Pregnancy, Drug Use, and Why Prison Is Not the Solution

@HuffPost

In New Hampshire, a bill to redefine opioid use or addiction in “custodial parents,” including pregnant women, as child abuse is making its way through the legislature, despite vocal objection from the state’s medical community. Much media treatment of this bill and similar bills in other states presumes women are not generally held criminally responsible for terminating—or losing—a pregnancy.

This illusion is increasingly hard to sustain.

In March 2015, Purvi Patel, a 33-year-old woman in Indiana, was sentenced to 20 years imprisonment for, prosecutors claim, inducing an abortion. Patel has maintained she had a miscarriage, and has never tested positive for any of the abortifacients the prosecution claims she took. In fact, the pathologist for the prosecution partially relied on the long discredited “lung test“ to determine if the recovered fetus had been born alive: a practice from the 17th century disproven as bad science over a century ago. Whether a miscarriage or an induced abortion, it is clear that Patel is in jail for not carrying a pregnancy to term.

Indeed, state legislators increasingly seek to hold women criminally responsible for not having healthy pregnancy outcomes. Since the beginning of this year, at least eight state legislatures have introduced bills to redefine legal personhood as starting at “fertilization” or “conception.” Though voters have generally rejected personhood measures when put to a vote—three times in Colorado alone—they keep resurfacing in new versions.

From a medical perspective, fetal personhood bills make no sense. “Conception“ is not a medical term and is interchangeably used to refer to the moment an ovum is fertilized and the moment a fertilized ovum implants in the uterine lining. “Fertilization“ is a medical term—referring to fusion of male and female gametes to form a zygote—but not all fertilized ova implant in the uterine lining (that is: not all result in a pregnancy), and the precise moment of both fertilization and implantation is hard to determine. As a result, the length of a pregnancy is usually calculated with reference to the pregnant woman’s last period—when she clearly was not pregnant yet—because that moment is an observable factor that can be defined.

There are also obvious logistical problems with fetal personhood bills. An estimated 10 to 20 percent of known pregnancies end in miscarriages, with the actual number likely much higher as many women miscarry before they know they are pregnant. In addition, the risk of miscarriage is higher for specific groups of women, such as older women, women with weight problems, women who have already miscarried, those who have contracted infections or who have immune response issues, and those who regularly use drugs, including alcohol and nicotine.

As a result, the implementation of fetal personhood laws would require unconstitutional discrimination and invasion of privacy. If a fertilized ovum has the same rights as a person after birth, each miscarriage (or failure to implant) would need to be scrutinized for intentional or reckless neglect. Detection would only be possible by registering all incidents of unprotected sex, and effective surveillance would require regular pregnancy testing, in particular of women at risk of miscarriage (think mandatory weekly pregnancy testing for women over 40 until they reach menopause). Of course, no one is advocating this.

Proponents of punitive pregnancy-related provisions have, however, successfully advocated for the growing surveillance of pregnant women from marginalized or stigmatized communities through social services, and in particular through medical providers. The organization National Advocates for Pregnant Women has documented the growing arsenal of state laws that treat drug use and addiction in pregnant women as a form of child abuse. Because health care providers in all states must report child abuse to the authorities, this reframing forces doctors and nurses to breach patient confidentiality for pregnant women who admit to struggling with drug use or addiction. The predictable result is a breakdown in the therapeutic relationship at best, and at worst, a reluctance to seek care at all for the women who arguably need it the most.

Many of these bills are pushed through without consulting the medical community, which is the case for the bill currently pending in New Hampshire. House hearings are under way, and both pediatricians and obstetric-gynecologists will testify to its predictably disastrous effects on the provision of addiction treatment and child welfare.

To be sure, both child abuse and drug addiction are serious matters, which require appropriate state support. Attempts to redefine drug use or addiction as child abuse in pregnant women, however, disregard the medical and psychological needs of both abused children and pregnant women. Advocates of such legislation are attempting to transform the fiction of fetal personhood into law by appropriating the problem of child abuse and punishing pregnant women in need of treatment for substance dependency or addiction.

A fetus is not a child and a women’s right to choose an elective abortion should not be circumvented by legislating punishment for women in need of treatment for substance use disorders. Legislators should listen to the medical community. Whether the conversation is about elective abortion, treatment for substance use disorder, or any other medical intervention, decisions about care are best made by the patient in private consultation with her doctor.

Who is a "Criminal?" Exclusion of Vulnerable Groups from International AIDS Conference Nothing to Celebrate

@RHRealityCheck

As the International AIDS Conference ended in Washington D.C. last week, rumor has it that the lead organizer invited participants to celebrate the fact that “criminals” had been kept out of the conference. This with reference to the fact that sex workers and those convicted for drug crimes were prevented by current law from obtaining visas for the gathering.

Setting aside for a moment the insanity of excluding the voices of two groups very much affected by the HIV epidemic in general and by misdirected prevention policies in particular, and regardless of whether the rumors are true, we can use this opportunity to reflect on the definition, use, and potentially manipulative power of criminal laws and policies.

For starters, our concept of what is criminal is relative and fluid at best. When I did research on access to abortion for rape victims in Mexico in 2006 and 2007, I was shocked to learn that child victims of incest were considered criminals in many jurisdictions. Meanwhile, rapists could escape the label by marrying their victim, a relatively common provision in several other countries too, including Cameroon and Brazil. This notion of incest victims as criminals and rapists as... not criminals, illustrates the fluidity of the concept.

Sex workers too are not always breaking the law. In some jurisdictions, such as Canada until very recently, sex workers can avoid criminal sanctions by doing only out-calls or by working alone—conditions that tend to render their work more dangerous. In other jurisdictions, such as for example Nevada and New Zealand, sex work is generally legal, subject to regulation.

Punitive measures attached to drug use also depend on the jurisdiction, down to quite substantial differences on what constitutes an illegal substance in the first place. Considering the uncontested and severe health consequences of tobacco and alcohol overuse, it is amazing that these drugs are in legal circulation in the United States while other drugs with equal or lesser negative health implications are not. Moreover, there is now an overwhelming consensus that drug addiction is an illness rather than a malicious choice, and that treating it as an illness renders better (and cheaper) results than treating it as a crime.

But even if we believe existing criminal provisions in whichever jurisdiction we live in are just, the use of the criminal law to target specific populations for punishment should cause pause.

In the United States, Michelle Alexander has documented the highly selective application of the criminal law, in particular as it relates to drug-related infractions. For example, while whites and blacks use drugs at similar rates (and whites are slightly more likely to deal illegal drugs), blacks are overwhelmingly more likely to be targeted for arrest, prosecution, and punishment. Likewise, ambiguous criminal law provisions on sex work in Louisiana up until very recently allowed the police to apply the provisions with the most severe punishments to trans sex workers of color.

Such police discretion in the use of criminal law—even if one agrees with the provisions as they stand—converts the penal code into a very effective tool for repression and discrimination.

In fact, those who believe in the fairness of existing criminal laws should be particularly worried about the selective application of them. If you think that everyone who smokes pot belongs in jail (and that the threat of jail sentences is a good way to bring down pot use), shouldn't you be worried that individuals who are neither resource-poor nor of color hardly ever are punished (and therefore will not benefit from the dissuasive powers of the law)?

More to the point, the selective implementation of criminal sanctions creates the illusion that white, upper-middle class people can't be violent repeat offenders, something the exposure of Dominique Strauss-Kahn’s sexually aggressive nature—whether considered criminal or not—should by now have been dis-proven.

In other words, the definition of criminal offenses, the selective implementation of the law, and the resulting stereotypes generate a self-enforcing loop of discrimination and exclusion to the detriment of all. The exclusion of so many legitimate voices from this year’s AIDS conference is just one example. The incarceration of 10 percent of the adult black population in the United States is another.

“Criminal” is not an objective term, and the application of criminal sanctions has consequences that go way beyond jail sentences or fines. Policy makers would do well to remember that when they seek to devise solutions to the many human rights violations suffered by sex workers, injection drug users, and others vilified by the law.

Sensationalizing Drug Use in Pregnant Women: How the Media Perpetuates Racist and Ineffective Policies

@RHRealitycheck

Well before anyone could be certain of how Whitney Houston died, several news outlets rushed to describe her as a “crack cocaine user.” And in all likelihood many will think of the popular singer as succumbing to illegal drugs, even if alcohol eventually is found to be more closely related to her demise.

This is not all that different from how the media deals with infant and child health.

Regardless of the actual causes behind low birth weight, infant mortality, and early childhood health issues, media reports are sure to blame the “crack baby syndrome” or, more recently, women’s abuse of prescription pain killers.

This kneejerk reaction is unhelpful for a number of reasons.

First of all, a pregnant woman’s use of illicit drugs is neither the only nor the most damaging pregnancy phenomenon from the point of view of infant health.

Take, for example, legal drugs, such as alcohol and cigarettes. Peer reviewed research shows that over-consumption of alcohol can cause fetal alcohol syndrome (linked with permanent mental retardation), whereas cocaine seems to act only as one contributing factor in some pregnancies to increase non-permanent risk factors such as low birth weight. Approximately twice as many pregnant women drink alcohol frequently as use illicit drugs frequently during their pregnancies.

Epidemiological research published in the mid 1990s shows that the use of tobacco products in the United States at the time was responsible, each year, for tens of thousands of tobacco-induced miscarriages, infants born with low birth weight, infants who require admission to neonatal intensive care units, as well as an estimated 1900 to 4800 infant deaths. Though smoking has gone down over the past decades, around 17 percent of adult women in the United States still smoke, and generally continue to smoke during their pregnancies.

Even drugs administered to women who are in fertility treatment have been associated with low birth weight and premature birth.

Or let’s set aside drugs altogether. Malnutrition in pregnant women is one of the main causes of low birth weight and infant mortality worldwide. In this sense, it is worth noting that food insecurity and hunger has grown steadily in the United States since the start of the latest financial crisis in 2008. (Food insecurity exists whenever the availability of nutritionally-adequate and safe foods or the ability to acquire foods is limited or uncertain). According to the latest figures, about 17.2 million households in the United States suffered food insecurity in 2010, the highest number ever registered. Yet the government’s food stamp program is increasingly under attack by pundits and politicians.

Secondly, even a superficial read of arrest and prosecution figures for drug use during pregnancy reveal such a severe race and class bias that the very legitimacy of the approach must be questioned.

Since 1985, 80 percent of the more than 200 pregnant women or new mothers in over 20 states who have been arrested and charged with crimes related to substance use during pregnancy were black or Latina. In 2000, research in Pinellas County in Florida found that while white women and women of color used illegal drugs at comparable rates, black women were 10 times more likely than white women to be reported for child abuse related to substance use during pregnancy. That same year, data from the National Institute on Drug Abuse showed that while black women had a higher overall rate of illicit drug use than white women, most women who use illegal drugs during pregnancy were white. Even so, 41 of the 42 women arrested in South Carolina under a mandatory drug testing program were black. (The program was suspended in the mid-1990s because of allegations of racial discrimination).

Meanwhile, research published in 2006 shows that newborns with white mothers are much more at risk of alcohol and tobacco exposure than newborns with black or Latina mothers.

Moreover, in many cases women with private health insurance are not mandatorily tested for illicit drug use during pregnancy. In this sense, poverty itself is what singles a pregnant woman out for persecution. It is no coincidence that the main focus for drug prosecutions for pregnant women in the United States is crack cocaine, a drug almost exclusively used by the resource-poor. As Whitney Houston herself famously said in an interview in 2002: “I make too much money to ever smoke crack.”

The point here is not that pregnant women should use cocaine, or that the government—and society as a whole—does not have a legitimate interest in ensuring infant and child health.

The point is that the prosecution of drug use in pregnant women does nothing to fulfill a legitimate policy goal and in fact seems to be racially motivated—at least in the implementation—rather than spurred by a concern for children.

In fact, if the objective is to improve infant and child health, efforts to overcome poor nutrition, alcohol addiction, lack of adequate health care, physical abuse, and/or homelessness would make for much better investments. Sadly, such policies don’t make for as sensational news.