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  • Writer's pictureACTIVHISTorian

Controlling Women's Bodies is Part and Parcel of 'Healthcare Capitalism'

In a recent New York Times opinion piece, "Getting a Birth Control Pill Should Be Easy" (May 24, 2023), physician Eric Reinhart engages with the recent announcement that the F.D.A. will decide whether to follow an advisory panel's unanimous recommendation to allow a contraceptive pill, Opill, to be available over the counter. He argues for removing the normalization of "doctors' paternalistic authority and involvement in aspects of women's lives that [do] not in fact require expert medical supervision." Dr. Reinhart correctly notes that, "It is an open secret that much of the present role of U.S. physicians, of whom we have a substantial shortage, does not in fact need to be performed by medical doctors." He goes on to discuss some reasons why the U.S. has created this situation, including the role of "healthcare capitalism," which he points out has created and promoted America's private healthcare industry, limited public health options, and works to maximize doctors' market share and political influence.

What is not addressed in the article is the history of how women's bodies in particular came to be a site for physician influence--or interference--especially when it comes to contraception and other reproductive health needs, most of which do not require an M.D. to provide. Reinhart mentions the American Medical Association's opposition to...wait for it..."scope creep." Yes, the instrument that has come to symbolize the medical profession (as if it takes an M.D. to hear a heartbeat) must be associated only with physicians. Scope creep is the idea that nurses, physician assistances, pharmacists and other non-physicians might do harm if allowed to gain legal or billing authority (we saw that coming, right?).

That women's bodies are a particular focus for medical intervention is clear when one looks at the many condom options available in most any drug store or supermarket--with no doctor visit or prescription required. The so-called concerns put forth about "protecting" women from harm (always look more closely when protecting women is mentioned--and always used as an excuse to ward off "scope creep") tend to dismiss the fact women have the capacity to make decisions for themselves. I know, radical, right?!

So when did physicians get into the business of forcing women to visit them in order to get a diaphragm or other contraception option? When and how did physicians become such stringent gatekeepers--even though we are significantly short on physicians these days?

Over 100 years ago, Margaret Sanger (1879-1966, below) wanted to offer poor women access to contraception. She had learned much from her own mother's experience as a poor immigrant from Ireland, who birthed Margaret and 10 other children, dying in her forties; her father survived decades longer.

She also learned a lot in her nursing career, working among countless poor women who had no legal right to say no to a husband's sexual desires and no legal right to information about contraception. This was during the era of the Comstock Laws, which deemed information about birth control "obscene." Realize it was also illegal to donate to causes advocating access to birth control for women. Today, too many want to return to laws of an era when women had no right to decide anything about their bodies.

The chronology and historical plot line are more complex, and include the significant support of her husband, William (1873-1961), who termed Anthony Comstock a victim of "incurable sexophobia." But for now, an overview of one part of events.

In 1912, Sanger was already a trained nurse and was speaking out about a woman's right to control the frequency of childbirth. It was she who coined the term, "birth control." Not that the practice was new, but it was rarely openly talked about. What Sanger also knew--as did poor women--is that well-to-do white women were already limiting family size; for poor women, the upper classes seemed to have a "secret" they weren't sharing about how to cut down on the number of children born. Over the years, these women would beg Sanger for that secret.

Sanger wrote short articles titled, "What Every Girl Should Know" (and "What Every Mother Should Know") hoping to get information to girls sooner rather than later--or never. But the Comstock laws meant she was violating the laws by sending them through the U.S. mail. So, when her pursuers got too close, she headed to Europe where she met the amazing, globally-significant feminist Dutch physician, Dr. Aletta Jacobs (1854-1929, below right).

Jacobs taught Sanger about pessaries--aka: diaphragms, a female-controlled contraception device. Sanger smuggled boxes of them into the U.S. and in 1916 opened the first American birth control clinic in Brooklyn, New York. Yes, that was totally illegal! Days later, she was arrested (her husband was involved in this too).

In 1917, as the U.S. eased into WWI and plenty of condoms were made available to troops headed overseas, she was put on trial, convicted, and spent 30 days in jail.

What does all that have to do with needing to visit a doctor to get basic reproductive care in 2023? Well, a quasi-compromise was reached that continues to pervade women's reproductive care. Sanger managed to convince doctors to make them available (locally only, as the Comstock laws still held sway) but only physicians would be able to dispense a "prescription" for a diaphragm. And realize plenty of states, localities, and even the federal government continued to ban information about the diaphragm, a women's reproductive system, or even her physical body--as obscene.

Anyone notice that access to condoms was not on the agenda?

That men's bodies and reproductive care were not part of any discussion?

That men are in the middle of all this political, judiciary, and law enforcement but no mention of the horrors or obscenity of men using condoms?

Yes, condoms were available and had been industrially manufactured for decades once a dude named Goodyear figured out how to vulcanize rubber. And of course non-rubberized versions of condoms had been available for millennium. But early on they tended to be expensive. Plus, a man had to want to use one; the woman could not force the use of condoms and legally had no control over her body in marriage--and often enough, outside of it. That's the law, ma'am!

So whether due to a doctor's willingness to perform an abortion for a fee for a middle-class white woman, the willingness of a middle-class man to use a condom to limit family size (or protect his wife from the STDs he got at the brothel), richer families saw a precipitous drop in birthrates but poor families had no options.

So then and now, this isn't about some ungendered reproductive care, this continues to be about about women's access to reproductive care and options.

Sanger brings the larger, systemic, institutional issues to light in many of her speeches, articles, and letters but one experience she returns to again and again: that of a woman who had 3 children, had completed an abortion on herself, and was in serious trouble. Sanger and a doctor are eventually successful in "restoring her to her family circle," and the woman does not want them to go before "telling me something that I can do to avoid a future illness such as I have just passed through." The physician sat beside her and basically jokes that there is nothing she can do "as long as there were laws upon the statue books, and he advised her to get her husband to change the laws."

Because of course, women could not vote in most of the U.S., did not make the laws, and were still under the laws of "coverture," where a married woman's legal status was "covered" by that of her husband's. There was also nothing that indicated marital rape was...rape.

In a slightly different version of similar event (and Sanger's experience with women in similar situations was plentiful), she wrote that a doctor told a women who did not want to be pregnant again, to "tell [your husband] to sleep on the roof."

Three months later, Sanger is again called to the woman's home but the mother of three was "beyond relief" and died that same night, leaving behind the children and "the frantic, helpless husband."

Sanger claims it is at this point she tells her family she will give up nursing until she "had made it possible for the working women in America to have the knowledge to control birth. I decided I had no moral right to respect a law,--a worn-out piece of parchment,--obsolete in every respect.I had no right to respect this above human life, and I decided to violate it wholesale." Of course, Sanger's goal remains incomplete.

In closing, it's worth noting the problems with being unaware of relevant history. It is also worth noting the misuse, even blatant non-history the Supreme Court majority used in the 2022 Dobbs decision, revoking Roe v. Wade. It is also worth noting that Dobbs suggests that Casey v. Planned Parenthood is invalid. Yet that 1992 decision was the first time that coverture was directly, emphatically overturned. For the first time since the nation was founded, Casey ruled that, "Women do not lose their constitutionally protected liberty when they marry." 1992! And in 2023?

Yes, of course women should be able to get care that does not require an M.D. without having to visit an M.D. Interestingly, as Dr. Reinhart notes in his opinion piece, in the same year Casey was decided, at a conference on birth control, an official on the F.D.A.'s fertility and maternal health drugs advisory committee, Philip Corfman, noted that the birth control pill is safer than aspirin, something easily available over the counter. A hearing was to follow to assess the over-the-counter possibilities.

But one reason the hearing was canceled was that the program director of the National Women's Health Network, Cindy Parson, argued that it was exactly the need for a prescription that guided poor women to healthcare. The feminists promoting this idea thought that if a prescription was not needed, insurance might stop paying for it and impose added barriers to access. This is very much about how America's healthcare capitalism is set up. This very situation however says much about healthcare capitalism in the U.S., not about whether an M.D. is required to fit a diaphragm or give a prescription for The Pill.

One can hope the time will come when those classified as women, whose reproductive system still seems to be a full-on mystery to so many (often because little research exists that prioritizes women's health), will be able to say what they want and be trusted to make the best decisions they can for themselves. Maybe they will even be able to go to a supermarket and buy what they need on the same aisle as condoms and period products. Unfortunately, while Comstock is long dead, his moralistic attitudes about women's lives and bodies are very much alive.

Related Items of Interest

Excerpts from a version of Margaret Sanger's, "Woman and Birth Control," used here is found in Through Women's Eyes: An American History with Documents, 5th edition, vol 2. Ellen Carol DuBois and Lynn Dumenil, eds. Bedford/St. Martin's Press, 2019. Her papers are part of the Library of Congress.

And as a great follow up to Sanger's idea of educating girls and women about their own bodies, check out Rachel E. Gross's, Vagina Obscura: An Anatomical Voyage. W.W. Norton, 2022.

For more on Aletta Jacobs, see, Memories: My Life as an International Leader in Health, Suffrage, and Peace. Harriet Feinberg, ed. Translated by Annie Wright. The Feminist Press at the City University of New York, 1996.

More of Sanger's and Jacob's writings and books about both Sanger and Jacobs, as well as an inspiration to Sanger, Emma Goldman (1869-1940), are available.

PBS American Experience episodes available for Emma Goldman and Margaret Sanger.

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