abortion – Larkin Callaghan

The Health Implications of Sex-Selective Abortion

Anyone paying attention to the election this past year—or, frankly, even those who tried to avoid it—has at least a superficial understanding of what the abortion rights argument looks like in the United States.

But the long-term population health outcomes of abortion are generally not considered as part of the argument. That’s because when a woman terminates a pregnancy in America, the decision is rarely made based on the sex of the fetus. However, in many developing and growing countries, that is at the crux of a woman’s decision—and the significant shift in gender representation is changing their population health status, and perhaps even the picture of the burden of disease. One of the countries in which this is most evident is China.

Interestingly, and likely unsurprisingly for those invested in a woman’s right to choose, we see that sex selection is itself a manifestation of the gender inequities in economic and social standing in many of these countries—not so different than many of the reasons cited by women in the U.S. seeking abortions. So while the outcomes of sex-selective abortion abroad may pose different problems, it should be acknowledged that the need for abortion is rooted in similar circumstances around the globe.

This issue is addressed by one of the few research studies to explore the ramifications of China’s one-child policy, published in the New England Journal of Medicine (NEJM). China is a prime example of the increase in the male population due to women terminating pregnancies that were discovered to be female, a practice deemed illegal but nonetheless carried out widely.

The ratio of male to female live births in industrialized countries generally ranges from 1.03 – 1.07 (103,000 – 107,000 boys born for every 100,000 girls born). In China, since the inception of the one-child policy, the ratio has risen from 1.06 in 1979, to 1.11 in 1988, to 1.17 in 2001 (117,000 boys born for every 100,000 girls). Some regions show even higher numbers, with the Anhui, Guangdong, and Qinghai provinces reaching ratios as high as 1.3 (meaning that for every 130,000 boys born there are 100,000 girls born).

There are distinctions between urban and rural areas as well, since couples in rural provinces are generally allowed to have more than one child. The sex ratio comes in high at 1.13 for the first birth in urban regions, since one child is usually all a couple will be allowed. It peaks at 1.30 for the second birth (130,000 boys born for every 100,000 girls), which if couples are allowed to have, the preference is clearly male. This contrasts markedly with rural areas, in which the ratio for the first child is normal at 1.05 (105,000 boys for ever 100,000 girls), indicating that sex-selection is not a huge issue since rural couples are allowed a second child. However, the ratio sharply increases at second births, reaching 1.23 (123,000 boys for every 100,000 girls).

(Recently, China has noted that their thinking may be changing in regards to the one-child policy, with the possibility of extending the two-child allowance to everyone.)

This has unsurprising impacts on the health of the population. Some of the more pressing concerns noted by researchers that they articulate as a result of there being fewer women to marry and partner with include mental illness and socially disruptive behavior issues in men. Recently, studies have begun to document these trends, underscoring the significant long-term consequences of this gender imbalance. One recent study showed that even after adjusting for age, education, and income level, unmarried men in China were more likely to have lower self-esteem, higher depression, higher aggression, and more likely to have suicidal thoughts or actions than married men—at statistically significant levels.

The findings of another study, comprised of interviews conducted with people in China born just before and just after the implementation of the one-child policy showed similar results. Researchers found that the policy itself had created a less trusting and less trustworthy population, who are more risk-averse and less competitive, more pessimistic, less conscientious and even more neurotic. The impact of anti-social behaviors in a predominantly male population seems to be shifting the mental health profile of the entire nation.

More concerning as a result of sex-selective abortion and a decrease in the number of women available for marriage is the increased in trafficked women, and the subsequent increase in the number of commercial sex workers. Researchers note that a broad range of high-risk sex behaviors are often demanded by the surplus male clients, increasing the incidence of HIV and other sexually transmitted infections. This alone has been noted as having a likely significant affect on the spread of HIV throughout China, posing a major national public health threat for the country.

The health implications aren’t limited to reproductive health and mental illness. If it is in fact accurate that most of the children living in China’s orphanages are girls, it is unclear how the future healthcare needs of these girls as they age into women will be handled and by whom, with a rapidly growing aging population already relying heavily on the significantly less populous younger generation.

Critics of abortion—sex-selective or not—often cite mental health issues and resulting regret as major reasons why women should not get abortions. So what about the health status—physical and mental—of the women who have these procedures?

Recently, public health researchers have worked to create the first body of scientific literature answering these very concerns. A group of University of California, San Francisco researchers at the group Advancing New Standards in Reproductive Health (ANSIRH) recently presented some of the findings of their longitudinal research known as the Turnaway Study. They found that women who were seeking abortions and who were denied were more likely to have slipped into poverty a year later, more likely to be on public assistance, and less likely to have a job. There was no correlation between abortion and drug use, or abortion and depression.

Abroad, given that sex-selective abortion is usually a procedure performed by private providers due to legal restrictions, tracking this kind of information is extremely difficult. And while this research was limited to the experiences of American women, the results showing decreases in economic status and increases in reliance on some form of public assistance, if available, certainly seem like potential outcomes in countries with worse statistics in terms of gender equality and economic growth.

Is there a solution? The gender imbalance, and therefore the changing prevalence of certain diseases, will not balance out unless sex-selective abortion is essentially made impossible, but it is imperative that the issue of sex-selective abortion not become a rallying cry to end the right to the procedure overall for women. As seen by the work done by researchers in China and the findings by UCSF researchers, the issues surrounding the choice to have an abortion, whether in the United States or abroad, are complex and inextricably linked to the economic and social circumstances of the women.

To tackle the burgeoning disease differences emerging from the sex-selective abortions, the work must begin by tackling the fundamental issues regarding the reasons why women seek these abortions in the first place.

Originally published at The 2×2 Project.

Is This Real Life? The Reproductive Rights Version

My support of a woman’s right to choose is well-documented. I champion a woman’s freedom to make a decision about whether or not she should be carrying a fetus, and the availability of resources for her to safely and quickly terminate a pregnancy if she sees fit.

We are in troubled times. Ceaseless efforts to deny women these rights are abound, and I could link to hundreds of articles that document this, but the handful I’ve chosen certainly upset me enough. I, along with scores of women’s health advocates, have tried any number of measurable ways to fight back – raising more money; drafting opposing legislation and striking down initiatives; testifying before hearings; writing op-ed pieces that detail our positions and rationally lay out the reasons why these reproductive rights are essential to women’s health, well-being, and even economic prospects; explaining that abortions and contraception are also necessary for reasons far beyond prevention pregnancy, and that all reasons are valid and worthwhile.

We’ve been insulted, condescended to, systematically stripped of essential healthcare resources.

I’m tired. I’m tired of the hypocrisy of the anti-choice wing. Tired of the false rhetoric. Tired of their offensively misguided and false claims to care about women as much as they care about fetuses, tired of the aggressive push to force women to maintain pregnancies that they are unprepared for and do not want, and further impact their educational and economic statuses. Tired of the trumpeting of false information about contraception that is subsequently followed up by happily taking money from the very creators of products that prompted their supposed moral outrage. Tired of their total disregard of the reality of many of these women who make the decision to have an abortion. Tired of total disregard of the statistics that undermine their arguments about the United States valuing children and their yet-to-be-realized lives. Tired of the total disregard and dismissal of real ways that abortions could be prevented – complete and comprehensive sexual health education and easy access to a variety of contraceptives. Tired of the complete disdain for women as sexually independent beings, tired of their disgust of the sexual lives of women while giving men and their sperm an unlimited free pass and the ability to impregnate and take off without even a slap on the wrist. Tired of the inability to empathize and simultaneously mete out punishments to the half of the population they deem fit the ostensible crime of engaging in sexual activity. If you want to harp on the issue of responsibility, then it is essential to ensure that both parties are equally responsible in every way – and as about half of the links I have put in this post show, that simply does not happen. Women are disproportionately – vastly so – shouldered with the entire burden of and the entire blame. That’s the reality, and it can’t be separated from the issue.

I’m tired but not worn out. I remain entirely committed to this cause, and won’t be sidetracked by opponents who use everything from personal insults to false science to shaky numbers to try to distract me. Nancy Keenan, the president of NARAL, recently announced that she is stepping down – largely due to the fact that she feels millennials need to begin steering the abortion rights ship, to combat the intense dedication of anti-abortion activists. Over 50% of anti-choicers maintain that abortion is a primary issue for them in elections, while only about a quarter of pro-choicers say the same. Well, I’m here. This remains my number one issue. Are you with me?

A friend recently sent me yet another HuffPo article, that I certainly enjoyed, but that for some reason was the straw that broke my camel’s back in many ways, as I saw her argument struggling mightily to encompass all of the above reasons why we should protect contraceptive access for all women. I’m so tired, in fact, that my response to these attacks has been harrowingly brought down to the essential core that I never thought I would need to stray from when I first realized what being pro-choice was; stripped of the attempts to rationalize (issues of medical necessity outside of pregnancy prevention aside, issues of risk to the mother aside, issues of childcare concerns and education concerns aside) with those who are, in fact, irrational about these issues. What happens in my uterus is my business alone. If you want the babies that these fetuses become, that women made the decision they cannot care for, then there should be no difficulty in deciding that you should take them. Take them all. Take them lovingly and fully, not cynically or begrudgingly. Cultivate them for 9 months, care for the baby when it’s born, love her, feed him, clothe her, educate him, without any help from me. If your goal is to punish women who you think have made flagrantly immoral mistakes, let us air all of your dirty laundry as well, and dissect every single decision you in your life made, and force you to pay for it as we see fit. And by all means, find a way to keep the men who didn’t use condoms, or bullied their partners into not using contraception and subsequently fled, or who threatened or coerced their partner, sitting firmly next to a baby’s crib. Come up with solutions to the myriad of complex social and economic issues that contribute to reasons women get abortions. Re-educate yourself on the fundamental fact that it is not your right to dictate the decisions of another person, and while that lack of control may infuriate you, it’s the way it is. What happens in my uterus is my business alone. Wherever I go, the uterus goes. You don’t get to stake your judgment flag in my sex organs selectively at will, running “protectively” towards it when it suits you, and fleeing from it (and from what it carries) when it doesn’t. You don’t get to be there at all!

So don’t tell me that we have a collective duty to care for these unborn babies when what you are actually doing is attempting to control the freedom of women while doing everything you can to make sure that no true collectivism actually does benefit women or their babies.

Sebelius Caves, Girls Pay the Price

By now, I’m sure you’ve all heard that Kathleen Sebelius, the Secretary of Health and Human Services, has blocked the recommendation of the Food and Drug Administration that the over the counter (OTC) drug Plan B, commonly known as the ‘morning after pill,’ be made available without a prescription for girls of all ages. It is currently available without a prescription to girls ages 17 and up, and requires a prescription for girls ages 16 and below.

It is worth noting that this is the first time a Secretary of HHS has overruled the FDA. This is not insignificant. The purpose of HHS is to promote the health, safety, and well-being of Americans. The FDA is an obvious component of this. While the FDA is an agency of HHS, the purpose of the FDA is to promote and protect public health, through the regulation of OTC and prescription medications, vaccines, food safety, medical devices, and more. They do this through clinical trials and testing, which is how we come to know of drugs’ side effects as well as how significantly they aid in the relief of what they purport to treat. The FDA recruits researchers who understand both the purpose of and execution of this research. Attempts have been made to loosen the regulations of the FDA; for example, some terminally ill patients have petitioned the FDA to allow them to access experimental drugs after Phase I of a trial – the FDA has denied these requests due to the lack of research regarding a drug’s long-term effects post- Phase I. The FDA is not without criticisms; they have been accused of being both too hard and too lax on the pharmaceutical industry. Members of the FDA have also expressed feeling pushed to present certain results. Scientists at the FDA complained to Obama in 2009 that they felt pressured under the Bush administration to manipulate data for certain devices, and the Institute of Medicine also appealed for greater independence of the FDA from the powers of political management.

The commissioner of the FDA, who is a physician, reports to the Secretary of HHS. Sebelius’ job is not one of medicine or research, and requires a background in neither. It does require a background in politicking, which is exactly what we’re seeing here. The purpose of pointing that out, and of articulating that this is the first time a Secretary of HHS has overruled an FDA recommendation, is that Sebelius’ refute would not be based on differing scientific results, or research that opposes the FDA’s recommendations – because there is none. The override has different drivers, and the assumption floating out there – for good reason, since there is little alternate explanation – is to appease social conservatives and the anti-abortion contingents.

Plan B is not the abortion pill. It is the equivalent of an increased dose of a daily birth-control pill, and has no effect on already established pregnancies – it prevents pregnancy from occurring. Scientists within the FDA unanimously approved the access of the drug without a prescription for girls of all ages, after an expert panel put the recommendation forward. It is, to quote a USC pharmacist, one of few drugs that is so “simple, convenient, and safe.”

The conservative Family Research Council claims that requiring a prescription will protect girls from sexual exploitation and abuse – I fail to see how requiring a girl to get a prescription will protect against sexual violence, especially since girls may be attempting to get Plan B because sexual violence has already occurred. This comment is also a flagrant indication of misunderstanding of sexual violence and abuse – a young girl is not likely to disclose to an unknown physician that she is being sexually abused or assaulted and that’s why she needs a prescription for Plan B. Make no mistake, this ban is a victory for anti-abortion rights activists. If a girl cannot prevent a pregnancy from occurring, she is subsequently faced with trying to terminate an existing pregnancy (again – that could have been prevented!). Given how reproductive and abortion rights have been systematically chipped away at for the past few years, this girl who did not want the pregnancy and tried to prevent it from happening but was denied because she is shy of 17 years, will be in an even worse position. This is what anti-abortion activists are counting on – that once she is pregnant she will have to carry to term.

Plan B can prevent abortions from happening. HHS, with its mission of protecting the health and welfare of all citizens, should do everything they can to protect the health of girls’ reproductive development, which includes the prevention of unwanted pregnancy at its earliest stage. The girls under the age of 17 who need Plan B the most are the ones who also need it to be as easily accessible as possible. Much like requiring parental permission for abortions for girls under the age of 18, this ban actually can put girls at risk. Many girls will not have the family support, financial means, or healthcare to manage a pregnancy; some girls may face parental and familial abuse if they have to admit to needing to prevent a pregnancy with Plan B. What if a girl is a victim of sexual assault within her family? Should she be forced to deal not only with this trauma, but also have to determine how to prevent herself from being forced to carry a fetus to term as a result of this tragedy? Most girls under the age of 17 do not have easy access to clinicians and hospitals on their own, nor are they able to navigate our increasingly complex healthcare system on their own, which they would not only need to do to access Plan B, but would need to do within 72 hours for the pill to be effective. Girls whose bodies are not ready for pregnancy, girls who were victims of assault and rape and incest, girls whose futures will be dramatically changed and opportunities truncated – they all become casualties of this ban. Before we start sex-shaming and proclaiming that they shouldn’t have had sex if they didn’t want to deal with the consequences, let’s remember that these girls were not miraculously impregnated. Whether consensual or not, a boy was involved. This is a gendered issue – the girls are the ones who will have to deal with the lack of access to Plan B, physically, mentally, and emotionally.

Originally, advocates in 2003 successfully petitioned Plan B to be available OTC for girls 18 and up (after having been available with a prescription since 1999), but a judge overruled that decision and lowered the age to 17 after he deemed the decision had been made politically, not for scientific reasons. It appears that history is repeating itself.

Abortion Isn’t That Simple, Mr. Douthat

Ross Douthat, one of the NY Times conservative columnists whose pieces I occasionally force myself to read, wrote an article yesterday about sex-selective abortion. In short, he claimed that the reason 160 million women were “missing” (that is, the reason they were so outnumbered in many countries like India and China, as well as other nations in the Balkans and Central Asia) was because they were “killed” via sex-selective abortion. In his words, the women weren’t “missing,” they were “dead.” (He also claims that the author of the book he cites, Mara Hvistendahl of the book “Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men,” appropriates the issue to one of patriarchy, of greater social issues and inequities – which I agree with. He then says that “the sense of outrage that pervades her story seems to have been inspired by the missing girls themselves, not the consequences of their absence,” saying that she is more upset by the idea of abortion itself than she is about the issues surrounding abortion. Don’t you think that’s for her to decide? And doesn’t it seem she’s already decided what she thinks based on her book?)

Douthat, however, manages to contradict the crux of his argument near the start of his column.

He begins by saying “female empowerment often seems to have led to more sex selection, not less.” He then quotes Hvistendahl as saying “women use their increased autonomy to select for sons,” because male offspring bring higher social status. In countries like India, sex selection began in “the urban, well-educated stratum of society,” before spreading down the income ladder.

If this were the case – if in fact women had become truly empowered in their respective lands – culturally, politically, economically – then why would they be aborting based on the opposite – that men in their communities are still holding the cards? Are they imagining that men still hold positions of power and wealth in their countries, or are they living the ramifications of that painful reality everyday? Women do have some increased autonomy in many of these regions. But guess what? This autonomy has likely served to highlight the still very real inequities and disparities that exist in their communities, which contributes to the rates of sex-selective abortion. If women see which sex has the higher status, and one of the few autonomous decisions they can make is to choose the sex of their baby – they are likely going to choose the one with more status. This upsetting power dynamic shows just how far away true empowerment is for many of these women and their communities. If they felt their children would have the same opportunities if they were female than if they were male, the sex selection abortion Douthat decries would actually decrease. It is not the responsibility of the female fetus to ensure she is treated with the same respect and equality as the male fetus. Douthat seems to really care about female fetuses – but seems less interested in addressing the massive social, political, and economic issues that create so many difficulties for them once born. (His colleagues Paul Krugman and Nick Kristof seem to have handles on that. Too bad they were off yesterday.)

It seems that Douthat wants to push for the feelings of regret and remorse about abortion itself, separate from the issues surrounding it. Does sex-selection abortion sadden me? Yes. Does aborting a fetus that indicates it will have Down Syndrome sadden me? Yes. You know what else makes me sad? That a woman cannot afford a baby because she is single and has no familial or community support; because she has an abusive partner (homicide is the number one cause of death for pregnant women); because she has a low-wage hourly job that offers no maternity leave which could help her stay well while carrying the baby if needed; because she has no health insurance meaning she can’t access quality pre-natal care to make sure her baby would be healthy since we are systematically closing down those facilities that offer services for women who are uninsured (and also help provide birth control to prevent pregnancy!); because she has no way to pay for day care and she may have to quit her low-wage job to care for her baby; because she would then have no money for all the supplies, food, and developmental tools her baby would need to thrive which can lead to malnutrition, behavioral problems, child depression; because she could then become part of the 29.9% of families in poverty that are headed by single women, and her child could become part of the 35% of those in poverty who are under 18 years of age – the poverty rate for households headed by single women is significantly higher than the overall poverty rate.

We’ve cut child welfare services that aid women by the tens of millions in the past few years. Georgia alone cut over $10 million in Child Welfare Services. We’ve also cut subsidies that support adoption agencies – the organizations that help women find families that may be able to care for her baby were she to carry it to term – and who make sure these families are actually fit to do so! TANF (Temporary Assistance for Needy Families) provides women and families with aid so that children can be raised in their own homes or with relatives, instead of being placed in foster care and becoming wards of the state. How much have we cut from TANF? 17 of the poorest states, with some of the highest poverty rates in the nation, have already stopped receiving funds.

Birth control, one might say? Sure – birth control is expensive, so if she doesn’t have health insurance, she isn’t likely to be able to afford birth control (hey, Planned Parenthood can help with that, too! Seeing a pattern?) And if her partner refuses to wear a condom? If she is in an abusive relationship, if she fears leaving her partner, if she relies on her partner for added economic security – she’s much less likely to argue with him about the condom use. Or even feel that she has the agency to begin a negotiation discussion at all.

These facts make me sad. And all of these facts might lead a woman to decide she can’t have a baby. And many things not listed here may lead a woman to decide that she will not have a baby. And that she will have an abortion. Is it my decision? No. It’s not. It’s not yours or Ross Douthat’s, either. Again, Douthat represents the contingent of pro-lifers who want to make it seem like pro-choicers are cheering the performing of abortions right and left. What we are cheering is the right for women and respect of women to make their own decision based on their very specific personal circumstances. And given the fact that the medical establishment has not agreed with the pro-life camp in claiming that fetuses before a month into the third trimester can feel pain (reacting to stimuli does not equal pain, to reiterate, and pain without a cerebral cortex is seen by physicians as not possible), which has most recently become the pro-life camp’s wildly off-base rationale for preventing a woman’s right to choose, and given the fetus’ place of residence in the woman’s uterus as a part of her body, not as a human, these issues that Douthat sees as “sideline” are actually very much at the center of the argument. Bottom line – it’s the woman’s body. It’s the woman’s choice. She will be the one carrying it, she will be the one birthing it. No one else. So why should anyone else decide?

Additionally, it is not a crime for a woman to not want children. Since she is able to give birth, it is her decision as to when and how that will happen. Everything about her life and future will change once she has a baby. So she needs to be sure she is ready for that. How can one disagree with that? Douthat may not like it, but “the sense of outrage that pervades his story” (see what I did there? 😉 ) seems to me more rooted in his anger and frustration with his opinion not being considered by women in these decisions and not being able to control what a woman decides to do about what is going on in her body.

All of the things I listed – the job issues, the healthcare issues, the family and community issues, the issues that arise when a child doesn’t have access to food, clothing, and developmentally appropriate stimulation – are the causes. So why don’t we start figuring out how we can mitigate those facts and issues instead of attacking the effect – the abortion – which is a decision women come to after weighing all of those facts and issues just discussed. Douthat’s fear tactics of talking about female fetuses strewn across Indian hospitals is scary imagery. So is this:

And this:

homeless4 — Photo via Captain Hope's Kids Blog

And this:

philippines — Photo property of streetkidnews.blogsome.com

Want less abortions? How about providing health insurance, that covers both birth control and pre-post natal care? How about equal pay for equal work, so women are more financially and economically secure, providing them with the resources to stay out of poverty and keep their children out of it, too? How about child care in work environments, helping women who cannot afford day care can stay in their jobs and remain a part of the economy? While we’re at it, how about great public schools and clean community centers, so women know their children are being intellectually fed and socially stimulated in safe environments that help keep them out of more dangerous and potentially life-threatening social circles? How about comprehensive sex education so men and women know how to protect themselves not only from pregnancies but from diseases that can endanger a fetus and create complications during birth and cause health issues for them and their children – creating more expense, particularly if one has no health insurance.

Let’s talk then. And how about you follow me on Twitter?