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Journal of Law in Society Fall, 2003

Article

*187 REMARKS ON THE “CRACK” PROGRAM: COERCING WOMEN'S REPRODUCTIVE CHOICES

Renee Chelian [FNa1]

Introduction

As the President of MARAL (the Michigan affiliate of NARAL Pro-Choice America) and as a women's health care provider, I believe it is essential that we speak out and weigh in whenever women's reproductive rights are threatened. This is especially important when the women who are being targeted are some of society's most vulnerable. As you know, I am here today to share my thoughts and NARAL Pro-Choice America's position on the C.R.A.C.K. program, which has been offering money to drug-addicted women in exchange for sterilization and other forms of long-term birth control. First, I will offer a bit of background on the program to provide some context, then I will discuss some of the problems with this program. I will wrap up by sharing with you NARAL Pro-Choice America's position on the program.

In the last several years, a private organization known as C.R.A.C.K., which stands for “Children Requiring a CaringKommunity,” also called “Project Prevention,” has been offering money to drug addicts in exchange for sterilization or the use of long-term birth control. This program was started in California in 1997, and has been proliferating in major metropolitan areas throughout the United States.

The C.R.A.C.K. program offers a cash payment of $200 to women addicted to drugs or alcohol in exchange for their commitment to use permanent or long-term birth control methods including tubal ligation, a surgical form of sterilization; Depo-Provera, a contraceptive shot; intra-uterine devices, or IUDs; and Norplant, a five year contraceptive implant. [FN1]

*188 C.R.A.C.K. was launched in Stanton, CA in 1997 by Barbara Harris, after she failed to pass legislation that criminalized drug-addicted women who have children. [FN2] Harris has reported to the press that her motivation was to punishthe drug-addicted birth mother of her four adopted children.fter her legislative plan failed she turned her attention to the founding of C.R.A.C.K. [FN3] Supporters of the program include ultra- conservative philanthropist Richard Mellon Scaife, as well as a prominent right-wing radio talk show host, Dr. Laura Schlessinger. [FN4]

The organization does not pay for actual medical procedures. Instead, after receiving inquiries from the participants-often through their toll free number-C.R.A.C.K. sends out forms that must be completed by a doctor after participants undergo sterilization or obtain long-term birth control. Once the forms are mailed back to C.R.A.C.K. and they verify that the participants have satisfied requirements, C.R.A.C.K. mails participants a check for $200. [FN5] Most participants qualify for government-funded birth control and therefore are able to

use the $200 cash payment to buy whatever they want-including drugs.

The program has been steadily expanding to new metropolitan areas, and now claims to have 23 chapters throughout the United States. [FN6] *189 C.R.A.C.K. reports that as of March 17, 2003, of the 907 participants they claim to have paid, 372 have had tubal ligations, 361 received Depo Provera, 115 IUDs, and 37 Norplant. While the program is heavily targeted toward women, men may also receive payment for sterilization, and C.R.A.C.K. also claims to have provided the cash payments to 22 men for undergoing vasectomies. [FN7]

When the C.R.A.C.K. program first began, Harris paid participants on a sliding scale, offering more money to those who used the irreversible tubal ligation procedure for sterilization than to those who opted for the five- year contraceptive Norplant, and even less for those who agree to a year's worth of Depo-Provera shots, which last three months. [FN8] A news release in Oakland, CA early in the program was explicit about the preference for sterilization, “Get sterilized-Get $200.” [FN9] A firestorm of criticism led Harris to modify this approach and pay $200 for either sterilization or the use of long-term birth control methods like Depo-Provera, IUDs or Norplant. [FN10] C.R.A.C.K. does not offer the $200 payment for the use of shorter-term methods like the pill or barrier methods.

In order to reach its participants, C.R.A.C.K. advertises on billboards, bus benches and sometimes on benches outside welfare offices. [FN11] Some of C.R.A.C.K.'s advertisements read: “Don't Let a *190 Preg- nancy Ruin Your Drug Habit,” [FN12] “If You Are Addicted to Drugs, Get Birth Control, Get $200,” [FN13] “Stop the cycle of addicted newborns now!” [FN14]

In addition to outdoor advertising, C.R.A.C.K. also conducts outreach to local agencies that may come into contact with substance-abusing women, distributes fliers to hospitals, health clinics, police departments, proba- tion departments, jails, and homeless shelters and urges social service workers to refer women to the toll free number. [FN15] Most of this advertising appears to have been placed in poor communities of color, which has led many to charge C.R.A.C.K. with racism, eugenics and even genocidal intentions. [FN16]arbara Harris and C.R.A.C.K. dispute charges of racial targeting. As of March 17, 2003, C.R.A.C.K. reports that 437 Caucasian, 311 African American, 90 *191 Hispanic and 69 people of “other ethnic backgrounds” participated in the CRACK program. [FN17]

I. The C.R.A.C.K. Program Dehumanizes Women Struggling with Addiction

One major area of concern is that programs such as C.R.A.C.K. are fundamentally dehumanizing to women struggling with addiction, and they fail to account for the unique circumstances of each individual woman. C.R.A.C.K. Founder Barbara Harris revealed her attitude toward the women targeted by C.R.A.C.K. in an inter- view with the British edition of Marie Claire magazine when she said, “We don't allow dogs to breed. We spay them. We neuter them. We try to keep them from having unwanted puppies, and yet these women are literally having litters of children.” [FN18] She also has stated, “These women are not getting pregnant because they love children, but because they're totally irresponsible.” [FN19]

These comments suggest that Harris fails to see women who struggle with substance abuse as capable of the same sort of motivation for having children as all women. [FN20] This callous and dehumanizing attitude*192 is also reflected by the focus of the program. C.R.A.C.K. singles out a particular group of women and creates a social stigma that these women are not worthy of reproducing. As Lynn Paltrow, Executive Director of National Advocates for Pregnant Women, put it:

What she's doing is suggesting there are certain neighborhoods where it is dangerous for some people to be reproducing... It suggests they are not worthy of reproducing. It is very much like the eugenics history in America. The Nazis said if you just sterilized the sick people and Jews you would improve the economy. [FN21]

II. The C.R.A.C.K. Program Fails to Address the Problem of Addiction

Another disturbing aspect of this program is that rather than gearing its efforts toward improving the lives of women haunted by substance abuse problems, C.R.A.C.K. is strictly focused on preventing those women from having children. There is an increasing consensus that addiction, like many other diseases, is a disease that can be cured with appropriate treatment. Medical professionals and addiction specialists have heavily criticized Har- ris's approach, pointing out that contraceptive*193 options should be offered as a part of a larger comprehensive treatment plan managed by health care professionals concerned about the woman's well being.

As Bill McColl, executive director of the National Association of Alcoholism and Drug Abuse Counselors put it, “Two hundred dollars would buy more than a week of long-term residential care.” [FN22] He also called C.R.A.C.K. a “non-program [that] preys on addicts' need for cash, stigmatizes them as inhuman, raises ex- traordinary ethical questions and highlights our society's unwillingness to find real solutions for real problems.” [FN23] Indeed, Barbara Harris herself admitted that the well-being of the women who participate in C.R.A.C.K. is not a focus of the program when she said, “[i]t's sad that they are on drugs, but our program is not about the women. It's about the children.” [FN24]

Because of its callous failure to respond to the needs of women, the C.R.A.C.K. program can be viewed as one element of a broader trend towards punishing women for behavior during pregnancy. [FN25] However in this instance, rather than attempting to punish the woman for her behavior during pregnancy, the condemnation comes before the pregnancy.

III. The C.R.A.C.K. Program Targets Poor Women of Color

The C.R.A.C.K. program has been heavily criticized for targeting women of color. [FN26] Women of color have been disproportionately represented*194 in the C.R.A.C.K. program, with African Americans and Hispan- ics accounting for 401 of the 907 participants as of March 17, 2003. [FN27] In addition, C.R.A.C.K. focuses its advertising efforts largely in communities of color, [FN28] raising serious concerns about the potential for a re- turn to the shameful history of the United States eugenics programs which targeted women of color. [FN29] Bar- bara Harris counters charges of racism by pointing out that she is the adoptive mother of four African American children and married to an African American man, [FN30] but many critics believe this personal history is insuf- ficient to counter the charges of racial targeting.

IV. The C.R.A.C.K. Program Raises Serious Ethical Concerns and Compromises Reproductive Freedom

Some of the most disturbing aspects of C.R.A.C.K.'S approach are the serious ethical and reproductive rights concerns that are raised by the program. These concerns include the risk of coercion, potential problems with informed consent, and interference with reproductive choices.

Given that money is typically necessary to maintain a drug addiction, C.R.A.C.K. raises the question whether women undergoing procedures are being coerced, by the offer of cash, into relinquishing their fundamental

reproductive rights. The attraction of cash may be too muchfor an impoverished drug-addicted woman to res- ist.ome have equated the cash payments with a bribe to induce women to give up their rights in *195 exchange for drugs. Leading bioethicist Arthur Caplan, director of the University of Pennsylvania Center for Bioethics, summarized the problem when he stated, “[t]he history of sterilization is so fraught with controversy and abuse that when you offer poor, drug-addicted people $200, it looks like they're being bribed.” [FN31]

While Harris insists the program is not coercive, her statements reflect that even she acknowledges the sway that money has over those struggling with addiction. In an LA Times article in 1997, shortly after the program was founded, she stated, “All they're thinking about is getting money for drugs. Most of the people are probably going to use the money for drugs.” [FN32] Since many drug- abusing women are also afflicted with mental ill- ness, they may be especially vulnerable to the cash inducements offered by C.R.A.C.K. [FN33] It is important to note that coerced sterilization has the potential to irrevocably penalize a woman-even after recovery from addiction. Even absent sterilization, if women “choose” long-term birth control, the use of a cash payment to prompt that “choice” among other options is still coercive.

There are also questions about the ability of these women to offer their informed consent to such procedures. [FN34] Addicted women may not *196 be in a condition to be able to offer full and free consent to the procedures that they undergo in order to obtain the money. By placing vulnerable women into a position where they may make uninformed reproductive choices about their future fertility, the C.R.A.C.K. program risks comprom- ising women's reproductive freedom.he concerns about the ability of some women targeted by the program to offer their full, informed consent are especially troublesome in light of the fact that the program offers inducements for long-term, sometimes irreversible, methods, and fails to offer similar inducements for shorter-term methods and barrier methods that would better protect women from HIV and sexually transmitted infections.

Another problem with the program is that by offering payment to women for only certain birth control options, C.R.A.C.K. fails to account for the diverse health needs of women and narrows the choices available to them. C.R.A.C.K. only pays for tubal ligations, Depo-Provera, IUDs and Norplant. C.R.A.C.K. does not pay for condoms, [FN35] thereby discouraging their use and placing already at risk women at increased risk for sexually transmitted infections and HIV, which can be prevented by the use of condoms.

V. NARAL Pro-Choice America's Position on the C.R.A.C.K. Program

NARAL Pro-Choice America strongly opposes the C.R.A.C.K. program. At the core of our advocacy is the principle that every woman should have the right to choose, freely and voluntarily whether and when to bear a child. By paying women with substance abuse problems cash in exchange for a particular choice, at a time when they are desperate for money, the C.R.A.C.K. program risks coercing women into certain irrevocable or long- term choices. In the process, the C.R.A.C.K. program takes advantage of vulnerable women, offering them cash for giving up-often permanently-their reproductive rights. *197 NARAL Pro-Choice America opposes efforts to influence the reproductive choices of women through the use of financial incentives. Such efforts contravene the principals of autonomy and privacy that are central to reproductive freedom.

NARAL Pro-Choice America supports access to safe, effective and fully voluntary contraception for all women. For example, we support full funding for Title X and the expansion of Medicaid Family planning programs. We also believe that women should have a wide range of contraceptive options. C.R.A.C.K. emphasizes only long- term contraceptive methods (tubal ligation, IUDs, Depo Provera), which are non-barrier methods that may not be the best for women at increased risk of HIV and STD infection due to their substance abuse prob-

lems.

We at NARAL Pro-Choice America also believe that decisions about birth control and child-bearing are intensely personal decisions that every woman has the right to make for herself based upon her own unique circumstances, plans and values. Programs like C.R.A.C.K. that target and publicly urge certain groups of women to undergo sterilization or long-term birth control denigrate the very notion of individual reproductive freedom and fail to acknowledge that decisions about reproduction are intensely personal.

As an alternative to the C.R.A.C.K. approach, NARAL Pro-Choice America supports increased access to and funding for comprehensive and compassionate voluntary and confidential drug treatment programs that meet the needs of all women, including pregnant women and women with children, and the provision of voluntary, confidential treatment alternatives, education and abuse prevention programs. We also support strategies to address drug and alcohol abuse during pregnancy through programs designed to promote the birth of healthy babies and to achieve the best possible outcomes for pregnant women and their children. Rather than dehumanizing, coercing, and depriving women of their reproductive choices, we should continue to seek ways to help women struggling with addiction to recover. In addition, we should promote policies and programs that provide all women with the information and services they need to make fully informed reproductive choices.

[FNa1]. Renee Chelian is the President of MARAL (the Michigan affiliate of NARAL Pro-Choice America).

[FN1]. Project Prevention, How We Help the Children, at http:// cashforbirthcontrol.com/program/index.html.

[FN2]. Sharon Bernstein, Mother in the Middle: By Offering $200 to Addicted Women Who Agree to Have Their Tubes Tied, Barbara Harris Has Gone from Waitress to Lightening Rod, L.A. Times Magazine, May 14, 2000, at 11; Alexis Bloom, Crack Addicts Offered ‘Bribe’ To Be Sterilized, The Observer, Oct. 3, 1999, at 24.

[FN3]. Harris's first idea was to pass legislation to force women who use drugs during pregnancy to choose between long-term birth control or jail. See Bernstein, supra note 2, at 11.

[FN4]. Ronald J. Hansen, Plan Pays Addicts To Be Sterilized; Women Offered $200 In Effort to Stop Drug- Dependent Births, Detroit News, Dec. 8, 2000, at 7C.

[FN5]. Project Prevention, Frequently Asked Questions, at http:// cashforbirthcontrol.com/program/faqs.html.

[FN6]. Chicago, IL; Sacramento, CA; Phoenix, AZ; San Francisco, CA; Fresno, CA; Las Vegas, NV; Houston, TX; Seattle, WA; Pittsburgh, PA; San Diego, CA; Denver, CO; Dallas, TX; Detroit, MI; Nashville, TN; New Jersey; Los Angeles, CA; Washington, DC; New Orleans, LA; Florida; South Bend, IN; Salt Lake City, UT; Reno, NV; Albuquerque, NM. Project Prevention, New Chapters, at http:// cashforbirthcontrol.com/about/new_chapters.html (as of March 2003).

[FN7]. See id.

[FN8]. See Bernstein, supra note 2, at 11; Cecilia M. Vega, Sterilization Offer to Addicts Reopens Ethics Issue, N.Y. Times, Jan. 6, 2003, at B1.

[FN9]. Marianne Costantinou, Women Find Billboard Offensive; Organization Offering Money for Addicts to

Get Sterilized, The Dallas Morning News, Oct. 21, 1999, at 13A.

[FN10]. Bernstein, supra note 2, at 11.

[FN11]. Lynn Smith, Crack Moms Get Paid to Undergo Sterilization, The Toronto Star, May 14, 1998, at D7.

[FN12]. National Black Women's Health Project, Factsheet, Comments on CRACK; Discrimination in Disguise, Jan 1, 2001, at http:// www.blackwomenshealth.org/site/News2?page=NewsArticle&id=5116&news_iv_ctrl=-1.

[FN13]. Lisa Donovan & Sue Ellen Christian, Program Hopes to Sell Addicts on Birth Control; $200 for Proof of Sterilization, Chicago Tribune, July 23, 1999, at 1N.

[FN14]. Associated Press, Cash for Addicted Mothers, New York Newsday, July 25, 1999, at A27.

[FN15]. Smith, supra note 11, at D7; Vega, supra note 8, at B1; Donavan & Christian, supra note 13, at 1N.

[FN16]. See generally, Adam B. Wolf, Note, What Money Cannot Buy: A Legislative Response to C.R.A.C.K., 33 U. Mich. J. L. Reform 173, 175, 176, 189, 190 (discussing some of the responses to the C.R.A.C.K. program); Judith M. Scully, Cracking Open CRACK: Unethical Sterilization Movement Gains Momentum, Differ- ent Takes, Spring 2000, at http://hamp.hampshire.edu/~ clpp/DTNo2.htm (“Like earlier sterilization movements in the United States, C.R.A.C.K.'s program is based in eugenic philosophy.... C.R.A.C.K. vows to eliminate children born with drug addictions from the population because, according to C.R.A.C.K., these kids cost the tax- payers too much money.... If the cost to society is really the issue, as C.R.A.C.K. claims it is, the ‘logical’ exten- sion of this argument would be to expand the sterilization campaign to all of society's ‘burdens'-the poor, the disabled, the homeless, as well as the drug addicted. Does society really need to be reminded of the con- sequences of such thinking?”); Bernstein, supra note 2, at 11.

[FN17]. Project Prevention, Statistics, at http:// www.cashforbirthcontrol.com/reasons/statistics.html.

[FN18]. Committee on Women, Population and the Environment, Factsheet on C.R.A.C.K., at http://www.cwpe.org/issues/health_ html/contraceptives/crack/cwpe _factsheet.html, n.5 (quoting Mothers Paid to Stop Having Children, Marie Claire, (Dec. 1998)); Vega, supra note 8, at B1.

[FN19]. Bloom, supra note 2, at 24.

[FN20]. Lynn Paltrow, Executive Director of National Advocates for Pregnant Women, has pointed out that substance abusing women may get pregnant for many of the same reasons other women do.he suggestion of sterilization, however, is particularly attractive if there is no explanation about why a pregnant woman with a drug problem would want to become pregnant or to have a child in the first place. But drug-using pregnant women become pregnant and carry to term for the same range of reasons all women do. Because contraception failed. Because they fell in love again and hoped this time they could make their family work. Because they are “pro-life” and would never have an abortion. Because when they found out the beloved father of the baby was really already married, they thought it was too late to get a legal abortion. Because they do not know what their options might be. Because they have been abused and battered for so long they no longer believe they can really control any aspect of their lives including their reproductive lives. Because they wanted a child. Because their neighbors and friends, despite their drug use, had healthy babies and they believed theirs would be healthy too. Lynn M. Paltrow, Punishment and Prejudice: Judging Drug-Using Pregnant Women, in Julia E. Hanigsberg, Mother Troubles, Rethinking Contemporary Maternal Dilemmas (Julia E. Hanigsberg and Sara Ruddick eds.,

Beacon Press 1999), available at http:// www.advocatesforpregnantwomen.org/articles/ruddick.htm.

[FN21]. Vega, supra note 8, at B1.

[FN22]. Avram Goldstein, Group to Pay Addicts to Take Birth Control, Wash. Post, June 26, 2000, at B1.

[FN23]. Id.

[FN24]. Bloom, supra note 2, at 24.

[FN25]. See NARAL Pro-Choice America Foundation, Limitations on the Rights of Pregnant Women, March 2001, available at http://www.prochoiceamerica.org// facts/load- er.cfm?url=/commonspot/security/getlife.cfm&PageID=1957.

[FN26]. See National Black Women's Health Project, supra note 12; Judith M. Scully, Cracking Open CRACK: Unethical Sterilization Movement Gains Momentum, Different Takes, Spring 2000, at http://hamp.hampshire.edu/~clpp/DTNo2.htm; Wolf, supra note 16, at 188.

[FN27]. Project Prevention, Statistics, supra note 17.

[FN28]. Wolf, supra note 16, at 176. See also Costantinou, supra note 9; Pam Belluck, Cash-for-Sterilization Plan Draws Addicts and Critics, N.Y. Times, July 24, 1999, at A8.

[FN29]. Wolf, supra note 16, at 188-89 n. 109-11 and accompanying text. See also Scully, supra note 16.

[FN30]. Bernstein, supra note 2.

[FN31]. Robert Ourlian, Woman Offers Payment if Addicts Get Sterilization; Drugs: She Says She has First Taker in Plan To Cut Number of Crack Ravaged Babies. Critics Call Idea “Exploitive,” L.A. Times, October 24, 1997, at A3. Others concur, “[c]oercing women into sterilization by exploiting the condition of their addiction is just plain wrong,” said Steve Trombley, president and CEO of Planned Parenthood Chicago Area. “You are es- sentially bribing women with what will be used to buy drugs. You are supporting their behavior.” Donavan & Christian, supra note 13, at 1N.

[FN32]. Ourlian, supra note 31.

[FN33]. Goldstein, supra note 22.

[FN34]. Goldstein, supra note 22 (Larry Siegel, the D.C. health department deputy director in charge of substance abuse services, stated: “[i]t's unethical. We are talking about attempting to introduce a therapeutic inter- vention into a population of individuals who are unlikely to have been thoroughly informed of all the potential complications.”). See also Lynn Smith, Cash for Sterilization: Coercing Poor Women?; Chicago Sun Times, April 19, 1998, at 27 (“The issue is whether a woman who decides to undergo such a procedure does so voluntarily and with full consent,” said Rocio Cordoba, a staff attorney for the ACLU of Southern California. “If a woman is given financial incentives to do so, that raises questions. Two hundred dollars could mean a lot to somebody who has nothing.”).

[FN35]. See Project Prevention, Frequently Asked Questions, supra note 5. 5 J. L. Society 187

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