While the technology of long-term contraceptives is relatively new, many of the ethical and policy dilemmas surrounding their use are not. The history of the birth control movement in this country over the past 125 years provides clear examples of the tensions that have always existed between empowering women to control their fertility and promoting limitations on fertility for the disadvantaged. While this is not an exhaustive survey, several important developments in the history of the American birth control movement have been chosen to illustrate these tensions.

In the late nineteenth century, Victorian opinion tolerated promiscuity among men and promoted sexual self-control among women. Prostitutes were a common and accepted solution to this dichotomy. Despite the view that female sexuality was to serve the end of reproduction rather than the woman's pleasure, contraception was widely practiced among all social classes. ( McClearey p. 182) The methods employed varied by class, however, due to cost and availability. The upper classes were more likely to use relatively expensive methods of contraception such as condoms, spermicides, and douches. They might also have had access to diaphragms and cervical caps, which were smuggled in from Europe at a high cost. Withdrawal and rhythm were often the only methods available to the poor. In an era when menstrual cycles were poorly understood, pregnancies often resulted. Abortion, often self-induced and always dangerous, was resorted to frequently. It is estimated that by the 1850s one out of every five to six pregnancies in America ended with an abortion. Mortality from septic abortions was extremely high. In 1888, death from abortion was estimated to be fifteen times greater than maternal mortality. ( Conlin N/A)

During this era, American feminists supported the concept of "voluntary motherhood." Far from empowering women and providing them with sexual freedom, however, voluntary motherhood sustained traditional family roles for women. According to this concept, limiting family size enhanced women's ability to fulfill their societal roles as wives and mothers. Feminists were joined by moral reformers, who were concerned about excessive breeding among the lower classes, particularly immigrants. Targeting the lower class and members of minority groups in the effort to reduce fertility has strong historical roots in the late nineteenth century.

Although contraception was widely practiced in private, many were not willing to risk public expressions of support for it or admit to its use. This reluctance influenced public policy. Abortion was declared illegal for the first time in the United States in 1830. A majority of states had declared it so by 1870.[4] A great legal blow was dealt to contraception in 1873 with the passage of what came to be known as the Comstock laws--a federal statute that made it illegal to transport obscene materials through the mail. Contraceptive devices such as condoms and diaphragms, as well as sexually explicit literature, were confiscated under this law. It took the work of one of birth control ' s leading proponents, Margaret Sanger, to weaken its effects. ( Chesler & Sanger p.24)

Perhaps no name is more closely associated with birth control, family planning, and reproductive freedom for women than Margaret Sanger. The daughter of Irish immigrants, Sanger was born in 1879 and played a strong role in the birth control movement in the United States and abroad until her death in 1966. While she promoted access to birth control for all women, she focused particularly on the poor, as upper-class women had some access to contraception from their private physicians. Poor women did not. Sanger believed that uncontrolled fertility and large families were inextricably linked to poverty. Her efforts to empower poor women, however, had affinities with the eugenics movement. Many eugenicists supported the idea of limiting population growth, particularly among those they viewed as undesirable. They were greatly troubled by the idea that the upper classes would use birth control and the lower classes would continue to breed. The tension between empowering poor women to control their fertility for their own best interest and limiting fertility among the poor and the underclass persists to this day in the debate about long-acting contraceptives. ( Tolson p.21)

Shortly after moving to New York City in 1910 with her husband, William, and three young children, Sanger found part-time work as a visiting nurse. She ministered primarily to immigrant women who lived in the Lower East Side . At that same time, she and her husband joined the Socialist Party Local 5. Sanger became increasingly involved with birth control issues and activism, both as a consequence of her daily work with poverty stricken patients and her conversations with the activists who regularly congregated at her family's flat. As Sanger later remembered it that their living room became a gathering place where liberals, anarchists, socialists and I.W.W.'s could meet. Emma Goldman was a frequent visitor and it was not long before Sanger spent long evenings discussing the emancipation of women at Emma's home on East Thirteenth Street . Sanger was very impressed by Goldman's incisive intellect and incendiary rhetorical style. And, within the constraints established by her less flamboyant personal style, Sanger 's earliest written and oral rhetoric (including her speech at Fabian Hall) often echoes the sort of provocative arguments made by Goldman in her own series of birth control lectures, as well as her confrontational, unflinching stance. ( Family Planning p.1073)

Margaret Sanger brought birth control directly to the poor women of Brooklyn on 16 October 1916 when she opened a freestanding clinic in Brownsville . Immigrant women from many cultures lined up with their baby carriages to learn how to prevent future pregnancies. In the few weeks of the clinic's existence, 464 women were provided with sex education and contraceptive information. The clinic was raided by the New York City Vice Squad and Sanger and her sister, Ethel Byrne, the clinic's nurse, were jailed. The trial produced an important legal victory for birth control. The New York State Court of Appeals interpreted the law to allow for prescription of contraceptives by physicians, not only to prevent or cure venereal disease--an interpretation largely applied to men--but also for any health reason. This opened the door for physicians to prescribe contraceptives for women. Sanger's victory, however, was bought at a price. Birth control from that point on was a physician-dominated enterprise. Nurses, and to a large extent, women, were not to control the provision of contraceptives. ( Lungren p.78)

The first reported tubal sterilization was performed by Samuel Lungren, an Ohio physician, in 1880. The procedure was proposed in the early nineteenth century as a means of long-term contraception in women undergoing Caesarean sections. It was not until the latter part of the century, when asepsis and safer anesthesia were available, that Caesareans were attempted with any frequency, and even then they were still quite risky. The mortality rate for the sixty-eight Caesarean sections that had been performed in the U.S. from 1882 to 1891 was 40 percent. Surely, if a woman survived one section, avoidance of another might be desirable. Many of the early tubal ligations were recommended for "protective" indications, i.e., to protect the life and health of the woman.( Bordahl p.19)

After the turn of the century, however, eugenics was a dominant reason for tubal sterilization, particularly involuntary sterilization. Compulsory sterilization began to be recommended for individuals with hereditary disease, the "feeble-minded" (e.g., the insane and demented), and the mentally retarded. There were also racial overtones, as undesirable characteristics were perceived to occur more often in people of Asian and African origin and in the foreign-born. In addition, there were some moves to sterilize habitual criminals. While recommendations for habitual criminals dealt largely with men, efforts to control hereditary and mental illnesses were often directed at women. Efforts to train women living in mental institutions gave way to a program to keep them from reproducing. ( Bordahl p.19)

The view that deviance was hereditary was supported, in large part, by studies of two families: the Jukes and the Kallikaks. Richard Dugdale, a social reformer, studied 709 people over five generations in a family he called the Jukes. Although Dugdale believed both heredity and environment were to blame for the Jukes' propensity to crime, intemperance, and prostitution, he laid special emphasis on heredity, estimating that the family had cost society $1,308,000. In 1912 Henry Goddard contributed significantly to the belief that deviance was hereditary when he published The Kallikak Family. Goddard had been studying feeble-mindedness when he discovered the family, which he traced back over six generations. The progenitor had produced both a legitimate line, consisting of upstanding citizens, and an illegitimate line, consisting of large families with a disproportionate number of feeble-minded individuals.

Already concerned with the effects of immigration on population demographics, eugenicists were given superb ammunition with these two studies. The eugenics movement also received financial support from some of the country's most prominent philanthropists, including Mrs. E. H. Harriman, John D. Rockefeller, Dr. John Harvey Kellogg, and Samuel Fels. Even Theodore Roosevelt supported the movement, urging Americans to avoid "racial suicide." The upper classes must not be outnumbered in their progeny by immigrants and the lower class. ( Meehan p.68)

The nation's first involuntary sterilization law was passed in 1907 in Indiana . California followed suit in 1909 and by 1913, fourteen states had laws allowing involuntary sterilization. The effect of the laws varied. From 1907 to 1921 there were 3,233 documented sterilizations performed under state laws. These sterilizations were seen by many within the mental hygiene movement as beneficial to society and, at the very least, as not harmful to the individual. On the other hand, seven of the laws were declared unconstitutional. While there was much popular and professional support, eugenic sterilization was still controversial. Additional statutes, drafted with greater concern for constitutional constraints and greater care about guardians' consent, were more successful. Ultimately, the Supreme Court provided a boost for involuntary sterilization in Buck v. Bell In that 1927 decision, Oliver Wendell Holmes wrote: "It is better for the entire world, if instead of waiting to execute degenerative offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind." The number of states with sterilization laws increased to thirty and the number of involuntary sterilizations increased to more than 60,000 persons. Sterilization programs were active through the 1940s and 1950s, uninfluenced by reactions to Nazi sterilizations; indeed, there was a dramatic increase in the percentage of women who were sterilized in the U.S. after 1930. Eugenic sterilization virtually disappeared after the 1960s as the nation entered an era of awareness of patients' rights and, most especially, of the need for society to protect the vulnerable. ( Meehan p.68)

The major ethical conflict regarding sterilization today is balancing the rights of a mentally retarded or mentally disabled person to sexual freedom with a protection of her best interests regarding childbearing. Even in cases where it is clear that the individual has no ability to comprehend childbearing and may be harmed by the experience, it is difficult to obtain a court order for sterilization because of the history of the abuses.

Ethical issues have also come up in voluntary sterilization of mentally competent individuals. Some women, particularly poor women, have not had access to desired sterilization. Married women were sometimes required to have their husband's consent or were denied sterilizations until they had produced a certain number of children. Young women who had never given birth were also denied tubal ligations on the grounds that they cannot always be successfully reversed, should the woman later want children. Previous pregnancies, marital status, and age, while important considerations, should not be used to deny a woman a tubal sterilization if she really desires one. ( Meehan p.68)

Sterilizations have sometimes been advocated for women with serious medical conditions such as tuberculosis, diabetes, or cardiovascular disease. While these illnesses may make pregnancy medically undesirable, it is important to recognize that they are conditions more common among the poor and women of color. Thus, although sterilization under these circumstances may be offered with the best of medical intentions, it is apt to be perceived as racist or promoting eugenics. Counseling regarding sterilization as a contraceptive option must be done with sensitivity to the historical context. ( Meehan p.68)

The 1960s and 1970s saw great technological advances in contraception. The development and approval of oral contraceptives finally provided a highly effective form of contraception that was not associated with individual sexual acts. Intrauterine devices also became popular choices for women and couples who wanted to control fertility. Although IUDs would later become less available because of legal challenges related to side effects of the Dalkon Shield, they were a method of choice for many women during this time. ( McClearey p.182)

In addition to technological advances, there were legal and policy gains for birth control. A significant victory in this regard occurred in New York City in 1957, when Dr. Louis M. Hellman, in violation of the policies of the Commissioner of Hospitals, fitted with a diaphragm a severely diabetic woman who had just given birth. The media had been notified and the resulting coverage precipitated a policy change that allowed women to receive contraceptive counseling and devices in municipal hospitals in New York City .

In 1965 the Supreme Court declared contraception a constitutional fight for married couples, in Griswold v. Connecticut . The Comstock laws were finally repealed in 1971 and the Supreme Court guaranteed a woman's right to abortion in Roe v. Wade in 1973. This, however, did not ensure that women would have access to contraceptives and abortion services. Some women could not afford contraceptives. For others, partners or spouses prohibited the use of desired contraceptives. In addition, the fight against legalized abortion rages on, and has escalated to violent outbursts that threaten the providers and users of abortion services. There is also the danger that women who do not desire contraceptives will be coerced into using them by partners or social pressures.

The current ethical and policy issues with long-acting contraceptives have an important historical context. Well-intentioned efforts to empower all women, including poor women of color, must be balanced with a keen sense of the abuses evident in the history of the birth control movement. Racism and eugenic concerns have been consistent issues in debates about controlling fertility, and our targeted educational programs and initiatives must be sensitive to community concerns. Empowering women to make their own reproductive choices is a praiseworthy goal. It can only be achieved if we maintain an awareness of the successes and failures in the history of the birth control movement. ( Lungren p.78)