation (FGM) is the result—women mutilating their daughters to lessen sexual pleasure and the chance they will not be virgins at marriage and will be unfaithful after. Recent reports from UNICEF say 130 million women have been subject to FGM, at a rate of 2 million a year. Recent studies now put the estimate at 3 million a year, due to better reporting. But in certain nations the rate is declining. In Egypt and Guinea where almost all women ages 15-49 have had FGM, only half of their daughters have (or so the women report).

South Africa is currently considering a law to ban virginity tests for girls under age 16. Virginity testing is an ancient practice—it finds virgins for the men (for which they have to pay a higher dowry) and recently it has been used as a weapon the fight against AIDS. South Africa hasn’t found a similarly degrading test for male virginity, nor has it found a way to distinguish loss of female virginity by consensual sex, by child abuse or by exercise. It is hoped that the rape of virgins in the expectation that it will cure AIDS can now stop.

So, hopefully FGM will decline to extinction. One would hope virginity tests and re-virginization would too. After all, the most threatening part of my grandmother’s message was that women had the right to enjoy sex just as much as men do. The double standard is still with us. One way to eliminate it is to get at male fears of being cuckolded and follow the Costa Rican example. Let’s have men be sure who their children are, provide free genetic testing, and then maybe we can put the vaginal cosmetic surgeons out of business and let them get back to the botox we all need.

Happy Holidays!