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Opposing Coercion in Contraceptive Access and Care to Promote Reproductive Health Equity

  • Date: Oct 26 2021
  • Policy Number: 202110

Key Words: Contraception, Reproductive And Sexual Health, Health Equity

Abstract
Access to the full range of contraceptive methods and related services is an essential component of reproductive health equity and well-being, providing a means for individuals to avoid pregnancy if, when, and how they choose; however, people still encounter significant barriers to contraceptive access. Coercive interpersonal, institutional, and structural practices and policies contradicting human rights–based and person-centered approaches often impact contraceptive access and reproductive self-determination. Coercive practices can manifest in a variety of ways and include but are not limited to forced sterilization, provider preference for some contraceptive methods over others, disregard for patient preferences, incentives for the uptake of specific methods, and policies that influence the ability to stop using a contraceptive method at will. These practices disproportionately target individuals who are poor, young, incarcerated, or members of communities of color, as well as those with disabilities. This policy statement recommends that governmental agencies, policymakers, health care professional organizations, and APHA members advocate and secure funding for contraceptive programming that provides the full range of contraceptive methods to all people seeking contraceptive care; calls for the creation of protections against forced sterilization and other coerced usage of contraception; and calls for the adoption of person-centered contraceptive counseling and access strategies and associated quality and service metrics.

Relationship to Existing APHA Policy Statements

  • APHA Policy Statement 20153: Universal Access to Contraception 
  • APHA Policy Statement 20143: Sexuality Education as Part of a Comprehensive Health Education Program in K to 12 Schools
  • APHA Policy Statement 20111: Improving Access to Over the Counter Contraception by Expanding Insurance Coverage
  • APHA Policy Statement 200611: Ensuring that Individuals are Able to Obtain Contraceptives at Pharmacies
  • APHA Policy Statement 200610: Abstinence and U.S. Abstinence Only Education Policies: Ethical and Human Rights Concerns
  • APHA Policy Statement 200314: Support for Sexual and Reproductive Health and Rights in the United States and Abroad
  • APHA Policy Statement 200313: Preserving Access to Reproductive Health Care in Medicaid Managed Care
  • APHA Policy Statement 200122: Opposition to Coercion in Family Planning Decision Making
  • APHA Policy Statement LB20-01: A Call to Investigate and Prevent Further Violations of Sexual and Reproductive Health and Rights in Immigration Detention Centers
Problem Statement 
Contraception is a critical component of sexual and reproductive health equity and well-being that includes the range of methods and associated health care that assist individuals in achieving their reproductive desires. In the United States, 99% of presumed cisgender women report having ever used contraception.[1] Since people often spend most of their reproductive years managing their sexual and reproductive health by preventing and delaying pregnancy,[2] preventing sexually transmitted infections (STIs), and managing menstrual cycles, contraceptive access is essential. (Throughout this statement, we refer to potential contraceptive users as individuals or people rather than “women” because those who have the capacity to reproduce and need access to contraception include cisgender women and men and transgender, nonbinary, and gender expansive people. When citing research that does not provide descriptive information about the gender identities of study samples, we use the term “presumed cisgender women” because most research in this area focuses on that population.) Contraceptive use can improve health outcomes and reduce health and health care disparities, including reducing the risk of developing certain reproductive cancers,[3] preventing STIs,[4] and treating medical conditions.[5]  

Despite efforts to expand access, some people still experience challenges obtaining contraception due to a lack of insurance coverage,[6] transportation and time barriers,[6] limited awareness and knowledge of methods,[7] stigma,[6] religious or personal exemptions for clinicians,[8] and provider and method availability.[6] Evidence indicates that these barriers are especially limiting for accessing long-acting reversible contraceptive (LARC) methods as a result of their high up-front cost, lack of knowledge among potential users, and need for clinician training in insertion and removal.[9] LARC methods include intrauterine devices (IUDs) and hormonal implants, which are effective for 3–12 years without regular action on the part of the user.

The World Health Organization recognizes contraceptive access as a key strategy to improve social and health outcomes for people with the capacity for reproduction.[10] Reproductive self-determination has multiple social and economic benefits, yet communities that are underresourced are the least likely to experience the conditions that facilitate self-determination and, therefore, these benefits.[11] Because pregnancies classified as unintended are most frequent among youth, people with low incomes, and people of color, these groups have been targeted for public health interventions.[12] However, when those formulating public health goals prioritize cost-effectiveness and savings over reproductive self-determination, they may use shame or stigma to convey their message, resulting in coercive practices and programs.

Facilitating contraceptive access within a health equity frame means ensuring that people have the information they need to evaluate each method, have access to the full range of contraceptive options and related health care, and have autonomy in decision making (including choosing to not use a method) free of coercion from clinicians, partners, family members, or institutions. Contraceptive coercion refers to any attempt to influence or control someone’s access or ability to use or not use contraception as they wish.[13] Contraceptive coercion can:
  • Occur through threat or force (e.g., forced sterilization or LARC use)[14]
  • Occur interpersonally (e.g., clinician refusal to remove an LARC[15] or partner refusal to withdraw while ejaculating or sabotage of birth control pills[16])
  • Be explicit (e.g., compulsory LARC use or refusal to discuss a specific method) or implicit (e.g., provider preference or enthusiasm for LARC methods that may result in steering decision making and neglecting individuals’ preferences or values)[14,17]
  • Be facilitated through structures and policies (e.g., incentives to clinicians or individuals for uptake of certain methods or clinicians or institutions not offering access to or information about all contraceptive methods as seen in religiously affiliated health systems or LARC-only contraceptive access initiatives)

Research on contraceptive coercion is limited, with several qualitative studies addressing coercion from partners and health care providers[14,17,18] and quantitative or mixed-methods investigations focusing on reproductive coercion perpetrated by partners.[19–22] In a nationally representative sample, nearly 10% of men and 8% of women (both presumed cisgender) reported ever experiencing reproductive coercion from their partner, with respondents identifying as Black and Latinx reporting these experiences more than their White counterparts.[19] The literature is limited on structural forms of contraceptive coercion. Furthermore, the consequences of contraceptive coercion remain underexplored.[16,18] In clinical settings, experiences of contraceptive coercion from providers may facilitate disengagement from contraception and future health care seeking.[14,17] More evidence is needed to understand the degree to which contraceptive coercion influences reproductive self-determination and its impact on social and health outcomes.

Despite the lack of research, public health professionals must understand and address persistent structural contraceptive coercion. Historically, researchers exploited the bodies of people experiencing poverty to develop contraceptive technologies.[23] In early clinical trials in Puerto Rico, researchers tested the efficacy of the oral contraceptive pill without informed consent or provision of information about the research in Spanish and with little attention to the severe side effects users experienced.[23] After the legalization of contraception in 1965, supporters of eugenics presented the oral contraceptive pill as a solution to the so-called population boom “problem.”[12] Eugenics, a population control practice used to restrict the fertility of specific groups, was propelled by racist, ableist, and capitalist ideologies justifying state-sponsored discrimination, forced sterilization, and genocide as necessary interventions.[12] As federal and state governments launched programs to support women, children, and families, fiscally conservative lawmakers and interest groups lamented the allegedly high costs of supporting female-led households and suggested that recipients of public benefits be required or encouraged to limit their childbearing.[12] Communities that had limited resources and communities of color were flooded with contraceptives in response.[12] This focus on contraception unfolded in the wake of eugenicist compulsory sterilization laws passed by more than 30 states earlier in the 20th century, primarily targeting people with limited agency or socially marginalized identities, such as those with disabilities; Black, indigenous, and people of color; people with low incomes; and immigrants. Under these policies, many of which were in place through the 1970s, at least 60,000 individuals were sterilized without consent.[24]

The framing of contraception as a “social good” for those whose reproduction was deemed “undesirable” continued in the 20th century.[12] Norplant, a hormonal contraceptive implant, was described as a means of “reducing the underclass.”[25] The organization CRACK (Children Requiring A Caring Kommunity) offered individuals using drugs a cash incentive if they underwent sterilization or started using Norplant.[26] In 2017, a Tennessee county judge offered reduced sentences for people who chose an LARC or vasectomy.[27] Moreover, forced sterilization is not just history: as recently as 2010, at least 148 cisgender women and transgender people incarcerated in California prisons received tubal ligations without consent or required state approval,[28] and in 2020 several people detained in a Georgia Immigration and Customs Enforcement facility reported receiving hysterectomies without their consent.[29] In some states, proof of gender reassignment surgery is required for changing gender on legal documents, implicitly requiring sterilization for transgender, nonbinary, and gender expansive people to obtain legal recognition aligned with their authentic gender.[30]

Contraceptive coercion also exists beyond the scope of narrowly tailored programs. Some professional organizations have suggested that the efficacy of and lack of required user action for LARC methods mean that they should be considered “first-line” contraception and be promoted over all other methods, especially for “high-risk” populations (e.g., youth, people living with HIV, those using substances, people insured by Medicaid).[31,32] They recommend that clinicians employ LARC-first counseling in clinical visits, presenting methods in order of efficacy regardless of individuals’ preferences, values, and needs. However, scholars, clinicians, and reproductive justice advocates have condemned the LARC-first approach for its neglect of people’s contraceptive preferences by assuming that all individuals use contraception to prevent pregnancy and prioritize contraceptive effectiveness in decision making above all else.[9,33–35] In the LARC Statement of Principles, reproductive justice advocates endorsed people’s ability to decide what contraceptive methods are best for them when provided health information in a “medically ethical and culturally competent manner.”[33] Research on contraceptive preferences has shown that presumed cisgender women of color tend to prefer methods that they can control, particularly ones they can stop at will.[35] LARC coercion is particularly concerning given that these methods are “clinician controlled”: to stop use, a person must typically return to a clinician to remove the device.[14,36] Another example is seen in the response to the ongoing opioid crisis. Clinicians and public health professionals seeking to prevent neonatal abstinence syndrome and other developmental issues in infants have suggested targeting those with substance use disorder for free or low-cost LARC methods.[37] Such interventions penalize individuals by restricting their reproductive autonomy instead of targeting the oppressive systems (e.g., racism, sexism, classism, ageism, cisgenderism, heterosexism) at the root of reproductive health inequities.[38]

The limited existing metrics of clinical and public health success can also implicitly incentivize contraceptive coercion. The Department of Health and Human Services Office of Population Affairs (OPA) warns against using metrics that measure contraceptive care quality as the proportion of all women or postpartum women in a setting using an LARC method.[39] Such metrics should not be used to encourage higher rates of LARC use, “as this may lead to coercive practice.”[39] The lack of relevant metrics has implications for public health goal setting and policy development. For example, Healthy People 2030 goals include reducing teen pregnancy rates and increasing the number of teens using contraception, particularly LARC methods.[40] Yet such goals disregard the underlying causes of teen pregnancy, including that rates are highest in areas with little or no available sex education and more restrictions on contraception and abortion access, and deprioritize individuals’ preferences, creating a situation in which meeting a public health goal could be achieved and justified through coercive means.[9]

Efforts to encourage LARC use are found throughout current policies and practices. Medicaid policies that facilitate access to immediate postpartum LARC placement by allowing hospitals to bill for device cost and insertion separate from the global fee for labor and delivery remove a critical barrier to service provision; most states have launched such initiatives.[41] Typically, they target Medicaid beneficiaries; on its face, this may be due to state control over Medicaid policy. However, it is important to note that people insured by Medicaid are often targeted for public health interventions that routinely aim to reduce fertility rates,[42] especially since commercial insurers have yet to make immediate postpartum long-acting reversible contraception accessible. While reducing the cost of methods is critical for equitable contraceptive access, targeting people who are economically marginalized for interventions that prioritize specific methods is inequitable and constitutes a form of structural contraceptive coercion, which may also lead to interpersonal coercion. Indeed, emerging evidence suggests that these Medicaid policies may lead clinicians to pressure people giving birth to use LARC methods while actively laboring.[43]

LARC initiatives have generally focused on promoting uptake and continuation of IUD and implant use without attention to the full life cycle of use, which includes eventual removal, typically by a clinician. Individuals perceived as desiring LARC removal “too early” have described facing pressure from providers to continue use,[14] while some privately funded programs that pay for LARC insertion do not pay for removal.[44] In addition, in many states, Medicaid programs did not explicitly offer guidance on the provision of or reimbursement for LARC removal until recently. For example, until 2017, South Dakota’s Medicaid program explicitly would not pay for LARC removal if the reason for the removal was a desire to become pregnant[36]; the program still requires clinicians to counsel patients on the “long-term nature” of LARC methods and treatment options for side effects before removal.[45]

Contradicting human rights–based approaches, contraceptive coercion raises significant ethical issues. Human rights–based frames align with three key ethical principles: respect for persons, beneficence, and justice.[46] Respect for persons acknowledges that individuals can make decisions for themselves. This principle relates to reproductive autonomy: people exercising control over their body and fertility, including deciding if, when, and how they use contraception. The principles of beneficence and justice relate to reducing harm, increasing the likelihood of benefits, and ensuring that certain groups are not disproportionately incurring harm. In the context of contraceptive coercion, harms include discounting people’s preferences, needs, and values regarding contraception or experiences with side effects and limiting options that align with their preferences. Addressing contraceptive coercion, especially among groups that have experienced historical and contemporary mistreatment, may mitigate persistent sexual and reproductive health inequities and foster opportunities for individuals to make decisions that help them achieve sexual and reproductive health and well-being.

Evidence-Based Strategies to Address the Problem 
Education of target audiences: Educating and training clinicians, frontline health care workers, community-based providers (e.g., certified health education specialists, master certified health education specialists, community health workers), and other providers in person-centered contraceptive counseling is a critical strategy for preventing contraceptive coercion. The LARC-first counseling approach, which prioritizes method efficacy over other features and concerns, remains common.[31,32] This approach was explicitly developed to encourage use of LARC methods and may not be appropriate for individuals prioritizing characteristics other than effectiveness in contraceptive decision making.[35] Person-centered contraceptive counseling training may include techniques for offering person-centered care, an introduction to the reproductive justice framework and how to operationalize it in the context of contraceptive care, and opportunities for discussing examples of bias and coercion. In training regarding postpartum LARC methods, optimal timing of counseling should be discussed; ideally, counseling occurs early in prenatal care and not during active labor or immediately postpartum to ensure full consideration of options.[47]

A longer-term strategy to reduce contraceptive coercion is educating individuals about the full range of contraceptive methods, including method effectiveness, side effects, and mechanisms of how methods are used and function. Ideally, K–12 schools educate individuals through culturally relevant comprehensive sexuality education (CSE). Schools can provide CSE at discrete points throughout students’ careers. However, communities can realize its full benefits when CSE is provided early in a developmentally appropriate way, so youth are informed about their options before becoming sexually active; this includes tailoring educational approaches in line with the current evidence base on brain development, particularly to address cognitive, social, and emotional processing that affects decision making.[48] CSE is associated with increased awareness of contraception, including how it works and proper use.[49] It also should provide a strong base for people to make future decisions about contraception that align with their preferences. In addition, students should be made aware of the history of contraceptive coercion and that it is their right to receive the method of their choice—or to decline or stop method use at any time.[13] Unfortunately, access to CSE is limited in the United States, primarily as a result of local and state legislation, a lack of funding, parental or interest group opposition, and associated political concerns.[50] Health care providers can be powerful advocates for CSE at the local, state, and federal levels, especially frontline health care workers, staff at school-based health centers, and staff at Federally Qualified Health Centers and Title X clinics. These providers may also offer input and support on curriculum development and implementation.

Advocacy directed to a legislative or administrative body: Inequities in health care coverage and service provision lead to coercion in a range of ways. States and the federal government should require that all contraceptive methods, including vasectomies, over-the-counter methods such as emergency contraception, and barrier methods such as condoms, be available to anyone without cost sharing, removing financial barriers that may otherwise influence people’s decisions.[51] This coverage should include settings such as Title X publicly funded family planning clinics and Federally Qualified Health Centers and sufficiently cover the associated costs. In addition, all insurers should cover all services needed to support reproductive self-determination, including method switching and discontinuation and time spent providing counseling. Achieving parity in the contraceptive services covered by public and commercial insurance is another effective strategy for reducing the likelihood of contraceptive coercion. For example, in most states, only Medicaid covers the costs of immediate postpartum long-acting reversible contraception; this could be addressed by requiring commercial insurers to do the same.[41] Regulating or otherwise holding commercial insurers accountable for unbundling contraceptive services covered only by Medicaid would be a step toward equity in service provision and likely increase access overall by simplifying insurance billing and coding.

As described earlier, the United States has a long pattern of reproductive coercion, including forced sterilization. Government agencies responsible for these atrocities must be held accountable and make reparations for these human rights violations. Needed actions include passing laws banning coercive practices and establishing and providing financial support for past victims. For example, in response to the uncovering of the coercive drug court program in White County, Tennessee passed legislation banning judges from basing sentencing decisions on defendants’ use of or refusal to use contraception.[27] California banned sterilization in its jails and prisons in response to revelations about coercive sterilizations in the system.[52] While both of these practices were already unconstitutional, state legislation plays a vital role in reinforcing their illegality. Furthermore, U.S. states that practiced eugenics and forced sterilization in the 20th century should establish reparations programs for living survivors and their families. The establishment of reparations programs is important in beginning to rectify the injustices experienced by victims by imposing real accountability—both social and monetary—on the systems that supported them and preventing the revival of similar harmful programs.

The emphasis on LARC methods as a “silver bullet” to solve large-scale societal challenges, such as poverty,[53] has driven interest among private foundations and state and local governments to invest in LARC access initiatives, often including free LARC devices for people without health insurance. Such approaches are coercive because they encourage the use of certain methods by offering them for free while requiring cost sharing, even if minimal, for other methods and because they often do not include funding for removal of IUDs and implants. Instead, public and private funds should be invested in providing affordable or free comprehensive access to contraception for those who are uninsured in a range of health care settings. Such funding should be coupled with the other recommended evidence-based strategies to ensure that contraceptive access initiatives promote provision of high-quality, person-centered care.

Development of person-centered metrics of contraceptive care quality and access: In 2016, the National Quality Forum (NQF) endorsed two measures of quality in contraceptive care: one evaluates uptake of mostly to moderately effective contraceptive methods, and the other evaluates provision of LARC methods based on the proportion of patients in a setting using such methods.[54] Person-centered metrics that emphasize patient autonomy and experience in contraceptive care are an important complement to existing metrics that focus only on method uptake; used alone, uptake metrics may lead to coercion by incentivizing clinicians and health care systems to encourage LARC use.[55] Health care systems and clinicians should consider implementing the measure of person-centered contraceptive counseling adopted by NQF.[54] Using measures in tandem provides the opportunity to evaluate person-centered contraceptive care by creating a balance that could counteract the incentives created by metrics focused on the uptake of certain methods.[56] Tandem use may help minimize structural coercion (via the provision measure) and interpersonal coercion based on clinician bias (via the person-centered measure). Both types of coercion disproportionately affect communities with the fewest resources. Furthermore, metrics of contraceptive access should move beyond solely documenting the use of certain methods and focus on whether individuals’ contraceptive needs, as they define them, are met. Public health officials, health care administrators, researchers, primary care providers, and family planning providers can leverage implementation science to participate in developing, implementing, and evaluating person-centered quality and access metrics.

Opposing Arguments/Evidence
Some health care professional associations, public health initiatives, and health care workers advocate for an LARC-first model. The LARC-first counseling model was central to the Contraceptive CHOICE Project, which sought to increase LARC use.[57,58] The project’s success lent support to the assumption that fertility control was the most cost-effective way to address the upstream social and economic determinants of teen and unintended pregnancy.[53] 

Throughout U.S. history, politicized ideologies about reproduction have posited that childbearing among groups marginalized on the basis of race/ethnicity, socioeconomic status, and ability should be deterred because their reproduction is perceived as a “drain on society.”[12] On the surface, these ideologies may appear to be “common sense” because of the costs and challenges associated with child rearing in a country with a limited social safety net and a lack of family-friendly policies. However, by framing parenthood as a privilege rather than a human right, such ideologies use eugenicist logic to justify efforts to limit fertility or promote specific contraceptive methods (e.g., targeted LARC promotion) in these populations. 

Globally, LARC has been used as a population control tool to reduce fertility rates in contexts where “overpopulation” is perceived to occur.[59] However, the issue of “overpopulation” and its impact on climate change and related concerns is deeply contested, especially in highly industrialized countries such as the United States, where fertility rates continue to decline and the consumption of resources far outweighs that of underresourced nations with larger populations.[60] Additional research and interventions related to person-centered contraceptive care are needed to refute contraceptive coercion–related ideologies and mitigate these harms. LARC-first messaging, whether during a clinical encounter or in health promotion campaigns, may limit self-determination by presenting long-acting reversible contraception as the best and only responsible choice.[9,34] 

Alternative Strategies
There are no evidence-based counterpoints to our knowledge.

Action Steps

  1. APHA calls on public health departments, policymakers, health and social service  institutions, religious and faith-based organizations, and health care professional organizations (1) to advocate for and provide contraceptive programming and funding that promote access to all contraceptive methods and (2) to discourage new and modify existing programs that aim to increase contraceptive use, especially LARC uptake, without consideration of individuals’ preferences, particularly in populations that have been the targets of coercive practices and policies due to their income; racial or ethnic identity; sexual or gender identity; disability, HIV, or incarceration status; or substance use. Instead, programming and funding should be designed to increase access to the full range of contraceptive methods with person-centered, high-quality contraceptive care.
  2. APHA calls on elected officials, federal regulatory bodies, and public and commercial insurers to implement programs and policies that would increase the number of insured individuals, such as Medicaid expansion in all 50 states or the establishment of a public option or single-payer health care systems, and to expand the contraceptive coverage mandate to remove barriers to the immediate availability of and access to all contraceptive methods, related care (including device removal), and person-centered contraceptive counseling and education. 
  3. APHA calls on state and local elected officials and departments of education to advocate and secure funding for developmentally appropriate comprehensive sexuality education that is strengths based, inclusive, and medically accurate and discusses reproductive coercion. 
  4. APHA calls on all relevant federal agencies, including the Health Resources and Services Administration, OPA, and the Centers for Medicare & Medicaid Services (CMS), to provide funding to contraceptive care settings for staff training and public health programming in person-centered contraceptive counseling practices that center bodily autonomy and focus on individuals’ preferences, goals, and needs.
  5. APHA calls on all agencies and settings that provide contraceptive care, referrals, and education (including but not limited to Federally Qualified Health Centers, community-based social service programs, Title X family planning clinics, and religiously affiliated health care settings) to adopt and implement person-centered contraceptive access, quality, and service provision metrics that focus on equity, care experiences, and meeting individuals’ needs for contraception rather than solely focusing on contraceptive use.  
  6. APHA calls on all publicly funded institutions that impact and influence the access, health, and safety of people, including but not limited to CMS, the Indian Health Service, the Department of Justice, the Department of Homeland Security, and the Department of Veterans Affairs, to create and enforce protections against contraceptive coercion.

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