Empowered or Entrapped?

As she waits in the examining room for the nurse-practitioner, she flips through a pamphlet given to her by the receptionist. It's full of complicated words like "thrombosis," and "pulmonary embolism," and "ammenorhea." Latisha doesn't know these terms, and the pamphlet doesn't explain what they mean. She puts the slim booklet down and gazes idly out the window where she can see a woman waiting with four children. The woman is her sister; three of the children are hers. The baby cradled in her sister's arms is Latisha's. It reminds Latisha why she is here: the shot will keep her from getting pregnant. She doesn't want any more kids right now -- she wants to be the first woman in her family to graduate from school.

But she also remembers what happened when her sister got this same shot. It made her bleed all the time, so she never had it again. Latisha hopes this doesn't happen to her. She picks up the pamphlet again, and tries to pronounce those words, so she can ask the nurse about them.

Suddenly the door opens and in hurries the nurse, filling the hypodermic as she walks. Latisha knows the woman's busy; the waiting room is crowded with sick people waiting for her weekly visit. Latisha fumbles with the pamplet as the nurse swabs her arm with alcohol. "This'll just take a second," the nurse says, jabbing the needle into Latisha's skin. Before Latisha can find the page, the nurse is out the door. "See you in three months," the nurse mumbles as she leaves.

The drug injected into her arm is called Depo Provera -- also known as "The Shot." Latisha (who is fictional) could live in any American inner city, on a remote Indian reservation, or anywhere in the "developing" world.

To many, Depo Provera -- and a related drug, Norplant -- are ways to empower women by giving them powerful new options for birth control. But these same chemicals also have been used by judges and politicians as a way to punish women for crimes and behavior deemed unacceptable. And because those women are often Native, Black, or Latina, some call this use a subtle expression of racism.

Some even call it a form of genocide.

They oppose the products because of potential health risks and because both methods are essentially controlled by health care workers instead of the women themselves. And because both drugs are long-lasting, these activists charge that the result is de facto sterilization of minority and Third World women -- which is often no longer considered acceptable for Western governments to demand outright.

While some see these as sinister drugs created to manipulate fertility among minorities and the poor, others view these methods of birth control as revolutionary tools for expanding women's reproductive freedom.

"In many settings of the world, particularly in developing countries, women have very little say in whether they'll have sex," says Suzanna Banwell, a Maryland lawyer with a specialty in public health and women's issues. "The men control that. But Norplant and Depo can give them control over reproduction, if not over their sexuality."

But sometimes women find a catch-22: that control over their own body is transferred to health clinic workers instead. Norplant is most subject to this abuse because it is implanted under a woman's skin and expected to be used for five years. In a United Nations study of contraception in Bangladesh, women tell of harassment when asking for the birth-control device to be removed because of side effects:

At one clinic, a client said the doctor had asked for 10,000 taka (US $250) for removal, noting that the implant is expensive. The doctor was reported to have said, "While inserting Norplant, I told you that you might have lots of problems, so you should get yourself tubectomized [female sterilization] instead. But you opted for this method yourself." The client said that her husband had not agreed to let her be sterilized, and she could not disobey him because he might seek a divorce.

A subtler form of coercion is offering money to poor women who use the drugs. Like efforts in the courts and legislatures to force the contraceptives on poor women, the justification is sometimes thinly-veiled racism. Shortly after Norplant was approved by the FDA, a Philadelphia Inquirer editorial suggested that poor women be paid to use Norplant in order to "reduce the underclass." An angry columnist for the paper countered: "Not as quickly as just shooting them."

Norplant is also the target of a class action lawsuit that may surpass the massive number of silicone breast implant suits filed in recent years. At issue is the safety of the drug, whether the women were adequately informed of health risks, and whether the manufacturer supressed information.

While the company that makes Norplant stands behind the safety and efficacy of their product, legislation tailored to protect the company from such lawsuits recently passed Congress. This proposed law, "The Common Sense Product Liability Act Of 1996," was vetoed by President Clinton just last Thursday (May 2nd), citing its anti-consumer slant.

The latest political controversy involves men and Depo-Provera; California and other states have considered laws to "chemically castrate" child molesters and other sex criminals using extremely high doses of the drug.

While tests on an injectable male contraceptive (testosterone enanthate) began more than ten years ago, introductory trials are not expected to begin before the end of the century -- and that's assuming the pharmaceutical industry is willing to move forward in developing any new contraceptive at all.

And the strongest argument against Depo and Norplant really isn't about their efficacy. Both drugs are nearly 100 percent effective in preventing pregnancy. Both have health risks to women, but these risks are roughly the same as other oral or injected contraceptives. Instead, the safety issues focus on the main advantage of the drugs -- their longevity in the human body. Where a woman with an adverse reaction to The Pill can simply stop swallowing them, a woman using Depo must wait three months or more for the chemical to purge itself from her body. Norplant users must find a physician capable (and willing) to remove the implant -- no easy task in some parts of the world, including parts of this country.

These safety issues underlie the primary concern: Informed consent. Are women told enough about the true health risks to make a decision? Many critics note that the manufacturers aren't as forthcoming as might be desired, but much of the blame falls on the shoulders of health care providers. It is ultimately the responsibility of medical workers to inform women about the risks -- as well as the benefits -- of drugs like Depo and Norplant.

And so the debate begins.